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Endoscopy 2010; 42(10): 781-789
DOI: 10.1055/s-0030-1255779
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic radiofrequency ablation for Barrett’s esophagus: 5-year outcomes from a prospective multicenter trial[*]

D.  E.  Fleischer1 , B.  F.  Overholt2 , V.  K.  Sharma1 , A.  Reymunde3 , M.  B.  Kimmey4 , R.  Chuttani5 , K.  J.  Chang6 , R.  Muthasamy6 , C.  J.  Lightdale7 , N.  Santiago3 , D.  K.  Pleskow5 , P.  J.  Dean8 , K.  K.  Wang9
  • 1Mayo Clinic, Scottsdale, Arizona, USA
  • 2Gastrointestinal Associates, Knoxville, Tennessee, USA
  • 3Ponce Gastroenterology, Ponce, Puerto Rico, USA
  • 4Tacoma Digestive Disease Center, Tacoma, Washington, USA
  • 5Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
  • 6University California, Irvine, California, USA
  • 7Columbia Presbyterian Medical Center, New York, USA
  • 8GI Pathology, Memphis, Tennessee, USA
  • 9Mayo Clinic, Rochester, Minnesota, USA
Further Information

Publication History

submitted 23 April 2010

accepted after revision 16 May 2010

Publication Date:
20 September 2010 (online)

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Background and study aims: The AIM-II Trial included patients with nondysplastic Barrett’s esophagus (NDBE) treated with radiofrequency ablation (RFA). Complete eradication of NDBE (complete response-intestinal metaplasia [CR-IM]) was achieved in 98.4 % of patients at 2.5 years. We report the proportion of patients demonstrating CR-IM at 5-year follow-up.

Patients and methods: Prospective, multicenter US trial (NCT00489268). After endoscopic RFA of NDBE up to 6 cm, patients with CR-IM at 2.5 years were eligible for longer-term follow-up. At 5 years, we obtained four-quadrant biopsies from every 1 cm of the original extent of Barrett’s esophagus. All specimens were reviewed by one expert gastrointestinal pathologist, followed by focal RFA and repeat biopsy if NDBE was identified. Primary outcomes were (i) proportion of patients demonstrating CR-IM at 5-year biopsy, and (ii) proportion of patients demonstrating CR-IM at 5-year biopsy or after the single-session focal RFA.

Results: Of 60 eligible patients, 50 consented to participate. Of 1473 esophageal specimens obtained at 5 years 85 % contained lamina propria or deeper tissue (per patient, mean 30 [13], standard deviation [SD] 13). CR-IM was demonstrated in 92 % (46 / 50) of patients, while 8 % (4 / 50) had focal NDBE; focal RFA converted all these to CR-IM. There were no buried glands, dysplasia, strictures, or serious adverse events. Kaplan-Meier CR-IM survival analysis showed probability of maintaining CR-IM for at least 4 years after first durable CR-IM was 0.91 (95 % confidence interval [CI] 0.77 – 0.97) and mean duration of CR-IM was 4.22 years (standard error [SE] 0.12).

Conclusions: In patients with NDBE treated with RFA, CR-IM was demonstrated in the majority of patients (92 %) at 5-year follow-up, biopsy depth was adequate to detect recurrence, and all failures (4 / 4, 100 %) were converted to CR-IM with single-session focal RFA.

1 An oral presentation of this work was given at the American Society for Gastrointestinal Endoscopy (ASGE) Presidential Plenary Session at Digestive Diseases Week (DDW) 2010.

