Which type of treatment—pharmacologic, surgical, or endoscopic—is most effective in inducing reversal of Barrett's esophagus or dysplasia or in halting their progression to cancer?
TYPE OF REVIEW
This is a Cochrane review containing a meta-analysis of 16 randomized controlled trials.
RELEVANCE FOR NURSING
Barrett's esophagus is the premalignant stage of esophageal adenocarcinoma, a cancer with a rapidly increasing incidence in the Western world. It appears to be a complication of chronic gastroesophageal reflux disease, although asymptomatic individuals may also be affected. Because treatment outcomes for esophageal adenocarcinoma are poor, there is increasing interest in treating Barrett's esophagus.
CHARACTERISTICS OF THE EVIDENCE
A total of 1,074 adults (18 years of age and older) with a diagnosis of Barrett's esophagus were included in the meta-analysis. The interventions of interest were pharmacologic therapy, antireflux procedures, and endoscopic ablation, either as monotherapy or combination therapy. Primary outcomes were complete eradication of Barrett's esophagus or dysplasia or both at 12 months and reduction in the number of patients progressing to cancer at five years or the latest time point. Most studies didn't report on the primary outcomes.
A meta-analysis of three studies showed that, compared with H2-receptor antagonists (H2RA), antisecretory proton pump inhibitors (PPIs) significantly reduced the overall area of Barrett's esophagus at 12 months. A trial comparing antireflux surgery with H2RA (which was converted to PPI) found no difference in regression of Barrett's esophagus. It was noted that those who had successful surgery were significantly less likely to develop de novo dysplasia (3/58 versus 8/43).
A study comparing argon plasma coagulation (APC) with surveillance showed that APC induced eradication of Barrett's esophagus. Three trials comparing APC plus PPI with photodynamic therapy (PDT) demonstrated no statistical differences between groups in the eradication of Barrett's esophagus and dysplasia, but PDT caused significantly more drug reactions and complications.
Two studies comparing PDT using 5-amunolevulinic acid (5-ALA) or porfimer sodium plus PPI with PPI alone showed that PDT induced significantly more eradication of Barrett's esophagus at two years as well as a reduction in progression to cancer at five years or the latest time point. There was also a significant reduction in the length, area, and progression to dysplasia in the PDT group in one of the studies, but also more complications. In another study radiofrequency ablation (RFA) resulted in eradication rates of 77% and 86% for Barrett's esophagus and dysplasia, respectively, compared with a sham treatment.
BEST PRACTICE RECOMMENDATIONS
Surgical and pharmacologic antireflux therapies have little or no significant effect on eradication of Barrett's esophagus and existing dysplasia, but antireflux surgery appears to provide symptomatic control, reduce dysplasia, and protect against the development of dysplasia compared with PPI and H2RA.
Endoscopic therapies such as APC and PDT have similar success rates in the eradication of Barrett's esophagus. RFA appears successful at eradicating Barrett's esophagus and dysplasia with fewer complications than PDT and would be the treatment of choice; however, long-term follow-up is needed before RFA can be used in routine clinical practice.
Comparing laparoscopic surgery with PPI alone for the regression of Barrett's esophagus and prevention of adenocarcinoma requires further research. Future studies should focus on assessing the safety and efficacy of PDT using 5-ALA versus porfimer sodium with particular interest in stricture risk and photosensitivity complications. Long-term randomized controlled trials on the efficacy of RFA to eradicate Barrett's esophagus and dysplasia are needed.
Rees JRE, et al. Treatment for Barrett's oesophagus. Cochrane Database Syst Rev 2010(1):CD004060.