Long-term results of electrical stimulation of the lower esophageal sphincter for treatment of proximal GERD

INTRODUCTION

Electrical stimulation of the lower esophageal sphincter (LES) in gastroesophageal reflux disease (GERD) patients, using EndoStim(®) LES stimulation system (EndoStim BV, the Hague, Netherlands), enhances LES pressure, decrease distal esophageal acid exposure, improves symptoms, and eliminates the need in many patients for daily GERD medications.

AIM

To evaluate, in a post hoc analysis, the effect of LES stimulation on proximal esophageal acid exposure in a subgroup of patients with abnormal proximal esophageal acid exposure.

METHODS

Nineteen patients (median age 54 years; IQR 47-64; men-10) with GERD partially responsive to proton pump inhibitors (PPI), hiatal hernia ≤ 3 cm, esophagitis ≤ LA grade C underwent laparoscopic implantation of the LES stimulator. LES stimulation at 20 Hz, 215 μs, 5-8 m Amp sessions was delivered in 6-12, 30 min sessions each day. Esophageal pH at baseline and after 12-months of LES stimulation was measured 5 and 23 cm above the manometric upper border of LES.

RESULTS

Total, upright and supine values of median (IQR) proximal esophageal pH at baseline were 0.4 (0.1-1.4), 0.6 (0.2-2.3), and 0 (0.0-0.2) %, respectively, and at 12 months on LES-EST were 0 (0-0) % (p = 0.001 total and upright; p = 0.043 supine comparisons). 24-hour distal esophageal acid exposure improved from 10.2 (7.6-11.7) to 3.4 (1.6-7.0) % (p = 0.001). Seven (37%) patients had abnormal (>1.1%) 24-hour proximal acid exposure at baseline; all normalized at 12 months (p = 0.008). In these 7 patients, total, upright, and supine median proximal acid exposure values at baseline were 1.7 (1.3-4.1), 2.9 (1.9-3.7), and 0.3 (0-4.9) %, respectively, and after 12 months of LES-EST were 0 (0-0.0), 0 (0-0.1), and 0 (0-0) % (p = 0.018 total and upright; p = 0.043 supine comparisons). Distal esophageal pH for this group improved from 9.3 (7.8-17.2) at baseline to 3.2 (1.1-3.7) % at 12-months (p = 0.043). There were no GI side effects such as dysphagia, gas-bloat or diarrhea or device or procedure related serious adverse events with LES-EST. There was also a significant improvement in their GERD-HRQL scores.

CONCLUSION

LES-EST is associated with normalization of proximal esophageal pH in patients with GERD and may be useful in treating those with proximal GERD. The LES-EST is safe without typical side effects associated with traditional antireflux surgery.

Establishing magnetic resonance imaging as an accurate and reliable tool to diagnose and monitor esophageal cancer in a rat model

OBJECTIVE

To assess the reliability of magnetic resonance imaging (MRI) for detection of esophageal cancer in the Levrat model of end-to-side esophagojejunostomy.

BACKGROUND

The Levrat model has proven utility in terms of its ability to replicate Barrett's carcinogenesis by inducing gastroduodenoesophageal reflux (GDER). Due to lack of data on the utility of non-invasive methods for detection of esophageal cancer, treatment efficacy studies have been limited, as adenocarcinoma histology has only been validated post-mortem. It would therefore be of great value if the validity and reliability of MRI could be established in this setting.

METHODS

Chronic GDER reflux was induced in 19 male Sprague-Dawley rats using the modified Levrat model. At 40 weeks post-surgery, all animals underwent endoscopy, MRI scanning, and post-mortem histological analysis of the esophagus and anastomosis. With post-mortem histology serving as the gold standard, assessment of presence of esophageal cancer was made by five esophageal specialists and five radiologists on endoscopy and MRI, respectively.

