Endoscopy 2022; 54(06): E261-E263
DOI: 10.1055/a-1516-3400
E-Videos

Eradication of neoplastic Barrett’s esophagus in patients with esophageal varices with a modified endoscopic mucosal resection technique and radiofrequency ablation

1   University Hospital Dr. Josep Trueta, Girona, Spain
2   Germans Trias i Pujol Hospital, Badalona, Spain
3   Endoscopy Unit, Teknon Medical Center, Quirónsalud Hospital, Barcelona, Spain
,
Michel Blé
3   Endoscopy Unit, Teknon Medical Center, Quirónsalud Hospital, Barcelona, Spain
,
David Busquets
1   University Hospital Dr. Josep Trueta, Girona, Spain
,
Isabel Serra
1   University Hospital Dr. Josep Trueta, Girona, Spain
,
Carmen López
1   University Hospital Dr. Josep Trueta, Girona, Spain
,
Xavier Aldeguer
1   University Hospital Dr. Josep Trueta, Girona, Spain
,
Carlos Huertas
1   University Hospital Dr. Josep Trueta, Girona, Spain
› Author Affiliations
 

Most patients with cirrhosis and portal hypertension eventually require liver transplantation. Esophageal neoplasia in this population (especially in patients who use alcohol and tobacco) might contraindicate liver transplantation. Early Barrett’s neoplasia should be treated with endoscopic resection if there are no signs of advanced adenocarcinoma, and complete eradication of all remaining Barrett’s epithelium should be striven for, preferably with radiofrequency ablation (RFA) [1]. However, these treatments may become challenging in patients with portal hypertension and esophageal varices, due to the risk of variceal bleeding and hepatic decompensation. Some reports have been published of endoscopic resection after a session of endoscopic variceal ligation, but without RFA for eradication therapy [2] [3]. We present a case series of three patients with esophageal varices and Barrett’s neoplasia successfully treated with a modified endoscopic resection technique and RFA ([Table 1]).

Table 1

Clinical characteristics and outcomes of three patients with Barrett’s esophagus and esophageal varices treated with a modified endoscopic mucosal resection technique and radiofrequency ablation.

Case 1[*]

Case 2

Case 3

Age (years)/gender

51/male

52/male

63/male

Prague classification

C6M7

C7M12

C2.5M5

Prior histology (biopsies)

HGD

HGD

HGD

Worst final histology

HGD

pT1a (intramucosal)

pT1a (intramucosal)

Number of lesions

Multifocal (> 3)

1

1

No. of sessions of EMR

5

3 (due to LGD in lateral margins)

1

No. of sessions of RFA

2

3

3

Complete eradication of dysplasia

Yes

Yes

Yes

Complete eradication of intestinal metaplasia

Unknown

Yes

Yes

Follow-up after complete eradication of dysplasia (months)

13

24

36

Follow-up after complete eradication of intestinal metaplasia (months)

14

29

Etiology of cirrhosis

HCV and alcohol

Alcohol

Alcohol

Child–Pugh/MELD score

A-6/9

B-8/15

A-6/11

Platelet count, 103/μL

145

80

141

INR

1.14

1.54

1.37

Size of varices

Large

Large

Large

Previous esophageal bleeding

Yes

No

No

NSBB prophylaxis (baseline)

Yes

No

Yes

Hiatal hernia size (cm)

3

5

3

Post-EMR bleeding

No

Yes (scar bleeding)

No

Other complications

No

No

No

EMR, endoscopic mucosal resection; HCV, hepatitis C virus; HGD, high-grade dysplasia; INR, international normalized ratio; LGD, low-grade dysplasia; MELD, model for end-stage liver disease; NSBB, nonselective β-blockers; RFA, radiofrequency ablation.

* In case 1 there was poor adherence to treatment and follow-up, with no surveillance endoscopy after the last RFA session.


Esophageal varices were confirmed by endoscopic ultrasound on prior endoscopy. All procedures were performed with the patient under deep sedation, and with antibiotic prophylaxis and somatostatin perfusion. After identifying and marking the target lesion, we “blocked” the distal-to-proximal variceal flow by endoscopic band ligation of visible esophageal varices distal to the lesion. Conventional band ligation-assisted endoscopic mucosal resection (EMR) of the target lesion was then performed in the same session ([Fig. 1], [Fig. 2]). Another EMR session was used if needed. When the lesions were completely removed, RFA was performed in a further session until complete eradication of Barrett’s esophagus was achieved ([Video 1], Case 3). No intraprocedural complications occurred. One patient presented delayed bleeding 8 days after EMR, but this did not require endoscopic treatment. No other relevant complications were seen.

Zoom Image
Fig. 1 The flow of the esophageal varices is from distal to proximal in the esophagus, as shown by the arrows. The target lesion is adjacent to the esophageal varices.
Zoom Image
Fig. 2 a–c Sequence of the modified band-ligation-assisted endoscopic mucosal resection (EMR). a The target lesion. b The esophageal varices are ligated distal to the target lesion to “block” the blood flow prior to EMR. c Post-EMR defect.

Video 1 Modified technique for endoscopic mucosal resection followed by radiofrequency ablation for eradication of neoplastic Barrett’s esophagus in the presence of esophageal varices.


Quality:

In conclusion, EMR of dysplastic lesions in Barrett’s esophagus with underlying esophageal varices, followed by RFA for complete eradication, is feasible. The use of band ligation to decrease the blood flow prior to EMR may be helpful.

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Competing interests

The authors declare that they have no conflict of interest.


Corresponding author

Hugo Uchima, MD
Endoscopy Unit, Teknon Medical Center
Vilana 12 Planta 1
Barcelona 08017
Spain   

Publication History

Article published online:
18 June 2021

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Zoom Image
Fig. 1 The flow of the esophageal varices is from distal to proximal in the esophagus, as shown by the arrows. The target lesion is adjacent to the esophageal varices.
Zoom Image
Fig. 2 a–c Sequence of the modified band-ligation-assisted endoscopic mucosal resection (EMR). a The target lesion. b The esophageal varices are ligated distal to the target lesion to “block” the blood flow prior to EMR. c Post-EMR defect.