Dysplasia in Barrett's esophagus: limitations of current management strategies

Dysplasia is a very imperfect biomarker for malignancy in Barrett's esophagus. Invasive cancer has been found in 30-40% of esophagi resected because preoperative endoscopic examinations had shown high-grade dysplasia. Reports on the natural history of this disorder are sometimes contradictory, but suggest that 10-30% of patients with high-grade dysplasia in Barrett's esophagus will develop a demonstrable malignancy within 5 yr of the initial diagnosis. Proposed management strategies for high-grade dysplasia include esophagectomy, endoscopic ablative therapies, endoscopic mucosal resection (EMR), and intensive endoscopic surveillance. Endoscopic ablative therapies and EMR may not be effective if neoplastic cells have invaded the submucosa or disseminated through mucosal lymphatic channels, and a number of studies suggest that the endoscopic therapies usually leave metaplastic or neoplastic epithelium with malignant potential behind. Limited data suggest that intensive endoscopic surveillance might be a reasonable approach for elderly or infirm patients, but some patients managed in this fashion have developed incurable esophageal cancers. The fundamental question of what is the appropriate length of follow-up for studies on dysplasia treatments has not been resolved. Although 5 yr might be considered the absolute minimum duration for a meaningful follow-up on dysplasia therapy, the follow-up duration in most studies is substantially less than 5 yr. Specific recommendations for management based on these considerations are proposed at the end of this report.

Surgical Treatment of Esophageal High-Grade Dysplasia

BACKGROUND

Barrett's esophagus, high-grade dysplasia (HGD), and invasive cancer are steps in the progression of esophageal adenocarcinoma. While surgery is recommended for resectable invasive adenocarcinoma, a number of treatment modalities are advocated for HGD. The purpose of this study is to determine the outcomes after surgery for HGD.

METHODS

We identified cases of HGD based on endoscopic biopsy in a single institution's databases from 1980 through 2001. Records were reviewed for patient characteristics, treatments, staging, and outcomes.

RESULTS

In a 22-year period, 869 cases of esophageal adenocarcinoma and 1,614 cases of Barrett's esophagus were diagnosed. Of these, 115 had HGD without pretreatment evidence of invasion. Forty-nine patients with HGD underwent resection (mean age, 59 years) as initial treatment. Forty-seven had endoscopic treatment (mean age, 70 years) by photodynamic therapy or endoscopic mucosal resection. Seven of the endoscopically treated patients failed, with three undergoing surgery and four observation. Nineteen patients were initially observed, with six eventually having surgery. For the 49 initially treated surgically, one (2%) operative mortality occurred. Invasive adenocarcinoma was present in 18 (37%). The five-year survival was 83% for all resected HGD patients (91% for those without invasion, 68% with invasion). Three of the eight deaths in those with invasion were from recurrent adenocarcinoma.

CONCLUSIONS

Surgical resection of esophageal HGD can be performed with low mortality and allows long-term survival. A significant percentage with an initial diagnosis of HGD will have invasive disease at resection. Surgery is the optimal treatment for HGD unless contraindicated by severe comorbidities.

Endoscopic ablation of Barrett’s esophagus using high power setting argon plasma coagulation: A prospective study

AIM: This prospective study evaluated the effectiveness of 90 W argon plasma coagulation (APC) for the ablation of Barrett’s esophagus (BE) that is considered to be the main risk factor for the development of esophageal adenocarcinoma.

METHODS: The results from 25 patients, observed at the First Department of General Surgery, University of Verona, Italy, from October 2000 to October 2003, who underwent APC for histologically proven BE were prospectively analyzed.

RESULTS: The ablation treatment was completed in all the patients but one (96%). The mean number of APC sessions needed to complete ablation was 1.6 (total number: 40). The eradication was obtained in the majority of cases by one session only (60%), two sessions were required in 24% of the cases and three or more in 16%. About 43% of the sessions were complicated. Retrosternal pain (22.5%) and fever (17.5%) were the most frequent symptoms. Only one major complication occurred, it was an hemorrhage due to ulcer formation on the treated esophagus that required urgent endoscopic sclerosis and admission. The follow-up was accomplished in all the patients with a mean period of 26.3 mo and 20 patients (84%) with a follow-up period longer than 24 mo. Only one patient showed a relapse of metaplastic mucosa 12 mo after the completion of ablation. The patient was hence re-treated and now is free from recurrence 33 mo later.