RESULTS

The accuracy of MRI and endoscopic analysis to correctly identify cancer vs. no cancer was 85.3% and 50.5%, respectively. ROC curves demonstrated that MRI rating had an AUC of 0.966 (p<0.001) and endoscopy rating had an AUC of 0.534 (p = 0.804). The sensitivity and specificity of MRI for identifying cancer vs. no-cancer was 89.1% and 80% respectively, as compared to 45.5% and 57.5% for endoscopy. False positive rates of MRI and endoscopy were 20% and 42.5%, respectively.

CONCLUSIONS

MRI is a more reliable diagnostic method than endoscopy in the Levrat model. The non-invasiveness of the tool and its potential to volumetrically quantify the size and number of tumors likely makes it even more useful in evaluating novel agents and their efficacy in treatment studies of esophageal cancer.

Patch esophagoplasty: esophageal reconstruction using biologic scaffolds

BACKGROUND

Standard techniques for surgical reconstruction of the esophagus remain suboptimal. Primary closure of diseased or injured esophagus has been associated with high morbidity, primarily due to leak and stricture, and synthetic materials are contraindicated due to the high risk of erosion and infection. Degradable bioscaffolds composed of extracellular matrix (ECM) have recently shown promising results in both pre-clinical and clinical settings to prevent stricture after extended endoscopic mucosal resection. We propose a novel surgical technique that utilizes an ECM scaffold as a reconstructive patch to augment the esophageal diameter during primary repair.

METHODS

Four patients requiring esophageal reconstruction underwent a patch esophagoplasty using an ECM scaffold composed of porcine urinary bladder ECM. The full thickness wall of the esophagus was replaced with an ECM patch that was sutured to the edges of the remaining esophagus, similar to the patch angioplasty performed in vascular procedures.

RESULTS

All patients had a favorable clinical outcome with immediate recovery from the procedure and reinstated oral intake after 7 days. One patient had a micro leak at day 5 that closed spontaneously 2 days after drainage. Follow-up studies including barium swallow and esophagogastroduodenoscopy (EGD) showed adequate esophageal emptying through the surgical segment in all patients. The EGD showed complete mucosal remodeling at 2 months, with approximately 20% area contraction at the patch level. The area of the defect was indistinguishable from surrounding healthy tissue. Biopsy of the patch area showed normal squamous epithelium. One of the patients had a separate intrathoracic stricture that required further surgery. Clinical outcomes were otherwise favorable in all cases.

CONCLUSIONS

An alternative for the treatment of esophageal stenosis is presented which uses a biological scaffold and an innovative surgical procedure. Additional work, including prospective studies and long-term follow-up, is required to fully evaluate the potential of this bioscaffold-based regenerative medicine approach for esophageal reconstruction.

Management of early-stage esophageal neoplasia (MESEN) consensus

BACKGROUND

Treatment of esophageal adenocarcinoma often involves surgical resection. Newer technologies in interventional endoscopy have led to a substantial paradigm shift in the management of early-stage neoplasia in Barrett's esophagus comprising high-grade dysplasia (HGD), intramucosal carcinoma, and, in some cases, submucosal carcinoma. However, there has been no consensus regarding the indications for esophageal preservation in these cases. In this work, consensus guidelines were established for the management of early-stage esophageal neoplasia considering clinically relevant aspects (age, comorbidities, and social environment) in each scenario.

METHODS

Seventeen experts were invited to participate based on their background and clinical expertise at high-volume centers. A questionnaire was created that included four clinical scenarios covering a wide range of situations within HGD and/or early esophageal neoplasia, particularly where controversies are likely to exist. Each of the clinical scenarios was open to discussion subdivided by patient age (20, 50, and 80 s). For each clinical scenario an expert was chosen to defend that position. Each defense triggered a subsequent discussion during a consensus meeting. Conclusions of that discussion together with an accompanying literature analysis allowed experts to confirm or change their original choices and served as the basis for the recommendations stated in this article.

RESULTS

There was 100 % consensus supporting esophageal preservation in patients with HGD, independent of patient age or Barrett's length. In patients with T1a adenocarcinoma, consensus for preservation was not reached (65 %) for young and middle-aged individuals but was supported for elderly patients (100 %). For T1b adenocarcinoma, consensus was reached for surgical resection (90 %), leaving organ preservation for patients with very low risk of nodal invasion or poor surgical candidates.

