Hybrid Argon Plasma Coagulation Research Articles

A127 ENDOSCOPIC MUCOSAL RESECTION WITH HYBRID-ARGON PLASMA ABLATION TO PREVENT RECURRENCE OF 20 MM NON-PEDUNCULATED COLORECTAL POLYPS: A MULTI-CENTER PROSPECTIVE CLINICAL STUDY

Abstract Background Endoscopic mucosal resection (EMR) is the mainstay of therapy for non-pedunculated colorectal polyps 20 mm or larger. Post EMR recurrence rates are about 15% if no margin ablation technique is used. Aims Study aim was to evaluate recurrence rates if hybrid Argon Plasma Coagulation ablation (h-APC) is routinely used after the EMR to ablate the margins, base and vessels. Methods A prospective multi-center study including adult patients (18-89 years) undergoing EMR of non-pedunculated colorectal polyps 20 mm or larger was conducted. h-APC was used to ablate all post EMR margins and to ablate the post EMR resection surface and visible submucosal vessels. The primary outcome was the biopsy proven recurrence rate at the first follow-up colonoscopy (4-6 months after EMR). All the resection sites were visually inspected, and biopsies were obtained from the EMR scar. Secondary outcomes included technical success and complication rates. Results A total of 220 EMRs were performed during the study for h-APC ablation of non-pedunculated colorectal polyps, with a size of ≥20 mm. The average size of the polyps included in the study was 35.7 mm (ranging from 20 mm to 100 mm). Among all resected polyps, 16.8% were sessile serrated lesions (SSL), while 66.3% were adenomas. Additionally, 4 cases of cancer were in the study. The application of hot snare EMR with h-APC ablation was technically successful and completed for all cases. The mean duration of the EMR procedure was 19.6 minutes, ranging from 2.3 to 103 minutes, while the mean duration of h-APC ablation was 6.4 minutes, ranging from 1 to 65 minutes. A total of 147 EMRs with follow up examination (57 EMR involving lesions 40mm or larger) are available currently. The overall recurrence rate was 1.3% (2 out of 147 cases). For cases where complete base ablation was achieved, there was a 0% recurrence rate, including lesions 40mm or larger. For lesions measuring 40mm or larger, the recurrence rate was 1.8% (1 out of 54 cases). Out of the 220 total EMRs conducted, perforations were observed in 0.9% (2 cases, managed conservatively with antibiotics only), and clinically significant bleeding occurred in 2.3% (5 cases). In particular, clinically significant bleeding was noted in 2.3% (4 out of 167 cases) of lesions without clipping and in 4.0% (4 out of 99 cases) for right-sided lesions without clipping. Conclusions In this multicenter study EMR in combination with h-APC demonstrated a high technical success rate with low complication rates and showed very low post EMR recurrence in the preliminary data analysis. Funding Agencies Erbe

Efficacy and Safety of Argon Plasma Coagulation for the Ablation of Barrett's Esophagus: A Systemic Review and Meta-Analysis.

Argon plasma coagulation (APC) is an alternate ablative method to radiofrequency ablation for the treatment of Barrett's esophagus (BE), and it is preferred due to its lower cost and widespread availability. The present meta-analysis aimed to analyze the safety and efficacy of APC for the management of BE. A literature search from January 2000 to November 2022 was done for studies analyzing the outcome of APC in BE. The primary outcomes were clearance rate of intestinal metaplasia and adverse events (AE). Pooled event rates were expressed with summative statistics. A total of 38 studies were included in the final analysis. The pooled event rate for clearance rate of intestinal metaplasia with APC in BE was 86.8% (95% confidence interval [CI], 83.5% to 90.2%), with high-power and hybrid APC having a higher rate compared to standard APC. The pooled incidence of AE with APC in BE was 22.5% (95% CI, 15.3% to 29.7%), without any significant difference between the subgroups, with self-limited chest pain being the commonest AE. The incidence of serious AE was only 0.4% (95% CI, 0.0% to 1.0%), while stricture development was seen only in 1.7% (95% CI, 0.9% to 2.6%) of cases. The pooled recurrence rate of BE was 16.1% (95% CI, 10.7% to 21.6%), with a significantly lower recurrence with high-power APC than standard APC. High-power and hybrid APC seem to have an advantage over standard APC in terms of clearance rate and recurrence rate. Further studies are required to compare the efficacy and safety of hybrid APC with standard APC and radiofrequency ablation.

