Incidence and outcomes of poor healing and poor squamous regeneration after radiofrequency ablation therapy for early Barrett’s neoplasia

Abstract

Background Although endoscopic eradication therapy with radiofrequency ablation (RFA) is effective in most Barrett’s Esophagus (BE) patients, some might experience poor healing (PH) and/or poor squamous regeneration (PSR). We aimed to evaluate PH/PSR incidence and treatment outcomes. Methods We included all patients treated with RFA for early BE neoplasia, from a nationwide Dutch registry based on a joint treatment protocol. PH was defined as active inflammatory changes or visible ulcerations ≥3 months post-RFA, PSR as <50% squamous regeneration, and treatment success as complete eradication of BE (CE-BE). <b>Results</b> 1,386 patients (median BE C2M5) underwent RFA with baseline low-grade dysplasia (27%), high-grade dysplasia (30%), or early cancer (43%). In all 134 patients with PH (10%), additional time and acid suppression resulted in complete esophageal healing. 67/134 (50%) had normal regeneration with 97% CE-BE. In total, 74 patients had PSR (5%). As compared to patients with normal squamous regeneration, PSR patients had a higher risk for treatment failure (64% versus 2%, RR 27 [95% CI 18-40]) and progression to advanced disease (15% versus <1%, RR 30 [95% CI 12-81]). Higher BMI, longer BE, reflux esophagitis, and <50% squamous regeneration after baseline endoscopic resection were independently associated with PSR in multivariable logistic regression. <b>Conclusions</b> In half of the patients with PH, additional time and acid suppression may lead to normal squamous regeneration and excellent treatment outcomes. However, if patients experience PSR, the risk for treatment failure and progression to advanced disease is significantly increased with a relative risk of 27 and 30, respectively.

Bile acid sequestrants in poor healing after endoscopic therapy of Barrett’s esophagus

“…Nevertheless, in clinical practice, we regularly see patients in whom resection followed by ablation fails to achieve complete squamous epithelialization of the esophagus. 3 Thus, we observe inadequate healing with fibrin-covered ulceration, or healing with undesired Barrett's mucosa (neo-Barrett's). Some studies have reported BE recurrence after previous complete endoscopic therapy.…”

“…We observed wound healing disorders in almost every 8th patient in our cohort, which is in concordance with previous and recently published studies. 3 , 20 That means that a non-healing BE after endoscopic therapy is a frequent problem and must be considered by interventional endoscopists. The definition of complete eradication of intestinal metaplasia varies.…”

Today’s Mistakes and Tomorrow’s Wisdom in Endoscopic Treatment and Follow-Up of Barrett’s Esophagus

“…Finally, although ablation spares the patient the morbidity of many endoscopic resection procedures, "escape resection" should be used when ablation fails after repeated procedures. Indeed, the increased risk of neoplastic progression of the patients with poor squamous regeneration after ablation should be kept in mind [37].…”

Radiofrequency ablation: time to think of poor responders

“…Following their previous RFA outcome study, van Munster et al [4] present results of an observational study, again based on data from the Dutch Barrett's Expert Center registry, in this issue of Endoscopy. The study provides a detailed analysis of the characteristics and outcomes of patients with neoplastic BE who had a poor response to RFA therapy.…”