Endoscopic ablation of Barrett＇s esophagus using high power setting argon plasma coagulation： A prospective study

AIM: This prospective study evaluated the effectiveness of 90 W argon plasma coagulation (APC) for the ablation of Barrett's esophagus (BE) that is considered to be the main risk factor for the development of esophageal adenocarcinoma. METHODS: The results from 25 patients, observed at the First Department of General Surgery, University of Verona, Italy, from October 2000 to October 2003, who underwent APC for histologically proven BE were prospectively analyzed, RESULTS: The ablation treatment was completed in all the patients but one (96%). The mean number of APC sessions needed to complete ablation was 1.6 (total number: 40). The eradication was obtained in the majority of cases by one session only (60%), two sessions were required in 24% of the cases and three or more in 16%. About 43% of the sessions were complicated. Retrosternal pain (22.5%) and fever (17.5%) were the most frequent symptoms. Only one major complication occurred, it was an hemorrhage due to ulcer formation on the treated esophagus that required urgent endoscopic sclerosis and admission. The follow-up was accomplished in all the patients with a mean period of 26.3 mo and 20 patients (84%) with a follow-up period longer than 24 mo. Only one patient showed a relapse of metaplastic mucosa 12 mo after the completion of ablation. The patient was hence re-treated and now is free from recurrence 33 mo later. CONCLUSION: High power setting (90 W) APC showed to be safe and effective. The effects persist at a mean follow-up period of two years with a comparable cost in term of complications with respect to standard power settings. Further studies with greater number of patients are required to confirm these results and to assess if ablation reduces the incidence of malignant progression.     

Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole

BACKGROUND: Barrett's esophagus is a premalignant condition induced by gastroesophageal reflux. The aim of this prospective study was to assess the efficacy of argon plasma coagulation in combination with high-dose omeprazole therapy to ablate nondysplastic Barrett's epithelium. METHODS: In 73 patients with histologically confirmed Barrett's epithelium, argon plasma coagulation was used in combination with maximal acid suppression (omeprazole 40 mg three times a day). Histologic and endoscopic changes were evaluated at 6- and 12-month intervals. RESULTS: In 69 of 70 patients (98.6%) complete squamous regeneration was achieved after a median of 2 argon plasma coagulation sessions (range 1 to 5). During a median follow-up of 12 months (range 2 to 51 months) there has been no relapse or evidence of the development of dysplasia under continuous acid suppression. Three patients (4.3%) developed a mild stricture of the distal esophagus that resolved after a single session of bougie dilation. CONCLUSIONS: In our experience, argon plasma coagulation in combination with high-dose omeprazole treatment is an effective and safe technique for complete ablation of nondysplastic Barrett's epithelium. Restoration of squamous mucosa after argon plasma coagulation appears to be long-lasting.     

Eradication of Barrett's mucosa with argon plasma coagulation and acid suppression: immediate and mid term results

Background—Intestinal metaplastic mucosa inBarrett's oesophagus can be replaced by squamous epithelium aftermucosal thermal ablation associated with acid suppression therapy.
Aims—To assess whether restoration of squamousepithelium can be obtained after ablation of Barrett's oesophagususing argon plasma coagulation (APC) associated with proton pumpinhibitor (PPI) therapy.
Methods—Thirty one patients with Barrett'soesophagus received APC. Omeprazole (40 mg/day) was given from thefirst APC application to one month after completion of the treatment,then given symptomatically. Twenty four hour pH-metry was performedduring endotherapy.
Results—Complete re-epithelialisation wasvisualised at endoscopy in 25/31 patients (81%) after a mean number of2.4 APC sessions (range 1-4). Only partial squamousre-epithelialisation was observed in three patients and three othershad no eradication. At histological assessment, eradication ofBarrett's oesophagus was only confirmed in 19/31 patients (61%) dueto the presence of a few residual Barrett's glands under the newsquamous epithelium. Complete eradication was related to a Barrett'soesophagus segment length of less than 4 cm and the absence ofcircumferential extension but not to the normalisation of oesophagealacid exposure under PPI therapy. Seventeen patients with apparentlycomplete endoscopic and histological eradication of Barrett'soesophagus were re-evaluated at one year; eight (47%) disclosedrelapsing islands of Barrett metaplasia despite continuous omeprazoletherapy (10-40 mg/day).
Conclusions—APC combined with 40 mg omeprazoledaily can eradicate Barrett's mucosa with apparent squamousre-epithelialisation in the majority of patients even in the absence ofnormalisation of oesophageal acid exposure. However, one year afterendotherapy for Barrett's oesophagus, relapse is frequent but limitedin extent.

