Reply to Chai and Linghu

We appreciate the comments from Drs. Chai and Linghu. We agree that endoscopic resection has a definite role in the treatment of Barrett’s esophagus with high grade dysplasia (HGD) and intramucosal carcinoma (IMCA). We believe it is the treatment of choice for focal abnormalities, especially in areas with nodular mucosa, which frequently contain carcinoma. The data on endoscopic submucosal dissection (ESD) in Barrett’s esophagus are extremely limited. While en bloc resection may reduce recurrence rates compared with piecemeal resection or ablation, this technically demanding procedure can be even more challenging in the distal esophagus due to location and increased fibrosis in the submucosal layer from reflux-induced inflammation [1]. We also share the authors’ concerns about radical endoscopic resection or ESD with regard to bleeding, perforation, and stricture, as well as the time-consuming nature (and unclear reimbursement in the USA) of the ESD procedure.

We do not concur with the authors’ perceived limitations of ablation therapy. Depth of injury studies in both radiofrequency ablation [2] [3] and liquid nitrogen spray cryotherapy [4] demonstrate injury into the superficial submucosa (RFA) and mid-submucosa (cryotherapy) at current doses. Long-term follow-up with RFA in HGD shows a durable response to therapy with low rate of cancer progression [5], strongly supporting an adequate depth of treatment. Ablation near the cardia is technically more difficult. However, use of a clear endoscopic cap with cryotherapy does improve visibility, and studies have shown that in the majority of cases this area is adequately treated. Ablation does not permit a specimen to be obtained for evaluation of adequacy of resection. However, careful pre-ablation assessment with high-definition imaging, endoscopic resection of visible lesions, and detailed biopsies, as well as close post-ablation follow-up for identification of recurrence has been shown to be a successful management strategy [6]. A randomized trial comparing stepwise radical endoscopic resection (SRER) with focal resection and RFA showed comparable success rates, but the SRER group showed a significantly higher rate of stenosis and increased number of endoscopic procedures [7]. Finally, some patients are poor candidates for endoscopic resection due to the need for chronic anticoagulation or antiplatelet therapy that cannot be stopped for endoscopy, or their medical conditions place them at very high risk should a complication occur. In these cases, ablation is the preferred modality.

We thank Drs. Chai and Linghu for their insightful comments. The debate between resection and ablation is a dynamic one, and we look forward to further contributions in this area as ESD becomes more widely available.

References

• 1 Seewald S, Ang T L, Gotoda T, Soehendra N. Total endoscopic resection of Barrett esophagus.  Endoscopy. 2008;  40 1016-1020
• 2 Dunkin B J, Martinez J, Bejarano P A et al. Thin-layer ablation of human esophageal epithelium using a bipolar radiofrequency balloon device.  Surg Endosc. 2006;  20 125-130
• 3 Ganz R A, Utley D S, Stern R A et al. Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus.  Gastrointest Endosc. 2004;  60 1002-1010
• 4 Ribeiro A, Livingstone A, Bejarano P. First report of spray cryosurgery depth of injury to the human esophagus. 2010 Available at URL: http://www.sages.org/meetings/annual_meeting/2010/resources/ Last accessed 2 November 2011
• 5 Shaheen N J, Overholt B F, Sampliner R E et al. Durability of radiofrequency ablation in Barrett’s esophagus with dysplasia.  Gastroenterology. 2011;  141 460-468
• 6 Pech O, Behrens A, May A et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus.  Gut. 2008;  57 1200-1206
• 7 van Vilsteren F G, Pouw R E, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial.  Gut. 2011;  60 765-773