Radiofrequency Ablation Challenging Cases

Transcription

1 Radiofrequency Ablation Challenging Cases

2 Used abbreviations BE: Barrett s esophagus EC: Early cancer EID: Esophageal inner diameter ER: Endoscopic resection GEJ: Gastro-esophageal junction HGD: High-grade dysplasia LGD: Low-grade dysplasia RFA: Radiofrequency ablation

3 Challenges in RFA, 1: Narrowed esophagus and stenosis

4 Esophageal narrowing Case 1 (I) 69 year old man; BE C1M4 with a visible lesion; Piecemeal ER (4 pieces, >50% circumference); After 8 wks, the esophagus has stenosed at the ER site.

5 Esophageal narrowing Case 1 (II) During circumferential HALO 360 ablation using a 22 mm balloon, a non-transmural laceration occured; No second ablation pass was performed; Patient had some post-procedural pain and was admitted for 1 day. What went wrong?

6 Esophageal narrowing Case 1 (III) The sizing-procedure showed: EID: mm above and below the stenosis; EID: 23 mm at the level of the stenosis. Available catheter sizes: mm What would have been the most appropriate catheter size in this case?

7 Esophageal narrowing Case 1 (IV) Is the EID really 23 mm at the site of the stenosis?

8 Esophageal narrowing Case 1 (V), take home message Don t trust the sizing more than your own eyes ; Endoscopically, a stenosis is best seen from a distance; If in doubt: use a biopsy forceps for reference.

9 Esophageal narrowing Case 1 (VI) This esophagus requires endoscopic dilatation before any form of ablation can be performed; In fact: a one-step dilatation up to a diameter of 22 mm was performed in this patient.

10 Esophageal narrowing Case 2 (I) Sizing: Distance 32 cm EID mm C1M2 BE with HGD GEJ Diaphragm

11 Esophageal narrowing Case 2 (II) A 31 mm ablation catheter is used for primary RFA; After the 1 st ablation a transmural laceration occurs; Esophageal resection specimen shows a narrowed distal esophagus ( eosinophilic esophagitis ); Estimated diameter: 23 mm. What went wrong?

12 Esophageal narrowing Case 2 (III) Distance (cm) EID (mm) C1M2 BE with HGD GEJ Diaphragm

13 5 cm e.g. 30 cm 4 cm NOTE: 3 cm The difference in the start of cm-markings on the endoscope and catheter; Compared to the endoscope the catheters are stiffer and thus make a wider angle in the hypopharynx, causing it to end up ~2 cm more proximal.

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15 35 cm 35 cm At biteblock 35cm for scope and catheter shaft 35 cm 37 cm 41 cm 2 cm 4 cm 6 cm

16 Esophageal narrowing Case 2 (IV), take home message Markings on balloon shaft indicate the upper margin of the sizing area; Start sizing 5-6 cm above the treatment zone; Fix the position of the catheter on the bite block: May prevent it from moving in or out; Allows you to feel the balloon slipping up or down; Beware of short BE segments: you may be sizing in the hiatal hernia!

17 Esophageal narrowing Case 2 (V), take home message Reported perforations after HALO 360 ablation: 7 out of approximately 26,928 cases (0.03%); Causes: Excessive traction removing the balloon (n=1); Hypopharynx injury upon balloon insertion (n=1); No data (n=1); Balloon too large (n=4): eosinophilic esophagitis (1), prior stricture (1); Transmural lacerations are extremely rare after HALO 360 ablation. Data from HALO patient registry

18 Esophageal narrowing Case 3 (I) 82 year old man; BE C12M13, ER is performed for a lesion with HGD; Six weeks after ER the esophagus has healed with scarring at the resection site; HALO 360 ablation of residual BE with HGD.

19 Esophageal narrowing Case 3 (II) Distance (cm) EID (mm)

20 Esophageal narrowing Case 3 (III) HALO 360 with a 25 mm balloon; Good ablation effect, but laceration at the ER site; Antibiotics, contrast series (no leakage); The patient remained asymptomatic.

21 Sizing of EID Without prior ER Distance (cm) EID (mm) 31 30, , , , , , , ,6

22 Sizing of EID After prior ER ER

23 Sizing of EID After prior ER Distance (cm) EID (mm) 31 30, , ,1 ER scar 34 28, , , , ,6

24 Sizing of EID Overestimation of short stenosis Generator: 30.1 mm Generator: 18.1 mm Diameter tube: 18 mm Generator: 22.8 mm Diameter tube: 18 mm Generator: 25.0 mm Diameter tube: 18 mm

25 Esophageal narrowing Case 3 (IV), take home message Post-ER stenoses are generally short; Diameter tube: 18 mm Generator: 22,8 mm Diameter tube: 18 mm Generator: 25,0 mm The sizing procedure tends to overestimate the diameter at the site of the ER scar; Select your ablation catheter conservatively!

26 Tips and tricks to safely ablate BE with stenosis (I) Causes of stenosis: Prior ER, especially if the extent is >2 cm or > 50% of the circumference; Reflux stenosis at the upper end of the BE; Prior ulceration in a BE.

