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Yang D, King W, Aihara H, Karasik MS, Ngamruengphong S, Aadam AA, Othman MO, Sharma N, Grimm IS, Rostom A, Elmunzer BJ, Jawaid SA, Perbtani YB, Hoffman BJ, Akki AS, Schlachterman A, Coman RM, Wang AY, Draganov PV. Effect of endoscopic submucosal dissection on histologic diagnosis in Barrett's esophagus visible neoplasia. Gastrointest Endosc 2022; 95:626-633. [PMID: 34906544 DOI: 10.1016/j.gie.2021.11.046] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 11/30/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Data are limited on the role of endoscopic submucosal dissection (ESD) as a potential diagnostic and staging tool in Barrett's esophagus (BE) neoplasia. We aimed to evaluate the frequency and factors associated with change of histologic diagnosis by ESD compared with pre-ESD histology. METHODS This was a multicenter, prospective cohort study of patients who underwent ESD for BE visible neoplasia. A change in histologic diagnosis was defined as "upstaged" or "downstaged" if the ESD specimen had a higher or lower degree, respectively, of dysplasia or neoplasia when compared with pre-ESD specimens. RESULTS Two hundred five patients (median age, 69 years; 81% men) with BE visible neoplasia underwent ESD from 2016 to 2021. Baseline histology was obtained using forceps (n = 182) or EMR (n = 23). ESD changed the histologic diagnosis in 55.1% of cases (113/205), of which 68.1% were upstaged and 31.9% downstaged. The frequency of change in diagnosis after ESD was similar whether baseline histology was obtained using forceps (55.5%) or EMR (52.2%) (P = .83). In aggregate, 23.9% of cases (49/205) were upstaged to invasive cancer on ESD histopathology. On multivariate analysis, lesions in the distal esophagus and gastroesophageal junction (odds ratio, 2.1; 95 confidence interval, 1.1-3.9; P = .02) and prior radiofrequency ablation (odds ratio, 2.5; 95% confidence interval, 1.2-5.5; P = .02) were predictors of change in histologic diagnosis. CONCLUSIONS ESD led to a change of diagnosis in more than half of patients with BE visible neoplasia. Selective ESD can serve as a potential diagnostic and staging tool, particularly in those with suspected invasive disease. (Clinical trial registration number: NCT02989818.).
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Affiliation(s)
- Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - William King
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael S Karasik
- Division of Gastroenterology and Hepatology, Hartford Hospital, Hartford, Connecticut, USA
| | - Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Center, Baltimore, Maryland, USA
| | - Abdul Aziz Aadam
- Division of Gastroenterology and Hepatology, Northwestern Medicine Digestive Health Center, Chicago, Illinois, USA
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, USA
| | - Neil Sharma
- Division of Interventional Endoscopic Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, Indiana, USA
| | - Ian S Grimm
- Division of Gastroenterology and Hepatology, University of North Carolina Hospitals, Chapel Hill, North Carolina, USA
| | - Alaa Rostom
- Division of Gastroenterology and Hepatology, The Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - B Joseph Elmunzer
- Division of Gastroenterology and Hepatology, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Salmaan A Jawaid
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, Texas, USA
| | - Yaseen B Perbtani
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Brenda J Hoffman
- Division of Gastroenterology and Hepatology, The Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ashwin S Akki
- Department of Pathology Immunology and Laboratory Medicine, University of Florida, Gainesville, Florida, USA
| | - Alexander Schlachterman
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Roxana M Coman
- Division of Hospital Gastroenterology, Atrium/Navicent Health, Mercer University, College of Medicine, Macon, Georgia, USA
| | - Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
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Othman MO, Bahdi F, Ahmed Y, Gagneja H, Andrawes S, Groth S, Dhingra S. Short-term clinical outcomes of non-curative endoscopic submucosal dissection for early esophageal adenocarcinoma. Eur J Gastroenterol Hepatol 2021; 33:e700-e708. [PMID: 34091478 DOI: 10.1097/meg.0000000000002223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVES Few Western studies highlighted the outcomes of endoscopic submucosal dissection (ESD) for early esophageal adenocarcinoma (EAC). Data regarding the outcomes of noncurative ESDs remains scarce. In this study, we share our experience with ESD for early EAC with a focus on noncurative ESDs. METHODS A retrospective single-center analysis of consecutive patients who underwent ESD for early EAC from August 2015 through February 2020. Primary outcomes included the clinical outcomes of noncurative ESDs along with overall en bloc, R0 and curative resection rates. Secondary outcomes included comparing results between T1a and T1b tumors. RESULTS Final group included 23 T1a and 17 T1b EAC patients. Patients' median Charlson comorbidity index was five. En bloc resection rate was (97.5%). Compared to the T1b group, the T1a group had a statistically significantly higher R0 (78.3 vs. 41.2%; P = 0.0235), curative (73.9 vs. 11.8%; P = 0.0001) and accumulative endoscopic curative resection rates (82.6 vs. 23.5%; P = 0.0003). A study flowchart is presented in (Fig. 1). Out of the 21 noncurative ESDs, 10 patients (47.6%) underwent R0 esophagectomy, 6 patients (28.6%) are undergoing surveillance endoscopies without additional therapy, 3 patients (14.3%) underwent repeat curative ESD and 1 patient (4.76%) is receiving chemotherapy with surveillance endoscopy. Over median endoscopic follow-up of 22.5 months (IQR, 14.25-30.75), 2 out of 10 patients with noncurative ESDs had recurrent disease. CONCLUSIONS ESD achieved a higher curative resection rate in T1a EAC when compared to T1b. Despite a lower curative resection rate in T1b EAC, certain patients might benefit from a conservative multimodal therapy.
