Number Of Radiofrequency Ablation Sessions Research Articles

Factors influencing the cost-effectiveness of radiofrequency ablation for Barrett's esophagus with low-grade dysplasia in Australia.

Endoscopic eradication therapy using radiofrequency ablation (RFA) is considered an acceptable alternative to surveillance monitoring for Barrett's esophagus with low-grade dysplasia (LGD). This study aimed to estimate whether RFA for LGD is cost-effective and to determine which factors influence cost-effectiveness. A Markov model was developed to estimate the incremental cost per quality-adjusted life year (QALY) gained for RFA compared with endoscopic surveillance. An Australian longitudinal cohort study (PROBE-NET) provides the basis of the model. Replacing surveillance with RFA yields 10 fewer cases of HGD and 9 fewer esophageal adenocarcinoma (EAC)-related deaths per 1000 patients' treatment, given on average 0.192 QALYs at an additional cost of AU$9211 (€5689; US$6262) per patient (incremental cost-effectiveness ratio AU$47,815 per QALY). The model is sensitive to the rate of EAC from LGD health state, the utility values, and the number of RFA sessions. Hence, the incremental benefit ranges from 0.080 QALYs to 0.198 QALYs leading to uncertainty in the cost-effectiveness estimates. When the cancerous progression rate of LGD falls <0.47% per annum, the cost-effectiveness of RFA becomes questionable. RFA treatment of LGD provides significantly better clinical outcomes than surveillance. The additional cost of RFA is acceptable if the LGD to EAC rate is >0.47% per annum and no more than three RFA treatment sessions are provided. Accurate estimates of the risk of developing EAC in patients with LGD are needed to validate the analyses.

Multi-focal dysplasia is associated with high recurrence rates after successful ablation of dysplastic Barrett's esophagus

Background & AimsBarrett's esophagus (BE) might recur after complete eradication of intestinal metaplasia (CEIM). We investigated factors associated with recurrence of BE after successful Radiofrequency ablation (RFA). MethodsA longitudinal study of BE patients with dysplasia treated with RFA from 2014 to 2021 in two large referral centers. Recurrence was identified in histologic specimens. Factors associated with post-RFA recurrence were analyzed using Cox regression analysis. ResultsA total of 728 patients with BE were identified, 118 had underwent RFA, and 113 had sufficient follow up time. Mean age was 63.7 (±11.7) years, 73.5% were males, 59.3% had long segment of BE, and 30.1% had multifocal dysplasia. During 340.8 patient-years of follow-up, 15 patients (13.3%) had recurrence of BE, which represent an incidence rate of 4.41% per patient-year. Incidence rate of recurrence with dysplasia was 1.17% per patient-year. Multifocal dysplasia, number of RFA sessions, and endoscopic resection before RFA were associated with risk of recurrence in univariate analysis. However, in cox regression analysis only multifocal dysplasia (HR 10.99; 95% CI 2.83–22.62, p = 0.001) was associated with post-RFA recurrence. ConclusionTotal recurrence rates after CEIM are low, and multifocal dysplasia before the ablative therapy is significantly associated with BE recurrence after CEIM. Patients with multifocal dysplasia should be monitored rigorously after successful ablation.

Evaluation Of The Radiofrequency Ablation Of Lumbar Sympathetic Ganglia In Lower Limb Ischemic Ulcers In Indian Population

Antecedentes: la simpatectomía lumbar mediante radioablación es un tratamiento útil de la isquemia periférica. Sin embargo, la eficacia clínica con respecto a las úlceras de las extremidades inferiores no está suficientemente establecida en la población india. El estudio se realizó para evaluar el papel de la ablación por radiofrecuencia (ARF) de los ganglios simpáticos lumbares en la cicatrización de las úlceras isquémicas del miembro inferior. Método: El estudio prospectivo con 63 pacientes registrados en el servicio de Cirugía General con úlceras isquémicas de miembros inferiores entre diciembre de 2017 y julio de 2019 fueron tratados con ARF. Se excluyó del estudio a los pacientes con enfermedad cardiopulmonar, embarazadas, malformaciones congénitas o infección cutánea en el lugar de la intervención, o que padecían trastornos hemorrágicos. Se realizó una investigación clínica de la herida y se recopilaron datos demográficos. La reducción comparativa en el tamaño de la herida se evaluó mediante el ANOVA de Friedman (P &lt;0,001). La diferencia en la puntuación del dolor, la estancia hospitalaria y la distancia recorrida se evaluaron mediante la prueba de pares emparejados de Wilcoxon (P &lt;0,001), la prueba t para datos no emparejados y la prueba t para datos emparejados (P &lt;0,05). Resultado: la mayoría de los pacientes eran hombres (n = 40) con una edad media de 60,93 DE14,34 años. Se observó una reducción significativa en el tamaño de la herida, las puntuaciones de dolor y la estancia hospitalaria después del procedimiento (P &lt;0,001). El número de sesiones de RFA se asoció significativamente con el tamaño de la úlcera y la clasificación de Fontaine 2 y 3 (P &lt;0,0001). Conclusión: La ARF de los ganglios simpáticos lumbares es una posible modalidad de tratamiento para las úlceras isquémicas de las extremidades inferiores.

