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July 16th, 2013

Follow-up after Barrett esophagus ablation: How do you do it, and when do you stop (if ever)?

We have shifted the paradigm of treating neoplastic Barrett esophagus (BE) away from a choice between intensive surveillance or surgery and towards endoscopic ablation. In the last 5 years, I have done hundreds of BE ablations using radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR), and many thousands have been performed worldwide. However, on post-ablation surveillance, evidence is lacking on whether and when patients can be cut loose. Moreover, I am beginning to see patients who were believed to be cured after ablation (no signs of BE or neoplasia during years of surveillance) showing up with adenocarcinoma in the distal esophagus 4 or more years later.

Until now, I have been telling my patients that once they are BE- and dysplasia-free, I want them to undergo surveillance every 4 months for 1 year, then every 6 months for 1 year, then yearly for a couple of years, and then every other year if things remain stable.

But given the uncertainties I’ve outlined above, I am interested in discussing your practices and recommendations for surveillance after ablation for BE.

On that note, what would your approach be in the following cases?

1) If a patient with high-grade dysplasia has their BE completely ablated (no BE and no dysplasia), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

2) If a patient with low-grade dysplasia has their BE completely ablated (no BE and no dysplasia), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

3) If a patient with NO dysplasia has their BE completely ablated (no BE and no dysplasia), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

4) Do you ever tell patients that they are cured and no longer need surveillance (e.g., after 5 years, after 10 years, etc.)?

5) If a patient with dysplasia has their neoplastic BE completely ablated (no dysplasia but residual BE), what surveillance period do you recommend for the following year? Year two? Beyond 2 years?

Please join the discussion to shed some light on this issue.

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Gastroenterology Research: Author M. Brian Fennerty, M.D.

M. Brian Fennerty, MD

Editor-in-Chief

NEJM Journal Watch Gastroenterology

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