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Barret M, Prat F. Diagnosis and treatment of superficial esophageal cancer. Ann Gastroenterol 2018; 31:256-265. [PMID: 29720850 PMCID: PMC5924847 DOI: 10.20524/aog.2018.0252] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 02/07/2023] Open
Abstract
Endoscopy allows for the screening, early diagnosis, treatment and follow up of superficial esophageal cancer. Endoscopic submucosal dissection has become the gold standard for the resection of superficial squamous cell neoplasia. Combinations of endoscopic mucosal resection and radiofrequency ablation are the mainstay of the management of Barrett’s associated neoplasia. However, protruded, non-lifting or large lesions may be better managed by endoscopic submucosal dissection. Novel ablation tools, such as argon plasma coagulation with submucosal lifting and cryoablation balloons, are being developed for the treatment of residual Barrett’s esophagus, since iatrogenic strictures still hamper the development of extensive circumferential resections in the esophagus. Optimal surveillance modalities after endoscopic resection are still to be determined. The assessment of the risk of lymph-node metastases, as well as of the need for additional treatments based on qualitative and quantitative histological criteria, balanced to the patient’s condition, requires a dedicated multidisciplinary team decision process. The need for trained endoscopists, expert pathologists and surgeons, and specialized multidisciplinary meetings underlines the role of expert centers in the management of superficial esophageal cancer.
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Affiliation(s)
- Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Paris, France
| | - Frédéric Prat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Paris, France
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Kristo I, Rieder E, Paireder M, Schwameis K, Jomrich G, Dolak W, Parzefall T, Riegler M, Asari R, Schoppmann SF. Radiofrequency ablation in patients with large cervical heterotopic gastric mucosa and globus sensation: Closing the treatment gap. Dig Endosc 2018; 30:212-218. [PMID: 28884487 DOI: 10.1111/den.12959] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/31/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Symptomatic cervical heterotopic gastric mucosa, also known as cervical inlet patch (CIP), may present in various shapes and causes laryngopharyngeal reflux (LPR). Unfortunately, argon plasma coagulation, standard treatment of small symptomatic CIP, is limited in large CIP mainly because of concerns of stricture formation. Therefore, we aimed to investigate radiofrequency ablation (RFA), a novel minimally invasive ablation method, in the treatment of CIP focusing on large symptomatic patches. METHODS Consecutive patients with macroscopic and histological evidence of large (≥20 mm diameter) heterotopic gastric mucosa were included in this prospective trial. Primary outcome was complete macroscopic and histological eradication rate of CIP. Secondary outcome measures were symptom improvement, quality of life, severity of LPR and adverse events. RESULTS Ten patients (females, n = 5) underwent RFA of symptomatic CIP. Complete histological and macroscopic eradication of CIP was observed in 80% (females, n = 4) of individuals after two ablations. Globus sensations significantly improved from median visual analog scale score 8 (5-9) at baseline to 1.5 (1-7) after first ablation and 1 (1-2) after final evaluation (P < 0.001). Mental health scores significantly increased from 41.4 (± 8.5) to 54.4 (± 4.4) after RFA (P = 0.007). LPR improved significantly (P = 0.005) with absence of strictures after a mean follow up of 1.9 (± 0.5) years. CONCLUSIONS This is the first study on RFA focusing on therapy of large symptomatic heterotopic gastric mucosa. Hereby, we demonstrate that this new technique can be successfully implemented in patients where treatment was limited so far (NCT03023280).
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Affiliation(s)
- Ivan Kristo
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Erwin Rieder
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Paireder
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Katrin Schwameis
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Gerd Jomrich
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Werner Dolak
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Parzefall
- Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | | | - Reza Asari
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
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Knabe M, Blößer S, Wetzka J, Ell C, May A. Non-thermal ablation of non-neoplastic Barrett's esophagus with the novel EndoRotor® resection device. United European Gastroenterol J 2018; 6:678-683. [PMID: 30083329 DOI: 10.1177/2050640618758214] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 01/15/2018] [Indexed: 12/19/2022] Open
Abstract
Background International guidelines suggest endoscopic resection for all patients with low-risk mucosal cancer. Ultimately, it is essential to treat the remaining Barrett's esophagus as part of the treatment. Different thermal ablative therapies have been implemented to effect this treatment. They can lead to potential post-therapeutic stenosis. Furthermore, a histologic assessment of treated mucosa is not possible. Objective Clinical evaluation of a novel, non-thermal resection device (EndoRotor®) in the treatment of non-neoplastic Barrett's esophagus was conducted. Methods Fourteen patients with early Barrett's carcinoma were treated with endoscopic resection. Subsequently, EndoRotor® therapy was performed for resection of the remaining Barrett's mucosa. Complications were assessed during the study. After a three-month period patients received follow-up endoscopy to evaluate post-therapeutic stenosis. Results On average, 674 mm2 (172 mm2 - 1600 mm2) of Barrett's mucosa was treated with the novel device. In six (37.5%) cases, intra-procedural bleeding occurred with the need for hemostasis. All bleeding could be managed by endoscopic therapy alone. After a three-month follow-up there was no post-therapeutic stenosis registered. Conclusion EndoRotor® resection is a feasible non-thermal treatment of non-neoplastic Barrett's esophagus. Larger trials have to evaluate risks and benefits of this novel device.
