Treatment of Barrett's Esophagus with Confirmed Low-Grade Dysplasia
Clinical Scenario
This protocol addresses patients with Barrett's esophagus (BE) in whom low-grade dysplasia (LGD) has been pathologically confirmed. Confirmed LGD represents a clinically distinct situation that warrants an active management decision to reduce the risk of further progression.
Patient Population
Patients with Barrett's esophagus with confirmed esophageal low-grade dysplasia. Endoscopic therapy is recommended to reduce the risk of progression to high-grade dysplasia or esophageal adenocarcinoma (EAC); endoscopic surveillance remains an acceptable alternative.
Treatment Approach — partial overview
Management is built around endoscopic eradication therapy (EET), an approach that combines an initial endoscopic resection step with subsequent ablative therapy of the Barrett's segment. The full protocol specifies the preferred ablative technique, the sequencing of interventions, and the context in which acid suppression is initiated.
Complete technique selection, sequencing, and acid-suppression details are available in the full protocol below.
Clinical Goals
The primary targets are complete eradication of dysplasia (CED) and complete eradication of intestinal metaplasia (CEIM) of the esophagus, with both goals to be achieved by 18 months.
References
DOI: 10.14309/ajg.0000000000001680
- We suggest endoscopic therapy in patients with BE with confirmed LGD to reduce the risk of progression to HGD/EAC, with endoscopic surveillance of confirmed LGD as an acceptable alternative (strength of recommendation: conditional; quality of evidence: moderate).
- We suggest initial ER of any visible lesions before the application of ablative therapy in patients with BE undergoing EET (strength of recommendation: conditional; quality of evidence: very low).
- Contemporary practice includes endoscopic resection (ER) of any visible lesion within the BE segment, followed by ablative techniques such as RFA and cryotherapy to achieve complete eradication of dysplasia (CED) and IM (CEIM).
- Among patients undergoing EET, RFA is the preferred ablative technique.
- Priority quality indicators established include monitoring (i) the rate at which CEIM is achieved by 18 months in patients with BE-related dysplasia and IMC referred for EET (outcome measure, threshold 70%), (ii) the rate at which CED is achieved by 18 months in patients with BE-related dysplasia and IMC referred for EET (outcome measure, threshold 80%), and (iii) the rate at which adverse events are being tracked and documented in individuals after EET.
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