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Eluri S, Cotton CC, Kaul V, McKinley M, Pleskow D, Nishioka N, Hoffman B, Nieto J, Tsai F, Coyle W, Kothari S, Joshi V, Dumot J, Greenwald B, Habr FG, Shaheen NJ. Liquid nitrogen spray cryotherapy for eradication of dysplastic Barrett's esophagus: results from a multicenter prospective registry. Gastrointest Endosc 2024; 100:200-209. [PMID: 38272279 DOI: 10.1016/j.gie.2024.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/24/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
BACKGROUND AND AIMS Liquid nitrogen spray cryotherapy (SCT) is an alternative to radiofrequency ablation (RFA) for eradication of dysplastic Barrett's esophagus (BE). We aimed to assess the safety, efficacy, and durability of SCT in a multicenter U.S. registry. METHODS This is a multicenter prospective registry of adults with BE treated with truFreeze Spray Cryotherapy (Steris, Mentor, Ohio, USA) (4 community and 11 academic sites, 2013-2022). Complete eradication of intestinal metaplasia (CEIM) and dysplasia (CED) were assessed in BE with dysplasia or intramucosal adenocarcinoma. Kaplan-Meier analysis of CEIM and CED was performed. Hazard ratios for CEIM stratified by baseline risk factors were calculated. RESULTS Among 138 subjects with low-grade dysplasia (24%), high-grade dysplasia (49%), and intramucosal adenocarcinoma (27%), 34% received prior RFA therapy. Subjects received a median of 2 SCT sessions. Adverse events were uncommon, with 5.5% reporting strictures and 0.7% a perforation. Rates of CEIM and CED, respectively, were 66% and 84% after 2 years and 67% and 92% after 3 years. In RFA-naïve patients, CEIM was 77% and CED was 96% at 3 years. Increasing BE length (per centimeter: adjusted hazard ratio, 0.90; 95% confidence interval, 0.83-0.96) and prior treatment with RFA (adjusted hazard ratio, 0.39; 95% confidence interval, 0.22-0.69) were associated with a lower rate of CEIM. Recurrence occurred in 8.8% (n = 6) at a mean follow-up of 2.5 years after CEIM. CONCLUSION In this largest reported prospective cohort, liquid nitrogen SCT was safe and effective for the treatment of dysplastic and neoplastic BE. Response was lower in those with prior failed RFA; in that cohort, approximately 50% attained CEIM at 3 years.
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Affiliation(s)
- Swathi Eluri
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
| | - Cary C Cotton
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Vivek Kaul
- University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew McKinley
- Hofstra North Shore-LIJ School of Medicine, Hempstead, New York, USA
| | - Douglas Pleskow
- Gastroenterology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Norman Nishioka
- Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brenda Hoffman
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jose Nieto
- Borland Groover Clinic, Jacksonville, Florida, USA
| | | | | | - Shivangi Kothari
- University of Rochester Medical Center, Rochester, New York, USA
| | - Virendra Joshi
- Louisiana State University Medical Center, Baton Rouge, Louisiana, USA
| | - John Dumot
- University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Bruce Greenwald
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA; Center for Gastrointestinal Biology and Disease, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Wang D, Chen Y, Ji F, Hu JW, Zhou PH, Xu SC, Chen Y, Ye LP, Ye GL, Li R, Li ZS. Hybrid argon plasma coagulation for the treatment of Barrett's esophagus: A prospective, multicenter study. World J Clin Cases 2024; 12:3866-3872. [PMID: 38994274 PMCID: PMC11235429 DOI: 10.12998/wjcc.v12.i19.3866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND The incidence of Barrett's esophagus (BE) in China is lower compared to the Western populations. Hence, studies conducted in the Chinese population has been limited. The current treatment options available for BE treatment includes argon plasma coagulation (APC), radiofrequency ablation and cryoablation, all with varying degrees of success. AIM To determine the efficacy and safety of HybridAPC in the treatment of BE. METHODS The study cohort consisted of patients with BE who underwent HybridAPC ablation treatment. These procedures were performed by seven endoscopists from different tertiary hospitals. The duration of the procedure, curative rate, complications and recurrent rate by 1-year follow-up were recorded. RESULTS Eighty individuals were enrolled for treatment from July 2017 to June 2020, comprising of 39 males and 41 females with a median age of 54 years (range, 30 to 83 years). The technical success rate of HybridAPC was 100% and the overall curative rate was 98.15%. No severe complications occurred during the operation. BE cases were classified as short-segment BE and long-segment BE. Patients with short-segment BE were all considered cured without complications. Thirty-six patients completed the one-year follow-up without recurrence. Twenty-four percent had mild dysplasia which were all resolved with one post-procedural treatment. The mean duration of the procedure was 10.94 ± 6.52 min. CONCLUSION Treatment of BE with HybridAPC was found to be a simple and quick procedure that is safe and effective during the short-term follow-up, especially in cases of short-segment BE. This technique could be considered as a feasible alternative ablation therapy for BE.
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Affiliation(s)
- Dong Wang
- Department of Gastroenterology, Shanghai Ninth People's Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai 200011, China
| | - Yan Chen
- Department of Gastroenterology, Changhai Hospital, Shanghai 200438, China
| | - Feng Ji
- Department of Gastroenterology, The First Affiliated Hospital Zhejiang University School of Medicine, Hangzhou 311399, Zhejiang Province, China
| | - Jian-Wei Hu
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Ping-Hong Zhou
- Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai 200032, China
| | - Shu-Chang Xu
- Endoscopy Center, Tongji Hospital of Tongji University, Shanghai 200092, China
| | - Ying Chen
- Endoscopy Center, Tongji Hospital of Tongji University, Shanghai 200092, China
| | - Li-Ping Ye
- Department of Gastroenterology, Taizhou Hospital of Zhejiang Province, Taizhou 318001, Zhejiang Province, China
| | - Guo-Liang Ye
- Department of Gastroenterology, The Affiliated Hospital of Medicine School, Ningbo University, Ningbo 315021, Zhejiang Province, China
| | - Rui Li
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou 215006, Jiangsu Province, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Shanghai 200438, China
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Smith ZL, Thorgerson AM, Dawson AZ, Wani S. Incidence of Esophageal Adenocarcinoma, Mortality, and Esophagectomy in Barrett's Esophagus Patients Undergoing Endoscopic Eradication Therapy. Dig Dis Sci 2023; 68:4439-4448. [PMID: 37863992 DOI: 10.1007/s10620-023-08107-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 09/05/2023] [Indexed: 10/22/2023]
Abstract
INTRODUCTION Endoscopic eradication therapy (EET) is the preferred treatment for Barrett's esophagus (BE)-related neoplasia patients. However, the impact of EET on critical outcomes, outside of clinical trials and registry data, remains scarcely studied. We aimed to assess real-world practice patterns and clinical outcomes among BE patients undergoing EET. METHODS TriNetX is a large research network comprising linked inpatient and outpatient electronic-health record-derived data from over 80,000,000 patients. Patients with a diagnosis of BE from 2015 to 2020 were identified and included if they underwent EET during the study period. The primary outcome was the progression to EAC after index EET. Secondary outcomes included rate of esophagectomy, and all-cause mortality. All outcomes were stratified by baseline histology. The incidence of EAC and all-cause mortality were reported in person-years and adjusted for age and sex. RESULTS A total of 4114 patients were analyzed. Distribution of baseline histology was as follows: NDBE (11.8%), LGD (21.4%), HGD (26.4%), EAC (20.8%), and unspecified (19.6%). The total incidence of EAC after index EET was 6.01 per 1000 person-years (PY) for the entire cohort with the highest rate in HGD patients (12.9/1000 PY). The incidence of all-cause mortality was 13.23 per 1000 PY with the highest rates in EAC patients (25.1 per 1000 PY). Rates of esophagectomy were < 1% for all grades of dysplasia. CONCLUSION The results of this study provide "real-world" data on critical outcomes for BE patients undergoing EET, demonstrating a low risk of incident EAC, all-cause mortality, and need for esophagectomy.
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Affiliation(s)
- Zachary L Smith
- Division of Gastroenterology and Hepatology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Abigail M Thorgerson
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aprill Z Dawson
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, WI, USA
- Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Mail Stop F735, 1635 Aurora Court, Rm 2.031, Aurora, CO, 80045, USA.
