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Radadiya D, Desai M, Patel H, Velji-Ibrahim J, Spadaccini M, Srinivasan S, Khurana S, Thoguluva Chandrasekar V, Perisetti A, Repici A, Hassan C, Sharma P. Endoscopic submucosal dissection and endoscopic mucosal resection for Barrett's-associated neoplasia: a systematic review and meta-analysis of the published literature. Endoscopy 2024. [PMID: 38942058 DOI: 10.1055/a-2357-6111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
BACKGROUND The role of endoscopic submucosal dissection (ESD) in the treatment of Barrett esophagus-associated neoplasia (BEN) has been evolving. We examined the efficacy and safety of ESD and endoscopic mucosal resection (EMR) for BEN. METHODS A database search was performed for studies reporting efficacy and safety outcomes of ESD and EMR for BEN. Pooled proportional and comparative meta-analyses were performed. RESULTS 47 studies (23 ESD, 19 EMR, 5 comparative) were included. The mean lesion sizes for ESD and EMR were 22.5 mm and 15.8 mm, respectively; most lesions were Paris type IIa. For ESD, pooled analysis showed rates of en bloc, R0, and curative resection, and local recurrence of 98%, 78%, 65%, and 2%, respectively. Complete eradication of dysplasia and intestinal metaplasia were achieved in 94% and 59% of cases, respectively. Pooled rates of perforation, intraprocedural bleeding, delayed bleeding, and stricture were 1%, 1%, 2%, and 10%, respectively. For EMR, pooled analysis showed rates of en bloc, R0, and curative resection, and local recurrence of 37%, 67%, 62%, and 6%, respectively. Complete eradication of dysplasia and intestinal metaplasia were achieved in 94% and 75% of cases. Pooled rates of perforation, intraprocedural bleeding, delayed bleeding, and stricture were 0.1%, 1%, 0.4%, and 8%, respectively. The mean procedure times for ESD and EMR were 113 and 22 minutes, respectively. Comparative analysis showed higher en bloc and R0 resection rates with ESD compared with EMR, with comparable adverse events. CONCLUSION ESD and EMR can both be employed to treat BEN depending on lesion type and size, and center expertise.
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Affiliation(s)
- Dhruvil Radadiya
- Gastroenterology, University of Kansas School of Medicine, Kansas City, United States
| | - Madhav Desai
- Gastroenterology, University of Minnesota Medical Center, Minneapolis, United States
- Gastroenterology and Hepatology, The University of Texas Health Science Center at Houston, Houston, United States
| | - Harsh Patel
- Gastroenterology, University of Kansas School of Medicine, Kansas City, United States
| | - Jena Velji-Ibrahim
- Internal Medicine, University of South Carolina School of Medicine, Greenville, United States
| | - Marco Spadaccini
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Sachin Srinivasan
- Gastroenterology, University of Kansas School of Medicine, Kansas City, United States
| | - Shruti Khurana
- Gastroenterology, University of Kansas School of Medicine, Kansas City, United States
| | | | - Abhilash Perisetti
- Gastroenterology, Kansas City VA Medical Center, Kansas City, United States
| | - Alessandro Repici
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Cesare Hassan
- Endoscopy Unit, Humanitas Clinical and Research Center - IRCCS, Rozzano, Italy
| | - Prateek Sharma
- Gastroenterology, University of Kansas School of Medicine, Kansas City, United States
- Gastroenterology, Kansas City VA Medical Center, Kansas City, United States
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Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
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Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
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3
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Ekeke CN, Chan EG, Fabian T, Villa-Sanchez M, Luketich JD. Recommendations for Surveillance and Management of Recurrent Esophageal Cancer Following Endoscopic Therapies. Surg Clin North Am 2021; 101:415-426. [PMID: 34048762 DOI: 10.1016/j.suc.2021.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
With advancing endoscopic technology and screening protocols for Barrett disease, more patients are being diagnosed with early-stage esophageal cancer. These early-stage patients may be amendable to endoscopic therapies, such as endomucosal resection and ablation. These therapies may minimize morbidity, but the elevated risk of recurrence cannot be overlooked. This article reports outcomes and recommendations for surveillance and management of recurrent esophageal cancer following endoscopic therapies.
