Hybrid APC for Barrett's esophagus, author disclosures as listed. Given the rising incidence of esophageal adenocarcinoma, detection, diagnosis, and endoscopic eradication therapy for Barrett's esophagus is critical. There are various treatment modalities for Barrett's esophagus-related neoplasia. Radiofrequency ablation uses a balloon-based or focal catheter to ablate the tissue to a consistent depth. Argon plasma coagulation relies on a jet of ionized argon gas that generates thermal energy, and cryoablation is freezing of the tissue with either nitrous oxide or liquid nitrogen. A new technique called hybrid argon plasma coagulation is demonstrated here. Hybrid APC uses conventional APC but preceded by submucosal injection using a high-pressure water jet system to lift the surface epithelium. Here we review the setup for hybrid APC, and these are the supplies you will need. You turn on the water jet system, and this will prompt you to insert a new cartridge. Making sure that the port is facing outwards, you align the two holes and click the cartridge into place. Next you will want to connect your IV tubing to the port. You take your APC catheter and connect one end to the electrosurgical unit and the other to the water jet system. Now you are ready to prime the catheter to make sure there is no air in the line. You continue until you are sure that you have an even and steady stream. We present a case of a 61-year-old female with GERD and long segment Barrett's esophagus C8M8 with confirmed low-grade dysplasia who presents for upper endoscopy. We examine the Barrett segment in white light very carefully and then under narrow band imaging. The proximal extent of the Barrett segment is marked here using the APC catheter at 30 watts. Note that marking is optional and the catheter is 7 French or 2.3 millimeters in diameter. Next we perform injection to create a saline cushion that protects the deeper layers and muscularis from thermal injury. Notice there is no needle. The system facilitates high-pressure injection all through the catheter. We make sure to keep the catheter tip close to the tip of the scope and if the fluid is not penetrating the mucosa, you can roll the catheter toward the wall to achieve a less tangential angle with use of the distal attachment cap. We typically prefer to lift the entire area and then ablate everything as you see in this case. However, for long segments, an alternative approach is to lift a portion of the mucosa and then continue to lift and ablate until the entire segment is treated. With the needle-free injection system activated by the foot pedal, either strategy is easy and convenient. And for normal treatment naïve tissue, the starting settings for the water jet system is effect 25 to 30, but if the tissue has been previously treated, you can increase the pressure and PSI by increasing to effect 35 to 40 and even increasing by increments of 5 until the desired lift is accomplished. During the first pass, you can ablate with extreme precision with pulsed APC at 60 watts at a flow rate of 0.8 to 1 liter per minute. Here we are starting with a circumferential burn, which typically works well for shorter segments, but as this is a longer segment, we then proceed to burn in longitudinal strips. Since you control the dosimetry, you can burn to the desired tissue effect. The goal is to achieve a grayish or tan-brown appearance of the tissue, and note that a large area can be ablated in a single session. Next we use the distal attachment cap to mechanically clear the tissue surface of the ablation debris. Scraping is always performed prior to the second pass ablation. Some of the injection may have dissipated, so we selectively inject again as needed for the second pass. Additional APC is performed, this time at 40 watts, and the goal is really here to identify skip areas, areas that appear pink and would benefit from additional therapy. In areas where the goal tissue effect has clearly been achieved, you do not need to treat a second time. The technique highlights include optional marking of the site at 30 watts, injection of a blue-tinted saline solution using the needle-free high-pressure water jet system until the target area is raised, a first-pass ablation of pulsed APC at 60 watts, followed by tissue cleaning of the ablation debris, a second injection, and a second-pass ablation at 40 watts. The patient did well and returned for follow-up endoscopy three months later. Her endoscopy demonstrated neosquamous mucosa, and there was no endoscopic or histologic evidence of Barrett's esophagus. In our initial experience using hybrid APC for 22 patients, most who were previously treated or refractory, 86% of patients achieved complete eradication of intestinal metaplasia with two treatment-related strictures. In conclusion, we demonstrate hybrid APC, which combines a submucosal saline injection with conventional APC in one catheter, as a simple, efficient, and effective method for treating Barrett's esophagus-related neoplasia.

hybrid argon plasma coagulation

Barrett's esophagus

treatment modalities

radiofrequency ablation

cryoablation