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Marques de Sá I, Pereira AD, Sharma P, Dinis-Ribeiro M. Systematic review of the published guidelines on Barrett's esophagus: should we stress the consensus or the differences? Dis Esophagus 2020:doaa115. [PMID: 33249488 DOI: 10.1093/dote/doaa115] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 09/30/2020] [Accepted: 10/04/2020] [Indexed: 12/11/2022]
Abstract
Multiple guidelines on Barrett's esophagus (BE) have being published in order to standardize and improve clinical practice. However, studies have shown poor adherence to them. Our aim was to synthetize, compare, and assess the quality of recommendations from recently published guidelines, stressing similarities and differences. We conducted a search in Pubmed and Scopus. When different guidelines from the same society were identified, the most recent one was considered. We used the GRADE system to assess the quality of evidence. We included 24 guidelines and position/consensus statements from the European Society of Gastrointestinal Endoscopy, British Society of Gastroenterology, American Society for Gastrointestinal Endoscopy, American Gastroenterological Association, American College of Gastroenterology, Australian guidelines, and Asia-Pacific consensus. All guidelines defend that BE should be diagnosed when there is an extension of columnar epithelium into the distal esophagus. However, there is still some controversy regarding length and histology criteria for BE diagnosis. All guidelines recommend expert pathologist review for dysplasia diagnosis. All guidelines recommend surveillance for non-dysplastic BE, and some recommend surveillance for indefinite dysplasia. While the majority of guidelines recommend ablation therapy for low-grade dysplasia without visible lesion, others recommend ablation therapy or endoscopic surveillance. However, controversy exists regarding surveillance intervals and biopsy protocols. All guidelines recommend endoscopic resection followed by ablation therapy for neoplastic visible lesion. Several guidelines use the GRADE system, but the majority of recommendations are based on low and moderate quality of evidence. Although there is considerable consensus among guidelines, there are some discrepancies resulting from low-quality evidence. The lack of high-quality evidence for the majority of recommendations highlights the importance of continued well-conducted research in this field.
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Affiliation(s)
- Inês Marques de Sá
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
| | - António Dias Pereira
- Department of Gastroenterology, Instituto Português de Oncologia de Lisboa Francisco Gentil EPE, Lisbon, Portugal
| | - Prateek Sharma
- University of Kansas School of Medicine, Kansas City, KS, USA
- Division of Gastroenterology, Veterans Affairs Medical Center, Kansas City, KS, USA
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute of Porto, Porto, Portugal
- Faculty of Medicine, CINTESIS (Center for Health Technology and Services Research), University of Porto, Porto, Portugal
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Alzoubaidi D, Hussein M, Sehgal V, Makahamadze C, Magee CG, Everson M, Graham D, Sweis R, Banks M, Sami SS, Novelli M, Lovat L, Haidry R. Cryoballoon ablation for treatment of patients with refractory esophageal neoplasia after first line endoscopic eradication therapy. Endosc Int Open 2020; 8:E891-E899. [PMID: 32665972 PMCID: PMC7340530 DOI: 10.1055/a-1149-1414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/12/2020] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Cryoablation with the Cryoballoon device is a novel ablative therapy that uses cycles of freezing and thawing to induce cell death. This single-center prospective study evaluated the feasibility of the focal cryoablation device for the treatment of areas of refractory esophageal neoplasia in patients who had undergone first line endoscopic eradication therapy (EET). Complete remission of dysplasia (CR-D) and complete remission of intestinal metaplasia (CR-IM) at first follow-up endoscopy, durability of disease reversal, rates of stenosis and adverse events were studied. Patients and methods Eighteen cases were treated. At baseline, nine patients had low-grade dysplasia (LGD), six had high-grade dysplasia (HGD) and three had intramucosal carcinoma (IMC). Median length of dysplastic Barrett's esophagus (BE) treated was 3 cm. The median number of ablations per patient was 11. Each selected area of visible dysplasia received 10 seconds of ablation. One session of cryoablation was performed per patient. Biopsies were performed at around 3 months post-ablation. Results CR-D was achieved in 78 % and CR-IM in 39 % of patients. There were no device malfunction or adverse events. Stenosis was noted in 11 % of cases. At a median follow up of 19-months, CR-D was maintained in 72 % of patients and CR-IM in 33 %. Conclusions Cryoablation appears to be a viable rescue strategy in patients with refractory neoplasia. It is well tolerated and successful in obtaining CR-D and CR-IM in patients with treatment-refractory BE. Further trials of dosimetry, efficacy and safety in treatment-naïve patients are underway.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Mohamed Hussein
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Vinay Sehgal
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | | | - Cormac G. Magee
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Martin Everson
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - David Graham
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Rami Sweis
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Matthew Banks
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Sarmed S. Sami
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Marco Novelli
- Department of Histopathology, University College London Hospital (UCLH), London, UK
| | - Laurence Lovat
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Rehan Haidry
- Division of Surgery and interventional science, University College London (UCL), London, UK
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
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Alzoubaidi D, Graham D, Bassett P, Magee C, Everson M, Banks M, Novelli M, Jansen M, Lovat LB, Haidry R. Comparison of two multiband mucosectomy devices for endoscopic resection of Barrett's esophagus-related neoplasia. Surg Endosc 2019; 33:3665-3672. [PMID: 30671663 PMCID: PMC6795619 DOI: 10.1007/s00464-018-06655-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 12/24/2018] [Indexed: 02/07/2023]
Abstract
Background Esophageal adenocarcinoma carries a poor prognosis and therefore treatment of early neoplasia arising in the precursor condition Barrett’s esophagus (BE) is desirable. Visible lesions arising in BE need endoscopic mucosal resection for accurate staging and removal. Resection modalities include a cap-based system with snare and custom-made multiband mucosectomy (MBM) devices (Duette, Cook Medical Ltd). A new MBM device has recently become available (Captivator, Boston Scientific Ltd). Objectives A retrospective pilot study to compare the efficacy, safety, specimen size and histology of endoscopic mucosal resection (EMR) specimens resected with two MBM devices (Cook Duette and Boston Captivator) in treatment naive patients undergoing endoscopic therapy for BE neoplasia. Methods Consecutive EMR procedures carried out by a single experienced endoscopist were analysed. All visible lesions were marked and resected using one of the two MBM devices. All resected specimens were analysed by the same two experienced pathologists. The resected specimens in both groups were analysed for maximum diameter, minimum diameter, surface area and depth. Results Twenty consecutive patients were analysed (18M + 2F; mean age 74) in the Duette group and 20 (17M + 3F; mean age 72) in the Captivator group. A total of 58 specimens were resected in the Duette and 63 in the Captivator group. Min diameter, max diameter, surface area and depth of the ER specimens resected by the Captivator device were significantly larger than that by the Duette device [min diameter 9.89 mm vs 9.07 mm (p = 0.019); max diameter: 13.54 mm vs 12.38 mm (p = 0.024); surface area: 135.40 mm2 vs 113.89 mm2 (p = 0.005); depth 3.71 mm vs 2.89 (p = 0.001)]. Conclusions These two MBM devices showed equivalent efficacy and safety outcomes, but the EMR Captivator device resected specimens with a larger area in the esophagus when compared with the Duette device. A possible advantage of this is in situations where en bloc resections with fewer EMRs are desirable for larger lesions.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery & Interventional Science, University College London (UCL), Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK.