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Affiliation(s)
- Mohamed O Othman
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine.,Baylor St Luke's Medical Center
| | - Firas Bahdi
- Baylor St Luke's Medical Center.,Department of Medicine, Baylor College of Medicine, Houston
| | | | | | - Sherif Andrawes
- Division of Gastroenterology, Staten Island University Hospital, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Staten Island University Hospital, Staten Island, New York
| | - Shawn Groth
- Baylor St Luke's Medical Center.,Division of General Thoracic Surgery, Baylor College of Medicine
| | - Sadhna Dhingra
- Baylor St Luke's Medical Center.,Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas, USA
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Duvvuri A, Desai M, Srinivasan S, Chandrashekar VT, Vennelaganti S, Vennalaganti P, Jani B, Lim D, Ciscato C, Spaggiari P, Consolo P, Porter J, Ferrara E, Kennedy K, Gupta N, Mathur S, Sharma P, Repici A. Surveillance of neo-squamous epithelium after ablation of Barrett's esophagus: is it better to use jumbo over standard biopsy forceps? Dis Esophagus 2020; 33:doaa044. [PMID: 32462180 DOI: 10.1093/dote/doaa044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/03/2020] [Accepted: 04/28/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS As obtaining adequate tissue on biopsy is critical for the detection of residual and recurrent intestinal metaplasia/dysplasia in Barrett's esophagus (BE) patients undergone Barrett's endoscopic eradication therapy (BET), we decided to compare the adequacy of biopsy specimens using jumbo versus standard biopsy forceps. METHODS This is a two-center study of patients' post-radiofrequency ablation of dysplastic BE. After BET, jumbo (Boston Scientific©, Radial Jaw 4, opening diameter 2.8 mm) or standard (Boston Scientific©, Radial Jaw 4, opening diameter 2.2 mm) biopsy forceps were utilized to obtain surveillance biopsies from the neo-squamous epithelium. Presence of lamina propria and proportion of squamous epithelium with partial or full thickness lamina propria was recorded by two experienced gastrointestinal pathologists who were blinded. Squamous epithelial biopsies that contained at least two-thirds of lamina propria were considered 'adequate'. RESULTS In a total of 211 biopsies from 55 BE patients, 145 biopsies (29 patients, 18 males, mean age 61 years, interquartile range [IQR] 33-83) were obtained using jumbo forceps and 66 biopsies (26 patients, all males, mean age 65 years, IQR 56-76) using standard forceps biopsies. Comparing jumbo versus standard forceps, the proportion of specimens with any subepithelial lamina propria was 51.7% versus 53%, P = 0.860 and the presence of adequate subepithelial lamina propria was 17.9% versus 9.1%, P = 0.096 respectively. CONCLUSIONS Use of jumbo forceps does not appear to have added advantage over standard forceps to obtain adequate biopsy specimens from the neo-squamous mucosa post-ablation.
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Affiliation(s)
- Abhiram Duvvuri
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Madhav Desai
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Sachin Srinivasan
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | | | - Sreekar Vennelaganti
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | | | - Bhairvi Jani
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Diego Lim
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Camilla Ciscato
- Department of Gastroenterology, Istituto Clinico Humanitas, Rozzano, Lombardy, Italy
| | - Paola Spaggiari
- Department of Gastroenterology, Istituto Clinico Humanitas, Rozzano, Lombardy, Italy
| | - Pierluigi Consolo
- Department of Gastroenterology, Istituto Clinico Humanitas, Rozzano, Lombardy, Italy
| | - Jaime Porter
- Department of Gastroenterology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Elisa Ferrara
- Department of Gastroenterology, Istituto Clinico Humanitas, Rozzano, Lombardy, Italy
| | - Kevin Kennedy
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Neil Gupta
- Department of Gastroenterology, Loyola University Medical Center, Maywood, IL, USA
| | - Sharad Mathur
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Prateek Sharma
- Department of Gastroenterology, Veterans Affairs Medical Center, Kansas City, MO, USA
| | - Alessandro Repici
- Department of Gastroenterology, Istituto Clinico Humanitas, Rozzano, Lombardy, Italy
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Spadaccini M, Bhandari P, Maselli R, Spaggiari P, Alkandari AA, Varytimiadis L, Semeraro R, Di Leo M, Galtieri PA, Craviotto V, Lamonaca L, D'Amico F, Attardo S, Brambilla T, Sharma P, Hassan C, Repici A. Multi-band mucosectomy for neoplasia in patients with Barrett's esophagus: in vivo comparison between two different devices. Surg Endosc 2019; 34:3845-3852. [PMID: 31586245 DOI: 10.1007/s00464-019-07150-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Accepted: 09/24/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Multi-band mucosectomy (MBM) is effective and safe for Barrett's neoplasia. No studies have yet compared the efficacy and safety of the MBM devices commercially available: Duette™ (CookMedical) and Captivator™ (BostonScientific). Our aim is to compare the two devices. METHODS This is a dual-center retrospective case-control study (Rozzano, Portsmouth) comparing efficacy, safety, and histology of resected specimens between Duette™ (DUE) and Captivator™ (CAPT). Efficacy was assessed by R0 and local recurrence (LR) rate. Bleedings, perforations, and strictures were recorded as safety outcomes. Moreover, the specimens were re-examined by two pathologists, blinded about the study group, to assess the maximum thickness of both the whole specimens and the resected submucosal layer. RESULTS Seventy-six patients (38 per group) were included. The two groups did not differ in terms of baseline characteristics. R0 resection was achieved in 96.7% versus 96.3% (p = ns) and LR were recorded in 4/38 (10.5%) versus 3/38 (7.9%) in DUE and CAPT group, respectively (p = ns). Considering Duette™ versus Captivator™, 2 versus 3 patients developed a symptomatic stricture. Only one post-procedural bleeding occurred (Captivator™). Maximum medium thicknesses of specimens and of resected submucosa did not differ between the groups. CONCLUSIONS MBM is safe and effective for resecting visible lesions using either of the two available devices.
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Affiliation(s)
- Marco Spadaccini
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy.
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK
| | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Paola Spaggiari
- Pathology Unit, Humanitas Research Hospital, 20089, Rozzano, Italy
| | - Asma A Alkandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK
| | - Lazaros Varytimiadis
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, PO6 3LY, UK
| | - Rossella Semeraro
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Milena Di Leo
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Piera Alessia Galtieri
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Vincenzo Craviotto
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Laura Lamonaca
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Ferdinando D'Amico
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | - Simona Attardo
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
| | | | - Prateek Sharma
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, 64128, USA
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Humanitas Research Hospital, Via Manzoni 56, 20089, Rozzano, Milan, Italy
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Lo WCY, Uribe-Patarroyo N, Hoebel K, Beaudette K, Villiger M, Nishioka NS, Vakoc BJ, Bouma BE. Balloon catheter-based radiofrequency ablation monitoring in porcine esophagus using optical coherence tomography. BIOMEDICAL OPTICS EXPRESS 2019; 10:2067-2089. [PMID: 31086717 PMCID: PMC6484999 DOI: 10.1364/boe.10.002067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/15/2019] [Accepted: 03/12/2019] [Indexed: 05/05/2023]
Abstract
We present a microscopic image guidance platform for radiofrequency ablation (RFA) using a clinical balloon-catheter-based optical coherence tomography (OCT) system, currently used in the surveillance of Barrett's esophagus patients. Our integrated thermal therapy delivery and monitoring platform consists of a flexible, customized bipolar RFA electrode array designed for use with a clinical balloon OCT catheter and a processing algorithm to accurately map the thermal coagulation process. Non-uniform rotation distortion was corrected using a feature tracking-based technique, which enables robust, frame-to-frame analysis of the temporal fluctuation of the complex OCT signal. With proper noise calibration, precise delineation of the thermal therapy zone was demonstrated using cumulative complex differential variance in porcine esophagus ex vivo with the integrated OCT-RFA system, as validated by nitroblue tetrazolium chloride (NBTC) histology. The ability to directly and accurately visualize the thermal coagulation process at high resolution is critical to the precise delivery of thermal energy to a wide range of epithelial lesions.