Keywords:Barrett's oesophagus; argon plasma coagulation; omeprazole; gastro-oesophageal reflux; Barrett's adenocarcinoma

     

Endoscopic ablation of dysplastic Barrett's oesophagus comparing argon plasma coagulation and photodynamic therapy: a randomized prospective trial assessing efficacy and cost-effectiveness

OBJECTIVE: Endoscopic mucosal ablation is a promising technique that is used to treat dysplastic Barrett's oesophagus. The purpose of this study was to investigate the efficacy and cost-effectiveness of two promising techniques, argon plasma coagulation (APC) and photodynamic therapy (PDT), in the ablation of dysplastic Barrett's oesophagus. MATERIALS AND METHODS: Twenty-six patients with dysplastic Barrett's oesophagus (21 M, median age 60 years, median length 4 cm, 23 low-grade dysplasia (LGD), 3 high-grade dysplasia (HGD)) were randomized to APC: 13 patients, PDT: 13 patients. APC was performed at a power setting of 65 W and argon gas flow at 1.8 l/min in 1-6 sessions (mean 5). PDT was performed 48 h after intravenous injection of Photofrin 2 mg/kg with a 630 nm red laser light, 200 J/cm through a PDT balloon in one session. All patients received treatment with high-dose proton pump inhibitors. Cost analysis was undertaken and the results were assessed by endoscopy and biopsies at 4 months and 12 months after therapy. RESULTS: All patients in both groups showed a reduction in the length of Barrett's oesophagus. The median length of Barrett's oesophagus eradicated at the 4-month follow-up: APC 65%, PDT 57% and at the 12-month follow-up: APC 56%, PDT 60%. Dysplasia eradication at 4 months: APC 62%, PDT 77%, p = 0.03 (95% CI 0.66-0.96) and at 12 months APC 67%, PDT 77%. Buried columnar glands with intestinal metaplasia were seen in both groups, with one patient in the PDT arm developing adenocarcioma under the neo-squamous epithelium. Severe adverse events included APC 2/13 (15%) stricture, 1/13 (8%) odynophagia, chest pain and fever; PDT 2/13 (15%) photosensitivity, 2/13 (15%) stricture. PDT would cost an additional 266 pounds sterling for every percentage reduction in Barrett's length and 146 pounds sterling per percentage reduction in dysplasia compared with APC treatment. CONCLUSIONS: APC and PDT are equally effective in eradicating Barrett's mucosa, with PDT being the more expensive treatment. However, PDT is more effective in eradicating dysplasia and the extra benefits of PDT are generated at an extra cost. The occurrence of buried columnar glands and carcinoma warrants caution. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium to justify these interventions.     

The efficacy and safety of argon plasma coagulation therapy in Barrett's esophagus.