What Is "Cold" and What Is "Hot" in Mucosal Ablation for Barrett's Oesophagus-Related Dysplasia: A Practical Guide.

Over the last two decades, endoscopic eradication therapy has been established as the therapeutic strategy of choice for patients with Barrett's oesophagus-related dysplasia and early oesophageal adenocarcinoma. With a multimodal approach, ablative therapies have been highly effective in achieving remarkable eradication rates of metaplastic epithelium with an acceptable adverse event rate. Among ablative techniques, radiofrequency ablation is currently considered as the first-line option as its efficacy and safety are strongly supported by relevant data. Nevertheless, radiofrequency ablation is costly, and not universally available, or applicable to every situation. Moreover, primary failure and recurrence rates are not negligible. In the last few years, cryotherapy techniques and hybrid argon plasma coagulation have been increasingly assessed as potential novel ablative therapies. Preliminary data have been promising and suggest that they may even have a role as first-line options, alternatively to radiofrequency ablation. The aim of this review is to provide a practical guide for the ablation of Barrett's oesophagus, with emphasis on the different ablative options.

Hybrid Argon Plasma Coagulation for Barrett's Esophagus and for Colonic Mucosal Resection-A Systematic Review and Meta-Analysis.

Hybrid argon plasma coagulation (hAPC) is a novel technique that combines conventional argon plasma coagulation and waterjet submucosal expansion. The aims of this metanalysis were to evaluate the efficacy and safety of hAPC in the setting of Barret's esophagus (BE) ablation and as an adjunct to colonic endoscopic mucosal resection (EMR). Four electronic databases were searched, and the results were analyzed by two independent authors. Random-effects meta-analyses of the proportions of endoscopic and histologic remission (for BE), recurrence, and post-procedure adverse events were performed using R. Studies' reporting quality was also assessed. From the 979 identified records, 13 studies were included (10 regarding BE and three colonic EMR). The pooled percentages of endoscopic and histologic remission after hAPC for BE were 95% (95% confidence interval [CI] 91-99, I2 = 34) and 90% (95%CI 84-95, I2 = 46), respectively, while major adverse events and recurrence were registered in 2% (95%CI 0-5, I2 = 41) and 11% (95%CI 2-27, I2 = 11), respectively. Concerning hAPC-assisted EMR, the pooled percentages of major adverse events and recurrence were 5% (95%CI 2-10, I2 = 0) and 1% (95%CI 0-3, I2 = 40). Evidence suggests that the main advantages of hAPC are the increase in safety in the setting of BE ablation and the reduction of local recurrence after colonic EMR. Trials comparing hAPC with standard strategies are required to support its use for these indications.

Combining endoscopic mucosal resection with hybrid argon plasma coagulation to reduce local colorectal lesion recurrence: a video tutorial.

Endoscopic mucosal resection (EMR) is a safe, effective, and surgery-sparing technique for removing large colorectal lesions [1]. Although piecemeal EMR is recommended for polyps > 20 mm in size, it remains a suboptimal technique for complete lesion resection, with high rates of residual polyp and recurrence rates reaching 15 % [2]. Hybrid argon plasma coagulation (hAPC) is a novel approach allowing ablation of resection margins and surface after EMR. hAPC combines waterjet injection and argon plasma coagulation (APC) in a single device. On-demand, repeatable saline cushioning without instrument exchange reduces thermal ablative insult to deep tissue structures, allowing for effective destruction of micro-remnants with reduced risk of perforation. High technical success and low recurrence rates (0 %) were shown in a pilot study using EMR in combination with hAPC [3]. A prospective international multicenter study showed that the local recurrence rate was only 2.2 % when using hAPC after EMR [4]. One recent meta-analysis found the local recurrence rate to be 3.3 % after hot EMR and margin ablation at 12-month follow-up [5].

Commentary.

Local recurrence after piecemeal endoscopic mucosal resection (EMR) is common and it is a major drawback of this technique. Thermal ablation of resection margins after EMR using snare-tip soft coagulation has been shown to decrease the risk of local recurrence in a randomized trial [1]. Hybrid argon plasma coagulation (hAPC) is an alternative ablation technique that can be used to perform margin ablation. Recent studies on hAPC for post-EMR margin ablation showed low rates of local recurrence.

Hybrid argon plasma coagulation in Barrett's esophagus: a systematic review and meta-analysis.