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Affiliation(s)
- William C Y Lo
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02142, USA
| | - Néstor Uribe-Patarroyo
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
| | - Katharina Hoebel
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
| | - Kathy Beaudette
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
| | - Martin Villiger
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
| | - Norman S Nishioka
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
- Department of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Boston, Massachusetts 02114, USA
| | - Benjamin J Vakoc
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02142, USA
| | - Brett E Bouma
- Wellman Center for Photomedicine, Massachusetts General Hospital and Harvard Medical School, 40 Blossom Street, Boston, Massachusetts 02114, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts 02142, USA
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Endoscopic submucosal dissection compared to endoscopic mucosal resection for early Barrett esophagus neoplasia. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Wani S, Qumseya B, Sultan S, Agrawal D, Chandrasekhara V, Harnke B, Kothari S, McCarter M, Shaukat A, Wang A, Yang J, Dewitt J. Endoscopic eradication therapy for patients with Barrett's esophagus-associated dysplasia and intramucosal cancer. Gastrointest Endosc 2018; 87:907-931.e9. [PMID: 29397943 DOI: 10.1016/j.gie.2017.10.011] [Citation(s) in RCA: 107] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 10/25/2017] [Indexed: 02/07/2023]
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Endoscopic submucosal dissection for Barrett's early neoplasia: a multicenter study in the United States. Gastrointest Endosc 2017; 86:600-607. [PMID: 27688205 DOI: 10.1016/j.gie.2016.09.023] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Accepted: 09/18/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The role of endoscopic submucosal dissection (ESD) in Barrett's early neoplasia is not well defined, with most studies originating from Asia and Europe. We aimed to assess the efficacy, safety, and results of ESD in Barrett's esophagus (BE) with high-grade dysplasia (HGD) and early adenocarcinoma (EAC) across centers in the United States. METHODS Multicenter retrospective analysis on 46 patients with BE who underwent ESD for BE-HGD or EAC, or both, between January 2010 and April 2015. The primary endpoint was the rate of en bloc resection. Secondary aims included rate of R0 (complete) and curative resection, a comparison of pre- and post-ESD histology, procedure-related adverse events, and rate of remission at follow-up. RESULTS Median age was 69 years (range, 42-82 years). The median resected specimen size was 45 mm (range, 13-125 mm). En bloc and curative resection rates were 96% (44/46) and 70% (32/46), respectively. Most lesions (11/20; 55%) diagnosed as BE-HGD on biopsy were upstaged to intramucosal or invasive EAC on post-ESD histopathology. There were 4 early (<48 hours) adverse events (3 bleeding and 1 perforation), and all were treated endoscopically. Seven patients (15%) developed esophageal strictures that were managed endoscopically. Complete remission of BE neoplasia was found in 100% (32/32) of patients with curative resection at median follow-up of 11 months (range, 2-25 months). CONCLUSIONS This is the largest multicenter series of ESD for early neoplastic BE from the United States. ESD appears to be safe and effective, with high en bloc and curative resection rates in the treatment of early BE neoplasia.
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Abstract
Barrett esophagus (BE) is the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer associated with a poor 5-year survival rate. The stepwise pathologic progression of BE to invasive cancer provides an opportunity to halt progression and potentially decrease incidence and ultimately the morbidity and mortality related to this lethal cancer. Endoscopic eradication therapy (EET) in patients at increased risk of progression to invasive EAC (intramucosal EAC, high-grade dysplasia, and low-grade dysplasia) is a practice that is endorsed by multiple societies and has replaced esophagectomy as the standard of care for these patients. Although the effectiveness, safety, and durability of EET have been demonstrated in several studies, this review addresses the several challenges with EET that need to be considered to optimize patient outcomes. Finally, the critical role of training, competence, and quality indicators in EET are emphasized in this era of value-based health care practice.
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Wani S, Rubenstein JH, Vieth M, Bergman J. Diagnosis and Management of Low-Grade Dysplasia in Barrett's Esophagus: Expert Review From the Clinical Practice Updates Committee of the American Gastroenterological Association. Gastroenterology 2016; 151:822-835. [PMID: 27702561 DOI: 10.1053/j.gastro.2016.09.040] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The purpose of this clinical practice update expert review is to define the key principles in the diagnosis and management of low-grade dysplasia (LGD) in Barrett's esophagus patients. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Practice Advice 1: The extent of Barrett's esophagus should be defined using a standardized grading system documenting the circumferential and maximal extent of the columnar lined esophagus (Prague classification) with a clear description of landmarks and visible lesions (nodularity, ulceration) when present. Practice Advice 2: Given the significant interobserver variability among pathologists, the diagnosis of Barrett's esophagus with LGD should be confirmed by an expert gastrointestinal pathologist (defined as a pathologist with a special interest in Barrett's esophagus-related neoplasia who is recognized as an expert in this field by his/her peers). Practice Advice 3: Expert pathologists should report audits of their diagnosed cases of LGD, such as the frequency of LGD diagnosed among surveillance patients and/or the difference in incidence of neoplastic progression among patients diagnosed with LGD vs nondysplastic Barrett's esophagus. Practice Advice 4: Patients in whom the diagnosis of LGD is downgraded to nondysplastic Barrett's esophagus should be managed as nondysplastic Barrett's esophagus. Practice Advice 5: In Barrett's esophagus patients with confirmed LGD (based on expert gastrointestinal pathology review), repeat upper endoscopy using high-definition/high-resolution white-light endoscopy should be performed under maximal acid suppression (twice daily dosing of proton pump inhibitor therapy) in 8-12 weeks. Practice Advice 6: Under ideal circumstances, surveillance biopsies should not be performed in the presence of active inflammation (erosive esophagitis, Los Angeles grade C and D). Pathologists should be informed if biopsies are obtained in the setting of erosive esophagitis and if pathology findings suggest LGD, or if no biopsies are obtained, surveillance biopsies should be repeated after the anti-reflux regimen has been further intensified. Practice Advice 7: Surveillance biopsies should be performed in a four-quadrant fashion every 1-2 cm with target biopsies obtained from visible lesions taken first. Practice Advice 8: Patients with a confirmed histologic diagnosis of LGD should be referred to an endoscopist with expertise in managing Barrett's esophagus-related neoplasia practicing at centers equipped with high-definition endoscopy and capable of performing endoscopic resection and ablation. Practice Advice 9: Endoscopic resection should be performed in Barrett's esophagus patients with LGD with endoscopically visible abnormalities (no matter how subtle) in order to accurately assess the grade of dysplasia. Practice Advice 10: In patients with confirmed Barrett's esophagus with LGD by expert GI pathology review that persists on a second endoscopy, despite intensification of acid-suppressive therapy, risks and benefits of management options of endoscopic eradication therapy (specifically adverse events associated with endoscopic resection and ablation), and ongoing surveillance should be discussed and documented. Practice Advice 11: Endoscopic eradication therapy should be considered in patients with confirmed and persistent LGD with the goal of achieving complete eradication of intestinal metaplasia. Practice Advice 12: Patients with LGD undergoing surveillance rather than endoscopic eradication therapy should undergo surveillance every 6 months times 2, then annually unless there is reversion to nondysplastic Barrett's esophagus. Biopsies should be obtained in 4-quadrants every 1-2 cm and of any visible lesions. Practice Advice 13: In patients with Barrett's esophagus-related LGD undergoing ablative therapy, radiofrequency ablation should be used. Practice Advice 14: Patients completing endoscopic eradication therapy should be enrolled in an endoscopic surveillance program. Patients who have achieved complete eradication of intestinal metaplasia should undergo surveillance every year for 2 years and then every 3 years thereafter to detect recurrent intestinal metaplasia and dysplasia. Patients who have not achieved complete eradication of intestinal metaplasia should undergo surveillance every 6 months for 1 year after the last endoscopy, then annually for 2 years, then every 3 years thereafter. Practice Advice 15: Following endoscopic eradication therapy, the biopsy protocol of obtaining biopsies in 4 quadrants every 2 cm throughout the length of the original Barrett's esophagus segment and any visible columnar mucosa is suggested. Practice Advice 16: Endoscopists performing endoscopic eradication therapy should report audits of their rates of complete eradication of dysplasia and intestinal metaplasia and adverse events in clinical practice.
