ENDOSCOPIC THERAPY FOR BARRETT'S OESOPHAGUS

Barrett’s oesophagus or columnar lined oesophagus is among the most intriguing of gastroenterological conditions. This is because of its pathogenesis, prevalence, association with reflux disease, male sex and, in particular, the potential for neoplastic degeneration to adenocarcinoma. The current and dramatic rise in the incidence of oesophageal adenocarcinoma is centred on the UK (5–8.7/100 000), over double that of the USA (3.7/100 0000). This epidemic is fairly localised and is not evident in Asia, where squamous cell cancer remains the predominant oesophageal malignancy. Large rises in incidence, up to 30% per year, have been seen in West European White men, a rise not mirrored in Eastern Europe.1,2 At present the incidence remains paralleled by mortality. The prognosis of oesophageal cancer remains universally poor; median survival has hardly changed from 0.75 years between 1973 and 1977 to 0.9 years between 1993 and 1999. This almost trivial change has led some to suggest that the change could be accounted for by improved reporting and detection bias rather than any important therapeutic advance.3 Gradual malignant degeneration within a segment of Barrett’s oesophagus occurs in a probabilistic rather than in a deterministic manner. Barrett’s appears to be a necessary intermediary step. The relatively long time sequence to cancer may allow early intervention with endoscopic ablation, thus offering the possibility of preventing the lethal development of symptomatic oesophageal adenocarcinoma. Stark choices face patient and clinician in the presence of a degenerating “possibly” premalignant Barrett’s mucosa. Radical therapy offers an overaggressive, “possibly” flawed approach if the diagnosis and prognosis remain uncertain. It cannot be considered a triumph to have a millimetre of worrying but superficial disease and remove a whole oesophagus. The alternative of surveillance presents other concerns. It offers intermittent endoscopic inspection at proscribed, economically viable, and societal designated intervals, and awaits …