Management of Barrett’s Esophagus by Dysplasia Grade

Overall Treatment Stratification

• The American Gastroenterological Society recommends that management be based on dysplasia grade: non‑dysplastic disease requires surveillance with proton‑pump inhibitor (PPI) therapy for symptom control; confirmed low‑grade dysplasia (LGD) should be treated with radiofrequency ablation (RFA); and high‑grade dysplasia (HGD) requires endoscopic eradication therapy (EET) with RFA and endoscopic mucosal resection (EMR) for any visible lesions. 1

Non‑Dysplastic Barrett’s Esophagus

• Endoscopic eradication therapy is not recommended for the general population with non‑dysplastic Barrett’s esophagus because evidence does not show a reduction in cancer risk or cost‑effectiveness compared with surveillance. 2, 3, 4

Low‑Grade Dysplasia (LGD)

• Diagnosis of LGD must be confirmed by at least two pathologists, preferably including an expert in esophageal histopathology, before any therapeutic intervention. 2, 5, 4
• A repeat high‑definition white‑light endoscopy within 3–6 months is advised to exclude any visible lesions. 1
• Any visible lesion must be resected endoscopically first to allow accurate histologic grading. 1
• RFA achieves histologic remission (reversion to normal‑appearing squamous epithelium) in approximately 90 % of treated patients. 6, 3, 4
• Both endoscopic eradication therapy and continued surveillance are acceptable options; the choice should be made through shared decision‑making between clinician and patient. 2, 5

High‑Grade Dysplasia (HGD)

• Endoscopic eradication therapy is the preferred treatment for HGD. 1
• When HGD is associated with visible mucosal irregularities, EMR should be performed first to stage the lesion, followed by ablation of the remaining Barrett’s epithelium. 5, 3, 4
• RFA has been shown in randomized sham‑controlled trials to reduce progression to esophageal cancer. 6, 3, 4
• Approximately 70–80 % of patients with HGD can be successfully managed with endoscopic eradication therapy, avoiding the need for surgery. 6, 3, 4
• Esophagectomy remains an alternative but is associated with higher morbidity compared with ablative endoscopic approaches. 6, 3, 4
• Patients considered for esophagectomy should be referred to high‑volume surgical centers specializing in foregut cancers. 6, 3, 4

Early Esophageal Adenocarcinoma

• For T1a (intramucosal) adenocarcinoma, endoscopic resection is preferred over esophagectomy. 1
• For T1b (submucosal) disease with low‑risk features (≤ 500 µm invasion, well‑to‑moderate differentiation, no lymphovascular invasion), endoscopic therapy is reasonable, especially in patients who are poor surgical candidates. 1

Technical Aspects of Endoscopic Eradication Therapy

• Ablation should be applied to (1) all visible columnar mucosa, (2) 5–10 mm proximal to the squamocolumnar junction, and (3) 5–10 mm distal to the gastro‑esophageal junction. 1
• Ablation is performed only on flat Barrett’s epithelium without active inflammation or visible abnormalities. 1
• Complete eradication of all Barrett’s epithelium is more effective than focal therapy. 2, 5, 4

Center and Operator Requirements

• Endoscopic eradication therapy should be performed by expert endoscopists in high‑volume centers that treat at least 10 new Barrett’s cases per year. 1

Post‑Ablation Surveillance

• Therapy is continued until there is complete absence of columnar epithelium on high‑definition white‑light endoscopy. 1
• After complete eradication, four‑quadrant biopsies of the neosquamous mucosa and the gastric cardia are recommended. 1

Critical Pitfalls and Caveats

• Visible lesions must never be ablated without prior endoscopic resection for accurate staging. 1
• Cryotherapy lacks sufficient evidence for the treatment of dysplasia and cannot be recommended. 2, 5

Complications

• The most common adverse event after endoscopic therapy is post‑procedural stricture formation, occurring in roughly 6 % of cases. 1

Chemoprevention (Adjunctive Considerations)

• Patients should be screened for cardiovascular risk factors that may warrant aspirin therapy for unrelated indications. 5

Management of Barrett's Esophagus

Medical Management for Non-Dysplastic Barrett's Esophagus

• The American College of Gastroenterology recommends proton pump inhibitors (PPIs) as the cornerstone of medical therapy for symptom control of gastroesophageal reflux disease (GERD) in patients with non-dysplastic Barrett's esophagus, but not for cancer prevention 7
• Antireflux surgery should not be offered to prevent neoplastic progression of Barrett's esophagus, as it is not superior to medical therapy for this purpose, according to the American Gastroenterological Association 7, 8
• The American College of Gastroenterology suggests that surgery should only be considered in patients with poor or partial symptomatic response to PPIs 7

Surveillance Strategy

• The American College of Gastroenterology recommends that all patients with Barrett's esophagus require endoscopic surveillance to monitor for progression to dysplasia and adenocarcinoma, with intervals stratified by Barrett's segment length 7, 8
• Proper biopsy protocol is critical, with 4-quadrant biopsies every 2 cm of Barrett's segment for patients without known dysplasia, and every 1 cm for patients with known dysplasia, as recommended by the American Society for Gastrointestinal Endoscopy 7

Management of Low-Grade Dysplasia (LGD)

• Radiofrequency ablation (RFA) should be offered to patients with confirmed low-grade dysplasia diagnosed from biopsy samples taken at two separate endoscopies, according to the American College of Gastroenterology 7, 9
• RFA therapy for low-grade dysplasia leads to reversion to normal-appearing squamous epithelium in 90% of cases, as reported in Gastroenterology 9

Management of High-Grade Dysplasia (HGD)

• For high-grade dysplasia without visible lesions, endoscopic ablation treatment is recommended to prevent progression to invasive cancer, with RFA therapy reducing progression to esophageal cancer, as demonstrated in randomized sham-controlled trials 9
• For high-grade dysplasia with visible mucosal irregularities, endoscopic resection should be performed first to determine the T stage of the neoplasia, followed by ablation of any residual Barrett's epithelium, as recommended by the American College of Gastroenterology 7, 9

Management of Early Esophageal Adenocarcinoma

• For T1a (intramucosal) esophageal adenocarcinoma, endoscopic resection should be offered as first-line treatment, followed by ablation of remaining Barrett's epithelium, according to the American College of Gastroenterology 7

Common Pitfalls and Caveats

• The American College of Gastroenterology recommends against attempting to eliminate esophageal acid exposure through high-dose PPIs or antireflux surgery solely for prevention of esophageal adenocarcinoma, as this approach is not supported by evidence 7, 8
• Cryotherapy currently lacks adequate evidence to recommend its use for confirmed dysplasia or to assess its ability to achieve sustained reversion to squamous epithelium, as reported in Gastroenterology 9
• Chemoprevention with aspirin or NSAIDs is not recommended specifically for Barrett's esophagus, though patients should be screened for cardiovascular risk factors for which aspirin might be indicated for other reasons, according to the American Heart Association 7