Length of Barrett\u2019s segment predicts failure of eradication in radiofrequency ablation for Barrett\u2019s esophagus: a retrospective cohort study

BackgroundWe aim to investigate factors that may contribute to failure of eradication of dysplastic Barrett’s Esophagus among patients undergoing radiofrequency ablation treatment.MethodsA retrospective review of patients undergoing radiofrequency ablation for treatment of Barrett’s Esophagus was performed. Data analyzed included patient demographics, medical history, length of Barrett’s Esophagus, number of radiofrequency ablation sessions, and histopathology. Subsets of patients achieving complete eradication were compared with those not achieving complete eradication.ResultsA total of 107 patients underwent radiofrequency ablation for Barrett’s Esophagus, the majority white, overweight, and male. Before treatment, 63 patients had low-grade dysplasia, and 44 patients had high-grade dysplasia or carcinoma. Complete eradication was achieved in a majority of patients (57% for metaplasia, and 76.6% for dysplasia). Failure of eradication occurred in 15.7% of patients. The median number of radiofrequency ablation treatments in patients achieving complete eradication was 3 sessions, compared to 4 sessions for failure of eradication (p = 0.06). Barrett’s esophagus length of more than 5 cm was predictive of failure of eradication (p < 0.001).ConclusionsRadiofrequency ablation for dysplastic Barrett’s Esophagus is a proven and effective treatment modality, associated with a high rate of complete eradication. Our rates of eradication from a center starting an ablation program are comparable to previously published studies. Length of Barrett’s segment > 5 cm was found to be predictive of failure of eradication in patients undergoing radiofrequency ablation.

An Image Fusion System for Estimating the Therapeutic Effects of Radiofrequency Ablation on Hepatocellular Carcinoma.

BackgroundDuring ultrasound-guided radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC), high echoic areas due to RFA-induced microbubbles can help calculate the extent of ablation. However, these areas also decrease visualization of target tumors, making it difficult to assess whether they completely cover the tumors. To estimate the effects of RFA more precisely, we used an image fusion system (IFS).Patients and methodsWe enrolled patients with a single HCC who received RFA with or without the IFS. In the IFS group, we drew a spherical marker along the contour of a target tumor on reference images immediately after administering RFA so that the synchronized spherical marker represented the contour of the target tumor on real-time ultrasound images. When the high echoic area completely covered the marker, we considered the ablation to be complete. We compared outcomes between the IFS and control groups.ResultsWe enrolled 25 patients and 20 controls, and the baseline characteristics were similar between the two groups. The complete ablation rates during the first RFA session were significantly higher in the IFS group compared with those in the control group (88.0% vs. 60.0%, P = 0.041). The number of RFA sessions was significantly smaller in the IFS group compared with that in the control group (1.1 ± 0.3 vs. 1.5 ± 0.7, P = 0.016).ConclusionsThe study suggested that the IFS enables a more precise estimation of the effects of RFA on HCC, contributing to enhanced treatment efficacy and minimized patient burden.

Comparison of Safety, Efficacy, and Long-term Outcomes of Radiofrequency Ablation (RFA) for Treatment of Dysplastic Barrettʼs in a Low-Volume Center Compared to Published Standards from High-Volume Centers

