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Rubenstein JH, Sawas T, Wani S, Eluri S, Singh S, Chandar AK, Perumpail RB, Inadomi JM, Thrift AP, Piscoya A, Sultan S, Singh S, Katzka D, Davitkov P. AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia. Gastroenterology 2024; 166:1020-1055. [PMID: 38763697 PMCID: PMC11345740 DOI: 10.1053/j.gastro.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. METHODS The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. CONCLUSIONS This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Tarek Sawas
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida
| | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia; Advanced Center for Endoscopy, West Virginia University Medicine, Morgantown, West Virginia
| | - Apoorva K Chandar
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - John M Inadomi
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - David Katzka
- Division of Gastroenterology and Hepatology, Columbia University, New York, New York
| | - Perica Davitkov
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Gastroenterology, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
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Bahdi F, Katti CC, Mansour N, Gagneja H, Anandasabapathy S, Othman MO. Outcomes of endoscopic submucosal dissection (ESD) plus radiofrequency ablation (RFA) for nodular Barrett's esophagus. Scand J Gastroenterol 2023; 58:123-132. [PMID: 35968576 DOI: 10.1080/00365521.2022.2111226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although Endoscopic Submucosal Dissection (ESD) was proven superior to Endoscopic Mucosal Resection (EMR) in achieving higher complete remission rates for neoplastic Barrett's Esophagus (BE), its safety with Radiofrequency Ablation (RFA) remains unstudied. We share our experience with ESD + RFA for nodular BE eradication. METHODS A retrospective study of all patients ≥18-years with nodular BE who underwent ESD + RFA between September 2015 and December 2020 at our tertiary center. Patients with advanced adenocarcinoma requiring esophagectomy were excluded. Primary outcomes included adverse events (AE) rates and complete eradication rates for adenocarcinoma (CE-EAC), dysplasia (CE-D), and intestinal metaplasia (CE-IM). Secondary outcomes included local recurrence rates following eradication. RESULTS Eighteen patients were included with a total of 22 ESDs performed and a median of 2 RFA sessions-per-patient [IQR: 1.25, 3]. Sixteen patients were males and/or white (88.9%) with a median BMI of 29.75 kg/m2 [IQR: 26.9, 31.5]. Fourteen patients had long-segment BE (77.7%) while 16 had hiatal hernias (88.9%). Median resection size was 12.1 cm2 [IQR: 5.6, 20.2]. AEs included one intraprocedural micro-perforation (4.5%) and 4 strictures (22.2%), only one of which developed post-RFA. All AEs were successfully treated endoscopically. Over a median of 42.5 months [IQR: 28, 59.25], CE-EAC was achieved in 13 patients (100%), CE-D in 15 patients (100%), and CE-IM in 14 patients (77.8%). Following eradication, 2 patients had recurrent dysplasia (2/15, 13.3%) and one had recurrent intestinal metaplasia (1/14, 7.1%). CONCLUSION In high-risk patients with long-segment neoplastic BE requiring extensive endoscopic resection, ESD + RFA offers excellent complete eradication rates with rare additional adverse events by RFA. Standard endoscopic surveillance following eradication remains important.
