William C. Palmer, MD from the Mayo Clinic in Jacksonville, Florida, USA shares this video case, “Endoscopic management of high-grade dysplastic Barrett’s esophagus with esophageal varices.”
Our video demonstrates the case of a 62-year-old woman with esophageal varices and long-segment Barrett’s esophagus (Prague C1-M6) with high-grade dysplasia and focal intramucosal adenocarcinoma who was treated with esophageal band ligation. Portal hypertension related to decompensated alcoholic cirrhosis precluded classic Barrett’s treatments. Over 6 months of follow up, she experienced regression of the Barrett’s mucosa as well as control of the esophageal varices.
This video is particularly important, as it highlights a potential endoscopic management option for high-grade Barrett’s dysplasia and early neoplasia, in patients at high risk of post-endoscopic procedure or post-surgical bleeding complications. Standard endoscopic Barrett’s therapies (endomucosal resection, radiofrequency ablation, photodynamic therapy, etc.) and surgical therapies (esophagectomy) are not ideal options in such patients, secondary to significant portal hypertension. Lower risk treatments are needed for patients in which control of high-grade Barrett’s is indicated. In cirrhotic patients who are potentially liver transplantation candidates, definitive treatment is indicated for high risk lesions. Band ligation may be one option.
Endoscopists can learn several key lessons from this case. First, endoscopic band ligation may provide regression of dysplastic or malignant Barrett’s mucosa, and may be quite useful in high-risk patients. Second, it is unknown if complete regression of Barrett’s dysplasia is possible with banding alone. While band ligation is ideal for treatment of esophageal varices, further study is needed to replicate these findings in a larger sample size. Our group at Mayo Clinic is currently reviewing a larger series of such patients we have treated similarly to determine if band ligation shows further promise as definitive treatment for dysplastic Barrett’s in the presence of esophageal varices.
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