Review
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Oncol. Mar 15, 2022; 14(3): 568-586
Published online Mar 15, 2022. doi: 10.4251/wjgo.v14.i3.568
Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies
Kevin Kyung Ho Choi, Santosh Sanagapalli
Kevin Kyung Ho Choi, AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
Santosh Sanagapalli, Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
Author contributions: Choi KKH collected and analyzed the data and wrote the manuscript; Sanagapalli S conceived the review and critically revised the manuscript.
Conflict-of-interest statement: There were no conflicts-of-interest in the writing of the article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Santosh Sanagapalli, FRACP, MBBS, Doctor, Department of Gastroenterology, St Vincent’s Hospital, Hospital Road, Darlinghurst 2010, NSW, Australia. santosh.sanagapalli@svha.org.au
Received: May 22, 2021
Peer-review started: May 22, 2021
First decision: October 3, 2021
Revised: November 12, 2021
Accepted: February 15, 2022
Article in press: February 15, 2022
Published online: March 15, 2022
Processing time: 292 Days and 2.7 Hours
Abstract

Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.

Keywords: Barrett’s esophagus; Endoscopic eradication therapy; Dysplasia; Adenocarcinoma; Natural history; Radiofrequency ablation

Core Tip: Barrett’s esophagus (BE) is an important premalignant condition. The last two decades have seen treatment paradigms increasingly shift towards endoscopic eradication therapy for dysplastic and early neoplastic cases, where it appears safe and effective. We herein provide a comprehensive review of the literature relating to Barrett’s natural history and comparative efficacy of surveillance, endoscopic and surgical therapies for BE by histological stage.