ASGE Annual Postgraduate Course: Clinical Challenges and Real-Time Decision Making in GI Endoscopy (On-demand) | May 2023-Draganov

Draganov_Barretts Cut vs Ablate Debate

Pdf Summary

Barrett's Esophagus is a condition in which the lining of the esophagus changes, increasing the risk of developing esophageal cancer. The current algorithm for therapy of dysplastic/neoplastic Barrett's esophagus involves the removal of all visible irregularities of the tissue through endoscopic resection, commonly done with endoscopic mucosal resection (EMR). After this, the remaining flat Barrett's epithelium is ablated, usually using radiofrequency ablation (RFA). However, there are downsides to ablation, including the burden on the patient due to multiple sessions and potential discomfort. Complications are relatively uncommon but can occur. The quality of RFA is still an issue, with expert centers having better outcomes. Additionally, ablation has a high recurrence rate.<br /><br />One downside of ablation is the imperfect pre-procedure staging, with various imaging techniques and biopsies used for evaluation. Another challenge is the lack of a final definitive pathology, meaning that it is uncertain what disease state was present before ablation and what the exact outcome of the procedure is. EMR, which provides post-procedure tissue diagnosis and staging, is considered acceptable but still leaves some uncertainty.<br /><br />Endoscopic submucosal dissection (ESD) is an alternative to EMR with advantages such as en-bloc resection, lower recurrence, and the ability to treat lesions that are not suitable for EMR. ESD is also useful for cases of suspected submucosal invasion or lesions that arise after ablation. However, ESD is technically complex.<br /><br />The current algorithm for therapy of dysplastic/neoplastic Barrett's esophagus involves the removal of all visible irregularities with endoscopic resection, expanding the role of ESD alongside EMR. Ablation of the remaining flat Barrett's epithelium can be done using various methods, including RFA, cryoablation, and hybrid argon plasma coagulation. Overall, the goal is to remove or destroy the abnormal tissue to reduce the risk of esophageal cancer.

Keywords

Barrett's Esophagus

esophageal cancer

endoscopic resection

endoscopic mucosal resection

radiofrequency ablation

complications

pre-procedure staging

final definitive pathology

endoscopic submucosal dissection

en-bloc resection