Endoscopic water jets used to ablate Barrett's esophagus: preliminary results of a new technique

The optimal management of Barrett's esophagus, a precursor to esophageal adenocarcinoma, remains controversial. Current therapy includes surveillance and ablative or resection techniques of varying safety and efficacy. This study aimed to determine the feasibility of a new catheter-based, endoscopic water jet ablation technique.

A high-pressure flexible catheter that can be passed through the working port of a standard gastroscope was used. The catheter had micro-drilled holes on one side near the tip. A 1-cm water jet was delivered under foot pedal control and endoscopic view at pressures adjusted from 150 to 400 psi. After approval from the authors' Institutional Review Board, tissue segments from fresh esophagectomy specimens were ablated by the catheter without use of an endoscope. Using gross appearance and histologic analysis, variable ablation pressures and times were evaluated.

Using variable pressures and times, 11 ablation sessions were performed: 5 for normal esophagus, 4 for normal stomach, and 2 across the gastroesophageal junction in the setting of Barrett's esophagus. Ablation pressures of 150 to 300 psi for 30 to 60 s resulted in selective ablation of mucosa with preservation of the submucosa and muscularis propria. The depth of the ablation was determined by gross inspection at the time of ablation and confirmed by histologic evaluation. There was no embedding of epithelial cells in the muscularis propria. In a single normal esophagus specimen, a jet applied at 400 psi for 120 s in a confined area resulted in gross perforation.

Selective ablation of esophageal and gastric epithelium using a catheter-based water jet ablation technique is feasible. The preliminary data from this study investigating a nonendoscopic technique show that the mucosa can be removed with preservation of the underlying submucosa and muscular layers. Further studies are warranted that focus on defining more precisely the pressure and duration required for optimal results and the practical application of this technique endoscopically.