Fewer Complications With RF Ablation of Barrett's Esophagus

Jenni Laidman

May 29, 2014

Although both radiofrequency ablation (RFA) and complete endoscopic mucosal resection (EMR) are effective in eliminating dysplastic Barrett's esophagus, resection results in 5 times more complications than ablation, a new analysis shows.

The results were published in the May issue of Gastrointestinal Endoscopy.

In their study, Georgina Chadwick, MRCP, a clinical research fellow at the Royal College of Surgeons in the United Kingdom, and colleagues evaluated 22 studies involving 1087 patients — 532 treated with complete EMR and 555 treated with RFA.

The individual studies were small, ranging from 11 to 169 participants.

Only 1 was a direct comparison of EMR and RFA in patients with Barrett's esophagus with high-grade dysplasia or intramucosal cancer. It was 1 of 2 randomized controlled trials; the other compared RFA with sham treatment. Only 3 studies had control groups.

Although patient characteristics were similar among the studies, the median length of Barrett's esophagus varied from 2 to 10 cm.

Of the patients treated with complete EMR, 95% (95% confidence interval [CI], 87% - 99%) were cancer-free after a median follow-up of 23 months. Of the patients treated with RFA, 92% (95% CI, 85% - 96%) were cancer-free after a median follow-up of 21 months.

Intestinal metaplasia was eradicated to a similar extent with EMR and RFA (89% vs 88%). However, escape treatment was more common after complete EMR (50% vs 11%).

There were more short-term adverse events — often acute bleeding — with EMR than with RFA (12.0% vs 2.5%).

The most frequent long-term adverse event — esophageal stricture requiring additional treatment — was more common with EMR than with RFA (38% vs 4%). The persistence of glandular epithelium beneath new squamous epithelium was also more common with EMR (3.8% vs 0.0%).

Progression to cancer was rare after treatment, although the researchers note that no clear conclusion can be reached. During the median follow-up period of just under 2 years, the number of subsequent cancer diagnoses was similar in the EMR and RFA groups (9 vs 11).

"These results should be interpreted with caution because studies to date have been small and follow-up periods short," the researchers write.

Although EMR and RFA appear to be similarly effective, "adverse events are significantly greater after EMR," Dr. Chadwick told Medscape Medical News. "Further research needs to be done to prove the long-term — 5 or 10 year — durability of both treatments to confirm their superiority over surgery in the management of dysplastic Barrett's."

This meta-analysis confirms what other studies have found, particularly the 2 randomized controlled trials, said Kenneth Wang, MD, a gastroenterologist at the Mayo Clinic in Rochester, Minnesota, who was not involved in the study.

"I don't think there's anything new in this meta-analysis. Most secondary analyses rarely contradict what randomized controlled trials say. It's good to know, when you sum up all the data, that it confirms what you believe, but it's certainly not earth-shattering," said Dr. Wang, who is past president of the American Society for Gastrointestinal Endoscopy.

Clinicians in the United States are far more likely to use RFA than clinicians in Europe, Dr. Wang told Medscape Medical News.

In addition, this analysis does not include studies published last year that showed very high recurrence rates after RFA. "But the authors bring that up as a potential reason why you might want to consider mucosal resection," Dr. Wang said.

Although the 5-year follow-up in the randomized controlled trial that compared RFA with sham treatment appeared positive, "the authors didn't take into account what definition was used for recurrence," Dr. Wang reported. For instance, a patient who has had several treated recurrences but is cancer free at year 5 would be counted as not having recurrent disease. "The 5-year study looks good because most of the patients have been retreated," he explained.

There is little value in comparing RFA and EMR, said Steven DeMeester, MD, professor of surgery at the University of Southern California in Los Angeles, who was not involved in the study.

"It's setting up a comparison that, in most people's minds, isn't a comparison that you're particularly interested in," he said. "Most of the time, these treatments are complementary to one another, and very commonly both are employed in the same patients. It's not really a useful analysis to directly compare them."

Dr. DeMeester noted that endoscopic resection can be used to treat all kinds of high-grade dysplasia in Barrett's esophagus, whereas RFA is limited to flat non-nodular tissue. "It would be interesting to determine whether it's more effective to use endoscopic resection and RF for short segments of Barrett's, but in long segments, almost nobody is going to take that on with an endoscopic resection technique. The risk of stricture is too high."

This study was not designed to compare endoscopic treatments with esophagectomy, but Dr. Chadwick told Medscape Medical News that the British Society of Gastroenterology is clearly "in favor of endoscopic treatment over surgery as the treatment of choice for the management of [high-grade dysplasia], given the lower associated morbidity and mortality. Esophagectomy "is associated with significant morbidity and mortality," the researchers report.

"Morbidity, yes. Mortality, no," said Dr. DeMeester. "Several studies have shown that the mortality in esophagectomy in this group of patients is 1% or less. This gets misquoted again and again and again. The mortality rate for this group of patients — white, male, relatively affluent — is not high. I'm not suggesting it's the preferred therapy, but it needs to be considered as an option in patients with long Barrett's, multifocal disease, difficult-to-control reflux, and poor motility — things like that."

Dr. Chadwick, Dr. Wang, and Dr. DeMeester have disclosed no relevant financial relationships.

Gastrointest Endosc. 2014;79:718-731.e3. Abstract

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