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Affiliation(s)
- Chigozirim N Ekeke
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - Ernest G Chan
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - Thomas Fabian
- Department of Surgery, Section of Thoracic Surgery, Albany Medical Center, 43 New Scotland Avenue, MC-50, R-113, Albany, NY 12208, USA
| | - Manuel Villa-Sanchez
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C800, Pittsburgh, PA 15213, USA
| | - James D Luketich
- Department of Cardiothoracic Surgery, The University of Pittsburgh School of Medicine and the University of Pittsburgh Medical Center, 200 Lothrop Street, Suite C816, Pittsburgh, PA 15213, USA.
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4
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Shimamura Y, Iwaya Y, Kobayashi R, Rodriguez de Santiago E, Muwanwella N, Raftopoulos S, Mosko JD, May GR, Kandel G, Kortan P, Marcon N, Teshima CW. Clinical and pathological predictors of failure of endoscopic therapy for Barrett's related high-grade dysplasia and early esophageal adenocarcinoma. Surg Endosc 2020; 35:5468-5479. [PMID: 32989547 DOI: 10.1007/s00464-020-08037-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Multimodal endoscopic treatment for Barrett's esophagus (BE) related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) is safe and effective. However, there is a paucity of data to predict the response to endoscopic treatment. This study aimed to identify predictors of failure to achieve complete eradication of neoplasia (CE-N) and complete eradication of intestinal metaplasia (CE-IM). METHODS We performed a retrospective analysis of prospectively collected data of all HGD/EAC cases treated endoscopically at a tertiary referral center. Only patients with confirmed HGD/EAC from initial endoscopic mucosal resection (EMR) were included. Potential predictive variables including clinical characteristics, endoscopic features, and index histologic parameters of the EMR specimens were evaluated using multivariate Cox regression. RESULTS A total of 457 patients were diagnosed with HGD/EAC by initial EMR from January 2008 to January 2019. Of these, 366 patients who underwent subsequent endoscopic treatment with or without RFA were included. Cumulative incidence rates at 3 years for CE-N and CE-IM were 91.4% (95% CI 87.8-94.2%) and 66.8% (95% CI 61.2-72.3%), respectively during a median follow-up period of 35 months. BE segment of 3-10 cm (HR 0.45; 95% CI 0.36-0.57) and > 10 cm (HR 0.25; 95% CI 0.15-0.40) were independent clinical predictors associated with failure to achieve CE-N. With respect to CE-IM, increasing age (HR 0.88; 95% CI 0.78-1.00) was another predictor along with BE segment of 3-10 cm (HR 0.37; 95% CI 0.28-0.49) and > 10 cm (HR 0.15; 95% CI 0.07-0.30). Lymphovascular invasion increased the risk of CE-N and CE-IM failure in EAC cases. CONCLUSION Failure to achieve CE-N and CE-IM is associated with long-segment BE and other clinical variables. Patients with these predictors should be considered for a more intensive endoscopic treatment approach at expert centers.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Yugo Iwaya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ryosuke Kobayashi
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramon Y Cajal, IRYCIS, Universidad de Alcala, Madrid, Spain
| | - Niroshan Muwanwella
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jeffrey D Mosko
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gary R May
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gabor Kandel
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Paul Kortan
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Norman Marcon
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Christopher W Teshima
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
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Shimamura Y, Iwaya Y, Goda K, Teshima CW. Endoscopic treatment of Barrett's esophagus: What can we learn from the Western perspective? Dig Endosc 2018; 30:182-191. [PMID: 28816408 DOI: 10.1111/den.12950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/14/2017] [Indexed: 02/08/2023]
Abstract
