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Levink IJM, Tearney GJ, Erler NS, Wolfsen HC, Siersema PD, Wallace MB. Barrett's Epithelial Thickness, Assessed by Volumetric Laser Endomicroscopy, Is Associated With Response to Radiofrequency Ablation. Clin Gastroenterol Hepatol 2021; 19:1160-1169.e2. [PMID: 32434069 DOI: 10.1016/j.cgh.2020.05.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/05/2020] [Accepted: 05/08/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA) is the most common treatment for flat Barrett's esophagus (BE), but reasons for varying outcomes are poorly understood. A recently developed contrast-enhancement algorithm allows reliable measurement of Barrett's epithelial thickness (BET) from volumetric laser endomicroscopy (VLE) images and correlation with response to RFA. Using this algorithm, we investigated whether patients with thicker Barrett's mucosa are less likely to respond to RFA. In the future, this algorithm may guide choice of RFA dosing or endoscopic resection. METHODS We performed a retrospective analysis on all patients with BE who received a baseline VLE scan between May 2015 and October 2016, followed by RFA and 1 follow-up exam, from 14 institutions participating in the United States VLE registry. We measured BET on equidistant locations by estimating the distance between the esophageal surface and the superficial edge of the deepest lamina propria. The primary outcome variable was the percentage reduction in Prague length; secondary outcome variables were complete remission of intestinal metaplasia (CRIM) and presence of strictures after 12 months. RESULTS Images from 61 patients were included in our final analysis. Mean BET per patient ranged from 224 μm to 705 μm. A 100 μm thicker mean BET per patient resulted in a 12% lower response to treatment, measured by a reduction of Prague length (P = .03), after adjustment for confounders. We found an association between mean BET and CRIM, but not with stricture formation. CONCLUSIONS Based on measurements on contrast-enhanced VLE images, we found that BET correlates with response to RFA. For clinical implementation, larger studies with a standardized follow-up and development of computer-aided image analysis systems are needed.
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Affiliation(s)
- Iris J M Levink
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida; Division of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands; Division of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Guillermo J Tearney
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Nicole S Erler
- Division of Biostatistics, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Peter D Siersema
- Division of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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2
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Vosko S, Gupta S, Shahidi N, Hourigan LF, van Hattem WA, Bar-Yishay I, Schoeman S, Sidhu M, Burgess NG, Lee EYT, Bourke MJ. Snare-tip soft coagulation is effective and efficient as a first-line modality for treating intraprocedural bleeding during Barrett's mucosectomy. Endoscopy 2021; 53:511-516. [PMID: 32659800 DOI: 10.1055/a-1218-6089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED BACKGROUND : Intraprocedural bleeding (IPB) during multiband mucosectomy (MBM) for Barrett's neoplasia can obscure the endoscopic field. Current hemostatic devices may affect procedure continuity and technical success. Snare-tip soft coagulation (STSC) as a first-line therapy for primary hemostasis has not previously been studied in this setting. METHODS Between January 2014 and November 2019, 191 consecutive patients underwent 292 MBM procedures for Barrett's neoplasia within a prospective observational cohort in two tertiary care centers. A standard MBM technique was performed. IPB was defined as bleeding obscuring the endoscopic field that required intervention. The primary outcome was the technical success and efficacy of STSC. RESULTS IPB occurred in 63 MBM procedures (21.6 %; 95 % confidence interval 17.3 % - 26.7 %). STSC was attempted as first-line therapy in 51 IPBs, with the remainder requiring alternate therapies because of pooling of blood. STSC achieved hemostasis in 48 cases (94.1 % by per-protocol analysis; 76.2 % by intention-to-treat analysis). No apparatus disassembly was required to perform STSC. CONCLUSIONS STSC is a safe, effective, and efficient first-line hemostatic modality for IPB during MBM for Barrett's neoplasia.
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Affiliation(s)
- Sergei Vosko
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sunil Gupta
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Neal Shahidi
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia.,Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Luke F Hourigan
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Gallipoli Medical Research Institute, School of Medicine, The University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - W Arnout van Hattem
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Iddo Bar-Yishay
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Scott Schoeman
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Mayenaaz Sidhu
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Nicholas G Burgess
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia.,Westmead Clinical School, University of Sydney, Sydney, New South Wales, Australia
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Spadaccini M, Belletrutti PJ, Attardo S, Maselli R, Chandrasekar VT, Galtieri PA, Fugazza A, Anderloni A, Carrara S, Pellegatta G, Hassan C, Sharma P, Repici A. Safety and efficacy of multiband mucosectomy for Barrett's esophagus: a systematic review with pooled analysis. Ann Gastroenterol 2021; 34:487-492. [PMID: 34276186 PMCID: PMC8276358 DOI: 10.20524/aog.2021.0620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background According to guidelines, all visible lesions in Barrett’s esophagus (BE) should be endoscopically resected. Available methods of endoscopic resection include the cap-assisted technique and, more recently, multiband mucosectomy (MBM). Data on the efficacy and safety of MBM have yet to be systematically reviewed. We performed the first systematic review with pooled analysis to evaluate the outcomes of MBM in patients with BE. Methods Electronic databases (Medline, Scopus, EMBASE) were searched up to August 2019. Studies including patients with BE who underwent MBM were eligible. The primary outcome was the adverse events rate. Secondary outcomes were the proportions of complete resections and R0 resections. Outcomes were assessed by pooling data using a random or fixed-effect model, according to the degree of heterogeneity, to obtain a proportion with a 95% confidence interval. Results Fourteen studies were eligible (1334 procedures, 986 patients). The adverse event rate was 5.3%. Immediate and post-procedural bleeding, perforations and strictures occurred in 0.2%, 0.7%, 0.3% and 3.9% of procedures, respectively. Focal lesions were resected at a complete rate of 97.6% with an R0 resection rate of 94.1%. Conclusion MBM is a safe and effective technique for treating visible lesions in BE.
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Affiliation(s)
- Marco Spadaccini
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici).,Department of Biomedical Sciences, Humanitas University, MI, Italy (Marco Spadaccini, Alessandro Repici)
| | - Paul J Belletrutti
- Medicine Department, University of Calgary, Calgary, Canada (Paul J. Belletrutti)
| | - Simona Attardo
- Gastroenterology Unit "AOU Ospedale Maggiore della Carità", Novara, Italy (Simona Attardo)
| | - Roberta Maselli
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | | | - Piera Alessia Galtieri
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Alessandro Fugazza
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Andrea Anderloni
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Silvia Carrara
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Gaia Pellegatta
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy (Cesare Hassan)
| | - Prateek Sharma
- Gastroenterology and Hepatology "Kansas City VA Medical Center", USA (Viveksandeep Thoguluva Chandrasekar, Prateek Sharma)
| | - Alessandro Repici
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici).,Department of Biomedical Sciences, Humanitas University, MI, Italy (Marco Spadaccini, Alessandro Repici)
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Çolak Ş, Gürbulak B, Çakar E, Bektaş H. Resection of Mucosal and Submucosal Gastrointestinal Lesions and a Double Endoscope Experience. JSLS 2019; 23:JSLS.2018.00096. [PMID: 30880899 PMCID: PMC6408942 DOI: 10.4293/jsls.2018.00096] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: The patients who underwent endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for mucosal and submucosal lesions of the esophagus, stomach, and duodenum and the advantages of the double endoscope method we used for traction during ESD were evaluated. Material and Methods: The patients who underwent ESD and EMR due to upper gastrointestinal lesions were evaluated retrospectively between January 2014 and April 2018 in our endoscopy unit. Result: The mean age of 10 patients with esophageal lesions was 53 years. ESD was performed for 7 lesions and EMR for 3 lesions. The most common lesion was leiomyoma and the median size of the lesions was 1.4 cm (range, 0.6–2.5 cm). The median age of 26 patients with gastric lesions was 61 years. EMR were performed for 11 lesions and ESD for 15 lesions. Double endoscope was used in 6 patients. One patient had intramucosal carcinoma, while the other lesions were benign and dysplasia was the most common lesion. The median size of lesions was 1.8 cm (range, 1–3 cm). All lesions were evaluated with endoscopic ultrasonography. Bleeding was seen in 4 patients and perforation in 1 patient during ESD and defect was closed with endoscopic clips. Conclusion: The advantages of endoscopic resections; short hospitalization, low complication rates, patient comfort, and doesn't require the general anesthesia. For endoscopic resection, we think that the second endoscope shortens the duration of the procedure, reduces the complication rate, and increases the comfort of the endoscopist.
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Affiliation(s)
- Şükrü Çolak
- Istanbul Training and Research Hospital, Department of General Surgery, Fatih, Istanbul, Turkey
| | - Bünyamin Gürbulak
- Istanbul Training and Research Hospital, Department of General Surgery, Fatih, Istanbul, Turkey
| | - Ekrem Çakar
- Istanbul Training and Research Hospital, Department of General Surgery, Fatih, Istanbul, Turkey
| | - Hasan Bektaş
- Istanbul Training and Research Hospital, Department of General Surgery, Fatih, Istanbul, Turkey
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Azari FS, Roses RE. Management of Early Stage Gastric and Gastroesophageal Junction Malignancies. Surg Clin North Am 2019; 99:439-456. [PMID: 31047034 DOI: 10.1016/j.suc.2019.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal and gastric carcinomas are prevalent malignancies worldwide. In contrast to the poor prognosis associated with advanced stages of disease, early stage disease has a favorable prognosis. Early stage gastric cancer (ESGC) is defined as cancer in which the depth of invasion is limited to the submucosal layer of the stomach on histologic examination, regardless of lymph node status. ESGC that meets standard or expanded criteria can be treated via endoscopic mucosal resection and endoscopic submucosal dissection. Similar indications for endoscopic interventions exist for gastroesophageal junction and esophageal malignancies."
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Affiliation(s)
- Feredun S Azari
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA
| | - Robert E Roses
- Department of Surgery, Hospital of the University of Pennsylvania, 3400 Spruce Street, 4 Silverstein Pavilion, Philadelphia, PA 19104, USA.
