Endoscopic Eradication Therapy of Barrett’s Esophagus and Related Neoplasia
Summary of Recommendations
General Implementation Considerations
- In patients with BE, counsel tobacco cessation and weight loss if overweight.
- Refer patients with dysplastic BE to high-volume endoscopists with expertise in EET, pathologists with expertise in BE neoplasia, with access to multidisciplinary care.
- Histologic diagnosis of BE dysplasia or early cancer should be confirmed by an expert pathologist.
- In patients undergoing management of dysplastic BE, optimize reflux control with medication, lifestyle modifications, and assessing adherence.
- Before embarking on EET, discuss risks and benefits of EET, need for adherence with reflux management, expected outcomes, need for continued surveillance after completion of EET, with adequate time to assess patient values and preferences.
- The goal of EET should be complete eradication of intestinal metaplasia and neoplasia.
- Failure to achieve complete eradication of intestinal metaplasia should prompt reassessment and optimization of reflux control.
- Endoscopists and practices performing EET are encouraged to monitor key outcomes and quality metrics, including complete eradication of intestinal metaplasia and neoplasia and adverse events.
In individuals with BE with HGD, the AGA recommends EET over surveillance.
( Moderate , Strong )Implementation Considerations:
- Following completion of EET, surveillance should be performed at 3, 6, and 12 months, then annually.
- Surveillance endoscopies after EET should obtain targeted tissue sampling of visible lesions and random biopsies of the cardia and distal 2 cm of the tubular esophagus.
In individuals with BE with LGD, the AGA suggests EET over surveillance.
( Low , Conditional (weak) )Comment: Patients who place a higher value on the well-defined harms, and lower value on the uncertain benefits regarding reduction of esophageal cancer mortality would reasonably select surveillance.
Implementation Considerations:
- Following completion of EET, surveillance should be performed at years 1 and 3 after CEIM, then revert to surveillance intervals used in nondysplastic BE.
- The tissue sampling protocol during surveillance should be performed the same as in surveillance after EET for HGD.
In patients undergoing EET, the AGA suggests resection of visible lesions followed by ablation of the remaining BE segment over resection of the entire BE segment.
( Very Low , Conditional (weak) )Implementation Considerations:
- In patients with only a small area of BE beyond the visible lesion, completion endoscopic resection in the same setting is acceptable and may be preferred over repeated procedure to perform ablation.
- RFA is the preferred ablative modality.
- Patients suspected of having T1 EAC should be referred for consideration of EET.
- Endoscopic resection is the test of choice over endoscopic ultrasound for distinguishing EAC from HGD and for staging depth of invasion in early cancer.
- The vast majority of neoplastic lesions may be managed with EMR rather than ESD.
- Patients with large bulky neoplastic lesions or lesions highly suspicious of at least T1b invasion (for instance, those with depressed, Paris IIc or IIa + c lesions) and deemed candidates for endoscopic resection might benefit from ESD over EMR.
- Patients with previously failed EMR might benefit from ESD.
Recommendation Grading
Abbreviations
- AGA: American Gastroenterological Association
- BE: Barrett’s Esophagus
- CEIM: Complete Eradication Of Intestinal Metaplasia
- EAC: Esophageal Adenocarcinoma
- EET: Endoscopic Eradication Therapy
- EMR: Endoscopic Mucosal Resection
- ESD: Endoscopic Submucosal Dissection
- HGD: High-grade Dysplasia
- LGD: Low-grade Dysplasia
- NDBE: Nondysplastic Barrett’s Esophagus
- RFA: Radiofrequency Ablation
- sEMR: Stepwise Endoscopic Mucosal Resection
Disclaimer
Overview
Title
Endoscopic Eradication Therapy of Barrett’s Esophagus and Related Neoplasia
Authoring Organization
American Gastroenterological Association
Publication Month/Year
May 17, 2024
Last Updated Month/Year
July 10, 2024
Supplemental Implementation Tools
Document Type
Guideline
Country of Publication
US
Document Objectives
Barrett’s esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia.
PICO Questions
Should patients with BE with HGD undergo EET?
Should patients with BE with LGD undergo EET?
Should patients with BE without dysplasia undergo EET?
In patients undergoing EET, should patients undergo resection of the entire BE segment vs resection of visible lesions followed by ablation of the remaining BE segment?
In patients undergoing endoscopic resection of a visible lesion, should patients undergo primary ESD vs EMR?
Inclusion Criteria
Male, Female, Adult, Older adult
Health Care Settings
Ambulatory, Outpatient, Operating and recovery room
Intended Users
Nurse, nurse practitioner, physician, physician assistant
Scope
Management
Diseases/Conditions (MeSH)
D001471 - Barrett Esophagus, D004938 - Esophageal Neoplasms, D005770 - Gastrointestinal Neoplasms
Keywords
esophageal adenocarcinoma, Barrett’s esophagus, Endoscopic Eradication Therapy, neoplasia, Barrett esophagus
Source Citation
Rubenstein JH, Sawas T, Wani S, Eluri S, Singh S, Chandar AK, Perumpail RB, Inadomi JM, Thrift AP, Piscoya A, Sultan S, Singh S, Katzka D, Davitkov P. AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia. Gastroenterology. 2024 Jun;166(6):1020-1055. doi: 10.1053/j.gastro.2024.03.019. PMID: 38763697.