Endoscopic eradication rests on a single organizing principle: the Barrett segment holds two kinds of tissue that need two different treatments. Visible disease is resected first because the resection specimen is the staging test, and the flat field is ablated second. Reverse that order and you destroy the information the whole plan depends on. The case. A patient with a visible 1 cm nodule in a Barrett segment is referred for ablation. Why is radiofrequency ablation the wrong first move, and what must happen before any of the flat segment is touched? Topics coveredTwo tissues, two treatments: resect visible disease, ablate the flat fieldWhy resection precedes ablation: the specimen is the staging testEMR technique: suck-and-cut and cap-band methodsEMR upstages the histology in a third to a half of casesESD for larger or bulky lesions where en bloc margins matterRadiofrequency ablation as the workhorse for the flat segmentCryotherapy as an alternative and for RFA-refractory diseaseComplete eradication of intestinal metaplasia as the endpointPost-eradication surveillance and recurrence at the neosquamous junctionBuried Barrett and stricture as the main complications Key decisionsResect any visible nodule before ablating: ablating it destroys the specimen and the depth-of-invasion information that decides endoscopic versus surgical managementEMR is a staging step, not just therapy: it changes the histologic diagnosis in roughly one third to one half of nodular casesRadiofrequency ablation treats the flat field, not visible lesions; the endpoint is complete eradication of intestinal metaplasiaPost-eradication patients still need surveillance: recurrence at the gastroesophageal junction is the reasonT1a mucosal cancer is endoscopically curable; T1b submucosal invasion generally moves the patient toward surgical or multimodal therapy For the full chapter with MCQs, tables, and primary-guideline references, visit www.boardpearls.com.Questions or feedback: [email protected]. (00:00) - Opening: two tissues, two treatments (01:30) - Resect first, ablate second, and why (04:30) - EMR technique and its role as staging (08:00) - ESD for larger lesions (10:00) - Radiofrequency ablation and cryotherapy (13:00) - Endpoint and post-eradication surveillance

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