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• W2054357509 abstract "This issue of Gastrointestinal Endoscopy contains a single center randomized trial of endoscopic ablation therapy vs. surveillance in patients with Barrett's esophagus.1.Ackroyd R. Tam W. Schoeman M. Devitt P.G. Watson D.I. Prospective randomized controlled trial of argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus in patients following anti-reflux surgery.Gastrointest Endosc. 2004; 59: 1-7Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Ackroyd et al.1.Ackroyd R. Tam W. Schoeman M. Devitt P.G. Watson D.I. Prospective randomized controlled trial of argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus in patients following anti-reflux surgery.Gastrointest Endosc. 2004; 59: 1-7Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar are to be congratulated for this significant trial. Patients with predominantly non-dysplastic Barrett's esophagus were treated with 60 W of argon plasma coagulation (APC) or underwent surveillance after laparoscopic fundoplication. Thirty-nine patients were followed for 1 year. Complete elimination of Barrett's esophagus was achieved in 60% of patients in the APC group and, interestingly, in 15% of those in the surveillance group. Was the reversal in the surveillance group caused by fundoplication, surveillance endoscopic biopsies, or a postoperative sampling problem?It would be interesting to know the specific length of the short-segment Barrett's esophagus in the 3 patients in whom Barrett's esophagus was reversed in the surveillance group. Were any of the six 24-hour pH monitoring studies abnormal? One patient with recurrent reflux symptoms had relapse in the form of “columnar islands” and the fundoplication was not determined to be intact. This example emphasizes the importance of effective control of reflux symptoms after ablation therapy to maintain the new squamous epithelium. Documentation of the possibility of “buried Barrett's glands” in the biopsy specimens of squamous islands in the surveillance group would have been a provocative observation to contrast with the intestinal metaplasia underlying new squamous epithelium in the APC group.What is the current status of endoscopic ablation therapy of Barrett's esophagus? This editorial will focus on the endoscopic modalities, the results of trials, the goal of therapy, the candidates for therapy, and the unanswered questions.Thermal therapyEndoscopic ablative modalities include thermal, photodynamic, and mechanical. Thermal therapies destroy the surface of the esophagus as a result of generation of heat: electrocoagulation, APC, heat probe, and Nd:YAG laser. The first two have been most commonly applied, perhaps because they are most readily available in GI endoscopy units and result in relatively superficial injury with few major complications. At least 12 independent centers have evaluated APC in 444 patients with Barrett's esophagus, making this far and away the most commonly performed thermal technique.The variability of the results in relation to the successful reversal of Barrett's esophagus, residual intestinal metaplasia underlying new squamous epithelium, and complications highlight the lack of standardization in the application of APC. In a number of published series, complete reversal of Barrett's esophagus has ranged from 38%2.Kahaleh M. VanLaethem J.L. Nagy N. Cremer M. Deviere J. Long-term follow-up and factors predictive of recurrence in Barrett's esophagus treated by argon plasma coagulation and acid suppression.Endoscopy. 2002; 34: 950-955Crossref PubMed Scopus (98) Google Scholar to 98.6%,3.Schulz H. Miehlke S. Antos D. Schentke K.U. Vieth M. Stolte M. Bayerdorffer E. Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole.Gastrointest Endosc. 2000; 51: 659-663Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar with a median follow-up of 36 and 12 months, respectively. The low response rate in the former study was attributed to a strict definition of relapse, including “any biopsy showing glandular formation in the submucosa.” In addition, after endoscopic therapy “only standard doses of proton pump inhibitors (PPI) were given.”Underlying intestinal metaplasia has ranged from none3.Schulz H. Miehlke S. Antos D. Schentke K.U. Vieth M. Stolte M. Bayerdorffer E. Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole.Gastrointest Endosc. 2000; 51: 659-663Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar to 30%.4.Byrne J.P. Armstrong G.R. Attwood S.E.A. Restoration of the normal squamous lining in Barrett's esophagus by argon beam plasma coagulation.Am J Gastroenterol. 1998; 93: 1810-1815Crossref PubMed Scopus (176) Google Scholar The former series used higher energy (90 W) and a higher dose of PPI (omeprazole 40 mg three times a day) than other series. Interestingly, in this series in which high energy was used, only 3 patients (4.3%) developed strictures, requiring one dilation. In a series in which lower energy was used, there were two perforations4.Byrne J.P. Armstrong G.R. Attwood S.E.A. Restoration of the normal squamous lining in Barrett's esophagus by argon beam plasma coagulation.Am J Gastroenterol. 1998; 93: 1810-1815Crossref PubMed Scopus (176) Google Scholar and one death as part of the early experience. When using 65 to 70 W, there were 3 strictures requiring dilation, 5 patients with a mediastinal syndrome (high fever and pleural effusion) and one with pneumomediastinum.5.Pereiera-Lima J. Busnello J.V. Saul C. Toneloto E.B. Lopes C.V. Rynkowski C.B. et al.High power setting argon plasma coagulation for the eradication of Barrett's esophagus.Am J Gastroenterol. 2000; 95: 1661-1668PubMed Google Scholar Not only the level of energy, but other aspects of application must relate to complications. These include mucosal contact with variable pressure and repeated treatment to the same area.Photodynamic therapyPhotodynamic therapy involves the administration of a photosensitizer and the use of an activating wave length of light to a targeted area or the entire Barrett's esophagus. Singlet oxygen is formed, which results in destruction of esophageal mucosa. A more superficial injury results with the orally administrated photosensitizer 5-aminolevulinic acid (5ALA), which has been used to treat high-grade dysplasia (HGD) and superficial adenocarcinoma.6.Gossner L. Stolte M. Sroka R. Rick K. May A. Hahg E.G. et al.Photodynamic ablation of high-grade dysplasia and early cancer in Barrett's esophagus by means of 5-aminolevulinic acid.Gastroenterology. 1998; 114: 448-455Abstract Full Text Full Text PDF PubMed Scopus (410) Google Scholar The photosensitizer used in North America has been porfimer sodium, which is given intravenously and results in deep injury. Overholt et al.7.Overholt B.F. Panjehpour M. Halberg D.L. Photodynamic therapy for Barrett's esophagus with dysplasia and/or early carcinoma: long-term results.Gastrointest Endosc. 2003; 58: 183-188Abstract Full Text PDF PubMed Scopus (282) Google Scholar have an extensive experience with 101 patients (the majority with HGD) followed more than a minimum of 4 years. A cylindrical diffuse or a windowed centering balloon was used for light delivery. In the intention-to-treat analysis, 54% had no residual Barrett's esophagus. The success of elimination of low-grade dysplasia (LGD), HGD, and cancer was 93%, 78%, and 44%, respectively; suggesting that HGD and cancer are more resistant to this therapy. The overall stricture rate was 30%, indicating the greater depth of injury.A multicenter, randomized, partially blinded study of patients documented to have HGD compared with a control group undergoing endoscopic surveillance has been reported in abstract form.8.Overholt B. Lightdale C. Wang K. Canto M. Burdick S. Barr H. et al.International, multicenter, partially blinded, randomised study of the efficacy of photodynamic therapy (PDT) using porfimer sodium (POR) for the ablation of high-grade dysplasia (HGD) in Barrett's esophagus (BE): results of 24-month follow-up.Gastroenterology. 