A 68-year-old man with a longstanding history of gastro-oesophageal reflux disease undergoes surveillance endoscopy. Biopsies from the lower oesophagus confirm high-grade dysplasia on a background of Barrett's oesophagus. There is no visible lesion or submucosal invasion on endoscopic ultrasound. What is the most appropriate next step in management?

• A Oesophagectomy
• B High-dose proton pump inhibitor therapy and repeat endoscopy in 3 months
• C Endoscopic mucosal resection or radiofrequency ablation ✓
• D Photodynamic therapy alone

Explanation

High-grade dysplasia in Barrett's oesophagus without submucosal invasion is best managed endoscopically. Endoscopic mucosal resection (EMR) is used for any visible lesion to obtain histology and achieve local resection, while radiofrequency ablation (RFA) eradicates the remaining dysplastic Barrett's mucosa; combined, these approaches achieve eradication rates exceeding 90%. Oesophagectomy carries significant morbidity and mortality and is reserved for cases with T1b (submucosal) or deeper invasion. Acid suppression alone does not reverse high-grade dysplasia. Photodynamic therapy has largely been superseded by RFA.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

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Written and medically reviewed by the StethoPrep medical team.