We report on the use of an overtube and thin enteroscope to perform radiofrequency
ablation (RFA) using the HALO90 system (BARRX Medical, Sunnyvale, California, USA) in a 73-year-old man who had undergone
radiotherapy to a head and neck squamous cell carcinoma and distal esophagectomy for
adenocarcinoma of the esophagus (Ivor Lewis operation). He still had Barrett’s epithelium
present in the remaining esophagus with tongues extending 4 cm proximally to the anastomosis.
Histology revealed low grade dysplasia.
As a result of the previous radiation therapy, his proximal esophagus was tortuous,
stiffened, and partially stenotic. However, it was possible to pass a regular endoscope
(GIF-E160; Olympus, Tokyo, Japan) and the HALO360 device. An initial ablation using the HALO360 device successfully eradicated 90 % of the Barrett’s epithelium. At follow-up endoscopy,
however, some metaplastic epithelium still remained that needed to be ablated with
a HALO90 device. Because of the distorted esophageal anatomy, it was not possible to advance
the scope with this device as it kinked at a point 22 cm distal to the incisors.
We therefore decided to place an overtube, with outer and inner diameters of 19.5 mm
and 16.7 mm respectively, into the esophagus (Guardus; US Endoscopy, Mentor, Ohio,
USA). This overtube consists of two tubes. The inner part contains an extension that
covers the shaft of the endoscope, which allows it to be passed smoothly across kinks
and strictures. In addition, the distal part of the overtube is soft and tapered.
Once the overtube had passed the stricture and esophageal kinking, the scope and inner
overtube were removed.
As the standard gastroscope (9.8 mm outer diameter) loaded with the HALO90 device could not be advanced into the overtube, we elected to use a smaller diameter
enteroscope (EN-450T5; Fujifilm, Tokyo, Japan). Because of its narrower outer diameter
(9.4 mm) passage of this scope with the loaded HALO90 device was feasible ([Fig. 1]) and RFA was effectively applied ([Fig. 2]).
Fig. 1 The enteroscope loaded with the HALO90 device is easily advanced through the overtube, which is bridging the curves and
stenosis present in the upper esophagus.
Fig. 2 The overtube has been pulled back slightly to expose the scope with HALO90 system and effective radiofrequency ablation is then applied to the remaining Barrett’s
epithelium.
An effective ablation of the remaining Barrett’s epithelium was mandatory in this
patient with a history of esophageal adenocarcinoma [1]
[2]
[3]. The challenges of delivering therapy were overcome by adapting to the difficult
anatomy using other available instruments, such as the overtube and a thinner endoscope.
The presence of the overtube allowed us to easily negotiate the tortuous, kinked,
and stenotic esophagus.
We anticipate that more patients who require RFA for Barrett’s epithelium but who
have difficult esophageal anatomy will be encountered in the future. These include
patients with problems such as esophageal stenosis, diverticuli, and pharyngeal pouches.
Although delivery of RFA can be accomplished with the smaller HALO60 device, the device is not widely available, and it may still not be possible to pass
it through a tortuous and stenotic esophagus. Thus, we believe that the use of an
overtube represents a viable solution to allow RFA to be performed using the various
HALO devices.
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