BACKGROUND: Thermoablation is being used to eliminate the metaplastic epithelium of Barrett's esophagus and allow its reversal into squamous epithelium in an acid-controlled environment. This study assessed the efficacy and safety of a new thermoablation technique, argon plasma coagulation. METHODS: Patients with circumferential Barrett's esophagus 2 to 5 cm long were enrolled. Acid suppression was accomplished with lansoprazole. One-half the circumference of Barrett's mucosa was treated with argon plasma coagulation, and the other half served as an internal control. After macroscopic squamous re-epithelialization occurred, biopsy specimens were obtained from both areas systematically. RESULTS: Nine patients, all men with a mean age of 51.1 years, completed the study. During 24-hour esophageal pH monitoring a pH less than 4 occurred on average 2.8% of the time with a mean dose of lansoprazole of 70 mg/day. Squamous re-epithelialization developed in treated areas in all 9 patients. Biopsy showed that 7 of 9 patients (77.8%) had squamous re-epithelialization without intestinal metaplasia. Biopsy showed that 2 of 9 patients (22.2%) had squamous re-epithelialization with evidence of underlying intestinal metaplasia. There were no serious complications. CONCLUSIONS: Argon plasma coagulation in an acid-controlled environment was both efficacious and safe in the treatment of Barrett's esophagus. However, the reappearance of squamous epithelium after therapy did not exclude the presence of underlying intestinal metaplasia.     

Endoscopic ablation of Barrett''s esophagus using argon plasma coagulation: a prospective study after fundoplication

The aim of the prospective clinical study presented here is to test the effectiveness of a multimode approach consisting of argon plasma coagulation combined with laparoscopic fundoplication in the management of Barrett's esophagus. Argon plasma coagulation was performed in 19 patients with Barrett's esophagus who had previously undergone surgical antireflux treatment. The mean follow-up time was 17 months, ranging between 6 and 27 months. Squamous epithelium was completely restored in all patients. In 68.4% of cases two sessions were required. The most frequent complications were chest discomfort and retrosternal pain. In 11 patients the symptoms lasted 3 days and in six cases persisted for a longer period, requiring analgesic medication. Short-term dysphagia and odynophagia were observed in four patients.     

Long-term follow-up after complete ablation of Barrett＇s esophagus with argon plasma coagulation

AIM: To report the long-term outcome of patients after complete ablation of non-neoplastic Barrett's esophagus (BE) with respect to BE relapse and development of intraepithelial neoplasia or esophageal adenocarcinoma. METHODS: In 70 patients with historically proven non neoplastic BE, complete BE ablation was achieved by argon plasma coagulation (APC) and high-dose proton pump inhibitor therapy (120 mg omeprazole daily). Sixty-six patients (94.4%) underwent further surveillance endoscopy. At each surveillance endoscopy four-quadrant biopsies were taken from the neo-squamous epithelium at 2 cm intervals depending on the pre-treatment length of BE mucosa beginning at the neo-Z-line, and from any endoscopically suspicious lesion. RESULTS: The median follow-up of 66 patients was 51 mo (range 9-85 mo) giving a total of 280.5 patient years. A mean of 6 biopsies were taken during surveillance endoscopies. In 13 patients (19.7%) tongues or islands suspicious for BE were found during endoscopy. In 8 of these patients (12.1%) non-neoplastic BE relapse was confirmed histologically giving a histological relapse rate of 3% per year. In none of the patients, intraepithelial neoplasia nor an esophageal adenocarcinoma was detected. Logistic regression analysis identified endoscopic detection of islands or tongues as the only positive predictor of BE relapse (P= 0.0004). CONCLUSION: The long-term relapse rate of non neoplastic BE following complete ablation with high-power APC is low (3% per year).     

氩离子凝固治疗联合质子泵抑制剂治疗Barrett食管的临床观察

目的探讨内镜下氩离子凝固治疗联合质子泵抑制剂治疗Barrett食管的临床疗效。方法选择我院2008年8月-2010年6月经胃镜检查、病理活检确诊为Barrett食管的患者54例,采用随机抽样法分成两组,分别为对照组、实验组,每组各27例。对照组：内镜下氩离子凝固术治疗;实验组：内镜下氩离子凝固术治疗后口服埃索美拉唑40mg,1次／d,维持治疗6个月。各组均进行了为期12个月的随访监测,对其临床疗效、并发症、不良反应进行评估。结果两组患者治疗总有效率均为100％,治疗后对照组不良反应发生率为25．93％,实验组为33．33％,两组比较差异无统计学意义（P〉0．05）;对照组存在不同的临床症状,实验组临床症状缓解率为100％,两组比较差异有统计学意义（P〈0．05）;两组均在治疗后第3个月随访中未见复发,对照组在第6个月随访中发现2例复发,复发率为7．41％,第12个月随访中发现5例复发,复发率为18．52％,实验组在治疗后第6个月随访中未见复发,第12个月随访中发现有1例复发,复发率为3．70％,两组比较差异有统计学意义（P〈0．05）。结论氩离子凝固术能有效逆转Barrett食管黏膜,是一种安全、有效的治疗方法。联合质子泵抑制剂不仅能明显改善症状,还可减少复发,值得临床推广应用。     