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Affiliation(s)
- Firas Bahdi
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Chafik Clement Katti
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Nabil Mansour
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA.,Baylor St Luke's Medical Center, Houston, TX, USA
| | | | - Sharmila Anandasabapathy
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA.,Baylor St Luke's Medical Center, Houston, TX, USA
| | - Mohamed O Othman
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA.,Baylor St Luke's Medical Center, Houston, TX, USA
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Comparative Outcomes of Cap Assisted Endoscopic Resection and Endoscopic Submucosal Dissection in Dysplastic Barrett's Esophagus. Clin Gastroenterol Hepatol 2022; 20:65-73.e1. [PMID: 33220523 PMCID: PMC8128933 DOI: 10.1016/j.cgh.2020.11.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 11/05/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic resection is an important component of the endoscopic treatment of Barrett's esophagus (BE) with dysplasia and intramucosal adenocarcinoma. Endoscopic resection can be performed by cap-assisted endoscopic mucosal resection (cEMR) or endoscopic submucosal dissection (ESD). We compared the histologic outcomes of ESD vs cEMR, followed by ablation. METHODS We queried a prospectively maintained database of all patients undergoing cEMR and ESD followed by ablation at our institution from January 2006 to March 2020 and abstracted relevant demographic and clinical data. Our primary outcomes included the rate of complete remission of dysplasia (CRD): absence of dysplasia on surveillance histology, and complete remission of intestinal metaplasia (CRIM): absence of intestinal metaplasia. Our secondary outcome included complication rates. RESULTS We included 537 patients in the study: 456 underwent cEMR and 81 underwent ESD. The cumulative probabilities of CRD at 2 years were 75.8% and 85.6% in the cEMR and ESD groups, respectively (P < .01). Independent predictors of CRD were as follows: ESD (hazard ratio [HR], 2.38; P < .01) and shorter BE segment length (HR, 1.11; P < .01). The cumulative probabilities of CRIM at 2 years were 59.3% and 50.6% in the cEMR and ESD groups, respectively (P > .05). The only independent predictor of CRIM was a shorter BE segment (HR, 1.16; P < .01). CONCLUSIONS BE patients with dysplasia or intramucosal adenocarcinoma undergoing ESD reach CRD at higher rates than those treated with cEMR, although CRIM rates at 2 years and complication rates were similar between the 2 groups.
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Leggett CL, Katzka DA. As far as the AI can see. Endoscopy 2021; 53:884-885. [PMID: 34438451 DOI: 10.1055/a-1352-4811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
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Hanada Y, Wang KK. Safety and feasibility of same-day discharge after esophageal endoscopic submucosal dissection. Gastrointest Endosc 2021; 93:853-860. [PMID: 32721491 DOI: 10.1016/j.gie.2020.07.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is used for treating early luminal GI cancers. ESD is the standard of care in Asia, where it results in multiday admissions for observation. The goal of our study was to evaluate the safety and feasibility of same-day discharge (SDD) after ESD. METHODS This is a retrospective cohort study of adults who underwent similar esophageal ESD with a Clutch Cutter device (DP2618DT; Fujifilm) at the Mayo Clinic (Rochester, Minn, USA) from 2017 to 2019 with a single endoscopist. The primary end point was postprocedural adverse events within 7 days of ESD. RESULTS Of 96 patients (75% male, mean age, 70 ± 10.3 years) undergoing a total of 140 ESDs, 85 were SDD versus 55 admissions. Of the 55 admits, 53 were discharged within 24 hours, whereas 2 were admitted for 2 to 3 days for reasons unrelated to the ESD procedure. Admissions were more likely to have a history of antiplatelet/anticoagulant use (56.4% vs 34.1%; P = .01) and higher mean American Society of Anesthesiologists (ASA) score (3.2 vs 2.9; P = .007). Admissions had larger resections (28.6 vs 20.1 mm; P < .0001) with longer procedural durations (103.4 vs 62 minutes; P < .0001). Among SDDs, no intraprocedural or postprocedural adverse events were seen. Among admissions, 1 (1.8% vs 0%; P = .39) experienced intraprocedural bleeding requiring endoscopic intervention, 1 required transfusion before discharge within 24 hours of ESD (1.8% vs 0%; P = .39), and 1 required rehospitalization and endoscopic intervention within 7 days to address an active bleed along the resection margin (1.8% vs 0%; P = .39). CONCLUSIONS SDD after esophageal ESD is safe and feasible. An experienced endoscopist can determine if SDD can be considered in patients with ASA physical classification status ≤2 who undergo resections off antiplatelet/anticoagulant therapy and do not experience intraprocedural adverse events.
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Affiliation(s)
- Yuri Hanada
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Jacobs C, Draganov PV, Yang D. Endoscopic submucosal dissection for esophageal neoplasia in the West: Are we there yet? Gastrointest Endosc 2020; 92:1275-1276. [PMID: 33237000 DOI: 10.1016/j.gie.2020.06.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Accepted: 06/28/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Chelsea Jacobs
- Department of Medicine, University of Florida, Gainesville, Florida, USA
| | - Peter V Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, USA
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Response. Gastrointest Endosc 2020; 92:1276. [PMID: 33237002 DOI: 10.1016/j.gie.2020.09.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 09/19/2020] [Indexed: 02/08/2023]
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