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de Matos MV, da Ponte-Neto AM, de Moura DTH, Maahs ED, Chaves DM, Baba ER, Ide E, Sallum R, Bernardo WM, de Moura EGH. Treatment of high-grade dysplasia and intramucosal carcinoma using radiofrequency ablation or endoscopic mucosal resection + radiofrequency ablation: Meta-analysis and systematic review. World J Gastrointest Endosc 2019; 11:239-248. [PMID: 30918589 PMCID: PMC6425278 DOI: 10.4253/wjge.v11.i3.239] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Revised: 02/13/2019] [Accepted: 02/20/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The progression of Barrett’s esophagus (BE) to early esophageal carcinoma occurs sequentially; the metaplastic epithelium develops from a low-grade dysplasia to a high-grade dysplasia (HGD), resulting in early esophageal carcinoma and, eventually, invasive carcinoma. Endoscopic approaches including resection and ablation can be used in the treatment of this condition.
AIM To compare the effectiveness of radiofrequency ablation (RFA) vs endoscopic mucosal resection (EMR) + RFA in the endoscopic treatment of HGD and intramucosal carcinoma.
METHODS In accordance with PRISMA guidelines, this systematic review included studies comparing the two endoscopic techniques (EMR + RFA and RFA alone) in the treatment of HGD and intramucosal carcinoma in patients with BE. Our analysis included studies involving adult patients of any age with BE with HGD or intramucosal carcinoma. The studies compared RFA and EMR + RFA methods were included regardless of randomization status.
RESULTS The seven studies included in this review represent a total of 1950 patients, with 742 in the EMR + RFA group and 1208 in the RFA alone group. The use of EMR + RFA was significantly more effective in the treatment of HGD [RD 0.35 (0.15, 0.56)] than was the use of RFA alone. The evaluated complications (stenosis, bleeding, and thoracic pain) were not significantly different between the two groups.
CONCLUSION Endoscopic resection in combination with RFA is a safe and effective method in the treatment of HGD and intramucosal carcinoma, with higher rates of remission and no significant differences in complication rates when compared to the use of RFA alone.
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Affiliation(s)
- Mileine Valente de Matos
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
| | - Alberto Machado da Ponte-Neto
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
| | - Ethan Dwane Maahs
- Genetics, Genomics and Development (Molecular and Cell Biology) Department, University of California Berkeley, Berkeley, CA 97420, United States
| | - Dalton Marques Chaves
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
| | - Elisa Ryoka Baba
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
| | - Edson Ide
- Gastrointestinal Endoscopy Unit, Gastroenterology Department, University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
| | - Rubens Sallum
- Gastrointestinal Surgery, Gastroenterology Department, University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
| | - Wanderley Marques Bernardo
- Thoracic Surgery Department, Instituto do Coração (InCor, Heart Institute), University of Sao Paulo School of Medicine, São Paulo, SP 05403-000, Brazil
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Levink IJM, Wolfsen HC, Siersema PD, Wallace MB, Tearney GJ. Measuring Barrett's Epithelial Thickness with Volumetric Laser Endomicroscopy as a Biomarker to Guide Treatment. Dig Dis Sci 2019; 64:1579-1587. [PMID: 30632054 PMCID: PMC6522645 DOI: 10.1007/s10620-018-5453-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 12/31/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Radiofrequency ablation (RFA) treatment outcomes vary for unknown reasons. One hypothesis is that variations in Barrett's epithelial thickness (BET) are associated with reduced RFA efficacy for thicker BET and strictures for thinner BET. Volumetric laser endomicroscopy (VLE) is an imaging modality that acquires high-resolution, depth-resolved images of BE. However, the attenuation of light by tissue and the lack of layering in Barrett's tissue challenge BET measurements and the study of relationships between thickness and RFA outcomes. We aimed to quantify BET and compared the reliability of standard and contrast-enhanced VLE images. METHODS Baseline VLE scans from BE patients without prior ablative therapy and a Prague (M) length of > 1 cm were obtained from the US VLE Registry. An algorithm was applied to the VLE images to flatten the mucosal surface and enhance the contrast of different esophageal wall layers. Subsequently, BET was measured by two independent VLE readers using both contrast- and non-contrast-enhanced datasets. In order to validate these adjusted images, intra- and interobserver agreements were calculated. RESULTS VLE scans from fifty-seven patients were included in this study. BET was measured at eight equidistant locations on the selected cross-sectional images at 0.5 cm intervals from the GEJ to the proximal-most extent of BE. The intra-observer coefficients of the two readers for the contrast-enhanced images were 0.818 (95% CI 0.798-0.836) and 0.890 (95% CI 0.878-0.900). The interobserver agreement for the contrast-enhanced images (0.880; 95% CI 0.867-0.891) was significantly better than for the original images (0.778; 95% CI 0.754-0.799). CONCLUSION We developed an algorithm that improves VLE visualization of the mucosal layers of the esophageal wall and enables rapid and reliable measurement of BET. Interobserver variability measurements were significantly reduced when using contrast enhancement. Studies are underway to correlate BET with treatment response.
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Affiliation(s)
- I. J. M. Levink
- 0000 0004 0443 9942grid.417467.7Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA ,0000 0004 0444 9382grid.10417.33Division of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Noord 10, 6525 GA Nijmegen, The Netherlands ,000000040459992Xgrid.5645.2Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - H. C. Wolfsen
- 0000 0004 0443 9942grid.417467.7Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - P. D. Siersema
- 0000 0004 0444 9382grid.10417.33Division of Gastroenterology and Hepatology, Radboud University Medical Center, Geert Grooteplein Noord 10, 6525 GA Nijmegen, The Netherlands
| | - M. B. Wallace
- 0000 0004 0443 9942grid.417467.7Division of Gastroenterology and Hepatology, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - G. J. Tearney
- 0000 0004 0386 9924grid.32224.35Department of Pathology & Wellman Center for Photomedicine, Massachusetts General Hospital, 55 Fruit St., Boston, MA 02114 USA
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Endoscopic eradication therapy for Barrett’s esophagus: Adverse outcomes, patient values, and cost-effectiveness. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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9
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di Pietro M, Canto MI, Fitzgerald RC. Endoscopic Management of Early Adenocarcinoma and Squamous Cell Carcinoma of the Esophagus: Screening, Diagnosis, and Therapy. Gastroenterology 2018; 154:421-436. [PMID: 28778650 PMCID: PMC6104810 DOI: 10.1053/j.gastro.2017.07.041] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/16/2022]
Abstract
Because the esophagus is easily accessible with endoscopy, early diagnosis and curative treatment of esophageal cancer is possible. However, diagnosis is often delayed because symptoms are not specific during early stages of tumor development. The onset of dysphagia is associated with advanced disease, which has a survival at 5 years lower than 15%. Population screening by endoscopy is not cost-effective, but a number of alternative imaging and cell analysis technologies are under investigation. The ideal screening test should be inexpensive, well tolerated, and applicable to primary care. Over the past 10 years, significant progress has been made in endoscopic diagnosis and treatment of dysplasia (squamous and Barrett's), and early esophageal cancer using resection and ablation technologies supported by evidence from randomized controlled trials. We review the state-of-the-art technologies for early diagnosis and minimally invasive treatment, which together could reduce the burden of disease.
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Affiliation(s)
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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10
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Efficacy and safety outcomes of multimodal endoscopic eradication therapy in Barrett's esophagus-related neoplasia: a systematic review and pooled analysis. Gastrointest Endosc 2017; 85:482-495.e4. [PMID: 27670227 DOI: 10.1016/j.gie.2016.09.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Focal EMR followed by radiofrequency ablation (f-EMR + RFA) and stepwise or complete EMR (s-EMR) are established strategies for eradication of Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC)/intramucosal carcinoma (IMC). The objective of this study was to derive pooled rates of efficacy and safety of individual methods in a large cohort of patients with BE and to indirectly compare the 2 methods. METHODS PubMed, Embase, Web of Science, Cochrane, and major conference proceedings were searched. A systematic review and pooled analysis were carried out to determine the following outcomes in patients with BE undergoing either f-EMR + RFA or s-EMR: (1) complete eradication rates of neoplasia (CE-N) and intestinal metaplasia (CE-IM); (2) recurrence rates of cancer (EAC), dysplasia, and IM; (3) incidence rates of adverse events. Mixed logistic regression was performed as an exploratory analysis to examine differences in outcomes between the 2 methods. RESULTS Nine studies (774 patients) of f-EMR + RFA and 11 studies (751 patients) of s-EMR were included. Patients undergoing f-EMR + RFA had high BE eradication rates (CE-N, 93.4%; CE-IM, 73.1%), whereas strictures occurred in 10.2%, bleeding in 1.1%, and perforations in 0.2% of patients. Recurrence of EAC, dysplasia, and IM was 1.4%, 2.6%, and 16.1%, respectively, in this group. Patients undergoing s-EMR also showed high BE eradication rates (CE-N, 94.9%; CE-IM, 79.6%) but a higher rate of adverse events (strictures in 33.5%, bleeding in 7.5%, and perforation in 1.3%). Recurrence of EAC, dysplasia, and IM was 0.7%, 3.3%, and 12.1%, respectively, in the s-EMR group. Mixed logistic regression showed that patients undergoing s-EMR might be more likely to develop esophageal strictures (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.61-13.85; P = .005), perforation (OR, 7.00; 95% CI, 1.56-31.33; P = .01), and bleeding (OR, 6.88; 95% CI, 2.19-21.62; P = 0.001) compared with f-EMR + RFA. CONCLUSIONS In patients with HGD/EAC, f-EMR followed by RFA seems to be equally effective as and safer than s-EMR.
