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Jovani M, Wallace M. Is complete endoscopic resection still a viable option for Barrett's-related dysplasia and neoplasia? Clin Gastroenterol Hepatol 2014; 12:2011-4. [PMID: 25004460 DOI: 10.1016/j.cgh.2014.06.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Revised: 06/30/2014] [Accepted: 06/30/2014] [Indexed: 02/07/2023]
Affiliation(s)
- Manol Jovani
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Michael Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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52
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Dunbar KB, Spechler SJ. Controversies in Barrett esophagus. Mayo Clin Proc 2014; 89:973-84. [PMID: 24867396 DOI: 10.1016/j.mayocp.2014.01.022] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/06/2014] [Accepted: 01/22/2014] [Indexed: 02/06/2023]
Abstract
Barrett esophagus develops when metaplastic columnar epithelium predisposed to develop adenocarcinoma replaces esophageal squamous epithelium damaged by gastroesophageal reflux disease. Although several types of columnar metaplasia have been described in Barrett esophagus, intestinal metaplasia with goblet cells currently is required for a definitive diagnosis in the United States. Studies indicate that the risk of adenocarcinoma for patients with nondysplastic Barrett esophagus is only 0.12% to 0.38% per year, which is substantially lower than previous studies had suggested. Nevertheless, the incidence of esophageal adenocarcinoma continues to rise at an alarming rate. Regular endoscopic surveillance for dysplasia is the currently recommended cancer prevention strategy for Barrett esophagus, but a high-quality study has found no benefit of surveillance in preventing deaths from esophageal cancer. Medical societies currently recommend endoscopic screening for Barrett esophagus in patients with multiple risk factors for esophageal adenocarcinoma, including chronic gastroesophageal reflux disease, age of 50 years or older, male sex, white race, hiatal hernia, and intra-abdominal body fat distribution. However, because the goal of screening is to identify patients with Barrett esophagus who will benefit from endoscopic surveillance and because such surveillance may not be beneficial, the rationale for screening might be made on the basis of faulty assumptions. Endoscopic ablation of dysplastic Barrett metaplasia has been reported to prevent its progression to cancer, but the efficacy of endoscopic eradication of nondysplastic Barrett metaplasia as a cancer preventive procedure is highly questionable. This review discusses some of these controversies that affect the physicians and surgeons who treat patients with Barrett esophagus. Studies relevant to controversial issues in Barrett esophagus were identified using PubMed and relevant search terms, including Barrett esophagus, ablation, dysplasia, radiofrequency ablation, and endoscopic mucosal resection.
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Affiliation(s)
- Kerry B Dunbar
- Department of Medicine, VA North Texas Healthcare System, and the Department of Medicine, Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center at Dallas.
| | - Stuart Jon Spechler
- Department of Medicine, VA North Texas Healthcare System, and the Department of Medicine, Division of Gastroenterology and Hepatology, University of Texas Southwestern Medical Center at Dallas
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53
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Komeda Y, Bruno M, Koch A. EMR is not inferior to ESD for early Barrett's and EGJ neoplasia: An extensive review on outcome, recurrence and complication rates. Endosc Int Open 2014; 2:E58-64. [PMID: 26135261 PMCID: PMC4423274 DOI: 10.1055/s-0034-1365528] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Accepted: 02/24/2014] [Indexed: 12/21/2022] Open
Abstract
Background and study aims In recent years, it has been reported that early Barrett's and esophagogastric junction (EGJ) neoplasia can be effectively and safely treated using endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Multiband mucosectomy (MBM) appears to be the safest EMR method. The aim of this systematic review is to assess the safety and efficacy of MBM compared with ESD for the treatment of early neoplasia in Barrett's or at the EGJ. Methods A literature review of studies published up to May 2013 on EMR and ESD for early Barrett's esophagus (BE) neoplasia and adenocarcinoma at the EGJ was performed through MEDLINE, EMBASE and the Cochrane Library. Results on outcome parameters such as number of curative resections, complications and procedure times are compared and reported. Results A total of 16 studies met the inclusion criteria for analysis in this study. There were no significant differences in recurrence rates when comparing EMR (10/380, 2.6 %) to ESD (1/333, 0.7 %) (OR 8.55; 95 %CI, 0.91 - 80.0, P = 0.06). All recurrences after EMR were treated with additional endoscopic resection. The risks of delayed bleeding, perforation and stricture rates in both groups were similar. The procedure was considerably less time-consuming in the EMR group (mean time 36.7 min, 95 %CI, 34.5 - 38.9) than in the ESD group (mean time 83.3 min, 95 %CI, 57.4 - 109.2). Conclusions The MBM technique for EMR is as effective as ESD when comparing outcomes related to recurrence and complication rates for the treatment of early Barrett's or EGJ neoplasia. The MBM technique is considerably less time-consuming.
