1
|
Puthenpura MM, Sanaka KO, Qin Y, Thota PN. Management of nondysplastic Barrett’s esophagus: When to survey? When to ablate? Ther Adv Chronic Dis 2022; 13:20406223221086760. [PMID: 35432847 PMCID: PMC9008814 DOI: 10.1177/20406223221086760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/23/2022] [Indexed: 11/30/2022] Open
Abstract
Barrett’s esophagus (BE), a precursor for esophageal adenocarcinoma (EAC), is
defined as salmon-colored mucosa extending more than 1 cm proximal to the
gastroesophageal junction with histological evidence of intestinal metaplasia.
The actual risk of EAC in nondysplastic Barrett’s esophagus (NDBE) is low with
an annual incidence of 0.3%. The mainstay in the management of NDBE is control
of gastroesophageal reflux disease (GERD) along with enrollment in surveillance
programs. The current recommendation for surveillance is four-quadrant biopsies
every 2 cm (or 1 cm in known or suspected dysplasia) followed by biopsy of
mucosal irregularity (nodules, ulcers, or other visible lesions) performed at 3-
to 5-year intervals. Challenges to surveillance include missed cancers,
suboptimal adherence to surveillance guidelines, and lack of strong evidence for
efficacy. There is minimal role for endoscopic eradication therapy in NDBE. The
role for enhanced imaging techniques, artificial intelligence, and risk
prediction models using clinical data and molecular markers is evolving.
Collapse
Affiliation(s)
- Max M. Puthenpura
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Krishna O. Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Yi Qin
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH, USA
| | - Prashanthi N. Thota
- Center of Excellence for Barrett’s Esophagus, Department of Gastroenterology/A30, Digestive Disease & Surgery Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195,USA
| |
Collapse
|
2
|
Dr. Velanovich's contributions to understanding Barrett's Esophagus and its treatment. Am J Surg 2022; 224:821-822. [DOI: 10.1016/j.amjsurg.2022.02.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 02/25/2022] [Accepted: 02/26/2022] [Indexed: 11/20/2022]
|
3
|
|
4
|
Herbella FAM, Schlottmann F, Patti MG. Antireflux Surgery and Barrett's Esophagus: Myth or Reality? World J Surg 2017; 42:1798-1802. [PMID: 29264726 DOI: 10.1007/s00268-017-4394-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND It may seem questionable if antireflux surgery still has a role in the management of patients with Barrett's esophagus (BE) in the current era when antireflux surgery is facing a steady decline, obesity is increasing, pharmacologic treatment for gastroesophageal reflux disease (GERD) is in its splendor, and endoscopic techniques are used more frequently. It is questionable if patients with BE should be operated to stop GERD and to prevent cancer. The aim of this study was to determine the role of antireflux surgery in patients with BE. METHODS Literature review. RESULTS The role of antireflux operations is, in fact, very controversial and neglected. BE is a different phenotype of GERD with a distinct pathophysiology linked to severe reflux of bile and acid, due to a marked anatomic disruption of the gastroesophageal barrier. Published series show that a fundoplication adequately controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion antireflux procedure) may prevent esophageal adenocarcinoma. CONCLUSIONS In conclusion, a fundoplication efficiently controls GERD and symptoms in BE patients. A fundoplication (or even better a bile diversion procedure) may also prevent esophageal adenocarcinoma.
Collapse
Affiliation(s)
- Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of Sao Paulo, Rua Diogo de Faria 1087 cj 301, Sao Paulo, SP, 04037-003, Brazil.
| | - Francisco Schlottmann
- Departments of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
| | - Marco G Patti
- Departments of Medicine and Surgery, University of North Carolina, Chapel Hill, NC, USA
| |
Collapse
|
5
|
|
6
|
Sharma N, Ho KY. Columnar lined Barrett's oesophagus. Br J Hosp Med (Lond) 2015; 76:703-6. [PMID: 26646332 DOI: 10.12968/hmed.2015.76.12.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Over the past few years, the definition of Barrett's oesophagus has altered with no real agreement on histological understanding. This article highlights the increasing confusion regarding Barrett's oesophagus with a focus on the all-too-frequently ignored aspect of the columnar lined oesophagus.
Collapse
Affiliation(s)
- Neel Sharma
- Visiting Clinical Research Fellow, National University Hospital Singapore, 119228, Singapore
| | - Khek Yu Ho
- Senior Consultant in the Division of Gastroenterology and Hepatology, National University Hospital Singapore, 119228, Singapore
| |
Collapse
|
7
|
Kristo I, Schoppmann S, Riegler M, Püspök A, Emmanuel K, Spaun G, Wrba F, Wenzl E, Schöfl R, Schreiber F, Häfner M, Madl C. Austrian expert panel recommendation for radiofrequency ablation of Barrett’s esophagus. Eur Surg 2015. [DOI: 10.1007/s10353-015-0362-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
8
|
Subramanian CR, Triadafilopoulos G. Endoscopic treatments for dysplastic Barrett's esophagus: resection, ablation, what else? World J Surg 2015; 39:597-605. [PMID: 24841804 DOI: 10.1007/s00268-014-2636-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic eradication therapy for dysplastic Barrett's esophagus (BE) comprises resection and mucosal ablation techniques. Over the years, these techniques have been tried with success, not only for dysplastic Barrett's epithelium but also for non-dysplastic Barrett's epithelium and early adenocarcinoma. Endoscopic resection is usually carried out for visible lesions, either as endoscopic mucosal resection (EMR), which is practiced widely in Western countries, or as endoscopic submucosal dissection, which is more popular in Japan and throughout Asia. Among ablative techniques are photodynamic therapy, cryotherapy, and radiofrequency ablation (RFA). METHODS We reviewed the published evidence pertaining to endoscopic treatments of dysplastic BE, with emphasis on the various resection and ablative techniques, their safety, efficacy, durability of effect, and tolerability. RESULTS Both resection and ablation procedures performed endoscopically have been proved effective, and safe for treating dysplastic BE and early adenocarcinoma. Among the ablative techniques, RFA has shown to be more effective and safe, and is preferred for most cases. CONCLUSIONS Endoscopic therapies have revolutionized the treatment of BE and have minimized the need for surgical intervention in many patients. Concomitant treatment of acid reflux with proton pump inhibitors and continuous surveillance are essential. Combination techniques such as EMR followed by RFA may be also considered in some cases.