The incidence of Barrett's esophagus (BE)-related neoplasia in Western countries has increased in the past several decades and, even in Eastern countries, it appears to be increasing. Endoscopic therapies are the first-line treatment for BE-related neoplasia; however, there is still no standardized treatment strategy. Most of the data have been published from Western countries where the ultimate goal of treatment is complete eradication of BE mucosa removing subtle synchronous lesions and preventing metachronous neoplasia. A multimodality approach that combines endoscopic resection and radiofrequency ablation (RFA) has been widely accepted in the West. In contrast, the lack of access to RFA treatment in the East has meant that endoscopic resection is the only feasible option. There is a wide divergence in treatment strategies for BE-related neoplasia between the East and the West. It is very important to consider these basic differences in the context of the currently available evidence to date. Therefore, the purpose of this article is to review the recent literature and to provide an overview of the endoscopic treatment options for BE.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yugo Iwaya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Kenichi Goda
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Christopher W Teshima
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
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Yamashita DT, Li C, Bethune D, Henteleff H, Ellsmere J. Endoscopic mucosal resection for high-grade dysplasia and intramucosal carcinoma: a Canadian experience. Can J Surg 2017; 60:129-133. [PMID: 28338468 DOI: 10.1503/cjs.013515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is increasingly being used as a first-line treatment for Barrett esophagus (BE) with high-grade dysplasia (HGD) and intramucosal adenocarcinoma (IMC). We reviewed our experience with endoscopic treatment of BE with HGD and IMC at our institution with respect to eradication rates, complications and long-term recurrence. METHODS We performed a single-centre retrospective review of all patients referred between October 2010 and August 2014 for EMR with dysplastic BE or IMC. We performed EMR using a cap-fitted endoscope, and the procedure was repeated every 3 months until eradication or progression of disease. RESULTS A total of 28 patients were identified: 16 with dysplastic BE (14 HGD, 1 low-grade dysplasia, 1 intermediate dysplasia) and 12 with IMC. Complete eradication of HGD was achieved in 11 of 14 (79%) patients. Three of 12 (25%) patients initially referred with suspected IMC were found to have invasive adenocarcinoma on EMR. Eradication was successful in 8 of 9 (89%) patients with true IMC, with 1 patient progressing to salvage esophagectomy. Complications occurred in 2 of 28 (7%) patients; both had esophageal strictures managed with dilatation. Median duration of follow-up was 371 days. CONCLUSION Our experience supports the safety of EMR as a first-line treatment for patients with BE with dysplasia and IMC in early short-term follow-up.
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Affiliation(s)
- Denise Tami Yamashita
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Chao Li
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Drew Bethune
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - Harry Henteleff
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
| | - James Ellsmere
- From the Division of General, Surgery, Dalhousie University, Halifax, NS (Yamashita, Li, Ellsmere); and the Division of Thoracic Surgery, Dalhousie University, Halifax, NS (Bethune, Henteleff)
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7
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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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Parsi MA, Trindade AJ, Bhutani MS, Melson J, Navaneethan U, Thosani N, Trikudanathan G, Watson RR, Maple JT. Cryotherapy in gastrointestinal endoscopy. VideoGIE 2017; 2:89-95. [PMID: 29905303 PMCID: PMC5991494 DOI: 10.1016/j.vgie.2017.01.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Key Words
- AVM, arteriovenous malformation
- BE, Barrett’s esophagus
- CE-D, complete elimination of dysplasia
- CE-IM, complete elimination of intestinal metaplasia
- CPT, Current Procedural Terminology
- GAVE, gastric antral vascular ectasia
- HGD, high-grade dysplasia
- RFA, radiofrequency ablation
- RP, radiation proctopathy
- RVU, relative value unit
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Ratone JP, Bories E, Caillol F, Pesenti C, Godat S, Poizat F, Cassan CD, Giovannini M. Oral steroid prophylaxis is effective in preventing esophageal strictures after large endoscopic resection. Ann Gastroenterol 2016; 30:62-66. [PMID: 28042239 PMCID: PMC5198248 DOI: 10.20524/aog.2016.0085] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/05/2016] [Indexed: 12/13/2022] Open
Abstract
