Radiofrequency Ablation for Barrett’s Esophagus

Overview

• What is Radiofrequency Ablation?

  Radiofrequency ablation (RFA) is a procedure using high-energy radio waves to burn and destroy pre-cancerous cells. This method has been used to treat various conditions in different parts of the body, including precancerous conditions of the esophagus. Special devices are made to deliver the energy in different settings.

• What is Barrett’s esophagus?

  Barrett’s esophagus is a condition in which the normal lining of the wall of the esophagus (the food pipe connecting the mouth to the stomach) is being replaced by cells similar to that of the small intestine due to acid reflux from the stomach. This is found in about 10 to 15 percent of patients with gastroesophageal reflux disease (GERD).

• What is dysplasia?

  Dysplasia describes the presence of precancerous changes in the cells. The level of dysplasia tells how extensive the precancerous changes are.

  • “No Dysplasia” means that the Barrett’s esophagus cells show no precancerous changes.
  • “Low-Grade Dysplasia” means that the cells show some of the early characteristics of cancer.
  • “High-Grade Dysplasia” means that the cells show more advanced changes of cancer. The worse the stage of dysplasia, the higher the risk that the Barrett’s esophagus will go on to become cancer.
• Why do we need to treat Barrett’s esophagus when precancerous changes occur?

  Barrett’s esophagus does not generally “heal” itself or change back to normal tissue, even when it is being treated with the acid reflux medicines that stops heartburn. Medications such as omeprazole, esomeprazole, lansoprazole, pantoprazole, dexlansoprazole, and rabeprazole, which are commonly used for acid reflux, will not make Barrett’s esophagus go away. Barrett’s esophagus can progress into a precancerous state in a small percentage of patients. If these precancerous cells are not eliminated, they can further progress into esophageal cancer. Treatment of dysplasia with RFA in patients with Barrett’s esophagus has been shown to prevent esophageal cancer.

• How does radiofrequency ablation cure Barrett’s esophagus?

  RFA uses heat energy to destroy the precancerous cells. The burned tissue sloughs off over 48 to 72 hours following the procedure. The patient is then treated with a high dose of proton pump inhibitor, a potent acid suppressive medicine, and an ulcer coating agent called sucralfate. Over a period of six to eight weeks, the area will be replaced by new, normal lining.

• When do we consider RFA for Barrett’s esophagus?

  Guidelines from the American College of Gastroenterology published in 2015 recommend that all patients with high grade dysplasia be treated with RFA therapy. Patients with nodules, or bumps, in their Barrett’s may require removal of these bumps prior to treatment with RFA. This removal of nodules is known as endoscopic mucosal resection, or “EMR.” 

  For patients with confirmed low-grade dysplasia and without a short life expectancy, endoscopic therapy such as RFA is considered as the preferred treatment. In the case of low-grade dysplasia, another alternative to RFA is to continue to monitor the condition with endoscopies every 12 months, and only to perform the RFA treatments if the Barrett’s shows progression to high-grade dysplasia or early cancer. This is because low-grade dysplasia turns to cancer less frequently than high-grade dysplasia.

• Should all patients with Barrett’s esophagus be treated with RFA?

  Because the progression of Barrett’s esophagus without dysplasia to esophageal cancer is very rare and the long-term benefit of treating these tissues to prevent esophageal cancer is not known; the ACG guidelines do not recommend the routine use of RFA in this situation. This is a very important point, and means that most patients who have Barrett’s esophagus will not require RFA, since most patients do not develop precancerous changes. 

• How effective is radiofrequency ablation therapy?

  Overall, RFA completely removes Barrett’s esophagus and dysplasia in a high proportion of patients, as shown in results from multiple clinical studies. The success rate is about 80 to 90 percent. However, once the RFA removes the Barrett’s, there is no guarantee that it might not develop again down the road. In fact, over 10 percent of patients who are treated successfully for Barrett’s esophagus with RFA develop have Barrett’s again months to years after the first treatment.

  Fortunately, repeat treatments with ablation can eliminate these abnormal tissues entirely.  Because of the possibility that the Barrett’s can form again, your doctor will likely recommend that you have regular endoscopies even after you have been successfully treated.

• How is RFA performed?

