ASGE-JGES Endoscopic Submucosal Dissection ESD (On-demand)

Yamamoto _Barrett

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This document reviews the diagnosis and endoscopic management of Barrett’s Esophagus (BE) related dysplasia and adenocarcinoma, highlighting the lack of international consensus in terminology, diagnostic criteria, and treatment strategies. BE-related neoplasia is increasingly significant, particularly with esophageal adenocarcinoma (EAC) becoming the predominant esophageal cancer subtype in the U.S., and its incidence rising in Japan.<br /><br />Multiple professional societies, including the Japan Esophageal Society (JES), American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and Japan Gastroenterological Endoscopy Society (JGES), have published guidelines providing definitions, diagnostic approaches, and management recommendations.<br /><br />Endoscopically, the Seattle protocol with random biopsies combined with targeted biopsies using white light imaging (WLI) and image-enhanced endoscopy (IEE) such as narrow-band imaging (NBI) and magnifying endoscopy plays a critical role in detecting and delineating tumor extent. Endoscopic eradication therapy (EET) is indicated mainly for high-grade dysplasia (HGD) or early-stage EAC (cT1a, well- or moderately differentiated), aiming for complete eradication of neoplasia and intestinal metaplasia (CEN and CEIM).<br /><br />Endoscopic submucosal dissection (ESD) is preferred over endoscopic mucosal resection (EMR) for larger (>20 mm), bulky, or scarred lesions due to better en bloc and R0 resection rates, improved pathological assessment, and lower local recurrence. Japanese practice emphasizes ESD exclusively, striving for curative (R0) resection without ablation.<br /><br />Magnifying NBI and acetic acid chromoendoscopy improve tumor margin assessment, including detecting subepithelial tumor spread, which may be concealed by squamous epithelium. While ESD shows superior long-term outcomes with low recurrence rates, challenges remain in managing long-segment BE (LSBE) neoplasia due to diffuse and irregular lesions, lack of consensus on ablation, and risk of post-ESD strictures.<br /><br />In conclusion, magnifying image-enhanced endoscopy enhances diagnostic accuracy and facilitates curative resection. However, BE management strategies vary globally, influenced by local expertise and healthcare frameworks.

Keywords

Barrett's Esophagus

Esophageal Adenocarcinoma

Endoscopic Submucosal Dissection

Endoscopic Mucosal Resection

Image-Enhanced Endoscopy

Narrow-Band Imaging

Seattle Protocol

Endoscopic Eradication Therapy

High-Grade Dysplasia

Japanese Gastroenterological Guidelines