Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?

Abstract

The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.