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Chandan S, Bapaye J, Khan SR, Deliwala S, Mohan BP, Ramai D, Dhindsa BS, Goyal H, Kassab LL, Aziz M, Kamal F, Facciorusso A, Adler DG. Safety and efficacy of liquid nitrogen spray cryotherapy in Barrett's neoplasia - a comprehensive review and meta-analysis. Endosc Int Open 2022; 10:E1462-E1473. [PMID: 36397870 PMCID: PMC9666080 DOI: 10.1055/a-1906-4967] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 07/20/2022] [Indexed: 10/17/2022] Open
Abstract
Background and study aims Barrett's esophagus (BE) is a precursor condition to esophageal adenocarcinoma (EAC), resulting in transformation of the squamous epithelium of distal esophagus to columnar-lined epithelium with intestinal metaplasia (IM). Liquid nitrogen spray cryotherapy (LNSC) is a non-contact method of BE eradication and has been used both as primary and salvage therapy. We conducted a systematic review and meta-analysis to assess the safety and efficacy of LNSC. Methods We searched multiple databases from inception through December 2021 to identify studies on use of LNSC for Barrett's neoplasia. Pooled estimates were calculated using random-effects model and results were expressed in terms of pooled proportions with relevant 95 % confidence intervals (CIs) of complete eradication (CE) of dysplasia(D), high grade dysplasia (HGD) and IM. Results Fourteen studies with 707 patients were included in our final analysis. Overall pooled rates of CE-D, CE-HGD and CE-IM were 80.8 % (CI 77.4-83.8; I 2 62), 90.3 % (CI 85.2-93.7; I 2 33) and 55.8 % (CI 51.7-59.8; I 2 73) with follow up ranging from 4.25 months to 69.7 months. In patients with follow up beyond 24 months, the rates of CE-D and CE-IM were 83.6 % (CI 77.6-88.2; I 2 60) and 54.7 % (CI 47.6-61.6; I 2 81). Among LNSC naïve patients with prior history of endoscopic resection, the rates were 79.9 % (CI 73.3-85.2; I 2 50) and 67.1 % (CI 59.5-73.8; I 2 0). Pooled rate of therapeutic failures, defined as lack of response to LNSC therapy, was 23.6 % (CI 19.4-28.3; I 2 73). Post LNSC strictures and perforation pooled rates were 4 % and 0.8 %, respectively, which are similar to those previously reported for RFA. Conclusions Our analysis suggests that liquid nitrogen spray cryotherapy is an acceptable treatment for BE in both ablation naïve and experienced patients.
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Affiliation(s)
- Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, Nebraska, United States
| | - Jay Bapaye
- Department of Internal Medicine, Rochester General Hospital, Rochester, New York, New York, United States
| | - Shahab R. Khan
- Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Smit Deliwala
- Internal Medicine, Hurley Medical Center, Flint, Michigan, United States
| | - Babu P. Mohan
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, United States
| | - Banreet S. Dhindsa
- Division of Gastroenterology and Hepatology, University of Nebraska Medical Center, Omaha, Nebraska, United States
| | - Hemant Goyal
- Department of Gastroenterology, The Wright Center for Graduate Medical Education, Scranton, Pennsylvania, Unites States
| | - Lena L. Kassab
- Internal Medicine, Mayo Clinic, Rochester, Minnesota, United States
| | - Muhammad Aziz
- Division of Gastroenterology and Hepatology, University of Toledo, Toledo, Ohio, United States
| | - Faisal Kamal
- Division of Gastroenterology, University of California-San Francisco, California, United States
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Douglas G. Adler
- Center for Advanced Therapeutic Endoscopy (CATE), Centura Health, Porter Adventist Hospital, Denver, Colorado, United States
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Gotink AW, Peters Y, Bruno MJ, Siersema PD, Koch AD. Nonthermal resection device for ablation of Barrett's esophagus: a feasibility and safety study. Endoscopy 2022; 54:545-552. [PMID: 34521118 DOI: 10.1055/a-1644-4326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Several techniques exist for the eradication of Barrett's esophagus (BE); however, all have limitations regarding successful conversion to squamous epithelium and a complication profile. We aimed to assess the feasibility and safety of a new nonthermal device, the EndoRotor, for the eradication of BE as a first-line ablation technique. METHODS Patients with BE were prospectively included at two tertiary referral centers in The Netherlands. INCLUSION CRITERIA BE length 2-5 cm, with low grade dysplasia, high grade dysplasia, or residual BE after endoscopic resection (ER) of a lesion containing early neoplasia. EXCLUSION CRITERIA previous ER > 50 % circumference, or previous ablation therapy. Follow-up endoscopy was performed 3 months after ablation therapy. Outcomes were the percentage of endoscopically visible BE surface regression and complications. RESULTS 30 patients were included (age 66 years, interquartile range [IQR] 59-73, median BE C0M3, 25 male). Overall, 18 patients underwent ER prior to ablation. Median percentage BE ablated was 100 % (IQR 94 %-100 %). Median visual BE surface regression at 3-month follow-up was 80 % (IQR 68 %-95 %). Multiple residual Barrett's islands were commonly seen. Six patients (20 %) had a treatment-related complication requiring intervention, including one perforation (3 %), one postprocedural hemorrhage (3 %), and four strictures (13 %). Post-procedural pain was reported in 18 patients (60 %). CONCLUSIONS Endoscopic ablation of BE using this novel nonthermal device was found to be technically demanding, with a longer procedure time compared with established ablation techniques and a high complication rate. Based on these results, we do not recommend its use as a first-line ablation technique for the eradication of BE.
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Affiliation(s)
- Annieke W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center, Rotterdam, The Netherlands
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Maione F, Chini A, Maione R, Manigrasso M, Marello A, Cassese G, Gennarelli N, Milone M, De Palma GD. Endoscopic Diagnosis and Management of Barrett's Esophagus with Low-Grade Dysplasia. Diagnostics (Basel) 2022; 12:diagnostics12051295. [PMID: 35626450 PMCID: PMC9141542 DOI: 10.3390/diagnostics12051295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 02/05/2023] Open
Abstract
Barrett’s Esophagus is a common condition associated with chronic gastroesophageal reflux disease. It is well known that it has an association with a higher incidence of esophageal adenocarcinoma, but this neoplastic transformation is first preceded by the onset of low and high-grade dysplasia. The evaluation of low grade dysplastic esophageal mucosa is still controversial; although endoscopic surveillance is preferred, several minimally invasive endoscopic therapeutic approaches are available. Endoscopic mucosal resection and radiofrequency ablation are the most used endoscopic treatments for the eradication of low-grade dysplasia, respectively, for nodular and flat dysplasia. Novel endoscopic treatments are cryotherapy ablation and argon plasma coagulation, that have good rates of eradication with less complications and post-procedural pain.
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Affiliation(s)
- Francesco Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
- Correspondence: (F.M.); (R.M.)
| | - Alessia Chini
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Rosa Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
- Correspondence: (F.M.); (R.M.)
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Alessandra Marello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Nicola Gennarelli
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
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Genere JR, Visrodia K, Zakko L, Hoefnagel SJM, Wang KK. Spray cryotherapy versus continued radiofrequency ablation in persistent Barrett's esophagus. Dis Esophagus 2022; 35:6512102. [PMID: 35059707 DOI: 10.1093/dote/doab084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/09/2021] [Indexed: 12/11/2022]
Abstract
Radiofrequency ablation (RFA) is the first-line treatment for flat Barrett's esophagus (BE) with dysplasia, however its role for persistent Barrett's esophagus (PBE) is unclear. PBE requires additional RFA sessions or application of cryotherapy to improve therapeutic response. We performed a retrospective cohort study evaluating cases of PBE treated by endoscopic eradication programs, with and without spray cryotherapy, and evaluated their safety and efficacy. We retrospectively identified patients with PBE, defined as ≤50% BE reduction or unchanged dysplasia after at least two RFA sessions. PBE was treated either by continued RFA (RFA Group) or converting to spray cryotherapy (CRYO Group), both followed by surveillance period. The rate of adverse events (AE), complete response of intestinal metaplasia (CRIM) and complete response of dysplasia (CRD) were recorded. A total of 46 patients, 23 per group, underwent 622 endoscopic therapies. Circumferential BE length was longer in the CRYO Group, but other baseline characteristics were similar, including maximal BE length. Esophageal strictures accounted for 14/16 total AE, 71% of which were RFA related, compared with 14% related to spray cryotherapy (P = 0.02). Overall CRIM/CRD rates in CRYO (83%) and RFA (96%) groups were not statistically different (P = 0.16), however cases in the CRYO Group required more treatment encounters (Median 19 vs. 12, P ≤ 0.01). Multimodal endotherapy is effective for eradicating PBE. Treatment programs incorporating spray cryotherapy are associated with less esophageal strictures but may require more treatment sessions to achieve eradication.
