Endoscopic laser ablation of nondysplastic Barrett's epithelium: Is it worthwhile?

The clinical value of endoscopic ablation of nondysplastic Barrett's epithe lium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need fur endoscopic surveillance in these patients. E ighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pu mp inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed wi th noncontact fibers and a power output of 60 watts. The mean number of tre ament sessions was three (range 1 to 5), and the mean energy delivered duri ng each session was 2800 joules (range 600 to 4800 joules). All patients we re given a standard dose of omeprazole (40 mg/day) throughout the study per iod. In Mo patients a mild distal esophageal stricture occurred and require d a single dilatation. Macroscopic and histologic eradication of the specia lized columnar epithelium was documented in 8 of 12 patients with tongues o f Barrett's metaplasia, in one of four patients with circumferential Barret t's metaplasia, and in two of two patients with short-segment Barrett's eso phagus. In five patients (28%) only a partial ablation could be achieved de spite repeated laser treatment. Two patients (11%), one with tongues and th e other with circumferential Barrett's metaplasia, were considered nonrespo nders. Adenocarcinoma undermining regenerated squamous epithelium was found , 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mea n follow-up period of 14 months (range 4 to 32 months), two patients presen ted with recurrent Barrett's metaplasia: one at 8 months after successful N issen fundoplication and the other after 1 year of continuous omeprazole tr eatment. Progression of Barrett's metaplasia was found in two other patient s receiving pharmacologic therapy in whom a partial response to laser treat ment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplasti c Barrett's esophagus, performed in conjunction with omeprazole treatment a nd followed by antireflux surgery allows a partial regression of specialize d columnar epithelium in most patients. However, this is a time-consuming p rocedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic survei llance.