| | - David Graham
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - Paul Bassett
- Statsconsultancy Ltd, 40 Longwood Lane, Amersham, HP7 9EN, UK
| | - Cormac Magee
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - Martin Everson
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - Matthew Banks
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
| | - Marco Novelli
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Marnix Jansen
- Department of Pathology, University College London Hospital NHS Foundation Trust, London, UK
| | - Laurence B Lovat
- Division of Surgery & Interventional Science, University College London (UCL), Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
| | - Rehan Haidry
- Division of Surgery & Interventional Science, University College London (UCL), Charles Bell House, 43-45 Foley Street, London, W1W 7TS, UK
- Department of Gastroenterology, University College London Hospital NHS Foundation Trust, London, UK
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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Yamashita DT, Li C, Bethune D, Henteleff H, Ellsmere J. Endoscopic mucosal resection for high-grade dysplasia and intramucosal carcinoma: a Canadian experience. Can J Surg 2017; 60:129-133. [PMID: 28338468 DOI: 10.1503/cjs.013515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is increasingly being used as a first-line treatment for Barrett esophagus (BE) with high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC). We reviewed our experience with endoscopic treatment of BE with HGD and IMC at our institution with respect to eradication rates, complications and long-term recurrence. METHODS We performed a single-centre retrospective review of all patients referred between October 2010 and August 2014 for EMR with dysplastic BE or IMC. We performed EMR using a cap-fitted endoscope, and the procedure was repeated every 3 months until eradication or progression of disease. RESULTS A total of 28 patients were identified: 16 with dysplastic BE (14 HGD, 1 low-grade dysplasia, 1 intermediate dysplasia) and 12 with IMC. Complete eradication of HGD was achieved in 11 of 14 (79%) patients. Three of 12 (25%) patients initially referred with suspected IMC were found to have invasive adenocarcinoma on EMR. Eradication was successful in 8 of 9 (89%) patients with true IMC, with 1 patient progressing to salvage esophagectomy. Complications occurred in 2 of 28 (7%) patients; both had esophageal strictures managed with dilatation. Median duration of follow-up was 371 days. CONCLUSION Our experience supports the safety of EMR as a first-line treatment for patients with BE with dysplasia and IMC in early short-term follow-up.
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Affiliation(s)
- Denise Tami Yamashita
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Chao Li
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Drew Bethune
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Harry Henteleff
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - James Ellsmere
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
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Feuerstein JD, Castillo NE, Akbari M, Belkin E, Lewandowski JJ, Hurley CM, Lloyd S, Leffler DA, Cheifetz AS. Systematic Analysis and Critical Appraisal of the Quality of the Scientific Evidence and Conflicts of Interest in Practice Guidelines (2005-2013) for Barrett's Esophagus. Dig Dis Sci 2016; 61:2812-2822. [PMID: 27307064 DOI: 10.1007/s10620-016-4222-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/31/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Barrett's esophagus (BE) is a condition that has a small but important risk of progressing to esophageal cancer. To date, no study has assessed the strength of evidence supporting the recommendations for BE. We sought to assess the overall quality of the recommendations and strength of the BE using the AGREE II instrument. METHODS A PubMed search was performed to identify guidelines published pertaining to BE. Every guideline was reviewed using the AGREE II format to assess the methodological rigor and validity of the guideline. Additionally, guidelines were reviewed for the level of evidence used to support recommendations, conflicts of interest (COI), and differences in recommendations. Statistical analysis was performed using Stata (version 12). RESULTS In total, 234 manuscripts were identified of which 8 guidelines published between 2005 and 2013 pertained to BE. Seventy-five percentage (6/8) graded the evidence used to formulate recommendations. Of the 126 recommendations with supporting evidence, 6 % were supported by level A evidence, 49 % level B evidence, and 45 % level C evidence. Using the AGREE II format, the highest overall assessment grade was the BSG BE guideline (6.5 ± 0.6) followed by the AGA (5.5 ± 0.6). The highest rated domains were scope and purpose (mean 77 range 24-96) and clarity of presentation (mean 75), while the lowest rated domains were editorial independence (mean 32 range 0-92) and applicability of the guideline (mean 35 range 7-90). There was significant variability in recommendations regarding who to screen for BE and surveillance intervals. Finally, only 50 % of the guidelines disclosed if COI were present and 75 % (3/4) reported potentially relevant COI. CONCLUSIONS Majority of the BE guideline fail to meet the AGREE II domains, and most of the recommendations are level B or C quality evidence. Further interventions are necessary to improve the overall quality of the guidelines.
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Affiliation(s)
- Joseph D Feuerstein
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA.