27 Tips and tricks to safely ablate BE with stenosis (II) Fixate the balloon during inflation: Balloon tends to slip at the level of stenosis during inflation; Stenosis in short BE: balloon may slip into the hiatal hernia; Do not trust the sizing more than your own eyes. Sizing overestimates ER stenoses, therefore, be conservative in the selection of an ablation catheter in the case of prior ER or visible narrowing.

28 Tips and tricks to safely ablate BE with stenosis (III) If the sizing balloon comes back bloody: re-inspect; Visual inspection for laceration after the sizing procedure is no safeguard against laceration; In case of doubt inflate and deflate the ablation balloon and inspect (without actually ablating); In case of doubt: dilate first to 18 mm before scheduling the HALO 360 procedure; Alternative: use the HALO 360 above/below the stenosis and use the HALO 90 catheter at the level of the stenosis.

29 Challenges in RFA, 2: The bottle-shaped esophagus

30 Bottle shaped esophagus Case 1 (I) 65 year old man; BE C12M14 BE with HGD and no visible lesions; Proximal reflux stenosis.

31 Bottle shaped esophagus Case 1 (II) Sizing: 22cm 19.6mm

32 Bottle shaped esophagus Case 1 (III) This is a bottle shaped BE: classical for LSBE. How to ablate this? Option 1: Pick small-sized balloon for the upper part, ablate lower part and hope for the best for the efficacy distally. In case at FU the effect is found to be poor at this level: use larger balloon for second HALO 360 session, the upper end will not likely require circumferential RFA. Option 2: Use two balloons in the first session.

33 Bottle shaped esophagus Case 1 (IV) Treated with 2 HALO 360 sessions (22 and 28 mm balloon); Followed by HALO 90 of islands; 100% eradication of BE and dysplasia reached.

34 Challenges in RFA, 3: Poor healing after RFA treatment

35 Poor healing Case 1 (I) 72 year old man, BE C14M16, prior ER, PDT, APC; Carcinoma in biopsies during follow up; What do you see and what to do next?

36 Poor healing Case 1 (II) Several relative stenoses caused by previous treatment; Abnormal mucosal patterns, carcinoma in 1 visible lesion; Minimal EID 18-20mm (open biopsy forceps), appears suited for RFA; After sizing, upper 12 cm was treated with 22 mm balloon, leaving most suspicious area distally untreated.

37 Poor healing Case 1 (III) 2 months after RFA, poor healing and little regression are observed; What to do? Check medication and compliance: Esomaprazole 2x40 mg, sucralfate 4x1, ranitidine 1x300 mg; Compliance was good; Esomaprazole dosage was doubled to 2x 80 mg daily.

38 Poor healing Case 1 (IV) 4 months after RFA the ablation zone has still not completely healed; 2 biopsies of the suspicious area distally show T1M3.

39 Poor healing Case 1 (V) Given the patients age and comorbidity, it is decided to stop RFA treatment and perform ER; Piecemeal ER of the lesion shows T1M3 adenocarcinoma; Questran is added to medication.

40 Poor healing Case 1 (VI) Almost 7 months after the initial HALO 360 treatment the treated area has still not completely healed; No dysplasia is found in biopsies.

41 Poor healing Case 1 (VII) A year after RFA the esophagus has finally healed; No dysplasia in biopsies obtained at 1 year follow-up; Next follow-up endoscopy is scheduled in 1 year; Plan: conservative approach, only ER in the case of visible abnormalities.

42 Poor healing Case 2 (I) 60 year old man; BE C10M11, ER for suspicious lesion; ER specimen shows a T1M3 cancer and HGD is found in random biopsies.

43 Poor healing Case 2 (II) Primary circumferential HALO 360 ablation is performed; 3 months after RFA treatment a poor response is seen.

44 Poor healing Case 2 (III) Esomeprazole is doubled (80mg BID), cholestyramine added; A second HALO 360 session is performed; 3 months after the second HALO 360, no significant surface regression is seen and the BE mucosa appears swollen; Biopsies show no signs of dysplasia (baseline: HGD); Plan: No further RFA treatment, but endoscopic surveillance.

45 Poor healing Case 2 (IV) First HALO 360 After 1 st HALO 360 After 2 nd HALO 360

46 Poor healing Case 1 & 2 (I), take home message Poor healing and/or poor response after HALO 360 is rare; May occur more often in patients with long BE; May be related to inadequate acid suppressant therapy; The real predictive factors are yet unknown.

47 Poor healing Case 1 & 2 (II), take home message Stepwise approach in case of poor healing: Check compliance to medication; Check co-medication for caustic agents (e.g. potassium, iron tablets, NSAIDS); Double PPI dose, add cholestyramine (no scientific proof); Repeat HALO 360 ; Allow longer intervals between RFA sessions.

48 Poor healing Case 1 & 2 (III), take home message Again no response? Repeat mapping after complete healing; Visible lesions: ER; Consider surgery in case of irresectable visible lesions; No visible lesions and no dysplasia: endoscopic follow-up; No visible lesions and HGD: Option 1: endoscopic FU with ER in case of visible lesions Option 2: esophagectomy Option 3: Nissen fundoplication (after 24h ph monitoring) followed by RFA after adequate acid control. Please note: in case esophagectomy is required at a later stage, the fundoplication complicates the esophagectomy.

