Goals of endoscopic eradication therapy in Barrett’s esophagus: a narrative review

Abstract

Barrett’s esophagus is a premalignant condition, and endoscopic eradication therapy is indicated upon development of early neoplasia. Therapy consists of endoscopic resection for visible lesions, if present, followed by endoscopic ablation for remaining flat Barrett’s epithelium. Since Barrett’s esophagus with early neoplasia in itself is asymptomatic disease, the ultimate goal of endoscopic eradication therapy is to prevent progression to advanced cancer: a disease stage with limited treatment options and a poor prognosis. The preventive nature of endoscopic treatment may give rise to debate about the preferred endpoint to pursue. Establishment of a careful balance between the benefits of endoscopic eradication therapy against its risks, such as complications and other adverse events, may help to define the optimum endpoint for each individual patient. To date, various endpoints have been used in regular practice and different endpoints are used in clinical studies. The most important differences between these endpoints are whether all visible Barrett’s epithelium is eradicated or all dysplasia and cancer; and whether the endpoint is assessed on endoscopic examination only or with histologic confirmation. In this narrative review, we aim to evaluate these different endpoints of endoscopic eradication therapy with potential advantages and limitations, and present three clinical vignettes each with a different suggestion for an appropriate treatment endpoint.