Introduction: Radiofrequency ablation (RFA) is an established treatment modality for Barrett's esophagus with dysplasia (BE-D), favored given its cost effectiveness, low recurrence and adverse event rates, and greater patient satisfaction. Although it is practiced universally, comparative data between low-volume versus high-volume centers is lacking. The aim of our study is to evaluate safety, efficacy and long term outcomes of RFA in a low-volume center, and compare it to existing published values from highvolume centers, in an attempt to improve quality and establish better practice standards. Methods: Our IRB approved retrospective study involved all patients enrolled in Barrett's RFA program at our institution between 2010 and 2014. Results: A total of 24 patients were identified, but data on 4 was partly unavailable due to change of endoscopy software during this period, and were hence excluded.Charts of 20 patients (M: F=18:2, Caucasian:Black=16:4) were finally reviewed. The common symptoms for EGD referral included heartburn (85%), water brash (15%), dysphagia (15%), nausea (10%) and GI bleeding (10%). The biopsies showed high-grade dysplasia (HGD) in 10, low-grade dysplasia (LGD) in 9 and one patient had mix of LGD-HGD. 4/20 patients had nodules, who underwent EMR but none had adenocarcinoma. No other treatment was attempted on any of these patients before RFA. The number of RFA sessions needed for complete resolution of BE was variable - 1 session (1 patient), 2 sessions (7 patients), 3 sessions (5 patients), 4 sessions (4 patients), 5 sessions (1 patient) and 6 sessions (1 patient). One patient was lost to follow-up after 5thsession. Circumferential ablation was used in 80% of the patients in first round, 14% in second round and only focal therapy was needed in patients after that. The RFA treatments were welltolerated, with transient nausea being the commonest post-procedure complaint (50%), followed by mild chest discomfort and dysphagia (16.7%). None of the patients had any serious complications including perforation or bleeding. None of the patients developed adenocarcinoma of the esophagus during the course of follow-up till date. Conclusion: RFA was found to be safe and equally efficacious in a low-volume center, as is in highvolume centers, and long term outcomes were reassuring. These results call for greater use of RFA in management of dysplastic BE, in non-referral centers also.

Minor Anesthesia-Related Events During Radiofrequency Ablation for Barrett's Esophagus Are Associated with an Increased Number of Treatment Sessions.

There is limited data regarding the prevalence and clinical impact of sedation-related adverse events (SRAEs) during radiofrequency ablation (RFA) for dysplastic Barrett's esophagus (BE). Our primary aim was to measure SRAE during RFA. Secondary aims were to identify risk factors for adverse events, and to determine whether SRAEs impacted the number of RFA treatments to achieve complete eradication of dysplasia (CE-D). We conducted a retrospective analysis of 120 consecutive patients undergoing initial RFA for dysplastic BE between 2008 and 2014. The main outcome measures were SRAEs and the number of RFA sessions required to achieve CE-D. Of 120 initial RFA procedures, 83% were performed with MAC and 17% with GET. SRAEs occurred in 32%, including 25% of MAC patients (25/100) and 65% (12/20) GET patients. The most frequent SRAE was hypotension (23%, n=27/120), followed by hypoxia (n=9/120), arrhythmia (n=4/120), and one unplanned intubation. There were no premature procedure terminations. After adjusting for length of BE mucosa and ASA score, the occurrence of a SRAE was associated with requiring more (>4)RFA sessions to achieve CE-D, OR 3.45 (95% CI 1.49-7.99). Mean RFA sessions required to achieve CE-D was 5±1 in patients with SRAE, compared to 3±0.7 in patients without SRAE during the first treatment session (p<0.001). SRAE during RFA for dysplastic BE occurs at a rate typical of other advanced endoscopic procedures. Patients who experience minor events related to anesthesia during the first RFA are likely to require more RFA treatment sessions to achieve CE-D.

Ten-year survival of hepatocellular carcinoma patients undergoing radiofrequency ablation as a first-line treatment.

To investigate the long-term survival and prognostic factors in hepatocellular carcinoma (HCC) patients undergoing radiofrequency ablation (RFA) as a first-line treatment. From 2000 to 2013, 316 consecutive patients with 404 HCC (1.0-5.0 cm; mean: 3.2 ± 1.1 cm) underwent ultrasonography-guided percutaneous RFA as a first-line treatment. There were 250 males and 66 females with an average age of 60.1 ± 10.8 years (24-87 years). Patients were followed for 1 year to > 10 years after RFA (234, 181, 136, and 71 for 3, 5, 7, and 10 years, respectively). Overall local response rates and long-term survival rates were assessed. Survival results were generated using Kaplan-Meier estimates, and multivariate analysis was performed using the Cox regression model. In total, 548 RFA sessions were performed and major complications occurred in 10 sessions (1.8%). Local tumor progression and/or new tumor development were observed in 43.3% (132/305) of the patients during the follow-up period. Overall 5- and 10-year survival rates were 49.7% and 28.4%, respectively. Based on multivariate analysis, three factors were identified as independent prognostic factors for overall survival: Child-Pugh classification (HR = 4.054, P < 0.001), portal vein hypertension (HR = 2.743, P = 0.002), and tumor number (HR = 2.693, P = 0.003). The local progression-free 5- and 10-year survival rates were 42.7% and 19.5%. In addition to the Child-Pugh classification and the number of tumors, the number of RFA sessions (HR = 1.550, P = 0.002) was associated with local progression-free survival. RFA can achieve acceptable outcomes for HCC patients as a first-line treatment, especially for patients with Child-Pugh class A, patients with a single tumor and patients without portal vein hypertension.