2003; 124 ([abstract]): A20Abstract Full Text PDF Google Scholar After a minimal follow-up of 2 years, there was a significant reduction of HGD (77% vs. 39%) and a 50% reduction of the development of cancer in the photodynamic therapy (PDT) arm. The detailed long-term results of this study, which resulted in Food and Drug Administration (FDA) approval, are eagerly awaited.Mechanical therapyThe major mechanical mode of endoscopic ablation, other than an intensive biopsy protocol, is EMR. One group has led the way in the application of this technique with a large series,9.Ell C. May A. Gossner L. Pech O. Gunter E. Mayer G. et al.Endoscopic mucosal resection of early cancer and high grade dysplasia in Barrett's esophagus.Gastroenterology. 2000; 118: 670-677Abstract Full Text Full Text PDF PubMed Scopus (689) Google Scholar long-term follow-up,10.May A. Gossner L. Pech O. Fritz A. Gunter E. Mayer G. et al.Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach.Eur J Gastroenterol Heptaol. 2002; 14: 1085-1091Crossref PubMed Scopus (352) Google Scholar and a randomized trial assessing different EMR techniques.11.May A. Gossner L. Behrens A. Kohnen R. Vieth M. Stolte M. et al.A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus.Gastrointest Endosc. 2003; 58: 167-175Abstract Full Text PDF PubMed Scopus (182) Google Scholar A low-risk group with early stage cancer in Barrett's esophagus included 35 patients with a lesion diameter of 2 cm or less, well or moderately differentiated, and limited to the mucosa. With a mean of 1.3 treatments, complete reversal of cancer was achieved in 97% of patients.9.Ell C. May A. Gossner L. Pech O. Gunter E. Mayer G. et al.Endoscopic mucosal resection of early cancer and high grade dysplasia in Barrett's esophagus.Gastroenterology. 2000; 118: 670-677Abstract Full Text Full Text PDF PubMed Scopus (689) Google Scholar At a mean follow-up of 1 year, 17% of cases had a local recurrence or metachronous cancer in the residual Barrett's esophagus. One case of spurting bleeding occurred; bleeding was controlled endoscopically. Seventy patients with HGD or early stage adenocarcinoma treated with EMR were included in a series of 115 patients. With a mean follow-up of 34 months, local remission was achieved in 98% with a complication rate of 9.5%.10.May A. Gossner L. Pech O. Fritz A. Gunter E. Mayer G. et al.Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach.Eur J Gastroenterol Heptaol. 2002; 14: 1085-1091Crossref PubMed Scopus (352) Google Scholar Again a 30% recurrent metachronous lesion rate was observed.EMR represents a major advance in the treatment of esophageal disease. The availability of more extensive tissue than provided by biopsies enables more accurate staging of the depth of invasion.12.Nijhawan P.K. Wang K.K. Endoscopic mucosal resection for lesions with endoscopic features suggestive of malignancy and high-grade dysplasia within Barrett's esophagus.Gastroenterology. 2000; 52: 328-332Scopus (243) Google Scholar Recurrent and metachronous cancer highlights the need for treating the entire at-risk lesion–all of the Barrett's esophagus. This is similar to the need to resect the entire Barrett's esophagus in an esophagectomy procedure.13.Heitmiller R.F. Redmond M. Hamilton S.R. Barrett's esophagus with high grade dysplasia: an indication for prophylactic esophagectomy.Ann Surg. 1996; 224: 66-71Crossref PubMed Scopus (307) Google ScholarThe recognition of the need to eliminate all intestinal metaplasia is highlighted by the recent application of a combination of modalities. Photodynamic therapy with porfimer sodium and Nd:YAG laser,14.Overholt B. Panjehpour M. Tefftellar E. Rose M. Photodynamic therapy for treatment of early adenocarcinoma in Barrett's esophagus.Gastrointest Endosc. 1993; 39: 73-76Abstract Full Text PDF PubMed Scopus (114) Google Scholar EMR, and PDT with 5ALA or meta-tetra(hydroxyphenyl)chlorin,10.May A. Gossner L. Pech O. Fritz A. Gunter E. Mayer G. et al.Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach.Eur J Gastroenterol Heptaol. 2002; 14: 1085-1091Crossref PubMed Scopus (352) Google Scholar and EMR and PDT with porfimer sodium15.Buttar N.S. Wang K.K. Lutzke L.S. Krishnadath K.K. Anderson M.A. et al.Combined endoscopic mucosal resection and photodynamic therapy for esophageal neoplasia with Barrett's esophagus.Gastrointest Endosc. 