| | - Natalia E Castillo
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Mona Akbari
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Edward Belkin
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Jeffrey J Lewandowski
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Christine M Hurley
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Samuel Lloyd
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Daniel A Leffler
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
| | - Adam S Cheifetz
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis St 8E Gastroenterology, Boston, MA, 02215, USA
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Thota PN, Sada A, Sanaka MR, Jang S, Lopez R, Goldblum JR, Liu X, Dumot JA, Vargo J, Zuccarro G. Correlation between endoscopic forceps biopsies and endoscopic mucosal resection with endoscopic ultrasound in patients with Barrett's esophagus with high-grade dysplasia and early cancer. Surg Endosc 2016; 31:1336-1341. [PMID: 27444824 DOI: 10.1007/s00464-016-5117-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2016] [Accepted: 07/12/2016] [Indexed: 12/27/2022]
Abstract
BACKGROUND Patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) or intramucosal cancer (IMC) on endoscopic forceps biopsies are referred to endoscopic therapy even though forceps biopsies do not reflect the disease extent accurately. Endoscopic mucosal resection (EMR) and endoscopic ultrasound (EUS) are frequently used for staging prior to endoscopic therapy. Our aims were to evaluate: (1) if endoscopic forceps biopsies correlated with EMR histology in these patients; (2) the utility of EUS compared to EMR; and (3) if accuracy of EUS varied based on grade of differentiation of tumor. METHODS This is a retrospective review of patients referred to endoscopic therapy of BE with HGD or early esophageal adenocarcinoma (EAC) who underwent EMR from 2006 to 2011. Age, race, sex, length of Barrett's segment, hiatal hernia size, number of endoscopies and biopsy results and EUS findings were abstracted. RESULTS A total of 151 patients underwent EMR. In 50 % (75/151) of patients, EMR histology was consistent with endoscopic forceps biopsy findings. EMR resulted in change in diagnosis with upstaging in 21 % (32/151) and downstaging in 29 % (44/151). In patients with HGD on EMR, EUS staging was T0 in 74.1 % (23/31) but upstaged in 25.8 % (8/31). In patients with IMC on EMR, EUS findings were T1a in 23.6 % (9/38), upstaged in 18.4 % (7/38) and downstaged in 57.8 % (22/38). EUS accurately identified EMR histology in all submucosal cancers. Grade of differentiation was reported in 24 cancers on EMR histology. There was no correlation between grade and EUS staging. CONCLUSIONS EUS is of limited utility in accurate staging of BE patients with HGD or early EAC. Endoscopic forceps biopsy correlated with EMR findings in only 50 % of patients. Irrespective of the endoscopic forceps biopsy results, all BE patients with visible lesions should be referred to EMR.
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Affiliation(s)
- Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Center of Excellence for Barrett's Esophagus, Cleveland Clinic, Cleveland, OH, 44195, USA.
| | - Alaa Sada
- Department of Gastroenterology and Hepatology, Center of Excellence for Barrett's Esophagus, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Center of Excellence for Barrett's Esophagus, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Sunguk Jang
- Department of Gastroenterology and Hepatology, Center of Excellence for Barrett's Esophagus, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Rocio Lopez
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - John R Goldblum
- Department of Biostatistics, Cleveland Clinic, Cleveland, OH, USA
| | - Xiuli Liu
- Department of Biostatistics, Cleveland Clinic, Cleveland, OH, USA
| | - John A Dumot
- Digestive Health Institute, University Hospitals, Cleveland, OH, USA
| | - John Vargo
- Department of Gastroenterology and Hepatology, Center of Excellence for Barrett's Esophagus, Cleveland Clinic, Cleveland, OH, 44195, USA
| | - Gregory Zuccarro
- Department of Gastroenterology and Hepatology, Center of Excellence for Barrett's Esophagus, Cleveland Clinic, Cleveland, OH, 44195, USA
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Chadwick G, Groene O, Taylor A, Riley S, Hardwick RH, Crosby T, Greenaway K, Cromwell DA. Management of Barrett's high-grade dysplasia: initial results from a population-based national audit. Gastrointest Endosc 2016; 83:736-42.e1. [PMID: 26283273 DOI: 10.1016/j.gie.2015.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 08/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Previous studies reported significant variation in the management of patients with Barrett's esophagus. However, these are based on self-reported clinical practice. The aim of this study was to examine the management of high-grade dysplasia in Barrett's esophagus in England by using patient-level data and to compare practice with guidelines. METHODS From April 2012 to March 2013, National Health Service (NHS) trusts in England prospectively collected data on patients newly diagnosed with high-grade dysplasia (HGD) of the esophagus as part of the National Oesophago-Gastric Cancer Audit. Data were collected on patient characteristics, diagnosis and endoscopic findings, treatment planning, and therapy. RESULTS Between April 2012 and March 2013, NHS trusts reported 465 cases of HGD. Diagnosis was confirmed by a second pathologist in 79.4% of cases (270/340), and 86.0% (374/465) had their treatment planned at a multidisciplinary team meeting. A total of 290 patients (62.4%) were managed endoscopically (frequently with endoscopic resection or radiofrequency ablation), whereas 26 patients (5.6%) had esophagectomy. The proportion of patients managed by surveillance varied by age (P < .001), ranging from 19.5% in patients aged <65 years to 63.8% in patients aged ≥85 years. More patients received active treatment if their cases were discussed at a multidisciplinary meeting (73.5% vs 44.3%; P < .001) or managed at higher-volume trusts (87.8% vs 55.4%; P < .001). CONCLUSIONS There was marked variation in the management of HGD across England, with a third of patients receiving no active treatment. Patients discussed at a specialist multidisciplinary meeting or managed in high-volume trusts were more likely to receive active treatment.
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Affiliation(s)
- Georgina Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Imperial College, Department of Surgery and Cancer, 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 and Tropical Medicine, London, United Kingdom
| | - Angelina Taylor
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Stuart Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, United Kingdom
| | | | - Tom Crosby
- Velindre Cancer Centre, Cardiff, Wales, United Kingdom
| | | | - David A 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 and Tropical Medicine, London, United Kingdom
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Haidry RJ, Butt MA, Dunn JM, Gupta A, Lipman G, Smart HL, Bhandari P, Smith L, Willert R, Fullarton G, Di Pietro M, Gordon C, Penman I, Barr H, Patel P, Kapoor N, Hoare J, Narayanasamy R, Ang Y, Veitch A, Ragunath K, Novelli M, Lovat LB. Improvement over time in outcomes for patients undergoing endoscopic therapy for Barrett's oesophagus-related neoplasia: 6-year experience from the first 500 patients treated in the UK patient registry. Gut 2015; 64:1192-9. [PMID: 25539672 PMCID: PMC4515987 DOI: 10.1136/gutjnl-2014-308501] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 11/29/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Barrett's oesophagus (BE) is a pre-malignant condition leading to oesophageal adenocarcinoma (OAC). Treatment of neoplasia at an early stage is desirable. Combined endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) is an alternative to surgery for patients with BE-related neoplasia. METHODS We examined prospective data from the UK registry of patients undergoing RFA/EMR for BE-related neoplasia from 2008 to 2013. Before RFA, visible lesions were removed by EMR. Thereafter, patients had RFA 3-monthly until all BE was ablated or cancer developed (endpoints). End of treatment biopsies were recommended at around 12 months from first RFA treatment or when endpoints were reached. Outcomes for clearance of dysplasia (CR-D) and BE (CR-IM) at end of treatment were assessed over two time periods (2008-2010 and 2011-2013). Durability of successful treatment and progression to OAC were also evaluated. RESULTS 508 patients have completed treatment. CR-D and CR-IM improved significantly between the former and later time periods, from 77% and 56% to 92% and 83%, respectively (p<0.0001). EMR for visible lesions prior to RFA increased from 48% to 60% (p=0.013). Rescue EMR after RFA decreased from 13% to 2% (p<0.0001). Progression to OAC at 12 months is not significantly different (3.6% vs 2.1%, p=0.51). CONCLUSIONS Clinical outcomes for BE neoplasia have improved significantly over the past 6 years with improved lesion recognition and aggressive resection of visible lesions before RFA. Despite advances in technique, the rate of cancer progression remains 2-4% at 1 year in these high-risk patients. TRIAL REGISTRATION NUMBER ISRCTN93069556.