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Affiliation(s)
- Juan Reyes Genere
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Kavel Visrodia
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Liam Zakko
- Connecticut Gastroenterology, Bristol, CT, USA
| | - Sanne J M Hoefnagel
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kenneth K Wang
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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8
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van Munster SN, Frederiks CN, Nieuwenhuis EA, Alvarez Herrero L, Bogte A, Alkhalaf A, Schenk BE, Schoon EJ, Curvers WL, Koch AD, van de Ven SEM, de Jonge PJF, Tang TJ, Nagengast WB, Peters FTM, Westerhof J, Houben MHMG, Bergman JJGHM, Pouw RE, Weusten BLAM. Incidence and outcomes of poor healing and poor squamous regeneration after radiofrequency ablation therapy for early Barrett's neoplasia. Endoscopy 2022; 54:229-240. [PMID: 34062597 DOI: 10.1055/a-1521-6318] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic eradication therapy with radiofrequency ablation (RFA) is effective in most patients with Barrett's esophagus (BE). However, some patients experience poor healing and/or poor squamous regeneration. We evaluated incidence and treatment outcomes of poor healing and poor squamous regeneration. METHODS We included all patients treated with RFA for early BE neoplasia from a nationwide Dutch registry based on a joint treatment protocol. Poor healing (active inflammatory changes or visible ulcerations ≥ 3 months post-RFA), poor squamous regeneration (< 50 % squamous regeneration), and treatment success (complete eradication of BE [CE-BE]) were evaluated. RESULTS 1386 patients (median BE C2M5) underwent RFA with baseline low grade dysplasia (27 %), high grade dysplasia (30 %), or early cancer (43 %). In 134 patients with poor healing (10 %), additional time and acid suppression resulted in complete esophageal healing, and 67/134 (50 %) had normal squamous regeneration with 97 % CE-BE. Overall, 74 patients had poor squamous regeneration (5 %). Compared with patients with normal regeneration, patients with poor squamous regeneration had a higher risk for treatment failure (64 % vs. 2 %, relative risk [RR] 27 [95 % confidence interval [CI] 18-40]) and progression to advanced disease (15 % vs. < 1 %, RR 30 [95 %CI 12-81]). Higher body mass index, longer BE segment, reflux esophagitis, and < 50 % squamous regeneration after baseline endoscopic resection were independently associated with poor squamous regeneration in multivariable logistic regression. CONCLUSIONS In half of the patients with poor healing, additional time and acid suppression led to normal squamous regeneration and excellent treatment outcomes. In patients with poor squamous regeneration, however, the risk for treatment failure and progression to advanced disease was significantly increased.
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Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Charlotte N Frederiks
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Boudewijn E Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter J F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Cappelle a/d IJssel, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Frans T M Peters
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Hospital, Den Haag, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Abstract
Cryotherapy is an ablation modality relying on freeze-thaw cycles to promote cell death through intracellular ice crystal formation, ischemia, and apoptosis. Currently, 2 different cryotherapy systems are available for esophageal use. The first is cryospray ablation, which involves repetitive applications of liquid nitrogen. The second system, cryoballoon ablation, freezes the esophageal mucosa with liquid nitrous oxide using a compliant balloon. To date, studies have shown that cryotherapy is an effective and safe method for eradicating Barrett's esophagus; however, larger prospective series with longer follow-up are warranted to determine the clinical utility of cryotherapy in the treatment of Barrett's esophagus.
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Farina DA, Condon A, Komanduri S, Muthusamy VR. A Practical Approach to Refractory and Recurrent Barrett's Esophagus. Gastrointest Endosc Clin N Am 2021; 31:183-203. [PMID: 33213795 DOI: 10.1016/j.giec.2020.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic eradication therapy (EET) is recommended for patients with Barrett's esophagus (BE)-associated neoplasia and is effective in achieving complete eradication of intestinal metaplasia (CE-IM). However, BE that is refractory to EET, defined as partial or no improvement in dysplasia after less than or equal to 3 ablative sessions, and the development of recurrence post-EET is not uncommon. Identification of refractory BE or recurrent intestinal metaplasia should prompt esophageal physiologic testing and modification of antireflux strategy, as appropriate. In patients who ultimately fail standard EET despite optimization of reflux control, salvage EET with alternate modalities may need to be considered.
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Affiliation(s)
- Domenico A Farina
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - Ashwinee Condon
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
| | - Srinadh Komanduri
- Department of Gastroenterology and Hepatology, Northwestern University, 676 North St. Clair Street, Arkes Pavilion Suite 1400, Chicago, IL 60611, USA
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine at UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA.
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11
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Canto MI, Trindade AJ, Abrams J, Rosenblum M, Dumot J, Chak A, Iyer P, Diehl D, Khara HS, Corbett FS, McKinley M, Shin EJ, Waxman I, Infantolino A, Tofani C, Samarasena J, Chang K, Wang B, Goldblum J, Voltaggio L, Montgomery E, Lightdale CJ, Shaheen NJ. Multifocal Cryoballoon Ablation for Eradication of Barrett's Esophagus-Related Neoplasia: A Prospective Multicenter Clinical Trial. Am J Gastroenterol 2020; 115:1879-1890. [PMID: 33156107 DOI: 10.14309/ajg.0000000000000822] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Ablation of Barrett's esophagus (BE) is the preferred approach for the treatment of neoplasia without visible lesions. Limited data on cryoballoon ablation (CBA) suggest its potential clinical utility. We evaluated the safety and efficacy of CBA in a multicenter study of patients with neoplastic BE. METHODS In a prospective clinical trial, 11 academic and community centers recruited consecutive patients with BE of 1-6 cm length and low-grade dysplasia, high-grade dysplasia (HGD), or intramucosal adenocarcinoma (ImCA) confirmed by central pathology. Patients with symptomatic pre-existing strictures or visible BE lesions had dilation or endoscopic mucosal resection (EMR), respectively, before enrollment. A nitrous oxide cryoballoon focal ablation system was used to treat all visible columnar mucosa in up to 5 sessions. Study end points included complete eradication of all dysplasia (CE-D) and intestinal metaplasia (CE-IM) at 1 year. RESULTS One hundred twenty patients with BE with ImCA (20%), HGD (56%), or low-grade dysplasia (23%) were enrolled. In the intention-to-treat analysis, the CE-D and CE-IM rates were 76% and 72%, respectively. In the per-protocol analysis (94 patients), the CE-D and CE-IM rates were 97% and 91%, respectively. Postablation pain was mild and short lived. Fifteen subjects (12.5%) developed strictures requiring dilation. One patient (0.8%) with HGD progressed to ImCA, which was successfully treated with EMR. Another patient (0.8%) developed gastrointestinal bleeding associated with clopidogrel use. One patient (0.8%) had buried BE with HGD in 1 biopsy, not confirmed by subsequent EMR. DISCUSSION In patients with neoplastic BE, CBA was safe and effective. Head-to-head comparisons between CBA and other ablation modalities are warranted (clinicaltrials.gov registration NCT02514525).