内镜下氩离子凝固术联合奥美拉唑治疗Barrett食管76例临床及随访分析

目的探讨胃镜下氩离子凝固术联合奥美拉唑治疗Barrett食管的疗效。方法将胃镜检查并病理证实的76例Barrett食管（BE）患者随机分为对照组和治疗组,对照组36例给予口服奥美拉唑20 mg,1次/d;治疗组40例在胃镜下行氩离子凝固术（APC）,术后给予口服奥美拉唑20 mg,1次/d,对于一次治疗不能清除病灶的患者,4周后进行第二次清除,于术后3、6、12个月进行胃镜复查,对其疗效及并发症进行评估。结果对照组在治疗过程中,胃镜下BE长度和范围未见明显改变;至随访结束前,治疗组镜下保持完全清除的BE食管患者占APC治疗的72.5%,治疗组临床缓解率明显高于对照组（P〈0.05）。术后8例出现胸骨后不适,3例出现胸骨后疼痛,3例出现黏膜下气肿,2例出现低热。结论 Barrett食管的内镜下氩离子凝固术安全有效,有良好的临床应用前景。     

Treatment of Barrett's esophagus with argon plasma coagulation and antireflux surgery. A retrospective analysis

BACKGROUND/AIMS: The aim of this study was to assess the efficacy and the results of ablation of Barrett'esophagus by endoscopic argon plasma coagulation (APC) followed by fundoplication. METHODOLOGY: Between January 1999 and December 2004, 21 patients with histological proven, short BE and scheduled for fundoplication, were treated by APC. Treatment was repeated until histological confirmation of complete ablation was obtained. All patients underwent surgical correction of reflux by Nissen fundoplication. Response to treatment was assessed at follow up with endoscopy every 6 to 12 months. RESULTS: BE ablation was obtained in all patients after a mean of 3.6 APC sessions. There was no mortality and morbidity was 19% (4/21 patients). All patients underwent 360 degrees Nissen fundoplication as antireflux procedure. There was no operative mortality and no major complications requiring re-operation. Mean postoperative hospital stay was 7.9 days. Postoperatively 17/21 patients had at least one endoscopic control. The mean observation time was 17.5 months. Recurrence of Barrett epithelium was observed in 6 patients at a mean of 9.6 months after fundoplication. CONCLUSIONS: Our results show that the combination of APC and fundoplication is a safe and effective treatment option for most patients with uncomplicated BE. Although no cancer development was observed, larger studies with a longer follow up are required to assess the impact of APC on cancer risk.     