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Affiliation(s)
- R J Haidry
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - M A Butt
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK
| | - J M Dunn
- Guy's and St Thomas’ NHS foundation Trust, London, UK,Institute for Cancer Genetics and Informatics, Oslo University, Oslo, Norway
| | - A Gupta
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - G Lipman
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK
| | - H L Smart
- Department of Gastroenterology and Hepatology, Royal Liverpool University Hospital, Liverpool, UK
| | - P Bhandari
- Princess Alexandra Hospital, Portsmouth, UK
| | - L Smith
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - R Willert
- Central Manchester University Hospitals NHS Foundation Trust, Manchester,UK
| | | | | | - C Gordon
- Royal Bournemouth Hospital, Bournemouth, UK
| | - I Penman
- Royal Infirmary Edinburgh, Edinburgh, UK
| | - H Barr
- Oesophagogastric Surgery, Gloucestershire Hospital NHS Trust, Birmingham, UK
| | - P Patel
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - N Kapoor
- Digestive Diseases Centre, Aintree University Hospital, Liverpool, UK
| | - J Hoare
- St Mary's Hospital NHS Trust, London, UK
| | | | - Y Ang
- Centre of Gastrointestinal Sciences, University of Manchester, Salford Royal Foundation NHS Trust, Salford, UK
| | - A Veitch
- Department of Gastroenterology, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - K Ragunath
- Department of Gastroenterology, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - M Novelli
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - L B Lovat
- Research Department of Tissue and Energy, Division of Surgery and Interventional Science, University College London, London, UK,Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
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Abstract
PURPOSE OF REVIEW Here, we examine data on the long-term durability of endoscopic therapy in patients with mucosal neoplasia in Barrett's esophagus. RECENT FINDINGS Short-term success is seen in most patients undergoing endoscopic therapy for Barrett's esophagus neoplasia, but long-term outcomes are only just becoming available. SUMMARY The incidence of esophageal adenocarcinoma (EAC) continues to rise with poor survival seen in the majority of patients. The only known precursor to EAC is Barrett's esophagus. Although the risk of progression from metaplastic Barrett's esophagus to neoplasia is low, surveillance is advocated as patients who progress to mucosal neoplasia carry a significantly higher risk of progressing to invasive EAC. Minimally invasive endoscopic therapy with endoscopic resection and radiofrequency ablation are now the gold standard treatments for patients with intramucosal neoplasia in Barrett's esophagus. After successful treatment, follow-up is still required as long-term durability is not 100% and recurrences are not rare. This review highlights the need for vigilant follow-up, but emphasizes the consensus that most patients have durable disease reversal.
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11
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Pech O. Endoscopic therapy of high-grade dysplasia and intramucosal adenocarcinoma: 2 small steps for the endoscopists but a fine step forward for the patient. Gastrointest Endosc 2015; 81:1167-9. [PMID: 25864893 DOI: 10.1016/j.gie.2015.01.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/22/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brüder (St. John of God Hospital), Teaching Hospital of the University of Regensburg, Regensburg, Germany
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12
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Minimally invasive esophagectomy: results of a prospective phase II multicenter trial-the eastern cooperative oncology group (E2202) study. Ann Surg 2015; 261:702-7. [PMID: 25575253 DOI: 10.1097/sla.0000000000000993] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE The primary aim of this trial was to assess the feasibility of minimally invasive esophagectomy (MIE) in a multi-institutional setting. BACKGROUND Esophagectomy is an important, potentially curative treatment for localized esophageal cancer, but is a complex operation. MIE may decrease the morbidity and mortality of resection, and single-institution studies have demonstrated successful outcomes with MIE. METHODS We conducted a multicenter, phase II, prospective, cooperative group study (coordinated by the Eastern Cooperative Oncology Group) to evaluate the feasibility of MIE. Patients with biopsy-proven high-grade dysplasia or esophageal cancer were enrolled at 17 credentialed sites. Protocol surgery consisted of either 3-stage MIE or Ivor Lewis MIE. The primary end point was 30-day mortality. Secondary end points included adverse events, duration of hospital-stay, and 3-year outcomes. RESULTS Protocol surgery was completed in 95 of the 104 patients eligible for the primary analysis (91.3%). The 30-day mortality in eligible patients who underwent MIE was 2.1%; perioperative mortality in all registered patients eligible for primary analysis was 2.9%. Median intensive care unit and hospital stay were 2 and 9 days, respectively. Grade 3 or higher adverse events included anastomotic leak (8.6%), acute respiratory distress syndrome (5.7%), pneumonitis (3.8%), and atrial fibrillation (2.9%). At a median follow-up of 35.8 months, the estimated 3-year overall survival was 58.4% (95% confidence interval: 47.7%-67.6%). Locoregional recurrence occurred in only 7 patients (6.7%). CONCLUSIONS This prospective multicenter study demonstrated that MIE is feasible and safe with low perioperative morbidity and mortality and good oncological results. This approach can be adopted by other centers with appropriate expertise in open esophagectomy and minimally invasive surgery.