PTU-048 Initial Experience With Radiofrequency Ablation In Gastric Antral Vascular Ectasia And Radiation Proctitis

IntroductionGastric Antral Vascular Ectasia (GAVE) and radiation proctitis can cause chronic GI bleeding and may be severe enough to cause transfusion dependent anaemia.Current standard therapy for both these conditions is...

Gender Differences in Remission of Esophageal Intestinal Metaplasia after Radiofrequency Ablation

Few studies have assessed the effect of gender on remission rates after radiofrequency ablation (RFA) of Barrett's esophagus (BE). We aim to assess the effect of gender on the time to achieve complete remission of intestinal metaplasia (CRIM) among patients with BE, who underwent RFA. This was a retrospective, observational study using a large RFA database in a tertiary referral center. The primary outcome was time to CRIM compared between males and females. Covariates included age, race, smoking history, use of endoscopic mucosal resection (EMR), histology before RFA, and the number of RFA sessions. Time to CRIM (in months) was calculated using the Kaplan-Meier method and compared using the log-rank test. Multivariable Cox-proportional hazard models were used to assess for any association between time to CRIM and gender. Two hundred and fifty-seven patients, 11% (n=23) female, underwent RFA for BE between May 2005 and June 2012. Males and females were similar in mean age, race, smoking history, median BE length, history of EMR, and baseline histology. Median time to CRIM for females was longer than males (24 months (95% confidence interval (CI): 10.3-60.2) vs. 11.7 months (95% CI: 10-15), P=0.03). Using Cox-regression analysis, controlling for age, use of EMR, BE segment length, and the number of RFA sessions, female gender was associated with a 55% decrease in the rate of CRIM compared with that in males (hazard ratio=0.45 (95% CI: 0.25-0.82), P=0.009). Females take longer time to achieve CRIM when treated with RFA when compared with males of similar age and BE length.

Radiofrequency Ablation Using HALO™ Ablation Catheter for Gastric Antral Vascular Ectasia: A Case Series from a Community Hospital

Purpose: Gastric antral vascular ectasia (GAVE) is an infrequent cause of upper gastrointestinal bleeding, constituting 4% of non-variceal bleeds. Therapeutic options are limited which includes medical, endoscopic, and surgical treatment. We present this case series to evaluate the use of radiofrequency ablation (RFA) as a plausible option. Methods: We conducted a retrospective analysis of patients who underwent RFA for GAVE lesions at our institution. One patient underwent antrectomy 2 days after the first session of RFA and was therefore excluded from this study. One patient received first session of RFA recently and his post-treatment follow-up is not complete. For rest of the patients, their demographics, number of RFA sessions, type of catheter(s) used, total number of ablations and other treatment options used, hemoglobin (Hb) level, total number of blood transfusions required, and total number of days spent in the hospital due to anemia secondary to GAVE lesions before and after therapy were recorded. Results: A total of five (two male, three female) patients were included with a mean age of 81 years. Since one patient does not have complete follow-up after treatment, data pertaining to him is not used to make calculations. Both HALO90 and HALO90 Ultra were used. An average of 1.8 sessions (range 1-4) and 65 ablations (range 17-181) were applied per patient. After the completion of RFA, mean Hb increased from 9.13 gm/dL (range 7.6-11.6 gm/dL) to 11.05 gm/dL (range 9.3-11.75 gm/dL), the mean number of transfusions decreased from 41.25 units/patient (range 0-158) to 8.4 (range 0-10), and none of the patients were admitted to the hospital again with GI bleed or anemia after RFA. Two patients had no previous therapy while the other three had received multiple argon plasma coagulation (APC) sessions (3-13) prior to RFA. Only one patient received APC (two sessions) after RFA. Conclusion: RFA using HALO ablation catheter has been utilized safely in Barrett's Esophagus for ablation of metaplastic epithelium. Its use in GAVE lesions was first shown by Gross et al in 2007. Our case series evaluates the use of RFA in all the patients of GAVE lesions including those not responding to (APC). APC is the most studied and used form of treatment for GAVE, but it has a small surface area of 12 mm2 and hence has a small focal area of coverage. HALO90 and HALO90 Ultra have surface area of 260 mm2 and 520 mm2, respectively, and hence can be used to ablate larger surface areas. In our experience we found that all patients had an improvement in their Hb levels, blood transfusion requirements decreased markedly, and no one was admitted to hospital again with GI bleed or anemia. Our study shows benefits of RFA in GAVE lesions and this must be studied in a randomized controlled trial.