2001; 54: 682-688PubMed Scopus (217) Google Scholar have been used. In appropriately selected patients, multimodality endoscopic therapy can be successful (Fig. 1).The targetThe rationale for multimodality therapy is to individualize treatment based on the characteristics of the target lesion. Localized areas of HGD identified by optical techniques or a limited mucosal irregularity defined as a low-risk area are amenable to EMR. Diffuse or non-localized HGD is amenable to thermal therapy or PDT. Because HGD can be so difficult to differentiate from intramucosal cancer,16.Ormsby A.H. Petras R.E. Henricks W.H. Easley K. Rice T.W. Rybicki L.A. et al.Interobserver variation in the diagnosis of superficial oesophageal adenocarcinoma.Gut. 2002; 51: 671-676Crossref PubMed Scopus (177) Google Scholar a deeper injury, such as that achieved with PDT with porfimer sodium, may be advisable. As the sensitivity and specificity of EUS combined with FNA improves, more accurate staging of early cancers will be possible. The tissue provided by EMR also enables more accurate staging. Only localized disease can be treated with topical endoscopic ablation therapy. The 25% likelihood of regional lymph node metastases in cancer that invades through the muscularis mucosa requires more aggressive regional treatment in the form of surgery or chemoradiation.The goal of endoscopic therapyIn a patient with HGD, the goal is the prevention of the development of cancer. There is preliminary evidence from a randomized trial that PDT with porfimer sodium can achieve this.8.Overholt B. Lightdale C. Wang K. Canto M. Burdick S. Barr H. et al.International, multicenter, partially blinded, randomised study of the efficacy of photodynamic therapy (PDT) using porfimer sodium (POR) for the ablation of high-grade dysplasia (HGD) in Barrett's esophagus (BE): results of 24-month follow-up.Gastroenterology. 2003; 124 ([abstract]): A20Abstract Full Text PDF Google Scholar In a patient with early cancer, the proximate goal is the prevention of recurrent and metachronous cancer, which can develop in these high-risk patients.9.Ell C. May A. Gossner L. Pech O. Gunter E. Mayer G. et al.Endoscopic mucosal resection of early cancer and high grade dysplasia in Barrett's esophagus.Gastroenterology. 2000; 118: 670-677Abstract Full Text Full Text PDF PubMed Scopus (689) Google Scholar, 10.May A. Gossner L. Pech O. Fritz A. Gunter E. Mayer G. et al.Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach.Eur J Gastroenterol Heptaol. 2002; 14: 1085-1091Crossref PubMed Scopus (352) Google Scholar The ultimate goal is improved survival in Barrett's patients with early cancer. This will be a difficult target to achieve with the recognition that less than 5% of patients with Barrett's esophagus actually die from adenocarcinoma of the esophagus.17.VanDerBurgh A. Doos J. Hop W.J.C. VanBlankenstein M. Oesophageal cancer is an uncommon cause of death in patients with Barrett's oesophagus.Gut. 1996; 39: 5-8Crossref PubMed Scopus (302) Google Scholar, 18.MacDonald C.E. Wicks A.C. Playford R.J. Final results from 10 year cohort of patients undergoing surveillance for Barrett's oesophagus: observational study.BMJ. 2000; 321: 1252-1255Crossref PubMed Scopus (200) Google Scholar, 19.Anderson L.A. Murray L.J. Murphy S.J. Fitzpatrick D.A. Johnston B.T. Watson R.G.P. et al.Mortality in Barrett's oesophagus: results from a population based study.Gut. 2003; 52: 1081-1084Crossref PubMed Scopus (137) Google ScholarThe candidates for endoscopic therapyInitially, patients who refused surgery or were judged by a surgeon as not fit for surgery were considered candidates. With the progression of technology, the more widespread application of these techniques, and the emerging data herein reviewed; there has been an expansion of the pool of potential candidates. Many patients seek an alternative to surgery on being informed of the mortality and morbidity of the procedure. Although there are no direct comparison trials and experienced surgical centers have excellent results, the morbidity and mortality of endoscopic therapy can be projected to be considerably less than esophagectomy. Trials are now including patients who choose an endoscopic