A Randomized Controlled Trial of Ablation of Barrett’s Esophagus With Electrocautery vs. Argon Plasma Coagulation: Long-Term Results

Abstract

Background: Many modalities have been used to ablate Barrett’s esophagus (BE) including multipolar electrocoagulation (MPEC), argon plasma coagulation (APC), laser, heater probe, etc. However, long-term results and comparative effectiveness are not known. Aim: Our aim was to compare efficacy of achieving complete reversal (ie, endoscopic and histologic) between MPEC and APC in BE patients. Methods: Patients with BE, 2–6 cm long underwent 24-hour pH test on PPI therapy (rabeprazole 20 mg BID). Twenty-four-hour pH was performed by placing probe 5-cm above LES, after at least 7 days of PPI therapy. Patients were then randomized by BE length to undergo ablation with either MPEC or APC every 4–8 weeks till endoscopic reversal or maximum of 6 treatment sessions. If the patient developed reflux symptoms or had documented erosive esophagitis, PPI dose was increased. To document BE reversal, esophagus was sprayed with Lugol’s solution, and 4 quadrant jumbo biopsies every 2 cm were obtained. Biopsies were stained with H&E/alcian blue to detect residual intestinal metaplasia. Fisher’s exact test and logistic regression were done to study effect of BE length, pH scores, hernia size, PPI dose, and ablation modality in achieving BE reversal. Results: Thirty-five BE patients have been followed-up for at least 2 years after endoscopic ablation, 16 treated with MPEC, and 19 with APC. Mean age was 61 years (32–84 years), 34 males. Mean length of BE was 3.7 ± 1.7 cm. Median total time pH <4 was 0.6% (range 0–29.9%); median upright and supine values were 0.7% and 0% respectively. Acid exposure normalized in 26 patients (74%) on rabeprazole 20 mg BID. BE completely reversed in 24 patients (69%); 75% with MPEC, and 63% with APC (P = .49). Mean number of sessions required was 3.8 in MPEC and 3.4 in APC group (P = .48). There was no significant difference in either treatment type (MPEC vs. APC), pH results, BE length, PPI dose, or hernia size between patients with and without complete reversal. No GI bleed or perforations noted; one patient developed an esophageal stricture treated successfully with 1 dilation. Conclusions: In BE patients treated with MPEC or APC in combination with aggressive acid suppression, there are no significant predictors associated with achieving complete reversal of BE including BE length, 24-hour pH, hiatus hernia size, and PPI dose. At long-term follow-up (2 years), complete reversal of BE can be maintained in ∼ 70% of patients irrespective of technique, ie, MPEC vs. APC. Continued surveillance is still indicated in post-ablative setting.