Collapse
|
9
|
Singh R, Yeap SP, Cheong KL. Detection and characterization of early malignancy in the esophagus: what is the best management algorithm? Best Pract Res Clin Gastroenterol 2015; 29:533-44. [PMID: 26381300 DOI: 10.1016/j.bpg.2015.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/11/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023]
Abstract
Barrett's esophagus is a known precursor for esophageal adenocarcinoma. Early detection of dysplasia provides a window of opportunity for curative intervention. Several image-enhanced technologies have been developed to improve visualization of neoplasia. These however have not been found to be superior to the standard four quadrant random biopsy protocol. Patients are risk-stratified based on the degree of dysplasia found on biopsies and undergo either surveillance or treatment. Endoscopic therapy has become the mainstay of treatment for early neoplasia.
Collapse
Affiliation(s)
- Rajvinder Singh
- The Lyell McEwin Hospital & University of Adelaide Endoscopy Unit, Haydown Road, Elizabeth Vale, SA 5112, Australia.
| | - Sze Pheh Yeap
- The Lyell McEwin Hospital & University of Adelaide Endoscopy Unit, Haydown Road, Elizabeth Vale, SA 5112, Australia
| | - Kuan Loong Cheong
- The Lyell McEwin Hospital & University of Adelaide Endoscopy Unit, Haydown Road, Elizabeth Vale, SA 5112, Australia
| |
Collapse
|
10
|
Johnson CS, Louie BE, Wille A, Dunst CM, Worrell SG, DeMeester SR, Reynolds J, Dixon J, Lipham JC, Lada M, Peters JH, Watson TJ, Farivar AS, Aye RW. The Durability of Endoscopic Therapy for Treatment of Barrett's Metaplasia, Dysplasia, and Mucosal Cancer After Nissen Fundoplication. J Gastrointest Surg 2015; 19:799-805. [PMID: 25740341 DOI: 10.1007/s11605-015-2783-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Accepted: 02/18/2015] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) ± endoscopic resection (EMR) is an established treatment strategy for neoplastic Barrett's and intramucosal cancer. Most patients are managed with proton pump inhibitors. The incidence of recurrent Barrett's metaplasia, dysplasia, or cancer after complete eradication is up to 43 % using this strategy. We hypothesize the addition of fundoplication should result in a lower recurrence rates after complete eradication. METHODS Multi-institutional retrospective review of patients undergoing endotherapy followed by Nissen fundoplication RESULTS A total of 49 patients underwent RFA ± EMR followed by Nissen fundoplication. Complete remission of intestinal metaplasia (CR-IM) was achieved in 26 (53 %) patients, complete remission of dysplasia (CR-D) in 16 (33 %) patients, and 7 (14 %) had persistent neoplastic Barrett's. After fundoplication, 18/26 (70 %) remained in CR-IM. An additional 10/16 CR-D achieved CR-IM and 4/7 with persistent dysplasia achieved CR-IM. One patient progressed to LGD while no patient developed HGD or cancer. CONCLUSION Endoscopic therapy for Barrett's dysplasia and/or intramucosal cancer followed by fundoplication results in similar durability of CR-IM to patients being managed with PPIs alone after endoscopic therapy. However, fundoplication may be superior in preventing further progression of disease and the development of cancer. Fundoplication is an important strategy to achieve and maintain CR-IM, and facilitate eradication of persistent dysplasia.
Collapse
Affiliation(s)
- Corey S Johnson
- Division of Thoracic Surgery, Swedish Cancer Institute and Medical Center, Suite 900, 1101 Madison Street, Seattle, WA, 98105, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Yachimski P, Wani S, Givens T, Howard E, Higginbotham T, Price A, Berman K, Hosford L, Katcher PM, Ozanne E, Perzan K, Hur C. Preference of endoscopic ablation over medical prevention of esophageal adenocarcinoma by patients with Barrett's esophagus. Clin Gastroenterol Hepatol 2015; 13:84-90. [PMID: 24681073 PMCID: PMC4227952 DOI: 10.1016/j.cgh.2014.03.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Revised: 03/11/2014] [Accepted: 03/14/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic intervention or pharmacologic inhibition of cyclooxygenase might be used to prevent progression of Barrett's esophagus (BE) to esophageal adenocarcinoma (EAC). We investigated whether patients with BE prefer endoscopic therapy or chemoprevention of EAC. METHODS Eighty-one subjects with nondysplastic BE were given a survey that described 2 scenarios. The survey explained that treatment A (ablation), endoscopy, reduced lifetime risk of EAC by 50%, with 5% risk for esophageal stricture, whereas treatment B (aspirin) reduced lifetime risk of EAC by 50% and the risk of heart attack by 30%, yet increased the risk for ulcer by 75%. Subjects indicated their willingness to undergo either treatment A and/or treatment B if endoscopic surveillance were required every 3-5 years, every 10 years, or were not required. Visual aids were included to represent risk and benefit percentages. RESULTS When surveillance was required every 3-5 years, more subjects were willing to undergo treatment A than treatment B (78%, 63 of 81 vs 53%, 43 of 81; P < .01). There were no differences in age, sex, education level, or history of cancer, heart disease, or ulcer between patients willing to undergo treatment A and those willing to undergo treatment B. Altering the frequency of surveillance did not affect patients' willingness to undergo either treatment. CONCLUSIONS In a simulated scenario, patients with BE preferred endoscopic intervention over chemoprevention for EAC. Further investigation of the shared decision-making process regarding preventive strategies for patients with BE may be warranted.