Patients with Barrett's esophagus are at increased risk of developing esophageal adenocarcinoma. Endoscopic therapies aim to eradicate dysplastic and metaplastic tissues. Hybrid argon plasma coagulation (hybrid-APC) utilizes submucosal fluid injection to create a protective cushion prior to ablation that shields the submucosa from injury. We performed a pooled meta-analysis to evaluate the safety and efficacy of hybrid-APC. We conducted a systematic search of major electronic databases in April 2022. Studies that included patients with dysplastic and non-dysplastic Barrett's esophagus undergoing treatment with hybrid-APC were eligible for inclusion. Outcome measures included complete remission of intestinal metaplasia (CR-IM), stricture formation, serious adverse events, and number of sessions necessary to achieve CR-IM. Overall pooled CR-IM rate for patients undergoing hybrid-APC was 90.8% (95% confidence interval [CI], 0.872-0.939; I2=0%). Pooled stricture rate was 2.0% (95% CI, 0.005-0.042; I2=0%). Overall serious adverse event rate was 2.7% (95% CI, 0.007-0.055; I2=0%). Results of the current meta-analysis suggest that hybrid-APC is associated with high rates of CR-IM and a favorable safety profile. Interpretation of these results is limited by the inclusion of retrospective cohort and case series data. Randomized controlled trials that standardize treatment and outcome evaluation protocols are necessary to understand how this treatment option is comparable to the current standards of care.

Combining endoscopic mucosal resection with hybrid argon plasma coagulation to reduce local colorectal lesion recurrence: a video tutorial.

Combining endoscopic mucosal resection with hybrid argon plasma coagulation to reduce local colorectal lesion recurrence: a video tutorial.

EMR combined with hybrid argon plasma coagulation to prevent recurrence of large nonpedunculated colorectal polyps (with videos)

EMR is the mainstay of therapy for large colorectal polyps. Local recurrence after EMR is common and can be reduced using margin ablation. Our aim was to evaluate recurrence rates when using hybrid argon plasma coagulation (h-APC) ablation after EMR. Adult patients (aged 18-89 years) undergoing EMR of nonpedunculated colorectal polyps≥20mm were enrolled in a prospective multicenter study. h-APC was used to ablate all defect margins and also the resection surface in selected cases. The primary study outcome was recurrence rates found during the first follow-up colonoscopy. Secondary outcomes were technical success and adverse event rates. EMR with h-APC ablation was used in 101 polyps (84 patients, 46.4% women). EMR with h-APC ablation was technically successful in all cases (median EMR time, 15 minutes; median h-APC ablation time, 4 minutes). Median polyp size was 30mm (range, 20-60). Resected polyps were either adenomas (68/101 [67.3%]), sessile serrated lesions (27/101 [27%]), or adenocarcinomas (6/101 [6%]). The post-EMR recurrence rate was 2.2% (2/91) (95% confidence interval, .27-7.71). All 6 patients with cancer (intramucosal cancer, 4; T1sm cancer, 2) were found to have complete eradication of the primary tumor after EMR with h-APC, and none had lymph node metastasis. Four serious adverse events occurred in 3 patients (2 delayed bleeding [2.4%], 1 abdominal pain [1.2%], and 1 microperforation [1.2%]. All serious adverse events resolved with either endoscopic or antibiotic treatment only. EMR with h-APC showed a high technical success rate, low adverse event rate, and very low post-EMR recurrence rates. (Clinical trial registration number: NCT04015765.).

Hybrid argon plasma coagulation (HybridAPC) versus sharp excision for the treatment of endometriosis: a prospective randomized clinical trial

PurposeEndometriosis is a benign, but potentially serious gynaecological condition in terms of abdominal pain and impaired fertility. Laparoscopic excision techniques are considered the therapeutic standard. HybridAPC is presented as a novel technique for the non-contact thermal ablation of peritoneal endometriosis with simultaneous protection of the underlying thermosensitive structures by creating a needle-free elevated fluid cushion which enables a safer exposure and distance, as well as potentially improved peritoneal conditioning prior to APC.MethodsIn this prospective randomized clinical trial, 39 patients with 132 superficial endometriotic lesions in total were treated with HybridAPC or sharp excision in an initial laparoscopic procedure according to randomization. In a second-look laparoscopy, adhesion formation was rated macroscopically. Histologic samples were taken from previously treated areas for evaluation of eradication rate.ResultsThe eradication rate was not significantly different between HybridAPC treatment and sharp excision (65 vs. 81%, p = .55). Adhesions formed in 5% of HybridAPC-treated lesions and in 10% after sharp excision (p = .49). HybridAPC treatment was significantly faster than sharp excision (69 vs. 106 s, p < .05). No intra- and postoperative complications were registered.ConclusionThis clinical trial demonstrates the feasibility of this novel surgical technique with a promising impact on adhesion prevention. Compared to sharp excision, HybridAPC is likely to be a safe, tissue-preserving, and fast method for the treatment of peritoneal endometriosis.