49 Challenges in RFA, 4: Visible lesions popping-up during the treatment period

50 Visible lesions popping-up Case 1 (I) Male, 70 years old; BE C5M6; Two ER sessions for EC and HGD.

51 Visible lesions popping-up Case 1 (II) Histological image of the ER-specimen with mucosal cancer. 40x

52 Visible lesions popping-up Case 1 (III) Mapping endoscopy post-er, pre-rfa. LGD LGD LGD LGD LGD LGD LGD HGD HGD HGD HGD LGD HGD

53 Visible lesions popping-up Case 1 (IV) The patient was treated with primary circumferential RFA, using the HALO 360 system.

54 Visible lesions popping-up Case 1 (V) After initial RFA, the patient had 1 dilation for dysphagia; Two months after initial RFA, 80% regression of the Barrett segment was observed, with a residual BE island with thickened mucosa and an inflamed Z-line; HALO 90 treatment was performed.

55 Visible lesions popping-up Case 1 (VI) Passing the HALO 90 device through the stenosis was difficult, but the Z-line and island could be treated; Four months after initial RFA, there was still some residual BE mucosa seen, which was ablated with HALO 90.

56 Visible lesions popping-up Case 1 (VII) Six months after initial RFA, the same persisting island was observed, which also appeared to be slightly elevated; The island was removed by escape ER, using the multiband mucosectomy technique: T1sm1, radically removed.

57 Visible lesions popping-up Case 1 (VIII) Histological image of the escape ER-specimen with T1sm1 cancer. 20x

58 Visible lesions popping-up Case 1 (IX) 3 months after EMR no visible abnormalities are observed; Follow-up at 3, 6, 9 and 12 months with EUS and biopsies do not show residual signs of neoplasia or Barrett mucosa.

59 Visible lesions popping-up Case 1 (X), what to learn from this case? After 2 nd ER: After HALO 360 : After 1 st HALO 90 : After 2 nd HALO 90 : HALO 360 HALO 90 2 nd HALO 90 Escape ER LGD/HGD?????? T1sm1 Visible lesion 2 months after the HALO 360 treatment; Delay: 4 months; Visible lesions that pop-up : Biopsies or ER!

60 Visible lesions popping-up Case 2 (I) 43 year old man; BE C15M17, with LGD and HGD; Treated with HALO 360 ablation.

61 Visible lesions popping-up Case 2 (II) Two months after initial RFA, a residual island of elevated Barrett mucosa was observed; The island was resected with the multiband mucosectomy technique followed by RFA of the residual Barrett mucosa; Histological evaluation of the ER-specimen showed LGD.

62 Visible lesions popping-up Take home message The RFA protocol may cover a period of many months; Interval: 3 months after HALO 360 and 2 months after HALO 90; Maximum number of sessions: 2 HALO 360 and 3 HALO 90 ; If you wait with escape ER until the maximum of RFA sessions is performed the delay may be months after the 1 st RFA session; Beware of visible lesions that pop-up; Either biopsy them before ablation of perform an ER; Compare images obtained at different sessions to identify progression of lesions.

63 Challenges in RFA, 5: Difficult introduction or removal of the HALO 90 catheter

64 Tips and tricks for difficult introduction or removal of the HALO 90 catheter (I) Check for the presence of a Zenker s diverticulum; Ask the patient to swallow; Do NOT push any further if the cap tilts; NEVER use force! Use a spraying catheter or biopsy forceps as a guide to enter into the proximal esophagus; A CRE-balloon may be used to open the upper esophageal sphincter by manually inflating the balloon to low pressure, and to move the catheter in along with the balloon; Perform escape ER or APC instead of HALO 90 ablation.

65 Tips and tricks for difficult introduction or removal of the HALO 90 catheter (II) In the case of a difficult introduction a spraying catheter or a biopsy forceps, may be used as a guide to enter into the esophagus; First ensure that the throat is clean of mucus to avoid aspiration.

66 Tips and tricks for difficult introduction or removal of the HALO 90 catheter (III) The leading edge of the HALO cap is visible proximal to the arytenoids; A biopsy forceps is blindly advanced behind the arytenoids into the proximal esophagus; The endoscope is angulated downward, causing the leading edge of the HALO cap to touch the shaft of the biopsy forceps; After gently advancing the endoscope, using the biopsy forceps for guidance, the proximal esophagus is entered

67 Tips and tricks for difficult introduction or removal of the HALO 90 catheter (IV) APC may be used to ablate small residual islands.

68 Tips and tricks for difficult introduction or removal of the HALO 90 catheter (V) Passing the HALO 90 cap beyond a stenosis may be easier than removing it; The proximal end of the cap may impact as a hook behind a stenosis or upper esophageal sphincter; Angle the tip of the instrument UP in case of resistance during withdrawal of the endoscope.

69 RFA-Academia 2009 Program Committee: Jacques Bergman Guido Costamagna Horst Neuhaus