Collapse
Affiliation(s)
- Patrick Yachimski
- Division of Gastroenterology, Hepatology and Nutrition, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora CO USA
| | - Tonya Givens
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville TN USA
| | - Eric Howard
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville TN USA
| | - Tina Higginbotham
- Division of Gastroenterology, Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville TN USA
| | - Angie Price
- Veterans Administration Eastern Colorado Health Care System, Denver, CO USA
| | - Kenneth Berman
- Veterans Administration Eastern Colorado Health Care System, Denver, CO USA
| | - Lindsay Hosford
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora CO USA
| | - Paul Menard Katcher
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora CO USA
| | - Elissa Ozanne
- Geisel School of Medicine, Dartmouth College, Hanover, NH USA
| | - Katherine Perzan
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston,MA USA
| | - Chin Hur
- Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston,MA USA
| |
Collapse
|
12
|
Lightdale CJ. Radiofrequency ablation for nondysplastic Barrett's esophagus: certainly not for all. Gastrointest Endosc 2014; 80:873-6. [PMID: 25436399 DOI: 10.1016/j.gie.2014.05.331] [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: 04/22/2014] [Accepted: 05/28/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Charles J Lightdale
- Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, New York, USA
| |
Collapse
|
13
|
The case for ablating nondysplastic Barrett's esophagus. Gastrointest Endosc 2014; 80:866-72. [PMID: 25436398 DOI: 10.1016/j.gie.2014.06.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 06/03/2014] [Indexed: 02/08/2023]
|
14
|
Akiyama J, Bertelé A, Brock C, Hvid-Jensen F, Ichiya T, Krarup AL, Majewski M, Rubio CA, Sarosiek J, Scarpignato C, Schmidt PT, Teich S, Triadafilopoulos G, Wallner G. Benign and precursor lesions in the esophagus. Ann N Y Acad Sci 2014; 1325:226-41. [DOI: 10.1111/nyas.12534] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
| | - Anna Bertelé
- Division of Gastroenterology & Digestive Endoscopy; Maggiore University Hospital; Parma Italy
| | - Christina Brock
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
| | - Frederik Hvid-Jensen
- Department of Surgical Gastroenterology; Aarhus University Hospital; Aarhus Denmark
| | - Tamaki Ichiya
- Department of Pathology; Karolinska Institute and University Hospital; Stockholm Sweden
| | - Anne Lund Krarup
- Mech-Sense; Department of Gastroenterology and Hepatology; Aalborg University Hospital; Denmark
| | - Marek Majewski
- Texas Tech University Health Sciences Center; Texas Tech University; El Paso Texas
| | - Carlos A. Rubio
- Department of Pathology; Karolinska Institute and University Hospital; Stockholm Sweden
| | - Jerzy Sarosiek
- Texas Tech University Health Sciences Center; Texas Tech University; El Paso Texas
| | - Carmelo Scarpignato
- Laboratory of Clinical Pharmacology; Clinical Pharmacology & Digestive Pathophysiology Unit; Department of Clinical & Experimental Medicine; University of Parma; Parma Italy
| | - Peter Thelin Schmidt
- Department of Pathology; Karolinska Institute and University Hospital; Stockholm Sweden
| | - Steven Teich
- Division of Pediatric Surgery; The Ohio State University College of Medicine; Columbus Ohio
| | | | - Grzegorz Wallner
- Texas Tech University Health Sciences Center; Texas Tech University; El Paso Texas
| |
Collapse
|
15
|
Abstract
Barrett’s esophagus (BE) develops as a consequence of chronic esophageal acid exposure, and is the major risk factor for esophageal adenocarcinoma (EAC). The practices of endoscopic screening for—and surveillance of—BE, while widespread, have failed to reduce the incidence of EAC. The majority of EACs are diagnosed in patients without a known history of BE, and current diagnostic tools are lacking in their ability to stratify patients with BE into those at low risk and those at high risk for progression to malignancy. Nonetheless, advances in endoscopic imaging and mucosal therapeutics have provided unprecedented opportunities for intervention for BE, and have vastly altered the approach to management of BE-associated mucosal neoplasia.
Collapse
Affiliation(s)
- Patrick Yachimski
- Division of Gastroenterology Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA Division of Gastroenterology & Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Chin Hur
- Division of Gastroenterology Hepatology & Nutrition, Vanderbilt University Medical Center, Nashville, TN, USA Division of Gastroenterology & Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
16
|
Affiliation(s)
- Stuart J Spechler
- From the Esophageal Diseases Center, Department of Medicine, Veterans Affairs (VA) North Texas Health Care System, and the University of Texas Southwestern Medical Center, Dallas
| | | |
Collapse
|
17
|
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.
