Evaluating the Efficacy and Safety of Radiofrequency Ablation Compared to Endoscopic Surveillance in Managing Low-Grade Dysplasia in Barrett's Esophagus: A Systematic Review and Meta-Analysis.

Barrett's esophagus with low-grade dysplasia (BE-LGD) risks progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). Guidelines remain equivocal on managing non-nodular BE-LGD, endorsing either radiofrequency ablation (RFA) or endoscopic surveillance (ES). This systematic review compares RFA and ES in preventing progression to HGD/EAC to inform clinical practice.Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, MEDLINE, EMBASE, Web of Science, and Google Scholar were searched (September 2024) for randomized controlled trials (RCTs) comparing RFA and ES in BE-LGD. Outcomes included HGD/EAC progression, complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM), adverse events, and predictors of progression/response. Risk of bias (RoB) was assessed using Cochrane RoB 2. Meta-analysis used Mantel-Haenszel random-effects models.Four RCTs (n = 282) were included. The studies varied in follow-up duration and excluded patients with nodular BE-LGD. RFA was associated with reduced progression to HGD/EAC compared with ES (relative risk (RR) 0.23; 95% confidence interval (CI) 0.05-1.02; p = 0.05) and achieved higher CE-D and CE-IM both post-treatment (CE-D: RR 2.70; 95% CI 1.37-5.32; p = 0.004; CE-IM: RR 21.80; 95% CI 4.56-104.29; p < 0.0001) and durably (CE-D: RR 3.06; 95% CI 2.07-4.52; p < 0.00001; CE-IM: RR 61.60; 95% CI 8.66-438.21; p < 0.0001). Adverse events occurred only with RFA but were manageable. Single-study data reported that ES progression correlated with shorter Barrett's diagnosis time, more dysplasia-positive endoscopies, and longer circumferential Barrett's length. No significant predictors of RFA response emerged.In conclusion, RFA significantly reduces HGD/EAC progression in BE-LGD compared to ES, with superior CE-D/CE-IM rates and manageable adverse events, supporting its use as first-line therapy for non-nodular BE-LGD. Future studies should compare RFA to emerging therapies. The trials' restrictive eligibility criteria, variable center and operator expertise, differences in treatment protocols and ablation targets, and methodological issues-including early exclusions, cross-over, incomplete reporting, and potential conflicts of interest-limited generalizability and interpretation of long-term efficacy and safety.