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13
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Lada MJ, Watson TJ, Shakoor A, Nieman DR, Han M, Tschoner A, Peyre CG, Jones CE, Peters JH. Eliminating a need for esophagectomy: endoscopic treatment of Barrett esophagus with early esophageal neoplasia. Semin Thorac Cardiovasc Surg 2014; 26:274-84. [PMID: 25837538 DOI: 10.1053/j.semtcvs.2014.12.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2014] [Indexed: 12/19/2022]
Abstract
Over the past several years, endoscopic ablation and resection have become a new standard of care in the management of Barrett esophagus (BE) with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC). Risk factors for failure of endoscopic therapy and the need for subsequent esophagectomy have not been well elucidated. The aims of this study were to determine the efficacy of radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) in the management of BE with HGD or IMC, to discern factors predictive of endoscopic treatment failure, and to assess the effect of endoscopic therapies on esophagectomy volume at our institution. Data were obtained retrospectively for all patients who underwent endoscopic therapies or esophagectomy for a diagnosis of BE with HGD or IMC in our department between January 1, 2004, and December 31, 2012. Complete remission (CR) of BE or HGD or IMC was defined as 2 consecutive biopsy sessions without BE or HGD or IMC and no subsequent recurrence. Recurrence was defined by the return of BE or HGD or IMC after initial remission. Progression was defined as worsening of HGD to IMC or worsening of IMC to submucosal neoplasia or beyond. Overall, 57 patients underwent RFA with or without EMR for BE with HGD (n = 45) or IMC (n = 12) between 2007 and 2012, with a median follow-up duration of 35.4 months (range: 18.5-52.0 months). The 57 patients underwent 181 ablation sessions and more than half (61%) of patients underwent EMR as a component of treatment. There were no major procedural complications or deaths, with only 2 minor complications including 1 symptomatic stricture requiring dilation. Multifocal HGD or IMC was present in 43% (25/57) of patients. CR of IMC was achieved in 100% (12/12) at a median of 6.1 months, CR of dysplasia was achieved in 79% (45/57) at a median of 11.5 months, and CR of BE was achieved in 49% (28/57) at a median of 18.4 months. Following initial remission, 28% of patients (16/57) had recurrence of dysplasia (n = 12) or BE (n = 4). Progression to IMC occurred in 7% (4/57). All patients without CR continue endoscopic treatment. No patient required esophagectomy or developed metastatic disease. Overall, 6 patients died during the follow-up interval, none from esophageal cancer. Factors associated with failure to achieve CR of BE included increasing length of BE (6.0 ± 0.6 vs 4.0 ± 0.6cm, P = 0.03) and shorter duration of follow-up (28.5 ± 3.8 months vs 49.0 ± 5.8 months, P = 0.004). Shorter surveillance duration (17.8 ± 7.6 months vs 63.9 ± 14.4 months, P = 0.009) and shorter follow-up (21.1 ± 6.1 months vs 43.2 ± 4.1 months) were the only significant factors associated with failure to eradicate dysplasia. Our use of esophagectomy as primary therapy for BE with HGD or IMC has diminished since we began using endoscopic therapies in 2007. From a maximum of 16 esophagectomies per year for early Barrett neoplasia in 2006, we performed only 3 esophageal resections for such early disease in 2012, all for IMC, and we have not performed an esophagectomy for HGD since 2008. Although recurrence of BE or dysplasia/IMC was not uncommon, RFA with or without EMR ultimately resulted in CR of IMC in all patients, CR of HGD in the majority (79%), and CR of BE in nearly half (49%). No patient treated endoscopically for HGD or IMC subsequently required esophagectomy. In patients with BE with HGD or IMC, RFA and EMR are safe and highly effective. The use of endoscopic therapies appears justified as the new standard of care in most cases of BE with early esophageal neoplasia.
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Affiliation(s)
- Michal J Lada
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Thomas J Watson
- Department of Surgery, University of Rochester Medical Center, Rochester, New York..
| | - Aqsa Shakoor
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Dylan R Nieman
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Michelle Han
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Andreas Tschoner
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Christian G Peyre
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Carolyn E Jones
- Department of Surgery, University of Rochester Medical Center, Rochester, New York
| | - Jeffrey H Peters
- Chief Operating Officer, University Hospitals, Cleveland, Case Western Reserve University
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Treatment of High-Grade Dysplasia and Early Stage Esophageal Adenocarcinoma with an Endoscope: The Ultimate in Minimally Invasive, Curative Therapy. CURRENT SURGERY REPORTS 2014. [DOI: 10.1007/s40137-014-0066-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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Endoscopic methods in the treatment of early-stage esophageal cancer. Wideochir Inne Tech Maloinwazyjne 2014; 9:125-30. [PMID: 25097676 PMCID: PMC4105665 DOI: 10.5114/wiitm.2014.41620] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Revised: 11/15/2013] [Accepted: 11/25/2013] [Indexed: 02/07/2023] Open
Abstract
Most patients with early esophageal cancer restricted to the mucosa may be offered endoscopic therapy, which is similarly effective, less invasive and less expensive than esophagectomy. Selection of appropriate relevant treatment and therapy methods should be performed at a specialized center with adequate facilities. The selection of an endoscopic treatment method for high-grade dysplasia and early-stage esophageal adenocarcinoma requires that tumor infiltration is restricted to the mucosa and that there is no neighboring lymph node metastasis. In squamous cell carcinoma, this treatment method is accepted in cases of tumors invading only up to the lamina propria of mucosa (m2). Tumors treated with the endoscopic method should be well or moderately differentiated and should not invade lymphatic or blood vessels. When selecting endoscopic treatments for these lesions, a combination of endoscopic resection and endoscopic ablation methods should be considered.
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16
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Pech O, May A, Manner H, Behrens A, Pohl J, Weferling M, Hartmann U, Manner N, Huijsmans J, Gossner L, Rabenstein T, Vieth M, Stolte M, Ell C. Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus. Gastroenterology 2014; 146:652-660.e1. [PMID: 24269290 DOI: 10.1053/j.gastro.2013.11.006] [Citation(s) in RCA: 295] [Impact Index Per Article: 29.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Revised: 11/05/2013] [Accepted: 11/08/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Barrett's esophagus-associated high-grade dysplasia is commonly treated by endoscopy. However, most guidelines offer no recommendations for endoscopic treatment of mucosal adenocarcinoma of the esophagus (mAC). We investigated the efficacy and safety of endoscopic resection in a large series of patients with mAC. METHODS We collected data from 1000 consecutive patients (mean age, 69.1 ± 10.7 years; 861 men) with mAC (481 with short-segment and 519 with long-segment Barrett's esophagus) who presented at a tertiary care center from October 1996 to September 2010. Patients with low-grade and high-grade dysplasia and submucosal or more advanced cancer were excluded. All patients underwent endoscopic resection of mACs. Patients found to have submucosal cancer at their first endoscopy examination were excluded from the analysis. RESULTS After a mean follow-up period of 56.6 ± 33.4 months, 963 patients (96.3%) had achieved a complete response; surgery was necessary in 12 patients (3.7%) after endoscopic therapy failed. Metachronous lesions or recurrence of cancer developed during the follow-up period in 140 patients (14.5%) but endoscopic re-treatment was successful in 115, resulting in a long-term complete remission rate of 93.8%; 111 died of concomitant disease and 2 of Barrett's esophagus-associated cancer. The calculated 10-year survival rate of patients who underwent endoscopic resection of mACs was 75%. Major complications developed in 15 patients (1.5%) but could be managed conservatively. CONCLUSIONS Endoscopic therapy is highly effective and safe for patients with mAC, with excellent long-term results. In an almost 5-year follow-up of 1000 patients treated with endoscopic resection, there was no mortality and less than 2% had major complications. Endoscopic therapy should become the standard of care for patients with mAC.
