barrett 's oesophagus ( bo ) is characterized by replacing the distal oesophageal squamous mucosa with columnar epithelium containing specialized intestinal metaplasia ( i m ) . the metaplastic epithelium accumulates genetic changes over a period of time and can progress to dysplasia and cancer . these patients carry a cancer risk that is 30 to 125 times more than that of an age - matched population . screening for bo remains controversial , but regular surveillance is a standard practice once i m is identified . guidelines set out by the american college of gastroenterology , as well as those of several other national gastrointestinal societies , suggest that quadrantic biopsies should be conducted every 2 cm of bo during surveillance . however , with recent advanced imaging techniques such as autofluoroscence and narrow band imaging , biopsies can be targeted with good yield to detect early neoplasia . the main aim of treatment in bo is to control reflux symptoms and prevent the development of dysplasia and cancer . h2-receptor antagonists have shown benefits in controlling symptoms of bo but have not shown regression in the length of metaplastic epithelium . similarly , proton - pump inhibitors ( ppis ) are useful in treating oesophagitis associated with bo , but there is no consistent evidence to suggest significant regression of disease or benefits in preventing the development of neoplasia . control of reflux symptoms by ppis does not necessarily equate with complete inhibition of acid reflux and some patients can have bile reflux , which is known to influence the development and persistence of metaplastic epithelium . an increase in squamous islands is noted after ppi use , but studies show that i m is often present underneath those islands . chemoprevention measures using non - steroidal anti - inflammatory drugs and aspirin in bo have shown some benefits in preventing the development of neoplasia . however , results from the recent chemoprevention for barrett 's esophagus trial ( cbet ) were disappointing with regard to the use of celecoxib . ongoing trials like the aspirin esomeprazole chemoprevention trial ( aspect ) will throw light on to the role of aspirin in preventing barrett 's associated cancer of the oesophagus . laparoscopic anti - reflux surgeries like fundoplication have the benefit of controlling acid and bile reflux better than medical therapy , however , the ability to prevent the development of cancer in bo is conflicting . some studies have shown a progression to cancer in spite of surgery and there is no consistent evidence to suggest the regression of barrett 's mucosa following surgery . once high - grade dysplasia is identified , oesophagectomy has been the standard practice , however newer endotherapeutic techniques are now capable of treating dysplasia and early cancer , thereby avoiding major surgery . argon plasma coagulation ( apc ) uses an ionized electrically conducting argon beam that delivers a high local temperature of 130c leading to desiccation of tissue to a maximum depth of 3 to 4 mm , which is ideal to destroy the metaplastic epithelium . many studies involving apc have shown benefits of eradication of barrett 's mucosa and early neoplasia with restoration of squamous epithelium . multipolar electrocoagulation using a gold probe has been shown to be equally effective , with up to 70% of patients showing a complete reversal of barrett 's epithelium . unlike these techniques , photodynamic therapy ( pdt ) involves a non - thermal chemical process using a photosensitizing drug that can be given intravenously , orally or topically . the drug concentrates in the metaplastic and dysplastic epithelium and is sensitized by a bright light of appropriate wavelength to facilitate tissue necrosis . the main advantage of this technique is that larger areas can be uniformly treated with a single treatment session . pdt was found to be equally effective as apc in ablating barrett 's mucosa but more effective in eradicating dysplasia . oesophageal stricture and photosensitization are reported following the above techniques . currently , there is insufficient evidence to support the use of these techniques in non - dysplastic i m . endoscopic mucosal resection ( emr ) is an alternative technique to ablation in which the neoplastic epithelium is resected rather than ablated and hence gives a definitive histological diagnosis and potential cure . the emr cap technique uses a transparent cap attached to the endoscope , which allows suction of the abnormal mucosa into the cap after submucosal injection of adrenaline . oesophageal variceal ligation bands can be applied to the area of interest , followed by resection with a snare after removing the banding device . no significant difference in the diameter of resected specimens , or in complications , was observed between these two techniques . flat barrett 's neoplasia can also be removed using a monofilament polypectomy snare without the use of any submucosal lifting or additional devices . minor bleeding can occur in up to 10% of cases after emr , but major complications such as perforation and strictures are rare . the main aim of treatment in bo is to control reflux symptoms and prevent the development of dysplasia and cancer . h2-receptor antagonists have shown benefits in controlling symptoms of bo but have not shown regression in the length of metaplastic epithelium . similarly , proton - pump inhibitors ( ppis ) are useful in treating oesophagitis associated with bo , but there is no consistent evidence to suggest significant regression of disease or benefits in preventing the development of neoplasia . control of reflux symptoms by ppis does not necessarily equate with complete inhibition of acid reflux and some patients can have bile reflux , which is known to influence the development and persistence of metaplastic epithelium . an increase in squamous islands is noted after ppi use , but studies show that i m is often present underneath those islands . chemoprevention measures using non - steroidal anti - inflammatory drugs and aspirin in bo have shown some benefits in preventing the development of neoplasia . however , results from the