What Are the Outcomes of Endoscopic Radiofrequency Ablation for Very Long Segments of Barrett Esophagus Containing Neoplasia?

Background: Radiofrequency ablation (RFA) is safe and effective for eradicating Barrett esophagus (BE) and neoplasia. Most studies have limited the baseline length of BE (<10 cm) and little is therefore known about RFA for very long BE segments. Aim: Assess the safety and efficacy of RFA for BE ≥10 cm containing neoplasia. Methods: Eligible patients (pts) had BE ≥10 cm with LGD, HGD or early cancer (EC). Pts underwent focal endoscopic resection (ER) for visible lesions, followed by circumferential (C-RFA) and focal RFA (F-RFA) every 2-3 mo until complete remission achieved (CR, defined as endoscopic resolution of BE and no evidence of intestinal metaplasia (IM) or neoplasia on biopsy). Follow-up (FU) endoscopy with 4Q/2 cm biopsies was performed at 2, 6, and 12 mo. Results: 26 consecutive pts were included (21 M, age 66 yrs, median BE length 11cm, range 10-20). Baseline ER was performed in 18/26 pts: EC (11), HGD (6), LGD (1). Worst grade of residual BE prior to RFA (and after ER as applicable): HGD (16), LGD (10).At entry, 13 pts (50%) had a proximal reflux stenosis (3 required dilation). After circumferential RFA, 7/26 (27%) had a non-transmural laceration (4 at the reflux stenosis, 3 at the prior ER). All were able to complete RFA. One pt with a relative stenosis after ER, developed dysfagia after RFA and required dilatation.By Nov'08, 9 pts are still under treatment (median regression: 95%), in 3 pts (12%) treatment was discontinued due to poor neosquamous regeneration. 14 pts have completed treatment with CR-IM and CR-neoplasia achieved after a median of 1(IQR 1-1) C-RFA and 2(IQR 1-3) F-RFA sessions. Two pts had a focal ER for small persisting islands after RFA. After a median FU of 9 mo, no recurrence of neoplasia was found. In 1 pt a 0.5mm island was found during FU, distal to a reflux stenosis at the upper end of the initial BE. One pt had focal IM detected at the neo-z-line at a single FU endoscopy. No buried BE was found in 752 neosquamous biopsies. Conclusion: Pts having very long segments of BE (10-20 cm in this evaluation) present challenges that we have not observed in our more typical BE pts: 12% of our pts with BE≥10 cm showed poor healing after RFA, probably reflecting the severity of the underlying reflux disease. Reflux stenoses and scarring after ER resulted in superficial laceration after circumferential RFA in 27% of pts, but these events were manageable. Overall we were able to achieve a CR in 14/17 who have completed therapy in a similar number of RFA sessions as required in shorter segment BE cohorts. Aside from the challenges noted, very long segments of BE can be treated safely and effectively with RFA.