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di Pietro M, Trudgill NJ, Vasileiou M, Longcroft-Wheaton G, Phillips AW, Gossage J, Kaye PV, Foley KG, Crosby T, Nelson S, Griffiths H, Rahman M, Ritchie G, Crisp A, Deed S, Primrose JN. National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma. Gut 2024; 73:897-909. [PMID: 38553042 PMCID: PMC11103346 DOI: 10.1136/gutjnl-2023-331557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 02/15/2024] [Indexed: 05/12/2024]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett's oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett's oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett's oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett's-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett's oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.
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Affiliation(s)
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Gaius Longcroft-Wheaton
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
- Department of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Alexander W Phillips
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - James Gossage
- Department of Gastrointestinal Surgery, St Thomas' Hospital, London, UK
| | - Philip V Kaye
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kieran G Foley
- Division of Cancer and Genetics, Cardiff University, Cardiff, Cardiff, UK
| | - Tom Crosby
- Department of Clinical Oncology, Velindre University NHS Trust, Cardiff, UK
| | - Sophie Nelson
- Kenmore Medical Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Muksitur Rahman
- National Institute for Health and Care Excellence, London, UK
| | - Gill Ritchie
- National Institute for Health and Care Excellence, London, UK
| | - Amy Crisp
- National Institute for Health and Care Excellence, London, UK
| | - Stephen Deed
- National Institute for Health and Care Excellence, London, UK
| | - John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK
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2
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Lu W, Li P, Wen W, Jian Y. Comparison of Long-Term Survival Between cT1N0 Stage Esophageal Cancer Patients Receiving Endoscopic Dissection and Esophagectomy: A Meta-Analysis. Front Surg 2022; 9:917689. [PMID: 36017523 PMCID: PMC9396621 DOI: 10.3389/fsurg.2022.917689] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/21/2022] [Indexed: 11/28/2022] Open
Abstract
Background Endoscopic dissection (ED) shows relatively high clinical value in early esophageal cancer (cT1N0) such as lower incidence of postoperative complications and hospitalization costs and enhanced recovery. However, whether ED still has certain advantages over esophagectomy in terms of long-term survival remains unclear. Purpose The aim of this meta-analysis was to compare the long-term outcomes of ED and surgery in the treatment of cT1N0 esophageal cancer. Methods Several electronic databases including the PubMed, EMBASE, Web of Science and Cochrane Library databases were searched up to April 7, 2022 for studies which compared the overall survival (OS) and disease-specific survival (DSS) of cT1N0 esophageal cancer patients receiving the ED or esophagectomy. The hazard ratios (HRs) and 95% confidence intervals (CIs) were combined and all statistical analysis was conducted through STATA 15.0 software. Results A total of 12 studies involving 3,732 patients were enrolled. No significant difference in the OS between ED and surgery groups was observed (HR = 0.78, 95% CI, 0.59–1.04, p = 0.089). However, the DSS of the ED group was significantly longer than that of the surgery group (HR = 0.56, 95% CI, 0.39–0.82, p = 0.003). Conclusion In overall, the current evidence manifested that the long-term survival of cT1N0 esophageal cancer patients undergoing ED was not worse than that of patients undergoing esophagectomy. ED may be considered as the primary treatment for cT1N0 esophageal carcinoma patients.
