What is the best next step for a patient with reduced Barrett's esophagus (Barrett's esophagus) and low-grade dysplasia after 2 prior radiofrequency ablation (RFA) sessions?

From the Guidelines

For a patient with reduced Barrett's esophagus and persistent low-grade dysplasia after two radiofrequency ablation (RFA) sessions, the best next step is to proceed with observation/surveillance, as the risk of progression to high-grade dysplasia or adenocarcinoma is still present, but the patient has already undergone significant treatment and has shown reduction in the disease severity, and according to the most recent guidelines, both continued surveillance and treatment are reasonable options for patients with low-grade dysplasia 1.

The patient's history of two prior ablation sessions with radiofrequency ablation and the reduction of the original C6M8 Barrett's esophagus with high-grade dysplasia to C2M4 segment with low-grade dysplasia indicates that the treatment has been effective in reducing the disease severity. However, the persistence of low-grade dysplasia still carries a risk of progression to high-grade dysplasia or adenocarcinoma.

• The patient should continue on a high-dose proton pump inhibitor (PPI) such as omeprazole 40 mg twice daily or equivalent to control acid reflux and promote healing.
• Surveillance endoscopy should be performed at regular intervals, initially at 3-6 months, then annually for several years to monitor for recurrence, as recommended by the guidelines 1.
• The approach to recurrent disease is similar to that of the initial therapy, and visible recurrent nodular lesions require endoscopic resection, whereas flat areas of columnar mucosa in the tubular esophagus can be treated with mucosal ablation 1.
• Patients should be counseled on cancer risk in the absence of treatment, as well as after treatment, to allow for informed decision-making between the patient and the physician 1.

It is essential to note that the patient's history of extreme pain and dehydration after the ablation therapy on both occasions should be taken into consideration when deciding the next step, and the patient should be closely monitored for any adverse effects.

• The most recent guidelines recommend that endoscopic ablation should only be performed in the presence of flat BE without signs of inflammation and in the absence of visible abnormalities 1.
• The guidelines also recommend that mucosal ablation therapy should be applied to all visible esophageal columnar mucosa, 5-10 mm proximal to the squamocolumnar junction, and 5-10 mm distal to the gastroesophageal junction, as demarcated by the top of the gastric folds (ie, gastric cardia) using focal ablation in a circumferential fashion 1.

Overall, the best next step for this patient is to proceed with observation/surveillance, taking into consideration the patient's history and the most recent guidelines, and to closely monitor the patient for any adverse effects or recurrence of the disease.

From the Research

Best Next Step for Patient with Reduced Barrett's Esophagus and Low-Grade Dysplasia

The patient in question has undergone two prior radiofrequency ablation (RFA) sessions for Barrett's esophagus with high-grade dysplasia, resulting in a reduction to a C2M4 segment with low-grade dysplasia. Considering the patient's history and current condition, the best next step can be evaluated based on the following options:

• Observation/Surveillance: This approach involves regular monitoring of the patient's condition without immediate intervention.
• Cryotherapy: This is an alternative endoscopic treatment that can be used for Barrett's esophagus.
• Esophagectomy: This is a surgical procedure to remove part of the esophagus and is typically considered for more advanced cases.
• Continued RFA: Given the patient's history of RFA treatments, continuing with this approach could be a viable option.

Evidence-Based Recommendations

Studies have shown that RFA can be effective in reducing the risk of neoplastic progression in patients with Barrett's esophagus and low-grade dysplasia. For example:

• A study published in 2021 found that RFA modestly reduced the prevalence of low-grade dysplasia and the risk of progression at 3 years 2.
• A systematic review and meta-analysis published in 2021 concluded that RFA significantly reduced the risk of progression to high-grade dysplasia or esophageal adenocarcinoma compared to endoscopic surveillance 3.
• A randomized clinical trial published in 2014 demonstrated that RFA resulted in a reduced risk of neoplastic progression over 3 years of follow-up 4.
• A long-term outcome study published in 2020 reported that RFA significantly reduced the risk of malignant progression, with sustained clearance of Barrett's esophagus in 91% and low-grade dysplasia in 96% of patients 5.
• The American College of Gastroenterology (ACG) guidelines updated in 2022 recommend endoscopic eradication therapy, including RFA, for patients with Barrett's esophagus and low-grade dysplasia 6.

Key Points to Consider

• The patient has already undergone two RFA sessions with significant reduction in the extent of Barrett's esophagus and downgrading of dysplasia.
• RFA has been shown to be effective in reducing the risk of neoplastic progression in patients with Barrett's esophagus and low-grade dysplasia.
• The patient's current condition, with a flat epithelium and no nodules, suggests that continued RFA or surveillance could be appropriate options.

Based on the evidence, the best next step for the patient could be:

• Continued RFA, considering the patient's history of response to this treatment and the evidence supporting its effectiveness in reducing the risk of neoplastic progression.
• Alternatively, surveillance could be considered, given the patient's current condition and the fact that RFA can be repeated if necessary. However, the decision should be made on a case-by-case basis, taking into account the patient's individual risk factors and preferences.