How to handle esophageal metaplasia in 2014: a practical guide

Metaplasia of the esophagus is a precursor of esophageal adenocarcinoma, a cancer with a poor prognosis and an increasing incidence. Guidelines for surveillance are proposed by all professional societies with small differences in timing. However, there is still no consensus on the definition of Barrett's esopaghus (only intestinal metaplasia or all subtypes). The goal of surveillance of esophageal metaplasia has evolved from early detection of cancer to early detection of pre-cancerous metaplasia to allow endoscopic therapy. The endoscopic therapy has the intention to stage, to cure, to prevent progression and to prevent metachronous lesions to develop. Firm indications for endoscopic therapy are high rade dysplasia and mEAC. The actual treatment is EMR/ESD for all visual abnormalities and areas of cancer on biopsies, followed by RFA for the remaining metaplasia. For low grade dysplasia (LGD), surveillance versus RFA is still under discussion. The main reason for this is the wide interobserver variability with large differences in evolution between confirmed and unconfirmed LGD. The endoscopic treatment allows complete remission of dysplasia in most cases and of metaplasia in the majority of cases, with low complication rates and acceptable morbidity (treatable stenosis). However, a median of 3 treatments is usually required to achieve remission, and recurrence is as high as 15% in the following 5 years. Strategies to reduce recurrence like chemotherapy or anti-reflux surgery need to be explored better and can actually not decrease or replace surveillance.