instead of a surgical approach. The FDA has approved the use of porfimer sodium “for the ablation of precancerous lesions” (HGD) in Barrett's esophagus patients “who do not undergo surgery to remove the esophagus.”20.U.S. Food and Drug Administration FDA approves photofrin for treatment of pre-cancerous lesions in Barrett's esophagus.FDA. 2003; Google Scholar Recent evidence-based editorials elegantly highlight the information necessary to define the risk of endoscopic techniques in the management of high-risk patients with Barrett's esophagus.21.Fennerty M.B. Endoscopic ablation of Barrett's related neoplasia: what is the evidence supporting its use?.Gastrointest Endosc. 2003; 58: 246-247Abstract Full Text PDF PubMed Scopus (5) Google Scholar, 22.Scheiman J.M. Wang K.K. EMR for early stage esophageal cancer: setting the stage for improved patient outcomes.Gastrointest Endosc. 2003; 58: 244-245Abstract Full Text PDF PubMed Scopus (6) Google ScholarUnanswered questionsWith the expansion of available modalities, multimodality therapy, and the enlarging pool of candidate patients, many issues need to be resolved.All endoscopic ablation modalities have been combined with PPI therapy or, less commonly, antireflux surgery. What amount of esophageal acid control is necessary for effective ablation? Recurrent Barrett's esophagus has been observed after fundoplication failure1.Ackroyd R. Tam W. Schoeman M. Devitt P.G. Watson D.I. Prospective randomized controlled trial of argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus in patients following anti-reflux surgery.Gastrointest Endosc. 2004; 59: 1-7Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar and successful reversal has been observed with ongoing abnormal distal esophageal acid exposure.23.Sampliner R.E. Camargo L. Fass R. Impact of esophageal acid exposure on the endoscopic reversal of Barrett's esophagus.Am J Gastroenterol. 2002; 97: 270-272Crossref PubMed Google ScholarWhich endoscopic modality is most effective in reversing Barrett's esophagus? Overall, PDT with porfimer sodium seems to have the lowest frequency of buried intestinal metaplasia under new squamous epithelium. Yet, it also has the highest complication rate; at least 30% of patients develop strictures requiring dilation. The low frequency of underlying intestinal metaplasia and the high frequency of strictures are both presumably related to the depth of injury. No comparative trials of different modalities are yet published, let alone a comparison to esophagectomy–a potential “reference standard” therapy, or at least formerly the standard therapy.How are the individual techniques best applied? The recent comparative trial of EMR techniques is an example of a randomized effort to define technical superiority, yet none was demonstrated. There are so many technical issues to address: the level of energy applied, the form of application (i.e., a diffuser or centering balloon for porfimer sodium, oral ingestion or spraying of 5ALA), and the pressure applied and re-treating areas for thermal techniques.How can combination therapy be evaluated? When considering the variables for only one technique, the application of a number of techniques in a rapidly evolving field offers an overwhelming number of options to evaluate.What are the criteria for appropriate candidates? Development of a generally accepted staging approach would be helpful. Careful description of eligible patients would enable better comparison of patient populations in different centers and countries.What is the end point of endoscopic ablation therapy? Elimination of HGD is not sufficient because of persisting molecular abnormalities.24.Krishnadath K.K. Wang K.K. Taniguchi K. Sebo T.J. Buttar N.S. Anderson M.A. et al.Persistent genetic abnormalities in Barrett's esophagus after photodynamic therapy.Gastroenterology. 