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

An elderly lady with a C10M11 Barrett´s esophagus with high-grade dysplasia in flat mucosa, without any definite lesions. The patient was treated initial HALO³⁶⁰. At follow-up 3 months after the initial RFA session, 70% of the Barrett’s segment had been eradicated. There were still a number of circular areas larger than 2 cm that needed to be treated with additional HALO³⁶⁰ ablation. However, somewhat irregular mucosa was detected at 28-29 cm (Figure 1). Biopsies from this area were obtained and treatment was postponed to await the histological diagnosis of the biopsies.

The question is:

How can the irregular mucosa be explained, and could the RFA treatment have been performed in this case?

Figure 1, images obtained with iScan, A: Cardia, B & C: Irregular mucosa at 29 and  28 cm.

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

If the patient has undergone thorough endoscopic work-up and had inconspicuous high-grade dysplasia in the absence of any visible lesions, it is unlikely that new lesions will develop so quickly after the initial RFA treatment.

Most likely the mucosa irregularities reflect inflammatory changes after the prior RFA. Nevertheless, one should keep an eye out for any lesions that pop up during the RFA protocol.

In this case taking 1-2 biopsies and then proceeding with the HALO³⁶⁰ procedure would have been fine. On the other hand, postponing treatment until the remaining Barrett’s mucosa has become less inflamed (and thus more flat) may also have its advantages since it (theoretically) increases the success rate of the 2nd HALO³⁶⁰ treatment.