Endoscopic therapy for Barrett's oesophagus

The rationale for early detection and endoscopic intervention in patients with Barrett's oesophagus that are at risk of malignant degeneration is becoming increasingly self evident. The annual incidence of oesophageal carcinoma is rising at approximately 0.9% and is centred in the UK. Gastro-oesophageal reflux disease and Barrett's oesophagus are identifiable intermediaries. High grade dysplasia in Barrett's oesophagus is currently the best marker for malignant degeneration. Endoscopic and pathological certainty of dysplasia is difficult and challenging. Symptomatic oesophageal adenocarcinoma has a very poor prognosis. Current strategies of detection and intervention at cancer diagnosis have failed to significantly impact on the disease. A new paradigm of seeking out patients with premalignant phenotypes, followed by endoscopic ablation, is required. Endoscopic PDT has been shown in a randomised trial to significantly reduce the incidence of oesophageal carcinoma in patients with high grade dysplasia. Other endoscopic methods may also be effective, and endoscopic mucosal resection provides vital local staging and eradication of early disease. It is important to note that most patients with metaplastic Barrett's oesophagus will not die of oesophageal adenocarcinoma. Chemoprevention trials hold the promise of identifying societal and generalisable strategies for the management of those in the population with metaplastic Barrett's oesophagus.