Radiofrequency ablation for total Barrett’s eradication: a description of the endoscopic technique, its clinical results and future prospects

Stepwise circumferential and focal radiofrequency ablation using the HALO system is a novel and promising ablative modality for Barrett’s esophagus. Primary circumferential ablation is performed using a balloon-based bipolar electrode, while secondary treatment of residual Barrett’s epithelium is performed using an endoscope-mounted bipolar electrode on an articulated platform. It has been used as a single-modality treatment or in combination with other therapies. Recent studies suggest that this ablation technique is highly effective in removing Barrett’s mucosa and its associated dysplasia without the known drawbacks of photodynamic therapy or argon plasma coagulation, such as esophageal stenosis and subsquamous foci of intestinal metaplasia (also known as “buried Barrett”).
In this review paper we will explain the technical background of radiofrequency ablation using the HALO system, give a summary of its current status, and speculate on possible future applications.

References

• 1 Peters F P, Brakenhoff K P, Curvers W L. et al . Histologic evaluation of resection specimens obtained at 293 endoscopic resections in Barrett’s esophagus.  Gastrointest Endosc. 2008;  67 604-609
• 2 Westerterp M, Koppert L B, Buskens C J. et al . Outcome of surgical treatment for early adenocarcinoma of the esophagus or gastro-esophageal junction.  Virchows Arch. 2005;  446 497-504
• 3 Van Sandick J W, Van Lanschot J J, Ten Kate F J. et al . Pathology of early invasive adenocarcinoma of the esophagus or esophagogastric junction: implications for therapeutic decision making.  Cancer. 2000;  88 2429-2437
• 4 May A, Gossner L, Pech O. et al . Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett’s oesophagus: acute-phase and intermediate results of a new treatment approach.  Eur J Gastroenterol Hepatol. 2002;  14 1085-1091
• 5 Overholt B F, Panjehpour M, Halberg D L. Photodynamic therapy for Barrett’s esophagus with dysplasia and/or early stage carcinoma: long-term results.  Gastrointest Endosc. 2003;  58 183-188
• 6 Peters F P, Kara M A, Rosmolen W D. et al . Poor results of 5-aminolevulinic acid-photodynamic therapy for residual high-grade dysplasia and early cancer in Barrett’s esophagus after endoscopic resection.  Endoscopy. 2005;  37 418-424
• 7 Hage M, Siersema P D, van Dekken H. et al . 5-Aminolevulinic acid photodynamic therapy versus argon plasma coagulation for ablation of Barrett’s oesophagus: a randomised trial.  Gut. 2004;  53 785-790
• 8 Schulz H, Miehlke S, Antos D. et al . Ablation of Barrett’s epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole.  Gastrointest Endosc. 2000;  51 659-663
• 9 Van Laethem J L, Jagodzinski R, Peny M O. et al . Argon plasma coagulation in the treatment of Barrett’s high-grade dysplasia and in situ adenocarcinoma.  Endoscopy. 2001;  33 257-261
• 10 Krishnadath K K, Wang K K, Taniguchi K. et al . Persistent genetic abnormalities in Barrett’s esophagus after photodynamic therapy.  Gastroenterology. 2000;  119 624-630
• 11 Van Laethem J L, Peny M O, Salmon I. et al . Intramucosal adenocarcinoma arising under squamous re-epithelialisation of Barrett’s oesophagus.  Gut. 2000;  46 574-577
• 12 Mino-Kenudson M, Ban S, Ohana M. et al . Buried dysplasia and early adenocarcinoma arising in Barrett’s esophagus after porfimer-photodynamic therapy.  Am J Surg Pathol. 2007;  31 403-409
• 13 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
• 14 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
• 15 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
• 16 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
• 17 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
• 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
• 19 Sharma V K, Kim H J, Das A. et al . Successful ablation of Barrett’s esophagus (Barrett’s esophagus) with dysplasia using the HALO360 ablation system: a single-center experience [abstract].  Am J Gastroenterol. 2006;  101 535
• 20 Shaheen N J, Sharma P, Overholt B F. et al . A randomized, multicenter, sham-controlled trial of radiofrequency ablation (RFA) for subjects with Barrett’s esophagus (BE) containing dysplasia: interim results of the AIM dysplasia trial [abstract].  Gastroenterology. 2008;  134 A-A37
• 21 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
• 22 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
• 23 Pouw R E, Gondrie J J, Van Vilsteren F G. et al . Complications following circumferential radiofrequency energy ablation of Barrett’s esophagus containing early neoplasia [abstract].  Gastrointest Endosc. 2008;  67 AB145
• 24 Gondrie J J, Pouw R E, Sondermeijer C M. et al . Optimizing the technique for circumferential ablation of Barrett’s esophagus containing high-grade dysplasia using the HALO360 system [abstract].  Gastrointest Endosc. 2007;  65 AB151
• 25 Skacel M, Petras R E, Gramlich T L. et al . The diagnosis of low-grade dysplasia in Barrett’s esophagus and it implications for disease progression.  Am J Gastroenterol. 2000;  95 3383-3387
• 26 Beaumont H, Bergman J J, Pouw R E. et al . Preservation of the functional integrity of the distal esophagus after circumferential ablation of Barrett’s esophagus [abstract].  Gastroenterology. 2007;  132 A-A255
• 27 Gondrie J J, Rygiel A M, Sondermeijer C M. et al . Balloon-based circumferential ablation followed by focal ablation of Barrett’s esophagus containing high-grade dysplasia effectively removes all genetic alterations [abstract].  Gastroenterology. 2007;  132 A-A64
• 28 Finkelstein S D, Lyday W D. The molecular pathology of radiofrequency mucosal ablation of Barrett’s esophagus [abstract].  Gastroenterology. 2008;  134 A436
• 29 Morales T G, Camargo E, Bhattacharyya A. et al . Long-term follow-up of intestinal metaplasia of the gastric cardia.  Am J Gastroenterol. 2000;  95 1677-1680
• 30 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
• 31 Ell C, May A, Pech O. et al . Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer).  Gastrointest Endosc. 2007;  65 3-10
• 32 Pech O, Behrens A, May A D. 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
• 33 Peters F P, Kara M A, Rosmolen W D. et al . Stepwise radical endoscopic resection is effective for complete removal of Barrett’s esophagus with early neoplasia: a prospective study.  Am J Gastroenterol. 2006;  101 1449-1457
• 34 Sarosi G, Brown G, Jaiswal K. et al . Bone marrow progenitor cells contribute to esophageal regeneration and metaplasia in a rat model of Barrett’s esophagus.  Dis Esoph. 2008;  21 43-50
• 35 Berenson M M, Johnson T D, Markowitz N R. et al . Restoration of squamous mucosa after ablation of Barrett’s esophageal epithelium.  Gastroenterology. 1993;  104 1686
• 36 Paulson T G, Xu L, Sanchez C. et al . Neosquamous epithelium does not typically arise from Barrett’s epithelium.  Clin Cancer Res. 2006;  12 1701-1706