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Godat S, Caillol F, Autret A, Bories E, Pesenti C, Ratone JP, De Cassan C, Poizat F, Giovannini M. Endotherapy in case of relapse of neoplastic Barrett's esophagus after successful initial endoscopic resection. Surg Endosc 2017; 31:3703-3710. [PMID: 28078459 DOI: 10.1007/s00464-016-5409-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 12/30/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND Endotherapy in cases of neoplastic Barrett esophagus (BE) relapse after successful initial endoscopic management is commonly accepted, but few studies analyze this topic and also take into account the metachronous lesions. AIMS To evaluate the efficiency of endotherapy in the case of neoplastic BE relapse after successful complete endoscopic eradication of neoplastic BE and metaplastic BE. METHODS Retrospective review of medical records was collected in a computerized and prospective manner between 2000 and 2015, in a single tertiary care center. Recurrence was defined by histological presence of high-grade dysplasia or superficial adenocarcinoma at least 6 months after the end of successful initial endotherapy. RESULTS Eighteen patients were assessed (1F/17 M). Delay between initial treatment and relapse was 16.6 months (range 6-33). Endotherapy for relapse obtained a sustained and complete remission for 8/18 (44%) patients, with an average endoscopic follow-up of 28 months. The complication rate of endotherapy was 6%. Surgical management was required in 33% (2 pT2N0M0, 2 pTisN0M0, 1 pTm2N0M0 and 1 pTm3N0M0) and salvage radiochemotherapy in 17% (3/18). One patient treated by 6 sessions of ER was considered as a failure given the multiple sessions of endotherapy. Multivariate analysis showed that length of BE (>5 cm), late stenosis adverse events and the quality of vertical margin during initial ER are predictive factors for disease-free survival (p value < 0.01, Hazard Ratio up to 0.076). CONCLUSION Endotherapy could be a treatment for management of neoplastic BE relapse, but should be carefully used, with strict follow-up.
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Affiliation(s)
- Sébastien Godat
- Division of Gastroenterology, Paoli-Calmettes Institute, 232 Boulevard Sainte Marguerite - BP 156, 13273, Marseille Cedex 9, France.
| | - Fabrice Caillol
- Division of Gastroenterology, Paoli-Calmettes Institute, 232 Boulevard Sainte Marguerite - BP 156, 13273, Marseille Cedex 9, France
| | - Aurélie Autret
- Division of Biostatistics, Paoli-Calmettes Institute, Marseille, France
| | - Erwan Bories
- Division of Gastroenterology, Paoli-Calmettes Institute, 232 Boulevard Sainte Marguerite - BP 156, 13273, Marseille Cedex 9, France
| | - Christian Pesenti
- Division of Gastroenterology, Paoli-Calmettes Institute, 232 Boulevard Sainte Marguerite - BP 156, 13273, Marseille Cedex 9, France
| | - Jean Philippe Ratone
- Division of Gastroenterology, Paoli-Calmettes Institute, 232 Boulevard Sainte Marguerite - BP 156, 13273, Marseille Cedex 9, France
| | - Chiara De Cassan
- Division of Gastroenterology, Paoli-Calmettes Institute, 232 Boulevard Sainte Marguerite - BP 156, 13273, Marseille Cedex 9, France
| | - Flora Poizat
- Division of Pathology, Paoli-Calmettes Institute, Marseille, France
| | - Marc Giovannini
- Division of Gastroenterology, Paoli-Calmettes Institute, 232 Boulevard Sainte Marguerite - BP 156, 13273, Marseille Cedex 9, France
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12
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Evans RPT, Mourad MM, Fisher SG, Bramhall SR. Evolving management of metaplasia and dysplasia in Barrett's epithelium. World J Gastroenterol 2016; 22:10316-10324. [PMID: 28058012 PMCID: PMC5175244 DOI: 10.3748/wjg.v22.i47.10316] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/30/2016] [Accepted: 12/02/2016] [Indexed: 02/06/2023] Open
Abstract
Oesophageal cancer affects more than 450000 people worldwide and despite continued medical advancements the incidence of oesophageal cancer is increasing. Oesophageal cancer has a 5 year survival of 15%-25% and now globally attempts are made to more aggressively diagnose and treat Barrett's oesophagus the known precursor to invasive disease. Currently diagnosis the of Barrett's oesophagus is predominantly made after endoscopic visualisation and histopathological confirmation. Minimally invasive techniques are being developed to improve the viability of screening programs. The management of Barrett's oesophagus can vary greatly dependent on the presence and severity of dysplasia. There is no consensus between the major international medical societies to determine and agreed surveillance and intervention pathway. In this review we analysed the current literature to demonstrate the evolving management of metaplasia and dysplasia in Barrett's epithelium.
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13
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Outcomes of Radiofrequency Ablation for Dysplastic Barrett's Esophagus: A Comprehensive Review. Gastroenterol Res Pract 2016; 2016:4249510. [PMID: 28070182 PMCID: PMC5192328 DOI: 10.1155/2016/4249510] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 11/24/2016] [Indexed: 12/14/2022] Open
Abstract
Barrett's esophagus is a condition in which the normal squamous lining of the esophagus has been replaced by columnar epithelium containing intestinal metaplasia induced by recurrent mucosal injury related to gastroesophageal reflux disease. Barrett's esophagus is a premalignant condition that can progress through a dysplasia-carcinoma sequence to esophageal adenocarcinoma. Multiple endoscopic ablative techniques have been developed with the goal of eradicating Barrett's esophagus and preventing neoplastic progression to esophageal adenocarcinoma. For patients with high-grade dysplasia or intramucosal neoplasia, radiofrequency ablation with or without endoscopic resection for visible lesions is currently the most effective and safe treatment available. Recent data demonstrate that, in patients with Barrett's esophagus and low-grade dysplasia confirmed by a second pathologist, ablative therapy results in a statistically significant reduction in progression to high-grade dysplasia and esophageal adenocarcinoma. Treatment of dysplastic Barrett's esophagus with radiofrequency ablation results in complete eradication of both dysplasia and of intestinal metaplasia in a high proportion of patients with a low incidence of adverse events. A high proportion of treated patients maintain the neosquamous epithelium after successful treatment without recurrence of intestinal metaplasia. Following successful endoscopic treatment, endoscopic surveillance should be continued to detect any recurrent intestinal metaplasia and/or dysplasia. This paper reviews all relevant publications on the endoscopic management of Barrett's esophagus using radiofrequency ablation.
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14
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Koutsoumpas A, Wang LM, Bailey AA, Gillies R, Marshall R, Booth M, Sgromo B, Maynard N, Braden B. Non-radical, stepwise complete endoscopic resection of Barrett's epithelium in short segment Barrett's esophagus has a low stricture rate. Endosc Int Open 2016; 4:E1292-E1297. [PMID: 27995191 PMCID: PMC5161117 DOI: 10.1055/s-0042-118282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/13/2016] [Indexed: 12/16/2022] Open
Abstract
Background and aims: Radical endoscopic excision of Barrett's epithelium performing 4 - 6 endoscopic resections during the same endoscopic session results in complete Barrett's eradication but has a high stricture rate (40 - 80 %). Therefore radiofrequency ablation is preferred after endoscopic mucosal resection (EMR) of visible nodules. We investigated the clinical outcome of non-radical, stepwise endoscopic mucosal resection with a maximum of two endoscopic resections per endoscopic session. Methods: We analysed our prospectively maintained database of patients undergoing esophageal EMR for early neoplasia in Barrett's esophagus from 2009 to 2014. EMR was performed using a maximum of two band ligation mucosectomies per endoscopic session; thereafter, follow-up was 3-monthly and EMR was repeated as required for Barrett's eradication. Results: In total, 118 patients underwent staging EMR for early Barrett's neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumor stages or were managed conservatively. The remaining 91 patients with high grade dysplasia (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months. Remission of dysplasia/neoplasia was achieved in 95.6 % after 12 months treatment. Stepwise endoscopic Barrett's resection resulted in complete Barrett's eradication in 36/91 patients (39.6 %) in a mean of four sessions; 40/91 patients (44.0 %) had a short circumferential Barrett's segment (< 3 cm). In this group, repeated EMR achieved complete Barrett's excision in 85.0 %. One patient developed a stricture (1.1 %), one a delayed bleeding, and there were no perforations. Conclusion: In patients with a short Barrett's segment, non-radical endoscopic Barrett's resection at the time of scheduled endoscopy follow-up allows complete Barrett's eradication with very low stricture rate.
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Affiliation(s)
- Andreas Koutsoumpas
- Translational Gastroenterology Unit, Oxford
University Hospitals, Oxford, UK
| | - Lai Mun Wang
- Department of Pathology, Oxford University
Hospitals NHS Foundation Trust, Oxford, UK
| | - Adam A. Bailey
- Translational Gastroenterology Unit, Oxford
University Hospitals, Oxford, UK
| | - Richard Gillies
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Robert Marshall
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Michael Booth
- Department of Surgery, Royal Berkshire
Hospital, Reading, Berkshire, UK
| | - Bruno Sgromo
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Nick Maynard
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford
University Hospitals, Oxford, UK,Corresponding author Professor Barbara
Braden Consultant
GastroenterologistTranslational Gastroenterology
UnitOxford University
HospitalsOxfordOX3
9DUUK+44-1865-228763
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15
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Qumseya BJ, Wani S, Desai M, Qumseya A, Bain P, Sharma P, Wolfsen H. Adverse Events After Radiofrequency Ablation in Patients With Barrett's Esophagus: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2016; 14:1086-1095.e6. [PMID: 27068041 DOI: 10.1016/j.cgh.2016.04.001] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Revised: 03/29/2016] [Accepted: 04/01/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) is routinely used for treatment of Barrett's esophagus with dysplasia. Despite the relative safety of this method, there have been imprecise estimates of the rate of adverse events. We performed a systematic review and meta-analysis to assess the rate of adverse events associated with RFA with and without EMR. METHODS We searched MEDLINE, Embase, Web of Science, and Cochrane Central through October 22, 2014. The primary outcome of interest was the overall rate of adverse events after RFA with or without EMR. We used forest plots to contrast effect sizes among studies. RESULTS Of 1521 articles assessed, 37 met our inclusion criteria (comprising 9200 patients). The pooled rate of all adverse events from RFA with or without EMR was 8.8% (95% confidence interval [CI], 6.5%-11.9%); 5.6% of patients developed strictures (95% CI, 4.2%-7.4%), 1% had bleeding (95% CI, 0.8%-1.3%), and 0.6% developed a perforation (95% CI, 0.4%-0.9%). In studies that compared RFA with vs without EMR, the relative risk for adverse events was significantly higher for RFA with EMR (4.4) (P = .015). There was a trend toward higher proportions of adverse events in prospective studies compared with retrospective studies (11.3% vs 7.8%, P = .20). Other factors associated with adverse events included Barrett's esophagus and length and baseline histology. CONCLUSIONS In a systematic review and meta-analysis, we found the relative risk for adverse events from RFA to be about 4-fold higher with EMR than without; we identified factors associated with these events. Endoscopists should discuss these risks with patients before endoscopic eradication therapy.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, Thomasville, Georgia.
