Ablative procedures for prevention and treatment of esophageal adenocarcinoma

Ablation of Barrett's mucosa by endoscopic resection, photodynamic therapy or thermoablative methods in combination with adequate acid suppression leads to mucosal replacement largely by squamous epithelium. In appropriately selected cases, these methods have the potential to cure superficial Barrett's neoplasia. Endoscopic resection is an alternative to surgical resection of high-grade intraepithelial neoplasia or early esophageal adenocarcinoma, if the tumor is less than 20 mm in size, is not ulcerated, and does not exhibit differentiation grade 3 or lymph vessel infiltration on histological examination. In the presence of submucosal infiltration, the likelihood of lymph node infiltration is related to the infiltration depth. The risk of a noncurative endoscopic ablative approach has to be weighted against the general risk of surgery. With photodynamic or thermoablative treatment, the completeness of destruction of neoplastic tissue can only be judged at follow-up. These methods are therefore restricted to cases that have an increased surgical risk. Ablation of non-neoplastic Barrett's mucosa is currently not indicated.