Endoscopic management of Barrett esophagus

Endoscopy has a vital role in the diagnosis, screening, surveillance and treatment of Barrett esophagus. Over the past few decades, tremendous advances have been made in endoscopic technology, and the management of dysplasia and early cancer in Barrett esophagus has changed radically from being surgical to organ-sparing endoscopic therapy. Proper endoscopic techniques and systematic biopsy protocols improve dysplasia detection, and endoscopic surveillance improves outcomes in patients with Barrett esophagus and dysplasia. Endoscopic treatment can be tissue acquiring (as in endoscopic mucosal resection and endoscopic submucosal dissection) or ablative (as with photodynamic therapy, radiofrequency ablation and cryotherapy). Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective. Shared decision-making between the patient and physician is important while considering treatment for dysplasia in Barrett esophagus. Issues such as durability of response, importance of subsquamous Barrett epithelium and the optimal management strategy in patients with low-grade dysplasia and nondysplastic Barrett esophagus need to be studied further. Development of safer wide-field resection techniques, which would effectively remove all Barrett esophagus and obviate the need for long-term surveillance, is needed.