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Madhav Desai
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas
| | - Amira Qumseya
- Department of Biostatistics, Florida State University, Tallahassee, Florida
| | - Paul Bain
- Harvard School of Public Health, Boston, Massachusetts
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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16
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Li N, Pasricha S, Bulsiewicz WJ, Pruitt RE, Komanduri S, Wolfsen HC, Chmielewski GW, Corbett FS, Chang KJ, Shaheen NJ. Effects of preceding endoscopic mucosal resection on the efficacy and safety of radiofrequency ablation for treatment of Barrett's esophagus: results from the United States Radiofrequency Ablation Registry. Dis Esophagus 2016; 29:537-43. [PMID: 26121935 PMCID: PMC4977202 DOI: 10.1111/dote.12386] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The effects of preceding endoscopic mucosal resection (EMR) on the efficacy and safety of radiofrequency ablation (RFA) for treatment of nodular Barrett's esophagus (BE) is poorly understood. Prior studies have been limited to case series from individual tertiary care centers. We report the results of a large, multicenter registry. We assessed the effects of preceding EMR on the efficacy and safety of RFA for nodular BE with advanced neoplasia (high-grade dysplasia or intramucosal carcinoma) using the US RFA Registry, a nationwide study of BE patients treated with RFA at 148 institutions. Safety outcomes included stricture, gastrointestinal bleeding, and hospitalization. Efficacy outcomes included complete eradication of intestinal metaplasia (CEIM), complete eradication of dysplasia (CED), and number of RFA treatments needed to achieve CEIM. Analyses comparing patients with EMR before RFA to patients undergoing RFA alone were performed with Student's t-test, Chi-square test, logistic regression, and Kaplan-Meier analysis. Four hundred six patients were treated with EMR before RFA for nodular BE, and 857 patients were treated with RFA only for non-nodular BE. The total complication rates were 8.4% in the EMR-before-RFA group and 7.2% in the RFA-only group (P = 0.48). Rates of stricture, bleeding, and hospitalization were not significantly different between patients treated with EMR before RFA and patients treated with RFA alone. CEIM was achieved in 84% of patients treated with EMR before RFA, and 84% of patients treated with RFA only (P = 0.96). CED was achieved in 94% and 92% of patients in EMR-before-RFA and RFA-only group, respectively (P = 0.17). Durability of eradication did not differ between the groups. EMR-before-RFA for nodular BE with advanced neoplasia is effective and safe. The preceding EMR neither diminished the efficacy nor increased complication rate of RFA treatment compared to patients with advanced neoplasia who had RFA with no preceding EMR. Preceding EMR is not associated with poorer outcomes in RFA.
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Affiliation(s)
- N. Li
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - S. Pasricha
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - W. J. Bulsiewicz
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - R. E. Pruitt
- Nashville Gastrointestinal Specialists, Nashville, Tennessee
| | - S. Komanduri
- Northwestern University School of Medicine, Chicago, Illinois
| | | | | | - F. S. Corbett
- Gastroenterology Associates of Sarasota, Sarasota, Florida
| | - K. J. Chang
- University of California at Irvine, Orange, California, USA
| | - N. J. Shaheen
- Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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17
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Phoa KN, Pouw RE, Bisschops R, Pech O, Ragunath K, Weusten BLAM, Schumacher B, Rembacken B, Meining A, Messmann H, Schoon EJ, Gossner L, Mannath J, Seldenrijk CA, Visser M, Lerut T, Seewald S, ten Kate FJ, Ell C, Neuhaus H, Bergman JJGHM. Multimodality endoscopic eradication for neoplastic Barrett oesophagus: results of an European multicentre study (EURO-II). Gut 2016; 65:555-62. [PMID: 25731874 DOI: 10.1136/gutjnl-2015-309298] [Citation(s) in RCA: 179] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 02/07/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Focal endoscopic resection (ER) followed by radiofrequency ablation (RFA) safely and effectively eradicates Barrett's oesophagus (BO) containing high-grade dysplasia (HGD) and/or early cancer (EC) in smaller studies with limited follow-up. Herein, we report long-term outcomes of combined ER and RFA for BO (HGD and/or EC) from a single-arm multicentre interventional study. DESIGN In 13 European centres, patients with BO ≤ 12 cm with HGD and/or EC on 2 separate endoscopies were eligible for inclusion. Visible lesions (<2 cm length; <50% circumference) were removed with ER, followed by serial RFA every 3 months (max 5 sessions). Follow-up endoscopy was scheduled at 6 months after the first negative post-treatment endoscopic control and annually thereafter. OUTCOMES complete eradication of neoplasia (CE-neo) and intestinal metaplasia (CE-IM); durability of CE-neo and CE-IM (once achieved) during follow-up. Biopsy and resection specimens underwent centralised pathology review. RESULTS 132 patients with median BO length C3M6 were included. After entry-ER in 119 patients (90%) and a median of 3 RFA (IQR 3-4) treatments, CE-neo was achieved in 121/132 (92%) and CE-IM in 115/132 patients (87%), per intention-to-treat analysis. Per-protocol analysis, CE-neo and CE-IM were achieved in 98% and 93%, respectively. After a median of 27 months following the first negative post-treatment endoscopic control, neoplasia and IM recurred in 4% and 8%, respectively. Mild-to-moderate adverse events occurred in 25 patients (19%); all managed conservatively or endoscopically. CONCLUSIONS In patients with early Barrett's neoplasia, intensive multimodality endotherapy consisting of ER combined with RFA is safe and highly effective, and the treatment effect appears to be durable during mid-term follow-up. TRIAL REGISTRATION NUMBER NTR 1211, http://www.trialregister.nl.
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Affiliation(s)
- K Nadine Phoa
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
| | - Oliver Pech
- Department of Internal Medicine II, Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Krish Ragunath
- Department of Gastroenterology, Queens Medical Centre, Nottingham, UK
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Brigitte Schumacher
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Bjorn Rembacken
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, UK
| | - Alexander Meining
- Department of Gastroenterology, Klinikum rechts der Isar, Munich, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Augsburg Hospital, Augsburg, Germany
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Liebwin Gossner
- Department of Internal Medicine II, Karlsruhe Hospital, Karlsruhe, Germany
| | - Jayan Mannath
- Department of Gastroenterology, Queens Medical Centre, Nottingham, UK
| | - C A Seldenrijk
- Department of Pathology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Mike Visser
- Department of Pathology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Toni Lerut
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
| | - Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiebo J ten Kate
- Department of Pathology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Christian Ell
- Department of Internal Medicine II, Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Horst Neuhaus
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
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18
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Predictors Of Treatment Failure After Radiofrequency Ablation For Intramucosal Adenocarcinoma in Barrett Esophagus. Am J Surg Pathol 2016; 40:554-62. [DOI: 10.1097/pas.0000000000000566] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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19
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Belghazi K, Cipollone I, Bergman JJGHM, Pouw RE. Current Controversies in Radiofrequency Ablation Therapy for Barrett's Esophagus. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2016; 14:1-18. [PMID: 26891725 PMCID: PMC4783441 DOI: 10.1007/s11938-016-0080-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Barrett's esophagus (BE) is the most important risk factor for esophageal adenocarcinoma. Through the sequence of no dysplasia to low-grade dysplasia (LGD) and high-grade dysplasia (HGD), eventually early cancer (EC) may develop. The risk of neoplastic progression is relatively low, 0.5-0.9 % per patient per year. However, once diagnosed, esophageal adenocarcinoma is often irresectable, and 5-year survival is only 15 %. Therefore, non-dysplastic BE patients are kept under endoscopic surveillance to detect early neoplasia in a curable stage. In case of LGD confirmed by an expert pathologist, risk of neoplastic progression is high. In these confirmed LGD patients, prophylactic ablation using radiofrequency ablation (RFA) of the Barrett's segment has proven to significantly reduce risk of neoplastic progression. Once patients are diagnosed with HGD or EC, they have a clear indication for endoscopic treatment. The cornerstone for endoscopic management of early Barrett's neoplasia is endoscopic resection of mucosal abnormalities. Endoscopic resection (ER) provides a large tissue specimen for accurate histological evaluation to select those patients for further endoscopic management, who have neoplasia limited to the mucosa, well to moderately differentiated and without lymph-vascular invasion. After ER, the remainder of the Barrett's mucosa can be eradicated with RFA, to prevent occurrence of metachronous lesions.
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Affiliation(s)
- Kamar Belghazi
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ilaria Cipollone
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jacques J G H M Bergman
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Roos E Pouw
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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20
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David WJ, Qumseya BJ, Qumsiyeh Y, Heckman MG, Diehl NN, Wallace MB, Raimondo M, Woodward TA, Wolfsen HC. Comparison of endoscopic treatment modalities for Barrett's neoplasia. Gastrointest Endosc 2015; 82:793-803.e3. [PMID: 26071064 DOI: 10.1016/j.gie.2015.03.1979] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/27/2015] [Indexed: 01/10/2023]
Abstract
BACKGROUND There are few data comparing endoscopic treatment outcomes for Barrett's esophagus (BE). OBJECTIVE To compare treatment outcomes in BE patients treated with radiofrequency ablation (RFA), RFA after EMR, and porfimer sodium photodynamic therapy (Ps-PDT). DESIGN Retrospective, observational study. SETTING Single tertiary center between 2001 and 2013. PATIENTS A total of 342 BE patients treated with RFA (n = 119), EMR+RFA (n = 98), and Ps-PDT (n = 125). MAIN OUTCOME MEASUREMENTS Rates of complete remission of intestinal metaplasia (CRIM), BE recurrence, and adverse events. RESULTS Baseline BE high-grade dysplasia (HGD) and adenocarcinoma were more common in the Ps-PDT group (89%) compared with the EMR-RFA (70%) and RFA (37%) groups. At a median follow-up of 14.2 months, 173 patients (50.6%) achieved CRIM. CRIM was significantly more common in Ps-PDT patients compared with RFA (P < .001) and EMR-RFA (P < .001) patients on multivariable analysis. In patients who achieved CRIM, the rates of subsequent BE recurrence were relatively similar among the 3 groups. Although the rates of bleeding were similar, strictures were less common in RFA patients (2.4%) compared with EMR-RFA (13.3%, P = .001) and Ps-PDT (10.4%, P =.043) patients. CONCLUSION This study of endoscopic treatment for Barrett's dysplasia and neoplasia found that complete remission was achieved more often and more rapidly after Ps-PDT with similar disease recurrence rates compared with EMR or RFA. Adverse events were more common after EMR and Ps-PDT. Further studies are required to determine which ablation and resection techniques are ideally suited for each BE patient.