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Affiliation(s)
- Sachin Wani
- University of Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; University of Michigan Medical School, Ann Arbor, Michigan
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Coman RM, Gotoda T, Forsmark CE, Draganov PV. Prospective evaluation of the clinical utility of endoscopic submucosal dissection (ESD) in patients with Barrett's esophagus: a Western center experience. Endosc Int Open 2016; 4:E715-21. [PMID: 27556083 PMCID: PMC4993890 DOI: 10.1055/s-0042-101788] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 01/23/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) carries significant advantages over endoscopic mucosal resection. As such, ESD is an established therapy for esophageal squamous cell carcinoma but there are only limited data on ESD as therapy for Barrett's esophagus (BE). Thus, we prospectively evaluated the outcomes of ESD in patients with BE with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) performed in a Western center. PATIENTS AND METHODS This is a prospective cohort study. Indications for ESD included: (1) early EAC defined as lesions with intramucosal cancer or superficial submucosal invasion; (2) early EAC with positive lateral margin after EMR; and (3) nodularity with HGD that could not be removed en-bloc with EMR Results: From October 2013 to July 2015, 36 consecutive patients (median age 69, 32 males) underwent ESD at our center. Median procedure time was 88 minutes, with median maximal diameter of resected specimens of 49 mm. En-bloc, R0, and curative resection rates were 100 %, 81 %, and 69 %, respectively. Intramucosal EAC was found in 13 patients (36 %), and submucosal invasion in 13 patients (36 %). In 59 % of the cases, there was discrepancy in the pre- and post-ESD histopathologic diagnosis. Adverse events occurred in 8 patients (22 %), including one episode of bleeding treated with endoscopy and seven esophageal strictures, which were successfully managed with dilations. CONCLUSIONS ESD for BE with HGD/early EAC is feasible and safe with resulting very high en-bloc and R0 resection rates. ESD provided for more accurate pathologic evaluation and significant discrepancy between the pre- and post-ESD histopathological diagnosis was noted.
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Affiliation(s)
- Roxana M. Coman
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Christopher E. Forsmark
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Florida, United States,Corresponding author Peter V. Draganov, MD University of FloridaDivision of Gastroenterology, Hepatology, and Nutrition1329 SW 16th Archer RoadPO Box 100214Gainesville, FL 32610
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Abstract
Barrett's esophagus is the only identifiable premalignant condition for esophageal adenocarcinoma. Endoscopic eradication therapy (EET) has revolutionized the management of Barrett's-related dysplasia and intramucosal cancer. The primary goal of EET is to prevent progression to invasive esophageal adenocarcinoma and ultimately improve survival rates. There are several challenges with EET that can be encountered before, during, or after the procedure that are important to understand to optimize the effectiveness and safety of EET and ultimately improve patient outcomes. This article focuses on the challenges with EET and discusses them under the categories of preprocedural, intraprocedural, and postprocedural challenges.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Mail Stop F735, 1635 Aurora Court, Room 2.031, Aurora, CO 80045, USA.
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas, 4801 Linwood Boulevard, Kansas City, MO 64128, USA
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Milashka M, Calomme A, Van Laethem JL, Blero D, Eisendrath P, Le Moine O, Devière J. Sixteen-year follow-up of Barrett's esophagus, endoscopically treated with argon plasma coagulation. United European Gastroenterol J 2014; 2:367-73. [PMID: 25360314 DOI: 10.1177/2050640614549095] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/29/2014] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVE The thermal destruction of non-dysplastic Barrett's esophagus (BE) and its replacement by squamous epithelium is an attractive, but unproven strategy to avoid further development of dysplasia or cancer. The goal of this study was to estimate the persistence of restoration of squamous epithelium and the risk of cancer in BE that was eradicated using argon plasma coagulation (APC) in the absence of high-grade dysplasia, 16 years after its application. DESIGN We followed 32 patients with BE who underwent eradication of metaplastic epithelium using APC, up to 16 years later. RESULTS At the end of the initial treatment, 25 of 32 patients (78%) had complete endoscopic eradication, there was partial squamous re-epithelialization in four patients (13%) and it was absent in three patients (9%). We observed buried metaplastic glands under new squamous epithelium in 6 of the 25 patients who had complete endoscopic eradication. At follow-up, sustained complete endoscopic eradication was observed in 16 of 32 patients (50%), partial eradication in 11 of 32 patients (35%); there were two patients (6%) lost to follow-up and three patients (9%) developed esophageal adenocarcinoma. Two of the latest cases arose from the buried glands under neosquamous epithelium after complete eradication and one arose from a small remaining Barrett's segment. CONCLUSIONS We observed long-term re-epithelialization in the majority of patients who had previously had complete eradication of Barrett's esophagus. This did not provide protection against cancer development, as the incidence of cancers arising from buried glands or from residual Barrett's esophagus was similar to that observed in patients undergoing no specific treatment.