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Affiliation(s)
- Mate Knabe
- Department of Internal Medicine II, Sana Klinikum Offenbach (Teaching Hospital of the University of Frankfurt), Offenbach, Germany
| | - Sandra Blößer
- Department of Internal Medicine II, Sana Klinikum Offenbach (Teaching Hospital of the University of Frankfurt), Offenbach, Germany
| | - Jens Wetzka
- Department of Internal Medicine II, Sana Klinikum Offenbach (Teaching Hospital of the University of Frankfurt), Offenbach, Germany
| | - Christian Ell
- Department of Internal Medicine II, Sana Klinikum Offenbach (Teaching Hospital of the University of Frankfurt), Offenbach, Germany
| | - Andrea May
- Department of Internal Medicine II, Sana Klinikum Offenbach (Teaching Hospital of the University of Frankfurt), Offenbach, Germany
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Kraemer B, Scharpf M, Keckstein S, Dippon J, Tsaousidis C, Brunecker K, Enderle MD, Neugebauer A, Nuessle D, Fend F, Brucker S, Taran FA, Kommoss S, Rothmund R. A prospective randomized experimental study to investigate the peritoneal adhesion formation after waterjet injection and argon plasma coagulation (HybridAPC) in a rat model. Arch Gynecol Obstet 2018; 297:961-967. [PMID: 29362925 DOI: 10.1007/s00404-018-4661-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 01/09/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND This prospective, randomized, controlled, single-blinded study investigates the peritoneal adhesion formation of HybridAPC (waterjet elevation of the peritoneum with subsequent argon plasma coagulation) versus only waterjet (elevation with the same instrument, but without subsequent argon plasma coagulation) in a rat model (24 female Wistar rats). MATERIALS AND METHODS Bilateral lesions were created on the abdominal wall with HybridAPC on one sidewall and waterjet elevation on the other sidewall of the peritoneum in a standard fashion. After 10 days, the rats were euthanized to evaluate the peritoneal trauma sites. MAIN OUTCOME MEASURE(S) Adhesion incidence, quantity, and quality were scored 10 days postoperatively and studied histopathologically. RESULT(S) Incidence of adhesion formation was 2.3% for HybridAPC; no adhesions occurred for peritoneal elevation with saline (p = 1.00). Histologic evaluation revealed no acute inflammation in both groups. An overall moderate degree of granulation tissue formation and myonecrosis was observed in the HybridAPC group, whereas no chronic inflammation and myonecrosis occurred after elevation without thermal ablation (p < 0.0001). CONCLUSION(S) This study investigates the effect of waterjet elevation of the peritoneum with and without subsequent thermal ablation on adhesion formation in a rat model for the first time. Peritoneal waterjet elevation with saline does not provide any risk of adhesion formation. Thermal coagulation with APC after waterjet elevation of the peritoneum creates advantageous peritoneal conditions due to a permanent moist tissue surface and the cooling effect of the injected solution, resulting in no significant difference in adhesion formation compared to peritoneal elevation without thermal ablation. HybridAPC can thus be regarded as a beneficial coagulation method with only minor adhesion formation due to positive tissue effects of the combined waterjet.
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Affiliation(s)
- Bernhard Kraemer
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany.
| | - Marcus Scharpf
- Department of Pathology, University of Tuebingen, Liebermeisterstr. 8, 72076, Tübingen, Germany
| | - Simon Keckstein
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Julia Dippon
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Christos Tsaousidis
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Kristin Brunecker
- Erbe Elektromedizin GmbH, Waldhoernlestr. 17, 72072, Tübingen, Germany
| | | | | | - Daniela Nuessle
- Erbe Elektromedizin GmbH, Waldhoernlestr. 17, 72072, Tübingen, Germany
| | - Falko Fend
- Department of Pathology, University of Tuebingen, Liebermeisterstr. 8, 72076, Tübingen, Germany
| | - Sara Brucker
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Florin-Andrei Taran
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Stefan Kommoss
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany
| | - Ralf Rothmund
- Department of Obstetrics and Gynecology, University of Tuebingen, Calwerstr. 7, 72076, Tübingen, Germany
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di Pietro M, Canto MI, Fitzgerald RC. Endoscopic Management of Early Adenocarcinoma and Squamous Cell Carcinoma of the Esophagus: Screening, Diagnosis, and Therapy. Gastroenterology 2018; 154:421-436. [PMID: 28778650 PMCID: PMC6104810 DOI: 10.1053/j.gastro.2017.07.041] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/16/2022]
Abstract
Because the esophagus is easily accessible with endoscopy, early diagnosis and curative treatment of esophageal cancer is possible. However, diagnosis is often delayed because symptoms are not specific during early stages of tumor development. The onset of dysphagia is associated with advanced disease, which has a survival at 5 years lower than 15%. Population screening by endoscopy is not cost-effective, but a number of alternative imaging and cell analysis technologies are under investigation. The ideal screening test should be inexpensive, well tolerated, and applicable to primary care. Over the past 10 years, significant progress has been made in endoscopic diagnosis and treatment of dysplasia (squamous and Barrett's), and early esophageal cancer using resection and ablation technologies supported by evidence from randomized controlled trials. We review the state-of-the-art technologies for early diagnosis and minimally invasive treatment, which together could reduce the burden of disease.
