Optimal Prevention of Dysplasia Requires Complete Ablation of All Intestinal Metaplasia


This meta-analysis demonstrated that the rate of recurrent dysplasia was doubled when residual Barrett epithelium remained after endoscopic ablation.

Current guidelines suggest that endoscopic ablation be offered to patients with confirmed dysplasia in a segment of Barrett esophagus (BE). The authors of this meta-analysis examined long-term outcomes (almost 13,000 patient follow-up years) after ablation of dysplastic BE, comparing the 86% of patients who had complete remission of intestinal metaplasia with the 14% of patients who had eradication of dysplasia but with persistent metaplasia.

Dysplasia recurred in 5% of those with complete ablation of all metaplasia versus 12% of those who had ablation of dysplasia with persistent metaplasia. The development of high-grade dysplasia or cancer was also twice as likely when metaplasia persisted (3% vs.6%)

Comment

This important insight into the management of BE patients after ablation makes it clear that the goal should be complete eradication of all Barrett metaplasia, which decreases the risk for recurrent dysplasia and, more importantly, for developing high-grade dysplasia or cancer. Careful follow-up and retreatment of any persistent metaplasia is part of the eradication process. BE can also recur after ablation, which likewise increases the risk for an adverse outcome. Thus, regular surveillance is mandatory. Finally, earlier study findings suggest that high-dose proton-pump inhibitor therapy is another important component in preventing BE recurrence. This detailed process must be followed if optimal outcomes are to be achieved.

Source:NEJM

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