How to perform: HALO 360 Radiofrequency Ablation of Barrett s s Esophagus

Transcription

1 How to perform: HALO 360 Radiofrequency Ablation of Barrett s s Esophagus

2 Used abbreviations BE: EID: ER: RFA: Barrett s esophagus Esophageal inner diameter Endoscopic resection Radiofrequency ablation

3 HALO Ablation System RFA HALO 360 generator Buttons to adjust power (Watt) Buttons to adjust energy (Joule/cm 2 ) Display for EID (mm) Inflation pressure (psi) Volume buttons Display for energy and power settings and for general instructions Reset button Cable to connect the catheter to the generator (air and RF energy) Foot pedal to in/deflate balloon Foot pedal to activate electrode

4 HALO Ablation System HALO 360 sizing & ablation catheter Non-compliant 4cm long balloon catheter, for sizing of esophageal inner diameter. Balloon catheter, encircled by 60 electrode rings that alternate in polarity, over a length of 3-cm.

5 HALO Ablation System Technical background HALO 360 generator delivers radiofrequency energy, resulting in uniform, controlled ablation (~500 microns deep), due to: Automated RF energy delivery; Fixed amount RF energy density; Fixed power; Bipolar electrode array. Target mucosa Ablation depth Muscularis mucosae

6 How to perform: Primary circumferential ablation using the HALO 360 System

7 1) Preparations for HALO 360 ablation 2x 10 cc syringes with acetylcysteine 1%; Extra stiff guide wire e.g. Amplatz, Cook Europe; Spraying catheter e.g. Olympus PV-5 series; Soft distal attachment cap for endoscope e.g. Barrx, Olympus; 0.45 micron filter BÂRRX; HALO 360 sizing catheter; HALO 360+ ablation catheters in different sizes; HALO 360 generator or HALO FLEX generator; Preferably use a therapeutic endoscope (wider suction channel).

8 2) Inspection of the esophagus Inspect the esophagus: visible lesions? strictures? Clean esophageal wall by: spraying with acetylcysteine (1 %), and flushing with plain water (via syringe or waterjet). Record: top of the gastric folds; maximum proximal extent of the BE. Introduce a guide wire.

9 3) Sizing the esophageal inner diameter (I) Connect and calibrate the sizing catheter; Introduce the catheter over the guide wire, water may be used to facilitate introduction, but omit lubricant jelly.

10 3) Sizing the esophageal inner diameter (II) During calibration of the sizing balloon, do not remove the plastic sheet

11 5 cm e.g. 30 cm 4 cm NOTE: 3 cm The difference in the start of cm-markings on the endoscope and catheter; Compared to the endoscope the catheters are stiffer and thus make a wider angle in the hypopharynx, causing it to end up ~2 cm more proximal.

12

13 35 cm 35 cm At biteblock 35cm for scope and catheter shaft 35 cm 37 cm 41 cm 2 cm 4 cm 6 cm

14 Place the sizing catheter 6 cm above the maximum proximal extent of the BE segment, using the shaft centimeters for reference. Start sizing by hitting the grey foot pedal, while keeping the catheter shaft fixed to the bite-block.

15 After the measurement cycle, a mean esophageal inner diameter is displayed on the generator, and the sizing balloon automatically deflates. Repeat the measurements for every cm, moving proximally to distally.

16 Until a rapid increase in EID indicates the transition to the stomach or hiatal hernia.

17 4) Select appropriate catheter size Available catheter sizes: mm Recommended size: Based on the smallest measured diameter, select a catheter with a diameter closest to the smallest EID, e.g. EID 24mm: catheter 25mm, or EID 23mm: catheter 22mm. In case of prior ER, or pre-existing stenosis, select a catheter one size smaller than recommended to avoid complications, e.g. EID 32mm: not a 31mm but a 28mm catheter. Always select a catheter closest to the smallest EID, in case of prior ER take an additional step down.

18 5) First circumferential ablation pass (I) Connect the HALO 360+ catheter to the HALO 360/ HALO FLEX generator; Settings: power 300 Watt, energy 12 J/cm 2 ; Treatment regimen: 1x-clean-1x.

19 5) First circumferential ablation pass (II) Insert the ablation catheter over a guidewire. Do not use lubricant jelly on the electrode. Lubricant may be applied on the endoscope from cm, to minimize friction with the catheter shaft. The balloon catheter may be moistened with plain water. Introduce the endoscope alongside the catheter. When using a therapeutic endoscope flushing and suctioning can be performed with a minimal risk for aspiration, given the wide suctioning channel. Align the upper end of the electrode 1 cm above the most proximal extent of the BE (under endoscopic visualization).

20 Inflate the balloon via the grey foot pedal; Deflate the esophagus for optimal contact; Activate the electrode via the blue pedal.

21 Reposition the balloon distal to the first ablation zone, allowing 5-10mm overlap; Repeat ablations until the whole BE segment has been ablated once.

22 5) First circumferential ablation pass (video)

23 6) Cleaning procedure Cleaning off the coagulum from the ablation zone and electrode in between ablation passes has been proven to increase surface regression. Cleaning is performed by: Pushing coagulum off the ablation zone using a soft distal attachment cap; If necessary, forceful rinsing with water through a spraying catheter, using a pressure pistol, may be used to remove residual coagulum; Cleaning the electrode surface with a wet gauze,in a circular motion following the direction of the electrodes.

24 6) Cleaning procedure using the cap (video)

25 6) Cleaning by forceful water spraying (video)

26 7) Second circumferential ablation pass (I) Reintroduce the ablation catheter and endoscope; Align the upper end of the electrode with the upper end of the first ablation zone; Repeat ablations (using the same energy settings), until the whole BE segment has received two applications of energy.

27 7) Second circumferential ablation pass (video)

28 RFA-Academia Program Committee: Jacques Bergman Guido Costamagna Horst Neuhaus