Argon plasma coagulation therapy for ablation of Barrett's oesophagus.

arrett's oesophagus (BO) is undoubtedly associated with an increased risk of adenocarcinoma of the oesophagus. 1 Now that therapeutic endoscopy techniques have improved, it is therefore tempting to ablate Barrett's intestinal metaplasia in order to decrease the risk of tumour development. However , ablation therapy is still controversial , especially for patients having no dysplasia, due to: (1) their low risk of cancer; (2) the risk associated with the technique of ablation; and (3) the fact that we do not know if Barrett's ablation will really decrease the risk of cancer in the long term in an individual patient. The rationale for current ablative therapy began with the observation that destruction or ablation of intestinal metaplasia associated with acid suppression results in its rapid replacement by a squamous epithelium. 2 Several groups of investigators have performed clinical studies evaluating the effectiveness of BO ablation associated with proton pump inhibitor (PPI) treatment. For patient having non-dysplastic BO without dysplasia, argon plasma coagulation (APC) has been the most popular technique. 3–8 After 1–6 sessions, a success rate of BO eradication ranging from 42% to 98% was achieved. Chest pain was very frequent after treatment and other complications were unusual, although not negligible since they included strictures, 3 7 8 fever, 8 bleeding, 3 or even perforation and death. 4 8 More importantly for the long term usefulness of this therapy was the observation of persisting buried intestinal metaplasia under the squamous re-epithelialisation, which was observed in the first clinical trials 3–5 with a frequency of 8–30%. Also, at least two cases of adenocarcinoma arising under the squamous re-epithelialisation have been observed after APC, 9 10 suggesting that even surveillance (and biopsy targeting) could become more difficult after this therapy. More recent trials 7 8 have observed a very low incidence of buried glands, probably because of the use of higher PPI doses and of higher power settings of the APC resulting in a deeper injury, but also at the cost of a higher incidence of stric-tures. In the current issue of Gut, Basu and colleagues 11 report on a series of 50 patients with BO treated by APC and followed for one year [see page 776]. They used a 30 watt power setting of APC (which corresponds to the low rage of energy) and cleared the BO macroscopi-cally in 68% of cases, but 44% of those successful cases had buried glands at …