Visible endoscopic and histologic changes in the cardia, before and after complete Barrett's esophagus ablation

doi:10.1016/S0016-5107(05)00131-8

Gastrointestinal Endoscopy

Volume 61, Issue 4, April 2005, Pages 515-521

https://doi.org/10.1016/S0016-5107(05)00131-8 Get rights and content

Background

Adverse events associated with the thermal ablation of Barrett's esophagus (BE) include the generation of gastric mucosa buried beneath the neosquamous regrowth, and unrecognized development and growth of adenocarcinomas. No reports exist regarding the endoscopic appearance and histology of the cardia before and after BE ablation. The aim of our study was to assess the relative frequency of the occurrence of visible endoscopic and histologic changes in the cardia, before and after complete BE ablation.

Methods

A subset analysis of patients with uncomplicated BE, BE with dysplasia, or early carcinoma, who had been enrolled into one of 4 ongoing prospective studies of mucosal ablation, was examined. Eighty-two patients were identified who entered a BE ablation study, with 75 of these completing BE mucosal ablation. Cardia biopsy specimens were taken in all patients before ablation and serially after BE ablation. Cardia histology was graded by using the modified Sydney System for gastritis.

Results

Before ablation, cardia nodules were noted in 3, cardia intestinal metaplasia (IM) in 7 (8.5%), and none harbored cardia dysplasia. Postablation surveillance ranged from 3 to 75 months (mean 31.1 months [19.5]). Six subjects (8%) developed cardia nodules during surveillance; cardia IM was found in 21(28%), with 17 of these being a new finding (incidence of 25%). Cardia low-grade dysplasia incidence was 1.3% and high-grade dysplasia was 4% after BE ablation.

Conclusions

The pathophysiology of the abnormal cardia histology and the endoscopic lesions (nodules) is unclear, but endoscopic surveillance of not only the neosquamous epithelium but also the cardia should be considered after ablation, especially in those high-grade dysplasia and early adenocarcinoma BE patients.

Section snippets

Patients

Our institution has been conducting several ongoing, institutional review board–approved prospective studies on the thermal ablation of BE. Two separate randomized trials compare APC vs. monopolar electrocautery (MPEC) in BE patients without dysplasia or with low-grade dysplasia (LGD). Two other trials treated BE patients harboring high-grade dysplasia (HGD) or intramucosal or mucosal adenocarcinoma with Nd:YAG contact laser ablation or PDT with Photofrin. In each of these 4 BE ablation

Results

Eighty-two patients were enrolled into one of 4 BE ablation protocols. An overview of the BE thermal ablation method used is presented in Figure 1. An overview of demographic, endoscopic, and histologic features of the BE is shown in Table 1. Seventy-five patients have completed ablation treatments, and have achieved endoscopic and histologic destruction of all metaplastic columnar tissue within the tubular esophagus, with replacement by squamous epithelium. All patients except one were male,

Discussion

The gastric cardia exhibits a disturbing advancement in histologic changes of IM and dysplasia in BE patients after ablation therapy. The frequency of cardia IM and dysplasia (LGD or HGD) increased from 8.5% and 0%, respectively, before ablation, to 28% for IM and 5.3% for dysplasia. The histologic changes of cardia IM alone in postablation patients was not associated with any grossly visible mucosal changes; however, endoscopically visible lesions (nodules) were seen instead in conjunction