Gender Disparities in Remission of Esophageal Intestinal Metaplasia after Radio-frequency Ablation: ACG/Naomi Nakao Gender-Based Research Award

Purpose: Among the available ablative modalities, radiofrequency ablation (RFA) is the most commonly used for treatment of Barrett's esophagus (BE) with dysplasia. Few studies have assessed the effect of gender on remission rates after RFA. Preliminary studies indicate a potential biological difference between males and females with BE. We aim to assess the effect of gender on the time to achieve complete remission of intestinal metaplasia (CRIM) among patients with BE who underwent RFA. Methods: This was a retrospective, observational study using large RFA database in a tertiary referral center. The primary outcome was time to CRIM compared between males and females. Candidate predictor variables included patient age, sex, race, smoking history, use of endoscopic mucosal resection (EMR), and initial biopsy before RFA. Time to CRIM (in months) was calculated using the Kaplan-Meier method. Log-rank test was used for comparison. We used Multivariable cox-proportional hazard model to assess for any association between time to CRIM and predictor variables. Results: Two hundred fifty-seven patients underwent RFA for BE between May, 2005 and June, 2012. Of those, only 11% (n=26) were females. Males and females were similar in mean age, race, smoking history, median BE length, history of EMR, and baseline histology. Females required less RFA sessions compared to males (p=0.027). For males, median time to CRIM was 11.7 months [95% confidence interval [CI] 10 - 15]. For females, median time to CRIM was 24 months [95% CI 10.3 - 60.2]. The Log Rank χ2 statistic for the difference in time to CRIM was 4.7, with p=0.03. Kaplan-Meier curves of the time to CRIM stratified by gender are presented in Figure 1. Using cox-regression analysis, there was no evidence of confounding, collinearity, or effect modification in the final model. When controlling for age, use of EMR, BE segment length, and the number of RFA sessions, female gender was associated with 55% decrease in the rate of CRIM compared to males (HR = 0.45 [95% CI 0.25-0.82], p=0.009).FigureConclusion: Female patients take longer time to achieve remission of intestinal metaplasia when treated with radiofrequency ablation with or without endoscopic mucosal resection when compared to males of similar age and BE length. Further studies are needed to understand the potential factors leading to those important differences. Disclosure - Dr. Wolfsen is a consultant for CSA Medical, Ninepoint Medical, and Oncoscope. He receives research funding from BARRx Medical and Olympus America, Inc. Dr. Wallace is a consultant for Ninepoint Medical. He receives research funding from Olympus America, Inc, American BioOPTICS, and Fujinon.

Radiofrequency ablation for refractory gastric antral vascular ectasia (with video)

Gastric antral vascular ectasia (GAVE) is a cause of upper GI bleeding and chronic anemia. Although upper endoscopy with argon plasma coagulation (APC) is an accepted therapy for GAVE, many patients continue to bleed and remain transfusion dependent after therapy. Radiofrequency ablation (RFA) may provide an alternative therapeutic option for GAVE. To determine the efficacy and safety of RFA for patients with GAVE who remain transfusion dependent after APC treatment. Open-label prospective cohort study of patients with GAVE refractory to APC. Academic tertiary referral center. GAVE patients with previous failed APC therapy, chronic anemia, and transfusion dependence. Endoscopic RFA to the gastric antrum using the HALO(90) ULTRA ablation catheter until transfusion independence is achieved or a maximum of 4 sessions are performed. Transfusion requirements before and after RFA. Secondary outcomes are hemoglobin before and 6 months after RFA completion, number of RFA sessions, and complications. Twenty-one patients underwent at least 1 RFA session with ablation of GAVE lesions. At 6 months after completion of the course of RFA therapy, 18 of 21 patients (86%) were transfusion independent. Mean hemoglobin increased from 7.8 to 10.2 in responders (n = 18). Two adverse events occurred (minor acute bleeding and superficial ulceration); both resolved without intervention. Single-center, single-operator, and nonrandomized design. RFA is safe and effective for treating patients with refractory GAVE after attempted APC.

283 Patients Undergoing Radiofrequency Ablation (RFA) for Barrett's Related Neoplasia Have Improved Outcomes With Decreasing Length's of Baseline Barrett's Eosophagus (BE) and Increasing Number of RFA Sessions

283 Patients Undergoing Radiofrequency Ablation (RFA) for Barrett's Related Neoplasia Have Improved Outcomes With Decreasing Length's of Baseline Barrett's Eosophagus (BE) and Increasing Number of RFA Sessions

Influence of Fundoplication on Remission and Recurrence of Intestinal Metaplasia after Ablation of Barrettʼs Esophagus