Background Strictures are frequent complications of large endoscopic mucosal resections (EMR) and endoscopic submucosal dissections of the esophagus. Local or systemic steroid therapy has shown promise in the prevention of secondary stenosis. The aim of this study was to evaluate the safety and efficacy of systemic steroid therapy following endoscopic resection of at least hemi-circumferential esophageal mucosa. Methods This was a single-center retrospective study in a tertiary center. We evaluated patients who were treated with oral steroids between July 2013 and September 2015, after undergoing a large EMR for Barrett’s esophagus associated with dysplasia or carcinoma. The steroid protocol used was an initial dose of 30 mg prednisolone, tapered over 8 weeks. Exclusion criteria were a previous attempt at radiofrequency ablation or resection. Results Thirty-one patients (27 men) were analyzed: 13 with low-grade dysplasia Barrett’s esophagus, 16 with in situ adenocarcinoma, 1 with pT1SM1 adenocarcinoma, and 1 with pT1SM2 adenocarcinoma. Twenty-eight resections (28/31) were completed (R0) in 1-3 sessions (median 2), while 3 resections were R1. The median length of Barrett’s esophagus was C3M5 (range C0M2-C10M11) according to the Prague classification. The median follow up was 10 months (range 4-17), during which 4 patients (13%) developed a secondary stenosis. All stenoses were successfully treated by endoscopic dilation (range 1-4). No complications related to dilation or to the steroid therapy were observed. Conclusions Our rate of secondary stricture was lower than expected, given the rates of 17-88% in published studies. Systemic oral steroid therapy seems to be effective in reducing potential esophageal stenosis after EMR. Complementary randomized studies are required to confirm whether systemic steroids are an effective primary prophylaxis for esophageal stenosis.
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Affiliation(s)
- Jean-Philippe Ratone
- Endoscopy Unit (Jean-Philippe Ratone, Erwan Bories, Fabrice Caillol, Christian Pesenti, Sebastien Godat, Chiara De Cassan, Marc Giovannini)
| | - Erwan Bories
- Endoscopy Unit (Jean-Philippe Ratone, Erwan Bories, Fabrice Caillol, Christian Pesenti, Sebastien Godat, Chiara De Cassan, Marc Giovannini)
| | - Fabrice Caillol
- Endoscopy Unit (Jean-Philippe Ratone, Erwan Bories, Fabrice Caillol, Christian Pesenti, Sebastien Godat, Chiara De Cassan, Marc Giovannini)
| | - Christian Pesenti
- Endoscopy Unit (Jean-Philippe Ratone, Erwan Bories, Fabrice Caillol, Christian Pesenti, Sebastien Godat, Chiara De Cassan, Marc Giovannini)
| | - Sebastien Godat
- Endoscopy Unit (Jean-Philippe Ratone, Erwan Bories, Fabrice Caillol, Christian Pesenti, Sebastien Godat, Chiara De Cassan, Marc Giovannini)
| | - Flora Poizat
- Pathology Unit (Flora Poizat), Paoli-Calmettes Institute, Marseille, France
| | - Chiara De Cassan
- Endoscopy Unit (Jean-Philippe Ratone, Erwan Bories, Fabrice Caillol, Christian Pesenti, Sebastien Godat, Chiara De Cassan, Marc Giovannini)
| | - Marc Giovannini
- Endoscopy Unit (Jean-Philippe Ratone, Erwan Bories, Fabrice Caillol, Christian Pesenti, Sebastien Godat, Chiara De Cassan, Marc Giovannini)
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Ahn PH, Quon H, O'Malley BW, Weinstein G, Chalian A, Malloy K, Atkins JH, Sollecito T, Greenberg M, McNulty S, Lin A, Zhu TC, Finlay JC, Cengel K, Livolsi V, Feldman M, Mick R, Busch TM. Toxicities and early outcomes in a phase 1 trial of photodynamic therapy for premalignant and early stage head and neck tumors. Oral Oncol 2016; 55:37-42. [PMID: 26865261 DOI: 10.1016/j.oraloncology.2016.01.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Revised: 01/17/2016] [Accepted: 01/20/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Management of early superficial lesions in the head and neck remains complex. We performed a phase 1 trial for high-grade premalignant and early superficial lesions of the head and neck using photodynamic therapy (PDT) with Levulan (ALA). MATERIALS AND METHODS Thirty-five subjects with high grade dysplasia, carcinoma in situ, or microinvasive (⩽1.5mm depth) squamous cell carcinoma were enrolled. Cohorts of 3-6 patients were given escalating intraoperative light doses of 50-200J/cm(2) 4-6h after oral administration of 60mg/kg ALA. Light at 629-635nm was delivered in a continuous (unfractionated) or fractionated (two-part) schema. RESULTS PDT was delivered to 30/35 subjects, with 29 evaluable. There was one death possibly due to the treatment. The regimen was otherwise tolerable, with a 52% rate of grade 3 mucositis which healed within several weeks. Other toxicities were generally grade 1 or 2, including odynophagia (one grade 4), voice alteration (one grade 3), and photosensitivity reactions. One patient developed grade 5 sepsis. With a median follow-up of 42months, 10 patients (34%) developed local recurrence; 4 of these received 50J/cm(2) and two each received 100, 150, and 200J/cm(2). Ten (34%) patients developed recurrence adjacent to the treated field. There was a 69% complete response rate at 3months. CONCLUSIONS ALA-PDT is well tolerated. Maximum Tolerated Dose appears to be higher than the highest dose used in this study. Longer followup is required to analyze effect of light dose on local recurrence. High marginal recurrence rates suggest use of larger treatment fields.
