Reply to Conio et al.

We thank Dr. Conio and colleagues for their comments on our study. Our study showed that circumferential balloon-based radiofrequency ablation (c-RFA) and endoscopic resection in a single session is feasible in patients with Barrett’s esophagus containing early neoplasia in the setting of an expert center [1]. Complete response for neoplasia was achieved in all 20 patients (100 %) and complete response for intestinal metaplasia was achieved in 19 of 20 patients (95 %) in a per protocol analysis. The intention-to-treat analysis included four additional patients who did not finish treatment due to unrelated disease (n = 2) or who underwent curative surgery as they were not eligible for further endoscopic treatment after initial (staging) endoscopic resection (n = 2). Based on our results, we advise that endoscopic resection followed by RFA after 6 – 8 weeks remains the standard treatment protocol for the combined use of endoscopic resection and RFA for early Barrett’s neoplasia for the majority of cases [1] [2]. Single-session c-RFA and endoscopic resection should be reserved for selected patients with large lesions or those at high risk for stenosis.

The relatively higher complication rate in our study likely reflects the different case mix, with more complex disease at baseline compared with other studies on the combined use of endoscopic resection and RFA: we did not use exclusion criteria for lesion size, Barrett’s length, and prior dilation. One esophageal perforation occurred in our study, and was successfully closed endoscopically with the “over-the-scope” clip. Oral contrast series showed no leakage. The patient remained asymptomatic and was discharged from hospital after 3 days. Based on the clinical course and the required intervention this complication was graded as moderate. For many years our research group has used a set of predefined criteria for registering and grading complications related to endoscopic treatment of early esophageal neoplasia [3] [4] [5]. Based on these criteria, we consider an endoscopically managed perforation to be a moderate complication, except for perforations that result in a hospital stay of > 10 days, admission to the intensive care unit, or that require surgery. All complications in our study were graded according to these definitions.

For patients who require widespread endoscopic resection in neoplastic Barrett’s esophagus to completely remove the non-flat component and to guarantee optimal staging, the optimal management RFA approach remains unknown. For these patients, five endoscopic treatment approaches using endoscopic resection and/or RFA are available: 1) the standard approach of endoscopic resection followed by RFA after 2 months, with RFA preceded by dilation sessions in cases of resection-induced stenosis; 2) single session of c-RFA and endoscopic resection for highly selected patients; 3) endoscopic resection followed by focal HALO⁹⁰ RFA for short-segment Barrett’s esophagus; 4) complete stepwise endoscopic resection of the Barrett’s mucosa (for Barrett’s segments of < 5 cm); 5) endoscopic resection followed by c-RFA applied distally and proximally to the stenosis for long-segment Barrett’s esophagus. Conio et al. describe successful treatment using some of these approaches and we congratulate them for their thoughtful management of their patients. In our opinion, stepwise radical endoscopic resection should only be used for patients with large lesions who have only minimal remaining Barrett’s esophagus after the endoscopic resection of the visible lesion. In these patients, additional endoscopic resection of the remaining Barrett’s mucosa does not significantly increase the stenosis risk, as the necessary widespread resection of the visible lesion is bound to lead to stenosis anyway. For most cases, however, serial endoscopic resection and RFA is preferred over (stepwise) radical endoscopic resection, given the higher stenosis risk after radical endoscopic resection, as was demonstrated by a recent randomized trial [4].

The letter from Conio et al. illustrates that the management of patients with widespread neoplastic lesions in Barrett’s esophagus is custom-made; endoscopic treatment should be tailored to each individual patient. Therefore, endoscopic treatment of early esophageal neoplasia should be centralized in tertiary referral centers with multidisciplinary expertise [5].

• References

• 1 van Vilsteren FG, Alvarez Herrero L, Pouw RE et al. Radiofrequency ablation and endoscopic resection in a single session for Barrett’s esophagus containing early neoplasia: a feasibility study. Endoscopy 2012; 44: 1096-1104
• 2 Pouw RE, Gondrie JJ, Sondermeijer CM et al. Eradication of Barrett esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection. J Gastrointest Surg 2008; 12: 1627-1636
• 3 Pouw RE, Seewald S, Gondrie JJ et al. Stepwise radical endoscopic resection for eradication of Barrett’s oesophagus with early neoplasia in a cohort of 169 patients. Gut 2010; 59: 1169-1177
• 4 van Vilsteren FG, Pouw RE, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773
• 5 van Vilsteren FG, Pouw RE, Herrero LA et al. Learning to perform endoscopic resection of esophageal neoplasia is associated with significant complications even within a structured training program. Endoscopy 2012; 44: 4-12