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

Is it advisable to continue obtaining biopsies immediately distal to the neo Z-line, even in patients who have no endoscopic evidence of residual Barrett after succesful radiofrequency ablation? Considering that a) approximately ¼  of adults have such findings, b) that its natural history is not well known, and c) that no specific treatment is recommended  for that condition, what should be the most adequate management of those patients?

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

The clinical relevance of the presence of intestinal metapasia immediately distal to the neo-SCJ remains debatable, since it is unknown whether IM is a physiological finding or if it is the first sign of recurrence of Barrett. In a normal population IM can be detected in the cardia in up to 25% of patients and is not considered a premalignant condition [Morales, Am J Gastro, 1997] Studies and case reports have suggested that after thermal ablation therapy, the mucosal histology of the cardia undergoes a change. Two studies demonstrated a rise in presence of IM from 8.5% pre-ablation to 28% post-ablation [Sampliner, Dis Esophagus, 2006; Weston, Gastrointest Endosc, 2005]. Another study showed focal non-dysplastic IM in the cardia in two-thirds of patients with IM during follow-up evaluation after treatment with RFA [Pouw, Clin Gastroenterol Hepatol, 2010]. In this study IM was generally detected in a single biopsy and not reproduced at further follow-up visits. However, the number of patients investigated thus far remains small and moreover long-term follow-up data are limited. At the moment we therefore advise to obtain biopsies immediately distal to the neo-SCJ at every follow-up visit even after visible succesful ablation. Only dysplastic IM in the cardia should be treated.