CONCLUSION: High power setting (90 W) APC showed to be safe and effective. The effects persist at a mean follow-up period of two years with a comparable cost in term of complications with respect to standard power settings. Further studies with greater number of patients are required to confirm these results and to assess if ablation reduces the incidence of malignant progression.

[Endoscopic mucosa resection for superficial esophageal carcinoma: an alternative to radical surgery?]

Radical surgery is the standard of care for resectable esophagus cancers, with mortality less than 5% in heavily trained surgical teams. Nevertheless, the morbidity of surgery is quite high due to the procedure and due to the poor status of these patients. Endoscopic mucosal resection seems effective for the resection of superficial malignant lesions of esophagus with an acceptable morbidity profile. A correct staging has to confirm the superficial character of the lesion and exclude deeper infiltration into the digestive wall or nodal involvement. This technique might be an acceptable alternative to surgery or superficial lesions, particularly for patients at high risk for aggressive surgical procedure.

Barrett's oesophagus: the new endoscopic modalities have a future

Barrett's oesophagus is defined as the replacement of squamous oesophageal epithelium by intestinal metaplasia in the distal oesophagus. It is a fairly frequent complication of gastro-oesophageal reflux disease (GORD): 5-10% of patients with GORD suffer from Barrett's oesophagus. GORD is essential for the development of Barrett's oesophagus.1 Intestinal metaplasia is a premalignant lesion that may further develop into dysplasia and lead to adenocarcinoma of the oesophagus. The latter now accounts for almost 50% of oesophageal cancer cases in western countries, and the largest increase in its incidence was recorded during the past two decades. Patients with Barrett's oesophagus have a 2-25% risk of developing mild to severe dysplasia and a 2-5% risk of having adenocarcinoma: 30-150 times higher than the risk in the general population. Forty to fifty per cent of Barrett's oesophagus patients with severe dysplasia would present adenocarcinoma within 5 years.

p53 immunohistochemical expression in Barrett's esophagus before and after endoscopic ablation by argon plasma coagulation

OBJECTIVE

Few studies have evaluated p53 accumulation in the squamous mucosa contiguous (SMC) to Barrett's esophagus (BE) and in the new squamous epithelium after endoscopic ablation. We evaluated the p53 expression in BE, in the SMC, and in the new squamous mucosa generated after ablation by argon plasma coagulation (APC).

MATERIAL AND METHODS

Endoscopic biopsy specimens from 37 BE patients, before and after ablation by APC, were analyzed. The p53 immunostaining criterion used was the staining of at least half of the nuclei.

RESULTS

p53 was detected in BE in 5 (13.5%) cases. In all these cases, SMC was p53(+). In addition, SMC was p53(-) in all cases of p53(-) BE (p <0.001). In the 5 cases with p53(+) BE and SMC, the new squamous mucosa continued to be p53(+). However, in the 32 cases with p53(-) SMC, the new squamous mucosa was also p53(-) (p <0.001). No case with p53(+) SMC turned out to be p53(-) after ablation. Similarly, no case with p53(-) BE and SMC before eradication became p53(+) after ablation (p < 0.001).

CONCLUSIONS

p53 was highly prevalent in the contiguous squamous mucosa when it is present in BE. After ablation, none of the cases lost p53 expression, and none of the negative cases turned out to be positive.

Expression of inducible nitric oxide synthase is increased in rat Barrett's esophagus induced by duodenal contents reflux

Barrett's esophagus is a premalignant condition of esophageal adenocarcinoma. Inducible nitric oxide synthase (iNOS) is induced by cytokines and can generate locally high concentrations of nitric oxide (NO), whose metabolites can mediate genotoxicity and influence multistage carcinogenesis by causing DNA damage. Therefore, we evaluated the immunolocalization and expression of iNOS in surgically induced rat Barrett's esophagus. Esophagoduodenal anastomosis was performed in rats for inducing reflux of duodenal contents. Rats were killed at postoperative 10, 20, 30 and 40 weeks. We examined histologic changes and iNOS expression in esophagus by immunohistochemistry and reverse transcription-polymerase chain reaction. Eighty six percent of experimental rats showed Barrett's esophagus above esophagoduodenal junction. iNOS immunoreactivity was clearly observed in the epithelial cells of Barrett's esophagus, predominantly at the apical surface of epithelial cells. Cytoplasmic staining was also seen only in atypical Barrett's esophagus. iNOS mRNA was detected only in the lower esophagus of experimental group. In conclusion, this study suggests that iNOS has some roles on Barrett's esophagus formation.