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Affiliation(s)
| | | | - Wu Wen
- Correspondence: Yi Jian ; Wu Wen
| | - Yi Jian
- Correspondence: Yi Jian ; Wu Wen
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3
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Kvasha A, Khalifa M, Biswas S, Farraj M, Bramnik Z, Waksman I. Novel Transgastric Endoluminal Segmental Esophagectomy and Primary Anastomosis Technique: A Hybrid Transgastric Thoracoscopic Esophagectomy for the Treatment of High Grade Dysplasia and Early Esophageal Cancer in a Porcine Ex vivo Model. Front Surg 2021; 8:676031. [PMID: 34277694 PMCID: PMC8280354 DOI: 10.3389/fsurg.2021.676031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/17/2021] [Indexed: 11/13/2022] Open
Abstract
Multiple modalities are currently employed in the treatment of high grade dysplasia and early esophageal carcinoma. While they are the subject of ongoing investigation, surgery remains the definitive modality for oncological resection. Esophagectomy, however, is traditionally a challenging surgical procedure and carries a significant incidence of morbidity and mortality. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are considerably less invasive alternatives to esophagectomy in the diagnosis and treatment of high grade dysplasia, early esophageal squamous cell carcinoma and adenocarcinoma. However, many early esophageal cancer patients, with favorable histology, who could benefit from endoscopic resection, are referred for formal esophagectomy due to lesion characteristics such as unfavorable lesion morphology or recurrence after previous endoscopic resection. In this study we present a novel, hybrid thoracoscopic transgastric endoluminal segmental esophagectomy with primary anastomosis for the potential treatment of high grade dysplasia and early esophageal cancer in a porcine ex vivo model as a proposed bridge between endoscopic resection and the relatively high mortality and morbidity formal esophagectomy procedure. The novel technique consists of thoracoscopic esophageal mobilization in addition to transgastric endoluminal segmental esophagectomy and anastomosis utilizing a standard circular stapler. The technique was found feasible in all experimental subjects. The minimally invasive nature of this novel procedure as well as the utility of basic surgical equipment and surgical skill is an important attribute of this method and can potentially make it a treatment option for many patients who would otherwise be referred for a formal esophagectomy.
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Affiliation(s)
- Anton Kvasha
- Ziv Medical Center, Safed, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel
| | - Muhammad Khalifa
- Ziv Medical Center, Safed, Israel.,The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel
| | | | - Moaad Farraj
- The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.,The Baruch Padeh Medical Center, Tiberias, Israel
| | - Zakhar Bramnik
- The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.,The Baruch Padeh Medical Center, Tiberias, Israel
| | - Igor Waksman
- The Azrieli Faculty of Medicine, Bar-Ilan University, Tzfat, Israel.,Galilee Medical Center, Nahariya, Israel
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Ramay FH, Vareedayah AA, Visrodia K, Iyer PG, Wang KK, Eluri S, Shaheen NJ, Reddy R, Martin LW, Greenwald BD, Edwards MA. What Constitutes Optimal Management of T1N0 Esophageal Adenocarcinoma? Ann Surg Oncol 2019; 26:714-731. [DOI: 10.1245/s10434-018-07118-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Indexed: 12/27/2022]
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Feczko AF, Louie BE. Endoscopic Resection in the Esophagus. Thorac Surg Clin 2018; 28:481-497. [PMID: 30268294 DOI: 10.1016/j.thorsurg.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The article is a review of the principles behind endoscopic resection of esophageal dysplasia and early cancers. The techniques of endoscopic mucosal resection and endoscopic submucosal dissection are reviewed, and the supporting literature compared. Endoscopic resection is compared with esophagectomy for the management of these lesions and current areas of controversy with regard to T1b lesions and gastroesophageal reflux following resection are addressed.
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Affiliation(s)
- Andrew F Feczko
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Avenue, Seattle, WA 98104, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Avenue, Seattle, WA 98104, USA.
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Chilukuri P, Gromski MA, Johnson CS, Ceppa DKP, Kesler KA, Birdas TJ, Rieger KM, Fatima H, Kessler WR, Rex DK, Al-Haddad M, DeWitt JM. Impact of the development of an endoscopic eradication program for Barrett's esophagus with high grade dysplasia or early adenocarcinoma on the frequency of surgery. Endosc Int Open 2018; 6:E1085-E1092. [PMID: 30211296 PMCID: PMC6133650 DOI: 10.1055/a-0640-3030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/12/2018] [Indexed: 11/20/2022] Open
Abstract
Background and aims The impact of the advent of an institutional endoscopic eradication therapy (EET) program on surgical practice for Barrett's esophagus (BE)-associated high grade dysplasia (HGD) or suspected T1a esophageal adenocarcinoma (EAC) is unknown. The aims of this study are to evaluate the different endoscopic modalities used during development of our EET program and factors associated with the use of EET or surgery for these patients after its development. Methods Patients who underwent primary endoscopic or surgical treatment for BE-HGD or early EAC at our hospital between January 1992 and December 2014 were retrospectively identified. They were categorized by their initial modality of treatment during the first year, and the impact over time for choice of therapy was assessed by multivariable logistic regression. Results We identified 386 patients and 80 patients who underwent EET and surgery, respectively. EET included single modality therapy in 254 (66 %) patients and multimodal therapy in 132 (34 %) patients. Multivariable logistic regression showed that, for each subsequent study year, EET was more likely to be performed in patients who were older ( P = 0.0009), with shorter BE lengths ( P < 0.0001), and with a pretreatment diagnosis of HGD ( P = 0.0054) compared to surgical patients. The diagnosis of EAC did not increase the utilization of EET compared to surgery as time progressed ( P = 0.8165). Conclusion The introduction of an EET program at our hospital increased the odds of utilizing EET versus surgery over time for initial treatment of patients who were older, had shorter BE lengths or the diagnosis of BE-HGD, but not in patients with EAC.