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Affiliation(s)
- Mariana Milashka
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Annabelle Calomme
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Luc Van Laethem
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Blero
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Pierre Eisendrath
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier Le Moine
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Devière
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, ERASME Hospital, Université Libre de Bruxelles, Brussels, Belgium
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14
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Wani S, Abrams J, Edmundowicz SA, Gaddam S, Hovis CE, Green D, Gupta N, Higbee A, Bansal A, Rastogi A, Early D, Lightdale CJ, Sharma P. Endoscopic mucosal resection results in change of histologic diagnosis in Barrett's esophagus patients with visible and flat neoplasia: a multicenter cohort study. Dig Dis Sci 2013; 58:1703-9. [PMID: 23633158 PMCID: PMC4309270 DOI: 10.1007/s10620-013-2689-7] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 04/09/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND There are limited data on the effect of endoscopic mucosal resection (EMR) on changes of histopathologic diagnosis for Barrett's esophagus (BE) patients undergoing endoscopic eradication therapy (EET); especially those without visible lesions. AIM To compare the frequency of changes of diagnosis by EMR compared with pre-EMR biopsy diagnosis for patients with and without visible lesions. METHODS In this multicenter outcomes project, patients with Barrett's-related neoplasia undergoing EET at three tertiary-care centers were included. Patients undergoing biopsies followed by EMR within six months were included. The main outcome measures were frequency of overall change of histopathologic diagnosis, change based on pre-EMR biopsy diagnosis, and change based on the presence of visible lesions. RESULTS One-hundred and thirty-eight BE patients (low-grade dysplasia (LGD) 15 (10.9 %), high-grade dysplasia (HGD) 87 (63 %), esophageal adenocarcinoma (EAC) 36 (26.1 %)) were included; 114 (82.6 %) patients had visible lesions. EMR resulted in a change of diagnosis for 43 (31.1 %) patients (upgrade 14 (10.1 %); downgrade 29 (21 %)). For HGD patients, EMR downstaged dysplasia grade for 17 (19.5 %) cases and upstaged it to EAC for nine (10.3 %) cases. There was a change of diagnosis for 26 (29.9 %) HGD patients, irrespective of the presence or absence of visible lesions (p = 0.76). For EAC patients, EMR downstaged dysplasia grade in 10 (27.8 %) cases. There was a change of diagnosis for 10 (27.8 %) EAC patients, irrespective of the presence or absence of endoscopically visible lesions (p = 0.48). CONCLUSIONS EMR results in a change of diagnosis for approximately 30 % of BE patients with early neoplasia (with and without visible lesions) referred for EET.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado and Veterans Affairs Medical Center, Denver, CO, USA
| | - Julian Abrams
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Steven A. Edmundowicz
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Christine E. Hovis
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel Green
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neil Gupta
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - April Higbee
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Ajay Bansal
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Amit Rastogi
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
| | - Dayna Early
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St. Louis, MO, USA
| | - Charles J. Lightdale
- Division of Digestive and Liver Diseases, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Department of Veterans Affairs Medical Center and University of Kansas School of Medicine, 4801 E. Linwood Blvd, Kansas City, MO 64128-2295, USA
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15
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Koike T, Nakagawa K, Iijima K, Shimosegawa T. Endoscopic resection (endoscopic submucosal dissection/endoscopic mucosal resection) for superficial Barrett's esophageal cancer. Dig Endosc 2013; 25 Suppl 1:20-8. [PMID: 23480400 DOI: 10.1111/den.12047] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2012] [Accepted: 01/08/2013] [Indexed: 12/16/2022]
Abstract
Recently developed endoscopic resection (endoscopic submucosal dissection [ESD]/ endoscopic mucosal resection) has dramatically changed the therapeutic approach for Barrett's esophageal cancer. The rationale for endoscopic resection is that lesions confined to the mucosal layer have negligible risk for developing lymph node metastasis and can be successfully eradicated by endoscopic treatment as a curative treatment with minimal invasiveness. According to some reports that analyzed the rate of lymph-node involvement relative to the depth of mucosal or submucosal tumor infiltration, endoscopic resection is clearly indicated for intramucosal carcinoma and might be extended to lesions with invasion into the submucosa (<200 μm, sm1) because of the low risk for lymph node metastasis. Most Japanese experts recommend ESD for Barrett's esophageal cancer after accurate diagnosis of the margin of cancer using narrow band imaging with magnifying endoscopy because of its high curative rate. However, few studies have evaluated the long-term outcomes of endoscopic resection for Barrett's esophageal cancer in Japan. Further investigations should be conducted to establish endoscopic resection for Barrett's esophageal cancer.
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Affiliation(s)
- Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan.
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16
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Abstract
Barrett esophagus (BE) is a well-established premalignant condition for esophageal adenocarcinoma (EAC), a lethal cancer with a dismal survival rate. The current guidelines recommend surveillance of patients with BE to detect dysplasia or early cancer before the development of invasive EAC. Recently, endoscopic eradication therapies have been shown to be safe and effective in the treatment of BE-related high-grade dysplasia and early EAC. This article reviews the various treatment options for BE and discusses the current evidence and gaps in knowledge in the understanding of treatment of this condition. In addition, recommendations are provided in context to the recently published guidelines by the American Gastroenterological Association.
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Affiliation(s)
- Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Washington University School of Medicine, St Louis, MO 63110-1093, USA
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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.
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Affiliation(s)
- Fábio Segal
- Fábio Segal, Physician and Endoscopist at Hospital Moinhos de Vento, Porto Alegre-RS, 90.035-001, Brazil
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18
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Titi M, Overhiser A, Ulusarac O, Falk GW, Chak A, Wang K, Sharma P. Development of subsquamous high-grade dysplasia and adenocarcinoma after successful radiofrequency ablation of Barrett's esophagus. Gastroenterology 2012; 143:564-566.e1. [PMID: 22561053 PMCID: PMC5511030 DOI: 10.1053/j.gastro.2012.04.051] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2012] [Revised: 04/04/2012] [Accepted: 04/24/2012] [Indexed: 12/20/2022]
Abstract
Patients with Barrett's esophagus are frequently treated with radiofrequency ablation (RFA). Those that undergo this procedure have a low risk of developing subsquamous intestinal metaplasia, and none have been reported to develop subsquamous dysplasia or cancer. We report the development of subsquamous neoplasia in 3 patients who were treated with RFA for Barrett's esophagus (2 developed adenocarcinoma and 1 developed high-grade dysplasia). The identification of these cases indicates the need for continued surveillance following RFA, even after complete eradication of intestinal metaplasia, and caution for widespread use of ablation, especially in patients with low-risk Barrett's esophagus.
