Endoscopic Therapies for Barrett's-Associated Dysplasia
Endoscopic Therapies for Barrett's-Associated Dysplasia
Complications of endoscopic therapy should be divided into immediate and delayed outcomes. Immediate complications include bleeding and perforation. Current data have shown the overall major complication rate from endoscopic therapy is low, but this is higher than the risk of standard endoscopy, and varies between types of therapy. Photosensitivity reactions are common after PDT at a rate of 69%. Delayed complications from ablative therapy include stricture formation and buried metaplasia. As discussed above, the stricture rates for PDT and SRER are at least 30%. Despite the fact the most strictures from all types of endoscopic therapy are effectively treated with esophageal dilation, the associated cost and patient morbidity are not acceptable. Stricture rates associated with RFA and cryotherapy are in the range of 1–6%, which is much more acceptable. More recent data suggest the major complication rates of MPEC and APC are extremely low and similar to that of RFA.
Buried metaplasia defined as intestinal metaplasia was seen below the neosquamous epithelium. There have been reports of adenocarcinoma arising in subsquamous Barrett's with PDT and APC. The limited data available for cryotherapy suggest a 3% rate of buried glandular disease. Currently, only a single case of buried metaplasia has been published with RFA. That being said, our current understanding of the impact of buried intestinal metaplasia is limited. It is likely that increased utilization of a combined approach of EMR and ablation will further limit this possibility, regardless of its true impact.
Complications of Endoscopic Therapy
Complications of endoscopic therapy should be divided into immediate and delayed outcomes. Immediate complications include bleeding and perforation. Current data have shown the overall major complication rate from endoscopic therapy is low, but this is higher than the risk of standard endoscopy, and varies between types of therapy. Photosensitivity reactions are common after PDT at a rate of 69%. Delayed complications from ablative therapy include stricture formation and buried metaplasia. As discussed above, the stricture rates for PDT and SRER are at least 30%. Despite the fact the most strictures from all types of endoscopic therapy are effectively treated with esophageal dilation, the associated cost and patient morbidity are not acceptable. Stricture rates associated with RFA and cryotherapy are in the range of 1–6%, which is much more acceptable. More recent data suggest the major complication rates of MPEC and APC are extremely low and similar to that of RFA.
Buried metaplasia defined as intestinal metaplasia was seen below the neosquamous epithelium. There have been reports of adenocarcinoma arising in subsquamous Barrett's with PDT and APC. The limited data available for cryotherapy suggest a 3% rate of buried glandular disease. Currently, only a single case of buried metaplasia has been published with RFA. That being said, our current understanding of the impact of buried intestinal metaplasia is limited. It is likely that increased utilization of a combined approach of EMR and ablation will further limit this possibility, regardless of its true impact.