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Affiliation(s)
- Prianka Chilukuri
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mark A. Gromski
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | | | - Duy Khanh P. Ceppa
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Kenneth A. Kesler
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Thomas J. Birdas
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Karen M. Rieger
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Hala Fatima
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - William R. Kessler
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Douglas K. Rex
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Mohammad Al-Haddad
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA
| | - John M. DeWitt
- Division of Gastroenterology, Indiana University School of Medicine, Indianapolis, IN, USA,Corresponding author John M. DeWitt, MD Indiana University School of Medicine550 University BlvdSuite 4100IndianapolisIN 46202-5250USA+1-317-948-8144
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Zeng Y, Liang W, Liu J, He J. Endoscopic Treatment Versus Esophagectomy for Early-Stage Esophageal Cancer: a Population-Based Study Using Propensity Score Matching. J Gastrointest Surg 2017; 21:1977-1983. [PMID: 29030780 DOI: 10.1007/s11605-017-3563-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/24/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Endoscopic treatment (ET) is an alternative for selected patients with early-stage esophageal cancer. The primary aim of this study was to compare overall survival (OS) and esophageal cancer-specific survival (ECSS) of such patients after ET or esophagectomy. METHODS Propensity score matching (PSM) and Cox regression analysis were used to compare OS and ECSS of 2661 patients with ET or esophagectomy for early-stage (Tis-T1N0M0) disease. Patient information was retrieved from the Surveillance, Epidemiology, and End Results database. Subgroup analyses by T stage and tumor histology were also performed. RESULTS There were significant differences in age, sex ratio, year of diagnosis, cancer site, cancer stage, differentiation grade, tumor histology, tumor size, lymph nodes examined, and receipt of radiation therapy in the two treatment groups. PSM created 621 patient pairs. Multivariate analysis found no significant differences in OS (HR = 1.216, P = 0.279) or ECSS (HR = 0.692, P = 0.179) in the esophagectomy and ET groups. The results were similar for subgroup analyses limited to stage Tis, T1a, and T1b patients. ET was also associated with similar OS and ECSS in esophageal adenocarcinoma and squamous cell carcinoma patients. CONCLUSION In this population-based study using PSM, patients with stage Tis and T1N0M0 esophageal cancer with ET had OS and ECSS comparable to those treated by esophagectomy after adjusting for clinical variables. The results support ET as an alternative to esophagectomy in early esophageal cancer.
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Affiliation(s)
- Yuan Zeng
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Wenhua Liang
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jun Liu
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China.,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China
| | - Jianxing He
- Department of Thoracic Surgery, The First Affiliated Hospital of Guangzhou Medical University, No 151, Yanjiang Rd, Guangzhou, 510120, Guangdong Province, People's Republic of China. .,Guangzhou Institute of Respiratory Disease & China State Key Laboratory of Respiratory Disease & National Clinical Research Center for Respiratory Disease, Guangzhou, China.
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Advances in the Diagnosis and Treatment of Barrett's Esophagus and Early Esophageal Cancer; Summary of the Kelly and Carlos Pellegrini SSAT/SAGES Luncheon Symposium. J Gastrointest Surg 2017; 21:1342-1349. [PMID: 28243981 DOI: 10.1007/s11605-017-3390-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 02/20/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Patients with Barrett's esophagus (BE) are at increased risk of developing esophageal adenocarcinoma (EAC). The incidence of EAC is rising faster than any other cancer. DISCUSSION Patients with BE have a 30- to 40-fold increased risk of EAC. In the past 20 years, there have been dramatic advances in our understanding of the incidence and natural history of BE. Endoscopic treatment of BE is evolving. Even early EAC has been treated without esophagectomy and good oncologic results in the modern era.
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