2000; 119: 624-630Abstract Full Text Full Text PDF PubMed Scopus (124) Google Scholar To define the end point, the goals have to be clear: prevention of cancer, preservation of quality of life, cost-effectiveness.How can ablation be documented? Certainly an intensive biopsy protocol is necessary, but the specifics need to be defined and standardized. Until a “cure” can be defined, endoscopic surveillance seems prudent. The initial interval might be the same as for intensive surveillance of a patient with HGD, i.e., every 3 months. After repeated documentation of no HGD, no cancer, and no intestinal metaplasia, can we abandon surveillance?The future promises the refinement of existing techniques and the development of new ones. Clinical trials will better define appropriate techniques for specific targets and specific patients. A sound understanding of the biology of Barrett's esophagus and its neoplastic progression is essential for clinical application of endoscopic ablation. As understanding of the biology of Barrett's esophagus progresses, so will the selection of patients for endoscopic therapy and the individualization of therapy for each patient. This issue of Gastrointestinal Endoscopy contains a single center randomized trial of endoscopic ablation therapy vs. surveillance in patients with Barrett's esophagus.1.Ackroyd R. Tam W. Schoeman M. Devitt P.G. Watson D.I. Prospective randomized controlled trial of argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus in patients following anti-reflux surgery.Gastrointest Endosc. 2004; 59: 1-7Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar Ackroyd et al.1.Ackroyd R. Tam W. Schoeman M. Devitt P.G. Watson D.I. Prospective randomized controlled trial of argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus in patients following anti-reflux surgery.Gastrointest Endosc. 2004; 59: 1-7Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar are to be congratulated for this significant trial. Patients with predominantly non-dysplastic Barrett's esophagus were treated with 60 W of argon plasma coagulation (APC) or underwent surveillance after laparoscopic fundoplication. Thirty-nine patients were followed for 1 year. Complete elimination of Barrett's esophagus was achieved in 60% of patients in the APC group and, interestingly, in 15% of those in the surveillance group. Was the reversal in the surveillance group caused by fundoplication, surveillance endoscopic biopsies, or a postoperative sampling problem? It would be interesting to know the specific length of the short-segment Barrett's esophagus in the 3 patients in whom Barrett's esophagus was reversed in the surveillance group. Were any of the six 24-hour pH monitoring studies abnormal? One patient with recurrent reflux symptoms had relapse in the form of “columnar islands” and the fundoplication was not determined to be intact. This example emphasizes the importance of effective control of reflux symptoms after ablation therapy to maintain the new squamous epithelium. Documentation of the possibility of “buried Barrett's glands” in the biopsy specimens of squamous islands in the surveillance group would have been a provocative observation to contrast with the intestinal metaplasia underlying new squamous epithelium in the APC group. What is the current status of endoscopic ablation therapy of Barrett's esophagus? This editorial will focus on the endoscopic modalities, the results of trials, the goal of therapy, the candidates for therapy, and the unanswered questions. Thermal therapyEndoscopic ablative modalities include thermal, photodynamic, and mechanical. Thermal therapies destroy the surface of the esophagus as a result of generation of heat: electrocoagulation, APC, heat probe, and Nd:YAG laser. The first two have been most commonly applied, perhaps because they are most readily available in GI endoscopy units and result in relatively superficial injury with few major complications. At least 12 independent centers have evaluated APC in 444 patients with Barrett's esophagus, making this far and away the most commonly performed thermal technique.The variability of the results in relation to the successful reversal of Barrett's esophagus, residual intestinal metaplasia underlying new squamous epithelium, and complications highlight the lack of standardization in the application of APC. In a number of published series, complete reversal of Barrett's esophagus has ranged from 38%2.Kahaleh M. VanLaethem J.L. Nagy N. Cremer M. Deviere J. Long-term follow-up and factors predictive of recurrence in Barrett's esophagus treated by argon plasma coagulation and acid suppression.Endoscopy. 