In this case series, Trindade and colleagues elegantly describe the use of hybrid argon plasma coagulation (APC) in the management of five patients with refractory Barrett’s esophagus (BE)-related neoplasia. Although the end point of complete eradication of intestinal metaplasia (CE-IM) is achieved in 2 – 3 sessions of endoscopic eradication therapy in a substantial proportion of BE-related neoplasia patients, a small fraction of patients are diagnosed with refractory BE. This is often defined as inability to achieve CEIM in 5 – 6 sessions, with incomplete response defined as failure to achieve CEIM in 3 sessions. However, standardization of the definition of refractory BE is of critical importance. Risk factors for refractory BE include lack of long-term reflux control, hiatal hernia, and BE segment length > 5 cm.
A standardized antireflux protocol should be followed in all patients undergoing endoscopic eradication therapy. Appropriate reflux testing in individuals not responding to endoscopic therapy, followed by referral for antireflux surgery in select individuals, should be considered.
Future prospective studies are required to validate risk factors for refractory BE as well as successful management strategies, including optimal methods of reflux control and salvage endoscopic eradication therapy. Hybrid APC appears to be a meaningful addition to our therapeutic endoscopic armamentarium for the management of refractory BE.
26 August 2020 (online)
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