CONCLUSION

Advances in endoscopic imaging and therapy allow for organ preservation in most settings of early-stage neoplasia of the esophagus, provided that the patient understands the implications of this decision.

Abstract A48: Enhanced efficacy of cisplatin and 5-fluorouracil combination with AUY-922 in esophageal adenocarcinoma cells

Background: Esophageal Adenocarcinoma (EAC) continues to rise in incidence, with prognosis remaining poor despite advances in multimodality therapy. Several novel target agents are now being explored as an option for treating EAC. One potential target is heat shock protein 90 (Hsp90), a chaperone protein that is involved in many diverse biological processes including cell signaling, proliferation, and survival. Many of the client proteins are known oncoproteins that allow Hsp90 to stabilize cancer cell growth by supporting proliferation and preventing apoptosis. The isoform, Hsp90β, is constituently expressed, while Hsp90α is inducible during times of stress, with expression increased 2-10 fold in cancers. Our hypothesis is that Hsp90 inhibition, in combination with standard chemotherapeutic drugs, will cause EAC cancer cells to be more susceptible to apoptosis and reduce the rate of proliferation.

Methods: EAC cell lines, OE19 and OE33, were used to evaluate the effects of Hsp90 inhibitor, AUY-922, in cancer cell growth and apoptosis. ELISA of WST-1 and BrdU were used to determine the effective dosage and assess proliferation. Pathway inhibition was evaluated by Western Blot of Hsp90α and Hsp70. OE19, OE33, and patient samples of EAC tumor and gastroesophageal reflux tissue were used to assess the gene expression of Hsp90 and several client protein pathways by reverse transcription polymerase chain reaction (RT-PCR).

Results: The ED50 of AUY-922 was determined to be 30ηM. A combination of chemotherapeutic drugs, cisplatin and 5-fluorouracil (5-Fu), along with AUY-922 showed significantly decreased proliferation compared to untreated and single agent treated cell lines. Western blot demonstrated that Hsp90 was inhibited by AUY-922 treatment, by a decrease in expression of Hsp90α, and an increase in the expression of Hsp70. RT-PCR in the cell line treatment groups showed an impact on many client oncoproteins involved in cancer cell survival and Hsp90 was shown to be upregulated in tumor samples when compared to normal GERD samples.

Conclusion: The use of Hsp90 inhibitor, AUY-922, leads to reduced Hsp90 pathway expression, resulting in a degradation of many Hsp90 client proteins involved in cancer genesis. Cell proliferation was decreased with AUY-922 treatment, with the greatest demonstrated effect when used in combination with cisplatin and 5-Fu. Therefore, Hsp90 inhibition may have an application in multimodal EAC chemotherapy.

Citation Format: Christina L. Rotoloni, Jaclyn M. LaRosa, Michael J. Porter, Lori A. Kelly, Katherine Nega, Emily Wolfson, Yoshihiro Komastu, Juliann E. Kosovec, Pashtoon M. Kasi, Toshitaka Hoppo, Ali H. Zaidi, Blair A. Jobe. Enhanced efficacy of cisplatin and 5-fluorouracil combination with AUY-922 in esophageal adenocarcinoma cells. [abstract]. In: Proceedings of the Third AACR International Conference on Frontiers in Basic Cancer Research; Sep 18-22, 2013; National Harbor, MD. Philadelphia (PA): AACR; Cancer Res 2013;73(19 Suppl):Abstract nr A48.

A cross-sectional analysis of the prevalence of Barrett esophagus in otolaryngology patients with laryngeal symptoms

BACKGROUND

Populations at risk for esophageal adenocarcinoma remain poorly defined. Laryngeal symptoms can be secondary to laryngopharyngeal reflux (LPR) and can occur without associated gastroesophageal reflux symptoms such as heartburn and regurgitation.

GOAL

We sought to determine the prevalence of Barrett esophagus (BE) in otolaryngology patients with laryngeal symptoms±typical gastroesophageal reflux disease (GERD) symptoms.