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Affiliation(s)
- Marcia Irene Canto
- Department of Medicine (Gastroenterology), Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Arvind J Trindade
- Division of Gastroenterology at the Zucker School of Medicine of Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Julian Abrams
- Department of Medicine, Columbia University Medical Center, New York, New York, USA
| | - Michael Rosenblum
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, USA
| | - John Dumot
- Division of Gastroenterology at University Hospitals of Cleveland Medical Center, Cleveland, Ohio, USA
| | - Amitabh Chak
- Division of Gastroenterology at University Hospitals of Cleveland Medical Center, Cleveland, Ohio, USA
| | - Prasad Iyer
- Division of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - David Diehl
- Division of Gastroenterology, Geisinger Medical Center, Danby Pennsylvania, USA
| | - Harshit S Khara
- Division of Gastroenterology, Geisinger Medical Center, Danby Pennsylvania, USA
| | - F Scott Corbett
- Florida Digestive Health Specialists, Sarasota, Florida, USA
| | - Matthew McKinley
- Division of Gastroenterology at the Zucker School of Medicine of Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Eun Ji Shin
- Department of Medicine (Gastroenterology), Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Irving Waxman
- Division of Gastroenterology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Anthony Infantolino
- Division of Gastroenterology, Jefferson Medical Center, Philadelphia, Pennsylvania, USA
| | - Christina Tofani
- Division of Gastroenterology, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Jason Samarasena
- Division of Gastroenterology, University of California Irvine Medical Center, Irvine, California, USA
| | - Kenneth Chang
- Division of Gastroenterology, University of California Irvine Medical Center, Irvine, California, USA
| | - Bingkai Wang
- Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, USA
| | - John Goldblum
- Department of Pathology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Lysandra Voltaggio
- Department ofPathology, Johns Hopkins Medical Institutions Baltimore Maryland, USA
| | - Elizabeth Montgomery
- Department ofPathology, Johns Hopkins Medical Institutions Baltimore Maryland, USA
| | - Charles J Lightdale
- Division of Gastroenterology at the Zucker School of Medicine of Hofstra/Northwell, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Nicholas J Shaheen
- Division of Gastroenterology, University of North Carolina, Chapel Hill, North Carolina, USA
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12
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Pech O, Alqahtani SA. Update on endoscopic treatment of Barrett's oesophagus and Barrett's oesophagus-related neoplasia. Ther Adv Gastrointest Endosc 2020; 13:2631774520935241. [PMID: 32783025 PMCID: PMC7385822 DOI: 10.1177/2631774520935241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/24/2020] [Indexed: 11/15/2022] Open
Abstract
Endoscopic therapy of early Barrett’s oesophagus–related neoplasia is the treatment of choice for low-grade-dysplasia, high-grade dysplasia and mucosal Barrett’s cancer. Low-grade-dysplasia without any visible lesion should be ablated, preferably with radiofrequency ablation. In cases with the presence of a visible lesion, high-grade dysplasia and early Barrett’s adenocarcinoma, endoscopic resection techniques like multiband ligation endoscopic resection or endoscopic submucosal dissection should be applied. After complete resection of all visible neoplastic lesions, ablation of the remaining Barrett’s oesophagus should be performed to prevent recurrence. Ablation techniques available are radiofrequency ablation, argon plasma coagulation and cryoablation.
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Affiliation(s)
- Oliver Pech
- Department of Gastroenterology and interventional Endoscopy, St. John of God Hospital, Teaching Hospital of the University of Regensburg, Regensburg 93049, Germany
| | - Saleh A Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, MD, USA
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13
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Alzoubaidi D, Hussein M, Sehgal V, Makahamadze C, Magee CG, Everson M, Graham D, Sweis R, Banks M, Sami SS, Novelli M, Lovat L, Haidry R. Cryoballoon ablation for treatment of patients with refractory esophageal neoplasia after first line endoscopic eradication therapy. Endosc Int Open 2020; 8:E891-E899. [PMID: 32665972 PMCID: PMC7340530 DOI: 10.1055/a-1149-1414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 02/12/2020] [Indexed: 12/18/2022] Open
Abstract
Background and study aims Cryoablation with the Cryoballoon device is a novel ablative therapy that uses cycles of freezing and thawing to induce cell death. This single-center prospective study evaluated the feasibility of the focal cryoablation device for the treatment of areas of refractory esophageal neoplasia in patients who had undergone first line endoscopic eradication therapy (EET). Complete remission of dysplasia (CR-D) and complete remission of intestinal metaplasia (CR-IM) at first follow-up endoscopy, durability of disease reversal, rates of stenosis and adverse events were studied. Patients and methods Eighteen cases were treated. At baseline, nine patients had low-grade dysplasia (LGD), six had high-grade dysplasia (HGD) and three had intramucosal carcinoma (IMC). Median length of dysplastic Barrett's esophagus (BE) treated was 3 cm. The median number of ablations per patient was 11. Each selected area of visible dysplasia received 10 seconds of ablation. One session of cryoablation was performed per patient. Biopsies were performed at around 3 months post-ablation. Results CR-D was achieved in 78 % and CR-IM in 39 % of patients. There were no device malfunction or adverse events. Stenosis was noted in 11 % of cases. At a median follow up of 19-months, CR-D was maintained in 72 % of patients and CR-IM in 33 %. Conclusions Cryoablation appears to be a viable rescue strategy in patients with refractory neoplasia. It is well tolerated and successful in obtaining CR-D and CR-IM in patients with treatment-refractory BE. Further trials of dosimetry, efficacy and safety in treatment-naïve patients are underway.
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Affiliation(s)
- Durayd Alzoubaidi
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Mohamed Hussein
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Vinay Sehgal
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | | | - Cormac G. Magee
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Martin Everson
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - David Graham
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Rami Sweis
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Matthew Banks
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Sarmed S. Sami
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Marco Novelli
- Department of Histopathology, University College London Hospital (UCLH), London, UK
| | - Laurence Lovat
- Division of Surgery and interventional science, University College London (UCL), London, UK
| | - Rehan Haidry
- Division of Surgery and interventional science, University College London (UCL), London, UK
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
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14
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Rouphael C, Anil Kumar M, Sanaka MR, Thota PN. Indications, contraindications and limitations of endoscopic therapy for Barrett's esophagus and early esophageal adenocarcinoma. Therap Adv Gastroenterol 2020; 13:1756284820924209. [PMID: 32523628 PMCID: PMC7257851 DOI: 10.1177/1756284820924209] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 04/15/2020] [Indexed: 02/04/2023] Open
Abstract
Endoscopic eradication therapy (EET) has revolutionized management of Barrett's esophagus (BE)-associated neoplasia, traditionally treated by esophagectomy, which carries very high mortality and morbidity. EET, usually performed in the outpatient setting, has a safe risk profile. It is indicated in patients with BE with high-grade dysplasia and intramucosal cancer, confirmed, and persistent low-grade dysplasia, and in highly selected cases of non-dysplastic BE and submucosal cancers. Multiple EET modalities are available and can be categorized into two groups: ablation therapies and resection techniques with resection techniques usually reserved for nodular/raised lesions or lesions with suspected neoplasia. Patients usually require multiple ablation sessions with a goal of achieving complete eradication of metaplasia. Despite very good results, EET has its limitations and is not 100% effective: it targets a small subset of patients along the spectrum of BE and esophageal adenocarcinoma, as most patients with esophageal adenocarcinoma remain asymptomatic until the disease has progressed to advanced stages. Post-ablation surveillance is mandatory, as recurrences are common. An area of concern is buried metaplasia reported to occur following ablation therapy and thought to be from de novo growth of metaplastic tissue underneath the neosquamous epithelium, following ablation. The focus of this review article is to present the indications, contraindications and limitations of EET.
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Affiliation(s)
- Carol Rouphael
- Department of Gastroenterology and Hepatology,
Cleveland Clinic, Cleveland, OH, USA
| | - Mythri Anil Kumar
- Department of Gastroenterology and Hepatology,
Cleveland Clinic, Cleveland, OH, USA
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15
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Raphael KL, Trindade AJ. Management of Barrett’s esophagus with dysplasia refractory to radiofrequency ablation. World J Gastroenterol 2020; 26:2030-2039. [PMID: 32536772 PMCID: PMC7267696 DOI: 10.3748/wjg.v26.i17.2030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2019] [Revised: 04/08/2020] [Accepted: 04/24/2020] [Indexed: 02/06/2023] Open
Abstract
Radiofrequency ablation (RFA) is very effective for eradication of flat Barrett’s mucosa in dysplastic Barrett’s esophagus after endoscopic resection of raised lesions. However, in a minority of the time, RFA may be ineffective at eradication of the Barrett’s mucosa. Achieving complete eradication of intestinal metaplasia can be challenging in these patients. This review article focuses on the management of patients with dysplastic Barrett’s esophagus refractory to RFA therapy. Management strategies discussed in this review include optimizing the RFA procedure, optimizing acid suppression (with medical, endoscopic, and surgical management), cryotherapy, hybrid argon plasma coagulation, and EndoRotor resection.