In vivo evaluation of argon plasma coagulation in a porcine model

BACKGROUND: Argon plasma coagulation (APC) is a noncontact form of monopolar electrocautery. One purported advantage of APC includes a limit to the depth of injury. It is unclear from previous studies whether the depth of injury is limited to superficial tissue layers with the settings used in clinical practice. OBJECTIVE: To evaluate the depth and the area of APC-induced injury by using new modes of APC delivery in an in vivo porcine model in the setting of colonoscopy. DESIGN: Blinded quasi-experiment. SUBJECTS: Six swine. INTERVENTION: Colonoscopy with the swine under general anesthesia, with application of APC in 2 different pulsed modes and varying power settings and duration of application. MAIN OUTCOME MEASUREMENTS: Surface area and depth of colonic mucosal injury. Qualitative histologic analysis of each site of APC application was performed on formalin-fixed specimens after euthanizing the swine. RESULTS: Muscularis propria injury occurred in 22% of lesions with 10 W, 62% of lesions with 20 W, 86% of lesions with 40 W, and 80% of lesions with 60 W. Muscularis propria injury occurred in 42% of lesions at 1 second, 66% of lesions at 3 seconds, and 69% of lesions at 5 seconds. Depth of injury was significantly correlated with total energy delivered (P = .001, r = 0.75). Surface area was significantly associated with total energy delivered (P < .001, r = 0.81). LIMITATIONS: This study was performed in distal swine colon rather than human colon. Colon tissue response to APC injury may differ from swine to human colon. The application distance from the APC probe to the colonic tissue may have varied between applications. CONCLUSIONS: Muscularis propria injury occurs across a broad range of clinically used APC settings. The frequency of deep injury and the surface area of the lesion increases with total energy delivered. The lowest power settings (10-20 W) and the shortest durations have the lowest risk of deep tissue injury.     

Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video)

BACKGROUND: A Dieulafoy's lesion is a submucosal artery that may erode the epithelium and lead to severe hemorrhages. The safety and efficacy of argon plasma coagulation (APC) for the hemostasis of these lesions has not been studied. OBJECTIVE: To evaluate efficacy of APC alone in the hemostasis of Dieulafoy's lesions. DESIGN: A retrospective analysis of hemostasis by chart review, with long-term follow-up by outpatient visit or phone interview. SETTING: An academic hospital with 24-hour endoscopic service availability. PATIENTS: All patients with acute bleeding from a Dieulafoy's lesion treated with APC. INTERVENTIONS: Hemostasis was attempted with 2.3-mm APC probes, with settings varying from 40 W to 60 W, according to lesion location. MAIN OUTCOME MEASUREMENTS: Initial hemostasis, recurrent bleeding, and 30-day mortality rates. RESULTS: Twenty-three Dieulafoy's lesions were treated with APC, which represented 85% of all such lesions observed. Severe comorbidities and abnormal coagulation were present in 39% and 22%, respectively. Dieulafoy's lesions were located in the upper-GI tract in 20 patients (87%). Active bleeding was found in 20 patients (87%), a nonbleeding visible vessel was found in 2 patients (9%), and a minute mucosal defect below an adherent clot was found in 1 (4%). Initial hemostasis was achieved in all patients, without complications. An injection of an average volume of 3 mL of 1:10,000 epinephrine solution preceded APC in 3 cases for the identification of the bleeding lesion. Recurrent bleeding occurred in a patient after 48 hours; no bleeding-related deaths were observed during a median follow-up of 29 months. LIMITATIONS: Retrospective study. CONCLUSIONS: Dieulafoy's lesions can be successfully managed by APC alone.     

Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy

Objective. The aim of this study was to prospectively evaluate a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal (GI) endoscopy. Material and methods. From February to June 2005, 216 patients (167 M (77.3%), mean age 66 years) underwent treatment with hp-APC in a total of 275 sessions. Main indications were additive ablation therapy in Barrett's esophagus, palliative treatment of esophageal cancer, gastric polyps/carcinomas, angiodysplasias, Zenker's diverticula, and duodenal adenomas. The new hp-APC device (VIO 300 D with APC 2) was used (15–120 W) in upper GI endoscopy, push-enteroscopy, and double-balloon enteroscopy. Results. The mean number of treatment sessions required was 1.7 (1–5). For palliative tumor ablation in the esophagus, the number of sessions was 2.3 (1–5). Minor complications (pain, dysphagia, neuromuscular irritation, asymptomatic gas accumulation in the intestinal wall) were observed in 29/216 patients (13.4%). Major complications (perforation, stenosis occured) in 2 patients (0.9%). Conclusions. Hp-APC appears to be safe and effective in the treatment of various GI condition using different types of endoscopes including double-balloon enteroscopy. Because of the low number of treatment sessions required, hp-APC could be used as an alternative to Nd:YAG laser treatment in tumor debulking.     