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Affiliation(s)
- Yoriaki Komeda
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands,Corresponding author: Yoriaki Komeda MD Department of Gastroenterology and Hepatology, Erasmus Medical Center,3000 CA RotterdamThe Netherlands
| | - Marco Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Arjun Koch
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
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Chadwick G, Groene O, Markar SR, Hoare J, Cromwell D, Hanna GB. Systematic review comparing radiofrequency ablation and complete endoscopic resection in treating dysplastic Barrett's esophagus: a critical assessment of histologic outcomes and adverse events. Gastrointest Endosc 2014; 79:718-731.e3. [PMID: 24462170 DOI: 10.1016/j.gie.2013.11.030] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/19/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND With recent advances in endoscopy, endoscopic techniques have surpassed esophagectomy in the treatment of dysplastic Barrett's esophagus (BE). OBJECTIVE To compare the efficacy and safety of complete EMR and radiofrequency ablation (RFA) in the treatment of dysplastic BE. DESIGN Systematic review of literature. PATIENTS Diagnosis of BE with high-grade dysplasia or intramucosal cancer. INTERVENTION Complete EMR or RFA. MAIN OUTCOME MEASUREMENTS Complete eradication of dysplasia and intestinal metaplasia at the end of treatment and after >12 months' follow-up. Adverse event rates associated with treatment. RESULTS A total of 22 studies met the inclusion criteria. Only 1 trial directly compared the 2 techniques; most studies were observational case series. Dysplasia was effectively eradicated at the end of treatment in 95% of patients after complete EMR and 92% after RFA. After a median follow-up of 23 months for complete EMR and 21 months for RFA, eradication of dysplasia was maintained in 95% of patients treated with complete EMR and 94% treated with RFA. Short-term adverse events were seen in 12% of patients treated with complete EMR but in only 2.5% of those treated with RFA. Esophageal strictures were adverse events in 38% of patients treated with complete EMR, compared with 4% of those treated with RFA. Progression to cancer appeared to be rare after treatment, although follow-up was short. LIMITATIONS Small studies, heterogeneous in design, with variable outcome measures. Also follow-up durations were short, limiting evaluation of long-term durability of both treatments. CONCLUSION RFA and complete EMR are equally effective in the short-term treatment of dysplastic BE, but adverse event rates are higher with complete EMR.
