Complications Following Circumferential Radiofrequency Energy Ablation of Barrett's Esophagus Containing Early Neoplasia

Abstract

Background: Primary circumferential ablation (CA) and secondary focal ablation using radiofrequency energy has been proven effective in eradicating dysplasia and intestinal metaplasia (IM) in patients with Barrett's esophagus (BE). The aim of this study was to evaluate complications following primary CA in patients with BE +/− dysplasia, with and without prior endoscopic resection (ER) of visible abnormalities. Methods: All CA treatments were performed at our centre (July 2005-present) under one or more EC approved protocols and prospectively entered into a dedicated database. According to each protocol, BE patients with high-grade dysplasia (HGD) or intramucosal cancer (IMC) first underwent ER to remove visible lesions and IMC, followed by primary CA 6 weeks later to treat residual BE +/- dysplasia. Results: 65 patients (50 men, median age 69 years, median Prague C4M6) were treated with primary CA; in 47 patients a prior ER had been performed. Four patients (6%) were hospitalized after CA for observation of fever (n = 1), chest pain (n = 2), and injury to a previous ER site followed by a negative contrast study (n = 1). After conservative treatment and analgesics, all were discharged after 24-48 hours. In four patients (6%) a superficial laceration was observed immediately after CA. In one patient this was accompanied by a bleeding that was treated with adrenaline injection and hot biopsy forceps coagulation. All lacerations remained asymptomatic and did not require further treatment. Superficial lacerations all occurred in patients with prior ER (median of 2 resections, 33% of the circumference and 2.5 cm in length), and in whom the diameter of the ablation catheter exceeded the smallest diameter measured during preceding sizing of the esophageal inner diameter (ID). No lacerations were seen when an ablation catheter with a smaller diameter than the smallest measured ID was used (p = 0.09). Five patients (8%) developed dysphagia, resolved with a median of 3 (IQR 1-5) endoscopic dilatations. These patients all had prior widespread ER (median of 3 resections, 50% of the circumference, and 2 cm length), multiple ER sessions, or a narrow esophagus at baseline. Conclusion: Primary CA using radiofrequency energy is safe in patients without prior ER. If ER is performed to resect visible abnormalities, complications at subsequent CA can be avoided by limiting the extent of the ER to 50% of the circumference and 2 cm in length, and by conservative selection of the diameter of the ablation catheter.