Endoscopic Resection and Ablation in Barrett’s Oesophagus


diameter, but this fascinating new method is associated with several problems and disadvantages. There is a substantial complication rate, including bleedings (up to more than 8%) and perforations (at least 4% in non-ulcerated cancers).8


Nevertheless, as in all endoscopic


procedures, the complication rate decreases with increasing experience of the endoscopist. Moreover, ESD requires long procedure times of up to several hours and has a slow learning curve and a high degree of operator dependency.


Endoscopic Ablation Techniques


Argon plasma coagulation (APC) and radiofrequency ablation (RFA) are the most commonly used ablation techniques today. These methods should not be chosen as a primary treatment approach for early Barrett’s neoplasia. None of the ablative treatment methods is able to provide a specimen of a neoplastic lesion in Barrett’s oesophagus. Therefore, when treating a neoplasia with one of the available ablative treatment modalities, a possible problem will be the underestimation of a neoplastic lesion and the endoscopist might end up treating a submucosal carcinoma or cancer infiltrating lymph vessels harbouring lymphatic spread. Nevertheless, ablative methods are used as an additional tool in Barrett’s neoplasia, e.g. for the ablation of the residual Barrett’s segment after ER of the neoplasia, or for the ablation for small remnants of a neoplasia.


Indications for Endoscopic Resection and/or Ablation in Barrett’s Oesophagus Barrett’s Oesophagus without Neoplastic Changes Barrett’s epithelium without dysplasia should not be ablated for several reasons. The risk associated with any ablative technique does not justify their use facing an overall cancer risk in patients with Barrett’s oesophagus of approximately 0.5–0.6% per year.9,10


In


addition, complete ablation of Barrett’s epithelium cannot be guaranteed. Recurrence of Barrett’s epithelium can occur even after complete eradication. Therefore, there would be still a need for follow- up endoscopies. Ablation of non-dysplastic Barrett’s oesophagus should therefore only be performed within prospective clinical trials at the present time.


Barrett’s Oesophagus with Low-grade Intra-epithelial Neoplasia


Once an early neoplastic lesion is found in Barrett’s oesophagus, endoscopic eradication may be indicated. A major problem of the diagnosis of LGIN is the fact that regenerative changes are frequently overdiagnosed as LGIN. Therefore, a second opinion by a gastrointestinal (GI) expert pathologist should always be sought.11,12


A


recent study from Amsterdam demonstrated that LGIN is often overdiagnosed by non-expert pathologists.11


In the case of confirmed


LGIN on biopsy (second pathologist), the presence of a visible abnormality should lead to ER since LGIN often goes along with lesions with higher grades of dysplasia. However, in many cases LGIN cannot be re-localised. In such a situation, follow-up endoscopy including high-resolution endoscopy and chromoendoscopy is the diagnostic method of choice.


Barrett’s Oesophagus with High-grade Intra-epithelial Neoplasia


There is wide agreement that the finding of HGIN is an indication for endoscopic treatment. HGIN is very often located next to cancer lesions, and adenocarcinoma is diagnosed in the resected specimen after ER or surgery in up to 40% of cases. Only by ER can a true


EUROPEAN GASTROENTEROLOGY & HEPATOLOGY REVIEW


tissue diagnosis be obtained. This treatment approach should therefore be chosen over any ablation modality.


Early Barrett’s Cancer


Mucosal Barrett’s cancer should also be treated endoscopically. It has been shown that there is almost no risk of lymph node metastasis in patients with adenocarcinoma limited to the mucosal layer (T1m1–4), and therefore endoscopic treatment can be considered to be curative in these lesions.13–15


However, in case of deep submucosal invasion or lymph (L1) or blood vessel infiltration (V1), oesophageal resection should be performed since there is an increased risk of lymph node metastasis in these cases.


one patient was referred to surgery and one patient died (not tumour related) before complete remission could be achieved. Eighteen out of the remaining 19 patients achieved complete remission after a mean of 2.9 ER and 5.3 months. The calculated five-year overall survival rate was 66%. No tumour-related death occurred. These promising results suggest that ER may have potential in low-risk submucosal Barrett’s cancer in a highly experienced centre. However, a recently published retrospective analysis of oesophagectomy samples from 80 patients with submucosal Barrett’s cancer showed that 12.9% of patients with Tsm1 Barrett’s cancer had malignant lymph nodes.17


Whether cancers limited to the upper submucosal layer (sm1) are eligible for ER in selected cases is not yet clear. Surgical series have been able to show that patients with sm1 Barrett’s cancer have a very low risk of metastatic lymph nodes, but larger series reporting on the endoscopic treatment of these patients are still lacking. A recently published series from Wiesbaden demonstrated that ER appeared to be safe in patients with low-risk submucosal cancer (T1sm1, G1–2, L0, V0, macroscopic type I or II a, b). Twenty-one patients were treated by ER;16


Final conclusions cannot be made on this


matter at the present time and further data are needed in order to give evidence-based recommendations.


Outcomes of Ablation and Resection Argon Plasma Coagulation and Multipolar Electrocoagulation


Argon plasma coagulation (APC) is a non-contact thermal technique using ionised argon gas to deliver a monopolar high-frequency current, in order to coagulate tissue. The ionised argon gas is delivered through a flexible teflon probe and applied dynamically. APC is considered a standard technique for ablation especially of short segments of Barrett’s oesophagus, e.g. after ER of Barrett’s neoplasia. Complications of APC are strictures, relatively rarely bleedings and very rarely perforations. Sub-squamous Barrett’s epithelium after APC ablation, so-called ‘buried glands’, is described in 5–25% of patients, which poses a disadvantage of this technique.


A prospective randomised trial by Sharma and co-workers compared APC and the technique of multipolar electrocoagulation (MPEC) for ablation of non-dysplastic Barrett’s oesophagus in 35 patients.18


The


complete remission rate of Barrett’s epithelium was similar in both groups (75 versus 63%; p=0.49).


Cryotherapy


Cryotherapy works by freezing the mucosa to induce cell death. There are two current techniques: carbon dioxide and liquid nitrogen. In contrast to RFA and APC, cryotherapy has not yet become a clinical standard in ablation of Barrett’s oesophagus.


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