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Affiliation(s)
- Georgina Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Oliver Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sheraz R Markar
- Department of Surgery and Cancer, St. Mary's Hospital, London, United Kingdom
| | - Jonathan Hoare
- Department of Gastroenterology, St. Mary's Hospital, London, United Kingdom
| | - David Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - George B Hanna
- Department of Surgery and Cancer, St. Mary's Hospital, London, United Kingdom
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55
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Guo J, Liu Z, Sun S, Liu X, Wang S, Ge N. Ligation-assisted endoscopic enucleation for treatment of esophageal subepithelial lesions originating from the muscularis propria: a preliminary study. Dis Esophagus 2014; 28:312-7. [PMID: 24592944 DOI: 10.1111/dote.12192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
An innovative ligation-assisted endoscopic enucleation (EE-L) technique was developed for the diagnosis and treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria by combining endoscopic band ligation and endoscopic enucleation techniques. The aim of the study was to evaluate efficacy and safety of EE-L technique in the treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria. Forty-seven esophageal subepithelial lesions (smaller than 12 mm) originating from the muscularis propria in 44 patients were treated with EE-L between September 2010 and September 2012. The lesion was first aspirated into the transparent cap attached to the tip of endoscope. The elastic band was then released around its base. The purpose of ligation was to force the lesion to assume a polypoid form with a pseudostalk. Endoscopic enucleation was then performed until the tumor was completely enucleated from muscularis propria using a hook knife and forceps. All tumors (median diameter: 8.2 ± 2.3 mm, range: 4-12 mm) were enucleated completely. Histopathology identified 45 tumors (95.7%) as leiomyoma, 2 (4.3%) tumors as gastrointestinal stromal tumor with very low risk. The mean time of the EE-L procedure was 12.5 ± 4.6 minutes (range: 6-23 minutes). Two patients experienced self-limiting, non-life-threatening hemorrhage after EE-L. No perforation and massive hemorrhage requiring further endoscopic or surgical intervention occurred. There were no recurrences during the 6-24 months follow-up period. EE-L offers the option of localized treatment of small esophageal muscularis propria tumors (smaller than 12 mm) with relatively few complications and low mortality, and provides the advantage of allowing a histopathological diagnosis. All the resected lesions in this study had a benign pathology.
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Affiliation(s)
- J Guo
- Endoscopic Center, Shengjing Hospital of China Medical University, Shenyang, Liaoning Province, China
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56
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Conio M, Fisher DA, Blanchi S, Ruggeri C, Filiberti R, Siersema PD. One-step circumferential endoscopic mucosal cap resection of Barrett's esophagus with early neoplasia. Clin Res Hepatol Gastroenterol 2014; 38:81-91. [PMID: 23856637 DOI: 10.1016/j.clinre.2013.05.015] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 05/24/2013] [Accepted: 05/29/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Focal endoscopic mucosal resection (EMR) of visible intraepithelial lesions arising within Barrett's esophagus (BE) may miss synchronous lesions that are not endoscopically apparent. Stepwise radical endoscopic resection would obviate this concern by removing all BE; however, it requires repeated endoscopy which may increase the risk of complications, particularly for patients with circumferential BE. The aim of the study was to evaluate the safety and efficacy of one-step complete circumferential resection of BE by cap-assisted EMR (EMR-C) among patients with circumferential BE and high-grade dysplasia or intramucosal carcinoma. PATIENTS AND METHODS Between January 2003 and March 2010, 47 patients with circumferential BE and biopsy-proven high-grade dysplasia or intramucosal cancer underwent EMR-C. We evaluated: (1) complete eradication of neoplasia, (2) complete eradication of metaplasia, and (3) complications including bleeding and esophageal stricture. RESULTS Complete eradication of neoplasia and complete eradication of metaplasia were achieved after a median follow-up of 18.4 months in 91% (43/47) of patients. After EMR-C, two patients (one IMC, one invasive cancer) underwent esophagectomy. Histology of the resected specimens showed no residual disease and a T1bN0 lesion, respectively. Two patients had progression of neoplasia. A stenosis occurred in 18 out of 45 patients (40%). All stenoses were treated with dilations and two required temporary placement of a covered stent. CONCLUSION One-step complete EMR-C is a safe and effective technique which can be considered in patients with early neoplastic lesions. Although 40% of patients developed dysphagia, this could well be managed endoscopically.
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Affiliation(s)
- Massimo Conio
- Department of Gastroenterology, General Hospital, Sanremo, Italy.