Purpose: Radiofrequency ablation (RFA) is an effective treatment for Barrett's dysplasia in conjunction with adequate acid reflux control. Fundoplication is a treatment option for persistent gastroesophageal reflux in spite of optimal pharmacotherapy. Our aim was to assess the effect of fundoplication in achieving complete remission of intestinal metaplasia (CRIM) and recurrence after successful RFA. Methods: We performed a retrospective cohort analysis of patients who underwent RFA for Barrett's dysplasia at a tertiary referral center from Jan. 2003 to Jun. 2012. All patients were on proton pump inhibitors following RFA. CRIM was defined as the absence of intestinal metaplasia (IM) in 2 consecutive endoscopies with biopsies. Recurrence was defined as the reappearance of IM with any grade of dysplasia after CRIM. Demographic and endoscopic factors associated with CRIM or recurrences were assessed by univariate and multivariate analyses. The effect of pre-RFA fundoplication to either time to CRIM or recurrence was assessed by Kaplan-Meier survival estimates. Results: A total of 206 patients were included in the analysis. There were 28 (13.6%) patients who had pre-RFA fundoplication. Patients were followed for 26.69 ±18.91 months after their first RFA session. Baseline characteristics are summarized in Table 1 which showed no significant difference between those with and without fundoplication. There was no association of fundoplication with either achieving CRIM (HR 0.93, 95% CI: 0.47-1.65) or recurrence (HR 0.99, 0.15-3.81) after controlling for age, number of RFA sessions, length of Barrett's esophagus (BE) segment and hiatal hernia in a multivariate Cox proportional hazards analysis. Figure 1 presents the Kaplan-Meier plot of patients with and without fundoplication in relation to CRIM. Time intervals for both CRIM (p=0.87) and recurrence (p=0.90) were not different between the two groups based on Mantel-Cox statistics.Table: Baseline characteristics of subjects with and without pre-RFA fundoplicationFigure: [62]Conclusion: In our cohort of patients, fundoplication was not associated with either time to CRIM or recurrence. Future studies with long term follow-up data and evidence of sufficient acid control, measured by pH impedance after fundoplication are needed to assess the effect of surgical reflux control on BE eradication following RFA. Disclosure: Dr. Wang - Consultant and research support from: Covidien (Barrx); Ninepoint Medical; CDX Diagnostics; Fujinon; Pinnacle Biologics; Ms. Lutzke - Research support: Covidien (Barrx); Fujinon; Ninepoint; Dr. Prasad Iyer - Research support: Takeda.

The Neo-Squamocolumnar Junction after Radiofrequency Ablation (RFA): Do We Need to Biopsy if Normal Appearing on Endoscopy?

Purpose: RFA is a safe and effective treatment for Barrett's esophagus (BE) with dysplasia and may decrease risk of progression to esophageal adenocarcinoma. Intestinal metaplasia (IM) of the gastro-esophageal junction (GEJ) has previously been shown to have a substantially lower cancer progression risk compared to BE. As a result, biopsy acquisition of an irregular z-line is discouraged. The proportion of patients with dysplasia or IM of the GEJ in the absence of endoscopic evidence of BE post-ablation is not known. AIM: We evaluated the proportion of post-RFA patients with IM or dysplasia of the GEJ who had no endoscopic evidence of BE. Methods: We reviewed all patients with BE and high grade dysplasia (HGD) who were referred for RFA at a tertiary care referral center between 3/2004 and 3/2012. The EGD reports of all patients following RFA were reviewed. Those patients who did not have any columnar metaplasia visualized in the esophagus and those with an irregular Z line, without tongues, islands or nodules, were assessed. Presence of an irregular z-line was defined as a columnar segment < 1 cm. The pathology from each GEJ biopsy was then reviewed for evidence of intestinal metaplasia or dysplasia. Results: Seventy three patients (63 male, age 64.3±10 years, BMI 29.9±5.4 kg/m2, all with entry histology of HGD and all without endoscopic evidence of BE) fulfilled the inclusion criteria. Patients were followed for a mean length of 25±19 months following initial RFA. Forty six patients (63%) had documented evidence of an irregular z-line on endoscopic evaluation. Fifteen patients (20.2%) were found to have either IM or dysplasia of the GEJ following a normal EGD post-RFA [5 (6.8%) with HGD, 5 (6.8%) with low-grade dysplasia, 1 (1.4%) indefinite for dysplasia and 4 (5.5%) with IM]. Univariate analysis did not show age (p=0.08), BMI (p=0.99), gender (p=0.96), number of RFA sessions (p=0.65) or presence of irregular z-line (p=0.36) to be associated with having an abnormal GEJ biopsy. On multivariate analysis, controlling for the presence of an irregular Z-line and number of RFA treatments; presence of hiatal hernia was found to increase the risk of IM or dysplasia of the GEJ [OR 1.45 (1.1-2.04), p=0.02]. Conclusion: In our cohort of patients, 20% had findings of dysplasia or IM of GEJ after RFA with no endoscopic evidence of BE. The rate of overall dysplasia (15%), especially HGD (7%), is higher than would be expected with IMGEJ patients (7% and 0%, respectively) found on population based screening by our group. Unlike IMGEJ in patients without a prior diagnosis of BE, we recommend routine biopsies of the GEJ in post-RFA patients with a normal appearing esophagus during surveillance endoscopy. Disclosure: Dr. Wang - Consultant: Covidien (Barrx), Ninepoint Medical Research, CDX Diagnostics, Pinnacle Biologics. Research: Covidien (Barrx), Fujinon, Ninepoint Medical. Lori Lutzke - Research: Covidien (Barrx), Fujinon, Ninepoint Medical. Dr. Iyer - Consultant: Takeda.

