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Testing of endoscopic ablation techniques for Barrett’s oesophagus should follow a “top down approach”
Barrett’s oesophagus (BO) is a condition that causes many controversies. Identification and treatment of Barrett’s patients gives rise to many questions such as: how great is the risk of malignant degeneration for the entire group of Barrett’s patients and for individual patients? Does this risk justify the efforts, costs, and risk of endoscopic surveillance? Are we doing more harm than good in subjecting patients with non-dysplastic BO to endoscopic surveillance? Are we reducing patients’ quality of life by making them (and their insurance companies) unduly worry about their condition?1,2 The ultimate solution to these problems would be a cure for the condition, either by reverting Barrett’s mucosa to normal squamous mucosa or by preventing its malignant degeneration once it has developed.
Protagonists of surgical antireflux procedures have claimed that elimination of reflux of gastric and duodenal contents into the oesophagus will prevent malignant transformation in BO but such a protective effect is not generally accepted.3,4 Acid suppressant therapy by proton pump inhibitors (PPIs) cannot reverse Barrett’s mucosa but may reduce the risk of developing dysplasia and cancer in BO, as based on ex vivo studies and two recent retrospective analyses of BO cohorts.5–7 Data however are conflicting, and at best circumstantial evidence for a protective effect of PPIs has been provided. Several other chemoprevention agents (for example, aspirin or non-steroid anti-inflammatory drugs) are currently under investigation, but none has yet emerged as clinically relevant.
A variety of endoscopic techniques have been used to convert non-dysplastic Barrett’s mucosa into normal squamous mucosa. Examples of these techniques are laser photocoagulation, multipolar electrocoagulation, argon plasma coagulation, radiofrequency ablation, cryoablation, and photodynamic therapy.8,9, …
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