Radiofrequency Ablation for Dysplastic Barrett’s Esophagus

When Barrett’s esophagus progresses to have abnormal histologic features, this can be classified as low-grade or high-grade dysplasia. Although most cases of Barrett’s esophagus do not progress to dysplastic changes, when high-grade dysplasia is present, these lesions have a significant risk of progression to esophageal adenocarcinoma, reported as high as 20% per year. Throughout the years, controversy has existed as to how to treat Barrett’s esophagus and dysplasia in the setting of Barrett’s esophagus. Radiofrequency ablative (RFA) therapy has now become the standard of care for high-grade dysplasia as opposed to observation alone, esophagectomy, or photodynamic therapy. Ablation in these patients has demonstrated a high rate of complete eradication of dysplasia and decreased disease progression. It is important, however, that the endoscopist recognize and look for nodular disease prior to ablation. Any visible raised lesion must be addressed with endoscopic mucosal resection (EMR) prior to ablation in order to ensure that the ablation reaches the muscularis mucosae. In addition, sampling error can lead to under-staging in raised lesions, and EMR allows for a more accurate diagnosis which could lead to a treatment alternative more appropriate than ablation. We recommend that patients have two endoscopies in high definition with biopsies and within 2 months prior to undergoing ablation. Furthermore, it is recommended that the biopsies be reviewed by a pathologist specialized in Barrett’s esophagus.