A Cross-Sectional Analysis of the Prevalence of Barrett's Esophagus in Otolaryngology Patients With Laryngeal Symptoms

BACKGROUND: Radiofrequency ablation (RFA) is an endoscopic ablation modality that typically requires multiple treatment sessions to fully eliminate dysplastic tissue. It is unclear if increasing experience reduces complications or the necessary number of ablation sessions, and how many ablations are necessary to achieve competence. AIM: To assess the learning curve for physicians performing RFA. METHODS: This was a retrospective study of patients treated with RFA for BE at a tertiary care referral center between June 2006 and November 2010. Pertinent information was extracted from medical records, including: demographics, pre-ablation histology, indicators of GERD activity (symptoms, erosive esophagitis), upper endoscopy findings (Prague criteria, hiatus hernia), ablation outcomes (elimination of metaplasia and dysplasia), and complications (stricture, bleeding). Endoscopist experience was measured by the number of treatment sessions performed prior to initiation of therapy for each patient. Patients with incomplete treatment and those who initiated treatment in the last 6 months were excluded. Patient characteristics and treatment outcomes were examined among 4 quartiles of endoscopist experience by non-parametric tests (Fisher's exact test for categorical variables and Kruskal-Wallis one-way ANOVA for continuous variables). Linear regression and Pearson's correlation were performed to assess the strength of the association between endoscopist experience and number of sessions necessary for complete ablation. RESULTS: Among 305 RFA treatments by 3 physicians in 113 patients, 245 treatments were in 77 patients who completed therapy more than 6 months prior and were included in the analysis. Over time, there was a significant reduction in the number of RFA sessions and time required to complete therapy, from an average of 4.4 sessions and 226 days in the earliest quartile to 2.3 sessions and 111 days in the most recent quartile (p<0.05 for both). Operator experience and number of RFA sessions to complete treatment were significantly correlated(r=0.38, p<0.001). Linear regression identified operator experience (p<0.001) and Prague M length (p<0.001) as independent predictors of number of treatment sessions to complete eradication of BE. By this model, an endoscopist needs to perform 81 ablations to average 3.0 treatments per patient. Complication rates did not differ significantly dependent on operator experience (p=0.26). CONCLUSIONS: There was a clinically and statistically significant learning curve associated with endoscopic ablation of BE, with initial subjects requiring approximately 2.1 additional treatment sessions for complete ablation. After 81 ablations an endoscopist is projected to average 3.0 treatments per patient. For optimal delivery, this procedure should be performed in high volume centers.

Yield of TransNasal Endoscopy in an Unselected General Medical Population

BACKGROUND: Radiofrequency ablation (RFA) is an endoscopic ablation modality that typically requires multiple treatment sessions to fully eliminate dysplastic tissue. It is unclear if increasing experience reduces complications or the necessary number of ablation sessions, and how many ablations are necessary to achieve competence. AIM: To assess the learning curve for physicians performing RFA. METHODS: This was a retrospective study of patients treated with RFA for BE at a tertiary care referral center between June 2006 and November 2010. Pertinent information was extracted from medical records, including: demographics, pre-ablation histology, indicators of GERD activity (symptoms, erosive esophagitis), upper endoscopy findings (Prague criteria, hiatus hernia), ablation outcomes (elimination of metaplasia and dysplasia), and complications (stricture, bleeding). Endoscopist experience was measured by the number of treatment sessions performed prior to initiation of therapy for each patient. Patients with incomplete treatment and those who initiated treatment in the last 6 months were excluded. Patient characteristics and treatment outcomes were examined among 4 quartiles of endoscopist experience by non-parametric tests (Fisher's exact test for categorical variables and Kruskal-Wallis one-way ANOVA for continuous variables). Linear regression and Pearson's correlation were performed to assess the strength of the association between endoscopist experience and number of sessions necessary for complete ablation. RESULTS: Among 305 RFA treatments by 3 physicians in 113 patients, 245 treatments were in 77 patients who completed therapy more than 6 months prior and were included in the analysis. Over time, there was a significant reduction in the number of RFA sessions and time required to complete therapy, from an average of 4.4 sessions and 226 days in the earliest quartile to 2.3 sessions and 111 days in the most recent quartile (p<0.05 for both). Operator experience and number of RFA sessions to complete treatment were significantly correlated(r=0.38, p<0.001). Linear regression identified operator experience (p<0.001) and Prague M length (p<0.001) as independent predictors of number of treatment sessions to complete eradication of BE. By this model, an endoscopist needs to perform 81 ablations to average 3.0 treatments per patient. Complication rates did not differ significantly dependent on operator experience (p=0.26). CONCLUSIONS: There was a clinically and statistically significant learning curve associated with endoscopic ablation of BE, with initial subjects requiring approximately 2.1 additional treatment sessions for complete ablation. After 81 ablations an endoscopist is projected to average 3.0 treatments per patient. For optimal delivery, this procedure should be performed in high volume centers.