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Affiliation(s)
- Waseem J David
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; Florida State University, Archbold Medical Group, Thomasville, Georgia, USA
| | - Yazen Qumsiyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA; University of Vermont College of Medicine, Burlington, Vermont, USA
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Massimo Raimondo
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Timothy A Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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21
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Balmadrid B, Hwang JH. Endoscopic resection of gastric and esophageal cancer. Gastroenterol Rep (Oxf) 2015; 3:330-8. [PMID: 26510452 PMCID: PMC4650978 DOI: 10.1093/gastro/gov050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/23/2015] [Indexed: 12/18/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) techniques have reduced the need for surgery in early esophageal and gastric cancers and thus has lessened morbidity and mortality in these diseases. ESD is a relatively new technique in western countries and requires rigorous training to reproduce the proficiency of Asian countries, such as Korea and Japan, which have very high complete (en bloc) resection rates and low complication rates. EMR plays a valuable role in early esophageal cancers. ESD has shown better en bloc resection rates but it is easier to master and maintain proficiency in EMR; it also requires less procedural time. For early esophageal adenocarcinoma arising from Barrett’s, ESD and EMR techniques are usually combined with other ablative modalities, the most common being radiofrequency ablation because it has the largest dataset to prove its success. The EMR techniques have been used with some success in early gastric cancers but ESD is currently preferred for most of these lesions. ESD has the added advantage of resecting into the submucosa and thus allowing for endoscopic resection of more aggressive (deeper) early gastric cancer.
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Affiliation(s)
- Bryan Balmadrid
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
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Pasricha S, Cotton C, Hathorn KE, Li N, Bulsiewicz WJ, Wolf WA, Muthusamy VR, Komanduri S, Wolfsen HC, Pruitt RE, Ertan A, Chmielewski GW, Shaheen NJ. Effects of the Learning Curve on Efficacy of Radiofrequency Ablation for Barrett's Esophagus. Gastroenterology 2015; 149:890-6.e2. [PMID: 26116806 PMCID: PMC4584171 DOI: 10.1053/j.gastro.2015.06.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 05/11/2015] [Accepted: 06/17/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Complete eradication of Barrett's esophagus (BE) often requires multiple sessions of radiofrequency ablation (RFA). Little is known about the effects of case volume on the safety and efficacy of RFA or about the presence or contour of learning curves for this procedure. METHODS We collected data from the US RFA Patient Registry (from 148 institutions) for patients who underwent RFA for BE from July 2007 to July 2011. We analyzed the effects of the number of patients treated by individual endoscopists and individual centers on safety and efficacy outcomes of RFA. Outcomes, including stricture, bleeding, hospitalization, and complete eradication of intestinal metaplasia (CEIM), were assessed using logistic regression. The effects of center and investigator experience on numbers of treatment sessions to achieve CEIM were examined using linear regression. RESULTS After we controlled for potential confounders, we found that as the experience of endoscopists and centers increased with cases, the numbers of treatment sessions required to achieve CEIM decreased. This relationship persisted after adjusting for patient age, sex, race, length of BE, and presence of pretreatment dysplasia (P < .01). Center experience was not significantly associated with overall rates of CEIM or complete eradication of dysplasia. We did not observe any learning curve with regard to risks of stricture, gastrointestinal bleeding, perforation, or hospitalization (P > .05). CONCLUSIONS Based on analysis of a large multicenter registry, efficiency of the treatment, as measured by number of sessions needed to achieve CEIM, increased with case volume, indicating a learning curve effect. This trend began to disappear after treatment of approximately 30 patients by the center or individual endoscopist. However, there was no significant association between safety or efficacy outcomes and previous case volume.
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Affiliation(s)
- Sarina Pasricha
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Cary Cotton
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Kelly E. Hathorn
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - Nan Li
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - William J. Bulsiewicz
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | - W. Asher Wolf
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
| | | | | | | | - Ron E. Pruitt
- Nashville Gastrointestinal Specialists, Nashville, TN
| | - Atilla Ertan
- University of Texas School of Medicine, Houston, TX
| | | | - Nicholas J. Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC
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Subramanian CR, Triadafilopoulos G. Endoscopic treatments for dysplastic Barrett's esophagus: resection, ablation, what else? World J Surg 2015; 39:597-605. [PMID: 24841804 DOI: 10.1007/s00268-014-2636-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic eradication therapy for dysplastic Barrett's esophagus (BE) comprises resection and mucosal ablation techniques. Over the years, these techniques have been tried with success, not only for dysplastic Barrett's epithelium but also for non-dysplastic Barrett's epithelium and early adenocarcinoma. Endoscopic resection is usually carried out for visible lesions, either as endoscopic mucosal resection (EMR), which is practiced widely in Western countries, or as endoscopic submucosal dissection, which is more popular in Japan and throughout Asia. Among ablative techniques are photodynamic therapy, cryotherapy, and radiofrequency ablation (RFA). METHODS We reviewed the published evidence pertaining to endoscopic treatments of dysplastic BE, with emphasis on the various resection and ablative techniques, their safety, efficacy, durability of effect, and tolerability. RESULTS Both resection and ablation procedures performed endoscopically have been proved effective, and safe for treating dysplastic BE and early adenocarcinoma. Among the ablative techniques, RFA has shown to be more effective and safe, and is preferred for most cases. CONCLUSIONS Endoscopic therapies have revolutionized the treatment of BE and have minimized the need for surgical intervention in many patients. Concomitant treatment of acid reflux with proton pump inhibitors and continuous surveillance are essential. Combination techniques such as EMR followed by RFA may be also considered in some cases.
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Palmer WC, Di Leo M, Jovani M, Heckman MG, Diehl NN, Iyer PG, Wolfsen HC, Wallace MB. Management of high grade dysplasia in Barrett's oesophagus with underlying oesophageal varices: A retrospective study. Dig Liver Dis 2015; 47:763-8. [PMID: 26066379 DOI: 10.1016/j.dld.2015.05.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 05/10/2015] [Accepted: 05/14/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic treatment of Barrett's oesophagus leading to high grade dysplasia with oesophageal varices may lead to bleeding complications. AIMS Estimate effectiveness of endoscopic band-ligation in oesophageal varices patients treated for high grade dysplasia, and compare to endoscopically treated non-oesophageal varices high grade dysplasia patients. METHODS Retrospective comparative study. All 8 high grade dysplasia patients with varices who were treated initially with band-ligation at Mayo Clinic between 8/1/1999 and 2/28/2014 were compared with reference group of 52 high grade dysplasia patients treated endoscopically. RESULTS One high grade dysplasia patients patient with oesophageal varices (12.5%) achieved complete remission of intestinal metaplasia defined by at least one followup endoscopy with normal biopsies, and 3 (37.5%) achieved complete remission of dysplasia defined by at least one followup endoscopy with non-dysplastic biopsies. 39 (75.0%) endomucosal resection/radiofrequency ablation patients experienced at least one followup endoscopy with normal biopsies, and 49 (94.2%) experienced non-dysplastic biopsies. Both of these endpoints occurred significantly more often in the endomucosal resection/radiofrequency ablation group compared to the high grade dysplasia with oesophageal varices group (p=0.016 and p=0.025, respectively). CONCLUSIONS High grade dysplastic Barrett's can be safely managed with band-ligation. However, resolution of Barrett's epithelium is rarely achieved with banding alone.
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Affiliation(s)
- William C Palmer
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, USA.
| | - Milena Di Leo
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, Milan, Italy
| | - Manol Jovani
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Research Hospital, Milan, Italy
| | - Michael G Heckman
- Division of Biomedical Statistics and Informatics, Mayo Clinic Jacksonville, USA
| | - Nancy N Diehl
- Division of Biomedical Statistics and Informatics, Mayo Clinic Jacksonville, USA
| | - Prasad G Iyer
- Department of Gastroenterology and Hepatology, Mayo Clinic Rochester, USA
| | - Herbert C Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, USA
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic Jacksonville, USA
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Abstract
The absolute incidence of esophageal adenocarcinoma has increased 7-fold over the past 5 decades, and esophageal adenocarcinoma is the most rapidly increasing epithelial malignancy in the United States. The incidence of early esophageal cancer has also increased proportionately. In the past decade, radiofrequency ablation has become the standard first-line therapy for high-grade dysplasia when found in the precursor lesion to esophageal adenocarcinoma, Barrett's esophagus. Success in the endoscopic management of high-grade dysplasia has furthered efforts to treat early esophageal cancers endoscopically. Although surgery remains the mainstay of treatment for more advanced tumors, national guidelines now recommend endoscopic mucosal resection followed by radiofrequency ablation for intramucosal carcinomas and T1a cancers. T1b cancers represent a more challenging group-very good results have been reported in highly selected subsets of patients with T1b tumors; however, many recommendations favor individualization or a surgical approach for this stage. This review examines the current data and recommendations regarding the endoscopic management of early esophageal adenocarcinomas.