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Affiliation(s)
- Peter H Ahn
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States.
| | - Harry Quon
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States; Department of Radiation Oncology, Johns Hopkins University, 401 N. Broadway, Baltimore, MA 21231, United States
| | - Bert W O'Malley
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Gregory Weinstein
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Ara Chalian
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Kelly Malloy
- Department of Otolaryngology-Head and Neck Surgery, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States; Department of Otolaryngology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI 48109, United States
| | - Joshua H Atkins
- Department of Anesthesiology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Thomas Sollecito
- Department of Oral Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Martin Greenberg
- Department of Oral Medicine, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Sally McNulty
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Alexander Lin
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Timothy C Zhu
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Jarod C Finlay
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Keith Cengel
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
| | - Virginia Livolsi
- Department of Pathology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Michael Feldman
- Department of Pathology, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Rosemarie Mick
- Department of Biostatistics and Epidemiology, University of Pennsylvania, 423 Guardian Drive, Philadelphia, PA 19104, United States
| | - Theresa M Busch
- Department of Radiation Oncology, University of Pennsylvania, 3400 Civic Center Blvd, Philadelphia, PA 19104, United States
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Kozarek RA. Photodynamic therapy in esophageal cancer. GASTROINTESTINAL INTERVENTION 2015. [DOI: 10.18528/gii1400008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Brown J, Alsop B, Gupta N, Buckles DC, Olyaee MS, Vennalaganti P, Kanakadandi VN, Saligram S, Sharma P. Effectiveness of focal vs. balloon radiofrequency ablation devices in the treatment of Barrett's esophagus. United European Gastroenterol J 2015; 4:236-41. [PMID: 27087952 DOI: 10.1177/2050640615594549] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 06/09/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND AIMS The safety and efficacy of radiofrequency ablation (RFA) in treatment of Barrett's esophagus (BE)-associated dysplasia has been well established. The effectiveness of focal and balloon RFA devices has not been compared. Therefore, the aim of our study was to assess the effectiveness of focal and balloon RFA devices in the treatment of BE by calculating absolute and percentage change in BE length with RFA therapy by comparing pre- and post-treatment BE length. PATIENTS AND METHODS This is a retrospective cross-sectional study of patients who underwent at least one treatment with either focal and/or balloon RFA devices who were identified from two tertiary centers. Patients' demographics, hiatal hernia, pre- and post-treatment BE length, prior use of endoscopic therapies and number of sessions were recorded. RESULTS Sixty-one patients who had undergone 161 RFA treatment sessions met inclusion criteria. There was no significant difference in percentage change in BE length with greater number of RFA sessions. RFA with a focal device resulted in greater percentage reduction in BE length compared to the balloon system (73% vs. 39%, p < 0.01). After adjusting for initial BE length, pre-treatment BE length, hernia status, prior endoscopic mucosal resection (EMR), prior RFA, and prior EMR/RFA sessions, RFA with a focal device at each session remained an independent predictor for a significant reduction in BE extent as compared to the balloon system. CONCLUSION The focal RFA device alone was more effective in treatment of BE compared to the balloon system, with a greater reduction in extent of BE. The focal RFA device for endoscopic eradication therapy of BE should be considered the preferred technique.
