April 10th, 2013
Barrett esophagus with dysplasia: Endoscopic resection or endoscopic burning?
The effectiveness of endoscopic ablation of neoplastic (dysplastic) Barrett esophagus (BE) has made it the new standard of care in many communities; referrals to surgeons have largely disappeared. However, the procedure is still evolving — from thermal ablation by laser in the 1980s and early 1990s to BICAP probes and Argon Plasma Catheter (APC) in the mid-to-late 1990s to specific radiofreqency catheters (Barrx Halo 360 and 90 systems) in the current decade. Cryoablation catheters are also now available.
At the same time, endoscopic mucosal resection (EMR) technique has also evolved with the Duette and other systems. EMR now allows “wide area” resection of flat BE as well as the original approach of targeted resection of mucosal nodules and depressions.
So, with such a large variety of effective techniques available for treating limited flat BE mucosa, let me present a case study and ask what you would do.
A patient has 2 cm of circumferential BE with a single 1-cm tongue extension. Biopsies demonstrate focal high-grade dysplasia and widespread low-grade dysplasia. Careful inspection with high-definition, white-light and narrow-band imaging reveals no surface irregularity and minimal vascular heterogeneity.
- Which endoscopic technique would you use to initially treat this patient’s BE? Why?
- Which technique would you use in follow-up sessions? Why?
- How much of the BE would you treat at the first session?
- Would you treat circumferentially or the entire segment?
- How many weeks apart would you conduct treatment sessions?
I look forward to the discussion.
3 Responses to “Barrett esophagus with dysplasia: Endoscopic resection or endoscopic burning?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
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Endoscopic submucosal dissection is feasible, safe and ideal. Enbloc resectiob helps with full histological assessment including resection margin. Since it is near GO junction scope can be retroverted and resection is easier.
Other technuqes such as EMR and ablatation are inferior to ESD. The alternatives are popular and talked about because western endoscpists do not have the skill and patience to practice and perfect the gold standard
I would remove the high dysplastic area by duette, and do APC or RFA for the remaining by circumferential treatment after two weeks, then after one month
treatement:0ne session Ffa 3cm ballon; endoscopy with biopsies for FU ;