[Peptic diseases]

The therapeutical acquisitions of the year 2004 are: 1. The sequential treatment of the Helicobacter pylori infection reaches an eradication rate of 95%. 2. The use of COX-2 inhibitors reduced significantly the gastrointestinal side effects of anti-inflammatory treatments. Since cardiac averse effects of certain COX-2 inhibitors had been reported, the treatments with COX-2 inhibitors came widely into question. In the case of patients with risk of NSAID induced gastrointestinal toxicity, the alternative is to return to a treatment with non specific NSAID associated to an prophylactic PPI treatment.

Patient preferences for the management of high-grade dysplasia in Barrett's esophagus

Surgical esophagectomy, intensive endoscopic surveillance, and mucosal ablative techniques, particularly photodynamic therapy (PDT), have been proposed as possible management strategies for Barrett's high-grade dysplasia (HGD). Each option has advantages and disadvantages, and no firm consensus exists for the preferred strategy at this time. The purpose of this pilot study was to gain insight into patient preferences in Barrett's HGD management. Twenty patients with Barrett's esophagus were enrolled in a questionnaire study. The three possible management options for Barrett's HGD including each option's potential benefits and harms were presented to the subject in a formalized presentation that was designed to be easily comprehendible by patients. The subjects rated each strategy using a health-related quality of life instrument and chose one of the management strategies assuming they were found to have HGD. The average feeling thermometer rating scale values for the management strategies were as follows: endoscopic surveillance, 79; esophagectomy, 46; and PDT, 60. When asked to choose a strategy, 14 (70%) chose endoscopic surveillance, 3 (15%) chose esophagectomy, and 3 (15%) chose PDT. These findings were statistically significant (P = 0.0024). The patients who chose endoscopic surveillance felt "comfortable" with endoscopy, while the most common concern about esophagectomy, and PDT was the risk of death and the unknown risk of recurrence, respectively. In summary, when patients with Barrett's esophagus were presented with three options to manage HGD, the majority chose endoscopic surveillance. Familiarity with endoscopic surveillance was the predominant reason for the choice.

Surgery for early stage esophageal adenocarcinoma

Current treatment recommendations for early esophageal adenocarcinoma range from radical esophagectomy with extensive lymphadenectomy, limited surgical resection with/without regional lymphadenectomy to endoscopic mucosectomy or ablation. A comparison of treatment associated morbidity, tumor recurrence rates, and functional outcome suggests that none of these alternatives can be universally recommended. Rather, an individualized strategy should be employed based on depth of tumor penetration into the mucosa/submucosa, presence of lymph node metastases, multicentricity of tumor growth, length of the underlying Barrett mucosa and comorbidity of the affected patient. Endoscopic mucosectomy may suffice for an isolated focus of high-grade neoplasia or mucosal cancer, provided the neoplasia and underlying Barrett mucosa can be removed completely. Surgical resection is the treatment of choice for tumors invading the submucosa, multicentric tumors and recurrence after endoscopic mucosectomy. The extent of surgical resection must be guided by the length of the Barrett mucosa. In most instances a complete tumor resection and removal of the entire Barrett mucosa can be achieved by a limited transabdominal approach, and therefore subtotal esophagectomy may not be necessary. Application of the sentinel node technology may in the future allow to limit systematic lymphadenectomy to the rather small subgroup of patients who in fact have lymph node metastases.

[Laparoscopic Nissen fundoplication and esophageal intestinal metaplasia: preliminary observations]

The aim of this preliminary study conducted in a few cases was the retrospective evaluation of the effects of laparoscopic Nissen fundoplication on oesophageal intestinal metaplasia. Seventy-seven patients with hiatal hernia underwent digital videofluorography, endoscopy with biopsies, motility studies and 24-h oesophageal pH-monitoring. On the basis of the results of the diagnostic procedures and considering the patients' ages and response to proton-pump inhibitor treatment, 8 patients underwent laparoscopic Nissen fundoplication; in 5 cases intestinal metaplasia was present at histopathological examination. Two of these had Barrett's oesophagus at endoscopy and intestinal metaplasia was associated with low-grade dysplasia in both at histology; the other 3 did not present a columnar mucosa at endoscopy and 1 had low-grade dysplasia. In all 5 patients, at 1 year postoperative histopathological control, disappearance or decrease of metaplastic epithelium and regression of dysplasia were noted, with excellent results in terms of reflux symptoms at clinical control. On the basis of these preliminary data, it is our opinion that antireflux surgery is not only a suitable treatment in the management of Barrett's oesophagus but also has a favourable effect on intestinal metaplasia regression when a normal oesophageal mucosa is present.

