Purpose of review: To evaluate timing and patient selection for endoscopic ablative therapy in Barrett's esophagus.
Recent findings: There has been an explosion in the literature describing ablative therapy in Barrett's esophagus. Most recent data describe radiofrequency ablation (RFA), but other data pertain to photodynamic therapy (PDT) and other modalities. Most studies are cohort or case series. Reversion to squamous epithelium is the most common primary outcome. Cancer incidence data are scarce. RFA appears well tolerated. The main side-effect is chest pain, which can be managed with oral analgesics. Stricture occurs in 0-8% and is amenable to endoscopic dilatation. Infrequent side-effects include bleeding and perforation. Complete reversion to squamous epithelium occurs in more than 90% of nondysplastic and low-grade dysplasia and more than 80% in high-grade dysplasia patients, and the treatment appears durable for at least 2-5 years of available follow-up. Treatment of low-grade or nondysplastic disease may be cost-effective. PDT data suggest that all-cause mortality is similar to surgery for dysplastic Barrett's esophagus. The stricture rate appears higher, and rates of complete reversion to neosquamous epithelium are lower than that of RFA, although definitive comparisons are lacking.
Summary: The excellent efficacy, side-effect profile, and cost-effectiveness appear to make RFA the intervention of choice in cases of high-grade dysplasia. RFA for low-grade dysplasia may be of value in young patients and/or those with long segment or multifocal disease. Treatment of nondysplastic Barrett's esophagus is of uncertain value. PDT appears to have a higher stricture rate and to be more expensive than RFA.