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Affiliation(s)
- Jesica Brown
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Benjamin Alsop
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Neil Gupta
- Gastroenterology, Loyola University, USA
| | - Daniel C Buckles
- Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Mojtaba S Olyaee
- Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | | | - Vijay Naag Kanakadandi
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Shreyas Saligram
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
| | - Prateek Sharma
- Gastroenterology and Hepatology, Veterans Affairs Medical Center, USA; Gastroenterology and Hepatology, University of Kansas Medical Center, USA
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Abstract
Early esophageal cancer is confined to the mucosa or submucosa of the esophagus. While most esophageal cancer is detected at an advanced stage (requiring surgical resection, chemotherapy, and radiation), early-stage mucosal lesions may be detected through Barrett's surveillance programs or incidentally on diagnostic upper endoscopies performed for other reasons. These early-stage cancers are often amenable to endoscopic therapies, including mucosal resection, ablation, and cryotherapy. Studies suggest equivalent survival rates and reduced morbidity but higher recurrence rates with endoscopic removal of early-stage cancers compared to surgical resection. There is emerging data regarding the efficacy and long-term outcomes of endoscopic therapy for early esophageal cancer that is promising, and further research is needed to better define the role of endoscopic therapy in the management of early esophageal cancer.
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Affiliation(s)
- Vaishali Patel
- Division of Gastroenterology, Duke University Medical Center, 190 Grey Elm Trail, Durham, NC, 27713, USA,
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Saligram S, Tofteland N, Wani S, Gupta N, Mathur S, Vennalaganti P, Kanakadandi V, Giacchino M, Higbee A, Lim D, Rastogi A, Bansal A, Sharma P. Long-term results of the mucosal ablation of Barrett's esophagus: efficacy and recurrence. Endosc Int Open 2015; 3:E189-94. [PMID: 26171429 PMCID: PMC4486038 DOI: 10.1055/s-0034-1391669] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 10/31/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS It has been postulated that the endoscopic ablation of Barrett's esophagus can lead to complete eradication of the disease. This study was undertaken to evaluate the efficacy of endoscopic eradication therapy for Barrett's esophagus and the rates of recurrence of intestinal metaplasia. PATIENTS AND METHODS As part of an initial randomized controlled trial, patients with nondysplastic or low grade dysplastic Barrett's esophagus underwent mucosal ablation. Following ablation, the patients had annual surveillance endoscopies. Recurrence was defined as the presence of intestinal metaplasia after initial complete eradication had been achieved. RESULTS A total of 28 patients with Barrett's esophagus were followed for a mean of 6.4 years after ablation therapy. At baseline, the majority of the patients had nondysplastic Barrett's esophagus (79 %). Initial complete eradication of intestinal metaplasia was achieved at a mean of 4.1 months. During long-term follow-up, initial recurrence of intestinal metaplasia was seen in 14 of the 28 of patients (50 %) at a mean of 40 months, and further maintenance ablation therapy was applied. At the final follow-up, 36 % of the patients had complete eradication of intestinal metaplasia, 18 % of the patients had intestinal metaplasia, and 21 % had died of unrelated causes; invasive esophageal adenocarcinoma had developed in 1 patient. CONCLUSIONS The long-term results of this study demonstrate a recurrence rate of 50 % after complete eradication of Barrett's esophagus with endoscopic eradication therapy. In addition, re-recurrence (in 36 %), even after further maintenance endoscopic eradication therapy, and deaths unrelated to the disease (21 %) occurred. Complete remission of Barrett's esophagus appears to be a difficult goal to achieve. These results call into question the role of ablation in patients with low risk Barrett's esophagus.