Gastroesophageal reflux disease and Barrett's esophagus

Several articles have been published during the last year that may affect the management of patients with gastroesophageal reflux disease (GERD) and/or Barrett's esophagus in the near future. A new method of measuring esophageal pH has been introduced that does not require an indwelling transnasal catheter and may allow a more physiological assessment of esophageal acid exposure. Several articles discussed the use of endoscopic antireflux procedures, and a sham-controlled randomized study was published concerning the Stretta procedure. A long-term follow-up study and a decision analysis study have again fueled the debate concerning the relevance of surveillance of Barrett's patients, whereas other studies focused on techniques that may improve the detection of specialized intestinal metaplasia and dysplasia within the Barrett's segment. Finally, several studies have reported promising results with the endoscopic treatment of Barrett's metaplasia and early neoplasia using ablation techniques or endoscopic resection modalities. This review summarizes the most important articles in the field of GERD and Barrett's esophagus that have been published in peer-reviewed journals during the last year that are relevant to the practicing endoscopist.

Laparoskopische stumpfe Ösophagusdissektion mit abdomineller und mediastinaler Lymphknotendissektion beim Barrett-Karzinom

Esophageal resection has still a high morbidity and mortality. Minimal-invasive procedures don't have such complications. We describe a case of a patient with a Barrett-Carcinoma who was operated on by laparoscopic blunt esophageal dissection with abdominal and mediastinal lymph node dissection (tumor stage: pT3pN1 (2/16) G2). The postoperative course was without any complications.

Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus

BACKGROUND

The aim of this study was to evaluate the endoscopic and the histologic effects of a balloon-based bipolar radiofrequency electrode for ablation of porcine and human esophageal epithelium.

METHODS

All procedures were performed with a balloon-based, bipolar radiofrequency system that creates a circumferential, thin-layer epithelial ablation zone within the esophagus. In Phase I, multiple ablations were created in 10 farm swine, followed by acute euthanasia and histologic assessment for completeness of epithelial removal and ablation depth. In Phase II, multiple ablations were created in 19 farm swine, with varying power and energy density, followed by endoscopy at 2 and 4 weeks to assess stricture formation. In Phase III, 3 ablations were created in 12 farm swine, with varying energy density (5, 8, 10, 12, 15, or 20 J/cm 2 ) at 350 W. Animals were euthanized at 48 hours. Histologic examination determined the percentage of epithelium removed and the ablation depth. In Phase IV, 3 patients underwent esophageal epithelial ablation before esophagectomy, creating separate lesions proximal to the tumor. Completeness of epithelial ablation and ablation depth was quantified histologically.

RESULTS

In Phase I, complete removal of esophageal epithelium was achieved at energy density settings of 9.7 to 29.5 J/cm 2 . In Phase II, 9.7 and 10.6 J/cm 2 produced no stricture, whereas more than 20 J/cm 2 produced a stricture in every case. In Phase III, 8-20 J/cm 2 resulted in 100% epithelial ablation. Five and 8 J/cm 2 spared the muscularis mucosae, whereas 10 J/cm 2 caused injury to the muscularis mucosae but preserved the submucosa. In Phase IV, histologic examination demonstrated full-thickness epithelial removal in areas of electrode contact. Ablation extended only to the muscularis mucosae, without injury to submucosa.

CONCLUSIONS

In the porcine and the human esophagus, circumferential, full-thickness ablation of epithelium without direct injury to the submucosa is possible and was well tolerated. In all cases, depth of ablation was linearly related to energy density of treatment.

Endoscopic ablation of Barrett's oesophagus: a randomized-controlled trial of photodynamic therapy vs. argon plasma coagulation

BACKGROUND

Barrett's oesophagus is the major risk factor for oesophageal adenocarcinoma. 5-Aminlevulinic acid-induced photodynamic therapy and argon plasma coagulation have been shown to be effective for ablating Barrett's oesophagus, but a comparative trial of these two modalities has not been reported.

