Today's Mistakes and Tomorrow's Wisdom in Endoscopic Treatment and Follow-Up of Barrett's Esophagus.

Abstract

Background: Endoscopic therapy has replaced esophagectomy for the management of early Barrett's neoplasia, allowing for the curative treatment of intramucosal adenocarcinoma, dysplastic Barrett's esophagus (BE), and the prevention of metachronous recurrences.

Summary: Endoscopic therapy relies on the resection of any visible lesion, suspicious of harboring cancer, followed by the eradication of the residual BE, potentially harboring dysplastic foci. Currently, endoscopic mucosal resection (EMR) using the multiband mucosectomy technique is the gold standard for the resection of visible lesions. Endoscopic submucosal dissection (ESD) is feasible with comparable complication rates to EMR, but longer procedural times. It is still limited to EMR failures or suspected submucosal adenocarcinoma. Eradication of residual BE mainly relies on radiofrequency ablation, with over 90% efficacy in expert centers. Despite initial complete eradication of BE, intestinal metaplasia and dysplasia recur in time, justifying prolonged endoscopic surveillance.

Key messages: The first step of the therapeutic endoscopy for BE is a careful diagnostic evaluation, searching for visible(s) lesion(s). EMR is the recommended resection technique for visible lesions. ESD has not demonstrated its superiority on EMR in routine practice. Endoscopic follow-up after Barrett's eradication therapy is mandatory.