STUDY

We performed a cross-sectional study of otolaryngology clinic patients who reported laryngeal symptoms. Symptoms, medications, and exposure histories were obtained. Unsedated transnasal endoscopy was performed. Suspected BE was biopsied and confirmed histologically. Risk factors and prevalence of BE were assessed.

RESULTS

Two hundred ninety-five patients were enrolled [73% male, median age 60 y (interquartile range 51 to 68 y)]. The overall prevalence of BE was 11.8% (n=33). Antisecretory medication use was present in 56% (n=156) of patients at enrollment. Compared with patients without BE, patients with BE were more likely to be male (P=0.01) and to report occupational lung injury (P=0.001). Duration, but not severity of laryngeal symptoms, significantly increased the odds of BE (odds ratio, 5.64; 95% confidence interval, 1.28-24.83; for a duration of symptoms >5 y). Of patients with BE, 58% (n=19) had coexisting LPR and GERD symptoms and 30% (n=10) had only LPR symptoms. Presence and size of hiatal hernia and length of columnar-lined esophagus were significant risk factors for BE.

CONCLUSIONS

Long-standing laryngeal symptoms are associated with the presence of BE in otolaryngology patients. Patients with chronic laryngeal symptoms and no identifiable ear, nose, or throat etiology for those symptoms may benefit from endoscopic screening regardless of whether typical GERD symptoms are present.

Smoothened inhibition leads to decreased proliferation and induces apoptosis in esophageal adenocarcinoma cells

The Hedgehog (Hh) pathway is known to be active in Barrett's carcinogenesis. Therefore, we evaluated the efficacy and underlying mechanisms of inhibition of cancer cell growth by the smoothened (Smo) antagonist BMS-833923 in esophageal adenocarcinoma (EAC) cell lines. Cell proliferation and apoptosis were evaluated by flow cytometry, Western blotting, immunofluorescence, and quantitative reverse transcription polymerase chain reactions. Results showed that the Smo antagonist led to reduced Hh pathway activity, resulting in decreased cell proliferation and induction of apoptosis via the intrinsic pathway in the esophageal cancer cells. In conclusion, the Smo antagonist may have application as an EAC chemotherapeutic agent.

Reflux: Pathophysiology to Management

Program Description:

This miniseminar will highlight advances in science and management of extra esophageal reflux. For decades, management of reflux has focused on acid suppression, often with variable patient outcome. Advances in understanding the mechanism of extra esophageal reflux have demonstrated the importance of all reflux events, from acid to alkaline. This miniseminar will feature thought provoking perspectives from leaders in translational and clinical research. Pathophysiology, surgical, and medical management of extra esophageal reflux will be highlighted.

Educational Objectives:

1) Evaluate the impact of reflux mediated injury to the epithelia of the upper aerodigestive tract. 2) Recognize that management of reflux is more than acid suppression. Appreciate the role of surgical management of extraesophageal symptoms. 3) Identify shifts in management of reflux mediated laryngitis.

Prevention of Barrett esophagus and esophageal adenocarcinoma by smoothened inhibitor in a rat model of gastroesophageal reflux disease

BACKGROUND

Activated hedgehog (Hh) pathway is associated with development of both Barrett esophagus (BE) and esophageal adenocarcinoma (EAC). We hypothesize that blockade of the Hh pathway with smoothened (Smo) inhibitor can prevent the development of BE/EAC in the Levrat model, in which induced gastroduodenoesophageal reflux (GDER) leads to esophageal carcinogenesis.

METHODS

GDER was induced in 6- to 8-week-old male Sprague-Dawley rats. The Smo inhibitor (10 mg/kg/d) was given orally on postoperative weeks 10 to 16, 18 to 22, and 24 to 28, and rats were killed on week 28. The primary outcome measure was the incidence of BE and EAC. To examine potential therapeutic effects of Smo inhibition on tumor tissue, semiquantitative immunohistochemistry for Ki-67 and caspase 3 was performed. In treated animals that developed cancer, gene expression was analyzed.

