Successful reversal of Barrett's esophagus with multipolar electrocoagulation despite inadequate acid suppression

Background: Barrett's epithelium is a risk factor for esophageal cancer. In this study we attempted to reverse Barrett's epithelium in an acid-reduced environment by using multipolar electrocoagulation. Methods: All patients had specialized columnar epithelium of at least 2 cm in length. Patients with dysplasia on successive screening examinations wer e excluded. Esophageal motility and 24-hour pH studies were performed befor e therapy and at 9 and 18 weeks. All patients received lansoprazole 30 mg t wice a day regardless of pH study results. Multipolar electrocoagulation wa s applied to one side of the esophagus (2 to 3 cm per session) with the con tralateral side serving as control. Biopsies were obtained from each 2 cm l ength at each endoscopy and reviewed by a single, blinded pathologist. At t he 9-week evaluation of the treatment side, all patients elected to undergo multipolar electrocoagulation therapy for the control side. Results: Twenty-seven patients completed the study: 21 men and 6 women, age s 33 to 81 years, length of specialized columnar epithelium 2 to 10 cm. End oscopy at the 18-week follow-up showed normal mucosa (n = 16), residual sma ll (< 3 mm) islands or tongue-shaped extensions of apparent specialized col umnar epithelium (n = 7), untreated distal strips (< 5 mm) of apparent spec ialized columnar epithelium at the gastroesophageal junction (n = 3), and p ersistent specialized columnar epithelium (n = 1). Histologically, only 5 o f 27 patients had residual specialized columnar epithelium at week 18. Of 1 6 patients with a normal endoscopic appearance, one still had specialized c olumnar epithelium on biopsy. While on lansoprazole, pH studies were normal in 15 of 26 patients at 9 weeks. Of 22 patients with histologic evidence o f specialized columnar epithelium reversal, 10 had persistently abnormal 24 -hour pH studies (pH < 4, 6.1% to 33.7% of total time). Four of five patien ts with residual specialized columnar epithelium on biopsy had persistent r eflux. Side effects of multipolar electrocoagulation were transient, and tr eatment did not adversely alter motility patterns. Conclusions: Multipolar electrocoagulation therapy can induce re-epithelial ization with normal squamous mucosa in most patients with specialized colum nar epithelium and does not adversely affect esophageal motility. Adequate acid suppression is not mandatory for therapy to be effective in the short term.