| | - Deborah A Fisher
- Department of Gastroenterology, Durham Veterans Affairs Medical Center and Duke Medical Center, NC, USA
| | - Sabrina Blanchi
- Department of Gastroenterology, General Hospital, Sanremo, Italy
| | | | - Rosa Filiberti
- Epidemiology, Biostatistics and Clinical Trials, IRCCS, San Martino - IST National Institute for Cancer Research, Genova, Italy
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, The Netherlands
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57
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Tomizawa Y, Iyer PG, Wong Kee Song LM, Buttar NS, Lutzke LS, Wang KK. Safety of endoscopic mucosal resection for Barrett's esophagus. Am J Gastroenterol 2013; 108:1440-7; quiz 1448. [PMID: 23857478 PMCID: PMC3815637 DOI: 10.1038/ajg.2013.187] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2012] [Accepted: 05/09/2013] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic mucosal resection (EMR) is an established technique for the management of Barrett's esophagus (BE). Although EMR is generally perceived to be a relatively safe procedure, the published data regarding EMR-related complications are variable and the expertise of those performing EMR is often not disclosed. Our aim was to determine the complication rates in a large cohort of patients who underwent EMR at a specialized BE unit. METHODS A prospectively maintained database was reviewed for patients with BE who underwent EMR from January 1995 to August 2008. EMR was performed in patients with neoplastic appearing lesions. Bleeding, stricture, and perforation related to EMR were reviewed as the main outcome measurements. RESULTS In all, 681 patients (83% male; mean age 70 years old) underwent a total of 1,388 endoscopic procedures and 2,513 EMRs. Median length of BE was 3.0 cm (interquartile range (IQR) 1-7). A single experienced endoscopist performed 99% of the EMR procedures. EMR was performed using commercially available EMR kits in 95% (77% cap-snare and 18% band-snare) and a variceal band ligation device in 5% of cases. No EMR-related perforations occurred during the study period. The rate of post-EMR bleeding was 1.2% (8 patients). Seven patients were successfully treated endoscopically and one needed surgery. The rate for symptomatic strictures after EMR was 1.0% (7 cases), and all of the cases did not involve intervening ablation therapies. All strictures were successfully treated with endoscopic dilation. CONCLUSIONS This is the largest series reported to date on EMR in BE. In this large retrospective study, EMR for BE was associated with a low rate of complications for selected patients when performed by experienced hands.
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Affiliation(s)
- Yutaka Tomizawa
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G. Iyer
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Louis M. Wong Kee Song
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Navtej S. Buttar
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Lori S. Lutzke
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Barret’s Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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58
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Lin JL. T1 esophageal cancer, request an endoscopic mucosal resection (EMR) for in-depth review. J Thorac Dis 2013; 5:353-6. [PMID: 23825773 DOI: 10.3978/j.issn.2072-1439.2013.06.03] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2013] [Accepted: 06/03/2013] [Indexed: 12/31/2022]
Abstract
Endoscopic management of superficial esophageal adenocarcinoma has gained wider acceptance with the growing literature on its efficacy. Patient selection is critical in deciding who should be a candidate for surgery or endoscopy in the management of T1 esophageal cancer. This article discusses the key role EMR plays in the diagnostic evaluation.
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Affiliation(s)
- James L Lin
- Division of Gastroenterology, City of Hope, 1500 East Duarte Rd, Duarte, CA 91010, USA
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59
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Abstract
PURPOSE OF REVIEW Endoscopic eradication therapy is frequently used to treat dysplasia and early cancers in Barrett's esophagus. This review addresses some of the recent developments in the field of endoscopic eradication therapy for Barrett's esophagus. RECENT FINDINGS Data on the effectiveness of Barrett's esophagus ablation programs have been published recently, with excellent results for dysplasia eradication. Studies describing long-term results have shed light on the durability of endoscopic ablation, with recurrence of Barrett's esophagus and neoplasia seen in some cases, particularly at the gastroesophageal junction. Risk factors for failed ablation include longer Barrett's esophagus segments and persistent gastroesophageal reflux. New developments include studies combining radiofrequency ablation (RFA) and endoscopic mucosal resection into a single endoscopic session, endoscopic submucosal dissection for Barrett's esophagus neoplasia, and a simplified RFA algorithm. New data on the cost-effectiveness of RFA have also been published, suggesting that RFA is cost-effective for both high-grade and low-grade dysplasia, but not for nondysplastic Barrett's esophagus. A systematic review has shown that lymph node metastases are rare (∼2%) with intramucosal adenocarcinoma, supporting the use of endoscopic eradication for that lesion. SUMMARY Research and clinical experience with the endoscopic therapies for Barrett's esophagus continue to grow. Proper patient selection and technique are critical for ensuring a good outcome. Endoscopic surveillance after any of the ablative therapies still appears to be necessary.