The Effect of Operator Experience on Treatment of Dysplastic Barrett's Esophagus With Radiofrequency Ablation

BACKGROUND: Radiofrequency ablation (RFA) is an endoscopic ablation modality that typically requires multiple treatment sessions to fully eliminate dysplastic tissue. It is unclear if increasing experience reduces complications or the necessary number of ablation sessions, and how many ablations are necessary to achieve competence. AIM: To assess the learning curve for physicians performing RFA. METHODS: This was a retrospective study of patients treated with RFA for BE at a tertiary care referral center between June 2006 and November 2010. Pertinent information was extracted from medical records, including: demographics, pre-ablation histology, indicators of GERD activity (symptoms, erosive esophagitis), upper endoscopy findings (Prague criteria, hiatus hernia), ablation outcomes (elimination of metaplasia and dysplasia), and complications (stricture, bleeding). Endoscopist experience was measured by the number of treatment sessions performed prior to initiation of therapy for each patient. Patients with incomplete treatment and those who initiated treatment in the last 6 months were excluded. Patient characteristics and treatment outcomes were examined among 4 quartiles of endoscopist experience by non-parametric tests (Fisher's exact test for categorical variables and Kruskal-Wallis one-way ANOVA for continuous variables). Linear regression and Pearson's correlation were performed to assess the strength of the association between endoscopist experience and number of sessions necessary for complete ablation. RESULTS: Among 305 RFA treatments by 3 physicians in 113 patients, 245 treatments were in 77 patients who completed therapy more than 6 months prior and were included in the analysis. Over time, there was a significant reduction in the number of RFA sessions and time required to complete therapy, from an average of 4.4 sessions and 226 days in the earliest quartile to 2.3 sessions and 111 days in the most recent quartile (p<0.05 for both). Operator experience and number of RFA sessions to complete treatment were significantly correlated(r=0.38, p<0.001). Linear regression identified operator experience (p<0.001) and Prague M length (p<0.001) as independent predictors of number of treatment sessions to complete eradication of BE. By this model, an endoscopist needs to perform 81 ablations to average 3.0 treatments per patient. Complication rates did not differ significantly dependent on operator experience (p=0.26). CONCLUSIONS: There was a clinically and statistically significant learning curve associated with endoscopic ablation of BE, with initial subjects requiring approximately 2.1 additional treatment sessions for complete ablation. After 81 ablations an endoscopist is projected to average 3.0 treatments per patient. For optimal delivery, this procedure should be performed in high volume centers.

Utility of contrast‐enhanced ultrasonography with Sonazoid in radiofrequency ablation for hepatocellular carcinoma

Kupffer imaging in contrast-enhanced ultrasonography (CEUS) with Sonazoid, which lasts for 60 min or longer, may be useful in ultrasound-guided percutaneous tumor ablation. The utility of Sonazoid in radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) was investigated in this study. We analyzed a total of 716 HCC nodules that were detected on dynamic computed tomography in 316 patients. Detectability of these nodules was compared between CEUS and conventional ultrasonography. The effectiveness in the treatment was assessed by comparing the mean numbers of treatment sessions of RFA in patients treated with CEUS and that in historical controls matched for tumor and background conditions. Detectability of tumor nodule was 83.5% in conventional ultrasonography and 93.2% in CEUS (P=0.04). Sixty-nine nodules in 52 patients were additionally detected with CEUS. The number of additionally detected tumor nodules was positively correlated with serum albumin level (P=0.016). The number of RFA sessions was 1.33±0.45 with CEUS as compared to 1.49±0.76 in the historical controls (P=0.0019). CEUS with Sonazoid is useful for HCC detection in patients with a well-conserved liver function reservoir. The decrease in RFA session numbers indicated the utility of Sonazoid in RFA treatment of HCC.