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Strauss AC, Agoston AT, Dulai PS, Srivastava A, Rothstein RI. Radiofrequency ablation for Barrett's-associated intramucosal carcinoma: a multi-center follow-up study. Surg Endosc 2015; 28:3366-72. [PMID: 24950726 DOI: 10.1007/s00464-014-3629-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA), with or without endoscopic mucosal resection (EMR), has been validated as a safe, effective and durable treatment option for dysplastic Barrett's esophagus. Its durability in eradicating Barrett's-associated intramucosal carcinoma (IMC), however, is unclear. We set out to assess the long-term safety and efficacy of RFA for IMC. METHODS Retrospective review of two tertiary care facility records for patients undergoing RFA, with or without EMR, for biopsy-proven IMC. Our primary outcome of interest was to quantify the rate of durable complete eradication for intestinal metaplasia and for IMC and associated dysplasia. A multi-variate regression analysis was performed to identify features which correlate with durable eradication of IMC/dysplasia. Our secondary outcome of interest was treatment-related complications. RESULTS 36 patients (26 male; mean age 64 ± 12 years), with a mean Barrett's length of 3.5 ± 2.5 cm, underwent RFA for biopsy-proven IMC. EMR was performed in 31 (86%) prior to or during RFA. Complete eradication of IMC/dysplasia was achieved in 32/36 (89%) and patients required a mean of 1 ± 1 EMR and 2 ± 1 RFA sessions to achieve eradication. During a mean follow-up period of 24 ± 19 months, durable complete eradication of IMC/dysplasia was achieved in 29/36 (81%) patients. On multi-variate regression analysis, undergoing an EMR prior to RFA was associated with an increased likelihood of maintaining durable eradication of IMC/dysplasia (p = 0.03). Treatment-related complications included: bleeding (3%) and stricture formation (19%). CONCLUSION RFA is an effective and durable treatment option for Barrett's-associated IMC. Greater than 80% of patients will achieve and maintain complete eradication of IMC at a mean of 2 years follow-up.
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Affiliation(s)
- Adam C Strauss
- Department of Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA,
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Kastelein F, van Olphen S, Steyerberg EW, Sikkema M, Spaander MCW, Looman CWN, Kuipers EJ, Siersema PD, Bruno MJ, de Bekker-Grob EW. Surveillance in patients with long-segment Barrett's oesophagus: a cost-effectiveness analysis. Gut 2015; 64:864-71. [PMID: 25037191 DOI: 10.1136/gutjnl-2014-307197] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Accepted: 07/04/2014] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Surveillance is recommended for Barrett's oesophagus (BO) to detect early oesophageal adenocarcinoma (OAC). The aim of this study was to evaluate the cost-effectiveness of surveillance. DESIGN We included 714 patients with long-segment BO in a multicentre prospective cohort study and used a multistate Markov model to calculate progression rates from no dysplasia (ND) to low-grade dysplasia (LGD), high-grade dysplasia (HGD) and OAC. Progression rates were incorporated in a decision-analytic model, including costs and quality of life data. We evaluated different surveillance intervals for ND and LGD, endoscopic mucosal resection (EMR), radiofrequency ablation (RFA) and oesophagectomy for HGD or early OAC and oesophagectomy for advanced OAC. The incremental cost-effectiveness ratio (ICER) was calculated in costs per quality-adjusted life-year (QALY). RESULTS The annual progression rate was 2% for ND to LGD, 4% for LGD to HGD or early OAC and 25% for HGD or early OAC to advanced OAC. Surveillance every 5 or 4 years with RFA for HGD or early OAC and oesophagectomy for advanced OAC had ICERs of €5.283 and €62.619 per QALY for ND. Surveillance every five to one year had ICERs of €4.922, €30.067, €32.531, €41.499 and €75.601 per QALY for LGD. EMR prior to RFA was slightly more expensive, but important for tumour staging. CONCLUSIONS Based on a Dutch healthcare perspective and assuming a willingness-to-pay threshold of €35.000 per QALY, surveillance with EMR and RFA for HGD or early OAC, and oesophagectomy for advanced OAC is cost-effective every 5 years for ND and every 3 years for LGD.
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Affiliation(s)
- F Kastelein
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - S van Olphen
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Pathology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E W Steyerberg
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - M Sikkema
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M C W Spaander
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - C W N Looman
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E J Kuipers
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - E W de Bekker-Grob
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Peter S, Mönkemüller K. Ablative Endoscopic Therapies for Barrett's-Esophagus-Related Neoplasia. Gastroenterol Clin North Am 2015; 44:337-53. [PMID: 26021198 DOI: 10.1016/j.gtc.2015.02.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus (BE) is more common in developed countries. Endoscopic therapy is an effective treatment method in management of dysplastic BE. Ablation by thermal energy, freezing, or photochemical injury completely eradicates dysplasia and specialized intestinal metaplasia resulting in neosquamation of esophagus. Among the ablative modalities, radiofrequency ablation (RFA) is the most studied with safe, effective, and durable long-term outcomes. Cryotherapy, argon plasma coagulation, and photodynamic therapy can be offered in select patients when RFA is unavailable, has failed, or is contraindicated. Future research on natural disease progression, biomarkers, advanced imaging, and application of endoscopic techniques will lead to better clinical outcomes for BE-associated neoplasia.
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Affiliation(s)
- Shajan Peter
- Department of Gastroenterology, Basil I. Hirschowitz Endoscopic Centre of Endoscopic Excellence, University of Alabama at Birmingham, 6th Floor Jefferson Tower, 625 19th Street South, Birmingham, AL 35249, USA.
| | - Klaus Mönkemüller
- Department of Gastroenterology, Basil I. Hirschowitz Endoscopic Centre of Endoscopic Excellence, University of Alabama at Birmingham, 6th Floor Jefferson Tower, 625 19th Street South, Birmingham, AL 35249, USA
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Cotton CC, Wolf WA, Pasricha S, Li N, Madanick RD, Spacek MB, Kathleen F, Dellon ES, Shaheen NJ. Recurrent intestinal metaplasia after radiofrequency ablation for Barrett's esophagus: endoscopic findings and anatomic location. Gastrointest Endosc 2015; 81:1362-9. [PMID: 25817897 PMCID: PMC4439393 DOI: 10.1016/j.gie.2014.12.029] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/07/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett's esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence is common after CEIM, and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well-described. OBJECTIVE Describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence. DESIGN Retrospective cohort. SETTING Single referral center. PATIENTS A total of 198 patients with BE with at least 2 surveillance endoscopies after CEIM. INTERVENTIONS RFA, EMR, surveillance endoscopy. MAIN OUTCOME MEASUREMENTS The anatomic location and histologic grade of recurrence. RESULTS In a mean 3.0 years of follow-up, 32 (16.2%; 95% confidence interval [CI], 11.0%-22.0%) patients had recurrence of disease, 5 (2.5%; 95% CI, 0.3%-4.7%) of whom progressed beyond their worst before-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence>1 cm proximal to the GEJ always was accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white light or narrow-band imaging for recurrence was 59.4% (42.4%, 76.4%), and the specificity was 80.6% (77.2%, 84.0%). LIMITATIONS Single-center study. CONCLUSION Recurrent intestinal metaplasia often is not visible to the endoscopist and is most common near the GEJ. Random biopsies>1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.
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Affiliation(s)
- Cary C. Cotton
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - W. Asher Wolf
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Sarina Pasricha
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Nan Li
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ryan D. Madanick
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Melissa B. Spacek
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Ferrell Kathleen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Evan S. Dellon
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
- Corresponding author contact information: Nicholas J. Shaheen, MD, MPH, Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, CB#7080, Chapel Hill, North Carolina 27599- 7080. ; fax: (919) 843-2508
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Small AJ, Sutherland SE, Hightower JS, Guarner-Argente C, Furth EE, Kochman ML, Forde KA, Bewtra M, Falk GW, Ginsberg GG. Comparative risk of recurrence of dysplasia and carcinoma after endoluminal eradication therapy of high-grade dysplasia versus intramucosal carcinoma in Barrett's esophagus. Gastrointest Endosc 2015; 81:1158-66.e1-4. [PMID: 25650071 DOI: 10.1016/j.gie.2014.10.029] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Accepted: 10/23/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic therapy is the preferred approach for the management of Barrett's esophagus (BE) patients with high-grade dysplasia (HGD) and intramucosal carcinoma (IMC). Little is known about outcome differences in patients with HGD versus IMC. OBJECTIVE To determine and compare the rate of recurrent dysplasia or neoplasia in patients with HGD or IMC undergoing endoscopic therapy. DESIGN Retrospective cohort study. PATIENTS A total of 246 BE patients with either HGD or IMC referred for endoscopic therapy. INTERVENTION Patients underwent EMR and/or ablation therapy with the goal of complete eradication of all dysplasia/neoplasia and intestinal metaplasia (CE-IM). Patients were assigned to either the HGD or IMC group based on highest pathology grade at the start of therapy. MAIN OUTCOME MEASUREMENTS Complete eradication and recurrence of IM and/or HGD/neoplasia were assessed among patients with HGD versus IMC. Only patients with CE-IM (documented eradication of all dysplasia/neoplasia and IM on a single endoscopy) were included for analysis of recurrence rates and risk factors. RESULTS CE-IM was achieved in 113 of 135 patients (83.7%) with HGD and in 84 of 111 patients (75.7%) with IMC (P = .16). Overall recurrence rates of dysplasia or neoplasia after CE-IM were similar in both groups (HGD, 8.0% vs IMC, 9.5%; P = .44; relative risk, 1.2; 95% confidence interval, 0.5-3.0) and remained similar in patients with 5 years of surveillance after CE-IM (HGD, 13.5% vs IMC, 11.4%; P = .53; relative risk, 0.85; 95% confidence interval, 0.3-2.7). LIMITATIONS Retrospective, observational study and evolution of endoscopic modalities and experience. CONCLUSION Endoluminal therapy can successfully achieve eradication of IM and dysplasia or neoplasia in BE patients with HGD and IMC at comparable rates. There were no differences in the rates of recurrent HGD/IMC in the 2 groups.