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60
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Haidry RJ, Dunn JM, Butt MA, Burnell MG, Gupta A, Green S, Miah H, Smart HL, Bhandari P, Smith LA, Willert R, Fullarton G, Morris J, Di Pietro M, Gordon C, Penman I, Barr H, Patel P, Boger P, Kapoor N, Mahon B, Hoare J, Narayanasamy R, O'Toole D, Cheong E, Direkze NC, Ang Y, Novelli M, Banks MR, Lovat LB. Radiofrequency ablation and endoscopic mucosal resection for dysplastic barrett's esophagus and early esophageal adenocarcinoma: outcomes of the UK National Halo RFA Registry. Gastroenterology 2013; 145:87-95. [PMID: 23542069 DOI: 10.1053/j.gastro.2013.03.045] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 03/13/2013] [Accepted: 03/21/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) or early neoplasia increasingly receive endoscopic mucosal resection and radiofrequency ablation (RFA) therapy. We analyzed data from a UK registry that follows the outcomes of patients with BE who have undergone RFA for neoplasia. METHODS We collected data on 335 patients with BE and neoplasia (72% with HGD, 24% with intramucosal cancer, 4% with low-grade dysplasia [mean age, 69 years; 81% male]), treated at 19 centers in the United Kingdom from July 2008 through August 2012. Mean length of BE segments was 5.8 cm (range, 1-20 cm). Patients' nodules were removed by endoscopic mucosal resection, and the patients then underwent RFA every 3 months until all areas of BE were ablated or cancer developed. Biopsies were collected 12 months after the first RFA; clearance of HGD, dysplasia, and BE were assessed. RESULTS HGD was cleared from 86% of patients, all dysplasia from 81%, and BE from 62% at the 12-month time point, after a mean of 2.5 (range, 2-6) RFA procedures. Complete reversal dysplasia was 15% less likely for every 1-cm increment in BE length (odds ratio = 1.156; SE = 0.048; 95% confidence interval: 1.07-1.26; P < .001). Endoscopic mucosal resection before RFA did not provide any benefit. Invasive cancer developed in 10 patients (3%) by the 12-month time point and disease had progressed in 17 patients (5.1%) after a median follow-up time of 19 months. Symptomatic strictures developed in 9% of patients and were treated by endoscopic dilatation. Nineteen months after therapy began, 94% of patients remained clear of dysplasia. CONCLUSIONS We analyzed data from a large series of patients in the United Kingdom who underwent RFA for BE-related neoplasia and found that by 12 months after treatment, dysplasia was cleared from 81%. Shorter segments of BE respond better to RFA; http://www.controlled-trials.com, number ISRCTN93069556.
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Affiliation(s)
- Rehan J Haidry
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jason M Dunn
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohammed A Butt
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Matthew G Burnell
- Department of Biostatistics, University College London, London, United Kingdom
| | - Abhinav Gupta
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sarah Green
- National Medical Laser Centre, University College London, London, United Kingdom
| | - Haroon Miah
- National Medical Laser Centre, University College London, London, United Kingdom
| | - Howard L Smart
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | | | - Lesley Ann Smith
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Robert Willert
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | | | - John Morris
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | | | | | - Ian Penman
- Royal Infirmary Edinburgh, Edinburgh, United Kingdom
| | - Hugh Barr
- Gloucestershire Hospital NHS Trust, Gloucestershire, United Kingdom
| | - Praful Patel
- Southampton University Hospital, Southampton, United Kingdom
| | - Philip Boger
- Southampton University Hospital, Southampton, United Kingdom
| | - Neel Kapoor
- Aintree University Hospital, Liverpool, United Kingdom
| | - Brinder Mahon
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | | | | | - Edward Cheong
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | | | - Yeng Ang
- Centre of Gastrointestinal Sciences, University of Manchester, Salford Royal Foundation NHS Trust, Salford, United Kingdom
| | - Marco Novelli
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Matthew R Banks
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Laurence Bruce Lovat
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom.
