Radiofrequency ablation and endoscopic mucosal resection in Barrett’s esophagus with early neoplasia. Can we avoid complications?

In the article by van Vilsteren et al. [1], the rationale behind simultaneous treatment of Barrett’s esophagus with radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR) was to reduce the risk of perforation that could have been caused by the pressure of the HALO360° probe used for RFA (BÂRRX Medical, Sunnyvale, California, USA) on tissue scarred by previous extended EMR. However, the results did not support the idea that this is a safer or more effective strategy for management of Barrett’s esophagus.

In intention-to-treat analysis, complete remission of Barrett’s esophagus was only achieved in 79 % of patients. Additionally, 40 % of the patients required repeat EMR to remove residual and synchronous foci of neoplasia. A perforation occurred and was judged as a “moderate” complication. The standard evaluation for perforation is that it is a severe complication. In addition, a significant number of bleeding complications were reported.

In our experience, patients with Barrett’s esophagus (C6M8) who underwent previous extended EMR (involving > 50 % of the esophageal circumference) of a 30-mm type IIa lesion, followed 6 weeks later by RFA with a 360° probe, experienced a laceration of the scar with a spurting hemorrhage that was controlled with epinephrine – saline injection and hemoclip.

It is not necessary to use the HALO360° probe, as ablation with the 90° probe is effective. We have performed circumferential EMR in patients with 4-cm intraepithelial neoplastic lesions (type IIa and IIb), with associated smaller synchronous lesions, arising in Barrett’s esophagus. The Barrett’s length ranged from C7M9 to C10M10. At 12 days after resection, all patients complained of dysphagia and dilation was performed. The RFA was delivered 4 weeks after EMR and a preliminary dilation was still necessary to introduce the endoscope with the HALO90° probe. The new HALO90° probe (4 cm long; BÂRRX Medical) was used in two patients. We were able to treat the remaining Barrett’s esophagus, and the RFA treatment was repeated 4 weeks later to ablate the residual Barrett’s mucosa. Endoscopic surveillance showed no remnants of Barrett’s esophagus and biopsies did not detect specialized intestinal metaplasia underneath the neosquamous epithelium. This approach would avoid the onset of perforation in this subgroup of patients with very long extensions of Barrett’s esophagus. We also routinely treat patients who have Barrett’s esophagus of ≤ 4 cm, even those cases involving the whole circumference, with one-step complete EMR (article submitted).

• References

• 1 van Vilsteren FG, Alvarez Herrero L, Pouw RE et al. Radiofrequency ablation and endoscopic resection in a single session for Barrett’s esophagus containing early neoplasia: a feasibility study. Endoscopy 2012; 44: 1096-1104