Barrett's esophagus without dysplasia: Wait or ablate?

In Barrett’s esophagus, metaplastic columnar epithelium that is predisposed to malignancy replaces the stratified squamous epithelium that normally lines the distal esophagus [1]. Barrett’s metaplasia develops as a result of chronic esophageal inflammation caused by the gastroesophageal reflux of noxious material like acid and bile. Endoscopic ablation of this metaplasia has been proposed as a way to prevent cancer. Recent attention has focused on radiofrequency ablation (RFA), which uses endoscopic guidance to position a balloon with a circumferential array of electrodes (the HALO ablation balloon) to deliver radiofrequency energy to the metaplastic esophageal epithelium. Patients are treated with proton pump inhibitors (PPIs) to control acid reflux, and the ablated columnar epithelium heals with the growth of new (neo)squamous epithelium. In 30–46% of patients, treatment with the HALO balloon leaves behind visible foci of Barrett’s metaplasia, which can be eradicated with a smaller, endoscope-mounted ablation device (the HALO ablation catheter) [2]. Using both devices, RFA can safely eliminate all visible evidence of Barrett’s metaplasia in up to 98% of patients [3], and RFA has been shown to prevent the progression from high-grade dysplasia to cancer in Barrett’s esophagus in a randomized, controlled trial [4]. In a recent medical position statement, the American Gastroenterological Association has recommended endoscopic eradication therapy for the treatment of patients with confirmed high-grade dysplasia in Barrett’s esophagus, but not for the general population of patients with nondysplastic Barrett’s esophagus [5]. Noting the safety and apparent efficacy of RFA, however, some authorities feel that these guidelines are too restrictive, and argue that virtually all patients with Barrett’s esophagus should be treated with RFA, irrespective of dysplasia [6]. El-Serag and Graham recently have argued that, intellectually, ablation for Barrett’s esophagus is the same as routine colonoscopic polypectomy for colorectal polyps, and that the practice of limiting endoscopic ablation only to Barrett’s esophagus with dysplasia or early cancer is like limiting polypectomy only to polyps that are large or already malignant [7]. Arguments that RFA should be used to treat patients with non-dysplastic Barrett’s esophagus are based on the premise that the procedure is effective at decreasing the long-term risk of esophageal cancer. However, it is important to appreciate that no study yet has established that efficacy. Rather, efficacy in preventing cancer in nondysplastic Barrett’s esophagus is inferred from short-term studies showing that RFA prevents the progression from high-grade dysplasia to cancer, and from studies showing that RFA can eliminate visible evidence of Barrett’s metaplasia for up to 5 years. Unfortunately, elimination of visible evidence of Barrett’s metaplasia does not establish that the cancer risk has been eliminated because of two unresolved issues: (1) The frequency with which RFA buries metaplastic glands with malignant potential under a layer of neosquamous epithelium (where they are hidden from the endoscopist) is not clear and, (2) the frequency with which Barrett’s metaplasia recurs after initial complete eradication is not clear. In this issue of Digestive Diseases and Sciences, Vaccaro et al. shed some light on the issue of recurrent Barrett’s metaplasia [8]. The investigators studied 47 patients who had RFA for Barrett’s esophagus, mostly with dysplasia, and who had S. J. Spechler (&) Division of Gastroenterology, VA North Texas Healthcare System, The University of Texas Southwestern Medical Center, 4500 South Lancaster Road, Dallas, TX 75216, USA e-mail: SJSpechler@AOL.com