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61
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Chandra S, Gorospe EC, Leggett CL, Wang KK. Barrett's esophagus in 2012: updates in pathogenesis, treatment, and surveillance. Curr Gastroenterol Rep 2013; 15:322. [PMID: 23605564 PMCID: PMC3815689 DOI: 10.1007/s11894-013-0322-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Barrett's esophagus (BE) is the only established precursor lesion in the development of esophageal adenocarcinoma (EAC) and it increases the risk of cancer by 11-fold. It is regarded as a complication of gastroesophageal reflux disease. There is an ever-increasing body of knowledge on the pathogenesis, diagnosis, treatment, and surveillance of BE and its associated dysplasia. In this review, we summarize the latest advances in BE research and clinical practice in the past 2 years. It is critical to understand the molecular underpinnings of this disorder to comprehend the clinical outcomes of the disease. For clinical gastroenterologists, there is also continuous growth of endoscopic approaches which is daunting, and further improvements in the detection and treatment of BE and early EAC are anticipated. In the future, we may see the increased role of biomarkers, both molecular and imaging, in both diagnostic and therapeutic strategies for BE.
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Affiliation(s)
- Subhash Chandra
- Barrett's Esophagus Unit, Division of Gastroenterology and Hepatology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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62
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Vignesh S, Hoffe SE, Meredith KL, Shridhar R, Almhanna K, Gupta AK. Endoscopic Therapy of Neoplasia Related to Barrett's Esophagus and Endoscopic Palliation of Esophageal Cancer. Cancer Control 2013; 20:117-29. [DOI: 10.1177/107327481302000205] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Background Barrett's esophagus (BE) is the most important identifiable risk factor for the progression to esophageal adenocarcinoma. Methods This article reviews the current endoscopic therapies for BE with high-grade dysplasia and intramucosal cancer and briefly discusses the endoscopic palliation of advanced esophageal cancer. Results The diagnosis of low-grade or high-grade dysplasia (HGD) is based on several cytologic criteria that suggest neoplastic transformation of the columnar epithelium. HGD and carcinoma in situ are regarded as equivalent. The presence of dysplasia, particularly HGD, is also a risk factor for synchronous and metachronous adenocarcinoma. Dysplasia is a marker of adenocarcinoma and also has been shown to be the preinvasive lesion. Esophagectomy has been the conventional treatment for T1 esophageal cancer and, although debated, is an appropriate option in some patients with HGD due to the presence of occult cancer in over one-third of patients. Conclusions Endoscopic ablative modalities (eg, photodynamic therapy and cryoablation) and endoscopic resection techniques (eg, endoscopic mucosal resection) have demonstrated promising results. The significant morbidity and mortality of esophagectomy makes endoscopic treatment an attractive potential option.
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Affiliation(s)
| | - Sarah E. Hoffe
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | | | - Ravi Shridhar
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
| | | | - Akshay K. Gupta
- H. Lee Moffitt Cancer Center & Research Institute, Tampa, Florida
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63
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Enestvedt BK, Ginsberg GG. Advances in endoluminal therapy for esophageal cancer. Gastrointest Endosc Clin N Am 2013; 23:17-39. [PMID: 23168117 DOI: 10.1016/j.giec.2012.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer is managed as well as in the palliation of dysphagia related to advanced esophageal cancer. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective therapies for accurate histopathologic staging and provide a potential for complete cure. Mucosal ablative techniques (radiofrequency ablation and cryotherapy) are effective adjuncts to EMR and ESD and reduce the occurrence of synchronous and metachronous lesions within the Barrett esophagus. The successes of these techniques have made endoscopic therapy the primary means of management of early esophageal cancer.
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Affiliation(s)
- Brintha K Enestvedt
- Division of Gastroenterology, Temple University, Philadelphia, PA 19140, USA.
