Traitement endoscopique de l'endobrachyœsophage

Aims of the treatment of Barrett's oesophagus (BO) are disappearance of symptoms and inflammatory complications of gastro-oesophageal reflux disease (GORD), prevention of occurrence of dysplasia and adenocarcinoma, and early treatment of high-grade dysplasia (HGD) and adenocarcinoma. Anti-secretory treatment with proton-pump inhibitors (PPI) must result in disappearance of both symptoms and oesophagitis. The only correction of symptoms, as well as normalization of pHmetry, are not considered as adequate criteria for efficiency of treatment. It has not been demonstrated that treatment with PPI prevented occurrence of dysplasia and adenocarcinoma so the only BO is not an indication for treatment with PPI, which results in only partial regression of height and/or surface of BO. Endoscopic ablation of BO, combined with PPI, allows complete regression of intestinal metaplasia in about 50% of cases. Photodynamic therapy (PDT) seems the best technique for treatment of HGD and mucosal adenocarcinoma. This treatment is not indicated in case of low-grade dysplasia, since its benefit on survival is less clear than for HGD. Endoscopic treatment does not suppress the need for prolonged endoscopic follow-up since BO recurs in approximately one third of patients. For HGD isolated or associated with mucosal adenocarcinoma (proven by endoscopic ultrasound), endoscopic treatment can consist in mucosectomy or ablation with PDT or plasma argon coagulation (PAC) of these lesions if localized, possibly followed by complete ablation of BO by PAC, and always associated with an efficient treatment of GORD by PPI or anti-reflux surgery. Submucosal adenocarcinomas must be treated by oesophagectomy if allowed by the general condition of the patient.