AIMS

To compare photodynamic therapy and argon plasma coagulation for the ablation of Barrett's oesophagus.

METHODS

A total of 68 patients (54 male, 14 female; median age 61) with Barrett's oesophagus were randomized to photodynamic therapy (n = 34) or argon plasma coagulation (n = 34). Photodynamic therapy was performed using 5-aminlevulinic acid (30 mg/kg) and red light. Argon plasma coagulation was administered at a power setting of 65 W. Multiple treatment sessions were performed, with follow-up to 24 months.

RESULTS

All patients showed a macroscopic reduction in the area of Barrett's oesophagus. This was greatest in the argon plasma coagulation group with 33 of 34 (97%) ablated, compared with 17 of 34 (50%) in the photodynamic therapy group; in the remainder, there was a reduction in the length of Barrett's oesophagus (median 50%, range: 5-90). Buried glands were found in 24% of photodynamic therapy patients, and in 21% of argon plasma coagulation patients. The median follow-up is 12 months (range: 6-24).

CONCLUSIONS

Photodynamic therapy and argon plasma coagulation are both effective for ablating Barrett's oesophagus. Argon plasma coagulation appears more effective than photodynamic therapy, but the impact of both on carcinoma development requires larger studies with long-term follow-up.

[Barrett's esophagus]

The diagnosis of Barrett's esophagus is rendered based on proof of intestinal metaplasia in the tubular portion of the esophagus. Barrett's develops in a percentage of patients with gastroesophageal reflux disease; risk factors include a long history of the disease, age over 40 years and Caucasian skin. Specifics about a genetic predisposition have not become known to date. Each year, around one out of every 200 patients with Barrett's epithelium develop adenocarcinoma of the esophagus, the incidence of which has risen dramatically over the past two decades. Apart from the early stages, the prognosis for this type of Barrett's carcinoma is extremely unfavorable, even after esophagectomy. It therefore appears sensible to examine patients with a long history of reflux and/or frequently recurrent reflux symptoms and to develop screening strategies for timely detection of persons with Barrett's esophagus along with subsequent monitoring. This would involve regular endoscopic studies accompanied by biopsies aimed at excluding or demonstrating the intraepithelial neoplasms that count as direct precursors to cancer. Treatment of nonneoplastic Barrett's esophagus can be symptomatic. Although theoretically logical, the benefits of normalizing esophageal acid exposure have not been proven. When high-grade intraepithelial neoplasms or mucosal carcinomas have been confirmed, local endoscopical resection and/or ablation appear sufficient, since the risk of lymph node metastasis is extremely low. Previous studies on this subject have been very promising, but should be continued and/or verified. Definitive therapy of more advanced tumor stages is currently given according to multimodal concepts established in an interdisciplinary manner.

[Merendino procedure with preservation of the vagus for early carcinoma of the gastroesophageal junction]

Optimal therapy for early carcinoma of the gastroesophageal junction remains uncertain. Treatment alternatives discussed today reach from endoluminal techniques to radical esophagectomy with 2- or 3-field lymphadenectomy. In this context, the Merendino procedure with preservation of the vagal innervation to the stomach appears as an interesting therapeutic alternative. This paper summarizes indications, operative technique, and functional results with respect to postoperative quality of life in view of 2 cases operated in our department.

Economic comparison of current endoscopic practices: Barrett's surveillance vs. ulcerative colitis surveillance vs. biopsy for sprue vs. biopsy for microscopic colitis

Health care costs are an increasingly important study outcome. Endoscopic practice consumes a large proportion of gastroenterology-related health expenses. An economic comparison of several currently accepted endoscopic practices was performed, ranking them according their cost-effectiveness, as viewed from the payer perspective. The cost-effectiveness of four currently accepted standard endoscopic practices was examined: small bowel biopsy to assess for celiac sprue, colonoscopic biopsy to assess for microscopic colitis, surveillance of Barrett's esophagus, and surveillance of chronic ulcerative colitis (CUC). Parameter estimates were obtained from the published literature. Charges were based on Medicare professional plus facility/technical fees. Performing colonoscopic biopsies for microscopic colitis in the setting of chronic nonbloody diarrhea was the most cost-effective practice ($2447/case detected), while small bowel biopsy for sprue in the setting of a patient with a first-degree relative with sprue ($3042/case detected) or with anemia ($2982/case detected) was also a cost-effective approach. Small bowel biopsy in the setting of diarrhea ($3900/case detected) was less cost-effective, while CUC surveillance ($14,119/detection of dysplasia) and performance of small bowel biopsy in an asymptomatic patient ($15,209/case detected) were clearly the least economical. As efforts are made to reduce the costs of health care, more attention will be focused on the cost-effectiveness of routine endoscopic practices. Although, our findings put endoscopic practices into economic perspective, future perspective, future prospective trials are required to confirm the validity of these findings.

