Optimal Endoluminal Treatment of Barrett's Esophagus: Integrating Novel Strategies into Clinical Practice

Raf Bisschops

Disclosures

Expert Rev Gastroenterol Hepatol. 2010;4(3):319-333. 

In This Article

Abstract and Introduction

Abstract

Endoluminal therapy has become the first-choice treatment over the last 5 years for early Barrett's neoplasia limited to the mucosa. Long-term follow-up data on endoscopic resection have demonstrated the oncological safety of endoscopic resection in comparison to surgery. However, there is a high rate of recurrent disease, which can be avoided using additional ablation of the remaining Barrett. Radiofrequency ablation was recently introduced as an efficacious means to ablate Barrett's epithelium with a better safety profile than older ablation techniques. Recent studies show that endoscopic resection can be safely combined with radiofrequency ablation for treating dysplastic Barrett's after removal of visible lesions. This constitutes a completely new treatment paradigm that will be integrated in routine clinical practice in the forthcoming years.

Introduction

The incidence of esophageal adenocarcinoma and associated death has risen significantly over the last few decades in Western countries.[1,2] The high rate of mortality associated with this disease results from both late detection, especially in patients who are not under surveillance, and from surgery-related mortality.[3] Patients who are under surveillance are often diagnosed at an earlier disease stage[4,5] and a subset of these patients are eligible for endoluminal treatment. Over the last 5 years a change in treatment paradigm has occurred for the management of these early lesions. Owing to relatively high mortality from surgery and excellent outcomes of endoscopic resection (ER), early Barrett's neoplasia is no longer considered to be a primary indication for subtotal esophagectomy. Endoluminal therapy includes different techniques for resection and ablation. ER can be performed by the lift and snare technique, cap-assisted endoscopic resection (Cap-ER), a multiband mucosectomy (MBM) device or endoscopic submucosal dissection (ESD). Ablation techniques include argon plasma coagulation (APC), photodynamic therapy (PDT), cryotherapy and radiofrequency ablation (RFA).

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