Case provided by:
Dr. Adolfo Parra Blanco
Hospital Universitario Central de Asturias, Oviedo, Spain

A 76-yr old lady without any relevant past medical history, was recently diagnosed with multifocal inconspicuous high-grade dysplasia in a C10M11 Barrett´s esophagus (Figure 1).  Three sessions of RFA were applied so far (1x HALO³⁶⁰ 12J/cm²), and 2x HALO⁹⁰ sessions 15J/cm2 (Figure 2). In all three sessions it was difficult to pass the ablation catheters to the oesophagus, probably because of osteophyte compression. In the first RF session (with the HALO³⁶⁰) ablation was attempted from 21 cm, but the ablation balloon slipped inwards when inflated, probably because of reduced diameter of the esophagus at that location. Then at the second RFA procedure, 2 cm circumferential Barrett´s mucosa was found at 21 cm, and ablation was performed with HALO⁹⁰ (15J/cm2). At the time of the third procedure, three Barrett´s islands were found at 21 cm, the largest diameter of the whole lesions together being 2 cm. It was very difficult to pass to the esophagus the HALO⁹⁰ and a guidewire was required. A double ablation was performed on those remaining islands, and some others including the cardia. All visible islands were successfully targeted, and well burnt. Then the endoscopist balanced the risk of leaving some Barrett´s mucosa left in this session if the second double application of RFA was not performed, against the risk of cervical oesophagus perforation if the HALO⁹⁰ was withdrawn to clean the electrode and reinserted. The endoscopist decided not to perform a second “double” ablation, and the procedure was finished.

The questions are:

- Is one double ablation with HALO⁹⁰ enough in cases with just remaining islands, if the endoscopist is confident that the desired areas have been well targeted?

- Would it be possible to perform only one double ablation regimen in patients with marked difficulty to pass the ablation HALO⁹⁰ catheter, in order to reduce the risk of perforation?

Suggestion provided on behalf of the RFA Academia training committee by:
Dr. Jacques Bergman
Dept. of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands

In some cases it can indeed be difficult to pass the HALO⁹⁰ catheter and in the case of narrowing it is sometimes even necessary to perform dilatation to allow passage of the HALO⁹⁰ catheter to reach the residual Barrett mucosa. The optimal use of the HALO⁹⁰ has not yet been established, but until now we have found the 2x2x15J/cm² regimen more effective than 2x 15J/cm², and we regression percentage is higher when using the 2x2x regimen. But in some cases, 2x 15J/cm² may also be enough.

At this moment, the Amsterdam group is comparing the 2x2x15 J/cm² with cleaning in between the ablation passes, with 3x 15J/cm² (3 burns immediately after each other). If the latter turns out to be equally effective as the 2x2x15J/cm² that will increase the practical use of the HALO⁹⁰ a lot, but we have to await the results of this study.

In this case, however, you can really only wait and see what the result is. It sounds like this patient with her long Barrett segment responded really good to the prior HALO³⁶⁰ and HALO⁹⁰ treatment, so your last treatment may have been effective as well.

I fully agree with you that in this case the risk of a second introduction is not balanced with a higher efficacy of the ablation by a second 2×12 ablation. You may also consider to use APC to patch up small islands the remain at further follow-up visits in this case.

And maybe in the future you can use the 3x15J/cm² regimen if you are having these kind of difficulties introducing the HALO⁹⁰ catheter again.