The most appropriate next step in management is endoscopic ablation. Barrett esophagus (BE) is a precancerous condition that can progress to esophageal cancer. Risk factors associated with BE are older age, male gender, white ethnicity, gastroesophageal reflux disease (GERD), hiatal hernia, high BMI, smoking, and an abdominal distribution of fat. This patient has high-grade dysplasia, a high-risk feature of the condition. Treatment to remove BE is recommended for patients with confirmed high-grade dysplasia and can be done with endoscopic therapies such as radiofrequency ablation, photodynamic therapy, or endoscopic mucosal resection. Choice of treatment may be influenced by local expertise and patient preference.

Esophagectomy is the treatment of choice for esophageal cancer if the patient is a surgical candidate. Esophagectomy may be required in patients with BE and high-grade dysplasia if ablation has failed or progression to cancer occurred during endoscopic treatment. Endoscopic treatment should be attempted for this patient before surgery would be appropriate.

Fundoplication would be indicated in a patient with refractory GERD. Fundoplication has not been shown to reduce the risk of progression of BE with high-grade dysplasia to cancer and is therefore not an appropriate choice.

A repeat surveillance upper endoscopy in 3 to 5 years would be appropriate in a patient with BE with no dysplasia. Because this patient has high-grade dysplasia, more aggressive management is necessary.