RESULTS

Thirty-eight of 48 controls and 32 of 46 treated animals survived to 28 weeks. messenger ribonucleic acid (mRNA) expression of Indian Hh, a ligand of transmembrane receptor patched 1, was 184× higher in BE and 99× higher in EAC compared with normal esophageal tissue (P = 0.0239 and P = 0.0004, respectively). Compared with controls, the incidence of BE and EAC was decreased in treated animals by 35.7% (relative risk reduction, 36%; P = 0.0015) and 36% (relative risk reduction, 62%; P = 0.0033), respectively. Compared with untreated EAC, Ki-67 was downregulated (P = 0.04) and cleaved caspase 3 was no different in treated EAC (P = 0.398). Of the 84 well-known genes involved in cancer drug resistance, 50 were dysregulated in treated EAC (P < 0.05 for each gene).

CONCLUSIONS

Smo inhibitor prevents the development of BE and EAC in an in vivo model of GDER.

Preoperative diagnostic workup before antireflux surgery: an evidence and experience-based consensus of the Esophageal Diagnostic Advisory Panel

BACKGROUND

Gastroesophageal reflux disease (GERD) is a very prevalent disorder. Medical therapy improves symptoms in some but not all patients. Antireflux surgery is an excellent option for patients with persistent symptoms such as regurgitation, as well as for those with complete symptomatic resolution on acid-suppressive therapy. However, proper patient selection is critical to achieve excellent outcomes.

STUDY DESIGN

A panel of experts was assembled to review data and personal experience with regard to appropriate preoperative evaluation for antireflux surgery and to construct an evidence and experience-based consensus that has practical application.

RESULTS

The presence of reflux symptoms alone is not sufficient to support a diagnosis of GERD before antireflux surgery. Esophageal objective testing is required to physiologically and anatomically evaluate the presence and severity of GERD in all patients being considered for surgical intervention. It is critical to document the presence of abnormal distal esophageal acid exposure, especially when antireflux surgery is considered, and reflux-related symptoms should be severe enough to outweigh the potential side effects of fundoplication. Each testing modality has a specific role in the diagnosis and workup of GERD, and no single test alone can provide the entire clinical picture. Results of testing are combined to document the presence and extent of the disease and assist in planning the operative approach.

CONCLUSIONS

Currently, upper endoscopy, barium esophagram, pH testing, and manometry are required for preoperative workup for antireflux surgery. Additional studies with long-term follow-up are required to evaluate the diagnostic and therapeutic benefit of new technologies, such as oropharyngeal pH testing, multichannel intraluminal impedance, and hypopharyngeal multichannel intraluminal impedance, in the context of patient selection for antireflux surgery.

Surgical management of gastroesophageal junction tumors

Surgical resection remains the mainstay of potentially curative therapy for gastroesophageal junction (GEJ) tumors. However, because of the location of the tumor at the boundary between the esophagus and stomach, GEJ tumors have been a source of controversy in regard to their definition, classification, staging and surgical management. The definition of GEJ tumors was addressed with the development of the three-tiered Siewert's classification scheme. There remain many controversies regarding the appropriate surgical approach and the extent of the lymphadenectomies for these tumors. For locally advanced, resectable GEJ tumors, an aggressive surgical resection should be considered and the approach predicated by tumor location as defined by the Siewert's classification. Limited resections for earlier stage tumors have also been evaluated.

A novel esophageal-preserving approach to treat high-grade dysplasia and superficial adenocarcinoma in the presence of chronic gastroesophageal reflux disease

BACKGROUND

The optimal treatment strategy of esophageal high-grade dysplasia (HGD) and superficial adenocarcinoma remains controversial.

METHODS

Here, we describe endoscopic, circumferential mucosal-submucosal en-bloc resection of the entire abnormal esophageal epithelium with extracellular matrix (ECM) placement to regenerate neoepithelium and minimize stricture. That procedure was then followed by a laparoscopic fundoplication as a novel esophageal-preserving approach to treat HGD and superficial adenocarcinoma in the face of chronic gastroesophageal reflux disease (GERD).