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Affiliation(s)
- Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St John of God Hospital, University of Regensburg, Regensburg, Germany
| | - Andrea May
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Hendrik Manner
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Angelika Behrens
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Jürgen Pohl
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Maren Weferling
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Urs Hartmann
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Nicola Manner
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Josephus Huijsmans
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany
| | - Liebwin Gossner
- Department of Internal Medicine II, Klinikum Karlsruhe, Karlsruhe, Germany
| | - Thomas Rabenstein
- Department of Gastroenterology, Diakonissen Krankenhaus, Speyer, Germany
| | - Michael Vieth
- Institute of Pathology, Bayreuth Hospital, University of Erlangen-Nuremberg, Bayreuth, Germany
| | - Manfred Stolte
- Department of Pathology, Klinikum Kulmbach, Kulmbach, Germany
| | - Christian Ell
- Department of Internal Medicine II, HSK Wiesbaden, University of Mainz, Wiesbaden, Germany.
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17
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Davila ML, Hofstetter WL. Endoscopic management of Barrett's esophagus with high-grade dysplasia and early-stage esophageal adenocarcinoma. Thorac Surg Clin 2013; 23:479-89. [PMID: 24199698 DOI: 10.1016/j.thorsurg.2013.07.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Several endoscopic procedures have been recently developed for the treatment of Barrett's esophagus and early esophageal cancer, including endoscopic resection, radiofrequency ablation, and cryoablation. This review article discusses ideal candidates for endoscopic therapies, current treatment modalities, clinical and safety outcomes, and specific management recommendations.
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Affiliation(s)
- Marta L Davila
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 146, Houston, TX 77030, USA.
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18
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Advanced esophageal cancer in patients who underwent radiofrequency ablation for barrett esophagus with high-grade dysplasia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 8:17-22. [PMID: 23571789 DOI: 10.1097/imi.0b013e31828db550] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE We sought to evaluate clinicopathologic features of patients who underwent esophageal surgery after radiofrequency ablation (RFA) treatment using the HALO system for Barrett esophagus (BE) with high-grade dysplasia (HGD). METHODS We evaluated patients from our hospital database who underwent esophagectomy from August 2006 to January 2012 after previously receiving RFA for BE. Information on demographics, time between RFA and surgery, indications for surgery, and final esophageal pathology was collected. RESULTS In our study, we selected 102 patients who underwent esophagectomy. Five patients had a history of RFA for BE with HGD. Three patients were referred because of persistent HGD despite RFA, and all three patients had HGD in the esophagectomy specimen. Two patients presented with a benign diagnosis (esophageal perforation and leiomyoma), and both of these patients had pathologic stage T3N2M0 adenocarcinoma of the esophagus in the resected specimen. One of these patients had normal mucosa overlying carcinoma in the muscularis propria and adventitia. The patients with stage T3N2M0 cancer did not have pre-RFA endoscopic ultrasound, first treatment of RFA with HALO, or surveillance endoscopic biopsy every 3 months. CONCLUSIONS Radiofrequency ablation for BE with HGD may mask underlying esophageal cancer. Patients who are counseled to undergo RFA for HGD should be aware that RFA could lead to delayed diagnosis and delayed treatment of invasive esophageal cancer without careful patient selection, appropriate RFA use, and close surveillance.
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19
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Abstract
This article reviews the current management of esophageal cancer, including staging and treatment options, as well as providing support for using multidisciplinary teams to better manage esophageal cancer patients.
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20
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Kim MP, Brown KN, Schwartz MR, Blackmon SH. Advanced Esophageal Cancer in Patients who Underwent Radiofrequency Ablation for Barrett Esophagus with High-Grade Dysplasia. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Min P. Kim
- Department of Surgery, Weill Cornell Medical College, New York, NY USA
- Department of Surgery, The Methodist Hospital, Houston, TX USA
| | - Kendra N. Brown
- Department of Surgery, The Methodist Hospital, Houston, TX USA
| | - Mary R. Schwartz
- Department of Pathology and Genomic Medicine, The Methodist Hospital, Houston, TX USA
| | - Shanda H. Blackmon
- Department of Surgery, Weill Cornell Medical College, New York, NY USA
- Department of Surgery, The Methodist Hospital, Houston, TX USA
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21
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Barrett's Esophagus: Emerging Knowledge and Management Strategies. PATHOLOGY RESEARCH INTERNATIONAL 2012; 2012:814146. [PMID: 22701199 PMCID: PMC3369502 DOI: 10.1155/2012/814146] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Revised: 03/08/2012] [Accepted: 03/26/2012] [Indexed: 12/14/2022]
Abstract
The incidence of esophageal adenocarcinoma (EAC) has increased exponentially in the last 3 decades. Barrett's esophagus (BE) is the only known precursor of EAC. Patients with BE have a greater than 40 folds higher risk of EAC compared with the general population. Recent years have witnessed a revolution in the clinical and molecular research related to BE. However, several aspects of this condition remain controversial. Data regarding the true prevalence of BE have varied widely. Recent studies have suggested a lower incidence of EAC in nondysplastic BE (NDBE) than previously reported. There is paucity of prospective data showing a survival benefit of screening or surveillance for BE. Furthermore, the ever-increasing emphasis on healthcare cost containment has called for reexamination of the screening and surveillance strategies for BE. There is a need for identification of reliable clinical predictors or molecular biomarkers to risk-stratify patients who might benefit the most from screening or surveillance for BE. Finally, new therapies have emerged for the management of dysplastic BE. In this paper, we highlight the key areas of controversy and uncertainty surrounding BE. The paper discusses, in detail, the current literature about the molecular pathogenesis, biomarkers, histopathological diagnosis, and management strategies for BE.
