Radiofrequency ablation of Barrett’s esophagus: outcomes of 429 patients from a multicenter community practice registry

 

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Background and study aims: The use of radiofrequency ablation (RFA) for complete eradication of Barrett’s esophagus has shown promise in trials conducted at predominantly tertiary academic centers; however less is known regarding outcomes in the community. We evaluated the safety and efficacy of RFA for Barrett’s esophagus delivered in a community practice setting.

Patients and methods: This was a multicenter registry conducted in community-based gastroenterology practices. Patients had confirmed intestinal metaplasia with or without dysplasia on biopsy of a Barrett’s esophagus. Intervention was step-wise RFA with follow-up esophageal biopsies. Endpoints were histology-based; complete response was defined as all biopsies at most recent endoscopy negative for intestinal metaplasia (CR-IM) or dysplasia (CR-D). Three cohorts were reported: 1) safety cohort, all patients; 2) efficacy cohort A, patients with at least one biopsy session after initial treatment; 3) efficacy cohort B, patients with at least one biopsy session ≥ 1 year after initial treatment.

Results: The safety cohort included 429 patients (71 % men, median age 59 years, median Barrett’s segment 3.0 cm). There were no serious adverse events (bleeding, perforation, death), and a stricture occurred after 1.1 % of cases (2.1 % of patients). In efficacy cohort A (n = 338), CR-IM and CR-D were achieved in 72 % and 89 % of patients, respectively (median follow-up 9 months). In efficacy cohort B (n = 137), CR-IM and CR-D were achieved in 77 % and 100 % of patients, respectively (median follow-up 20 months).

Conclusions: In this multicenter registry conducted at four community-based practices, the observed safety and efficacy outcomes associated with RFA for Barrett’s esophagus are comparable to those previously reported in multicenter trials from predominantly tertiary academic centers.

