Radiofrequency Ablation of Barrett’s Esophagus

Radiofrequency ablation (RFA) is a safe and effective thermal ablative therapy for dysplastic Barrett’s esophagus (BE) and, to a lesser extent, nondysplastic BE. Before the utilization of RFA, there must be an appropriate indication, assessment of potential contraindications, discussion of risks and benefits with patients, and careful endoscopic planning. The ease of performance of the procedure along with its efficacy and low rate of adverse events have established RFA as a reliable technique for endoscopic management of dysplastic BE.

Key points

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Radiofrequency ablation is a safe and effective thermal ablative therapy for dysplastic and nondysplastic Barrett’s esophagus.
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Before performance of radiofrequency ablation, careful endoscopic planning should occur and potential contraindications should be assessed for.
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Successful performance of radiofrequency ablation requires an understanding of the different tools available and a systematic approach to safe and effective application.

Introduction

The goal of ablation therapy is to eliminate dysplastic or metaplastic epithelium associated with Barrett’s esophagus (BE) through the use of thermal techniques, cryotherapy, or photodynamic therapy. Following ablation of dysplasia and specialized intestinal metaplasia (IM), in the setting of effective acid reflux suppression, normal squamous epithelium replaces the ablated tissue. In many/most cases, ablation therapy is used adjunctively after endoscopic resection of visible lesions.

Radiofrequency ablation (RFA) is a safe and effective means of thermal ablative therapy for BE that has become a widely adopted treatment of dysplastic and, to a lesser extent, nondysplastic BE. RFA uses direct contact alternating electrical current to generate thermal energy to produce precise, reproducible, and reliable superficial tissue necrosis, permitting neo-squamous mucosal regeneration and minimizing the risk for fibro-reactive stricture. RFA can be performed with circumferential and focal delivery devices (Covidien, Sunnyvale, CA).

Patient Selection

Indications and contraindications for radiofrequency ablation

Several categories of patients with BE may qualify for eradication therapy for BE ( Box 1 ). Patients with BE with high-grade dysplasia or greater have been shown to benefit from RFA as a monotherapy for bland, flat BE. RFA should not be used for primary eradication therapy for raised or nodular dysplastic BE. RFA should be used adjunctively in patients with nodular BE following endoscopic resection of all raised or nodular regions. Selected patients with low-grade dysplasia (LGD), who have multifocal LGD, or who have demonstrated persistence of LGD, confirmed by an expert gastrointestinal pathologist, may also be candidates for RFA. Highly selected patients with BE without dysplasia can be considered for RFA if they are at perceived increased risk for development of esophageal adenocarcinoma (EAC), such as those with a strong family history of EAC. In the future, incorporation of biomarkers as part of the prognostic workup for those with BE may identify patients who can derive the most benefit from RFA eradication therapy even in the absence of dysplasia.

Box 1

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