Management of Barrett's esophagus

Both the incidence of esophageal adenocarcinoma (EA) and its precursor, Barrett's esophagus (BE) is increasing rapidly in the western world. The progression of BE to EA follows the metaplasia-dysplasia-carcinoma sequence which makes BE the focus of intervention before the development of EA. Considerations are given on the feasibility of a screening program for the population at risk, followed by surveillance of patients found to have BE on endoscopy. Potential management options are then stratified based histological findings of various degrees of dysplasia. This begins with watchful waiting or surveillance as in the case of BE with no dysplasia and low-grade dysplasia (LGD). Ablative therapies such as radiofrequency ablation (RFA) can be considered in non-visible high-grade dysplasia (HGD). With visible lesions and intramucosal cancers, Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD) is generally recommended as a treatment and staging technique. Esophagectomy remains the treatment of choice in EA where there is a high risk of metastasis such as those with deeper submucosal invasion, lymph-vascular or neural invasion and those of higher tumour grade.