|Invited Lecture (JGES)|
|Sat. October 14th 11:20 - 12:00 Room 11: Fukuoka International Congress Center 502+503|
|Diagnosis and treatment of Barrett's esophagus with dysplasia: Current guidelines and new technologies|
|Yaroslavl Regional Cancer Hospital, Endoscopy Training Center, Yaroslavl State Medical University|
| Barrett's esophagus (BE) is among the most common conditions encountered by the western gastroenterologists. BE has been detected in 15% of patients with chronic GERD and in 1-2% of population subjects. Current guidelines continue to endorse screening of high-risk patients for BE. However, routine screening is limited to patients with reflux symptoms and multiple other risk factors. An accurate endoscopy report for BE includes documentation of the anatomical landmarks (diaphragm indentation, top of gastric folds). According to ESGE key performance measures for Barrett’s esophagus the Prague criteria should be used to report the results of endoscopic examination. The Paris classification is a uniform and relatively well established endoscopic classification for early neoplastic lesions with clinical value in terms of the prediction of the risk of submucosal invasion and therefore eligibility for endoscopic treatment. The optimal inspection time also includes rinsing the esophagus sufficiently to improve visualization, proper sedation and patient tolerance, and the use of high definition endoscopy as well as the Seattle protocol in Barrett’s surveillance.
The risk of developing early adenocarcinoma (EAC) substantially lower in subjects without intestinal metaplasia (IM) compared with those with IM. Dysplasia remains the best clinically available marker of cancer risk in patients with BE. A systematic biopsy protocol clearly detects more IM, dysplasia and early cancer compared with ad hoc random biopsies. In patients with low grade dysplasia (LGD) cancer risk is more than 6 time higher than in patients with IM. The highest risk in those who have high grade dysplasia (HGD), more than 10 times higher than in subjects with LGD.
Consideration of any endoscopic therapy in BE begins with a close inspection of the BE mucosa. The identification of mucosal irregularities including nodularity, ulceration or flat but irregular mucosal contour is essential to detecting the areas of highest yield for neoplasia. In this role, the adjunct use of a narrow light spectrum imaging technology, such as NBI, BLI and I-scan may aid in detecting mucosal irregularity. Endoscopic mucosal resection (EMR) and ablative techniques have garnered a significant role in the management of BE, particularly with dysplasia and early cancers. Radiofrequency ablation is the preferred endoscopic ablative therapy in patients with flat dysplastic lesions. Hybrid APC and cryotherapy is relatively new modalities for the management of BE. Endoscopic resection is recommended for the patients with visible lesions in BE. Endoscopic submucosal dissection (ESD) has been shown to be superior to EMR for excision of mucosal cancer larger than 15 mm in size, poorly lifting tumors, and lesions at risk for submucosal invasion.
Continued surveillance with high resolution white light endoscopy is recommended after successful endoscopic therapy in order to detect recurrence of intestinal metaplasia or dysplasia. Subtle mucosal abnormalities can be detected by advanced endoscopic imaging techniques, which should be used in experienced hands. The ultimate goals for these advanced imaging techniques are to improve the endoscopic detection of curable neoplasia in Barrett’s esophagus while reducing procedure time, expense, and sampling error.
In summary, care of the patient with BE has evolved rapidly in the past decade. Modern endoscopic techniques play an important role in detection, less invasive treatment and surveillance of patients with BE, especially with dysplasia and EAC. Current guidelines include the expanded use of endoscopic ablative therapy, especially their extension to patients with LGD based on data demonstrating both a lower risk of EAC in patients with nondysplastic BE after ablation or resection. It is likely that the development of several technologies will cause further evolution in care of patients with BE. These include the evolution of biomarkers to predict risk in BE and the use of advanced imaging and biomolecular technologies to allow recognition of areas of neoplasia within BE.