CONCLUSIONS

This approach could be an ideal option as an alternative to esophagectomy in selected patients.

Proximal reflux as a cause of adult-onset asthma: the case for hypopharyngeal impedance testing to improve the sensitivity of diagnosis

OBJECTIVES

To determine the patterns and proximity of reflux events in patients with adult-onset asthma (AOA) using hypopharyngeal multichannel intraluminal impedance (HMII) and to assess outcomes of antireflux surgery (ARS) in patients with AOA. DESIGN Retrospective review of prospectively collected data.

SETTING

University hospital. PATIENTS, INTERVENTIONS, AND OUTCOMES: All patients with AOA referred to our testing center underwent HMII, and those with abnormal proximal exposure, defined as laryngopharyngeal reflux at least once a day and/or high esophageal reflux at least 5 times a day, subsequently underwent ARS.

RESULTS

From October 1, 2009, through June 30, 2011, a total of 31 patients with AOA (4 men and 27 women; mean age, 53 years) underwent HMII. Of 27 patients with available information, 11 (41%) had objective evidence of reflux disease. Nineteen patients (70%) had concomitant typical reflux symptoms. Despite a frequently negative DeMeester score, abnormal proximal exposure, which occurred in the upright position, was observed in 19 patients (70%). Of 20 patients who subsequently underwent ARS, asthma symptoms improved in 18 (90%), and 6 of them discontinued or reduced pulmonary medications at a mean (range) follow-up of 4.6 (0.6-15.2) months. Pulmonary function test results before and after ARS revealed that of 5 patients, 4 (80%) had improvement of the forced expiratory volume in the first second of expiration and/or the peak expiratory flow rate, which correlated with symptomatic improvement.

CONCLUSIONS

Adult-onset asthma is associated with abnormal proximal exposure of the aerodigestive tract to refluxate; these patients respond to ARS despite negative pH test results. Patients with AOA should undergo testing with HMII because they would not be detected with conventional pH testing.

Oesophageal carcinoma

Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.

Oesophageal carcinoma

Oesophageal carcinoma affects more than 450,000 people worldwide and the incidence is rapidly increasing. Squamous-cell carcinoma is the predominant form of oesophageal carcinoma worldwide, but a shift in epidemiology has been seen in Australia, the UK, the USA, and some western European countries (eg, Finland, France, and the Netherlands), where the incidence of adenocarcinoma now exceeds that of squamous-cell types. The overall 5-year survival of patients with oesophageal carcinoma ranges from 15% to 25%. Diagnoses made at earlier stages are associated with better outcomes than those made at later stages. In this Seminar we discuss the epidemiology, pathophysiology, diagnosis and staging, management, prevention, and advances in the treatment of oesophageal carcinoma.

Esophagus and regenerative medicine

In addition to squamous cell carcinoma, the incidence of Barrett’s esophagus with high-grade dysplasia and esophageal adenocarcinoma is rapidly increasing worldwide. Unfortunately, the current standard of care for esophageal pathology involves resection of the affected tissue, sometimes involving radical esophagectomy. Without exception, these procedures are associated with a high morbidity, compromised quality of life, and unacceptable mortality rates. Regenerative medicine approaches to functional tissue replacement include the use of biological and synthetic scaffolds to promote tissue remodeling and growth. In the case of esophageal repair, extracellular matrix (ECM) scaffolds have proven to be effective for the reconstruction of small patch defects, anastomosis reinforcement, and the prevention of stricture formation after endomucosal resection (EMR). More so, esophageal cancer patients treated with ECM scaffolds have shown complete restoration of a normal, functional, and disease-free epithelium after EMR. These studies provide evidence that a regenerative medicine approach may enable aggressive resection of neoplastic tissue without the need for radical esophagectomy and its associated complications.