Collapse
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
| |
Collapse
|
18
|
Riegler M, Schoppmann SF. Selected commentary to “Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia. A randomized clinical trial”. Eur Surg 2014. [DOI: 10.1007/s10353-014-0262-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
|
19
|
Lenglinger J, See SF, Beller L, Cosentini EP, Asari R, Wrba F, Riegler M, Schoppmann SF. Review on novel concepts of columnar lined esophagus. Wien Klin Wochenschr 2013; 125:577-90. [PMID: 24061694 DOI: 10.1007/s00508-013-0418-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2012] [Accepted: 07/28/2013] [Indexed: 12/20/2022]
Abstract
BACKGROUND Columnar lined esophagus (CLE) is a marker for gastroesophageal reflux and associates with an increased cancer risk among those with Barrett's esophagus. Recent studies fostered the development of integrated CLE concepts. METHODS Using PubMed, we conducted a review of studies on novel histopathological concepts of nondysplastic CLE. RESULTS Two histopathological concepts-the squamo-oxyntic gap (SOG) and the dilated distal esophagus (DDE), currently model our novel understanding of CLE. As a consequence of reflux, SOG interposes between the squamous lined esophagus and the oxyntic mucosa of the proximal stomach. Thus the SOG describes the histopathology of CLE within the tubular esophagus and the DDE, which is known to develop at the cost of a shortened lower esophageal sphincter and foster increased acid gastric reflux. Histopathological studies of the lower end of the esophagus indicate, that the DDE is reflux damaged, dilated, gastric type folds forming esophagus and cannot be differentiated from proximal stomach by endoscopy. While the endoscopically visible squamocolumnar junction (SCJ) defines the proximal limit of the SOG, the assessment of the distal limit requires the histopathology of measured multilevel biopsies. Within the SOG, CLE types distribute along a distinct zonation with intestinal metaplasia (IM; Barrett's esophagus) and/or cardiac mucosa (CM) at the SCJ and oxyntocardiac mucosa (OCM) within the distal portion of the SOG. The zonation follows the pH-gradient across the distal esophagus. Diagnosis of SOG and DDE includes endoscopy, histopathology of measured multi-level biopsies from the distal esophagus, function, and radiologic tests. CM and OCM do not require treatment and are surveilled in 5 year intervals, unless they associate with life quality impairing symptoms, which demand medical or surgical therapy. In the presence of an increased cancer risk profile, it is justified to consider radiofrequency ablation (RFA) of IM within clinical studies in order to prevent the progression to dysplasia and cancer. Dysplasia justifies RFA ± endoscopic resection. CONCLUSIONS SOG and DDE represent novel concepts fusing the morphological and functional aspects of CLE. Future studies should examine the impact of SOG and DDE for monitoring and management of gastroesophageal reflux disease (GERD).
Collapse
Affiliation(s)
- Johannes Lenglinger
- Manometry Lab & Upper GI Service, Department of Surgery, University Clinic of Surgery, CCC-GET, Medical University of Vienna, Vienna General Hospital, Währinger Gürtel 18-20, 1090, Vienna, Austria
| | | | | | | | | | | | | | | |
Collapse
|
20
|
Kurian AA, Swanström LL. Radiofrequency ablation in the management of Barrett's esophagus: present role and future perspective. Expert Rev Med Devices 2013; 10:509-17. [PMID: 23895078 DOI: 10.1586/17434440.2013.811863] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Esophageal adenocarcinoma is the most rapidly increasing gastrointestinal cancer. Barrett's esophagus has been identified as a precancerous condition and major risk factor for esophageal cancer. Radiofrequency ablation has been shown to be a highly efficient in promoting remission of intestinal metaplasia. This technology has seen widespread clinical use since 2005. Radiofrequency ablation is common with all other ablative techniques; the concern that sound oncological principles are not being adhered to, that is, appropriate pathological staging, followed by appropriate definitive therapy. Endoscopic mucosal excision techniques are technically demanding; however, they are more attractive from an oncological perspective. Future research endeavors focusing on facilitation of large population screening, the identification of high risk phenotypes, endoscopic mucosal resection techniques will combat the esophageal adenocarcinoma epidemic.
Collapse
Affiliation(s)
- Ashwin A Kurian
- Providence Portland Cancer Center, 4805 NE Glisan Street, 6N60, Providence Cancer Center, Portland, OR 97213, USA
| | | |
Collapse
|
21
|
Abstract
The American Gastroenterological Association (AGA) defines Barrett's esophagus as the condition in which any extent of metaplastic columnar epithelium that predisposes to cancer development replaces the squamous epithelium that normally lines the distal esophagus. Although cardiac mucosa may be metaplastic, its malignant predisposition is not clear, and the AGA still requires the demonstration of intestinal metaplasia (with goblet cells) for a diagnosis of Barrett's esophagus. The AGA generally recommends endoscopic eradication therapy for patients with high-grade dysplasia, who otherwise develop esophageal adenocarcinoma at the rate of 6% per year. Endoscopic therapy is often curative for mucosal neoplasms in Barrett's esophagus because the risk of lymph node metastases is only 1-2%. American gastroenterologists generally do not recommend endoscopic therapy for patients whose neoplasms involve any portion of the submucosa because of the high rate of lymph node metastases that has been described in these cases. The management of low-grade dysplasia is disputed because of poor agreement among pathologists on the diagnosis and because of contradictory data on the natural history, but the AGA recommends that radiofrequency ablation (RFA) should be a therapeutic option for patients with confirmed low-grade dysplasia in Barrett's esophagus. Arguments for using RFA to treat nondysplastic Barrett's metaplasia are based on the premise that RFA decreases cancer risk, but no study has established that premise. In the absence of definitive data, concerns about the frequency and importance of buried metaplastic glands and recurrent metaplasia should temper enthusiasm for treating nondysplastic Barrett's esophagus with RFA.