  The patient will undergo an upper GI endoscopy, with a careful examination of the esophagus, stomach, and the upper part of the small bowel using a camera fixed at the end of a special tube called an endoscope. The location of the Barrett’s or dysplastic tissues will then be identified, and the doctor will choose the appropriate ablation catheter for the treatment.

• What should a patient expect before and after RFA?

  Before the procedure

  The preparation is similar to preparing for an upper endoscopy. Do not eat or drink after midnight the day of or at least eight hours before the procedure. Make an arrangement to have someone drive you home after the procedure. Aspirin or other blood thinning medications will need to be stopped a few days before the procedures. Please check with your doctor for specific recommendations.  

  Day of the procedure

  The procedure is usually performed in an outpatient setting under sedation. The time taken for the entire process may vary and usually takes less than one hour. Extra time is needed for preparation before the procedure and recovery from sedation after the procedure.

  After the procedure

  Because the esophagus is a sensitive organ, patients usually experience mild to intense chest pain, which improves gradually for several days following the procedure.  Pain medications and numbing medicines will be prescribed by your doctor to help with your symptoms. You will need to take an acid suppressive medicine, usually a double dose of proton pump inhibitor, and an ulcer coating medicine (sucralfate) to assist the healing of the treated areas. A follow-up appointment will be scheduled by your doctor.

• How many sessions are needed?

  On average, one to three RFA treatment sessions are required to completely remove all of the Barrett’s esophagus and or dysplastic tissue. A follow-up endoscopy is performed at two- to three-month intervals to reassess for further treatment.

• What is the recovery time from a RFA session?

  Patients recover from the sedation within 30 to 60 minutes. Oral pain medications and numbing solution may be needed to reduce the chest discomfort. A modified, soft diet is usually recommended for the first few days after the procedure. Patients may return to work the day after their procedure.

• What is the long-term follow-up?

  Low acid is preferred to allow the esophagus to replace the destroyed tissue with normal tissue, also known as squamous mucosa. All patients will be treated with high-dose acid suppressive medicine using a proton pump inhibitor indefinitely. After the Barrett’s has been destroyed and replaced by normal tissue, patients will need periodic upper endoscopy to ensure that the Barrett's mucosa does not recur.

• What are the adverse effects of RFA?

  RFA is a safe and well-tolerated procedure. However, a large proportion of patients may have chest pain or pain when swallowing for 24 to 48 hours following the procedure. Most symptoms typically resolve within a few days.

  About five percent of patients may develop narrowing of the esophagus, known as a stricture after RFA. A stricture may require additional procedures to stretch (dilate) the esophagus. Major bleeding or tear to the esophagus are uncommon and occur in less than 1 percent of patients.

• Are there any alternative treatments?

  Different therapies are available to destroy or remove Barrett’s esophagus or dysplasia, which you can discuss with your doctor. Some methods used currently include:

  • Cryotherapy – a freezing method using liquid nitrogen;
  • Photodynamic Therapy (PDT) – a method where a chemical is given intravenously, which makes the patient’s tissues reactive to a specific laser light. The light is then shined on the tissue to create a reaction that destroys the abnormal tissues;
  • Argon Plasma Coagulation (APC) – a procedure using high power electric current, which is delivered by spraying argon gas onto the tissue; and
  • Endoscopic Mucosal Resection (EMR) – an endoscopic procedure using special accessories to remove the abnormal tissues.

Author(s) and Publication Date(s)

Ronald Hsu, MD, FACG, FACP, FRCP, Clinical Professor of Medicine, University of California, Davis, School of Medicine – Published July 2019.

Sources

Shaheen NJ, Falk GW, PG Iyer et al: Diagnosis and Management of Barrett’s Esophagus. Am J Gastroenterol 2016; 111:30–50.

Shaheen NJ, Sharma P, Overholt BF et al: Radiofrequency ablation in Barrett’s esophagus with dysplasia with dysplasia. N Engl J Med 2009;360:2277-2288.

Orman ES, Li N, Shaheen NJ. Efficacy and durability of radiofrequency ablation for Barrett’s Esophagus: systemic review and meta-analysis. Clin Gastroenterol Hepatol 2013 Oct; 11(10):1245-55.

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