Radio-frequency (RF) ablation is a Barrett’s esophagus treatment that is used to treat the cellular changes caused by GERD that can progress to esophageal cancer. In this blog post, Dr. Chandrasoma explains how and when RF ablation is used, so you can make the best decision about your Barrett’s esophagus treatment.
How GERD damages the esophagus
GERD is a disease of the esophagus caused by reflux of acid gastric juice into the esophagus. Such reflux results in damage to the esophageal lining (mucosa, normally squamous epithelium), causing symptoms. The most common symptom of GERD is heartburn, which results from the effect of acid on the squamous epithelium. The acid damage, when severe, can cause erosions (breaks or ulcers) in the epithelium. These features, the symptom of heartburn (without endoscopy) or the presence of erosions (during endoscopy), define GERD.
GERD is usually treated with acid suppressive drugs. When acid is reduced, the squamous epithelium is restored to normal and heartburn usually decreases or stops. If there are erosions, these heal in most (90%) patients. As such, no treatment for GERD is needed to repair the epithelium.
One of the complications of GERD is that the normal squamous epithelial lining of the esophagus changes to a columnar (glandular) lining. This is called columnar lined esophagus. Columnar lined esophagus produces the same symptoms as GERD, but looks different during an endoscopy. Columnar lined esophagus cannot be diagnosed or excluded without endoscopy. Unlike the squamous epithelial damage, columnar lined esophagus does not reverse when the patient is treated with acid suppressive drugs.
Columnar lined esophagus is a dangerous complication in patients with GERD because it is the change that can progress through several stages to adenocarcinoma (cancer) of the esophagus. This progression varies in different patients with GERD and the risk of adenocarcinoma is small. However, it is important because drug therapy will not reversed it. For this reason, efforts have been made to find alternate forms of treatment. At this point, Barrett’s esophagus treatment should be considered.
Learn more: Defining esophageal cancer
How it works: Barrett’s esophagus treatment using RF ablation
Ablation therapy is on therapy currently available to treat columnar lined esophagus. During radio-frequency ablation, a special endoscopic device delivers radio-frequency energy to the surface of the esophageal lining. This burns the epithelium and causes it to slough away leaving an ulcer. The patient then takes acid suppressive drugs, which allow the esophagus to heal. During the healing process, the columnar epithelium comes back as squamous epithelium. RF ablation, when directed specifically to the columnar lined esophagus, is therefore a method of removing the abnormal columnar epithelium and replacing it with “normal” squamous epithelium (the word “normal” is in quotation marks because there is some question as to whether this new squamous epithelium is actually totally normal).
Learn more: RF ablation for Barrett’s esophagus
When is RF ablation appropriate?
Now that we have a technically feasible method of removing the potentially dangerous columnar lining in the esophagus, we must carefully consider when the use of this technology justified. There are three main reasons for this:
- The ablation procedure carries with it a small but definite complication rate.
- The ablation procedure adds a procedure as well as increases cost of care. In many patients, ablation requires more than one endoscopy procedure to be completed.
- The ablation procedure has a risk of failure. In a few patients, complete ablation cannot be achieved and in a larger number of patients, columnar epithelium recurs after a period of years.
Like everything else in medicine, there is a balance between what can be done and what needs to be done. For radio-frequency ablation, as a Barrett’s esophagus treatment, the risk and cost is not considered worthwhile for most patients with columnar lined esophagus. This Barrett’s esophagus treatment is considered worthwhile for a relatively small number of patients who are at high risk of progression to adenocarcinoma.
How columnar lined esophagus progresses
Let us look at the progression of columnar lined esophagus in a patient with GERD from simple columnar lined esophagus to adenocarcinoma. The actual risk of death from adenocarcinoma in these groups progressively increases:
- GERD with simple columnar lined esophagus, defined by the absence of a specific change in the columnar epithelium called intestinal metaplasia. This is very common and not associated with any risk of adenocarcinoma. As such, patients with columnar lined esophagus without intestinal metaplasia should not have radio-frequency ablation. The risks associated with the procedure are greater than the risk of adenocarcinoma.
- Columnar lined esophagus with intestinal metaplasia. This is the definition of Barrett’s esophagus. This occurs in a significant minority of patients with GERD. The presence of Barrett’s esophagus indicates a risk of 0.2-0.5% per year of developing adenocarcinoma. This risk is not believed to justify the risks or cost of radio-frequency ablation.
- Barrett’s esophagus with low-grade dysplasia. Low-grade dysplasia is a change that increases the risk of adenocarcinoma to an uncertain amount but greater than the 0.2 – 0.5% per year that is known for Barrett’s esophagus. Like for non-dysplastic Barrett’s esophagus, the present establishment and insurance provider stance is that radio-frequency ablation is not justified for Barrett’s esophagus with low-grade dysplasia. Some experts believe the risk is sufficiently high to justify radiofrequency ablation when there is low-grade dysplasia, but they have not been able to convince the insurers to pay for the procedure.
- Barrett’s esophagus with high-grade dysplasia. There is agreement that patients with Barrett’s esophagus who have high-grade dysplasia on a biopsy (confirmed by a second pathology expert) require RF ablation. The high risk of death from adenocarcinoma in this group justifies both risk and cost of ablation.
- Barrett’s esophagus with early invasive adenocarcinoma. Very early, invasive adenocarcinomas can now be treated by endoscopic procedures (e.g. endoscopic mucosal resection and endoscopic sub-mucosal dissection) that remove the early tumors. After the tumors are removed, and assuming no further surgery is needed, radio-frequency ablation is recommended to remove all the columnar epithelium with intestinal metaplasia that remains in the esophagus. The rationale here is that because we know that the epithelium has become cancerous in one area, the remainder is also at similar risk and needs to be ablated.
Remember: The decision is yours
There is one thing that must be clearly understood. Like everything else in medicine, the decision as to whether ablation is justified by risk is in the eye of the beholder. The critical question is: If I had Barrett’s esophagus without dysplasia or with low grade dysplasia, would I prefer to keep my epithelium with the known cancer risk or would I prefer to get ablation treatment? The answer to this question will vary with different people. However, the establishment and, most importantly, health care insurance companies (including Medicare) has decided that they will not pay for RF ablation as a Barrett’s esophagus treatment until high grade dysplasia occurs. They have a right to do this because they have to control cost. However, it is the patient’s right to have the procedure if he or she is willing to pay for it and believe that it is justified in their eyes.
Scroll down if you have questions about RF ablation or Barrett’s esophagus