Barrett's oesophagus is a sequel of gastro‐oesophageal reflux disease (GORD) and may be present in 5–15% of GORD patients in the western population.1,2,3
Barrett's oesophagus is premalignant, with oesophageal adenocarcinoma occurring at an overall incidence rate of 0.4–0.5% per year.4
It progresses through stages of dysplasia to cancer. Patients without dysplasia and those with low grade intraepithelial neoplasia (LGIN) have low rates of disease progression. In the presence of high grade intraepithelial neoplasia (HGIN), disease may progress at rates >10% per year.5,6
Surveillance endoscopy for Barrett's oesophagus—with the aim of detecting HGIN or early cancer in order to facilitate earlier therapeutic interventions—has been advocated by the American College of Gastroenterology, with the time interval of endoscopy being dependent on the presence and severity of dysplasia. In the absence of dysplasia, follow up endoscopy is performed at 3 years. When there is LGIN, endoscopy is performed yearly. If focal HGIN is present, endoscopy is repeated at 3‐monthly intervals, but in the presence of multifocal HGIN or intramucosal cancer (IMC), intervention is required.7
Oesophagectomy is traditionally regarded as the standard treatment option in the presence of HGIN or cancer. It is a definitive treatment which removes all neoplastic epithelia. This is important because of the limitation of endoscopic biopsy, which may not detect other foci of HGIN or IMC. In a series of patients who underwent oesophagectomy for HGIN detected by endoscopy, surgery revealed invasive cancer in 30–40% of cases which was missed preoperatively.8
However, oesophagectomy is also associated with the highest rates of procedure related mortality and long term morbidity. Mortality rates ranging from 2.5–20.3% have been reported, and 30–50% of patients may develop serious postoperative complications such as pneumonia, anastomotic leaks and myocardial infarction.9
In addition, there have been reports of patients whose preoperative biopsy specimens showed IMC that was not seen in the surgical specimens.10
There is thus a need for a less invasive alternative treatment strategy.
Endoscopic ablative therapies such as argon plasma coagulation (APC) and photodynamic therapy (PDT) have been proposed as less invasive alternatives to oesophagectomy, but are clearly not optimal. These therapies are limited by the lack of tissue for histological assessment, which is crucial for determining treatment adequacy, and the possibility that the ablation may be incomplete, with remnant Barrett's mucosa post treatment; this persistent Barrett's oesophagus will remain at risk for progression to adenocarcinoma.9
In a multicentre randomised study which compared PDT using porfimer sodium, combined with omeprazole, versus omeprazole alone, it was shown that although PDT was superior to omeprazole alone, complete ablation of HGIN was achieved in only 77% of cases, while complete ablation of Barrett's oesophagus was achieved in only 52%. In addition, oesophageal adenocarcinoma still occurred in 13% of cases in the treated group; strictures also occurred in 36% of cases.11
Poor results were also obtained when 5‐aminolevulinic acid‐PDT was used to treat patients with residual HGIN and IMC after endoscopic mucosal resection, with failure of PDT in 25% of cases, and recurrence of HGIN in 27% of successfully treated cases on follow up.12
APC has been used to ablate Barrett's oesophagus with HGIN and IMC as well, but the failure rate was 20%.13
In a study of patients with Barrett's oesophagus (both without dysplasia as well as with LGIN) treated with APC and acid suppression, a relapse rate of 62% over a median period of 36 months was reported. In addition, 5% of patients progressed to adenocarcinoma during this period.14
Endoscopic mucosal resection (EMR) is increasingly being utilised as an alternative to surgery in the management of HGIN and IMC of the gastrointestinal tract. Performing EMR is similar to resecting the diseased mucosa surgically. It is less invasive than surgery and, unlike ablative therapies, it provides tissue for histological assessment. The role of EMR in the treatment of early oesophageal squamous cell carcinoma, early gastric cancer and early colonic cancer is established and had been previously reviewed.15
More data on the role of EMR in the context of Barrett's oesophagus with HGIN and IMC are now available. This review will cover the rationale and indication for EMR in the context of Barrett's oesophagus, the techniques of EMR, the limitations of EMR for Barrett's oesophagus, and results of key published data.