Collapse
Affiliation(s)
- Stuart Jon Spechler
- Department of Medicine, VA North Texas Healthcare System, and The University of Texas Southwestern Medical Center at Dallas, Dallas, Tex., USA.
| |
Collapse
|
22
|
Estores D, Velanovich V. Barrett esophagus: epidemiology, pathogenesis, diagnosis, and management. Curr Probl Surg 2013; 50:192-226. [PMID: 23601575 DOI: 10.1067/j.cpsurg.2013.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
|
23
|
Abstract
Barrett's esophagus (BE) is a well-established pre-malignant lesion for esophageal adenocarcinoma, a condition that carries a dismal five-year overall survival rate of less than 15%. Among several available methods to eliminate BE, radiofrequency ablation (RFA) provides the most efficient modality, since it has been demonstrated to successfully eradicate BE with or without dysplasia with acceptable safety, efficacy and durability profiles. In conjunction with proton pump therapy, this new technology has quickly become the standard care for patients with dysplastic BE. However, several technical questions remain about how to deploy RFA therapy for maximum effectiveness and long-term favorable outcomes for all stages of the disease. These include how to select patient for therapy, what the best protocol for RFA is, when to use other modalities, such as endoscopic mucosal resection, and what should be considered for refractory BE. This review addresses these questions with the perspective of the best available evidence matched with the authors' experience with the technology.
Collapse
Affiliation(s)
- Junichi Akiyama
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655, Japan, El Camino GI Medical Associates, Mountain View, CA 94040, USA and Division of Gastroenterology, Stanford University Medical Center, Stanford, CA 94305, USA
| | | | | |
Collapse
|
24
|
Radiofrequency ablation of Barrett’s esophagus and early cancer within the background of the pathophysiology of the disease. Eur Surg 2012. [DOI: 10.1007/s10353-012-0183-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
|
25
|
Abstract
Barrett's esophagus is a pathologic change of the normal squamous epithelium of the esophagus to specialized columnar metaplasia. Barrett's esophagus is a result of prolonged exposure of the esophagus to gastroduodenal refluxate. Although Barrett's itself is not symptomatic, and, in fact, patients with Barrett's esophagus may be completely asymptomatic, it does identify patients at higher risk of developing esophageal adenocarcinoma. Traditionally, antireflux surgery was reserved for patients with symptoms, because it was believed that antireflux surgery did not eliminate Barrett's esophagus and reduce cancer risk. Rationale for the treatment of Barrett's esophagus beyond treating symptoms of gastroesophageal reflux disease stems from the hope to decrease, if not eliminate, the risk of adenocarcinoma. Treatment options ranged from medical acid suppression without surveillance to resection. Ablation, particularly endoscopic radio-frequency ablation, has become the standard of care for Barrett's esophagus with high-grade dysplasia. It role in nondysplastic or low-grade dysplastic Barrett's is less clear. Combined endoscopic mucosal resection with ablation is effective in nodular high-grade Barrett's esophagus. Resection should be reserved for patients with persistent high-grade dysplasia despite multiple attempts at endoscopic ablation or resection or for patients with evidence of carcinoma.
Collapse
Affiliation(s)
- Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
| |
Collapse
|
26
|
Assessment of columnar-lined esophagus in controls and patients with gastroesophageal reflux disease with and without proton-pump inhibitor therapy. Eur Surg 2012. [DOI: 10.1007/s10353-012-0159-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
|
27
|
Hunt GC, Coyle WJ, Pais SA, Adler DG, Degregorio B, Dimaio CJ, Dua KS, Enestvedt BK, Lee LS, McHenry L, Mullady DK, Rajan E, Sedlack RE, Shami VM, Tierney WM, Faulx AL. Core curriculum for EMR and ablative techniques. Gastrointest Endosc 2012; 76:725-9. [PMID: 22985639 DOI: 10.1016/j.gie.2012.04.440] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2012] [Accepted: 04/05/2012] [Indexed: 02/08/2023]
|
28
|
Segal F, Breyer HP. Diagnosis and management of Barrett’s metaplasia: What’s new. World J Gastrointest Endosc 2012; 4:379-86. [PMID: 23125895 PMCID: PMC3487185 DOI: 10.4253/wjge.v4.i9.379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2011] [Revised: 02/15/2012] [Accepted: 09/12/2012] [Indexed: 02/05/2023] Open
Abstract
Barrett’s esophagus (BE) is a complication of gastroesophageal reflux disease, and a premalignant lesion for esophageal adenocarcinoma (EAC). Observational studies suggest that endoscopic surveillance is associated with the detection of dysplasia and EAC at an early stage along with improved survival, but controversies still remain. The management of patients with BE involves endoscopic surveillance, preventive and clinical measures for cancer, and endoscopic and surgical approaches to treatment. Deciding upon the most appropriate treatment is a challenge. This study presents the results and the effectiveness of these practices.
