BARRx for total Barrett’s eradication - the new super weapon?

In this issue of Endoscopy, several pilot series appear to show the value of radiofrequency ablation (BARRx, HALO) in treating Barrett’s esophagus [1] [2] [3] [4], mostly with neoplastic changes, with the clear aim of total Barrett’s eradication. Initially, only circumferential ablation devices were used, later supplemented by a focal ablation device. Eradication rates of both Barrett’s esophagus and Barrett’s-associated neoplasia (if flat/invisible) are very high in the articles in this issue, with almost no complications. These reports follow an initial large series from the USA, which reported the treatment of nondysplastic Barrett’s esophagus, with a complete eradication rate of only 70 % initially [5]; later, with the help of focal ablation, a 98 % ablation rate of Barrett’s epithelium was reached [6]. Another large US registry series including only cases with high-grade dysplasia (HGIN) achieved a high eradication rate for HGIN (90 %), with only moderate results for eradicating all Barrett’s mucosa (54 %), but again only using the balloon device [7]. Other recent papers were either small or used BARRx only in special situations [8] [9].

Initially, we planned to have these papers accompanied by an Editorial. However, we think that this topic is of such importance that we decided to broaden the coverage and include detailed articles on the pathogenesis of recurrent Barrett’s esophagus following interventional therapy, pathology traps, and also alternative therapies. These articles will appear in one of the forthcoming issues of Endoscopy. For the time being, we want to stress only a few issues that the readers should bear in mind when reading these and other articles on BARRx.

The number of published reports of this technique is still relatively limited so the conclusions should be viewed with caution. Complications and failures, which were unforeseen initially, may occur later; on the other hand, the technique develops over time and may produce even better results following modification. Inclusion criteria. Initial large series 5, as well as partially one of our papers in this issue 4, included nondysplastic Barrett’s esophagus, whereas the other studies 1 2 3 7 dealt with dysplastic Barrett’s esophagus. It will be exceedingly difficult to prove that ablation of nondysplastic Barrett’s esophagus will have a clinical benefit without stratifying patients at risk, which is currently not reliably possible. Treatment modalities and combinations. Initially, only a circumferential ablation device (HALO360) was available. In 2006, a focal ablation device (HALO-90) was incorporated to treat small residual islands. The Amsterdam concept furthermore includes endoscopic mucosal resection of visible neoplasia 1 2, followed by the combined use of circumferential and focal ablation, and this approach is likely to reach the best results. So please check with every publication on this technology what was done, how often, and in which conditions. More appears to be better, evidently. The definition of complete ablation should be agreed upon. One, or preferably two, follow-up endoscopies using state-of-the art technology and careful inspection should show only squamous epithelium and none of the 1-2 cm/4-quadrant biopsies should show Barrett’s esophagus (either superficial or buried). From that point the follow-up clock starts to tick, and every endoscopic and/or histologic Barrett’s esophagus found thereafter is to be considered as recurrence. In the papers published to date, different definitions are used for residual and recurrent Barrett’s esophagus. A consensus among researchers is mandatory. Visible Barrett’s islands versus buried glands. Barrett’s esophagus can remain in small islands after ablation therapy and, as shown in most studies, these can be effectively (re)treated. These islands can be very small and may require either narrow band imaging or Lugol’s staining for their detection. The term ”buried Barrett’s” refers to subsquamous focci of Barrett’s esophagus after ablation therapy. ”Buried glands” can only be diagnosed if the biopsies were truly obtained from endoscopically completely normal squamous epithelium, and care must be taken to avoid the tangential cutting of biopsies from small overlooked Barrett’s islands which may be misinterpreted in the histopathologic assessment as containing subsquamous glands. For these reasons, it is mandatory to keep in mind all the endoscopic, bioptic, and histologic pitfalls associated with it. Reference centers versus routine practice. In daily life, all the above requirements are unlikely to be fulfilled. For this very reason, it is even more important to set high standards in initial and later studies.

Stepwise circumferential and focal ablation using the HALO system seems to be an exciting new therapy; we are very keen to see further detailed results, and quite a few studies are already under way. If the initial excellent results hold true in the long term, then we interventional endoscopists might have to change our policy on neoplastic Barrett’s esophagus, and some very interesting discussions about nondysplastic Barrett’s esophagus will start. We can only hope that marketing will listen to clinical research (we have seen what may happen if not with endoscopic antireflux procedures), but scientific evaluation is on a good way, I believe. As mentioned above, this issue is to be continued in our journal.

Competing interests: None

References

• 1 Gondrie R E, Pouw C M, Sondermeijer T. 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;  40 359-379
• 2 Gondrie R E, Pouw C M, Sondermeijer T. et al . Effective treatment of early Barrett’s neoplasia with stepwise circumferential and focal ablation using the HALO system.  Endoscopy. 2008;  40 370-379
• 3 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
• 4 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
• 5 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
• 6 Fleischer D E, Overholt B F, Sharma V K. et al . Endoscopic ablation of Barrett’s esophagus: a multi-center study with 2.5 year follow-up.  Gastrointest Endosc. 2008;  Epub ahead of print
• 7 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;  Epub ahead of print
• 8 Roorda A K, Marcus S N, Triadafilopoulos G. Early experience with radiofrequency energy ablation therapy for Barrett’s esophagus with and without dysplasia.  Dis Esophagus. 2007;  20 516-522
• 9 Hubbard N, Velanovich V. Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus in patients with fundoplications.  Surg Endosc. 2007;  21 625-628