Efficacy and one year follow up of argon plasma coagulation therapy for ablation of Barrett's oesophagus: factors determining persistence and recurrence of Barrett's epithelium

INTRODUCTION: Barrett's epithelium (BE) has malignant potential. Neither acid suppression nor antireflux surgery produce consistent or complete regression of the metaplastic epithelium. Endoscopic thermoablation with argon plasma coagulation (APC) offers a different approach but factors influencing its outcome have not been systematically examined. AIM: To assess the efficacy of APC and factors influencing initial and one year outcome. METHODS: Fifty patients, mean age 61.4 years, mean BE length 5.9 cm (range 3-19), underwent APC therapy at four weekly intervals while receiving proton pump inhibitor (PPI) therapy. BE margins were marked by India ink tattooing and extent was documented by grid drawings, photography, and 2 cm interval quadrantic jumbo biopsies. Twenty four hour ambulatory oesophageal pH studies were done while on PPIs before and after APC therapy, and Bilitec bilirubin monitoring after APC completion. RESULTS: A total of 68% of patients achieved >90% BE ablation after a median of four APC sessions. Persistent BE (>10% original BE area) was associated with longer initial BE length despite more APC sessions. Persistent acid and bile reflux on PPIs, although commoner in this group, were not significantly different from those successfully ablated. Fifteen of 34 patients (44%) with successful macroscopic clearance had buried glands, present in 8.3% of a total of 338 biopsies. At the one year follow up, only 32% of those with initial successful ablation showed no recurrence. BE recurred or increased in most with mean segment length increases of 1.1 cm and 1.6 cm, respectively, in patients with previous full ablation and those with persistent BE. The presence of buried glands did not predict BE recurrence. Patients who reduced their PPI dose had significantly greater BE recurrence. CONCLUSIONS: APC is most effective for shorter segment BE ablation but "buried" glands do occur. Recurrence of BE is common at one year, especially in those with initial persistent and/or long segment BE and those who reduce their PPI dose.     

Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy

OBJECTIVE: The aim of this study was to prospectively evaluate a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal (GI) endoscopy. MATERIAL AND METHODS: From February to June 2005, 216 patients (167 M (77.3%), mean age 66 years) underwent treatment with hp-APC in a total of 275 sessions. Main indications were additive ablation therapy in Barrett's esophagus, palliative treatment of esophageal cancer, gastric polyps/carcinomas, angiodysplasias, Zenker's diverticula, and duodenal adenomas. The new hp-APC device (VIO 300 D with APC 2) was used (15-120 W) in upper GI endoscopy, push-enteroscopy, and double-balloon enteroscopy. RESULTS: The mean number of treatment sessions required was 1.7 (1-5). For palliative tumor ablation in the esophagus, the number of sessions was 2.3 (1-5). Minor complications (pain, dysphagia, neuromuscular irritation, asymptomatic gas accumulation in the intestinal wall) were observed in 29/216 patients (13.4%). Major complications (perforation, stenosis occurred) in 2 patients (0.9%). CONCLUSIONS: Hp-APC appears to be safe and effective in the treatment of various GI condition using different types of endoscopes including double-balloon enteroscopy. Because of the low number of treatment sessions required, hp-APC could be used as an alternative to Nd:YAG laser treatment in tumor debulking.     

Treatment of Barrett esophagus with argon plasma coagulation with acid suppression--a prospective study]

26 patients with a Barrett's esophagus of at least 2 cm length (medium 4.9 cm) were treated with a combination of repeated argon-plasma-coagulation (APC) and a long-term acid suppression using proton pump inhibitors controlled by a 2 h pH monitoring. Eleven out of 26 patients (42%) showed endoscopically and histologically a complete eradication of the metaplastic cylindric epithelium (intention--to treat analysis). Nine patients (35%) had an endoscopic complete remission but remnants of the cylindric epithelium were found at the histologic examination. On an average one APC-session was necessary for 1 cm of initial length of the Barrett's esophagus. No serious complications were seen. It remains unclear if this therapy can reduce the long-term risks for adenocarcinoma of the esophagus in patients with Barrett's esophagus.