OPENING ARGUMENT

Stark strategies face patient and clinician in the presence of a degenerating dysplastic Barrett’s mucosa. Surgical removal offers an overaggressive flawed approach reminiscent of the politics of “Total War” (Karl Von Clausewitz 1780–1831: “Vom Kriege”). Decisive action assures eradication but without definitive knowledge of the threat and incurring extensive collateral damage. Surveillance waits for the cancer to develop; then offers a belated radical solution. Selective mucosal ablation is an active directed therapy offering a targeted pre-emptive preventative strike.

I propose that mucosal ablation is currently the procedure of choice to prevent Barrett’s cancer.

THE CONTEXT

Cancer in the columnar lined oesophagus develops through a multistep process initiated by chronic gastro-oesophageal reflux progressing through metaplasia, low grade dysplasia to high grade dysplasia which currently remains the best marker of cancer risk.¹ As many as 40% (range 0–73%) of patients with high grade dysplasia may already have a coexistent cancer,^1,2 and between 5% and 60% of patients will develop cancer during surveillance over 1–7 years.^3–5 The problems are that dysplasia and early cancer are …