Collapse
Affiliation(s)
- Fábio Segal
- Fábio Segal, Physician and Endoscopist at Hospital Moinhos de Vento, Porto Alegre-RS, 90.035-001, Brazil
| | | |
Collapse
|
29
|
Schoppmann SF, Azari R, Riegler FM. Selected commentary to "Incidence of adenocarcinoma among patients with Barrett's esophagus". Eur Surg 2012. [DOI: 10.1007/s10353-012-0101-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
30
|
Rajendra S, Sharma P. Management of Barrett's oesophagus and intramucosal oesophageal cancer: a review of recent development. Therap Adv Gastroenterol 2012; 5:285-99. [PMID: 22973415 PMCID: PMC3437535 DOI: 10.1177/1756283x12446668] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Barrett's oesophagus is the most important and recognizable precursor lesion for oesophageal adenocarcinoma, which is the one of the fastest growing cancers in the Western World. The incidence of oesophageal adenocarcinoma has increased 600% in the United States between 1975 and 2001 and is thought to represent a real increase in burden rather than a result of histologic or anatomical misclassification or overdiagnosis. Thus, the cancer risk in Barrett's oesophagus has to be managed and involves prevention (surveillance endoscopy), treating underlying gastroesophageal reflux disease (medically and or surgically) and endoscopic therapy to remove diseased epithelium in appropriate patient subgroups. In the last decade, new developments in imaging and molecular markers as well as an armamentarium of novel and effective endoscopic eradication therapy has become available to the endoscopist to combat this exponential rise in oesophageal adenocarcinoma. Paradoxically, the cancer risk in Barrett's oesophagus gets progressively downgraded which raises fundamental questions about our understanding of the known and unknown risk factors and molecular aberrations that are involved in the Barrett's metaplasia-dysplasia-carcinoma sequence. Future research has to be directed at these areas to fine tune our screening and surveillance programs to identify more accurately the high-risk group of progressors to oesophageal adenocarcinoma who would benefit most from endoscopic therapy.
Collapse
Affiliation(s)
- Shanmugarajah Rajendra
- Department of Gastroenterology & Hepatology, Bankstown-Lidcombe Hospital and South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, MO, USA
| |
Collapse
|
31
|
Spechler SJ. Buried (but not dead) Barrett's metaplasia: tales from the crypts. Gastrointest Endosc 2012; 76:41-3. [PMID: 22726464 PMCID: PMC6714040 DOI: 10.1016/j.gie.2012.02.053] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2012] [Accepted: 02/25/2012] [Indexed: 02/08/2023]
|
32
|
Zemlyak AY, Pacicco T, Mahmud EM, Tsirline VB, Belyansky I, Walters A, Heniford BT. Radiofrequency ablation offers a Reliable Surgical Modality for the Treatment of Barrett's Esophagus with a Minimal Learning Curve. Am Surg 2012. [DOI: 10.1177/000313481207800717] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Radiofrequency ablation (RFA) has gained popularity as treatment for Barrett's esophagus. Inclusive series of patients from initiation of our Barrett's Therapy Program were studied. Review of patients undergoing RFA for Barrett's was performed from September 2008 to May 2011. Patients’ outcomes were recorded and analyzed using standard statistical methods. Seventy patients were treated. Average age was 61 (28–70); 80 per cent were male. Seventy-four per cent had dysplasia; 44 low-grade and eight high-grade. A total of 75.7 per cent of patients had long and 24.3 per cent had short segment Barrett's. Procedures per patient ranged from one to seven. Number of treatments in long- and short-segment groups were not different ( P = 0.11). The maximum number of treatments in the short-segment group was five with a median of three (44.3%). For long segment, the maximum of RFA procedures was seven, with a median of three (30.8%). Average procedure time was 20.8 minutes for long and 17.9 minutes for short segment. Mean follow-up was 16.1 (2–38) months. Complete response was accomplished in 81 per cent. There were 93.3 per cent of complete responders in the short-segment group versus 75 per cent in the long ( P = 0.24). Complications included dysphagia (1), transient chest and cervical pain (1), and abdominal pain (1). Comparing the first 25 per cent of the RFA procedures to the later 75 per cent or first 50 per cent to second 50 per cent, there was no difference in operative time or complications. Two patients recurred, both in the long-segment group. RFA is a safe and effective means to eradicate Barrett's. By measure of treatment time, complication rate, and efficacy of therapy, there is minimal or no “learning curve” for experienced endoscopists.
Collapse
Affiliation(s)
- Alla Y. Zemlyak
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Thomas Pacicco
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Ebrahem M. Mahmud
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Victor B. Tsirline
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Igor Belyansky
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Amanda Walters
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| |
Collapse
|
33
|
Williamson JML, Almond LM, Shepherd NA, Barr H. Current management of Barrett's oesophagus. Br J Hosp Med (Lond) 2012; 73:271-7. [DOI: 10.12968/hmed.2012.73.5.271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- JML Williamson
- Department of Surgery, Bristol Royal Infirmary, Bristol BS2 8HW
| | - LM Almond
- Department of Oesophagogastric Surgery, Gloucestershire Royal Hospital, Gloucester
| | - NA Shepherd
- Histopathology, Gloucestershire Cellular Pathology Laboratory, Cheltenham General Hospital, Cheltenham, Gloucestershire
| | - H Barr
- Surgery in the Department of Oesophagogastric Surgery, Gloucestershire Royal Hospital, Gloucester
| |
Collapse
|
34
|
Dunki-Jacobs EM, Martin RCG. Endoscopic therapy for Barrett's esophagus: a review of its emerging role in optimal diagnosis and endoluminal therapy. Ann Surg Oncol 2011; 19:1575-82. [PMID: 22160480 DOI: 10.1245/s10434-011-2163-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2011] [Indexed: 12/13/2022]
Abstract
Barrett's esophagus (BE) is a premalignant lesion known to sequentially progress to esophageal adenocarcinoma. Management of BE has changed significantly over the last 5 years with the development of endoscopic resection and ablation, which has replaced esophagectomy as the treatment of choice in BE with high-grade dysplasia. The aim of this review is to discuss the details of these new endotherapies in regards to response and durability and to define the role of these new therapies in the current management of BE.
