Sanjay JagannathMD and Marcia I Canto MD MHS

Barrett's esophagus, defined as the replacement of normal esophageal squamous epithelium with specialized columnar metaplasia characterized by goblet cells (Sampliner, 1998), is a condition that often arises in the setting of chronic gastroesophageal reflux disease. The presence of Barrett's epithelium is clinically important because it represents a premalignant condition that predisposes to the development of esophageal adenocarcinoma (AC). There is a separate chapter on endoscopic ultrasound and fine needle aspiration (see Chapter 5, "Endoscopic Ultrasound and Fine Needle Aspiration").

The incidence of esophageal AC is the highest among all cancers in the United States and Western Europe. The estimated 5-year survival of esophageal cancer (EC) is a dismal 5 to 10%, and, currently, it represents the seventh leading cause of cancer death worldwide. The overall risk of developing EC in the setting of Barrett's epithelium is estimated to be approximately 0.5% per year; however, the relative risk of developing malignancy in Barrett's epithelium is 30 to 125 times greater than that reported in the non-Barrett's epithelium population (Drweitz et al, 1997; Shaheen et al, 2000; Conio et al, 2003; Provenzale et al, 1994). The risk of malignancy is greatest in Barrett's epithelium with advanced dysplasia, where the finding of occult AC in this population is as high as 30%. Prophylactic esophagectomy is generally recommended for patients with known high grade dysplasia, and it can often be performed with low mortality and excellent long term survival in high volume surgical centers (Heitmiller, 2003; Falk et al, 2000; Pellegrini and Pohl, 2000; Tseng et al, 2003). However, recent studies have emphasized the risks associated with surgical resection and thus generated interest in minimally invasive treatment techniques (Berkmeyer et al, 2002).

The question of what to do with patients who are not surgical candidates for an esophagectomy remains. The current recommendation is to perform ablative therapy of the esophagus for patients with dysplastic Barrett's epithelium or early mucosal AC. The goal of Barrett's epithelium ablation is to eliminate or at least downgrade mucosal dyspla-sia. The premise is that destruction of premalignant Barrett's epithelium followed by normal squamous re-epithelialization in an anacid environment results in curing of Barrett's epithelium and eliminates the risk of esophageal AC.

After the publication of the first case report in 1993, various ablative therapies have been reported, including laser therapy (Nd:YAG), argon plasma coagulator, multipolar or bipolar electrocoagulation, photodynamic therapy (PDT), endoscopic mucosal resection (EMR), and cryotherapy. Despite the paucity of well-designed trials with long term follow-up to support using ablative techniques, there is a general tendency among gastroenterologists to incorporate ablative techniques into their practice. In response to a survey conducted in 2002, only 15% of physicians believed ablation lowered the risk of AC and only 19% believed using ablation was supported by the medical literature; however, 25% of physicians did use ablation at the time of initial survey, and this percentage increased to 36% in the follow-up survey (Gross et al, 2002).

This chapter discusses the various ablative techniques that have been studied in patients and their results. It will not discuss, however, EMR indications or techniques since this is reviewed in a separate chapter dedicated to EMR (see Chapter 6, "Endoscopic Mucosal Resection"). In addition, discussions regarding experimental or possible future techniques (eg, cryotherapy, chemoprevention) will not be discussed, at this time, because there are no published human trials. The goal of successful ablation therapy should be complete ablation of Barrett's epithelium without evidence of recurrence over a long period of follow-up.

An important caveat is to note that there is currently no indication for ablative therapy of nondysplastic Barrett's epithelium outside of approved clinical trials. The risk of developing AC in the setting of nondysplastic Barrett's epithelium is very low, and these patients should be maintained on a proton pump inhibitor (PPI) and undergo routine endoscopic surveillance. Finally, the authors will discuss how they incorporate ablative techniques in their practice. There is a separate chapter on Barrett's esophagus (see Chapter 14, "Barrett's Esophagus").

Constipation Prescription

Constipation Prescription

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