Management strategies of Barrett's esophagus

Abstract

Barrett's esophagus is a condition resulting from chronic gastro-esophageal reflux disease with a documented risk of esophageal adenocarcinoma. Current strategies for improved survival in patients with Barrett's adenocarcinoma focus on detection of dysplasia. This can be obtained by screening programs in high-risk cohorts of patients and/or endoscopic biopsy surveillance of patients with known Barrett's esophagus (BE). Several therapies have been developed in attempts to reverse BE and reduce cancer risk. Aggressive medical management of acid reflux, lifestyle modifications, antireflux surgery, and endoscopic treatments have been recommended for many patients with BE. Whether these interventions are cost-effective or reduce mortality from esophageal cancer remains controversial. Current treatment requires combinations of endoscopic mucosal resection techniques to eliminate visible lesions followed by ablation of residual metaplastic tissue. Esophagectomy is currently indicated in multifocal high-grade neoplasia or mucosal Barrett's carcinoma which cannot be managed by endoscopic approach.

Keywords: Barrett’s esophagus; Diagnosis; Esophageal adenocarcinoma; Esophagectomy; Management strategies.

Figure 1

Endoscopic and histologic images of Barrett’s esophagus. A: Endoscopic view of salmon-colored mucosa above the gastro-esophageal junction; B: Intestinal metaplasia with goblet cells (arrows) was found in biopsy specimens at histology.

Figure 2

White-light and enhanced endoscopic images of non-dysplastic Barrett’s esophagus. A: White-light of Barrett’s esophagus; B: Narrow-band imaging endoscopic of Barrett’s esophagus; C: Probe-based confocal laser endomicroscopy (pCLE) images of Barrett’s esophagus. p-CLE image shows uniform villiform architecture, columnar cells (solid arrow) and dark goblet cells (dash arrow) predictive of non-dysplastic Barrett’s esophagus.

Figure 3

Enhanced narrow-band imaging and probe-based confocal laser endomicroscopy images of dysplastic Barrett’s esophagus. A: Narrow-band imaging images shows distorted pits with irregular microvasculature (white circle); B: The corresponding probe-based confocal laser endomicroscopy image shows disorganized, distorted villiform structure and crypts, dark columnar cells (dash arrow) and dilated irregular vessels (solid arrow); C: High-grade dysplasia was found at histology in biopsy specimens performed at this level.