Collapse
|
35
|
Parise P, Rosati R, Savarino E, Locatelli A, Ceolin M, Dua KS, Tatum RP, Braghetto I, Gyawali CP, Hejazi RA, McCallum RW, Sarosiek I, Bonavina L, Wassenaar EB, Pellegrini CA, Jacobson BC, Canon CL, Badaloni A, del Genio G. Barrett's esophagus: surgical treatments. Ann N Y Acad Sci 2011; 1232:175-95. [PMID: 21950813 DOI: 10.1111/j.1749-6632.2011.06051.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The following on surgical treatments for Barrett's esophagus includes commentaries on the indications for antireflux surgery after medical treatment; the effects of the various procedures on the lower esophageal sphincter; the role of impaired esophageal motility and delayed gastric emptying in the choice of the surgical procedure; indications for associated highly selective vagotomy, duodenal switch, and gastric electrical stimulation; therapeutic strategies for detection and treatment of shortened esophagus; the role of antireflux surgery on the regression of metaplastic mucosa and the risk of malignant progression; the detection of asymptomatic reflux brfore bariatric surgery; the role of non-GERD symptoms on the results of surgery; and the indications of Collis gastroplasty and choice of the type of fundoplication.
Collapse
Affiliation(s)
- Paolo Parise
- Department of General Surgery IV, Regional Referal Center for Esophageal Pathology, Pisa, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
36
|
Abstract
Barrett's esophagus has gained increased clinical attention because of its association with esophageal adenocarcinoma, a cancer with increasing incidence and poor survival rates. The goals of ablating Barrett's esophagus are to decrease esophageal cancer rates and to improve overall survival and quality of life. Different techniques have been developed and tested for their effectiveness eradicating Barrett's epithelium. This review assesses the literature associated with different ablative techniques. The safety and efficacy of different techniques are discussed. This review concludes with recommendations for the clinician, including specific strategies for patient care decisions for patients with Barrett's esophagus with varying degrees of dysplasia.
Collapse
|
37
|
Voltaggio L, Montgomery EA, Lam-Himlin D. A Clinical and Histopathologic Focus on Barrett Esophagus and Barrett-Related Dysplasia. Arch Pathol Lab Med 2011; 135:1249-60. [DOI: 10.5858/arpa.2011-0019-ra] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Barrett esophagus is a metaplastic, premalignant lesion associated with approximately 0.5% annual incidence of progression to esophageal adenocarcinoma. Diagnosis and screening of Barrett esophagus and Barrett-related dysplasia relies on histologic evaluation of endoscopic mucosal biopsies, a process that is burdened with interobserver variability.
Objectives.—To review the histologic features and classification of Barrett esophagus and Barrett-related dysplasia, to discuss the underlying difficulties in diagnosis and pitfalls, and to provide a brief review of new developments related to therapeutic modalities for patients diagnosed with dysplasia.
Data Sources.—Sources include a review of relevant literature indexed in PubMed (US National Library of Medicine).
Conclusions.—In spite of interobserver variability, histologic assessment of dysplasia is currently the accepted method of surveillance, and subsequent patient management is dictated by this evaluation. Although not universal, endoscopic therapy is increasingly important in replacing esophagectomy for patients with high-grade dysplasia or early carcinoma.
Collapse
|
38
|
Saunders MD, Nieponice A, Dvorak K, Goldman A, Diaz-Cervantes E, De-la-Torre-Bravo A, Sobrino-Cossio S, Torres-Durazo E, Martínez-Carrillo O, Gamboa-Robles J, Upton M, Appelman HD, Bonavina L, Rothstein RI, Velanovich V. Barrett's esophagus: endoscopic treatments I. Ann N Y Acad Sci 2011; 1232:140-55. [PMID: 21950811 DOI: 10.1111/j.1749-6632.2011.06049.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The following on endoscopic treatments of Barrett's esophagus includes commentaries on indications for endoscopic treatments; endo-luminal plication procedures; the cellular modifications induced by the endoscopic ablation therapies; eradication by banding without resection; the evaluation of complete ablation; recurrence after ablation; association of antireflux surgery; radiofrequency ablation; and nondysplastic Barrett's esophagus.
Collapse
Affiliation(s)
- Michael D Saunders
- Digestive Disease Center, University of Washington Medical Center, Seattle, Washington, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW This article discusses the various management options and gaps in knowledge in our current understanding of the epidemiology and neoplastic progression of Barrett's esophagus and how this affects the decision to treat patients with nondysplastic Barrett's esophagus (NDBE). RECENT FINDINGS Barrett's esophagus is the only known risk factor for esophageal adenocarcinoma (EAC), the most rapidly rising cancer in terms of incidence in the United States. The current management strategy is to enroll patients with Barrett's esophagus in surveillance programs. Despite these efforts, the incidence of EAC has continued to rise. Recent studies have shown endoscopic ablation therapies to be relatively safe and effective in the eradication of NDBE. However, all studies performed to date were cohort in nature with no randomized controlled trial data available at this time. At present, several critical questions remain unanswered: Will treatment of NDBE eliminate the risk of developing cancer? If not, just how effective is the treatment? Is it durable? Can surveillance be stopped after ablation? What are the risks? Would such treatment be cost-effective? SUMMARY It is possible that if future data can affirmatively answer some of these questions, ablation of NDBE would be reasonable in selected patients; however, until then, a wait and watch approach is likely to be the best option for most low-risk patients.
