Gut Check on Gastroenterology Archive

The answer to the question “What to do with Barrett’s: Ignore it or fry it” is simple: It depends on whether we are talking about Barrett’s with or without dysplasia! We now have ample evidence that  endoscopic interventions for dysplastic Barrett’s are effective in decreasing the incidence of cancer. As a matter of fact, the success of PDT, EMR and now RFA in treating dysplastic Barrett’s, makes routine use of surgery for Barrett’s with high-grade dysplasia inappropriate.

Is the same true for the majority of patients with Barrett’s that have no dysplasia and are at low risk for progression to dysplasia (life time risk <15%) or cancer (life time risk <5%)? Furthermore, how could an endoscopic intervention that is 1) expensive and 2) potentially harmful, benefit them in any way? I would answer these questions in this way: If eradicating Barrett’s metaplasia led to the “cure” of Barrett’s and thus obviated the need for further endoscopic surveillance, then an endoscopic intervention would be supportable and this response then requires answering two further questions: 1) Does endoscopic ablation lead to elimination of Barrett’s metaplasia and 2) can we eliminate surveillance endoscopy in those whose Barrett’s is eradicated?

The answer to the first question is an unequivocal yes. How about the answer to the second question and how many of you are comfortable telling a patient that has had all apparent Barrett’s eliminated by an endoscopic ablative method that they no longer need surveillance? If you actually tell them they no longer need surveillance once Barrett’s has been eliminated, then I can support you doing endoscopic treatment of non-dysplastic Barrett’s right now. If you are not comfortable with telling them they are cured and do not halt any further surveillance (e.g., fire the patient), then you should not be doing these procedures on non-dysplastic Barrett’s patients!

How long should we wait before we tell patients that have undergone Barrett’s ablation they are cured and no longer need surveillance? There are no data relating to this but we do know the residual risk is very low. My personal feeling is that if they have two successive surveillance exams that demonstrate no endoscopic or histological Barrett’s (5-6 years out) I would recommend that they forego further surveillance as any benefit from surveillance is questionable anyway.

Either way, the answer to “What should we do with Barrett’s: Ignore it or fry it?” appears pretty simple to me: if they have dysplasia-“fry it”; if they do not have dysplasia, “fry it” if you are willing to discharge them from surveillance, otherwise don’t intervene!