barrett's%20esophagus
BARRETT'S ESOPHAGUS
Barrett's esophagus is defined as the endoscopic finding in the distal esophagus of proximal-appearing columnar-lined esophagus of at least 1-cm length that is confirmed by histology.
It is considered a premalignant metaplastic condition that usually involves the distal esophagus.
It is postulated that exposure of the esophageal epithelium to acid damages the lining resulting in chronic esophagitis and its healing involves metaplastic process.

Surgical Intervention

Surgery for Acid Suppression 

  • Appropriate surgical candidates may consider fundoplication to control reflux symptoms
  • Surgical intervention to prevent adenocarcinoma remains unproven

Endoscopic Therapy

  • Goals of therapy include eradication of dysplasia and/or cancer, prevention of progression to invasive cancer and reduction of mortality from esophageal adenocarcinoma 
  • Visible lesions are resected then the mucosa is ablated to achieve complete eradication of intestinal metaplasia 
    • Eliminates Barrett's epithelium by removing the tissue (eg endoscopic mucosal resection or endoscopic submucosal dissection) and/or ablating the tissue (eg radiofrequency ablation, hybrid argon plasma coagulation or cryotherapy) 
    • Mucosal ablation should only be done with flat Barrett's esophagus without inflammation and visible abnormalities 
  • Most common complications include formation of stricture, bleeding and perforation 
  • Recurrent disease is treated similarly as that of the initial disease 
  • Counsel patients regarding cancer risk in the absence of or after endoscopic therapy

Low-Grade Dysplasia

  • If endoscopy shows a visible focal lesion, complete resection of the lesion should be performed; if focal lesions are absent, may consider radiofrequency ablation 
  • Patients with documented and persistent low-grade dysplasia may be managed with both endoscopic therapy and continued surveillance 

High-Grade Dysplasia

  • Preferred treatment over esophagectomy 
  • For patients with confirmed multifocal high-grade dysplasia, intervention should be considered (eg endoscopic mucosal resection, radiofrequency ablation or ablation using cryotherapy, photodynamic therapy, esophagectomy)
    • Complete endoscopic and histologic eradication of the Barrett’s esophagus segment along with other dysplastic lesions is the goal of endoscopic treatment in patients with Barrett’s esophagus-associated neoplasia 
    • Any visible raised or suspicious lesions should undergo diagnostic endoscopic resection in patients with dysplastic Barrett’s esophagus or early esophageal adenocarcinoma 
    • Radiofrequency ablation is the preferred endoscopic ablative therapy for patients with flat-type dysplastic Barrett’s esophagus non-nodular disease; undetected synchronous lesions can be treated and development of metachronous lesions can be prevented 
      • Mucosal ablation should be applied circumferentially using focal/targeted therapy to the GEJ/gastric cardia as this is an area that is difficult to treat and a common site for recurrent neoplasia 
  • As synchronous cancer can occur with high-grade dysplasia, intervention (eg endoscopic resection) instead of continued surveillance may be done 
    • Endoscopic resection may be performed if the lesion can be localized endoscopically

Esophagectomy 

  • Some clinicians recommend esophagectomy for healthy patients with high-grade dysplasia or patients with invasion of the submucosa, lymph node metastasis or failed endoscopic therapy
  • The natural history of high-grade dysplasia is variable and therefore, the decision to perform esophagectomy should be carefully considered
  • Associated with higher morbidity and mortality at low-volume institutions
  • Esophagectomy at a high-volume institution may be considered in patients who are fit for surgery with recurrent, diffuse, high-grade dysplasia that is confirmed by an expert/experienced gastrointestinal pathologist
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