Improving risk stratification in superficial (T1) gastroesophageal adenocarcinoma: Association of the intestinal phenotype (MUC2 positive) with prognosis

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Background: An increasing proportion of esophageal and gastroesophageal junction adenocarcinomas (EAC) are limited to the superficial mucosal layer (stage classification T1) at the time of diagnosis. Intramucosal lesions (stage classification T1a) are increasingly managed with endoscopic resection due to their relatively low risk of nodal metastasis and favorable prognosis compared to those with submucosal invasion (stage classification T1b). At esophagectomy, however, the majority of T1b EAC are node-negative; conversely, a small proportion of T1a EAC will have nodal metastasis at esophagectomy and/or develop recurrent disease. Additional prognostication tools, such as tumor biomarker panels, are needed to optimize treatment algorithms. Known to carry prognostic significance in other tumors, we evaluated mucin protein expression to determine whether the mucin phenotype in early EAC was associated with survival outcomes. Methods: We classified 141 induction naive, resected, T1 EAC as intestinal-, gastric- or ductal-type depending on the expression pattern of gastrointestinal mucins (MUC2, MUC5AC, MUC6 and MUC1) determined by immunohistochemistry (IHC) on tissue microarrays. CDX2 expression was assessed by IHC and EGFR amplification was assessed by in situ hybridization. The association between survival and mucin subtypes was determined in univariate and multivariate analyses. Results: The intestinal phenotype (MUC2+) is associated with poor prognosis in T1b (HR 2.1, 95%CI 1.1-4.0) and node negative T1 EAC (HR 2.5, 95%CI 1.1-5.7) after adjusting for other significant prognostic factors. Intestinal type EAC also showed accelerated time to first recurrence in these subgroups. The colloid histologic subtype and CDX2 expression were positively associated with MUC2 expression, but EGFR amplification was not. Conclusions: The mucin phenotype may serve as a useful adjunct to conventional risk assessment for optimizing therapy for potentially resectable, superficial EAC.

Recombinant vascular endothelial growth factor165 gene therapy improves anastomotic healing in an animal model of ischemic esophagogastrostomy

Proper anastomotic healing is dependent upon many factors including adequate blood flow to healing tissue. The aim of this study was to investigate the impact of vascular endothelial growth factor (VEGF(165)) transfection on anastomotic healing in an ischemic gastrointestinal anastomosis model. Utilizing an established opossum model of esophagogastrectomy followed by esophageal-gastric anastomosis, the gastric fundus was transfected with recombinant human vascular endothelial growth factor via direct injection of a plasmid-based nonviral delivery system. Twenty-nine animals were divided into three groups: two concentrations of VEGF and a control group. Outcomes included VEGF mRNA transcript levels, neovascularization, tissue blood flow, and anastomotic bursting pressure. To determine whether local injection resulted in a systemic effect, distant tissues were evaluated for VEGF transcript levels. Successful gene transfection was demonstrated by quantitative polymerase chain reaction analysis of anastomotic tissue, with significantly higher VEGF mRNA expression in treated animals compared to controls. At the gastric side of the anastomosis, there was significantly increased neovascularization, blood flow, and bursting pressure in experimental animals compared to controls. There were no differences in outcome measures between low- and high-dose VEGF groups; however, the high-dose group demonstrated increased VEGF mRNA expression across the anastomosis. VEGF production was not increased at distant sites in treated animals. In this animal model, VEGF gene therapy increased VEGF transcription at a healing gastrointestinal anastomosis without systemic VEGF upregulation. This treatment led to improved healing and strength of the acutely ischemic anastomosis. These findings suggest that VEGF gene therapy has the potential to reduce anastomotic morbidity and improve surgical outcomes in a wide array of patients.

