The Role of Photodynamic Therapy and Cryotherapy for the Management of Barrett’s Esophagus

Gastroesophageal reflux can cause injury to the normal stratified squamous epithelium of the esophagus. This injury may lead to replacement of the normal esophageal lining by a metaplastic columnar intestinal-like epithelium known as Barrett’s esophagus (BE). The clinical relevance of BE lies in its sequential progression from intestinal metaplasia (IM) to low-grade dysplasia (LGD), high-grade dysplasia (HGD), and, finally, invasive adenocarcinoma. In the absence of dysplasia, BE is associated with a low annual incidence of progression to adenocarcinoma (less than 0.5), but the incidence of progression to adenocarcinoma is up to five times as high when dysplasia is present. The management of BE with dysplasia and early cancer has shifted over the years, moving away from surgical resection (esophagectomy) to diagnostic and therapeutic endoscopy. Endoscopic therapy aims to remove the metaplastic or dysplastic tissue to a depth that destroys all the BE but minimizes damage to the submucosal layer of the esophagus to avoid stricture formation and transmural injury. Several treatment options—endoscopic mucosal resection (EMR) and tissue ablative therapies such as radiofrequency ablation (RFA), photodynamic therapy (PDT), and cryotherapy (CT)—have been recognized as safe and effective therapies to accomplish this and are now the standard of care in many expert centers. This chapter will focus on the role of photodynamic therapy and cryotherapy in the management of BE.