Benefit, tolerance, and safety of hybrid argon plasma coagulation for treatment of Barrett's esophagus: US pilot study.

Background and study aims A novel technique for Barrett’s esophagus (BE) ablation, termed hybrid APC, has recently been developed. The aims of this US pilot study were to evaluate the efficacy, tolerance and safety of hybrid APC for the treatment of BE. Patients and methods Patients with biopsy-proven BE referred to our tertiary care center over a 12-month period for mucosal ablation were eligible for this study. Efficacy of ablation was measured on follow-up endoscopy by demonstrating either a reduction of visible BE or biopsies proving complete resolution of intestinal metaplasia (CRIM). To evaluate tolerance and safety, patients were called on post-procedure days 1 and 7. Results Twenty-two patients with BE (4.5 % intramucosal carcinoma, 31.8 % high-grade dysplasia, 18.1 % low-grade dysplasia, 36.3 % non-dysplastic, 9.1 % indefinite for dysplasia) underwent 40 treatments with hybrid APC. All patients had endoscopic improvement of BE disease and 19 of 22 patients (86.4 %) achieved CRIM. With regard to tolerance, average pain scores (0 to 10 scale) on follow-up were 2.65 and 0.62 on days 1 and 7, respectively. With regards to safety, there were two treatment-related strictures (9.1 %) that required a single balloon dilation. Conclusions Hybrid APC appears to be promising in the treatment of BE. The ablation protocol used in this study demonstrated efficacy, tolerability, and a safety profile similar to radiofrequency ablation. Given the significant price difference between hybrid APC and other modalities for Barrett’s ablation, this modality may be more cost-effective. These results warrant further study in a large prospective multicenter trial.

Hybrid APC in Combination With Resection for the Endoscopic Treatment of Neoplastic Barrett's Esophagus: A Prospective, Multicenter Study.

INTRODUCTION:The current therapy of neoplastic Barrett's esophagus (BE) consists of endoscopic resection plus ablation, with radiofrequency ablation as the best studied technique. This prospective trial assesses a potential alternative, namely hybrid argon plasma ablation.METHODS:Consecutive patients with neoplastic BE undergoing ablation after curative endoscopic resection (89.6%) or primarily were included into this prospective trial in 9 European centers. Up to 5 ablation sessions were allowed for complete eradication of BE (initial complete eradication of intestinal metaplasia [CE-IM]), by definition including BE-associated neoplasia, documented by 1 negative endoscopy with biopsies. The main outcome was the rate of initial CE-IM in intention-to-treat (ITT) and per-protocol (PP) samples at 2 years. The secondary end points were the rate of recurrence-free cases (sustained CE-IM) documented by negative follow-up endoscopies with biopsies and immediate/delayed adverse events.RESULTS:One hundred fifty-four patients (133 men and 21 women, mean age 64 years) received a mean of 1.2 resection and 2.7 ablation sessions (range 1–5). Initial CE-IM was achieved in 87.2% of 148 cases in the PP analysis (ITT 88.4%); initial BE-associated neoplasia was 98.0%. On 2-year follow-up of the 129 successfully treated cases, 70.8% (PP) or 65.9% (ITT) showed sustained CE-IM; recurrences were mostly endoscopy-negative biopsy-proven BE epithelium and neoplasia in 3 cases. Adverse events were seen in 6.1%.DISCUSSION:Eradication and recurrence rates of Barrett's intestinal metaplasia and neoplasia by means of hybrid argon plasma coagulation at 2 years seem to be within expected ranges. Final evidence in comparison to radiofrequency ablation can only be provided by a randomized comparative trial.

