Which is the optimal treatment for Barrett’s esophagus with high grade dysplasia – ablation or complete endoscopic removal?

We read with great interest the article by Halsey et al. [1] on the pattern and sites of recurrence of Barrett’s esophagus with high grade dysplasia (HGD) following endoscopic liquid nitrogen spray cryotherapy. The authors concluded that ultimately this method achieved a 92 % complete response rate. They also concluded that random 4-quadrant biopsy is not sufficient during surveillance for the detection of recurrent lesions, and that biopsies should be performed routinely in the area immediately below the neosquamocolumnar junction (NSCJ). We think that this article is one of the most important papers to be published in recent years for guiding endoscopists in their choice of treatment for Barrett’s HGD and for suggestions of how to follow up the patient.

Cryotherapy is one of the multimodal endoscopic intervention ablation management options for Barrett’s HGD that have been presented in recent years. Others include argon plasma coagulation, radiofrequency ablation, photodynamic therapy, and multipolar electrocoagulation. Compared with surgical resection, this kind of endoscopic treatment is more effective and is associated with a lower rate of complications. However, in recent literature, endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) have also emerged as new endoscopic therapeutic interventions for Barrett’s HGD [2] [3] [4]. En bloc EMR or ESD achieves almost 100 % complete response rate for HGD diseases, but the procedures carry a high risk of complications, including hemorrhage, perforation, and stricture [5]. In addition, ESD is a time-consuming procedure and requires a long training period, and endoscopic ablation techniques are easy and safe but have high recurrence rates. Hence, we want to know which of the techniques represents the optimal treatment for Barrett’s HGD – ablation or complete endoscopic removal?

Barrett’s HGD and metaplasia are the strongest risk factors for progression to adenocarcinoma and, as the paper discusses, the risk increases to approximately 30 % in 5 years if HGD is present; conversely, it has been documented anecdotally in the literature that Barrett’s esophagus with low grade dysplasia (LGD) has little chance of progression to carcinoma [6]. In our experience, HGD near the opening of the cardia or the gastrocardia has the higher risk of developing into cancer, with approximately 60 % of lesions developing into intramucosal cancer in 2 years. These figures support those of Halsey et al., which showed that the region associated most frequently with the recurrence of HGD and subsequent development into cancer was the area just below the NSCJ. Therefore, only by resecting the lesions completely and in one piece can the disease be prevented from developing into cancer. We think there are three main limitations to the use of endoscopic ablation. First, the depth of the ablation is shallow and uneven and does not reach the submucosa. Second, the small space near the cardia and the positioning of the gastric folds make it difficult to ablate the lesion completely in this high risk area. Finally, the ablation technique damages the lesion and it is therefore not possible to obtain an intact specimen to assess whether or not the treatment has been thorough. These features could be the major causes of residual lesions and recurrence after ablation treatment in most cases of Barrett’s HGD.

In conclusion, we would prefer to use ESD or en bloc EMR for Barrett’s esophagus with HGD and endoscopic ablation for Barrett’s with LGD.

References

• 1 Halsey K D, Chang J W, Waldt A, Greenwald B D. Recurrent disease following endoscopic ablation of Barrett’s high-grade dysplasia with spray cryotherapy.  Endoscopy. 2011;  43 844-848
• 2 Semlitsch T, Jeitler K, Schoefl R et al. A systematic review of the evidence for radiofrequency ablation for Barrett’s esophagus.  Surg Endosc. 2010;  24 2935-2943
• 3 Menon D, Stafinski T, Wu H et al. Endoscopic treatments for Barrett’s esophagus: a systematic review of safety and effectiveness compared to esophagectomy.  BMC Gastroenterol. 2010;  10 111
• 4 Repaka A, Chak A. Endoscopic management of Barrett esophagus.  Nat Rev Gastroenterol Hepatol. 2011;  8 582-591
• 5 Sumiyama K, Gostout C J. Novel techniques and instrumentation for EMR, ESD, and full-thickness endoscopic luminal resection.  Gastrointest Endosc Clin N Am. 2007;  17 471-485
• 6 Srivastava A, Hornick J L, Li X et al. Extent of low-grade dysplasia is a risk factor for the development of esophageal adenocarcinoma in Barrett’s esophagus.  Am J Gastroenterol. 2007;  102 483-493