References

  • 1 Haggitt R C. Barrett's esophagus: pathogenesis, dysplasia, and adenocarcinoma.  Hum Pathol. 1994;  25 982-993
    CrossrefPubMedGoogle Scholar
  • 2 Winters Jr. C, Spurling T J, Chobanian S J. et al . Barrett’s esophagus: a prevalent, occult complication of gastroesophageal reflux disease.  Gastroenterology. 1987;  92 118-124
    CrossrefPubMedGoogle Scholar
  • 3 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
  • 4 Sharma P, McQuaid K, Dent J. et al . A critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop.  Gastroenterology. 2004;  127 310-330
    CrossrefPubMedGoogle Scholar
  • 5 Watson A, Heading R C, Shepherd N A. Guidelines for the diagnosis and management of Barrett’s columnar-lined oesophagus: a report of the Working Party of the British Society of Gastroenterology. London; British Society of Gastroenterology 2005
    PubMedGoogle Scholar
  • 6 Boyer J, Laugier R, Chemali M. et al . French Society of Digestive Endoscopy SFED guideline: monitoring of patients with Barrett’s esophagus.  Endoscopy. 2007;  39 840-842
    Article in Thieme ConnectPubMedGoogle Scholar
  • 7 Society for Surgery of the Alimentary Tract . SSAT patient care guidelines. Management of Barrett’s esophagus.  J Gastrointest Surg. 2007;  11 1213-1215
    CrossrefPubMedGoogle Scholar
  • 8 Inadomi J M. Surveillance in Barrett’s esophagus: a failed premise.  Keio J Med. 2009;  58 12-18
    CrossrefPubMedGoogle Scholar
  • 9 Shaheen N J, Provenzale D, Sandler R S. Upper endoscopy as a screening and surveillance tool in esophageal adenocarcinoma: a review of the evidence.  Am J Gastroenterol. 2002;  97 1319-1327
    CrossrefPubMedGoogle Scholar
  • 10 Montgomery E, Bronner M P, Goldblum J R. et al . Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation.  Hum Pathol. 2001;  32 368-378
    CrossrefPubMedGoogle Scholar
  • 11 Reid B J, Haggitt R C, Rubin E C. et al . Observer variation in the diagnosis of dysplasia in Barrett’s esophagus.  Human Pathol. 1988;  19 166-178
    CrossrefPubMedGoogle Scholar
  • 12 Alikhan M, Rex D, Khan A. et al . Variable pathologic interpretation of columnar lined esophagus by general pathologists in community practice.  Gastrointest Endosc. 1999;  50 23-26
    CrossrefPubMedGoogle Scholar
  • 13 Abrams J A, Kapel R C, Lindberg G M. et al . Adherence to biopsy guidelines for Barrett’s esophagus surveillance in the community setting in the United States.  Clin Gastroenterol Hepatol. 2009;  7 736-742
    CrossrefPubMedGoogle Scholar
  • 14 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
  • 15 Dulai G S, Jensen D M, Cortina G. et al . Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett’s esophagus.  Gastrointest Endosc. 2005;  61 232-240
    CrossrefPubMedGoogle Scholar
  • 16 Fitzgerald R C. Complex diseases in gastroenterology and hepatology: GERD, Barrett’s, and esophageal adenocarcinoma.  Clin Gastroenterol Hepatol. 2005;  3 529-537
    CrossrefPubMedGoogle Scholar
  • 17 Rabinovitch P S, Longton G, Blount P L. et al . Predictors of progression in Barrett’s esophagus III: baseline flow cytometric variables.  Am J Gastroenterol. 2001;  96 3071-3083
    CrossrefPubMedGoogle Scholar
  • 18 Reid B J, Levine D S, Longton G. et al . Predictors of progression to cancer in Barrett’s esophagus: baseline histology and flow cytometry identify low- and high-risk patient subsets.  Am J Gastroenterol. 2000;  95 1669-1676
    PubMedGoogle Scholar
  • 19 Wijnhoven B P, Hussey D J, Watson D I. et al . MicroRNA profiling of Barrett’s oesophagus and oesophageal adenocarcinoma.  Br J Surg. 2010;  97 853-861
    CrossrefPubMedGoogle Scholar
  • 20 Huang Q, Hardie L J. Biomarkers in Barrett’s oesophagus.  Biochem Soc Trans. 2010;  38 343-347
    CrossrefPubMedGoogle Scholar
  • 21 Wani S, Puli S R, Shaheen N J. et al . Esophageal adenocarcinoma in Barrett’s esophagus after endoscopic ablative therapy: a meta-analysis and systematic review.  Am J Gastroenterol. 2009;  104 502-513
    CrossrefPubMedGoogle Scholar
  • 22 Sharma P, Falk G W, Weston A P. et al . Dysplasia and cancer in a large multicenter cohort of patients with Barrett’s esophagus.  Clin Gastroenterol Hepatol. 2006;  4 566-572
    CrossrefPubMedGoogle Scholar