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Affiliation(s)
- Aaron J Small
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Scott E Sutherland
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Jessica S Hightower
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Carlos Guarner-Argente
- Gastroenterology Department, Hospital de Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Emma E Furth
- Department of Pathology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael L Kochman
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Wilmott Center for Endoscopic Innovation, Research, and Training
| | - Kimberly A Forde
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Meenakshi Bewtra
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA; Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gary W Falk
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gregory G Ginsberg
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
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Qumseya B, David W, Woodward TA, Raimondo M, Wallace MB, Wolfsen HC, Lukens FJ. Safety of esophageal EMR in elderly patients. Gastrointest Endosc 2014; 80:586-591. [PMID: 24703086 DOI: 10.1016/j.gie.2014.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 02/06/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR is commonly used to remove suspicious esophageal lesions among patients with Barrett's esophagus (BE). BE primarily affects older patients. Yet, the safety profile of EMR in elderly patients has not been well-described. OBJECTIVE We aimed to study the safety profile of EMR in elderly patients compared with younger patients. DESIGN Retrospective, observational, descriptive study that used a prospective database. SETTING Tertiary-care referral center. PATIENTS A total of 136 patients who underwent esophageal EMR for BE. INTERVENTIONS EMR with/without ablative therapy. MAIN OUTCOME MEASUREMENTS The rate of adverse events, including bleeding, stricture formation, and perforation between elderly (aged ≥75 years) and younger (aged <75 years) patients. RESULTS We identified 136 patients who underwent esophageal EMR who were followed-up in our clinic. Of those, 40% (n = 55) were aged ≥75 years (elderly group) and 60% (n = 81) were aged <75 years (younger group). There was no difference in rate of stricture formation or early or delayed bleeding when we compared elderly patients to younger patients. None of the patients had esophageal perforation. On multivariable logistic regression analysis, controlling for patient sex, EMR technique, and underlying pathology, older age was not associated with increased odds of adverse events (OR 0.88; 95% confidence interval, 0.42-1.9; P = .75). LIMITATIONS Single-center experience. CONCLUSION Rates of adverse events from EMR appear to be similar in elderly patients compared with younger patients. Overall, esophageal EMR seems to offer an acceptable safety profile in elderly patients.
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Affiliation(s)
- Bashar Qumseya
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Waseem David
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Timothy A Woodward
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Massimo Raimondo
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Michael B Wallace
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Herbert C Wolfsen
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
| | - Frank J Lukens
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida
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32
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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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Ablative therapy for esophageal dysplasia and early malignancy: focus on RFA. BIOMED RESEARCH INTERNATIONAL 2014; 2014:642063. [PMID: 25140320 PMCID: PMC4129136 DOI: 10.1155/2014/642063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/07/2014] [Indexed: 02/07/2023]
Abstract
Ablative therapies have been utilized with increasing frequency for the treatment of Barrett's esophagus with and without dysplasia. Multiple modalities are available for topical ablation of the esophagus, but radiofrequency ablation (RFA) remains the most commonly used. There have been significant advances in technique since the introduction of RFA. The aim of this paper is to review the indications, techniques, outcomes, and most common complications following esophageal ablation with RFA.
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Chadwick G, Groene O, Markar SR, Hoare J, Cromwell D, Hanna GB. Systematic review comparing radiofrequency ablation and complete endoscopic resection in treating dysplastic Barrett's esophagus: a critical assessment of histologic outcomes and adverse events. Gastrointest Endosc 2014; 79:718-731.e3. [PMID: 24462170 DOI: 10.1016/j.gie.2013.11.030] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 11/19/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND With recent advances in endoscopy, endoscopic techniques have surpassed esophagectomy in the treatment of dysplastic Barrett's esophagus (BE). OBJECTIVE To compare the efficacy and safety of complete EMR and radiofrequency ablation (RFA) in the treatment of dysplastic BE. DESIGN Systematic review of literature. PATIENTS Diagnosis of BE with high-grade dysplasia or intramucosal cancer. INTERVENTION Complete EMR or RFA. MAIN OUTCOME MEASUREMENTS Complete eradication of dysplasia and intestinal metaplasia at the end of treatment and after >12 months' follow-up. Adverse event rates associated with treatment. RESULTS A total of 22 studies met the inclusion criteria. Only 1 trial directly compared the 2 techniques; most studies were observational case series. Dysplasia was effectively eradicated at the end of treatment in 95% of patients after complete EMR and 92% after RFA. After a median follow-up of 23 months for complete EMR and 21 months for RFA, eradication of dysplasia was maintained in 95% of patients treated with complete EMR and 94% treated with RFA. Short-term adverse events were seen in 12% of patients treated with complete EMR but in only 2.5% of those treated with RFA. Esophageal strictures were adverse events in 38% of patients treated with complete EMR, compared with 4% of those treated with RFA. Progression to cancer appeared to be rare after treatment, although follow-up was short. LIMITATIONS Small studies, heterogeneous in design, with variable outcome measures. Also follow-up durations were short, limiting evaluation of long-term durability of both treatments. CONCLUSION RFA and complete EMR are equally effective in the short-term treatment of dysplastic BE, but adverse event rates are higher with complete EMR.
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Affiliation(s)
- Georgina Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Oliver Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Sheraz R Markar
- Department of Surgery and Cancer, St. Mary's Hospital, London, United Kingdom
| | - Jonathan Hoare
- Department of Gastroenterology, St. Mary's Hospital, London, United Kingdom
| | - David Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - George B Hanna
- Department of Surgery and Cancer, St. Mary's Hospital, London, United Kingdom
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Occurrence of invasive cancer after endoscopic treatment of Barrett's esophagus with high-grade dysplasia and intramucosal cancer in physiologically fit patients: time for a review of surveillance and treatment guidelines. Gastrointest Endosc 2014; 79:839-44. [PMID: 24447341 DOI: 10.1016/j.gie.2013.11.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Accepted: 11/15/2013] [Indexed: 02/08/2023]
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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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Abstract
PURPOSE OF REVIEW Endoscopic eradication therapy is frequently used to treat dysplasia and early cancers in Barrett's esophagus. This review addresses some of the recent developments in the field of endoscopic eradication therapy for Barrett's esophagus. RECENT FINDINGS Data on the effectiveness of Barrett's esophagus ablation programs have been published recently, with excellent results for dysplasia eradication. Studies describing long-term results have shed light on the durability of endoscopic ablation, with recurrence of Barrett's esophagus and neoplasia seen in some cases, particularly at the gastroesophageal junction. Risk factors for failed ablation include longer Barrett's esophagus segments and persistent gastroesophageal reflux. New developments include studies combining radiofrequency ablation (RFA) and endoscopic mucosal resection into a single endoscopic session, endoscopic submucosal dissection for Barrett's esophagus neoplasia, and a simplified RFA algorithm. New data on the cost-effectiveness of RFA have also been published, suggesting that RFA is cost-effective for both high-grade and low-grade dysplasia, but not for nondysplastic Barrett's esophagus. A systematic review has shown that lymph node metastases are rare (∼2%) with intramucosal adenocarcinoma, supporting the use of endoscopic eradication for that lesion. SUMMARY Research and clinical experience with the endoscopic therapies for Barrett's esophagus continue to grow. Proper patient selection and technique are critical for ensuring a good outcome. Endoscopic surveillance after any of the ablative therapies still appears to be necessary.
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Vieth M, Neumann H. Barrett oesophagus: Is RFA the overall answer to all Barrett oesophagus issues? Nat Rev Gastroenterol Hepatol 2013; 10:388-9. [PMID: 23629604 DOI: 10.1038/nrgastro.2013.75] [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: 12/24/2022]
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Haidry RJ, Dunn JM, Butt MA, Burnell MG, Gupta A, Green S, Miah H, Smart HL, Bhandari P, Smith LA, Willert R, Fullarton G, Morris J, Di Pietro M, Gordon C, Penman I, Barr H, Patel P, Boger P, Kapoor N, Mahon B, Hoare J, Narayanasamy R, O'Toole D, Cheong E, Direkze NC, Ang Y, Novelli M, Banks MR, Lovat LB. Radiofrequency ablation and endoscopic mucosal resection for dysplastic barrett's esophagus and early esophageal adenocarcinoma: outcomes of the UK National Halo RFA Registry. Gastroenterology 2013; 145:87-95. [PMID: 23542069 DOI: 10.1053/j.gastro.2013.03.045] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2012] [Revised: 03/13/2013] [Accepted: 03/21/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) or early neoplasia increasingly receive endoscopic mucosal resection and radiofrequency ablation (RFA) therapy. We analyzed data from a UK registry that follows the outcomes of patients with BE who have undergone RFA for neoplasia. METHODS We collected data on 335 patients with BE and neoplasia (72% with HGD, 24% with intramucosal cancer, 4% with low-grade dysplasia [mean age, 69 years; 81% male]), treated at 19 centers in the United Kingdom from July 2008 through August 2012. Mean length of BE segments was 5.8 cm (range, 1-20 cm). Patients' nodules were removed by endoscopic mucosal resection, and the patients then underwent RFA every 3 months until all areas of BE were ablated or cancer developed. Biopsies were collected 12 months after the first RFA; clearance of HGD, dysplasia, and BE were assessed. RESULTS HGD was cleared from 86% of patients, all dysplasia from 81%, and BE from 62% at the 12-month time point, after a mean of 2.5 (range, 2-6) RFA procedures. Complete reversal dysplasia was 15% less likely for every 1-cm increment in BE length (odds ratio = 1.156; SE = 0.048; 95% confidence interval: 1.07-1.26; P < .001). Endoscopic mucosal resection before RFA did not provide any benefit. Invasive cancer developed in 10 patients (3%) by the 12-month time point and disease had progressed in 17 patients (5.1%) after a median follow-up time of 19 months. Symptomatic strictures developed in 9% of patients and were treated by endoscopic dilatation. Nineteen months after therapy began, 94% of patients remained clear of dysplasia. CONCLUSIONS We analyzed data from a large series of patients in the United Kingdom who underwent RFA for BE-related neoplasia and found that by 12 months after treatment, dysplasia was cleared from 81%. Shorter segments of BE respond better to RFA; http://www.controlled-trials.com, number ISRCTN93069556.