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64
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May A. Barrett's esophagus: should we burn it all? Gastrointest Endosc 2012; 76:1113-5. [PMID: 23164511 DOI: 10.1016/j.gie.2012.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 09/12/2012] [Indexed: 02/08/2023]
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65
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Caillol F, Bories E, Pesenti C, Poizat F, Monges G, Guiramand J, Esterni B, Giovannini M. Radiofrequency ablation associated to mucosal resection in the oesophagus: experience in a single centre. Clin Res Hepatol Gastroenterol 2012; 36:371-7. [PMID: 22361442 DOI: 10.1016/j.clinre.2012.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 11/07/2011] [Accepted: 01/02/2012] [Indexed: 02/04/2023]
Abstract
UNLABELLED Endoscopic resection (EMR) and radiofrequency ablation (RFA) form part of the treatment of Barrett's oesophagus (BO), dysplasia, superficial adenocarcinoma (OAC) associated with BO. PATIENTS AND METHODS Between June 2008 and April 2011, 34 patients underwent treatment with RFA (HALO system(®)), in a tertiary centre. For the study, patients were divided into two groups. Group 1 (16 patients of average 60 years old; 14 men, two women) received EMR and RFA. Group 2 (18 patients averaging 59 years age; 14 men, four women) received RFA without EMR in the year preceding the RFA. RESULTS In group 1, high grade dysplasia (HGD) was eradicated in 12 cases (92%), low grade dysplasia (LGD) in three cases (100%). Complete response occurred in nine cases (56%), partial response in 100% of cases. Mean follow-up was 15 months. In group 2, HGD was eradicated in one patient (100%), LGD in three patients (64%). A complete response was achieved in eight patients, partial response in four cases (77%). Mean follow-up was 10 months. The complication rate for groups 1 and 2 was of 18% and 10% respectively. No complication prevented completion of treatment or continued monitoring. Recurrence was evaluated to 5% in both groups. CONCLUSION RFA associated with EMR is feasible, offering probably better results and a very important advantage: a more complete histology before follow-up. Our results show effective treatment of BO and associated dysplasia with a low rate of complication. Nevertheless, when new techniques of BO ablation are used, the need to obtain histology before treatment should not be forgotten.
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Affiliation(s)
- F Caillol
- Endoscopy unit, Paoli Calmette institute, 232, boulevard Ste-Marguerite, 13009 Marseille, France.
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Komanduri S. Endoscopic therapies for Barrett's-associated dysplasia: a new paradigm for a new decade. Expert Rev Gastroenterol Hepatol 2012; 6:291-300. [PMID: 22646252 DOI: 10.1586/egh.12.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The emergence of endoscopic therapies for Barrett's esophagus (BE)-associated dysplasia has significantly altered the management of this complex disease. Over the past decade, there has been a paradigm shift from that of pure surveillance to a more therapeutic approach in eradicating dysplastic BE. This strategy includes less invasive options than esophagectomy for high-grade dysplasia and early eradication of confirmed low-grade dysplasia. Although multiple modalities exist for endoscopic therapy, endoscopic mucosal resection coupled with radiofrequency ablation appears to be the most effective therapy, with minimal complications. Recent advances in endoscopic eradication therapies for dysplastic BE have fueled excitement for a significant weapon against the rising incidence of esophageal cancer.
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Affiliation(s)
- Sri Komanduri
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Abstract
This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.
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Affiliation(s)
- Gianluca Rotondano
- Division of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Italy.
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Green S, Bhandari P, DeCaestecker J, Barr H, Ragunath K, Jankowski J, Singh R, Longcroft-Wheaton G, Bennett C. Endoscopic therapies for the prevention and treatment of early esophageal neoplasia. Expert Rev Gastroenterol Hepatol 2011; 5:731-43. [PMID: 22017700 DOI: 10.1586/egh.11.80] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Esophageal cancers have traditionally been diagnosed late and prognosis has been dire. For many years the only real treatment option was esophagectomy with substantial morbidity and mortality. This situation has now changed dramatically. Improvements have been achieved in surgical outcomes and there is an array of new effective treatment options now available, particularly for the increasing proportion diagnosed with early-stage disease. Minimally invasive endoscopic therapies can now prevent, cure or palliate esophageal cancers. This article aims to investigate the role and evidence base for these new therapeutic options.
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Affiliation(s)
- Susi Green
- St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, UK.
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