recent chemoprevention for barrett 's esophagus trial ( cbet ) were disappointing with regard to the use of celecoxib . ongoing trials like the aspirin esomeprazole chemoprevention trial ( aspect ) will throw light on to the role of aspirin in preventing barrett 's associated cancer of the oesophagus . laparoscopic anti - reflux surgeries like fundoplication have the benefit of controlling acid and bile reflux better than medical therapy , however , the ability to prevent the development of cancer in bo is conflicting . some studies have shown a progression to cancer in spite of surgery and there is no consistent evidence to suggest the regression of barrett 's mucosa following surgery . once high - grade dysplasia is identified , oesophagectomy has been the standard practice , however newer endotherapeutic techniques are now capable of treating dysplasia and early cancer , thereby avoiding major surgery . argon plasma coagulation ( apc ) uses an ionized electrically conducting argon beam that delivers a high local temperature of 130c leading to desiccation of tissue to a maximum depth of 3 to 4 mm , which is ideal to destroy the metaplastic epithelium . many studies involving apc have shown benefits of eradication of barrett 's mucosa and early neoplasia with restoration of squamous epithelium . multipolar electrocoagulation using a gold probe has been shown to be equally effective , with up to 70% of patients showing a complete reversal of barrett 's epithelium . unlike these techniques , photodynamic therapy ( pdt ) involves a non - thermal chemical process using a photosensitizing drug that can be given intravenously , orally or topically . the drug concentrates in the metaplastic and dysplastic epithelium and is sensitized by a bright light of appropriate wavelength to facilitate tissue necrosis . the main advantage of this technique is that larger areas can be uniformly treated with a single treatment session . pdt was found to be equally effective as apc in ablating barrett 's mucosa but more effective in eradicating dysplasia . oesophageal stricture and photosensitization are reported following the above techniques . currently , there is insufficient evidence to support the use of these techniques in non - dysplastic i m . endoscopic mucosal resection ( emr ) is an alternative technique to ablation in which the neoplastic epithelium is resected rather than ablated and hence gives a definitive histological diagnosis and potential cure . the emr cap technique uses a transparent cap attached to the endoscope , which allows suction of the abnormal mucosa into the cap after submucosal injection of adrenaline . , oesophageal variceal ligation bands can be applied to the area of interest , followed by resection with a snare after removing the banding device . no significant difference in the diameter of resected specimens , or in complications , was observed between these two techniques . flat barrett 's neoplasia can also be removed using a monofilament polypectomy snare without the use of any submucosal lifting or additional devices . minor bleeding can occur in up to 10% of cases after emr , but major complications such as perforation and strictures are rare . en bloc dissection of large neoplastic lesions using a specially designed needle knife has been attempted by japanese endoscopists , but this necessitates expertise . a multiband mucosectomy device ( duette ; cook endoscopy , winston - salem , nc , usa , formerly wilson - cook medical inc ) , which allows resection of multiple areas using a technique like variceal banding ligation , is now commercially available . unlike the suck - band - and - cut technique , it does not need a withdrawal of the scope between resections . a newer technique of radiofrequency ablation ( rfa ) using a specially designed balloon known as the brrx halo system is available to ablate the neoplastic epithelium . any visible abnormalities in the neoplastic mucosa are removed by emr prior to rfa ( figure 1 ) . halo contains multiple electrodes encircling the outer surface of the balloon and can be used for circumferential ablation . any residual barrett 's epithelium can be removed by focal ablation with the halo system . initial reports suggest complete remission in dysplasia and barrett 's mucosa using this technique . the incidence of residual dysplasia , oesophageal stenosis and buried barrett 's mucosa was reported to be less with rfa circumferential ablation compared with other ablative techniques . ( a ) high - resolution white - light image of barrett 's oesophagus with subtle irregular mucosa at the 5 o'clock position , ( b ) autofluorescence imaging revealing an abnormal signal between the 2 and the 7 o'clock positions , ( c ) multiband mucosectomy ( duette ) endoscopic mucosal resection , ( d ) pathology showing intramucosal adenocarcinoma without submucosal invasion , ( e ) halo radiofrequency ablation of remaining barrett 's epithelium , and ( f ) post - ablation squamous regeneration . regular systematic surveillance of bo is warranted in the absence of any definitive measures available to prevent progression of disease . endoscopic therapy for early neoplasia in bo is promising , but the ideal method is yet to be decided . patients with barrett 's neoplasia should ideally be treated in a dedicated centre with the help of a committed multidisciplinary team . dr ragunath has received speaker honorarium , research support and 
 educational grants from astra - zeneca uk , cook medical uk , olympus - keymed uk and barx medical inc usa .
barrett 's oesophagus , which is thought to be a consequence of gastro - oesophageal reflux disease ( gord ) , is a well - recognized precursor of oesophageal adenocarcinoma . 
 medical therapies and anti - reflux surgeries for gord have shown conflicting results regarding the progression of barrett 's metaplasia to neoplasia . 
 after high - grade dysplasia or intramucosal cancer is identified , it has been standard practice to conduct an oesophagectomy , despite this having an associated risk of morbidity and mortality . in recent years 
 however , endoscopic therapy has become a viable alternative to oesophagectomy in treating early neoplasia .