2008 Annual Meeting Abstracts

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Background: Stepwise endoscopic circumferential and focal radiofrequency ablation (RFA) has been proven safe and effective for complete eradication of non-dysplastic Barrett’s esophagus (BE) in several trials. There is, however, little information regarding RFA for treatment of BE with high-grade dysplasia (HGD) or intramucosal carcinoma (IMC), and regarding the role, timing, and extent of endoscopic resection (ER) as adjuvant to RFA.AIM: Assess efficacy and safety of RFA for BE-HGD/IMC in pts +/- prior ER.
Methods: Enrolled pts had BE≤10 cm with HGD+/-IMC. Any visible lesions were endoscopically resected using the cap- or multiband mucosectomy (MBM) technique. Exclusions: cancer >T1m3, N+ disease on EUS. Circumferential ablation (CA) was performed with a balloon-based catheter and focal ablation (FA) with an endoscope-based catheter (HALO Systems). CA was performed 6wks after last ER (if applicable), followed by CA/FA every 2mos until BE was no longer evident on EGD. Thereafter, EGD with narrow band imaging and biopsies were performed at 2, 6, 12mos, then annually.
Results: 44 pts were included (35 M, median age 68yrs, median Prague C5M7). 35 ER sessions were performed in 31 pts (70%) prior to RFA. ER complications: 4 bleeds, 1 perforation. Worst ER histology per pt: 16 IMC, 12 HGD, 3 LGD. Post-ER/pre-RFA worst histology: 32 HGD, 10 LGD, 2 IM. Complete histological eradication of dysplasia and intestinal metaplasia (IM) was achieved in 43 pts (98%) after 1(1-2) CA and 2(1-2) FA, and 1 additional MBM in 3 pts. In one pt (2%) a 5-mm island with dysplasia persisted (protocol failure). In 3 pts a a non-transmural laceration (all asymptomatic) was observed at the level of the prior ER after CA using an ablation catheter with a relatively large diameter in relation to the esophageal diameter. Four pts developed dysphagia that resolved with dilations; all of them had widespread ER and/or a narrow esophagus at baseline. No stenoses or lacerations were observed in patients whithout prior ER.After a median of 12 mos (IQR 5-17) after last RFA, no dysplasia has recurred. In one patient, an endoscopically evident 1-mm BE island was identified at 18 mos after RFA, located where a 12 mo biopsy revealed 1 focus of subsquamous IM (SSIM). Five pts had focal IM detected immediately distal to the neo-squamocolumnar junction at a single FU. In 1475 biopsies obtained from neosquamous epithelium only one (0.07%) showed SSIM.
Conclusion: Stepwise CA and FA of BE-HGD/IMC with and without prior ER is highly effective in achieving complete eradication of dysplasia and IM (98%) and compares favorably to alternatives such as esophagectomy, radical ER or photodynamic therapy.

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