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Affiliation(s)
- Kara L Raphael
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY 11040, United States
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY 11040, United States
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16
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Feasibility study of endoscopic thermal coagulation with circumferential laser irradiation for treating esophageal tissue. Lasers Med Sci 2019; 35:893-900. [PMID: 31641966 DOI: 10.1007/s10103-019-02877-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 09/06/2019] [Indexed: 10/25/2022]
Abstract
Barrett's esophagus (BE) is associated with an intestinal metaplasia that replaces normal squamous epithelium by columnar epithelium. The aim of the current study was to evaluate the feasible endoscopic treatment on esophageal tissue with circumferential laser irradiation. A 532-nm laser was used to deliver 10 W in a continuous manner through a balloon catheter-integrated diffuser. Ex vivo leporine esophagus was tested to identify thermal responses at various irradiation times. In vivo testing in a porcine model was performed to evaluate the feasibility of endoscopic application with the integrated device for BE treatment. Goniometric measurements confirmed that the proposed device yielded uniform radial irradiation (i.e., 0.9 ± 0.1 in arbitrary unit). Emission profiles were well correlated with temperature distribution along the device. Ex vivo leporine testing demonstrated that the temperature rise increased with irradiation time. The maximum temperature increase was around 38 °C after 60-s irradiation (transient increase rate = 0.62 °C/s), and the corresponding thermal coagulation reached esophageal submucosa (1.5 ± 0.2 mm). In vivo porcine testing evidently presented circumferential thermal denaturation around the lumen along with mild inflammatory reaction and the degenerated squamous epithelium. The overall thickness of the irreversible thermal coagulation was 3.1 ± 0.2 mm. The proposed photothermal therapy can be a feasible endoscopic method to treat BE with the aid of circumferential irradiation and mechanical expansion. Further chronic in vivo testing will be pursued to understand chronic tissue response in terms of wound healing and complication.
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17
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Ahmed O, Ajani JA, Lee JH. Endoscopic management of esophageal cancer. World J Gastrointest Oncol 2019; 11:830-841. [PMID: 31662822 PMCID: PMC6815921 DOI: 10.4251/wjgo.v11.i10.830] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 05/29/2019] [Accepted: 08/28/2019] [Indexed: 02/05/2023] Open
Abstract
Esophageal cancer (EC) generally consists of squamous cell carcinoma (which arise from squamous epithelium) and adenocarcinoma (which arise from columnar epithelium). Due to the increased recognition of risk factors associated with EC and the development of screening programs, there has been an increase in the diagnosis of early EC. Early EC is amenable to curative therapy by endoscopy, which can be performed by either endoscopic resection or endoscopic ablation. Endoscopic resection consists of either endoscopic mucosal resection (preferred in cases of adenocarcinoma) or endoscopic submucosal dissection (preferred in cases of squamous cell carcinoma). Endoscopic ablation can be performed by either radiofrequency ablation, cryotherapy, argon plasma coagulation or photodynamic therapy, amongst others. Endoscopy can also assist in the management of complications post-esophageal surgery, such as anastomotic leaks and perforations. Finally, there is a growing role for endoscopy to manage end-of-life palliative symptoms, especially dysphagia. The growing use of esophageal stents, debulking therapy and dilation can assist in improving a patient’s quality of life. In this review, we examine the multiple roles of endoscopy in the management of patients with EC.
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Affiliation(s)
- Osman Ahmed
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Jaffer A Ajani
- Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology and Nutrition, University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
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18
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Abstract
Barrett esophagus is a metaplastic change in the lining of the distal esophageal epithelium, characterized by replacement of the normal squamous epithelium by specialized intestinal metaplasia. The presence of Barrett esophagus increases the risk of esophageal adenocarcinoma several-fold. Esophageal adenocarcinoma is a malignancy with rapidly rising incidence and persistently poor outcomes when diagnosed after the onset of symptoms. Risk factors for Barrett esophagus include chronic gastroesophageal reflux, central obesity, white race, male gender, older age, smoking, and a family history of Barrett esophagus or esophageal adenocarcinoma. Screening for Barrett esophagus in those with several risk factors followed by endoscopic surveillance to detect dysplasia or adenocarcinoma is currently recommended by society guidelines. Minimally invasive nonendoscopic tools for the early detection of Barrett esophagus are currently being developed. Multimodality endoscopic therapy-using a combination of endoscopic resection and ablation techniques-for the treatment of dysplasia and early adenocarcinoma is successful in eliminating intestinal metaplasia and preventing progression to adenocarcinoma, with outcomes comparable to those after esophagectomy. Risk stratification of those diagnosed with Barrett esophagus is a challenge at present, with active research focused on identifying clinical and biomarker panels to identify those with low and high risk of progression. This narrative review highlights some of the challenges and recent progress in this field.
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Affiliation(s)
- Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY.
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19
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Mohan BP, Krishnamoorthi R, Ponnada S, Shakhatreh M, Jayaraj M, Garg R, Law J, Larsen M, Irani S, Ross A, Adler DG. Liquid Nitrogen Spray Cryotherapy in Treatment of Barrett's Esophagus, where do we stand? A Systematic Review and Meta-Analysis. Dis Esophagus 2019; 32:5304729. [PMID: 30715267 DOI: 10.1093/dote/doy130] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/06/2018] [Indexed: 12/11/2022]
Abstract
Radiofrequency ablation (RFA) is the preferred treatment option for Barrett's esophagus (BE) to achieve complete eradication (CE) of dysplasia (D), and intestinal metaplasia (IM). Cryotherapy, using liquid nitrogen (LNC), is a cold-induced tissue-injury technique option for the ablation of BE. We conducted a systematic review and meta-analysis to assess the overall efficacy and safety of LNC in the treatment of BE. We conducted a search of multiple electronic databases and conference proceedings from inception through June 2018. The primary outcome was to estimate the pooled rates of CE-IM, CE-D, and CE-HGD. The secondary outcome was to estimate the risk of adverse events and recurrence of disease after LNC. Nine studies reported 386 patients who were treated with LNC. The pooled rate of CE-IM was 56.5% (95% CI 48.5-64.2, I2 = 47), pooled rate of CE-D was 83.5% (95% CI 78.3-87.7, I2 = 22.8), and pooled rate of CE-HGD was 86.5% (95% CI 64.4-95.8, I2 = 88.1). Rate of adverse events was 4.7%, and the risk of BE recurrence was 12.7%. On subgroup analysis, the pooled rate of CE-IM with LNC in patients who failed RFA was 58.4% (95% CI 47.2-68.8, I2 = 32.5), and the pooled rate of CE-D in the same population was 81.9% (95% CI 72.5-88.6, I2 = 5.9). CE-D rates with LNC are comparable to RFA while CE-IM rates appear to be lower than the rates achievable with RFA. CE-IM rate in RFA failed patients is 58.4% and thus LNC is a rescue option to consider in this population.
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Affiliation(s)
- B P Mohan
- DCH Medical Center, University of Alabama, Tuscaloosa, Alabama
| | - R Krishnamoorthi
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - S Ponnada
- Carilion Roanoke Memorial Hospital, Roanoke, Virginia
| | - M Shakhatreh
- Rapides Regional Medical Center, Alexandria, Louisiana
| | - M Jayaraj
- University of Nevada, Las Vegas, Nevada
| | - R Garg
- Cleveland Clinic Foundation, Cleveland, Ohio
| | - J Law
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - M Larsen
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - S Irani
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - A Ross
- Digestive Diseases Institute, Virginia Mason Medical Center, Seattle, Washington
| | - D G Adler
- Division of Gastroenterology and Hepatology, University of Utah School of Medicine, Salt Lake City, Utah, USA
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20
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Solomon SS, Kothari S, Smallfield GB, Inamdar S, Stein P, Rodriguez VA, Sima AP, Bittner K, Zfass AM, Kaul V, Trindade AJ. Liquid Nitrogen Spray Cryotherapy is Associated With Less Postprocedural Pain Than Radiofrequency Ablation in Barrett's Esophagus: A Multicenter Prospective Study. J Clin Gastroenterol 2019; 53:e84-e90. [PMID: 29351156 DOI: 10.1097/mcg.0000000000000999] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
GOALS AND BACKGROUND Two common endoscopic therapies for eradication of dysplastic Barrett's esophagus are radiofrequency ablation (RFA) and liquid nitrogen spray cryotherapy (LNC). There is no data comparing postprocedural pain. This study aimed to compare the incidence of postprocedural pain between the 2 ablation modalities. METHODS This is a multicenter prospective study in which pain intensity scores and the presence of dysphagia were assessed immediately before and after treatment, 48 hours posttreatment and at 3 weeks posttreatment using validated instruments. RESULTS Of 94 patients, 35 underwent LNC and 59 underwent RFA [36 with focal radiofrequency ablation (RFA-F) and 23 with circumferential radiofrequency ablation (RFA-C)]. Immediately posttreatment, patients in the LNC group reported an average Numeric Pain Scale score that was lower than in the RFA groups [LNC 0.41 vs. RFA-F 1.18 (P=0.026), LNC 0.41 vs. RFA-C 1.38 (P=0.010)]. These differences persisted at 48 hours posttreatment [LNC 0.76 vs. RFA-F 1.77 (P=0.013), LNC 0.76 vs. RFA-C 1.73 (P=0.018)]. The odds of pain after RFA were at least 5 times greater than after LNC [immediately posttreatment odds ratio, 5.26 (95% confidence interval, 1.85-14.29) and 48 h posttreatment odds ratio, 5.56 (95% confidence interval, 2.27-14.29)]. There was no difference in dysphagia after treatment in either group, at any time point (P=0.429). CONCLUSION LNC was associated with less postprocedural pain when compared with RFA. These results help inform patients and physicians about the expected symptoms after ablative endotherapy.