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Affiliation(s)
- Shreyas Saligram
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Nathan Tofteland
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Sachin Wani
- University of Colorado and Veterans Affairs Medical Center, Denver, Colorado, USA
| | - Neil Gupta
- Loyola University Health System, Maywood, Illinois, USA
| | - Sharath Mathur
- Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | | | - Vijay Kanakadandi
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | | | - April Higbee
- Veterans Affairs Medical Center, Kansas City, Missouri, USA
| | - Diego Lim
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Amit Rastogi
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Ajay Bansal
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Prateek Sharma
- Veterans Affairs Medical Center, Kansas City, Missouri, USA ,University of Kansas School of Medicine, Kansas City, Kansas, USA,Corresponding author Prateek Sharma, MD Department of Gastroenterology (111)Veterans Affairs Medical Center4801 East Linwood BoulevardKansas City, Missouri 64128-2295+1-412-708-5548
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Holt BA, Jayasekeran V, Williams SJ, Lee EYT, Bahin FF, Sonson R, Lord RV, Bourke MJ. Early metal stent insertion fails to prevent stricturing after single-stage complete Barrett's excision for high-grade dysplasia and early cancer. Gastrointest Endosc 2015; 81:857-64. [PMID: 25442084 DOI: 10.1016/j.gie.2014.08.022] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 08/18/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Barrett's esophagus with high-grade dysplasia (HGD) or intramucosal adenocarcinoma (IMC) can be effectively treated by single-session EMR, resulting in complete Barrett's excision (CBE). CBE provides accurate histology for staging and clinical confirmation of neoplasia eradication but is limited by a high risk of esophageal stricture formation. OBJECTIVE To evaluate the effectiveness of prophylactic temporary esophageal stenting to prevent post-CBE stricture formation. DESIGN AND SETTING Single-center, investigator-initiated feasibility study. PATIENTS Circumferential, short-segment Barrett's esophagus (≤C3≤M5) with HGD or IMC. INTERVENTION Single-stage CBE and insertion of a fully covered metal esophageal stent at 10 days that was removed at 8 weeks. Patients were followed for a minimum of 2 surveillance endoscopies. MAIN OUTCOME MEASUREMENT Symptomatic esophageal stricture formation. RESULTS At the end of the follow-up period, 8 patients (57.1%) required esophageal dilation for symptomatic CBE-related (n = 7) or stent-related (n = 4) strictures. A median of 3 surveillance endoscopies were performed over a median endoscopic follow-up of 17 months (range 4-25 months). Single-stage CBE successfully eliminated Barrett's intestinal metaplasia and neoplasia in 71.4% and 92.9% of patients, respectively. Four patients were admitted to the hospital, and 4 patients had early stent removal because of pain or dysphagia. LIMITATIONS Single-center feasibility study. CONCLUSIONS In a prospective study evaluating prophylactic esophageal stent insertion after single-stage CBE, esophageal strictures formed in more than of half the study cohort, and stents were associated with significant morbidity. An alternative method to reduce stricture formation is required. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01554280.).
