Endoscopic eradication of Barrett's esophagus

Multimodality EET is here to stay as a viable treatment option for BE patients with HGD and early mucosal EAC. Alternative treatment approaches, including esophagectomy, should be discussed with these patients; however, a paradigm shift in which the endoscopist plays a major role in the management of BE-related neoplasia seems inevitable. After careful examination of the BE segment by using advanced imaging techniques, EET starts with a diagnostic EMR in this group of patients because EMR has been shown to alter staging. In patients with positive deep margins and/or extensive submucosal invasion, surgical resection is advised, whereas patients with EAC and HGD confined to the mucosa can be treated endoscopically. Short, noncircumferential extents of BE (Prague grade C0M <3) can be eradicated with continued EMR in an effort to resect the entire BE area, whereas in those with longer, circumferential BE segments, a combination of EMR with mucosal ablation should be applied. The therapeutic objective of EET should be the complete treatment and removal of all neoplastic and metaplastic epithelium. At this time, close surveillance of these patients after EET is recommended to identify recurrent lesions. Local availability of equipment for enhanced imaging and endoscopic therapies, the expertise of the endoscopist, the experience of the pathologist in the histopathological evaluation of the resected specimens, and the expertise of the surgeon are all important variables in determining the optimal management of patients with BE undergoing EET. Conversely, the subgroup of BE patients without dysplasia and/or those with LGD should not undergo EET outside of study protocols until further data are available regarding the risks and benefits.