Successful treatment of Barrett’s esophagus with radiofrequency ablation in a patient with severe reflux esophagitis following fundoplication

We read with interest the article by van Vilsteren et al. titled “Predictive factors for initial treatment response after circumferential radiofrequency ablation for Barrett’s esophagus with early neoplasia: a prospective multicenter study,” published in a recent issue of Endoscopy [1]. The authors found the presence of reflux esophagitis to be the strongest predictor of a poor initial response after circumferential radiofrequency ablation (RFA) and suggested either optimizing medical therapy or fundoplication prior to RFA in order to increase the success rates of RFA [1].

We would like to share our recent experience of treating a 75-year-old man who had C6M9 Barrett’s esophagus with high grade dysplasia, grade D reflux esophagitis, and a large hiatal hernia. The reflux was refractory to maximal proton pump inhibitor (PPI) therapy. He underwent laparoscopic fundoplication, and endoscopy 3 months later showed complete resolution of the esophagitis. Subsequently, three RFA sessions with the Halo 90 device were performed, followed by one ‘touch-up’ argon plasma coagulation treatment to the residual small islands of Barrett’s epithelium. Biopsies revealed no dysplasia or intestinal metaplasia.

Despite concern that anatomical changes from fundoplication may impede sufficient contact between the esophageal mucosa and ablation catheter, several studies have demonstrated the efficacy and safety of RFA in patients with a history of fundoplication [2] [3] [4] [5]. However, there are no studies to date to show whether pre-emptive fundoplication in patients with endoscopic evidence of severe reflux disease would improve the efficacy of RFA in treating Barrett’s esophagus. It is postulated that persistent reflux impairs healing and re-epithelialization after RFA. While PPI only decreases the causticity of the refluxate, fundoplication has an advantage of providing a mechanical barrier to all refluxate [6]. A recent US RFA Registry study showed no significant difference in the response rates for RFA between those with and without a previous history of fundoplication [4]. However, the study did not target patients with erosive reflux disease at baseline prior to RFA, and fundoplication may have been performed in the remote past for other indications such as nonerosive reflux disease.

In conclusion, further studies are warranted to prove or disprove whether there is a role for pre-emptive fundoplication in individuals with Barrett’s esophagus and erosive reflux disease refractory to PPI.

• References

• 1 van Vilsteren FG, Alvarez Herrero L, Pouw RE et al. Predictive factors for initial treatment response after circumferential radiofrequency ablation for Barrett’s esophagus with early neoplasia: a prospective multicenter study. Endoscopy 2013; 45: 516-525
• 2 Hubbard N, Velanovich V. Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus in patients with fundoplications. Surg Endosc 2007; 21: 625-628
• 3 dos Santos RS, Bizekis C, Ebright M et al. Radiofrequency ablation for Barrett’s esophagus and low-grade dysplasia in combination with an antireflux procedure: a new paradigm. J Thorac Cardiovasc Surg 2010; 139: 713-716
• 4 Shaheen NJ, Kim HP, Bulsiewicz WJ et al. Prior fundoplication does not improve safety or efficacy outcomes of radiofrequency ablation: results from the U.S. RFA Registry. J Gastrointest Surg 2013; 17: 21-29
• 5 O’Connell K, Velanovich V. Effects of Nissen fundoplication on endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus. Surg Endosc 2001; 25: 830-834
• 6 Ireland AC, Holloway RH, Toouli J et al. Mechanisms underlying the antireflux action of fundoplication. Gut 1993; 34: 303-308