Diagnosis and management of Barrett's esophagus: What's next?

The past decade has led to marked improvements in our understanding regarding the pathogenesis and risk of progression of Barrett's esophagus (BE), enhanced imaging technology to improve dysplasia detection, and the development and refinement of endoscopic techniques, such as mucosal ablation and endoscopic mucosal resection(EMR), to eradicate BE. However, many questions remain including identifying which, if any, candidates are most appropriate for screening for BE; how to improve current surveillance protocols; predicting which patients with BE will develop neoplastic progression; identifying the most appropriate candidates for endoscopic eradication therapy; developing algorithms for appropriate management posteradication; and understanding the potential role of chemoprophylaxis. This article describes potential future advances regarding screening, surveillance, risk stratification, endoscopic eradication therapies, and chemoprevention and provides a potential future management strategy for patients with BE.     

Barrett's oesophagus: A case for PDT?

Summary

Barrett's oesophagus is indisputably rated as a precancerous disposition, but generally it has not been confirmed whether ablation techniques as a treatment of Barrett's mucosa, with or without mild dysplasia, do in fact provide an economically defensible form of carcinoma prevention. Photodynamic therapy (PDT) has basic advantages over the alternative thermal procedures, although there is still a lack of adequate clinical confirmation. For high-grade dysplasia or early carcinoma the gold standard is undoubtedly still radical surgery, with partial gastric and oesophageal resection. Based on the fact that there is considerable morbidity and mortality associated with radical surgery, which even in high-grade dysplasia or early carcinoma in Barrett's oesophagus amount to between 30% and 50%, and 3% and 5%, respectively, minimally invasive treatment modalities like endoscopic mucosal resection (EMR) or PDT might be an alternative. In cases of long Barrett's segments with large, circumferential or multifocal lesions, PDT should be considered as a primary form of local treatment while small, clearly located malignant lesions should be treated with EMR.     

Chemoprevention in Barrett's esophagus: A pill a day?

Esophageal adenocarcinoma is increasing in incidence. The main risk factor is the premalignant condition of Barrett's esophagus. There is great interest in chemoprevention to prevent or slow malignant transformation. There are many agents proposed as playing a role in chemoprevention; however, none is licensed for this role as yet. Aspirin possesses many favorable qualities for chemoprevention and is the focus of the largest randomized control trial in this field.     

Cryotherapy for Barrett's esophagus: Who, how, and why?

Cryotherapy is a noncontact ablation method that has long been used clinically in the treatment of a wide variety of malignant and premalignant diseases. The relative ease of use and unique mechanisms of cellular destruction make cryotherapy particularly attractive for the eradication of dysplastic Barrett's esophagus. Currently, liquid nitrogen and carbon dioxide are the most common cryogens used. Preliminary data with these agents have shown high efficacy in the reversal of dysplastic Barrett mucosa and excellent safety profiles. Intense investigation on cryotherapy ablation of Barrett's esophagus is ongoing.     

Endoscopic interventions in Barrett's esophagus: Do the dollars make sense?

Advances in the development of endoscopic therapies for Barrett's esophagus have resulted in the emergence of an important paradigm shift for management of early neoplasia and represent an opportunity to alter the natural history of the disease. Clinical incorporation of these endoscopic modalities may have significant implications for disease management and health care delivery from a cost perspective. This article reviews the current literature on the cost analyses of commonly used Barrett endoscopic interventions and summarizes the overall cost-effectiveness of these treatments as compared with surveillance or surgery.     

Barrett's esophagus surveillance: When, how often, does it work?

Barrett's esophagus is a well-known risk factor for the development of esophageal adenocarcinoma. Current practice guidelines recommend endoscopic surveillance of patients with Barrett's esophagus in an attempt to detect cancer at an early and potentially curable stage. This review addresses the rationale behind surveillance and criteria for inclusion of patients in surveillance programs as well as the appropriate technique and intervals that should be used. This work addresses other key topics in Barrett's esophagus surveillance, including the efficacy of surveillance programs, physician compliance with surveillance guidelines, cost-effectiveness of surveillance programs, and areas for future research.     

Endotherapy for Barrett's esophagus: Which, how, when, and who?

Recent developments in endoscopic therapeutic options for Barrett's esophagus (BE) early neoplasia have resulted in a dramatic paradigm shift in its clinical management. With multiple endoscopic choices available, it is important to discern subtle differences between these approaches based on the available current data and known limitations of each modality. The goals of endoscopic therapy of Barrett's neoplasia are to preserve the esophagus while ablating or removing the entire BE segment. This article reviews the currently available BE endoscopic treatments with emphasis on appropriate selection of patients, indications and timing of use, and clinical management considerations.     

The columnar-lined (Barrett's) esophagus. Can progression to cancer be prevented?

The risk of adenocarcinoma in patients with columnar-lined, or Barrett's, esophagus has risen dramatically in recent decades. In this article, Dr Stollman explains the difficulties in defining the condition and examines current strategies in prevention and management.     

Is topical delta-aminolevulinic acid adequate for photodynamic therapy in Barrett's esophagus? A pilot study

BACKGROUND AND STUDY AIMS: The methods of endoscopic ablation of metaplastic and dysplastic areas in Barrett's esophagus so far described, are not satisfactory with respect to efficacy and safety. Therefore we investigated whether photodynamic therapy (PDT) with topical delta-aminolevulinic acid (delta-ALA) leads to ablation of specialized columnar epithelium and eradication of low-grade dysplasia while not producing phototoxicity and systemic side effects. PATIENTS AND METHODS: 14 patients with histologically proven Barrett's esophagus, seven of whom had evidence of low-grade dysplasia, underwent endoscopic treatment with topical delta-ALA. Photoactivation (wavelength, 632 nm) was performed at 1.5 - 2 hours after drug administration using an argon dye laser. Patients received omeprazole 80 mg daily for 2 months; thereafter; maintenance therapy depended on reflux symptoms. Patients were endoscopically re-evaluated after 7 days, and subsequently at 3, 6, 12 and up to 48 months (mean follow up 33 months). Re-treatment with high-dose topical delta-ALA was offered to the 11 patients with remaining metaplasia and was carried out in five of them. RESULTS: Low-grade dysplasia was eradicated in all patients. One patient with no dysplasia before PDT developed a high-grade dysplasia after PDT. Complete ablation of Barrett's metaplasia was observed in 21 % of the patients after the first treatment session and in 20 % after the second treatment session. The mean reduction in the length of Barrett's metaplasia was 1.54 +/- 1.29 cm after the first PDT session and 1.02 +/- 0.80 cm after the second PDT session. Post-endoscopic pain and photosensitivity reactions were less frequent with low-dose delta-ALA PDT than with high-dose PDT (pain 15 %, 100 %, respectively; P = 0.001 by Fisher's exact test; phototoxicity, 0 %, 50 %, respectively; P = 0.021 by Fisher's exact test). CONCLUSION: Low-dose topical administration of delta-ALA provides ablation of low-grade dysplasia in the range obtained with oral delta-ALA. In addition, it is safe and well tolerated. Since, however, topical administration of delta-ALA is not able to consistently eradicate Barrett's esophagus, alternative methods will have to be developed.     

Land of plenty?

China will need to recruit around 150,000 nurses a year if ambitious plans to extend health care to all citizens are to be met.