Barrett's oesophagus: how should we manage it?

Abstract

Endoscopic surveillance remains the core management of non-dysplastic Barrett's oesophagus, although questions regarding its efficacy in reducing mortality from oesophageal adenocarcinoma have yet to be definitively answered, and randomised trial data are awaited. One of the main goals of current research is to achieve risk stratification, identifying those at high risk of progression. The recent British Society of Gastroenterology (BSG) guidelines on surveillance have taken a step in this direction with interval stratification on clinicopathological grounds. The majority of Barrett's oesophagus remains undiagnosed, and this has led to investigation of methods of screening for Barrett's oesophagus, ideally non-endoscopic methods capable of reliably identifying dysplasia. Chemoprevention to prevent progression is currently under investigation, and may become a key component of future treatment. The availability of effective endotherapy means that accurate identification of dysplasia is more important than ever. There is now evidence to support intervention with radiofrequency ablation (RFA) for low-grade dysplasia (LGD), but recent data have emphasised the need for consensus pathology for LGD. Ablative treatment has become well established for high-grade dysplasia, and should be employed for flat lesions where there is no visible abnormality. Of the ablative modalities, RFA has the strongest evidence base. Endoscopic resection should be performed for all visible lesions, and is now the treatment of choice for T1a tumours. Targeting those with high-risk disease will, hopefully, lead to efficacious and cost-effective surveillance, and the trend towards earlier intervention to halt progression gives cause for optimism that this will ultimately result in fewer deaths from oesophageal adenocarcinoma.

Keywords: BARRETT'S METAPLASIA; BARRETT'S OESOPHAGUS; CHEMOPREVENTION; ENDOSCOPY; SCREENING.

Figure 1

Guidelines for endoscopic surveillance of Barrett's oesophagus. Adapted from Fitzgerald et al, with permission. Note: the interval for repeat oesophagogastroduodenoscopy and biopsy after a finding of gastric metaplasia only, depends on the confidence of the endoscopic and histological findings and the number of biopsies taken. OGD, oesophagogastroduodenoscopy.

Figure 2

Algorithm for management of dysplastic Barrett's oesophagus. Adapted from Fitzgerald et al, with permission. LGD, low-grade dysplasia; HGD, high-grade dysplasia; OGD, oesophagogastroduodenoscopy; MDT, multidisciplinary team.

Figure 3

Algorithm for managing HGD and early oesophageal adenocarcinoma. Adapted from Fitzgerald et al, with permission. HGD, high-grade dysplasia; OAC, early oesophageal adenocarcinoma; MDT, multidisciplinary team; OGD, oesophagogastroduodenoscopy; RFA, radiofrequency ablation.