Background and Study Aims: In several series, argon plasma coagulation (APC) combined with acid suppression has led to short- or medium-term eradication of Barrett's esophagus. The present study was designed to assess the long-term outcome after this treatment. Patients and Methods: 39 patients with Barrett's esophagus, seven of them with low-grade dysplasia, underwent APC and received 40 mg omeprazole daily for eradication of the metaplastic epithelium. After the treatment period, patients were randomly assigned to receive 20 or 40 mg omeprazole daily for long-term acid suppression. Histological and endoscopic changes were evaluated annually. Univariate and multivariate analyses were used to test the following 10 variables as predictors of sustained reversal of Barrett's esophagus at the end of follow-up: age, gender, length of diseased segment, presence of hiatal hernia, circumferential nature of lesion, presence of low-grade dysplasia at initial biopsy, number of coagulation sessions, result of pH monitoring under protein pump inhibitor (PPI) treatment, omeprazole dosage, and initial response to therapy (after 1 month). Results: The median follow-up period was 36 months (range 12 - 48). The endoscopic and histological relapse rates at 1, 12, and 24 months, and end of follow-up were, respectively, 30 % and 44 % (12/39 and 17/39), 57 % and 54 % (16/28 and 15/28), 60 % and 57 % (17/28 and 16/28), and 62 % for both rates (23/37). According to multivariate analysis, shorter length of diseased segment and normalization of pH with PPI treatment were the only independent predictors of sustained long-term re-epithelialization. Among the seven patients with low-grade dysplasia, four experienced relapse after 1 month, and during the long-term follow-up, one was lost to follow-up and all the others experienced relapse, but only one developed low-grade dysplasia again. Cancer was found in two cases after 12 and 18 months, respectively. Conclusions: Persistence of acid reflux and greater length of diseased segment are the major factors associated with a high relapse rate after successful initial reversal. APC for ablation of Barrett's esophagus cannot be recommended.
References
1
Weinstein W M, Ippoliti A F.
The diagnosis of Barrett's esophagus: goblets, goblets, goblets.
Gastrointest Endosc.
1996;
44
91-95
4
Drewitz D J, Sampliner R E, Garewal H S.
The incidence of adenocarcinoma in Barrett's esophagus: a prospective study of 170 patients followed 4.8 years (see comments).
Am J Gastroenterol.
1997;
92
212-215
5
Paraf F, Flejou J F, Pignon J P. et al .
Surgical pathology of adenocarcinoma arising in Barrett's esophagus. Analysis of 67 cases.
Am J Surg Pathol.
1995;
19
183-191
6
Blot W J, Devesa S S, Kneller R W, Fraumeni Jr J F.
Rising incidence of adenocarcinoma of the esophagus and gastric cardia.
JAMA.
1991;
265
1287-1289
7
Devesa S S, Blot W J, Fraumeni Jr J F.
Changing patterns in the incidence of esophageal and gastric carcinoma in the United States.
Cancer.
1998;
83
2049-2053
8
Hamilton S R, Smith R R.
The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett's esophagus.
Am J Clin Pathol.
1987;
87
301-312
9
Spechler S J.
Endoscopic surveillance for patients with Barrett esophagus: does the cancer risk justify the practice?.
Ann Int Med.
1987;
106
902-904
10
Gore S, Healey C J, Sutton R. et al .
Regression of columnar lined (Barrett's) oesophagus with continuous omeprazole therapy.
Aliment Pharmacol Ther.
1993;
7
623-628
12
Malesci A, Savarino V, Zentilin P. et al .
Partial regression of Barrett's esophagus by long-term therapy with high-dose omeprazole.
Gastrointest Endosc.
1996;
44
700-705
13
Berenson M M, Johnson T D, Markowitz N R. et al .
Restoration of squamous mucosa after ablation of Barrett's esophageal epithelium.
Gastroenterology.
1993;
104
1686-1691
15
Laukka M A, Wang K K.
Initial results using low-dose photodynamic therapy in the treatment of Barrett's esophagus.
Gastrointest Endosc.
