Treatment of Barrett's esophagus

Barrett's esophagus represents the most serious consequence of chronic gastroesophageal reflux disease (GERD), primarily because of its association with an increased incidence of esophageal adenocarcinoma. Specific therapy for Barrett's esophagus should lead to the complete regression of the metaplastic epithelium with adequate squamous reepithelialization. Ideally, this regression should be permanent and be associated with a reduction in the incidence of adenocarcinoma. Several reports in the literature have assessed the effects of H2-blocker treatment of Barrett's epithelium, but none has clearly documented a significant and consistent regression of the metaplastic epithelium. Proton pump inhibitors have been shown to be superior to H2 blockers in the treatment of patients with severe esophagitis. Despite initial enthusiasm, it does not appear that a significant regression of Barrett's epithelium can be achieved, even with high doses of proton pump inhibitors given for a prolonged period of time. Various groups have assessed the effects of antireflux surgery on the regression of columnar epithelium and dysplasia and its potential protective effect on the subsequent development of carcinoma. Overall, it appears from these reports that antireflux surgery, despite adequate symptomatic results, does not significantly and consistently lead to a reduction in length or disappearance of the Barrett's mucosa, and does not prevent the development of dysplasia and its progression to carcinoma. More recently, numerous authors have documented the regression of Barrett's mucosa by using various endoscopic thermal modalities. Technological advances including laser and photodynamic therapy have allowed for endoscopic mucosal ablation. Long term results are more encouraging when this mucosal ablation is associated with aggressive antireflux therapy (medical or surgical). Further studies are required before these exciting new therapies can be recommended. Currently, none of these approaches can obviate the need for continued endoscopic surveillance.