Effects of Nissen Fundoplication on Ablation of Barrett’s Esophagus with Endoscopic, Endoluminal Radiofrequency Ablation

Background: Endoscopic, endoluminal radiofrequency ablation is achieving increasing acceptance as a mode of eliminating Barrett’s metaplasia and, thus, reducing the risk of developing esophageal adenocarcinoma. It is believed that reducing the exposure of the esophageal epithelium to acid is essential to achieve long-term ablation of Barrett’s esophagus. However, it is unclear whether the use of proton pump inhibitors or antireflux operations are more effective to accomplish this goal.
Methods: A review of all patients who underwent endoscopic, endoluminal radiofrequency ablation with the BARRx device (BARRx Medical, Sunnyvale, CA) were reviewed for date of initial ablation, length of Barrett’s epithelium, presence or performance of a Nissen fundoplication, all follow-up endoscopy and treatment, and posttreatment biopsy results. Patients were categorizes by the presence of a Nissen fundoplication and presence of Barrett’s metaplasia or dysplasia by biopsy at least 12 months following ablation and at last endoscopic follow-up. Data was analyzed by Fisher’s exact test and the Mann-Whitney U-test.
Results: Of 77 patients ablated, 47 had documented endoscopic follow-up at 12 months or longer following the ablation. Of these, 19 patients had Nissen fundoplications before, at the same time, or after ablation. The median length of Barrett’s epithelium, with interquartile range (IQR) was 3 (2-12) in patients with fundoplications compared to 3 (2-7) without fundoplications (p=NS). Median follow-up in months was 15 (12-24) in fundoplication patients compared to 12.5 (12-17) without (p=NS). One of 19 patients with fundoplications had persistent or recurrent Barrett’s epithelium, compared to 7 of 28 without fundoplications (p=0.03). Of patients without fundoplications, those who had persistent or recurrent Barrett’s had a median Barrett’s length of 10 cm (6-12 cm), compared to 3 cm (2-5 cm) in patients who had ablated Barrett’s (p=0.03). Follow-up length was similar in those with ablated epithelium, 15 (12-19), compared to those with persistent or recurrent Barrett’s, 12 (12-13) (p=NS).
Conclusions: Patients who had fundoplications in conjunction with endoluminal radiofrequency ablation were more likely to achieve durable ablation compared to patients who were treated with proton pump inhibitor therapy. It appears that patients with long-segment Barrett’s esophagus are at higher risk or persistent or recurrent Barrett’s metaplasia. Consideration for an antireflux operation should be given in patients with long-segment Barrett’s esophagus and planned endoluminal radiofrequency ablation.

Session: Podium Presentation

Program Number: S073