Resultados de la radiofrecuencia ablativa endoscópica en pacientes con Esófago de Barrett con tratamiento médico y quirúrgico eficazestudio clínico e inmunohistoquímico

Résumé

Barrett’s esophagus (BE) occurs when the distal oesophageal squamous mucosa is replaced with columnar epithelium containing intestinal metaplasia (IM) with globet cells, a condition considered as a precursor of esophageal adenocarcinoma. The appereance of BE is clearly vinculated to gastroesophageal reflux desease, which can be treated with proton pump inhibitor (PPI) therapy or by antireflux surgery. One of the endoscopic treatment modalities available for BE is radiofrequency ablation (RFA) using Barrx® system (Medtronic). Currently, endoscopy with biopsy is the gold standard for the diagnosis and surveillance for BE. However, it does not allow the diagnosis in advance of individuals who have a greater predisposition to cancer. Due to this, the development of strategies such as biomarkers is neccesary. This will assist us to stratify the EAC risk for each individual and thus, consider the ablative therapy in those patients with high risk of neoplasia. In order for the study to be carried out, patients with BE were selected from our hospital follow-up and were part of a previous randomised study. These patients received PPI therapy and antireflux surgery. We defined the efficacy of the treatment when we observe absence of acid reflux in ambulatory pH monitoring. To these selected patients we carried out radiofrequency ablation and endoscopic, histologic and immunohistochemical surveillance and, subsequently the results in both groups were compared. This study of patient cohort, single centre and experimental with 26 patients (14 with PPI therapy and 12 with Nissen fundoplication) was carried out at Virgen de la Arrixaca Hospital in Murcia (Spain), between May 2013 and May 2021. The study was approved by the Ethics Committee and the patients who participated gave their consent. All the patients were treated by RFA using Barrx® system. The Barrett length was classified according to C&M criteria. The surveillance was made with high resolution endoscopy and biopsies were taken using the Seattle protocol. Patients were incluided without dysplasia and with low grade dysplasia BE, excluding high grade dysplasia BE or carcinoma. The complete erradication of IM (CE-IM) was considered when there were no macroscopic data without IM on biopsy. Of 26 patients treated with RFA, 88.5% were male with a median of 47.9 ± 11.8 years and with a median Barrett’s length of 5.4 ± 1.8 cm. The median of treatments applied was 3.4 ±1.7 with no differences between the two groups. The efficacy of the ablative technique was high, with a CE-IM in 88.5%. The most frequently reported adverse effects after the directed clinical interview were chest pain in 46.2% and odynophagia in 30.8%. The most severe complication was stenosis (3.8%) which neccesitated endoscopic dilation treatment on two occasions. The following endoscopic surveillance lasted 3.9 ± 1.9 years. During this period, recurrences appeared in 13% of all patients who achieved the CE-IM. It should be noted that all the recurrences occured in the surgical treatment group, detected at 2.3 ± 1.5 years. Differences between the biomarkers were not observed within both groups of treatment. However, a regression of immunohistochemical activity in the cases of complete erradication of IM was observed together with its persistence when BE has not been erradicated. It can be concluded that RFA a safe and efficacious treatment that achieves the erradication of BE at endoscopic, histological and immunohistochemical levels with few side effects and low rates of complications.