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Affiliation(s)
- Sanjeev S Solomon
- Division of Gastroenterology, Virginia Commonwealth University Medical Center
| | - Shivangi Kothari
- Division of Gastroenterology, University of Rochester Medical Center, Rochester
| | - George B Smallfield
- Division of Gastroenterology, Virginia Commonwealth University Medical Center
| | - Sumant Inamdar
- Division of Gastroenterology, Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Northwell Health System, New Hyde Park, NY
| | - Peter Stein
- Division of Gastroenterology, Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Northwell Health System, New Hyde Park, NY
| | | | - Adam P Sima
- Department of Biostatistics, Virginia Commonwealth University, Richmond, VA
| | - Krystle Bittner
- Division of Gastroenterology, University of Rochester Medical Center, Rochester
| | - Alvin M Zfass
- Division of Gastroenterology, Virginia Commonwealth University Medical Center
| | - Vivek Kaul
- Division of Gastroenterology, University of Rochester Medical Center, Rochester
| | - Arvind J Trindade
- Division of Gastroenterology, Long Island Jewish Medical Center, Hofstra Northwell School of Medicine, Northwell Health System, New Hyde Park, NY
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21
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Cholapranee A, Trindade AJ. Challenges in Endoscopic Therapy of Dysplastic Barrett's Esophagus. ACTA ACUST UNITED AC 2019; 17:32-47. [PMID: 30663018 DOI: 10.1007/s11938-019-00215-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Barrett's esophagus (BE) is the only known measurable factor associated with esophageal adenocarcinoma. The development of endoscopic eradication therapy (EET) has transformed the way BE is managed. Given the fairly recent development of EET, its role in BE is still evolving. RECENT FINDINGS This paper discusses the challenges that endoscopists face at the preprocedural, intraprocedural, and postprocedural stages of BE management. These include challenges in risk stratification, dysplasia detection, ablation methods and dosimetry, choice of resection technique, and management of refractory disease. Despite the advances in EET in BE, there remain challenges that this review focuses on. Future research into these challenges will optimize ablation techniques and strategies in the future.
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Affiliation(s)
- Aurada Cholapranee
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA
| | - Arvind J Trindade
- Division of Gastroenterology, Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, Long Island Jewish Medical Center, 270-05 76th Avenue, New Hyde Park, NY, 11040, USA.
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22
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Chang KJ. Endoscopic foregut surgery and interventions: The future is now. The state-of-the-art and my personal journey. World J Gastroenterol 2019; 25:1-41. [PMID: 30643356 PMCID: PMC6328959 DOI: 10.3748/wjg.v25.i1.1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 02/06/2023] Open
Abstract
In this paper, I reviewed the emerging field of endoscopic surgery and present data supporting the contention that endoscopy can now be used to treat many foregut diseases that have been traditionally treated surgically. Within each topic, the content will progress as follows: "lessons learned", "technical considerations" and "future opportunities". Lessons learned will provide a brief background and update on the most current literature. Technical considerations will include my personal experience, including tips and tricks that I have learned over the years. Finally, future opportunities will address current unmet needs and potential new areas of development. The foregut is defined as "the upper part of the embryonic alimentary canal from which the pharynx, esophagus, lung, stomach, liver, pancreas, and part of the duodenum develop". Foregut surgery is well established in treating conditions such as gastroesophageal reflux disease (GERD), achalasia, esophageal diverticula, Barrett's esophagus (BE) and esophageal cancer, stomach cancer, gastric-outlet obstruction, and obesity. Over the past decade, remarkable progress in interventional endoscopy has culminated in the conceptualization and practice of endoscopic foregut surgery for various clinical conditions summarized in this paper. Regarding GERD, there are now several technologies available to effectively treat it and potentially eliminate symptoms, and the need for long-term treatment with proton pump inhibitors. For the first time, fundoplication can be performed without the need for open or laparoscopic surgery. Long-term data going out 5-10 years are now emerging showing extended durability. In respect to achalasia, per-oral endoscopic myotomy (POEM) which was developed in Japan, has become an alternative to the traditional Heller's myotomy. Recent meta-analysis show that POEM may have better results than Heller, but the issue of post-POEM GERD still needs to be addressed. There is now a resurgence of endoscopic treatment of Zenker's diverticula with improved technique (Z-POEM) and equipment; thus, patients are choosing flexible endoscopic treatment as opposed to open or rigid endoscopy options. In regard to BE, endoscopic submucosal dissection (ESD) which is well established in Asia, is now becoming more mainstream in the West for the treatment of BE with high grade dysplasia, as well as early esophageal cancer. In combination with all the ablation technologies (radiofrequency ablation, cryotherapy, hybrid argon plasma coagulation), the entire spectrum of Barrett's and related dysplasia and early cancer can be managed predominantly by endoscopy. Importantly, in regard to early gastric cancer and submucosal tumors (SMTs) of the stomach, ESD and full thickness resection (FTR) can excise these lesions en-bloc and endoscopic suturing is now used to close large defects and perforations. For treatment of patients with malignant gastric outlet obstruction (GOO), endoscopic gastro-jejunostomy is now showing better results than enteral stenting. G-POEM is also emerging as a treatment option for patients with gastroparesis. Obesity has become an epidemic in many western countries and is becoming also prevalent in Asia. Endoscopic sleeve gastroplasty (ESG) is now becoming an established treatment option, especially for obese patients with body mass index between 30 and 35. Data show an average weight loss of 16 kg after ESG with long-term data confirming sustainability. Finally, in respect to endo-hepatology, there are many new endoscopic interventions that have been developed for patients with liver disease. Endoscopic ultrasound (EUS)-guided liver biopsy and EUS-guided portal pressure measurement are exciting new frontiers for the endo-hepatologists.
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Affiliation(s)
- Kenneth J Chang
- H.H. Chao Comprehensive Digestive Disease Center, University of California, Irvine Medical Center, Orange, CA 92868, United States
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23
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Lal P, Thota PN. Cryotherapy in the management of premalignant and malignant conditions of the esophagus. World J Gastroenterol 2018; 24:4862-4869. [PMID: 30487696 PMCID: PMC6250921 DOI: 10.3748/wjg.v24.i43.4862] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Revised: 10/13/2018] [Accepted: 10/21/2018] [Indexed: 02/06/2023] Open
Abstract
Endoscopic cryotherapy is a relatively new thermal ablative modality used for the treatment of neoplastic lesions of the esophagus. It relies on cycles of rapid cooling and thawing to induce tissue destruction with a cryogen (liquid nitrogen or carbon dioxide) leading to intra and extra-cellular damage. Surgical treatment was once considered the standard therapeutic intervention for neoplastic diseases of the esophagus and is associated with considerable rates of morbidity and mortality. Several trials that evaluated cryotherapy in Barrett’s esophagus (BE) associated neoplasia showed reasonable efficacy rates and safety profile. Cryotherapy has also found applications in the treatment of esophageal cancer, both for curative and palliative intent. Cryotherapy has also shown promising results as salvage therapy in cases refractory to radiofrequency ablation treatment. Cryoballoon focal ablation using liquid nitrogen is a novel mode of cryogen delivery which has been used for the treatment of BE with dysplasia and squamous cell carcinoma. Most common side effects of cryotherapy reported in the literature include mild chest discomfort, esophageal strictures and bleeding. In conclusion, cryotherapy is an effective and safe method for the treatment of esophageal neoplastic processes, ranging from early stages of low grade dysplasia to esophageal cancer.
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Affiliation(s)
- Pooja Lal
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology, Digestive Disease Surgery Institute, Cleveland Clinic, Cleveland, OH 44195, United States
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24
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Abstract
The management of Barrett's esophagus and early esophageal adenocarcinoma has shifted away from esophagectomy and toward endoscopic techniques, including endoscopic resection and ablative therapies. The most commonly used ablative therapies are radiofrequency ablation and cryotherapy. Radiofrequency ablation has risen to the top of the management algorithm due to its favorable safety profile and established track record of efficacy in patients with dysplastic Barrett's. Cryotherapy offers early promise as an alternatively safe and effective ablative modality. We review radiofrequency ablation and cryotherapy techniques, and updated data regarding their efficacy and safety as well as their roles in the management of Barrett's esophagus.
