Radiofrequency Ablation: Stepwise circumferential and focal RFA of Barrett s s esophagus using the HALO System

Radiofrequency Ablation: Stepwise circumferential and focal RFA of Barrett s s esophagus using the HALO System

Used abbreviations BE: Barrett s esophagus EC: Early cancer ER: Endoscopic resection HGD: High-grade dysplasia LGD: Low-grade dysplasia RFA: Radiofrequency ablation

Contraindications for RFA Pregnancy; Prior radiation therapy to the esophagus; Esophageal varices at risk for bleeding; Presence of staples/clips in or around the esophagus. Prior Heller myotomy; Eosiniphilic esophagitis; Moderate to severe reflux esophagitis (grade C or D).

Pre-RFA precautions Anticoagulants: Continue aspirin for those with a good indication; Discontinue aspirin (7 days before, until 3 days after) in patients with an increased risk for complications (e.g. stricture); Stop coumarines (coumarines 3 days, warfarin 7 days) for low-risk patients, restart after 4-7 days; Continue coumarines for high-risk patients, titrate INR at 1.5-2.5. Implantable pacing device (e.g. AICD, neurostimulator, pacemaker): Check with the specialist responsible for the pacing device; No indication for antibiotic prophylaxis.

ER prior to RFA ER of visible lesions prior to RFA: Renders the mucosa flat for subsequent ablation; Allows for optimal histological staging of the disease.

ER prior to RFA ER may make subsequent RFA more difficult, due to scarring of the esophageal wall; Scarring of the esophagus, especially after widespread ER, may result in: Overestimation of the EID by the sizing balloon; Difficulties keeping the balloon in the right position; The need for different maneuvers to ablate all BE mucosa; The need to use different sizes of ablation catheters: This requires second level HALO ablation experience.

ER prior to RFA May cause complications such as lacerations, or even perforation, due to overstretching by the balloon; May increase the chance of symptomatic stenosis following RFA; May impair subsequent HALO 90 ablation sessions.

ER prior to RFA lessons from studies thus far ER followed by RFA is effective; RFA after more widespread ER may cause difficulties; Be less aggressive with resecting, it is advisable to limit the ER extent to <2 cm in length and <50% of the circumference; Be conservative when choosing the diameter of the ablation catheter of the ablation balloon.

T R E A T M E N T P R O T O C O L BE ER of any visible lesion Primary HALO360 ablation HALO360/90 ablation every 2 months max. 2x HALO360 max. 3x HALO90 Residual BE epithelium? NO EGD with NBI/Lugol and 4Q/1-2cm biopsies YES Escape ER

Treatment protocol After prior ER, schedule initial RFA after at least 6 weeks; Re-schedule patients for RFA at 8-12 week intervals; Depending on the extent of residual BE, additional ablation can be performed using the HALO 360 or HALO 90 system: Second circumferential ablation in case of: circumferential disease > 2 cm; multiple islands or tongues. Focal ablation in case of: circumferential disease <2 cm; diffuse islands or small tongues; irregular z-line; circular treatment Z-line (at least once).

Circular treatment neo-z-line Circular treatment with HALO 90 Contact HALO 360 balloon with upper gastric folds not sufficient Endoscopic inspection unreliable for presence of BE at gastric junction Sampling error of random biopsies for IM During HALO 90 ablation of islands, treat Z-line as well

Post-treatment care (I) Maintenance medication: High-dose proton pump inhibitors (e.g., esomeprazole 40 mg BID). Although there is no scientific evidence that additional H2- receptor antagonists or sucralfate improve woundhealing, extra acid suppressant therapy may be prescribed for two weeks after each therapeutic endoscopy: Ranitidine 300 mg before night; Sucralfate suspension 5 ml QID (200 mg/ml).

Post-treatment care (II) Avoid aspirin, NSAIDs for 7 days (depending on indication); Full liquid diet for 24 hours, then soft for 1 week; To relieve post-treatment discomfort, advise: 1:1 mixture of antacid (e.g. Maalox) and 2% viscous lidocaine; Acetominophen with codein (15mg/5ml), 15ml QID; Instruct to take as needed for discomfort. Instruct patients to contact you in the case of: Severe ongoing pain, fever, hematemesis, melena, dysphagia. Hand out a patient information waiver

What to expect after RFA treatment Chest discomfort, usually gone after 4-8 days; Some patients have severe pain complaints, prescribe medication as mentioned previously; Dysphagia is rare and mostly occurs in patients with prior widespread ER: Dysphagia may be observed in the first week following treatment, mostly complaints are transient and can be managed conservatively; Stenosis should only be dilated when endoscopy shows narrowing that cannot be passed with an endoscope.

Follow-up recommendations Schedule follow-up 2 months after the last treatment session to confirm eradication of BE mucosa; Then schedule follow-up 6 and 12 months after the last treatment session, and annually thereafter; Use a high-resolution endoscope with NBI-facilities (or comparable) to detect small residual islands, along the initial length of the BE.

Follow-up recommendations Take 4Q biopsies just distal (<0.5mm) to the neosquamocolumnar junction to confirm clearance of IM in this area; Take 4Q biopsies from the neosquamous epithelium every 1-2 cm over the initial length of the BE, to exclude buried glands. Do not obtain neosquamous biopsies <1 cm of the junction since buried glands may be misdiagnosed when you accidentally straddle the junction.

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