References

• 1 Spechler S J. Barrett’s esophagus.  N Engl J Med. 2002;  346 836-842
  CrossrefPubMedGoogle Scholar
• 2 Wang K K, Sampliner R E. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus.  Am J Gastroenterol. 2008;  103 788-797
  CrossrefPubMedGoogle Scholar
• 3 Peters J H, Hagen J A, DeMeester S R. Barrett’s esophagus.  J Gastrointest Surg. 2004;  8 1-17
  CrossrefPubMedGoogle Scholar
• 4 Wolfsen H C, Utley D, Peters J H. Endoscopic ablation of Barrett’s metaplasia and dysplasia. In: Yeo CJ, Dempsey DT, Klein AS, Pemberton JH, Peters JH, eds. Shackelford’s surgery of the alimentary tract. Philadelphia; Saunders Elsevier 2006: 365-373
  PubMedGoogle Scholar
• 5 Rex D K, Cummings O W, Shaw M. et al . Screening for Barrett’s esophagus in colonoscopy patients with and without heartburn.  Gastroenterology. 2003;  125 1670-1677
  CrossrefPubMedGoogle Scholar
• 6 Hirota W K, Loughney T M, Lazas D J. et al . Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric junction: prevalence and clinical data.  Gastroenterology. 1999;  116 277-285
  CrossrefPubMedGoogle Scholar
• 7 Ward E M, Wolfsen H C, Achem S R. et al . Barrett’s esophagus is common in older men and women undergoing screening colonoscopy regardless of reflux symptoms.  Am J Gastroenterol. 2006;  101 1572-1577
  PubMedGoogle Scholar
• 8 Cameron A J, Lomboy C T. Barrett’s esophagus: age, prevalence, and extent of columnar epithelium.  Gastroenterology. 1992;  103 1241-1245
  CrossrefPubMedGoogle Scholar
• 9 Cameron A J. Epidemiology of columnar-lined esophagus and adenocarcinoma.  Gastroenterol Clin North Am. 1997;  26 487-494
  CrossrefPubMedGoogle Scholar
• 10 Ronkainen J, Aro P, Storskrubb T. et al . Prevalence of Barrett’s esophagus in the general population: an endoscopic study.  Gastroenterology. 2005;  129 1825-1831
  CrossrefPubMedGoogle Scholar
• 11 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
  CrossrefPubMedGoogle Scholar
• 12 Dunkin B J, Martinez J, Bejarano P A. et al . Thin-layer ablation of esophageal epithelium using a bipolar radiofrequency balloon device.  Surg Endosc. 2006;  20 125-130
  CrossrefPubMedGoogle Scholar
• 13 Smith C D, Bejarano P A, Melvin W S. et al . Endoscopic ablation of intestinal metaplasia containing high-grade dysplasia in esophagectomy patients using a balloon-based ablation system.  Surg Endosc. 2007;  21 560-569
  CrossrefPubMedGoogle Scholar
• 14 Dulai G S, Jensen D M, Cortina G. et al . A randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus.  Gastrointest Endosc. 2005;  61 232-240
  CrossrefPubMedGoogle Scholar
• 15 Sharma V K, Wang K K, Overholt B F. et al . Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett’s esophagus: 1-year follow-up of 100 patients.  Gastrointest Endosc. 2007;  65 185-195
  CrossrefPubMedGoogle Scholar
• 16 Fleischer D E, Overholt B F, Sharma V K. et al . Endoscopic ablation of Barrett’s esophagus: a multicenter study with 2.5 year follow-up.  Gastrointest Endosc. 2008;  68 867-876
  CrossrefPubMedGoogle Scholar
• 17 Ganz R A, Overholt B F, Sharma V K. et al . Circumferential ablation of Barrett’s esophagus that contains high-grade dysplasia: a U.S. Multicenter Registry.  Gastrointest Endosc. 2008;  68 35-40
  CrossrefPubMedGoogle Scholar
• 18 Sharma V K, Kim H J, Das A. et al . A prospective pilot trial of ablation of Barrett’s esophagus with low-grade dysplasia using stepwise circumferential and focal ablation (HALO system).  Endoscopy. 2008;  40 380-387
  Article in Thieme ConnectPubMedGoogle Scholar
• 19 Gondrie J J, Pouw R E, Sondermeijer C M. et al . Stepwise circumferential and focal ablation of Barrett’s esophagus with high-grade dysplasia: results of the first prospective series of 11 patients.  Endoscopy. 2008;  40 359-369
  Article in Thieme ConnectPubMedGoogle Scholar
• 20 Gondrie J J, Pouw R E, Sondermeijer C M. et al . Effective treatment of early Barrett’s neoplasia with stepwise circumferential and focal ablation using the HALO system.  Endoscopy. 2008;  40 370-379
  Article in Thieme ConnectPubMedGoogle Scholar
• 21 Shaheen N J, Sharma P, Overholt B F. et al . Radiofrequency ablation in Barrett’s esophagus with dysplasia.  N Engl J Med. 2009;  360 2277-2288
  CrossrefPubMedGoogle Scholar
• 22 Pouw R E, Gondrie J J, Sondermeijer C M. et al . Eradication of Barrett esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection.  J Gastrointest Surg. 2008;  12 1627-1637
  CrossrefPubMedGoogle Scholar
• 23 Sharma V K, Jae K im, Das A. et al . Circumferential and focal ablation of Barrett’s esophagus containing dysplasia.  Am J Gastroenterol. 2009;  104 310-317
  CrossrefPubMedGoogle Scholar
• 24 Eldaif S M, Lin E, Singh K A. et al . Radiofrequency ablation of Barrett’s esophagus: short-term results.  Ann Thorac Surg. 2009;  87 405-410
