New directions in endoscopic therapy of Barrett' s esophagus

The key to prevention and early treatment of esophageal adenocarcinoma is the detection and eradication of neoplasia found in patients with Barrett's esophagus (BE). The approach to the management in BE has rapidly evolved based on the paradigm shift towards endoscopic therapy, on improved detection of neoplasia with increased appreciation for subtle lesions and enhanced endoscopic imaging modalities, and on a new set of endoscopic therapeutic modalities. This review briefly outlines the evolution of the current approach to neoplasia in BE, the appreciation for improved techniques and technologies to detect neoplasia, and the specific modalities currently used in the endoscopic treatment of Barrett's neoplasia. The goals of endoscopic therapy of Barrett's neoplasia are to preserve the esophagus while ablating or removing the entire Barrett's segment. The therapeutic modalities highlighted are endoscopic resection (endoscopic mucosal resection and endoscopic submucosal dissection), photodynamic therapy, radiofrequency ablation, and cryotherapy. Endoscopic resection is a tool to accurately provide a histological diagnosis of lesions in addition to treat neoplasia. In addition, to treating the known neoplasia, it is also important to treat the remainder of the at-risk Barrett's epithelium to address synchronous and metachronous lesions. This treatment of the entire Barrett's epithelium may be achieved with one or more modalities. With multiple endoscopic tools available, it is important to appreciate how to optimally address neoplasia in BE.