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25
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Inadomi J, Alastal H, Bonavina L, Gross S, Hunt RH, Mashimo H, di Pietro M, Rhee H, Shah M, Tolone S, Wang DH, Xie SH. Recent advances in Barrett's esophagus. Ann N Y Acad Sci 2018; 1434:227-238. [PMID: 29974975 DOI: 10.1111/nyas.13909] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Revised: 05/21/2018] [Accepted: 05/29/2018] [Indexed: 12/20/2022]
Abstract
Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma, one of the few cancers with increasing incidence in developed countries. The pathogenesis of BE is unclear with regard to either the cellular origin of this metaplastic epithelium or the manner in which malignant transformation occurs, although recent data indicate a possible junctional origin of stem cells for BE. Treatment of BE may be achieved using endoscopic eradication therapy; however, there is a lack of discriminatory tools to identify individuals at sufficient risk for cancer development in whom intervention is warranted. Reduction in gastroesophageal reflux of gastric contents including acid is mandatory to achieve remission from BE after endoscopic ablation, and can be achieved using medical or nonmedical interventions. Research topics of greatest interest include the mechanism of BE development and transformation to cancer, risk stratification methods to identify individuals who may benefit from ablation of BE, optimization of eradication therapy, and surveillance methods to ensure that remission is maintained after eradication is achieved.
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Affiliation(s)
- John Inadomi
- Division of Gastroenterology, University of Washington School of Medicine, Seattle, Washington
| | - Hani Alastal
- MRC Cancer Unit at the University of Cambridge, Cambridge, UK.,Faculty of Life Sciences and Education, University of South Wales, Newport City, UK
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, University of Milano School of Medicine, Milan, Italy.,Division of General Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Seth Gross
- Division of Gastroenterology, New York University, New York, New York
| | | | - Hiroshi Mashimo
- Division of Gastroenterology, Harvard Medical School, Boston, Massachusetts.,VA Boston Healthcare System, Boston, Massachusetts
| | | | - Horace Rhee
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - Marmy Shah
- Division of Gastroenterology, Loyola University Chicago Stritch School of Medicine, Chicago, Illinois
| | - Salvatore Tolone
- Division of General, Mini-Invasive and Bariatric Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - David H Wang
- Division of Hematology and Oncology, UT Southwestern Medical Center and VA North Texas Health Care System, Dallas, Texas
| | - Shao-Hua Xie
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
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26
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Visrodia K, Zakko L, Singh S, Leggett CL, Iyer PG, Wang KK. Cryotherapy for persistent Barrett's esophagus after radiofrequency ablation: a systematic review and meta-analysis. Gastrointest Endosc 2018; 87:1396-1404.e1. [PMID: 29476849 PMCID: PMC6557401 DOI: 10.1016/j.gie.2018.02.021] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/11/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS A small but significant proportion of patients with Barrett's esophagus (BE) have persistent dysplasia or intestinal metaplasia (IM) after treatment with radiofrequency ablation (RFA). Cryotherapy is a cold-based ablative modality that is increasingly being used in this setting. We aimed to better understand the efficacy of second-line cryotherapy in patients with BE who have persistent dysplasia or IM after RFA by conducting a systematic review and meta-analysis. METHODS We performed a systematic literature search of Pubmed, EMBASE, and Web of Science through September 1, 2017. Articles were included for meta-analysis based on the following inclusion criteria: ≥5 patients with BE treated with RFA had persistent dysplasia or IM; they subsequently underwent ≥1 session of cryotherapy with follow-up endoscopy; the proportions of patients achieving complete eradication of dysplasia (CE-D) and/or IM (CE-IM) were reported. The main outcomes were pooled proportions of CE-D and CE-IM by using a random effects model. RESULTS Eleven studies making up 148 patients with BE treated with cryotherapy for persistent dysplasia or IM after RFA were included. The pooled proportion of CE-D was 76.0% (95% confidence interval [CI] 57.7-88.0), with substantial heterogeneity (I2 = 62%). The pooled proportion of CE-IM was 45.9% (95% CI, 32.0-60.5) with moderate heterogeneity (I2 = 57%). Multiple preplanned subgroup analyses did not sufficiently explain the heterogeneity. Adverse effects were reported in 6.7% of patients. CONCLUSION Cryotherapy successfully achieved CE-D in three fourths and CE-IM in half of patients with BE who did not respond to initial RFA. Considering its favorable safety profile, cryotherapy may be a viable second-line option for this therapeutically challenging cohort of patients with BE, but higher-quality studies validating this remain warranted.
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Affiliation(s)
- Kavel Visrodia
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Liam Zakko
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Siddharth Singh
- Division of Gastroenterology, University of California
San Diego, La Jolla, California
| | - Cadman L. Leggett
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Department
of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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27
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Komanduri S, Muthusamy VR, Wani S. Controversies in Endoscopic Eradication Therapy for Barrett's Esophagus. Gastroenterology 2018; 154:1861-1875.e1. [PMID: 29458152 DOI: 10.1053/j.gastro.2017.12.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Revised: 11/05/2017] [Accepted: 12/20/2017] [Indexed: 02/07/2023]
Abstract
Advances in endoscopic eradication therapy for Barrett's Esophagus-associated neoplasia have resulted in a significant paradigm shift in the diagnosis and management of this complex disease. A robust body of literature critically evaluating outcomes of resection and ablative strategies has allowed gastroenterologists to make quality, evidence-based decisions for their patients. Despite this progress, there are still many unanswered questions and challenges that remain. Ultimately, identification of a cost-effective screening modality, biomarkers for risk stratification, and strides to eliminate post surveillance endoscopy after endoscopic eradication therapy are essential to reach our long-term goal for eradication of esophageal adenocarcinoma.
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Affiliation(s)
- Srinadh Komanduri
- Division of Gastroenterology and Hepatology, Northwestern University, Chicago, Illinois.
| | - V Raman Muthusamy
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California-Los Angeles, Los Angeles, California
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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28
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Trindade AJ, Pleskow DK, Sengupta N, Kothari S, Inamdar S, Berkowitz J, Kaul V. Efficacy of liquid nitrogen cryotherapy for Barrett's esophagus after endoscopic resection of intramucosal cancer: A multicenter study. J Gastroenterol Hepatol 2018; 33:461-465. [PMID: 28770555 DOI: 10.1111/jgh.13909] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 06/26/2017] [Accepted: 07/27/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM Liquid nitrogen cryotherapy (LNC) allows increased depth of ablation compared with radiofrequency ablation in Barrett's esophagus (BE). Expert centers may use LNC over radiofrequency ablation to ablate Barrett's esophagus after endoscopic resection of intramucosal cancer (IMCA). The aim of our study was to (1) evaluate the safety and efficacy of LNC ablation in patients with BE and IMCA and (2) to evaluate the progression to invasive disease despite therapy. METHODS This was a multicenter, retrospective study of consecutive patients with BE who received LNC following endoscopic mucosal resection (EMR) of IMCA. The outcomes evaluated were complete eradication of dysplasia and intestinal metaplasia and development of invasive cancer during follow up. The follow-up period was at least 1 year from initial LNC. RESULTS Twenty-seven patients were identified. The median Prague score was C3M5 (range C0M1-C14M14). After EMR+LNC, the median Prague score was C0M1 (range C0M0-C9M10); 22/27 patients (82%) achieved complete eradication of dysplasia after cryotherapy, and 19/27 patients (70%) achieved complete eradication of intestinal metaplasia. One out of 27 patients (4%) developed invasive cancer (disease beyond IMCA) over the study period. CONCLUSION Cryotherapy is an effective endoscopic tool for eradication of BE dysplasia after EMR for IMCA. Development of invasive cancer is low for this high-risk group.