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Heresbach D, Caillol F, Cholet F, Lamoulliate A, Luet D, Le Rhun M, Rahmi G, Vanbiervliet G, Demarquay JF, Marais C, Ponchon T, Giovannini M, Boyer J. Observatoire du traitement endoscopique par radiofréquence de l’œsophage de Barrett avec dysplasie ou de néoplasie : modalités et résultats. ACTA ACUST UNITED AC 2012. [DOI: 10.1007/s10190-012-0234-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Rice TW, Goldblum JR. Management of Barrett esophagus with high-grade dysplasia. Thorac Surg Clin 2011; 22:101-7, vii. [PMID: 22108694 DOI: 10.1016/j.thorsurg.2011.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
High-grade dysplasia in Barrett esophagus is a marker for future development of cancer and for the existence of synchronous cancer. A significant problem in management is intraobserver and interobserver variation in the diagnosis of high-grade dysplasia in Barrett esophagus, the natural history of which is poorly understood; thus, treatment decisions are problematic. The ability to preserve the esophagus with endoscopic mucosal ablation or resection and reduce morbidity of treatment has made endoscopic treatment the mainstay of therapy. Esophagectomy is reserved for treatment failures and for high-grade dysplasia not amenable to less aggressive therapies. This article outlines the data supporting current management strategies.
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Affiliation(s)
- Thomas W Rice
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Avenue/Desk J4-1, Cleveland, OH 44195, USA.
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24
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Konda VJ, Dalal K. Optimal management of Barrett's esophagus: pharmacologic, endoscopic, and surgical interventions. Ther Clin Risk Manag 2011; 7:447-58. [PMID: 22162921 PMCID: PMC3233528 DOI: 10.2147/tcrm.s23425] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Esophageal adenocarcinoma and its precursor, Barrett’s esophagus, are rapidly rising in incidence. This review serves to highlight the role of pharmacologic, endoscopic, and surgical intervention in the management of Barrett’s esophagus, which requires acid suppression and endoscopic assessment. Treatment with a proton pump inhibitor may decrease acid exposure and delay the progression to dysplasia. Patients who require aspirin for cardioprotection or other indications may also benefit in terms of a protective effect against the development of esophageal cancer. However, without other indications, aspirin is not indicated solely to prevent cancer. A careful endoscopic examination should include assessment of any visible lesions in a Barrett’s segment. An expert gastrointestinal pathologist should confirm neoplasia in the setting of Barrett’s esophagus. For those patients with high-grade dysplasia or intramucosal carcinoma, careful consideration of endoscopic therapy or surgical therapy must be given. All visible lesions in the setting of dysplasia should be targeted with focal endoscopic mucosal resection for both accurate histopathologic diagnosis and treatment. The remainder of the Barrett’s epithelium should be eradicated to address all synchronous and metachronous lesions. This may be done by tissue acquiring or nontissue acquiring means. Radiofrequency ablation has a positive benefit-risk profile for flat Barrett’s esophagus. At this time, endoscopic therapy is not indicated for nondysplastic Barrett’s esophagus. Esophagectomy is still reserved for selected cases with evidence of lymph node metastasis, unsuccessful endoscopic therapy, or with high-risk features of high-grade dysplasia or intramucosal carcinoma.
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Affiliation(s)
- Vani Ja Konda
- Section of Gastroenterology, Department of Medicine, University of Chicago Medical Center, Chicago, Illinois, USA
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Hoppo T, Rachit SD, Jobe BA. Esophageal Preservation in Esophageal High-Grade Dysplasia and Intramucosal Adenocarcinoma. Thorac Surg Clin 2011; 21:527-40. [DOI: 10.1016/j.thorsurg.2011.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Nava HR, Allamaneni SS, Dougherty TJ, Cooper MT, Tan W, Wilding G, Henderson BW. Photodynamic therapy (PDT) using HPPH for the treatment of precancerous lesions associated with Barrett's esophagus. Lasers Surg Med 2011; 43:705-12. [PMID: 22057498 PMCID: PMC3218433 DOI: 10.1002/lsm.21112] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVES Photodynamic therapy (PDT) with porfimer sodium, FDA approved to treat premalignant lesions in Barrett's esophagus, causes photosensitivity for 6-8 weeks. HPPH (2-[1-hexyloxyethyl]-2-devinyl pyropheophorbide-a) shows minimal photosensitization of short duration and promising efficacy in preclinical studies. Here we explore toxicity and optimal drug and light dose with endoscopic HPPH-PDT. We also want to know the efficacy of one time treatment with HPPH-PDT. STUDY DESIGN/MATERIALS AND METHODS Two nonrandomized dose escalation studies were performed (18 patients each) with biopsy-proven high grade dysplasia or early intramucosal adenocarcinoma of esophagus. HPPH doses ranged from 3 to 6 mg/m2 . At 24 or 48 hours after HPPH administration the lesions received one endoscopic exposure to 150, 175, or 200 J/cm of 665 nm light. RESULTS Most patients experienced mild to moderate chest pain requiring symptomatic treatment only. Six patients experienced grade 3 and 4 adverse events (16.6%). Three esophageal strictures were treated with dilatation. No clear pattern of dose dependence of toxicities emerged. In the drug dose ranging study (light dose of 150 J/cm at 48 hours), 3 and 4 mg/m2 of HPPH emerged as most effective. In the light dose ranging study (3 or 4 mg/m2 HPPH, light at 24 hours), complete response rates (disappearance of high grade dysplasia and early carcinoma) of 72% were achieved at 1 year, with all patients treated with 3 mg/m2 HPPH plus 175 J/cm and 4 mg/m2 HPPH plus 150 J/cm showing complete responses at 1 year. CONCLUSIONS HPPH-PDT for precancerous lesions in Barrett's esophagus appears to be safe and showing promising efficacy. Further clinical studies are required to establish the use of HPPH-PDT.
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Affiliation(s)
- Hector R Nava
- Roswell Park Cancer Institute, Buffalo, New York 14263, USA
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Bozio G, Baulieux J, Mabrut JY. The role of surgery in the management of Barrett's esophagus (from dysplasia to cancer). J Visc Surg 2011; 148:19-26. [PMID: 21310681 DOI: 10.1016/j.jviscsurg.2010.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The goal of this review is to evaluate, through a review of the surgical literature, the role of esophagectomy in the management of Barrett's esophagus as it evolves histologically from intestinal metaplasia through increasing grades of dysplasia to adenocarcinoma. We precisely define the indications and therapeutic modalities of esophagectomy for high-grade dysplasia, superficial adenocarcinoma, and invasive adenocarcinoma.