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Affiliation(s)
- Mohammad Titi
- Veterans Affairs Medical Center, Kansas City, Missouri,University of Kansas School of Medicine, Kansas City, Kansas
| | - Andrew Overhiser
- Veterans Affairs Medical Center, Kansas City, Missouri,University of Kansas School of Medicine, Kansas City, Kansas
| | - Ozlem Ulusarac
- Veterans Affairs Medical Center, Kansas City, Missouri,University of Kansas School of Medicine, Kansas City, Kansas
| | - Gary W. Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Amitabh Chak
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kenneth Wang
- Mayo Graduate School of Medicine, College of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Prateek Sharma
- Veterans Affairs Medical Center, Kansas City, Missouri; University of Kansas School of Medicine, Kansas City, Kansas, Missouri.
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19
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Fitzgerald RC, Rubenstein JH. Oracular guidance on clinical management of early neoplastic Barrett's esophagus. Gastroenterology 2012; 143:282-4. [PMID: 22722048 DOI: 10.1053/j.gastro.2012.06.023] [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] [Indexed: 02/06/2023]
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20
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Caillol F, Bories E, Pesenti C, Poizat F, Monges G, Guiramand J, Esterni B, Giovannini M. Radiofrequency ablation associated to mucosal resection in the oesophagus: experience in a single centre. Clin Res Hepatol Gastroenterol 2012; 36:371-7. [PMID: 22361442 DOI: 10.1016/j.clinre.2012.01.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2011] [Revised: 11/07/2011] [Accepted: 01/02/2012] [Indexed: 02/04/2023]
Abstract
UNLABELLED Endoscopic resection (EMR) and radiofrequency ablation (RFA) form part of the treatment of Barrett's oesophagus (BO), dysplasia, superficial adenocarcinoma (OAC) associated with BO. PATIENTS AND METHODS Between June 2008 and April 2011, 34 patients underwent treatment with RFA (HALO system(®)), in a tertiary centre. For the study, patients were divided into two groups. Group 1 (16 patients of average 60 years old; 14 men, two women) received EMR and RFA. Group 2 (18 patients averaging 59 years age; 14 men, four women) received RFA without EMR in the year preceding the RFA. RESULTS In group 1, high grade dysplasia (HGD) was eradicated in 12 cases (92%), low grade dysplasia (LGD) in three cases (100%). Complete response occurred in nine cases (56%), partial response in 100% of cases. Mean follow-up was 15 months. In group 2, HGD was eradicated in one patient (100%), LGD in three patients (64%). A complete response was achieved in eight patients, partial response in four cases (77%). Mean follow-up was 10 months. The complication rate for groups 1 and 2 was of 18% and 10% respectively. No complication prevented completion of treatment or continued monitoring. Recurrence was evaluated to 5% in both groups. CONCLUSION RFA associated with EMR is feasible, offering probably better results and a very important advantage: a more complete histology before follow-up. Our results show effective treatment of BO and associated dysplasia with a low rate of complication. Nevertheless, when new techniques of BO ablation are used, the need to obtain histology before treatment should not be forgotten.
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Affiliation(s)
- F Caillol
- Endoscopy unit, Paoli Calmette institute, 232, boulevard Ste-Marguerite, 13009 Marseille, France.
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Wani S, Early D, Edmundowicz S, Sharma P. Management of high-grade dysplasia and intramucosal adenocarcinoma in Barrett's esophagus. Clin Gastroenterol Hepatol 2012; 10:704-11. [PMID: 22507878 DOI: 10.1016/j.cgh.2012.03.030] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 03/22/2012] [Accepted: 03/28/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Sachin Wani
- University of Colorado and Veterans Affairs Medical Center, Denver, CO 80045, USA.
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22
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Abstract
PURPOSE OF REVIEW This article discusses the various controversies that surround the management of low-grade dysplasia (LGD) in Barrett's esophagus. RECENT FINDINGS Data on the clinical course of LGD patients with regards to rates of progression to high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) are highly variable. Recent data suggest that the rate of progression to EAC may be similar to that of patients with nondysplastic Barrett's esophagus (0.4-0.5% per year). There is significant interobserver variability in the diagnosis of LGD even among expert gastrointestinal pathologists. Data on various endoscopic eradication therapies (EET) specifically in this patient population are limited. Eradication of LGD and intestinal metaplasia can be achieved by radiofrequency ablation as demonstrated in a randomized controlled trial. Although treatment appears to be durable for up to 3 years, progression to HGD and EAC can occur, highlighting the need for close endoscopic surveillance even after EET. SUMMARY There is a need to risk stratify Barrett's esophagus patients with LGD to identify patients most likely to progress using a reliable and objective system that incorporates clinical features, advanced imaging techniques and biomarkers. If such a high risk group could be identified, they may benefit from EET, whereas, the majority may be managed conservatively.
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Abstract
This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.
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Affiliation(s)
- Gianluca Rotondano
- Division of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Italy.