  CrossrefPubMedGoogle Scholar
• 25 Velanovich V. Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus: initial results and lessons learned.  Surg Endosc. 2009;  10 2175-2180
  PubMedGoogle Scholar
• 26 Pouw R E, Wirths K, Eisendrath P. et al . Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia.  Clin Gastroenterol Hepatol. 2010;  8 23-29
  CrossrefPubMedGoogle Scholar
• 27 Hernandez J C, Reicher S, Chung D. et al . Pilot series of radiofrequency ablation of Barrett’s esophagus with or without neoplasia.  Endoscopy. 2008;  40 388-392
  Article in Thieme ConnectPubMedGoogle Scholar
• 28 Overholt B F, Lightdale C J, Wang K K. et al . Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett’s esophagus: international, partially blinded, randomized phase III trial.  Gastrointest Endosc. 2005;  62 488-498
  CrossrefPubMedGoogle Scholar
• 29 Seewald S, Ang T L, Gotoda T, Soehendra N. Total endoscopic resection of Barrett esophagus.  Endoscopy. 2008;  40 1016-1020
  Article in Thieme ConnectPubMedGoogle Scholar
• 30 Ragunath K, Krasner N, Raman V A. et al . Endoscopic ablation of dysplastic Barrett’s oesophagus comparing argon plasma coagulation and photodynamic therapy: a randomized prospective trial assessing efficacy and cost-effectiveness.  . 2005;  40 750-758
  CrossrefPubMedGoogle Scholar
• 31 Attwood S E, Lewis C J, Caplin S. et al . Argon beam plasma coagulation as therapy for high-grade dysplasia in Barrett’s esophagus.  . 2003;  1 258-263
  CrossrefPubMedGoogle Scholar
• 32 Wani S, Sayana H, Sharma P. Endoscopic eradication of Barrett’s esophagus.  Gastrointest Endosc. 2010;  71 147-166
  CrossrefPubMedGoogle Scholar
• 33 Manner H, May A, Miehlke S. et al . Ablation of nonneoplastic Barrett’s mucosa using argon plasma coagulation with concomitant esomeprazole therapy (APBANEX): a prospective multicenter evaluation.  Am J Gastroenterol. 2006;  101 1762-1769
  CrossrefPubMedGoogle Scholar
• 34 Sharma P, Wani S, Weston A P. et al . A randomized control trial of ablation of Barrett’s oesophagus with multipolar electrocoagulation versus argon plasma coagulation in combination with acid suppression: long term results.  Gut. 2006;  55 1233-1239
  CrossrefPubMedGoogle Scholar
• 35 Peters F P, Brakenhoff K P, Curvers W L. et al . Histologic evaluation of resection specimens obtained at 239 endoscopic resections in Barrett’s esophagus.  Gastrointest Endosc. 2008;  67 604-609
  CrossrefPubMedGoogle Scholar
• 36 Pech O, Gossner L, Manner H. et al . Prospective evaluation of the macroscopic types and location of early Barrett’s neoplasia in 380 lesions.  Endoscopy. 2007;  39 588-593
  Article in Thieme ConnectPubMedGoogle Scholar
• 37 Sharma P, Falk G W, Sampliner R. et al . Management of nondysplastic Barrett’s esophagus: where are we now?.  Am J Gastroenterol. 2009;  104 805-808
  CrossrefPubMedGoogle Scholar
• 38 Falk G W. Radiofrequency ablation of Barrett’s esophagus: should everybody get it?.  Gastroenterology. 2009;  136 2399-2401; discussion 2401 – 2402
  CrossrefPubMedGoogle Scholar
• 39 Lenglinger J, Riegler F M. Selected commentary to “Radiofrequency ablation in Barrett’s esophagus with dysplasia” (Shaheen NJ, Sharma P, Overholt BF et al. N Engl J Med 2009; 360: 2277 – 2288).  Eur Surg. 2009;  41 132-135
  CrossrefPubMedGoogle Scholar
• 40 Das A, Wells C, Kim H J. et al . An economic analysis of endoscopic ablative therapy for management of nondysplastic Barrett’s esophagus.  Endoscopy. 2009;  41 400-408
  Article in Thieme ConnectPubMedGoogle Scholar
• 41 Inadomi J M, Somsouk M, Madanick R D. et al . A cost-utility analysis of ablative therapy for Barrett’s esophagus.  Gastroenterology. 2009;  136 2101-2114
  CrossrefPubMedGoogle Scholar
• 42 Pohl H, Sonnenberg A, Strobel S. et al . Endoscopic versus surgical therapy for early cancer in Barrett’s esophagus: a decision analysis.  Gastrointest Endosc. 2009;  70 623-631
  CrossrefPubMedGoogle Scholar
• 43 Kerkhof M, van Dekken H, Steyerberg E W. et al . Grading of dysplasia in Barrett’s oesophagus: substantial interobserver variation between general and gastrointestinal pathologists.  Histopathology. 2007;  50 920-927
  CrossrefPubMedGoogle Scholar
• 44 Downs-Kelly E, Mendelin J E, Bennett A E. et al . Poor interobserver agreement in the distinction of high-grade dysplasia and adenocarcinoma in pretreatment Barrett’s esophagus biopsies.  Am J Gastroenterol. 2008;  103 2333-2340
  CrossrefPubMedGoogle Scholar
• 45 Montgomery E, Goldblum J R, Greenson J K. et al . Dysplasia as a predictive marker for invasive carcinoma in Barrett esophagus: a follow-up study based on 138 cases from a diagnostic variability study.  Hum Pathol. 2001;  32 379-388
  CrossrefPubMedGoogle Scholar

R. E. PruittMD 

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