Reply to Oh et al.

We thank Oh et al. for their interest in our study. Oh and colleagues suggest studying the effect of pre-emptive fundoplication in Barrett’s patients with erosive reflux disease refractory to proton pump inhibitors (PPIs), prior to radiofrequency ablation (RFA) treatment. They present a case of a Barrett’s patient with high grade dysplasia and a grade D reflux esophagitis that was successfully treated with RFA after laparoscopic fundoplication. We congratulate Oh et al. on their successful treatment of this challenging case. However, we feel that a conservative and stepwise approach towards management of reflux disease in this patient category should be preferred.

Although patients with active reflux esophagitis have a higher risk of failure of RFA treatment, this failure will occur in only a small proportion of patients. This is illustrated by our study [1]. In our cohort of 278 patients undergoing RFA for treatment of early Barrett’s neoplasia, active reflux esophagitis at baseline was the strongest independent predictor of a “poor initial response,” defined as less than 50 % surface regression of the Barrett’s segment at 3 months after primary balloon-based RFA. In our study, 15 patients (6 %) had signs of active reflux esophagitis at baseline, of whom 13 patients achieved a complete response after RFA. None of these patients required fundoplication during or after the treatment phase.

Two patients with active reflux esophagitis at baseline ultimately failed to achieve a complete conversion of their Barrett’s segment. Both had a “poor initial response” to primary circumferential RFA. One patient was referred for Nissen fundoplication after which RFA treatment was resumed. This patient ultimately achieved a complete response.

Therefore, ultimately, RFA treatment will fail in only a minority of patients with active reflux esophagitis prior to RFA.

The case presented by Oh et al. represents a very rare group of patients, with (i) an indication for RFA treatment for Barrett’s esophagus, given the presence of high grade dysplasia, and (ii) a potential indication for fundoplication because of a PPI-refractory reflux esophagitis grade D with a large hiatal hernia. In our experience with RFA treatment in Barrett’s patients we have rarely encountered patients with both indications and fundoplication is hardly ever required to enable subsequent RFA treatment [1] [2] [3] [4]. For patients with active reflux esophagitis prior to RFA or during the RFA treatment phase, we advise checking and optimizing acid suppression (e. g. maximize PPI dosage, add an H2-blocker at night) and the patient’s compliance with medication and lifestyle advice. Fundoplication may be considered only in patients with pathologic reflux shown during 24-h pH-monitoring after optimization of medical treatment and lifestyle factors. We also like to point out that in patients with active reflux esophagitis, the grade of dysplasia may be overestimated, since active inflammation in Barrett’s esophagus may mimic dysplasia during histological assessment. This should be taken into account before clinical decisions are made in patients with active reflux esophagitis.

Finally, we need to recognize that Barrett’s patients with early neoplasia are generally aged over 65 years and often have significant co-morbidity. In addition, these patients have large hiatal hernias, and often a shortened esophagus that renders antireflux surgery more challenging and less successful [5] [6] [7] [8] [9].

Therefore, fundoplication in combination with RFA treatment should in our opinion only be considered for individual patients: (i) who have proven to have a poor response after their first circumferential RFA treatment; (ii) who still have an unequivocal diagnosis of early neoplasia; and (iii) who have pathological reflux on 24-h pH-monitoring under optimal medical treatment.

• References

• 1 Van Vilsteren FG, Alvarez HerreroL, 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 Pouw RE, 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
• 3 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
• 4 Phoa KN, Pouw RE, van Vilsteren FG et al. Remission of Barrett’s esophagus with early neoplasia 5 years after radiofrequency ablation with endoscopic resection: a Netherlands cohort study. Gastroenterology 2013; 145: 96-104
• 5 Singhal T, Balakrishnan S, Hussain A et al. Management of complications after laparoscopic Nissen’s fundoplication: a surgeon's perspective. Ann Surg Innov Res 2009; 3: 1
• 6 Urbach DR, Khajanchee YS, Glasgow RE et al. Preoperative determinants of an esophageal lengthening procedure in laparoscopic antireflux surgery. Surg Endosc 2001; 15: 1408-1412
• 7 Miholic J, Hafez J, Lenglinger J et al. Hiatal hernia, Barrett’s esophagus, and long-term symptom control after laparoscopic fundoplication for gastroesophageal reflux. Surg Endosc 2012; 26: 3225-3231
• 8 Attwood SE, Lundell L, Hatlebakk JG et al. Medical or surgical management of GERD patients with Barrett's esophagus: the LOTUS trial 3-year experience. J Gastrointest Surg 2008; 12: 1646-1654 discussion 1654-1655
• 9 Solaymani-Dodaran M, Logan RF, West J et al. Mortality associated with Barrett’s esophagus and gastroesophageal reflux disease diagnoses-a population-based cohort study. Am J Gastroenterol 2005; 100: 2616-2621