This special issue of Endoscopy is dedicated to the subject of total Barrett eradication, that is the complete removal of Barrett esophagus and asso− ciated neoplasia by endoscopic resection and/or endoscopic ablation techniques. Many leading experts in the field have contributed to this im− portant issue. Drs. Shaheen and Spechler discuss the relevant methodological issues and pitfalls in studies of Barrett esophagus eradication [1], Drs. Curvers and Bansal offer recommendations for the endoscopic work−up of patients with Barrett esophagus−related neoplasia (BERN) [2], and Drs. Odze and Lauwers clearly describe how pre− and post−treatment histology should be evaluat− ed [3]. Subsequently, leaders in the field of thera− peutic endoscopy discuss the different available endoscopic treatment modalities for BERN: en− doscopic resection, argon plasma coagulation (APC), cryotherapy, photodynamic therapy (PDT), and radiofrequency ablation (RFA) [4 ± 7]. Finally, Drs. Peters [8] and Falk [9] look into the crystal ball to predict the future of endoscopic treatment of BERN from a surgeon’s and an en− doscopist’s viewpoint, respectively. Why has a special issue of Endoscopy been dedi− cated to this topic? The evidence is now accumu− lating that endoscopic treatment of BERN is safe and effective, suggesting that this approach should be preferred over esophagectomy in se− lected patients [10 ±12]. New endoscopic tools, most recently endoscopic resection and RFA, ap− pear to be effective not only in removing BERN but also in completely eradicating all associated Barrett mucosa in the majority of treated patients [13 ± 16]. As a result, many expert centers have adopted advanced imaging, endoscopic resec− tion, and ablation as their management strategy for BERN. In our opinion, the past five years have yielded a number of very promising advances for our field in the endoscopic diagnosis, staging, and man− agement of BERN. We have moved from an era of “survey most lesions and operate on those with high grade dysplasia and cancer,” to an era where we have the option to “survey all lesions, endoscopically treat selected lesions, and reserve surgery only for patients with invasive cancers involving the submucosa.” We are witnessing a significant paradigm shift ± one that is accompa− nied by new challenges that we must be prepared to address. These challenges include: maintain− ing technical excellence and safety with all pro− cedures, via robust training programs; ensuring that visible lesions are detected and properly staged prior to initiation of an endoscopic treat− ment regimen; preparing the patient for endo− scopic management; evaluating the evidence cri− tically to determine ideal patient selection crite− ria, and which disease states should be treated; and evaluating the financial realities of cost−ef− fectiveness and reimbursement. Regarding technical excellence, endoscopic re− section and ablative therapies for BERN generally encompass multiple endoscopic modalities for diagnosis, staging, and treatment. Done properly, we believe they are highly effective and quite safe for the patient. We need to develop training pro− grams for physicians and our advanced trainees so that currently reported efficacy and safety pro− files are maintained. Extracurricular training courses (see www.endosurgery.eu for examples) aimed at the entire spectrum of endoscopic man− agement are being developed to achieve these objectives. Endoscopic detection and proper staging of pa− tients with BERN prior to therapy, are essential. Most available studies come from expert centers with standardized endoscopic staging algo− rithms, high quality therapeutic interventions, rigorous endoscopic follow−up, and expert histo− pathological evaluation. Respectfully, a general endoscopist may not see as many cases of BERN as endoscopists in expert centers and therefore may not be as likely to recognize the subtle
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Apr 1, 2009
Avegail G Flores + 4
Open Access