Evaluation of proteomic profiles of normal mucosa, Barrett’s esophagus (BE), and esophageal adenocarcinoma (EAC) obtained from humans and the Levrat’s rat model of BE/EAC

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Background: EAC from BE is increasing, and prognosis is poor. Representative models are critical to understanding BE/EAC and developing therapies. We refined the Levrat’s model of BE/EAC and showed that a SMO inhibitor prevented BE/EAC (Proc ASCO 2012). To validate the rat model as representative of human and explore differentially expressed proteins/pathways, we evaluated the proteomic profiles of nl/BE/EAC from humans and rats. Methods: GE reflux was induced in 6-8 wk old male Sprague–Dawley rats by the Levrat’s procedure--approved by the IACUC. Incidence of BE/EAC at 28 wks was 90%/70%. Human nl/BE/EAC samples were obtained from the PENG database--IRB approved. Histology confirmed by a single pathologist (JD). Following LCM from paraffin, digests were analyzed in triplicate by nanoflow LC-MS/MS with a hybrid linear ion trap-Orbitrap Velos mass spectrometer followed by online nanoflow LC. Mass spectral data representing ~ 20-30,000 CID spectra were searched, and a quantitative estimate of relative abundance was obtained. Kruskal-Wallis non-parametric ANOVA was employed, and clusters were compared within and between humans and rats. Results: Data is available for rat tissues, 10 samples each for nl/BE/EAC. Heirarchical clustering of 410 features yielded 3 statistically significantly distinct groups corresponding to normal, BE and EAC (ANOVA p < 0.001). Pair-wise comparison between groups yielded statistically significant (p < 0.05) differential protein expression as follows: nl vs BE~550; nl vs EAC~450; BE vs EAC~150. For EAC, proteins were differentially expressed in pathways including: protein degradation/synthesis, cell death, growth and proliferation (NF-kB, EIF4A, Akt, b-tubulin). Analysis of human tissues and comparison to rat will be presented at the meeting. Conclusions: Proteomic evaluation of normal/BE/EAC tissues from the Levrat’s model of BE/EAC yielded distinct protein patterns for nl/BE/EAC. Proteins differentially expressed in EAC vs normal/EAC are involved in cancer related pathways. Differentially expressed proteins may provide targets for therapy, which could be tested in the Levrat’s model.

Feasibility, safety, acceptability, and yield of office-based, screening transnasal esophagoscopy (with video)

BACKGROUND

Endoscopic screening for esophageal neoplasia can identify patients eligible for early intervention for precancerous lesions. Unsedated transnasal esophagoscopy may provide an efficient and accurate endoscopic assessment with fewer risks and less cost, compared with conventional upper endoscopy.

OBJECTIVE

To assess the feasibility, safety, acceptability, and yield of unsedated transnasal esophagoscopy in a primary care population.

DESIGN

Multicenter, prospective, cross-sectional study.

SETTING

Two outpatient tertiary-care centers.

PATIENTS

This study involved a general medical clinic population aged between 40 and 85 years.

INTERVENTION

Unsedated, office-based transnasal esophagoscopy.

MAIN OUTCOME MEASUREMENTS

Procedure yield; completeness of examination; procedure length; adverse events and complications; choking, gagging, pain, or anxiety during the examination; and overall tolerability.

RESULTS

A total of 426 participants (mean [± standard deviation] age 55.8 ± 9.5 years; 43% male) enrolled in the study, and 422 (99%) completed the examination. Mean (± standard deviation) examination time was 3.7 ± 1.8 minutes. There were no serious adverse events, and 12 participants (2.8%) reported minor complications. Participants reported minimal choking, gagging, pain, or anxiety. The examination was well-tolerated by most participants. Overall, 38% of participants had an esophageal finding that changed management (34% erosive esophagitis, 4% Barrett's esophagus).

LIMITATIONS

Nonrandomized study, tertiary-care centers only, self-selected population with a large proportion reporting esophageal symptoms.

CONCLUSION

Unsedated transnasal esophagoscopy is a feasible, safe, and well-tolerated method to screen for esophageal disease in a primary care population. Endoscopic findings are common in this patient population.

Endoscopy and role of endoscopic resection in gastric cancer

Patient selection for endoscopic resection is based on meticulous endoscopic examination and histological assessment so as to avoid performing this procedure on patients with a high risk of lymph node involvement or metastatic disease. Currently, endoscopic mucosal resection (EMR) is used for tumors <2 cm, and endoscopic submucosal dissection (ESD) should be considered for tumors >2 cm. The advantage of ESD is that it achieves en-bloc resection of larger tumors, potentially reducing the risk of disease recurrence.