  • 23 Shaheen N J, Crosby M A, Bozymski E M, Sandler R S. Is there publication bias in the reporting of cancer risk in Barrett’s esophagus?.  Gastroenterology. 2000;  119 333-338
    CrossrefPubMedGoogle Scholar
  • 24 Anderson L A, Murray L J, Murphy S J. et al . Mortality in Barrett’s oesophagus: results from a population based study.  Gut. 2003;  52 1081-1084
    CrossrefPubMedGoogle Scholar
  • 25 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
  • 26 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
  • 27 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
  • 28 Lyday W D, Corbett F S, Kuperman D A. et al . Radiofrequency ablation of Barrett’s esophagus: outcomes of 429 patients from a multicenter community practice registry.  Endoscopy. 2010;  42 272-278
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 dos Santos R S, 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
    CrossrefPubMedGoogle Scholar
  • 30 Velanovich V. Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus: initial results and lessons learned.  Surg Endosc. 2009;  23 2175-2180
    CrossrefPubMedGoogle Scholar
  • 31 Sharma V K, Kim H J, Das A. et al . Circumferential and focal ablation of Barrett’s esophagus containing dysplasia.  Am J Gastroenterol. 2009;  104 310-317
    CrossrefPubMedGoogle Scholar
  • 32 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
  • 33 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 1627-1636
    CrossrefPubMedGoogle Scholar
  • 34 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
  • 35 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
  • 36 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
  • 37 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
  • 38 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
  • 39 Roorda A K, Marcus S N, Triadafilopoulos G. Early experience with radiofrequency energy ablation for Barrett’s esophagus with and without dysplasia.  Dis Esophagus. 2007;  20 516-522
    CrossrefPubMedGoogle Scholar
  • 40 Hubbard N, Velanovich V. Endoscopic endolumenal radiofrequency ablation of Barrett’s esophagus in patients with fundoplication.  Surg Endosc. 2007;  21 625-628
    CrossrefPubMedGoogle Scholar
  • 41 Wani S, Sayana H, Sharma P. Endoscopic eradication of Barrett’s esophagus.  Gastrointest Endosc. 2010;  71 147-166
    CrossrefPubMedGoogle Scholar
  • 42 Basu K K, Pick B, Bale R. et al . Efficacy and one year follow up of argon plasma coagulation therapy for ablation of Barrett’s oesophagus: factors determining persistence and recurrence of Barrett’s epithelium.  Gut. 2002;  51 776-780
    CrossrefPubMedGoogle Scholar
  • 43 Sharma P, Bhattacharyya A, Garewal H S. et al . Durability of new squamous epithelium after endoscopic reversal of Barrett’s esophagus.  Gastrointest Endosc. 1999;  50 159-164
    CrossrefPubMedGoogle Scholar
  • 44 Overholt B F, Wang K K, Burdick J S. et al . Five-year safety and efficacy of photodynamic therapy with Photofrin in Barrett’s high-grade dysplasia.  Gastrointest Endosc. 2007;  66 460-468
    CrossrefPubMedGoogle Scholar
  • 45 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
  • 46 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
  • 47 Ban S, Mino M, Nishioka N S. et al . Histopathologic aspects of photodynamic therapy for dysplasia and early adenocarcinoma arising in Barrett’s esophagus.  Am J Surg Pathol. 2004;  28 1466-1473
    CrossrefPubMedGoogle Scholar
  • 48 Sharma P, Morales T G, Bhattacharyya A. et al . Squamous islands in Barrett’s esophagus: what lies underneath?.  Am J Gastroenterol. 1998;  93 332-335
    CrossrefPubMedGoogle Scholar
  • 49 Shaheen N J, Goldblum J R, Sampliner R E. et al . Are biopsies after ablation for dysplastic Barrett’s esophagus of adequate depth to detect glandular mucosa beneath the neosquamous epithelium? Comparative histopathological outcomes from a randomized, sham-controlled trial (AIM Dysplasia Trial).  Gastroenterology. 2008;  134 A-724
    PubMedGoogle Scholar

1 An oral presentation of this work was given at the American Society for Gastrointestinal Endoscopy (ASGE) Presidential Plenary Session at Digestive Diseases Week (DDW) 2010.

D. E. FleischerMD 

Mayo Clinic, Scottsdale

13400 East Shea Boulevard
Scottsdale, AZ 85259-5499
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Fax: +1-480-301-8673

Email: Fleischer.David@mayo.edu