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Affiliation(s)
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Hamade N, Sharma P. Ablation Therapy for Barrett's Esophagus: New Rules for Changing Times. Curr Gastroenterol Rep 2017; 19:48. [PMID: 28819902 DOI: 10.1007/s11894-017-0589-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss different endoscopic techniques in the eradication of Barrett's esophagus (BE) as well as some controversies in the field of treatment. RECENT FINDINGS Patients with T1a esophageal adenocarcinoma and BE of high-grade dysplasia should undergo endoscopic ablative therapy. The most studied technique to date is radiofrequency ablation. It can be combined with endoscopic mucosal resection in cases containing nodular and flat lesions. Cryotherapy and APC have shown promise with good efficacy and safety profiles so far, but are not mainstream as more studies are needed. Surveillance is still required post-ablation since recurrence is common. Low-grade dysplasia can be treated with either endo-ablative therapy or surveillance. Non-dysplastic BE treatment is controversial and so far, only surveillance is recommended. Research is ongoing to better risk stratify these patients. Our ability to diagnose and treat BE has come a long way in the past few years with the goal of preventing its progression into malignancy. The advent of endoscopic techniques in the eradication of BE has provided a less invasive and safer modality of treatment as compared to surgical esophagectomy. Data in the form of randomized trials and high-volume registries has provided good evidence to support the efficacy of these techniques and their long-term durability.
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Affiliation(s)
- Nour Hamade
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MI, USA
| | - Prateek Sharma
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MI, USA. .,Department of Gastroenterology, Department of Veterans Affairs Medical Center, 4801 E. Linwood Boulevard, Kansas City, MI, 64128, USA.
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Tan WK, di Pietro M, Fitzgerald RC. Past, present and future of Barrett's oesophagus. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2017; 43:1148-1160. [PMID: 28256346 PMCID: PMC6839968 DOI: 10.1016/j.ejso.2017.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 02/06/2017] [Accepted: 02/06/2017] [Indexed: 02/08/2023]
Abstract
Barrett's oesophagus is a condition which predisposes towards development of oesophageal adenocarcinoma, a highly lethal tumour which has been increasing in incidence in the Western world over the past three decades. There have been tremendous advances in the field of Barrett's oesophagus, not only in diagnostic modalities, but also in therapeutic strategies available to treat this premalignant disease. In this review, we discuss the past, present and future of Barrett's oesophagus. We describe the historical and new evolving diagnostic criteria of Barrett's oesophagus, while also comparing and contrasting the British Society of Gastroenterology guidelines, American College of Gastroenterology guidelines and International Benign Barrett's and CAncer Taskforce (BOBCAT) for Barrett's oesophagus. Advances in endoscopic modalities such as confocal and volumetric laser endomicroscopy, and a non-endoscopic sampling device, the Cytosponge, are described which could aid in identification of Barrett's oesophagus. With regards to therapy we review the evidence for the utility of endoscopic mucosal resection and radiofrequency ablation when coupled with better characterization of dysplasia. These endoscopic advances have transformed the management of Barrett's oesophagus from a primarily surgical disease into an endoscopically managed condition.
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Affiliation(s)
- W K Tan
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - M di Pietro
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom
| | - R C Fitzgerald
- MRC Cancer Unit, University of Cambridge, Cambridge, United Kingdom.
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Abstract
Incidence of oesophageal adenocarcinoma has increased exponentially in the West over the past few decades. Following detection of advanced cancers, 5-year survival rates remain bleak, making identification of early neoplasia, which has a better outcome, important. Detection of subtle oesophageal lesions during endoscopy can be challenging, and advanced imaging techniques might improve their detection. High-definition endoscopy has become a standard in most endoscopy centres, and this technology probably provides better delineation of mucosal features than standard-definition endoscopy. Various image enhancement techniques are now available with the development of new electronics and software systems. Image enhancement with chromoendoscopy using dyes has been a cost-effective option for many years, yet these techniques have been replaced in some contexts by electronic chromoendoscopy, which can be used with the press of a button. However, Lugol's chromoendoscopy remains the gold standard to identify squamous dysplasia. Identification and characterization of subtle neoplastic lesions could help to target biopsies and perform endoscopic resection for better local staging and definitive therapy. In vivo histology with techniques such as confocal endomicroscopy could make endotherapy feasible within a shorter timescale than when relying on histology on tissue samples. Once early neoplasia is identified, treatments include endoscopic resection, endoscopic submucosal dissection or various ablative techniques. Endotherapy has the advantage of being a less invasive technique than oesophagectomy, and is associated with lower mortality and morbidity. Endoscopic ablation therapies have evolved over the past few years, with radiofrequency ablation showing the best results in terms of success rates and complications in Barrett dysplasia.
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