Collapse
|
40
|
Affiliation(s)
- Stuart Jon Spechler
- Division of Gastroenterology, VA North Texas Healthcare System, The University of Texas Southwestern Medical Center, 4500 South Lancaster Road, Dallas, TX 75216, USA,
| |
Collapse
|
41
|
Abstract
Barrett's esophagus (BE) is the premalignant lesion of esophageal adenocarcinoma (EAC) defined as specialized intestinal metaplasia of the tubular esophagus that results from chronic gastroesophageal reflux. Which patients are at risk of having BE and which are at further risk of developing EAC has yet to be fully established. Many aspects of the management of BE have changed considerably in the past 5 years alone. The aim of this review is to define the critical elements necessary to effectively manage individuals with BE. The general prevalence of BE is estimated at 1.6-3% and follows a demographic distribution similar to EAC. Both short-segment (<3 cm) and long-segment (≥3 cm) BE confer a significant risk for EAC that is increased by the development of dysplasia. The treatment for flat high-grade dysplasia is endoscopic radiofrequency ablation therapy. The benefits of ablation for non-dysplastic BE and BE with low-grade dysplasia have yet to be validated. By understanding the intricacies of the development, screening, surveillance, and treatment of BE, new insights will be gained into the prevention and early detection of EAC that may ultimately lead to a reduction in morbidity and mortality in this patient population.
Collapse
|
42
|
State of the art in the endoscopic imaging and ablation of Barrett's esophagus. Dig Liver Dis 2011; 43:365-73. [PMID: 21330224 DOI: 10.1016/j.dld.2011.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2010] [Accepted: 01/04/2011] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus is the result of long-term acid reflux and is a precursor to esophageal adenocarcinoma. Surgical resection of the esophagus has been the mainstay of treatment for high grade dysplasia and early cancer. However, recent advances in the endoscopic imaging and ablation technologies have made esophagectomy avoidable in patients with dysplasia and superficial neoplasia. In this article, we review the most relevant endoscopic imaging technologies, such as chromoendoscopy, narrow band and autofluorescence imaging, and confocal laser endomicroscopy. We also review the various endoscopic ablation technologies, such as endoscopic mucosal resection, photodynamic therapy, radiofrequency ablation, and cryotherapy. Finally, we focus on the studies that evaluate the efficacy of these imaging and ablation technologies in finding and eradicating neoplastic Barrett's esophagus.
Collapse
|
43
|
Triadafilopoulos G, Lombard CM, Jobe BA. "War and Peace" with Barrett's esophagus. Dig Dis Sci 2011; 56:988-92. [PMID: 21161381 DOI: 10.1007/s10620-010-1490-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
|
44
|
Abstract
Barrett's esophagus has been defined conceptually as the condition in which any extent of metaplastic columnar epithelium that predisposes to cancer development replaces the stratified squamous epithelium that normally lines the distal esophagus. The condition develops as a consequence of gastroesophageal reflux disease. Barrett's metaplasia has clinical importance primarily because of its malignant predisposition, and virtually all of the contentious clinical issues in Barrett's esophagus are related in some way to its cancer risk. This article considers some key clinical issues that impact the management of patients with Barrett's esophagus.
Collapse
Affiliation(s)
- Stuart Jon Spechler
- Department of Medicine, Veterans Affairs North Texas Healthcare System, Dallas, TX, USA.
| |
Collapse
|
45
|
Chennat J, Ferguson MK. Endoscopic interventions in Barrett's esophagus: Do the dollars make sense? Gastrointest Endosc Clin N Am 2011; 21:145-53. [PMID: 21112504 DOI: 10.1016/j.giec.2010.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Advances in the development of endoscopic therapies for Barrett's esophagus have resulted in the emergence of an important paradigm shift for management of early neoplasia and represent an opportunity to alter the natural history of the disease. Clinical incorporation of these endoscopic modalities may have significant implications for disease management and health care delivery from a cost perspective. This article reviews the current literature on the cost analyses of commonly used Barrett endoscopic interventions and summarizes the overall cost-effectiveness of these treatments as compared with surveillance or surgery.
Collapse
Affiliation(s)
- Jennifer Chennat
- Section of Gastroenterology, Department of Medicine, Center for Endoscopic Research and Therapeutics, The University of Chicago Medical Center, 5758 South Maryland Avenue, MC 9028, Chicago, IL 60637, USA.
| | | |
Collapse
|
46
|
Bansal A, Kahrilas PJ. Treatment of GERD complications (Barrett's, peptic stricture) and extra-oesophageal syndromes. Best Pract Res Clin Gastroenterol 2010; 24:961-8. [PMID: 21126707 PMCID: PMC3006235 DOI: 10.1016/j.bpg.2010.09.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 09/23/2010] [Indexed: 01/31/2023]
Abstract
Apart from typical reflux symptoms and oesophagitis, the clinical presentation of GERD can be dominated by mucosal complications of reflux (Barrett's oesophagus, oesophageal adenocarcinoma, Peptic structure) or by extra-oesophageal syndromes, most notably asthma, laryngitis, or chronic cough. Managing these entities is much less straightforward than with oesophagitis. With respect to adenocarcinoma, metaplasia and dysplasia are recognised precursors, but the potential of these lesions to evolve to cancer has not been shown to lessen as a result of treatment, medical or surgical. Consequently, management focuses on strategies to identify and eliminate high-grade dysplasia and intramucosal cancer, lesions that are potentially curable by endoscopic ablation or surgical resection. With respect to the extra-oesophageal GERD syndromes, these are increasingly recognised as multifactorial conditions with reflux as an exacerbating factor. Treatment trials have been generally disappointing and the clinical challenge remains in accurately identifying afflicted patients who might benefit from more intensive medical or surgical reflux treatment.
Collapse
Affiliation(s)
- Ajay Bansal
- Department of Medicine, Veterans Affairs Medical Center and University of Kansas, Kansas City, MO
| | - Peter J. Kahrilas
- Department of Medicine, The Feinberg School of Medicine, Northwestern University, Chicago, IL
| |
Collapse
|
47
|
|