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Affiliation(s)
- G Bozio
- Service de chirurgie générale, digestive et de la transplantation hépatique, hôpital de la Croix-Rousse, 103, grande rue de la Croix-Rousse, 69317 Lyon cedex 04, France
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Abstract
INTRODUCTION Esophageal cancer remains a challenging clinical problem, with overall long-term survivorship consistently at a level of approximately 30%. The incidence of esophageal cancer is increasing worldwide, with the most dramatic increase being seen with respect to esophageal adenocarcinoma. DISCUSSION Pretreatment staging accuracy has improved with the utilization of CT and PET scans, as well as endoscopic ultrasound and endoscopic mucosal resection. In an increasing percentage of patients, endoscopic techniques are being utilized in selected patients for the treatment of high-grade dysplasia in Barrett's and intramucosal cancer. Surgery remains the treatment of choice in all appropriate patients with invasive and locoregional esophageal cancer, although multimodality therapy is now used in most patients with stage II or stage III disease. CONCLUSION Outcomes for esophagectomy have been dominated by concerns regarding high mortality and morbidity; however, mortality rates associated with esophageal resection have dramatically decreased, especially in high-volume specialty centers. This manuscript highlights some of the evolutionary issues associated with staging and endoscopic and surgical treatments of Barrett's and esophageal cancer.
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Patil DT, Plesec TP, Goldblum JR. Low prevalence of invasive adenocarcinoma and occult cancer on esophageal resection for Barrett's esophagus with high-grade dysplasia: Evidence for conservative management. J Gastrointest Oncol 2011; 2:5-7. [PMID: 22811819 DOI: 10.3978/j.issn.2078-6891.2011.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2011] [Accepted: 02/05/2011] [Indexed: 11/14/2022] Open
Affiliation(s)
- Deepa T Patil
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH
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Abstract
The prevention and chemoprevention of cancer is based on identifying a pre-neoplastic lesion and altering the outcome by early intervention. Many of the gastrointestinal epithelial cancers are related to chronic inflammatory conditions for many years prior to cancer development. It is clear that treatment of the inflammatory condition can prevent and indeed reverse changes that predispose to cancer. This is most notable for helicobacter pylori infection of the stomach. Screening for Barrett's oesophagus and other conditions are more controversial and the results of large scale clinical trials are awaited. Nevertheless preventive strategies are highly attract health care interventions and are being actively considered.
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Affiliation(s)
- Hugh Barr
- Cranfield Health, Gloucestershire Royal NHS Foundation Trust, Great Western Road, Gloucester, GL13NN, UK.
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Konda VJA, Ferguson MK. Esophageal resection for high-grade dysplasia and intramucosal carcinoma: When and how? World J Gastroenterol 2010; 16:3786-92. [PMID: 20698041 PMCID: PMC2921090 DOI: 10.3748/wjg.v16.i30.3786] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
High-grade dysplasia (HGD) and intramucosal carcinoma (IMC) in the setting of Barrett’s esophagus have traditionally been treated with esophagectomy. However, with the advent of endoscopic mucosal resection and endoscopic ablative therapies, endoscopic therapy at centers with expertise is now an established treatment of Barrett’s-esophagus-related neoplasia, including HGD and IMC. Esophagectomy is today reserved for more selected cases with submucosal invasion, evidence for lymph node metastasis, or unsuccessful endoscopic therapy.
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Carr SR, Jobe BA. Esophageal Preservation in the Setting of High-Grade Dysplasia and Superficial Cancer. Semin Thorac Cardiovasc Surg 2010; 22:155-64. [DOI: 10.1053/j.semtcvs.2010.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2010] [Indexed: 12/17/2022]
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Spechler SJ, Fitzgerald RC, Prasad GA, Wang KK. History, molecular mechanisms, and endoscopic treatment of Barrett's esophagus. Gastroenterology 2010; 138:854-69. [PMID: 20080098 PMCID: PMC2853870 DOI: 10.1053/j.gastro.2010.01.002] [Citation(s) in RCA: 162] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 01/11/2010] [Accepted: 01/11/2010] [Indexed: 02/06/2023]
Abstract
This report is an adjunct to the American Gastroenterological Association Institute's medical position statement and technical review on the management of Barrett's esophagus, which will be published in the near future. Those documents will consider a number of broad questions on the diagnosis, clinical features, and management of patients with Barrett's esophagus, and the reader is referred to the technical review for an in-depth discussion of those topics. In this report, we review historical, molecular, and endoscopic therapeutic aspects of Barrett's esophagus that are of interest to clinicians and researchers.
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Affiliation(s)
- Stuart Jon Spechler
- VA North Texas Healthcare System and The University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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dos Santos RS, Bizekis C, Ebright M, DeSimone M, Daly BD, Fernando HC. Radiofrequency ablation for Barrett's esophagus and low-grade dysplasia in combination with an antireflux procedure: a new paradigm. J Thorac Cardiovasc Surg 2010; 139:713-6. [PMID: 20074750 DOI: 10.1016/j.jtcvs.2009.10.032] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Revised: 09/13/2009] [Accepted: 10/16/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Radiofrequency ablation for Barrett's esophagus in combination with an antireflux procedure has not been widely documented. We report our initial experience with radiofrequency ablation in association with antireflux procedure for Barrett's metaplasia and low-grade dysplasia. METHODS A total of 14 patients (10 male and 4 female patients) presented with Barrett's metaplasia (n=11) or low-grade dysplasia (n=3). Median age was 60 years (38-80 years). The severity of Barrett's esophagus was classified by length (in centimeters), appearance (circumferential/noncircumferential), and histology (1, normal; 2, Barrett's metaplasia; and 3, low-grade dysplasia). Radiofrequency ablation was performed with the HALO 360 degrees or 90 degrees systems (BARRX Medical, Sunnyvale, Calif). RESULTS Median follow-up was 17 months. The mean number of ablative procedures undertaken was 2.6 (range, 1-6). There was no mortality, but there were 2 perioperative complications after the antireflux procedure (pneumonia, 1; atrial fibrillation, 1). One patient had mild dysphagia requiring a single dilation 2 months after ablation. The mean length of Barrett's esophagus decreased from 6.2 to 1.2 cm after treatment (P=.001). Barrett's grade decreased significantly (P=.003). Before therapy, circumferential Barrett's esophagus was present in 13 patients. At last endoscopy, only 1 patient had circumferential Barrett's esophagus present. The number of radiofrequency ablation treatments was significantly (P < .05) associated with success. All patients receiving 3 or more treatments had complete resolution of Barrett's metaplasia. CONCLUSIONS Radiofrequency ablation performed either before or after an antireflux procedure is safe. This approach is effective for reducing or eliminating metaplasia and dysplasia. Long-term studies will be necessary to determine whether this approach can provide durable control of both reflux and Barrett's esophagus.
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Affiliation(s)
- Ricardo S dos Santos
- Department of Cardiothoracic Surgery, Boston University School of Medicine, Boston, MA, USA
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