Long-term outcomes after endoscopic eradication therapy for dysplastic and T1a adenocarcinoma related Barrett's esophagus: higher rate of late dysplastic recurrence with radio-frequency ablation monotherapy.

Abstract

Background & aims: There is conflicting literature describing the durability of complete remission of intestinal metaplasia (CRIM) after endoscopic eradication therapy (EET) for Barrett's esophagus (BE). We aim to assess the timeline, predictors and long-term outcomes of recurrence.

Methods: Data on 365 patients who underwent EET for dysplastic BE were collected prospectively between 2008 and 2022 at a Barrett's referral unit. Kaplan-Meier method and Epanechnikov-kernel density estimate were used to determine the cumulative incidence of recurrence following CRIM and the rate of recurrence over time. A logistic regression analysis was fitted to identify factors associated with recurrence.

Results: 216 patients achieved CRIM and were then followed for a median (IQR) 5.8 years (2.9, 7.2). Intestinal metaplasia (IM) recurred in 57 patients (26.4%) and dysplasia in 18 patients (8.3%). The time to recurrence peaked at 1.8 years. The cumulative recurrence risk within 2 years was 23.1% with an additional 29.2% risk over the next 10 years. Increased risks of any BE recurrence (Odds ratio (OR) 3.0; p=0.009), dysplastic (Relative risk ratio (RRR) 5.53; p=0.001) and late (≥2 years) recurrences (RRR 3.24; p=0.01) were associated with radio-frequency ablation (RFA) monotherapy, whereas combination endoscopic mucosal resection (EMR) and RFA was associated with a decreased risk of dysplastic recurrence (RRR 0.27; p=0.02).

Conclusion: The risk of recurrence is highest within the first 2 years post-CRIM, but remains significant long term. The risk of IM, dysplasia and late recurrence is higher when RFA was the sole modality used to achieve CRIM, raising the possibility that RFA provides a less durable response. These findings may impact treatment and surveillance decisions.