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Affiliation(s)
- Bronte A Holt
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Vanoo Jayasekeran
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Stephen J Williams
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Eric Y T Lee
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Farzan F Bahin
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Rebecca Sonson
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia
| | - Reginald V Lord
- St. Vincent's Centre for Applied Medical Research, University of Notre Dame School of Medicine, and University of New South Wales, Sydney, New South Wales, Australia
| | - Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Huntington JT, Walker JP, Meara MP, Hazey JW, Melvin WS, Perry KA. Endoscopic mucosal resection for staging and treatment of early esophageal carcinoma: a single institution experience. Surg Endosc 2014; 29:2121-5. [PMID: 25472745 DOI: 10.1007/s00464-014-3962-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Accepted: 10/25/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) has emerged for evaluation and treatment of esophageal nodules. We report our initial experience with EMR for T staging and management of early esophageal cancer. METHODS We reviewed patients undergoing EMR for esophageal adenocarcinoma between 2008 and 2013. The primary outcome measure was needed for esophagectomy. Secondary outcomes included complete eradication of adenocarcinoma, recurrence or persistence of cancer, nodal status for those undergoing esophagectomy, and complications of endoscopic treatment. RESULTS During the study period, 24 patients underwent EMR demonstrating carcinoma, and a grossly margin negative endoscopic resection was achieved in all cases. Ten patients (42 %) had evidence of submucosal invasion and were referred for esophagectomy. Patients with margin negative EMR (n = 10, 42 %) or positive radial margins (n = 4, 16 %) underwent endoscopic surveillance and treatment with radiofrequency ablation or repeat EMR as needed. Thirteen patients (93 %) with intramucosal cancer (IMC) have been successfully managed with ongoing endoscopic surveillance and treatment with a median follow-up of 15.5 months. One patient underwent esophagectomy due to recurrent IMC in the setting of long-segment multifocal high-grade dysplasia. There were no esophageal perforations, one patient developed a self-limited gastrointestinal hemorrhage following EMR, and one had an esophageal stricture following endoscopic management. CONCLUSIONS IMC can be successfully managed endoscopically and thus esophagectomy is avoided in a significant proportion of patients. Endoscopic management may be utilized in the setting of complete resection or radial margin involvement without evidence of submucosal invasion. Close endoscopic follow-up is of paramount importance even in those with negative margins, because recurrent disease may occur following EMR in these patients.
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Affiliation(s)
- Justin T Huntington
- Division of General and Gastrointestinal Surgery, The Ohio State University, Columbus, OH, 43210, USA,
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Clinical outcome of photodynamic therapy in esophageal squamous cell carcinoma. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY B-BIOLOGY 2014; 141:20-5. [DOI: 10.1016/j.jphotobiol.2014.09.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 08/25/2014] [Accepted: 09/02/2014] [Indexed: 01/30/2023]
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Kozarek RA. WITHDRAWN: Photodynamic therapy in esophageal cancer. GASTROINTESTINAL INTERVENTION 2014. [DOI: 10.1016/j.gii.2014.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Wang AY. Endoscopic submucosal tunnel dissection: the space between. Gastrointest Endosc 2013; 78:953-955. [PMID: 24237950 DOI: 10.1016/j.gie.2013.07.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 07/18/2013] [Indexed: 12/21/2022]
Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia Health System, Charlottesville, Virginia, USA
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Direct radiofrequency application improves pain and gait in collagenase-induced acute achilles tendon injury. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 2013:402692. [PMID: 24348697 PMCID: PMC3853797 DOI: 10.1155/2013/402692] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 10/22/2013] [Indexed: 11/19/2022]
Abstract
Radiofrequency (RF) is often used as a supplementary and alternative method to alleviate pain for chronic tendinopathy. Whether or how it would work for acute tendon injury is not addressed in the literatures. Through detailed pain and gait monitoring, we hypothesized that collagenase-induce acute tendinopathy model may be able to answer these questions. Gait parameters, including time, distance, and range of motion, were recorded and analyzed using a walking track equipped with a video-based system. Expression of substance P (SP), calcitonin gene related peptide (CGRP), and galanin were used as pain markers. Beta-III tubulin and Masson trichrome staining were used as to evaluate nerve sprouting, matrix tension, and degeneration in the tendon. Of fourteen analyzed parameters, RF significantly improved stance phase, step length, preswing, and intermediary toe-spread of gait. Improved gait related to the expression of substance P, CGRP, and reduced nerve fiber sprouting and matrix tension, but not galanin. The study indicates that direct RF application may be a valuable approach to improve gait and pain in acute tendon injury. Altered gait parameters may be used as references to evaluate therapeutic outcomes of RF or other treatment plan for tendinopathy.
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