Novel endoscopic therapies in Barrett’s esophagus: narrative review

: In the last decade, the management of Barrett’s esophagus (BE) has been broadly updated. Among the endoscopic ablative techniques, radiofrequency ablation (RFA) is highly effective and currently represents the standard of care for the eradication of BE after endoscopic resection of visible dysplastic lesions. Newly, some thermal and non-thermal endoscopic modalities have been investigated for treating BE, also as first-line in case of dysplasia. Data on the safety and efficacy of cryotherapy, hybrid argon plasma coagulation (APC) and EndoRotor resection have been recently reported in the literature. We aimed to review current evidence on novel endoscopic technologies emerging with the indication of treating BE, and to discuss their limitations, advantages and potential implementation in routine clinical practice as well as in clinical trials. A PubMed search was conducted up to August 2020 to identify relevant studies. Efficacy rates, in terms of dysplasia and metaplasia eradication, assessed for the emerging thermal and non-thermal endoscopic modalities are promising and similar to RFA. According to the present data, post-treatment stricture occurrence appears to be low especially after Hybrid-APC and EndoRotor. The current evidence on novel endoscopic techniques needs further endorsement by randomized clinical trials and meta-analysis. The comparison of these modalities to the traditional care by the ongoing clinical trials, particularly in naïve patients is highly warranted.

Safety and long-term efficacy of hybrid-argon plasma coagulation for the treatment of Barrett's esophagus: An Australian pilot study (with video)

Safety and long-term efficacy of hybrid-argon plasma coagulation for the treatment of Barrett's esophagus: An Australian pilot study (with video)

Hybrid argon plasma coagulation for Barrett's esophagus.

Video 1Hybrid APC for Barrett's esophagus.

S1858 Treatment of Squamous Dysplasia Using Hybrid Argon Plasma Coagulation

S1858 Treatment of Squamous Dysplasia Using Hybrid Argon Plasma Coagulation

S0958 Hybrid APC Assisted EMR for Large Colon Polyps to Reduce Local Recurrence, a Prospective Data Collection Study

INTRODUCTION: Large polyps >20 mm make up 5% of all polyps removed and are considered high-risk precancerous lesions Endoscopic mucosal resection (EMR) is a technique used to remove these polyps, but has a local recurrence rate of 10-30% at first follow up Recurrence is thought to be due to residual microscopic disease at the edge or base of the resected polyp Hybrid argon plasma coagulation (APC) is an innovative technique which can be used to ablate the remaining microscopic disease at the base and edge of the polyp thereby reducing local recurrence The aim of this study was to assess recurrence at 6 months following hybrid APC assisted EMR Secondary endpoints including post polypectomy bleeding and post polypectomy syndrome were also assessed METHODS: Patients in this single-center, prospective data collection study were referred to our institution for resection of polyps >20 mm After obtaining consent, eligible patients underwent endoscopy using the hybrid APC assisted EMR technique Participants were contacted 30 days after their procedure to assess adverse events At 6 months, patients were brought back in for a surveillance colonoscopy, and rate of polyp recurrence was calculated This study was approved by the Penn State Institutional Review Board RESULTS: At the time of this report, 25 (62 5%) of the 40 treated patients had completed the 6-month follow-up colonoscopy Three patients were lost to follow up, one patient withdrew for personal reasons, and 11 patients are currently awaiting rescheduling due to the COVID-19 pandemic Demographics of the included patients and characteristics of the study polyps are displayed in Table 1 and Table 2, respectively Post polypectomy bleeding was reported by 3 (7 5%) patients, and post polypectomy syndrome was reported by 1 (2 5%) patient None of the 25 patients who have completed the study showed recurrence at 6 months CONCLUSION: This prospective data collection study assessing 6-month recurrence rate using hybrid APC assisted EMR preliminarily resulted in a 0% local recurrence rate Secondary end points assessing post polypectomy syndrome and post polypectomy bleeding revealed an incidence of 2 5% and 7 5%, respectively This suggests that hybrid APC assisted EMR may be more effective at reducing the rate of polyp recurrence Additional studies assessing a larger population of patients in a randomized control trial would be recommended to ensure this data is generalizable to the general population

Management of Barrett's esophagus with dysplasia refractory to radiofrequency ablation.

Radiofrequency ablation (RFA) is very effective for eradication of flat Barrett’s mucosa in dysplastic Barrett’s esophagus after endoscopic resection of raised lesions. However, in a minority of the time, RFA may be ineffective at eradication of the Barrett’s mucosa. Achieving complete eradication of intestinal metaplasia can be challenging in these patients. This review article focuses on the management of patients with dysplastic Barrett’s esophagus refractory to RFA therapy. Management strategies discussed in this review include optimizing the RFA procedure, optimizing acid suppression (with medical, endoscopic, and surgical management), cryotherapy, hybrid argon plasma coagulation, and EndoRotor resection.