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24
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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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25
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Wani S, Falk GW, Post J, Yerian L, Hall M, Wang A, Gupta N, Gaddam S, Singh M, Singh V, Chuang KY, Boolchand V, Gavini H, Kuczynski J, Sud P, Bansal A, Rastogi A, Mathur SC, Young P, Cash B, Goldblum J, Lieberman DA, Sampliner RE, Sharma P. Risk factors for progression of low-grade dysplasia in patients with Barrett's esophagus. Gastroenterology 2011; 141:1179-86, 1186.e1. [PMID: 21723218 DOI: 10.1053/j.gastro.2011.06.055] [Citation(s) in RCA: 198] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2011] [Revised: 05/31/2011] [Accepted: 06/17/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Data vary on the progression of low-grade dysplasia (LGD) in patients with Barrett's esophagus (BE); in patients with LGD, we investigated the incidence of high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) and compared progression in patients with different forms of LGD (prevalent vs incident and multifocal vs unifocal). We assessed the effects of consensus diagnosis of LGD on progression rates to HGD and EAC among expert pathologists. METHODS In a multicenter outcomes project, 210 patients with BE and LGD (classified as incident, prevalent, or persistent) were included. Patients were followed up for an average of 6.2 years (959.6 patient-years). Persistent LGD was defined as detection of LGD on ≥2 consecutive occasions during the follow-up period and extent as either unifocal (LGD at one level of BE segment) or multifocal (>1 level). Histology specimens were reviewed by 2 blinded pathologists. RESULTS Six patients developed EAC (incidence of 0.44%/year), and 21 developed HGD (incidence of 1.6%/year). The incidence of the combination of HGD and EAC was 1.83%/year. There were no associations between presence of prevalent, incident, or persistent LGD and the extent of LGD with progression rates. Based on consensus diagnosis of 88 reviewed specimens, there was no difference in the progression of LGD to either EAC (the incidence based on analyses by the local pathologist was 0.18%/year, the incidence when there was agreement between the local and one central pathologist was 0.21%/year, and the incidence when all 3 pathologists were in agreement was 0.39%/year) or combined HGD and EAC (0.94%/year, 0.87%/year, and 0.84%/year, respectively). CONCLUSIONS Overall, patients with BE and LGD have a low annual incidence of EAC, similar to nondysplastic BE. There are no risk factors for progression and there is significant interobserver variation in diagnosis, even among expert pathologists.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA
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Ortiz-Fernández-Sordo J, Parra-Blanco A, García-Varona A, Rodríguez-Peláez M, Madrigal-Hoyos E, Waxman I, Rodrigo L. Endoscopic resection techniques and ablative therapies for Barrett’s neoplasia. World J Gastrointest Endosc 2011; 3:171-82. [PMID: 21954414 PMCID: PMC3180609 DOI: 10.4253/wjge.v3.i9.171] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 07/04/2011] [Accepted: 08/15/2011] [Indexed: 02/05/2023] Open
Abstract
Esophageal adenocarcinoma is the most rapidly increasing cancer in western countries. High-grade dysplasia (HGD) arising from Barrett’s esophagus (BE) is the most important risk factor for its development, and when it is present the reported incidence is up to 10% per patient-year. Adenocarcinoma in the setting of BE develops through a well known histological sequence, from non-dysplastic Barrett’s to low grade dysplasia and then HGD and cancer. Endoscopic surveillance programs have been established to detect the presence of neoplasia at a potentially curative stage. Newly developed endoscopic treatments have dramatically changed the therapeutic approach of BE. When neoplasia is confined to the mucosal layer the risk for developing lymph node metastasis is negligible and can be successfully eradicated by an endoscopic approach, offering a curative intention treatment with minimal invasiveness. Endoscopic therapies include resection techniques, also known as tissue-acquiring modalities, and ablation therapies or non-tissue acquiring modalities. The aim of endoscopic treatment is to eradicate the whole Barrett’s segment, since the risk of developing synchronous and metachronous lesions due to the persistence of molecular aberrations in the residual epithelium is well established.
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Affiliation(s)
- Jacobo Ortiz-Fernández-Sordo
- Jacobo Ortiz-Fernández-Sordo, Adolfo Parra-Blanco, Endoscopy Unit, Department of Gastroenterology, Central University Hospital of Asturias, Celestino Villamil S/N, Oviedo 33006, Asturias, Spain
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Vaira D, Gatta L, Ricci C, Castelli V, Fiorini G, Kajo E, Lanzini A. Gastroesophageal reflux disease and Barrett's esophagus. Intern Emerg Med 2011; 6:299-306. [PMID: 20614201 DOI: 10.1007/s11739-010-0427-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2010] [Accepted: 06/16/2010] [Indexed: 01/10/2023]
Abstract
Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. The spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epithelium (Barrett's esophagus), and adenocarcinoma. Barrett's esophagus is a premalignant lesion detected in the majority of patients with esophageal and gastroesophageal adenocarcinoma. The incidence of these cancers has been increasing in the United States and they are associated with a low rate of survival (5-year survival rate, 15-20%). When symptoms of gastroesophageal reflux disease are typical and the patient responds to therapy, no diagnostic tests are necessary to verify the diagnosis. Endoscopy is the primary test in patients whose condition is resistant to empirical therapy but its yield in this setting is low because of the poor correlation between symptoms attributed to the condition and endoscopic features of the disease. Clinical experience suggests that lifestyle modifications may be beneficial for gastroesophageal reflux disease although trials of the clinical efficacy of dietary or behavioral changes are lacking. Abundant data from randomized trials show benefits of inhibiting gastric acid secretion and suggest that proton-pump inhibitors are superior to H2-blockers and that both are superior to placebo. In patients with Barrett's esophagus, antireflux interventions are intended to control symptoms of reflux and promote healing of the esophageal mucosa. If a patient has symptoms refractory to proton-pump inhibitors or cannot tolerate such therapy, antireflux surgery, most commonly Nissen fundoplication, may be an alternative management approach. In patients with high-grade dysplasia, endoscopic therapies or surgical resection must be considered.
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Affiliation(s)
- Dino Vaira
- Department of Internal Medicine and Gastroenterology, S. Orsola Hospital, University of Bologna, Via Massarenti, 9, 40138, Bologna, Italy.
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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.
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Gisbert JP. [Ten major publications in 2010 with implications for clinical practice in gastroenterology]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:289-304. [PMID: 21474205 DOI: 10.1016/j.gastrohep.2011.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 02/28/2011] [Indexed: 05/30/2023]
Affiliation(s)
- Javier P Gisbert
- Servicio de Aparato Digestivo, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, España.
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30
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Patients with nondysplastic Barrett's esophagus have low risks for developing dysplasia or esophageal adenocarcinoma. Clin Gastroenterol Hepatol 2011; 9:220-7; quiz e26. [PMID: 21115133 DOI: 10.1016/j.cgh.2010.11.008] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 11/06/2010] [Accepted: 11/10/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The risks of dysplasia and esophageal adenocarcinoma (EAC) are not clear for patients with nondysplastic Barrett's esophagus (NDBE); the rate of progression has been overestimated in previous studies. We studied the incidences of dysplasia and EAC and investigated factors associated with progression of BE. METHODS The BE study is a multicenter outcomes project of a large cohort of patients with BE. Neoplasia was graded as low-grade dysplasia, high-grade dysplasia (HGD), or EAC. Patients followed up for at least 1 year after the index endoscopy examination were included, whereas those diagnosed with dysplasia and EAC within 1 year of diagnosis with BE (prevalent cases) were excluded. Of 3334 patients with BE, 1204 met the inclusion criteria (93.7% Caucasian; 88% male; mean age, 59.3 y) and were followed up for a mean of 5.52 years (6644.5 patient-years). RESULTS Eighteen patients developed EAC (incidence, 0.27%/y; 95% confidence interval [CI], 0.17-0.43) and 32 developed HGD (incidence, 0.48%/y; 95% CI, 0.34-0.68). The incidence of HGD and EAC was 0.63%/y (95% CI, 0.47-0.86). There were 217 cases of low-grade dysplasia (incidence, 3.6%/y; 95% CI, 3.2-4.1). Five and 10 years after diagnosis, 98.6% (n = 540) and 97.1% (n = 155) of patients with NDBE were cancer free, respectively. The length of the BE was associated significantly with progression (EAC <6 cm, 0.09%/y vs EAC ≥ 6 cm, 0.65%/y; P = 0.001). CONCLUSIONS There is a lower incidence of dysplasia and EAC among patients with NDBE than previously reported. Because most patients are cancer free after a long-term follow-up period, surveillance intervals might be lengthened, especially for patients with shorter segments of BE.