Cost-effectiveness of photodynamic therapy for high-grade dysplasia in Barrett's esophagus

BACKGROUND

Photodynamic therapy appears to be effective in ablating high-grade dysplasia in Barrett's esophagus. Our aim was to identify the most effective and cost-effective strategy for managing high-grade dysplasia in Barrett's esophagus without associated endoscopically visible abnormalities.

METHODS

By using decision analysis, the lifetime costs and benefits of 4 strategies for which long-term data exist were estimated by us: esophagectomy, endoscopic surveillance, photodynamic therapy, followed by esophagectomy for residual high-grade dysplasia; and photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia. It was assumed by us that there was a 30% prevalence of cancer in high-grade dysplasia patients and a 77% efficacy of photodynamic therapy for high-grade dysplasia and early cancer.

RESULTS

Esophagectomy cost 24,045 dollars, with life expectancy of 11.82 quality-adjusted life years. In comparison, photodynamic therapy followed by surveillance for residual high-grade dysplasia was the most effective strategy, with a quality-adjusted life expectancy of 12.31 quality-adjusted life years, but it also incurred the greatest lifetime cost (47,310 dollars) for an incremental cost-effectiveness of 47,410 dollars/quality-adjusted life years. The results were sensitive to post-surgical quality of life and survival, and to cancer prevalence if photodynamic therapy efficacy for cancer was less than 50%.

CONCLUSIONS

Photodynamic therapy followed by endoscopic surveillance for residual high-grade dysplasia appears to be cost effective compared with esophagectomy for patients diagnosed with high-grade dysplasia in Barrett's esophagus. Clinical trials directly comparing these strategies are warranted.

Quality of life after colon interposition by necessity for esophageal cancer replacement

BACKGROUND

After esophagectomy for cancer, the first choice for reconstruction of the gastrointestinal continuity is by gastric tube. When this is not feasible, a reconstruction by colon interposition can be performed. The aim of this study was to assess the quality of life in patients at least 6 months after esophageal cancer resection and colon interposition without signs of recurrent disease. The results were compared with previously published data of patients after esophageal cancer resection and gastric tube reconstruction.

PATIENTS AND METHODS

Between January 1993 and January 2002, 36 patients underwent esophageal cancer resection and gastrointestinal reconstruction by colon interposition. A one-time Quality of Life assessment was carried out in 14 patients who were still disease free after a median follow-up of 21 months (mean 35, range 7-97). The patients were visited at home and asked to fill in questionnaires which consisted of the Short Form-36 (SF-36) Health Survey to assess general quality of life, an adapted Rotterdam Symptom Checklist to assess disease-specific quality of life, a visual analogue scale, and an additional questionnaire concerning other specific effects of the operation.

RESULTS

All 14 patients returned the completed set of questionnaires. Compared to the previously published results of patients after gastric tube reconstruction patients with a colon interposition scored significantly (P < or = 0.05) lower in five of the eight subscales of the SF-36 questionnaire (i.e. general health, physical role, vitality, social functioning, and mental health). The most frequent symptoms measured by the Rotterdam Symptom Checklist were early satiety after a meal, dysphagia, diarrhea, loss of sexual interest, and fatigue. Six patients could not independently run their housekeeping and four patients still needed artificial enteral nutrition.

CONCLUSION

Based on the SF-36 questionnaire, patients after colon interposition by necessity have a poor general quality of life. Even long after the operation they have a broad spectrum of persisting symptoms. Prior to surgery, patients should be informed about the disabling long-term functional outcome of a colon interposition.

Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas.

MATERIALS AND METHODS

All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT.

RESULTS

In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia.

CONCLUSIONS

The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.