2002; 34: 950-955Crossref PubMed Scopus (98) Google Scholar to 98.6%,3.Schulz H. Miehlke S. Antos D. Schentke K.U. Vieth M. Stolte M. Bayerdorffer E. Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole.Gastrointest Endosc. 2000; 51: 659-663Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar with a median follow-up of 36 and 12 months, respectively. The low response rate in the former study was attributed to a strict definition of relapse, including “any biopsy showing glandular formation in the submucosa.” In addition, after endoscopic therapy “only standard doses of proton pump inhibitors (PPI) were given.”Underlying intestinal metaplasia has ranged from none3.Schulz H. Miehlke S. Antos D. Schentke K.U. Vieth M. Stolte M. Bayerdorffer E. Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole.Gastrointest Endosc. 2000; 51: 659-663Abstract Full Text Full Text PDF PubMed Scopus (161) Google Scholar to 30%.4.Byrne J.P. Armstrong G.R. Attwood S.E.A. Restoration of the normal squamous lining in Barrett's esophagus by argon beam plasma coagulation.Am J Gastroenterol. 1998; 93: 1810-1815Crossref PubMed Scopus (176) Google Scholar The former series used higher energy (90 W) and a higher dose of PPI (omeprazole 40 mg three times a day) than other series. Interestingly, in this series in which high energy was used, only 3 patients (4.3%) developed strictures, requiring one dilation. In a series in which lower energy was used, there were two perforations4.Byrne J.P. Armstrong G.R. Attwood S.E.A. Restoration of the normal squamous lining in Barrett's esophagus by argon beam plasma coagulation.Am J Gastroenterol. 1998; 93: 1810-1815Crossref PubMed Scopus (176) Google Scholar and one death as part of the early experience. When using 65 to 70 W, there were 3 strictures requiring dilation, 5 patients with a mediastinal syndrome (high fever and pleural effusion) and one with pneumomediastinum.5.Pereiera-Lima J. Busnello J.V. Saul C. Toneloto E.B. Lopes C.V. Rynkowski C.B. et al.High power setting argon plasma coagulation for the eradication of Barrett's esophagus.Am J Gastroenterol. 2000; 95: 1661-1668PubMed Google Scholar Not only the level of energy, but other aspects of application must relate to complications. These include mucosal contact with variable pressure and repeated treatment to the same area. Endoscopic ablative modalities include thermal, photodynamic, and mechanical. Thermal therapies destroy the surface of the esophagus as a result of generation of heat: electrocoagulation, APC, heat probe, and Nd:YAG laser. The first two have been most commonly applied, perhaps because they are most readily available in GI endoscopy units and result in relatively superficial injury with few major complications. At least 12 independent centers have evaluated APC in 444 patients with Barrett's esophagus, making this far and away the most commonly performed thermal technique. The variability of the results in relation to the successful reversal of Barrett's esophagus, residual intestinal metaplasia underlying new squamous epithelium, and complications highlight the lack of standardization in the application of APC. In a number of published series, complete reversal of Barrett's esophagus has ranged from 38%2.Kahaleh M. VanLaethem J.L. Nagy N. Cremer M. Deviere J. Long-term follow-up and factors predictive of recurrence in Barrett's esophagus treated by argon plasma coagulation and acid suppression.Endoscopy. 2002; 34: 950-955Crossref PubMed Scopus (98) Google Scholar to 98.6%,3.Schulz H. Miehlke S. Antos D. Schentke K.U. Vieth M. Stolte M. Bayerdorffer E. Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole.Gastrointest Endosc. 2000; 51: 659-663Abstract Full Text Full Text PDF PubM" @default.
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• W2054357509 title "Endoscopic ablative therapy for Barrett's esophagus: current status" @default.
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