Argon plasma coagulation for Barrett’s esophagus with low-grade dysplasia: a randomized trial with long-term follow-up on the impact of power setting and proton pump inhibitor dose

Abstract

<jats:p> Background This study evaluated the impact of power setting and proton pump inhibitor (PPI) dose on efficacy and safety of argon plasma coagulation (APC) of Barrett’s esophagus (BE) with low-grade dysplasia (LGD).</jats:p><jats:p> Methods 71 patients were randomized to APC with power set at 90 W or 60 W followed by 120 mg or 40 mg omeprazole. The primary outcome was the rate of complete (endoscopic and histologic) ablation of BE at 6 weeks. Secondary outcomes included safety and long-term efficacy.</jats:p><jats:p> Results Complete ablation rate in the 90 W/120 mg, 90 W/40 mg, and 60 W/120 mg groups was 78 % (18/23; 95 % confidence interval [CI] 61–95), 60 % (15/25; 95 %CI 41–79), 74 % (17/23; 95 %CI 56–92), respectively, at 6 weeks and 70 % (16/23; 95 %CI 51–88), 52 % (13/25; 95 %CI 32–72), and 65 % (15/23; 95 %CI 46–85) at 2 years post-treatment (differences not significant). Additional APC was required in 28 patients (23 residual and 5 recurrent BE). At median follow-up of 108 months, 66/71 patients (93 %; 95 %CI 87–99) maintained complete ablation. No high-grade dysplasia or adenocarcinoma developed. Overall, adverse events (97 % mild) did not differ significantly between groups. Chest pain/discomfort was more frequent in patients receiving 90 W vs. 60 W power (P &lt; 0.001). One patient had esophageal perforation and two developed stenosis.</jats:p><jats:p> Conclusions APC power setting and PPI dose did not impact efficacy and safety of BE ablation. Complete ablation of BE with LGD was durable in &gt; 90 % of patients, without any evidence of neoplasia progression in the long term.</jats:p>

The evolution of endoscopic therapy for Barrett’s esophagus

“…As previously discussed, APC was shown to have high initial eradication rates >95% 60 – 63 but a significant stricture formation rate in up to 4–9% of patients. Studies have shown that the combination of APC with prior submucosal injection, or hybrid-APC, can lower the depth of tissue damage, 105 , 106 possibly by up to 50% in comparison with standard APC.…”

“…While there is a great deal of heterogeneity regarding the efficacy and durability in achieving CE-D with APC, overall it has been shown to have high initial eradication rates >95%. 60 – 63 Unfortunately, BE treated with APC has been shown to result in a high rate of recurrent metaplasia and dysplasia in up to 35% of patients at long-term follow-up, and a risk of progression to EAC similar to patients who do not undergo ablative therapy at all (3% annual risk of progression), which may be due to buried glands under the neo-squamous epithelium that persist even after achieving complete eradication. 60 , 64 , 65 MPEC is another ablative therapy which requires direct contact between an endoscopic heater probe and the tissue being treated.…”

The role of ablation in the treatment of dysplastic Barrett’s esophagus

“…However, the differences were not significant, illustrating the APC power setting and PPI dose did not impact efficacy of BE ablation. 50 …”

“…Of the 71 patients who were randomized, 1 patient (1.4%) developed an esophageal perforation and 2 patients (2.8%) developed esophageal stenosis. 50 …”

New data on an old weapon: is argon plasma coagulation adequate treatment for dysplastic Barrett’s esophagus?

“…On this background, in this issue of Endoscopy, Wronska et al present the results of their randomized controlled trial of a well-established technology, argon plasma coagulation (APC), for the treatment of BE with low-grade dysplasia [5]. This remarkable single-center study randomized patients with BE and low-grade dysplasia to one of three arms: 1) high-energy APC (90 W)/high-dose proton pump inhibitor (PPI; 120 mg omeprazole daily); 2) high-energy APC/low-dose PPI (40 mg omeprazole daily); or 3) low-energy APC (60 W)/high-dose PPI.…”