229 Assessing Varying Techniques of Colonic Endoscopic Mucosal Resection and Subsequent Residual Adenoma at 6-Month Follow-Up

INTRODUCTION: Local recurrence at colonic endoscopic mucosal resection (EMR) sites of medium to large polyps is common at first follow-up (∼10–30%). Extended edge resection has not shown a benefit of reducing this rate; however, edge ablation with snare tip soft coagulation has shown reduced local recurrence. Hybrid argon plasma coagulation (APC) is a novel technique, which can be used to treat microscopic residual disease to prevent local recurrence at follow-up surveillance colonoscopy. This study aims to evaluate if treating both the edges and base of an EMR site with a novel technique, hybrid APC, can reduce the rate of local recurrence at 6-month follow-up versus standard EMR assessing a single endoscopist. METHODS: This is a single center retrospective case series of all colonic EMRs with 6-month surveillance performed by a single endoscopist at a tertiary care center using both standard EMR and hybrid APC assisted EMR from May 2018 to May 2019. The main outcome measure was recurrence of precancerous polyp at prior EMR site at 6-month surveillance colonoscopy. Secondary outcome measures were the rate of procedure associated complications, including post-polypectomy bleeding and post-polypectomy syndrome. RESULTS: A total of 84 EMRs, 38 utilized hAPC, were performed from in the study period. 25 patients (mean age: 65.4 years, 48% men) with 30 polyps were included who completed surveillance colonoscopy after 6 months to evaluate for recurrence (Table 1). The average resected polyp size was 32 mm. Residual polyp recurrence occurred at 4 prior EMR sites (13.3%), with all of the recurrences occurring in patients who underwent standard EMR (100%). There was no recurrence of residual polyps in patients treated with hAPC assisted EMR. Further, 4 patients (15.4%) experienced post-polypectomy bleeding complications within 6 months, with all complications associated with patients treated with standard EMR (Table 2). There was a statistically non-significant trend toward higher recurrence and complication rate in patients treated with standard EMR compared to hAPC assisted EMR. CONCLUSION: In this retrospective study of colonic EMRs, the use of hAPC at initial EMR was associated with decreased local recurrence rate of precancerous tissue at EMR sites and rate of early complications. The findings of this early retrospective study warrant further studies to determine the efficacy of hAPC in reducing the recurrence rate after 6 months and how it compares to standard EMR procedure with snare tip soft coagulation.

2130 Future of Endoscopy: Hybrid Argon Plasma Coagulation for Treatment of Intestinal Metaplasia of the Stomach

INTRODUCTION: Hybrid Argon Plasma Coagulation (Hybrid APC) is an advancement on standard APC technology; application of APC is preceded by high pressure needleless submucosal injection, with the same catheter. APC is indicated for the ablation of benign and dysplastic mucosal lesions such as vascular malformations and Barrett’s mucosa. Hybrid APC offers an advantage over efficacy and safety advantages over standard APC. The submucosal injection acts as a heat sink and disperses excess energy to ensure that the underlying layers (i.e.: muscularis propria) are unaffected. Only the mucosal layer is coagulated, in its entirety. CASE DESCRIPTION/METHODS: An 81 years-old Hispanic Male was found to have a 1.2 cm mucosal nodule along the incisura of the stomach (Figure 1). He underwent endoscopic ultrasound (EUS) of the lesion, which confirmed the presence of an isolated gastric nodule with no deep invasion of the muscularis propria, consistent with a T1N0Mx endoscopic staging. He subsequently underwent endoscopic submucosal dissection (ESD) of the lesion. Pathology of the specimen revealed multifocal high-grade dysplasia, arising in the background of extensive intestinal metaplasia. The deep margin was clear; however, the lateral resection margins showed focal involvement of intestinal metaplasia with low-grade dysplasia. In light of the diffuse mucosal dysplasia, the patient was successfully treated with widespread Hybrid APC of the residual intestinal metaplasia (Figures 2 and 3). DISCUSSION: Hybrid APC is an effective and efficient treatment modality for mucosal lesions. In one series of 50 patients; 96% achieved complete macroscopic remission of Barrett’s mucosa after a median of 3.5 APC sessions and 85% achieved complete histological remission. Hybrid APC is a promising technology as thermal injury depth is targeted and reduces deep injury as well as subsequent complications when it compared with Standard APC. Applications of hybrid APC will likely continue to grow as this modality is adopted into common parlance. This case is the first to describe the use of Hybrid APC for definitive treatment of intestinal metaplasia.