Discussion
Barrett’s esophagus, Barrett’s carcinoma, stenosis, Barrett
ADVERSE EVENTS, APC, COMPLICATION, BARRETT, STRICTURE, STENOSIS
Choosing the optimal ablation technique is likely to become increasingly important in the treatment of Barrett’s carcinoma in the future. Various methods have been emerging in recent years. The main points that speak for or against a method are ease of handling, the complication rate and the long-term results. Radiofrequency ablation is the method of first choice in most countries. It is regarded as being easy to learn, time-saving and effective. The traditional alternative is argon plasma coagulation. Both methods show good results, with moderate complication rates [Another nonthermal ablation technique using a through-the-scope device to resect nondysplastic Barrett’s mucosa is the EndoRotor [APC was the standard treatment until the introduction of RFA. Comparison of the two thermal ablation techniques is difficult, as RFA includes a balloon-based 360° device and focal devices with different lengths. In addition, the protocol for focal RFA has changed several times in recent years. The standard protocol, with 15 J/cmHybrid APC, as a further development of conventional APC, shows good safety results and has sufficient data in the treatment of Barrett’s esophagus [There are several important points that have influenced the present trial. The difference of adverse events between the two arms was unacceptably high, with a stenosis rate of 14.9% in the RFA arm versus 3.7% in the H-APC arm. When the study was initially planned, the simplified protocol had good published data, with a stenosis rate of around 9% [Most important weakness of the study is, that the calculated sample size was not reached. In respect to the present data and from ethical point of view, we believe that a continuation of the study on this basis is not give due to the large difference in adverse events between the various arms. However, the study is still the largest prospective randomized trial published so far. And the only published data comparing Hybrid-APC with RFA. With over 100 randomized patients it has relevant clinical impact. More over this, the variables used 2018 led to an initially over-calculated sample size as we have now much more scientific data on RFA simplified protocol and Hybrid-APC.Another major limitation of this trial was the low rate of possible per-protocol analysis. Only 26.7% of all patients completed the full study protocol, with follow-up appointments after 3, 6, 12 and 24 months. This was largely due to a lack of follow-up endoscopies as a result of the Covid-19 pandemic. Particularly during the first wave of Covid-19, all surveillance endoscopies were postponed.In conclusion, Hybrid-APC was used in this trial in a simplified form with only one ablation and without cleaning. This protocol is confirmed as safe, without any relevant drawbacks. It has rates of Barrett’s eradication similar to those with RFA, but the complication rate, and in particular the stricture rate, argue in favour of H-APC for thermal treatment in Barrett’s esophagus after endoscopic resection [