Endoscopic eradication therapy plus reflux control associated with decreased Barrett's recurrence rates

Endoscopic eradication therapy (EET) plus effective reflux control is associated with very low rates of recurrence in patients with Barrett's esophagus.

Researchers at a U.S. tertiary care center studied patients with Barrett's esophagus who were referred for EET to determine the effectiveness and durability of EET in a structured reflux management program, as well as whether optimized antireflux therapy helped achieve eradication. Patients were eligible for the study if they had endoscopically and pathologically confirmed dysplastic Barrett's esophagus or, in some cases, if they had nondysplastic disease but were thought to be high-risk (defined as younger than age 50 with long-segment Barrett's esophagus or a first-degree family history of esophageal adenocarcinoma). Consecutive patients referred for EET between 2008 and 2014 were enrolled in the study and received a standardized reflux management protocol that included twice-daily therapy with proton-pump inhibitors (PPIs) during the eradication stage. The study's primary outcomes were rates of complete eradication of intestinal metaplasia and recurrence of intestinal metaplasia or dysplasia. Results were published online Feb. 14 by the American Journal of Gastroenterology.

Overall, 221 patients completed EET and underwent at least two subsequent endoscopies for surveillance. Most patients (75%) were men, and most were white (96%). Median age was 65 years. Patients' antireflux medication history was assessed at enrollment, and all were prescribed PPI therapy (omeprazole, 40 mg) twice daily 30 minutes before breakfast and dinner if they were not already receiving it. EET was done with endoscopic mucosal resection and radiofrequency ablation (RFA). Standard reflux management protocol involved initial consultation that emphasized reflux control and PPI adherence, initiation or continuation of PPI therapy as described, medication reconciliation and assessment or remediation of PPI adherence at each study visit, and on-treatment reflux testing. Forty-six percent of patients had high-grade dysplasia/intramucosal carcinoma, 34.0% had low-grade dysplasia, and 20.0% had nondysplastic Barrett's esophagus.

Within a mean of 11.6±10.2 months, the overall rate of complete eradication of intestinal metaplasia was 93%; the overall rate of complete eradication of dysplasia was 96%. Sixty-four patients did not achieve complete eradication of intestinal metaplasia in three ablative sessions, and of these, 48 had pH testing. Nine of these 48 had their PPI dosing increased, and 39 had fundoplication; 9 and 37, respectively, eventually achieved complete eradication of intestinal metaplasia. Over a mean follow-up of 44±18.5 months, 10 patients had recurrence of intestinal metaplasia and three patients had recurrence of dysplasia. Presence of a hiatal hernia was the sole factor significantly predictive of recurrence. The recurrence rate of 4.8% in the current study was significantly lower than 10.9% of historical controls who had EET but did not receive an antireflux protocol (P=0.04) over a similar follow-up period.

The researchers noted that their study involved only one center with substantial expertise in gastroesophageal disease, that follow-up was relatively short, and that 20% of the study cohort was considered at higher risk for disease progression, among other limitations. However, they concluded that based on their results, reflux control plays an important role in the success of EET among patients with Barrett's esophagus. “In this setting, EET incorporating RFA is highly effective and has long-term durability with minimal early recurrence,” the authors wrote. “Early recognition of suboptimal reflux control is important for the success of EET in practice. These data provide preliminary evidence for potentially extending endoscopic surveillance intervals after EET.”