Editing Barrett's oesophagus (section)

== Management and surveillance: ==

=== Flat or nodular lesion     present within Barrett's: ===

** Refer to centre with EMR/ESD      for resection

=== '''Barrett's     <1cm''' ===

** No increased risk of      malignancy
** No clear guidelines, but      probably don't need to do another scope

=== '''Non-dysplastic     BE''': manage as     for GORD ===

** Symptom relief
** Continue PPI indefinitely
** Don't recommend anti-reflux      surgery just because of theoretical risk of progression - incidence of      cancer appears to be low
** If can't control symptoms      with lifestyle and medication, then they need anti-reflux surgery      (exactly same as uncomplicated GORD)
** Radiofrequency ablation is      unproven in this population
** '''Surveillance:'''
*** Non-dysplastic BE - 3-5       yearly - but could do much more frequently to limit progression to that       which can be treated endoscopically - some UGI surgeons do yearly scopes
**** If short segment        (<3cm), thoroughly biopsied, and no dysplasia, surveillance every        five years (10% risk of dysplasia)
**** Long segment every three        years (31% risk of dysplasia)
*** Consider stopping       surveillance in elderly or unfit patients, similar to NBCSP

=== '''Indefinite     for dysplasia''' ===

** BD PPI
** Re-scope Seattle protocol      3-6/12
** If still indefinite, review      with experienced pathologist and either surveillance every 12 months or      referral to Barrett's centre
** Most will regress to      non-dysplastic

=== '''Low-grade     dysplasia''' ===

** Repeat endoscopy ASAP with      Seattle protocol if you didn't do it initially - need to exclude more      advanced disease
** Need to review slides with      experienced pathologist
** Either start on PPI or      increase existing dose
** American College of      Gastroenterology suggests either endoscopic eradication (then follow-up      endoscopy in 6 months) or surveillance every six months for one year and      then annually until reversion
*** Most sensible way is       probably to check persistence, and refer for ablation if persistent
** Can be offered anti-reflux      surgery - given that most patients with LGD regress after surgery
** If persistent, may need      mucosal ablation

=== '''High-grade     dysplasia''' ===

** Review slides with      experienced pathologist
** '''Indication      for intervention'''      - ideally RFA
** Most get endoscopic therapy,      followed by surveillance gastroscopy three months later
** Careful repeat biopsy - look      out for focus of invasive carcinoma - use every imaging modality      available - white light, NBI, acetic acid
** Small lesions - endoscopic      resection - ideally take full thickness of mucosa and submucosa
** Can evaluate lesions larger      than 1-2cm for invasion using EUS - key point would be whether it is T1a      or T1b
** '''If HGD or      T1a (without LVI), options are oesophageal preservation therapy vs      oesophagectomy'''
*** Oncologically equivalent,       but long-term surveillance and multiple initial scopes required, and       recurrence is a risk
*** Oesophagectomy historically       gets good results in this group, with mortality under 1%
*** However, endoscopic       treatment and surveillance is much better now