1995;
42
59-63
16
Sampliner R E, Fennerty B, Garewal H S.
Reversal of Barrett's esophagus with acid suppression and multipolar electrocoagulation: preliminary results.
Gastrointest Endosc.
1996;
44
532-535
17
Barham C P, Jones R L, Biddlestone L R. et al .
Photothermal laser ablation of Barrett's oesophagus: endoscopic and histological evidence of squamous re-epithelialisation.
Gut.
1997;
41
281-284
18
Wahab P J, Mulder C J, den H artog, Thies J E.
Argon plasma coagulation in flexible gastrointestinal endoscopy: pilot experiences.
Endoscopy.
1997;
29
176-181
19
Grund K E, Storek D, Farin G.
Endoscopic argon plasma coagulation (APC): first clinical experiences in flexible endoscopy.
Endosc Surg Allied Technol.
1994;
2
42-46
20
van Laethem J L, Cremer M, Peny M O. et al .
Eradication of Barrett's mucosa with argon plasma coagulation and acid suppression: immediate and mid term results.
Gut.
1998;
43
747-751
21
Sampliner R E.
Practice guidelines on the diagnosis, surveillance, and therapy of Barrett's esophagus. The Practice Parameters Committee of the American College of Gastroenterology.
Am J Gastroenterol.
1998;
93
1028-1032
22
Johnson L F, Demeester T R.
Twenty-four-hour pH monitoring of the distal esophagus. A quantitative measure of gastroesophageal reflux.
Am J Gastroenterol.
1974;
62
325-332
23
van Laethem J L, Peny M O, Salmon I. et al .
Intramucosal adenocarcinoma arising under squamous re-epithelialisation of Barrett's oesophagus.
Gut.
2000;
46
574-577
24
Byrne J P, Armstrong G R, Attwood S E.
Restoration of the normal squamous lining in Barrett's esophagus by argon beam plasma coagulation.
Am J Gastroenterol.
1998;
93
1810-1815
25
Mork H, Barth T, Kreipe H H. et al .
Reconstitution of squamous epithelium in Barrett's oesophagus with endoscopic argon plasma coagulation: a prospective study.
Scand J Gastroenterol.
1998;
33
1130-1134
26
Schulz H, Miehlke S, Antos D. et al .
Ablation of Barrett's epithelium by endoscopic argon plasma coagulation in combination with high-dose omeprazole.
Gastrointest Endosc.
2000;
51
659-663
27
Pereira-Lima J C, Busnello J V, Saul C. et al .
High power setting argon plasma coagulation for the eradication of Barrett's esophagus.
Am J Gastroenterol.
2000;
95
1661-1668
28
Weston A P, Badr A S, Hassanein R S.
Prospective multivariate analysis of factors predictive of complete regression of Barrett's esophagus.
Am J Gastroenterol.
1999;
94
3420-3426
30
Ouatu-Lascar R, Fitzgerald R C, Triadafilopoulos G.
Differentiation and proliferation in Barrett's esophagus and the effects of acid suppression.
Gastroenterology.
1999;
117
327-335
31
Fass R, Yalam J M, Camargo L. et al .
Increased esophageal chemoreceptor sensitivity to acid in patients after successful reversal of Barrett's esophagus.
Dig Dis Sci.
1997;
42
1853-1858
32
Srinivasan R, Katz P O, Ramakrishnan A. et al .
Maximal acid reflux control for Barrett's oesophagus: feasible and effective.
Aliment Pharmacol Ther.
2001;
15
519-524
34
Inadomi J, Lieberman D, Lagergen J.
Cost-effectiveness of once in a lifetime screening by unsedated endoscopy in 50-year-old white males with uncomplicated GERD (abstract).
Gastroenterology.
2001;
120
Abstract 2116
35
Kearney D, Crump C, Maynard C.
A case-controlled study of endoscopy and mortality from adenocarcinoma of the esophagus or gastric cardia for persons with gastroesophageal reflux disease (abstract).
Gastroenterology.
2001;
120
Abstract 2118
