Indications, contraindications and limitations of endoscopic therapy for Barrett’s esophagus and early esophageal adenocarcinoma

Abstract

Endoscopic eradication therapy (EET) has revolutionized management of Barrett’s esophagus (BE)-associated neoplasia, traditionally treated by esophagectomy, which carries very high mortality and morbidity. EET, usually performed in the outpatient setting, has a safe risk profile. It is indicated in patients with BE with high-grade dysplasia and intramucosal cancer, confirmed, and persistent low-grade dysplasia, and in highly selected cases of non-dysplastic BE and submucosal cancers. Multiple EET modalities are available and can be categorized into two groups: ablation therapies and resection techniques with resection techniques usually reserved for nodular/raised lesions or lesions with suspected neoplasia. Patients usually require multiple ablation sessions with a goal of achieving complete eradication of metaplasia. Despite very good results, EET has its limitations and is not 100% effective: it targets a small subset of patients along the spectrum of BE and esophageal adenocarcinoma, as most patients with esophageal adenocarcinoma remain asymptomatic until the disease has progressed to advanced stages. Post-ablation surveillance is mandatory, as recurrences are common. An area of concern is buried metaplasia reported to occur following ablation therapy and thought to be from de novo growth of metaplastic tissue underneath the neosquamous epithelium, following ablation. The focus of this review article is to present the indications, contraindications and limitations of EET.

Guide mapping for effective superficial photothermal coagulation of the esophagus using computer simulations with ex vivo sheep model validation study

“…Endoscopic management of superficial abnormal tissue remains a valid challenge. Even though laser therapy (i.e., laser‐induced photothermal coagulation) has been gradually abandoned to treat superficial abnormal tissues, 37 it still has the potential for high safety and efficacy with minimal side effects. In addition, developments in optical imaging, fiber optical components, and diode laser technologies, which enable new probe designs, will bring laser therapy to the agenda more strongly again.…”

The role of ablation in the treatment of dysplastic Barrett’s esophagus

“…Contraindications for RFA include prior radiation to the esophagus which increases the risk of stricture formation and poor wound healing, esophageal varices, and in nodular or ulcerated BE as these patients would benefit from EMR for diagnosis, staging, and treatment. 15 …”

Subtotal esophageal endoscopic submucosal dissection for long-segment Barrett’s esophagus and adenocarcinoma

“…Currently, radiofrequency ablation, cryotherapy, or hybrid argon plasma coagulation after endoscopic resection are recommended as treatment methods for BE, including where high grade dysplasia is present 2 ; intraepithelial carcinoma has also been reported to be controllable by these methods. On the other hand, there is a risk of buried BE due to remnant BE after these endoscopic therapies 3 . In this case, ESD not only resulted in curative treatment of the EAC, confirmable by histologic assessment following R0 resection, but also resulted in complete en bloc resection of the BE, with no risk of remnant BE.…”