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Affiliation(s)
- Rehan J Haidry
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Jason M Dunn
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mohammed A Butt
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Matthew G Burnell
- Department of Biostatistics, University College London, London, United Kingdom
| | - Abhinav Gupta
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Sarah Green
- National Medical Laser Centre, University College London, London, United Kingdom
| | - Haroon Miah
- National Medical Laser Centre, University College London, London, United Kingdom
| | - Howard L Smart
- Royal Liverpool University Hospital, Liverpool, United Kingdom
| | | | - Lesley Ann Smith
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - Robert Willert
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, United Kingdom
| | | | - John Morris
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | | | | | - Ian Penman
- Royal Infirmary Edinburgh, Edinburgh, United Kingdom
| | - Hugh Barr
- Gloucestershire Hospital NHS Trust, Gloucestershire, United Kingdom
| | - Praful Patel
- Southampton University Hospital, Southampton, United Kingdom
| | - Philip Boger
- Southampton University Hospital, Southampton, United Kingdom
| | - Neel Kapoor
- Aintree University Hospital, Liverpool, United Kingdom
| | - Brinder Mahon
- Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | | | | | - Edward Cheong
- Norfolk and Norwich University Hospital, Norwich, United Kingdom
| | | | - Yeng Ang
- Centre of Gastrointestinal Sciences, University of Manchester, Salford Royal Foundation NHS Trust, Salford, United Kingdom
| | - Marco Novelli
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Matthew R Banks
- GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Laurence Bruce Lovat
- National Medical Laser Centre, University College London, London, United Kingdom; GI Services, University College Hospital NHS Foundation Trust, London, United Kingdom.
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Khangura SK, Greenwald BD. Endoscopic management of esophageal cancer after definitive chemoradiotherapy. Dig Dis Sci 2013; 58:1477-85. [PMID: 23325163 DOI: 10.1007/s10620-012-2554-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 12/24/2012] [Indexed: 01/29/2023]
Abstract
BACKGROUND Concurrent chemoradiotherapy (CRT) is a potentially curative non-surgical option for locally advanced esophageal cancer, with pathological complete response (CR) ranging from 13 to 49 %. The rate of persistent and recurrent disease within the esophagus remains high at 40-60 %, and treatment of these tumors may improve disease-free survival. The aim of this review is to assess the efficacy of salvage endoscopic therapies for recurrent esophageal cancer. METHODS Medline and Embase were searched for relevant studies published in the English-language literature that reported use of endoscopic modalities, including photodynamic therapy (PDT), endoscopic mucosal resection (EMR), and spray cryotherapy, as salvage therapies for esophageal cancer. RESULTS A total of 12 studies were identified. In small case series of PDT, CR varied from 20 to 100 %, with 1-, 3-, and 5-year overall survival rates of 65-80, 34-47, and 36 %, respectively. Data from three studies of EMR in squamous cell cancer show CR in 50 % of cases, with 3- and 5-year overall survival of 56-81 and 49 %, respectively. Endoscopic spray cryotherapy has recently been used in this setting with an observed CR of 37.5 %. CONCLUSIONS Endoscopic salvage therapies are options for those patients with disease limited to the superficial esophageal wall and those who are unfit to undergo salvage esophagectomy. Widespread application of endoscopic salvage therapies is limited by the lack of awareness and guidelines for endoscopic surveillance post-CRT and limited data on the effectiveness of endoscopic therapies.
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Affiliation(s)
- Sajneet K Khangura
- Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.
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Saligram S, Chennat J, Hu H, Davison JM, Fasanella KE, McGrath K. Endotherapy for superficial adenocarcinoma of the esophagus: an American experience. Gastrointest Endosc 2013; 77:872-6. [PMID: 23472998 DOI: 10.1016/j.gie.2013.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 01/03/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND EMR and ablation are increasingly being used alone or in combination for treatment of Barrett's neoplasia. Given a very low rate of lymph node metastasis, endotherapy has become an accepted treatment option for T1a esophageal adenocarcinoma (EAC) with low-risk features. OBJECTIVE To report our experience of endoscopic management of T1a EAC in a large, tertiary-care center. DESIGN Retrospective review. SETTING Tertiary-care referral center. PATIENTS Patients treated endoscopically for low-risk T1a EAC at our center. INTERVENTION EMR and endoscopic ablation. MAIN OUTCOME MEASUREMENTS Death related to esophageal cancer, remission of adenocarcinoma, dysplasia, and intestinal metaplasia. RESULTS A total of 54 patients underwent endotherapy for low-risk T1a EAC from 2006 to 2012. Mean (± SD) follow-up was 23 (± 16) months, mean (± SD) size of resected adenocarcinoma was 7.1 (± 4.3) mm, and mean (± SD) Barrett's esophagus length was 4.5 (± 3.9) cm. Band-assisted, cap-assisted, and lift and cut EMR were performed in 85%, 11%, and 4% of patients, respectively; 81% underwent additional ablative therapy (radiofrequency ablation 95%, cryotherapy 9%, photodynamic therapy 2%). Complete remission from cancer was achieved in 96%, complete remission from dysplasia in 87%, and complete remission from intestinal metaplasia in 59%. The overall survival was 89%; there were no deaths related to esophageal cancer. LIMITATIONS Retrospective study. CONCLUSION Endotherapy for T1a EAC was safe and effective in our American cohort. Endotherapy should be considered primary therapy for appropriate patients with low-risk lesions. Complete Barrett's esophagus eradication after EMR is important to reduce the development of metachronous lesions.
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Affiliation(s)
- Shreyas Saligram
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Abstract
Barrett's esophagus (BE) is an acquired condition characterized by replacement of stratified squamous epithelium by a cancer predisposing metaplastic columnar epithelium. Endoscopy with systemic biopsy protocols plays a vital role in diagnosis. Technological advancements in dysplasia detection improves outcomes in surveillance and treatment of patients with BE and dysplasia. These advances in endoscopic technology radically changed the treatment for dysplastic BE and early cancer from being surgical to organ-sparing endoscopic therapy. A multimodal treatment approach combining endoscopic resection of visible and/or raised lesions with ablation techniques for flat BE mucosa, followed by long-term surveillance improves the outcomes of BE. Safe and effective endoscopic treatment can be either tissue acquiring as in endoscopic mucosal resection and endoscopic submucosal dissection or tissue ablative as with photodynamic therapy, radiofrequency ablation and cryotherapy. Debatable issues such as durability of response, recognition and management of sub-squamous BE and optimal management strategy in patients with low-grade dysplasia and non-dysplastic BE need to be studied further. Development of safer wide field resection techniques, which would effectively remove all BE and obviate the need for long-term surveillance, is another research goal. Shared decision making between the patient and physician is important while considering treatment for dysplasia in BE.
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Abstract
Oesophageal carcinoma is one of the most virulent malignant diseases and a major cause of cancer-related deaths worldwide. Diagnosis and accuracy of pretreatment staging have substantially improved throughout the past three decades. Therapy is challenging and the optimal approach is still debated. Oesophagectomy is considered to be the procedure of choice in patients with operable oesophageal cancer. Endoscopic measures and limited surgical procedures provide an alternative in patients with early carcinomas confined to the oesophageal mucosa. Chemotherapy and radiotherapy or concurrent chemoradiotherapy are also frequently applied, either as definitive treatment or as neoadjuvant therapy within multimodal approaches. The question of whether multimodal treatment offers improved results has been the focus of many studies since the 1990s. Although results are discordant and even some meta-analyses remain inconclusive, it is now widely accepted that multimodal therapy leads to a modest survival benefit. The role of minimally invasive oesophagectomy is not yet defined. Endoscopic stent insertion, radiotherapy and other palliative measures provide relief of tumour-related symptoms in advanced, unresectable tumour stages.
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Abstract
Barrett's esophagus (BE) is a well-established pre-malignant lesion for esophageal adenocarcinoma, a condition that carries a dismal five-year overall survival rate of less than 15%. Among several available methods to eliminate BE, radiofrequency ablation (RFA) provides the most efficient modality, since it has been demonstrated to successfully eradicate BE with or without dysplasia with acceptable safety, efficacy and durability profiles. In conjunction with proton pump therapy, this new technology has quickly become the standard care for patients with dysplastic BE. However, several technical questions remain about how to deploy RFA therapy for maximum effectiveness and long-term favorable outcomes for all stages of the disease. These include how to select patient for therapy, what the best protocol for RFA is, when to use other modalities, such as endoscopic mucosal resection, and what should be considered for refractory BE. This review addresses these questions with the perspective of the best available evidence matched with the authors' experience with the technology.
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Affiliation(s)
- Junichi Akiyama
- National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku, Tokyo, 162-8655, Japan, El Camino GI Medical Associates, Mountain View, CA 94040, USA and Division of Gastroenterology, Stanford University Medical Center, Stanford, CA 94305, USA
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Enestvedt BK, Ginsberg GG. Advances in endoluminal therapy for esophageal cancer. Gastrointest Endosc Clin N Am 2013; 23:17-39. [PMID: 23168117 DOI: 10.1016/j.giec.2012.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer is managed as well as in the palliation of dysphagia related to advanced esophageal cancer. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective therapies for accurate histopathologic staging and provide a potential for complete cure. Mucosal ablative techniques (radiofrequency ablation and cryotherapy) are effective adjuncts to EMR and ESD and reduce the occurrence of synchronous and metachronous lesions within the Barrett esophagus. The successes of these techniques have made endoscopic therapy the primary means of management of early esophageal cancer.
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Affiliation(s)
- Brintha K Enestvedt
- Division of Gastroenterology, Temple University, Philadelphia, PA 19140, USA.
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Fleischer DE. Comparing apples with apples and oranges: the role of radiofrequency ablation alone versus radiofrequency ablation plus EMR for endoscopic management of Barrett's esophagus with advanced neoplasia. Gastrointest Endosc 2012; 76:740-2. [PMID: 22985641 DOI: 10.1016/j.gie.2012.07.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Accepted: 07/16/2012] [Indexed: 02/04/2023]
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