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Affiliation(s)
- Arvind J Trindade
- Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Douglas K Pleskow
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Neil Sengupta
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Shivangi Kothari
- Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
| | - Sumant Inamdar
- Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Joshua Berkowitz
- Hofstra Northwell School of Medicine, Long Island Jewish Medical Center, Northwell Health System, New Hyde Park, New York, USA
| | - Vivek Kaul
- Strong Memorial Hospital, University of Rochester Medical Center, Rochester, New York, USA
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29
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Trindade AJ, Inamdar S, Kothari S, Berkowitz J, McKinley M, Kaul V. Feasibility of liquid nitrogen cryotherapy after failed radiofrequency ablation for Barrett's esophagus. Dig Endosc 2017; 29:680-685. [PMID: 28303613 DOI: 10.1111/den.12869] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 03/13/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND AIM Radiofrequency ablation (RFA) for dysplastic Barrett's esophagus (BE) is highly effective. RFA failures are infrequent but can be a challenging cohort to manage. There are limited data on the feasibility of liquid nitrogen cryospray ablation for complete eradication of dysplasia (CE-D) and/or intestinal metaplasia (CE-IM) after RFA has failed to achieve CE-IM in patients with dysplastic BE. METHODS This is a retrospective review from two medical centers of prospectively maintained databases looking at patients that underwent liquid nitrogen cryospray ablation for refractory intestinal metaplasia post failed RFA. RESULTS Eighteen patients were identified that met inclusion criteria. Eleven patients had persistent dysplasia and IM following RFA and seven had persistent non-dysplastic IM. More than 80% of patients were male with long-segment BE (median length 8 cm). Seventy two percent of patients with dysplasia achieved CE-D after cryotherapy. Fifty percent (9/18) of all RFA failures achieved CE-IM with cryotherapy. In comparison, RFA has a CE-IM of 78% in a less challenging treatment naïve cohort from a large-scale meta-analysis of 3802 patients. No adverse events occurred in our cohort. CONCLUSION Cryospray ablation is feasible and safe for achieving CE-D and CE-IM after RFA failure. The CE-D rates are high with cryotherapy in this population. CE-IM with cryotherapy is acceptable in this difficult-to-treat cohort when compared to CE-IM rates with RFA in dysplastic BE treatment naïve patients (50% vs 78%).
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Affiliation(s)
- Arvind J Trindade
- Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, USA
| | - Sumant Inamdar
- Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, USA
| | - Shivangi Kothari
- Strong Memorial Hospital, University of Rochester Medical Center, Rochester, USA
| | - Joshua Berkowitz
- Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, USA
| | - Matthew McKinley
- Division of Gastroenterology, Department of Medicine, Hofstra Northwell School of Medicine, Northwell Health System, Long Island Jewish Medical Center, New Hyde Park, USA
| | - Vivek Kaul
- Strong Memorial Hospital, University of Rochester Medical Center, Rochester, USA
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30
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Hamade N, Sharma P. Ablation Therapy for Barrett's Esophagus: New Rules for Changing Times. Curr Gastroenterol Rep 2017; 19:48. [PMID: 28819902 DOI: 10.1007/s11894-017-0589-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss different endoscopic techniques in the eradication of Barrett's esophagus (BE) as well as some controversies in the field of treatment. RECENT FINDINGS Patients with T1a esophageal adenocarcinoma and BE of high-grade dysplasia should undergo endoscopic ablative therapy. The most studied technique to date is radiofrequency ablation. It can be combined with endoscopic mucosal resection in cases containing nodular and flat lesions. Cryotherapy and APC have shown promise with good efficacy and safety profiles so far, but are not mainstream as more studies are needed. Surveillance is still required post-ablation since recurrence is common. Low-grade dysplasia can be treated with either endo-ablative therapy or surveillance. Non-dysplastic BE treatment is controversial and so far, only surveillance is recommended. Research is ongoing to better risk stratify these patients. Our ability to diagnose and treat BE has come a long way in the past few years with the goal of preventing its progression into malignancy. The advent of endoscopic techniques in the eradication of BE has provided a less invasive and safer modality of treatment as compared to surgical esophagectomy. Data in the form of randomized trials and high-volume registries has provided good evidence to support the efficacy of these techniques and their long-term durability.
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Affiliation(s)
- Nour Hamade
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MI, USA
| | - Prateek Sharma
- Department of Internal Medicine, University of Kansas School of Medicine and Veterans Affairs Medical Center, Kansas City, MI, USA. .,Department of Gastroenterology, Department of Veterans Affairs Medical Center, 4801 E. Linwood Boulevard, Kansas City, MI, 64128, USA.
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31
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Abstract
PURPOSE OF REVIEW Providing an overview on types of cryotherapy for esophageal application and their role in the management of Barrett's esophagus. RECENT FINDINGS Recent studies have involved multiple types of cryotherapy including cryospray techniques that use either liquid nitrogen or carbon dioxide as the cryogenic fluid, and the CryoBalloon focal ablation device that uses nitrous oxide. Overall, studies report cryotherapy to be safe and effective in eradicating Barrett's epithelium. However, substantial variations among these studies in design and outcomes preclude direct comparisons of the results. Moreover, little is known of the long-term outcomes of cryotherapy, with only one report describing 5-year follow-up of patients treated with liquid nitrogen cryospray. SUMMARY The concept of cryotherapy is appealing. By preserving the extracellular matrix and inducing anesthetic effects, cryotherapy has the potential to enable deeper ablations with less pain and a lower rate of stricture formation than radiofrequency ablation. To date, however, these potential benefits remain unproved. Prospective studies with clearly defined endpoints and longer follow-up are necessary to determine the role of cryotherapy in the management of patients with Barrett's esophagus.
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32
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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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Abstract
Barrett esophagus (BE) is the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer associated with a poor 5-year survival rate. The stepwise pathologic progression of BE to invasive cancer provides an opportunity to halt progression and potentially decrease incidence and ultimately the morbidity and mortality related to this lethal cancer. Endoscopic eradication therapy (EET) in patients at increased risk of progression to invasive EAC (intramucosal EAC, high-grade dysplasia, and low-grade dysplasia) is a practice that is endorsed by multiple societies and has replaced esophagectomy as the standard of care for these patients. Although the effectiveness, safety, and durability of EET have been demonstrated in several studies, this review addresses the several challenges with EET that need to be considered to optimize patient outcomes. Finally, the critical role of training, competence, and quality indicators in EET are emphasized in this era of value-based health care practice.
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34
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Sengupta N, Sawhney MS. Advances in Imaging and Endoluminal Therapies for Early Esophageal and Gastric Cancers. Ann Surg Oncol 2016; 23:3774-3779. [PMID: 27464607 DOI: 10.1245/s10434-016-5425-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Neil Sengupta
- Section of Gastroenterology, University of Chicago Medical Center, Chicago, IL, USA
| | - Mandeep S Sawhney
- Division of Gastroenterology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.
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35
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Minor Anesthesia-Related Events During Radiofrequency Ablation for Barrett's Esophagus Are Associated with an Increased Number of Treatment Sessions. Dig Dis Sci 2016; 61:1591-6. [PMID: 26894399 DOI: 10.1007/s10620-016-4059-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Accepted: 01/22/2016] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is limited data regarding the prevalence and clinical impact of sedation-related adverse events (SRAEs) during radiofrequency ablation (RFA) for dysplastic Barrett's esophagus (BE). AIM Our primary aim was to measure SRAE during RFA. Secondary aims were to identify risk factors for adverse events, and to determine whether SRAEs impacted the number of RFA treatments to achieve complete eradication of dysplasia (CE-D). METHODS We conducted a retrospective analysis of 120 consecutive patients undergoing initial RFA for dysplastic BE between 2008 and 2014. The main outcome measures were SRAEs and the number of RFA sessions required to achieve CE-D. RESULTS Of 120 initial RFA procedures, 83 % were performed with MAC and 17 % with GET. SRAEs occurred in 32 %, including 25 % of MAC patients (25/100) and 65 % (12/20) GET patients. The most frequent SRAE was hypotension (23 %, n = 27/120), followed by hypoxia (n = 9/120), arrhythmia (n = 4/120), and one unplanned intubation. There were no premature procedure terminations. After adjusting for length of BE mucosa and ASA score, the occurrence of a SRAE was associated with requiring more (>4) RFA sessions to achieve CE-D, OR 3.45 (95 % CI 1.49-7.99). Mean RFA sessions required to achieve CE-D was 5 ± 1 in patients with SRAE, compared to 3 ± 0.7 in patients without SRAE during the first treatment session (p < 0.001). CONCLUSIONS SRAE during RFA for dysplastic BE occurs at a rate typical of other advanced endoscopic procedures. Patients who experience minor events related to anesthesia during the first RFA are likely to require more RFA treatment sessions to achieve CE-D.
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36
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Weusten BLAM, Bergman JJGHM. Cryoablation for managing Barrett's esophagus refractory to radiofrequency ablation? Don't embrace the cold too soon! Gastrointest Endosc 2015; 82:449-51. [PMID: 26279348 DOI: 10.1016/j.gie.2015.03.1965] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/16/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, the Netherlands
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