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SPECHLER STUARTJ, Sharma P, Souza RF, Inadomi JM, Shaheen NJ. American Gastroenterological Association technical review on the management of Barrett's esophagus. Gastroenterology 2011; 140:e18-52; quiz e13. [PMID: 21376939 PMCID: PMC3258495 DOI: 10.1053/j.gastro.2011.01.031] [Citation(s) in RCA: 783] [Impact Index Per Article: 60.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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32
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Abstract
Barrett's esophagus (BE) is defined as abnormal specialized columnar metaplasia with intestinalization in place of the normal squamous esophageal epithelium. Gastroesophageal reflux disease is a known risk factor for BE; nonetheless BE is also detected in asymptomatic individuals. Other risk factors for BE include smoking, male gender, age over 50 and obesity. Patients diagnosed with BE (without dysplasia) are recommended to undergo endoscopic surveillance every 3-5 years. Advances in imaging techniques (such as narrow band imaging, autofluorescence imaging and confocal laser endomicroscopy) have the potential to improve the detection of dysplasia and early cancer, thus making surveillance a more cost-effective endeavor. Patients with high grade dysplasia (HGD) and early cancer have a high rate of progression to invasive adenocarcinoma and traditionally these patients were treated with esophagectomy. The rapid advancement of endoscopic therapeutic techniques along with a low risk of complications have made endoscopic therapy an acceptable alternative to an esophagectomy in patients with HGD and early cancer. Several endoscopic treatment techniques such as endoscopic mucosal resection, multipolar electrocoagulation, photodynamic therapy, argon plasma coagulation, cryotherapy, and radiofrequency ablation have been studied for endoscopic treatment.
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Affiliation(s)
- Srinivas Gaddam
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, Kansas City, Missouri 64128-2295, USA
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Wani S, Mathur SC, Curvers WL, Singh V, Alvarez Herrero L, Hall SB, Ulusarac O, Cherian R, McGregor DH, Bansal A, Rastogi A, Ahmed B, Singh M, Gaddam S, Ten Kate FJ, Bergman J, Sharma P. Greater interobserver agreement by endoscopic mucosal resection than biopsy samples in Barrett's dysplasia. Clin Gastroenterol Hepatol 2010; 8:783-8. [PMID: 20472096 DOI: 10.1016/j.cgh.2010.04.028] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2010] [Revised: 03/25/2010] [Accepted: 04/26/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic mucosal resection (EMR) is an important diagnostic, staging, and therapeutic tool for patients with Barrett's esophagus (BE)-associated neoplasia. We analyzed the histopathologic characteristics of specimens collected during EMR compared with biopsy specimens from patients with BE and assessed interobserver variability in pathologists' assessment of EMR and biopsy specimens. METHODS We evaluated EMR (n = 251) and biopsy (n = 269) specimens collected from patients with BE at 2 tertiary referral centers. A detailed histologic analysis was performed for each EMR and biopsy specimen to determine the grade of dysplasia, depth of the specimen, proportion of specimen with dysplasia, and quality of samples. Interobserver agreement for both biopsy and EMR specimens (among 4 experienced pathologists) was calculated by using kappa statistics. RESULTS Histologic analysis showed that submucosa was present in the majority of EMRs, compared with biopsy specimens (88% vs 1%, P < .0001). Almost all biopsy specimens (99%) included lamina propria. However, the muscularis mucosa was observed in only 58% of biopsy specimens. For both EMR and biopsy specimens, the highest grade of dysplasia comprised < or =25% of the total area in >50% of the specimens. Interobserver agreement on the diagnosis of dysplasia was significantly greater for EMR specimens than biopsy specimens (low-grade dysplasia, 0.33 vs 0.22, P < .001; high-grade dysplasia, 0.43 vs 0.35, P = .018). CONCLUSIONS Submucosa can be examined in most samples collected from EMR; the distribution of neoplasia is focal within biopsy and EMR specimens. There is more interobserver agreement among pathologists in the analysis of EMR samples than biopsy specimens for the diagnosis of dysplasia.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology and Department of Pathology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA
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Fleischer DE, Odze R, Overholt BF, Carroll J, Chang KJ, Das A, Goldblum J, Miller D, Lightdale CJ, Peters J, Rothstein R, Sharma VK, Smith D, Velanovich V, Wolfsen H, Triadafilopoulos G. The case for endoscopic treatment of non-dysplastic and low-grade dysplastic Barrett's esophagus. Dig Dis Sci 2010; 55:1918-31. [PMID: 20405211 DOI: 10.1007/s10620-010-1218-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 03/22/2010] [Indexed: 12/24/2022]
Abstract
Non-dysplastic mucosa (ND-) in Barrett's esophagus (BE) shows clonal molecular aberrations, loss of cell cycle control, and other features of "neoplasia." These changes occur prior to morphologic expression of neoplasia (dysplasia). Morphologic evaluation of dysplasia is fraught with error, and, as a result, often leads to false-negative and false-positive diagnoses. Early "crypt dysplasia" is difficult to detect, and is often missed in routine biopsy specimens. Some studies show substantial progression rates of low-grade dysplasia (LGD), and crypt dysplasia, to esophageal adenocarcinoma (EAC). Dysplasia, even when fully developed, may, in certain circumstances, be difficult to differentiate from non-dysplastic (regenerating) BE. Radiofrequency ablation (RFA) is a safe and effective method for removing mucosa at risk of cancer. Given the difficulties of dysplasia assessment in mucosal biopsies, and the molecular characteristics of ND-BE, this technique should be considered for treatment of all BE patients, including those with ND or LGD. Post-ablation neo-squamous epithelium reveals no molecular abnormalities, and is biologically stable. Given that prospective randomized controlled trials of ablative therapy for ND-BE aiming at reducing EAC incidence and mortality are unlikely to be completed in the near future, endoscopic ablation is a valid management option. The success of RFA in achieving safe, uniform, reliable, and predictable elimination of BE allows surgeons to combine fundoplication with RFA. Currently, there is no type of treatment for dysplastic or non-dysplastic BE that achieves a complete response in 100% of patients, eliminates all risk of developing cancer, results in zero adverse events, is less expensive in terms of absolute costs than surveillance, is durable for 20+ years, or eliminates the need for surveillance. Regardless, RFA shows established safety, efficacy, durability, and cost-effective profiles that should be considered in the management of patients with non-dysplastic or low-grade dysplastic BE.
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Affiliation(s)
- David E Fleischer
- Department of Internal Medicine, Mayo Clinic in Arizona, Scottsdale, AZ 85259, USA.
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