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Basiliya K, Pang P, Honing J, di Pietro M, Varghese S, Gbegli E, Corbett G, Carroll NR, Godfrey EM. What can the Interventional Endoscopist Offer in the Management of Upper Gastrointestinal Malignancies? Clin Oncol (R Coll Radiol) 2023:S0936-6555(23)00183-8. [PMID: 37253647 DOI: 10.1016/j.clon.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 04/10/2023] [Accepted: 05/10/2023] [Indexed: 06/01/2023]
Abstract
The therapeutic possibilities of endoscopy have rapidly increased in the last decades and now allow organ-sparing treatment of early upper gastrointestinal malignancy as well as an increasing number of options for symptom palliation. This review contains an overview of the interventional endoscopic procedures in upper gastrointestinal malignancies. It describes endoscopic treatment of early oesophageal and gastric cancers, and the palliative options in managing dysphagia and gastric outlet obstruction. It also provides an overview of the therapeutic possibilities of biliary endoscopy, such as retrograde stenting and radiofrequency biliary ablation. Endoscopic ultrasound-guided therapeutic options are discussed, including biliary drainage, gastrojejunostomy and coeliac axis block. To aid in clinical decision making, the procedures are described in the context of their indication, efficacy, risks and limitations.
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Affiliation(s)
- K Basiliya
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK.
| | - P Pang
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - J Honing
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - M di Pietro
- Early Cancer Institute, University of Cambridge, Cambridge, UK
| | - S Varghese
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E Gbegli
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - G Corbett
- Department of Gastroenterology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - N R Carroll
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - E M Godfrey
- Department of Radiology, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
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van Munster SN, Verheij EPD, Nieuwenhuis EA, Offerhaus JGJA, Meijer SL, Brosens LAA, Weusten BLAM, Alkhalaf A, Schenk EBE, Schoon EJ, Curvers WL, van Tilburg L, van de Ven SEM, Tang TJ, Nagengast WB, Houben MHMG, Seldenrijk KCA, Bergman JJGHM, Koch AD, Pouw RE. Extending treatment criteria for Barrett's neoplasia: results of a nationwide cohort of 138 endoscopic submucosal dissection procedures. Endoscopy 2022; 54:531-541. [PMID: 34592769 DOI: 10.1055/a-1658-7554] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett's esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed in the Netherlands. METHODS Retrospective assessment of outcomes, using treatment and follow-up data from a joint database. RESULTS 130/138 patients had complete ESDs, with 126/130 (97 %) en bloc resections. Median (interquartile range (IQR)) procedure time was 121 minutes (90-180). Pathology findings were high grade dysplasia (HGD) (5 %) or esophageal adenocarcinoma (EAC) T1a (43 %) or T1b (52 %; 19 % sm1, 33 % ≥ sm2). Among resections of HGD or T1a EAC lesions, 87 % (95 %CI 75 %-92 %) were both en bloc and R0; the corresponding value for T1b EAC lesions was 49 % (36 %-60 %). Among R1 resections, 10/34 (29 %) showed residual cancer, all detected at first endoscopic follow-up. The remaining 24 patients (71 %) showed no residual neoplasia. Six of these patients underwent surgery with no residual tumor; the remaining 18 underwent endoscopic follow-up during median 31 months with 1 local recurrence (annual recurrence rate 2 %). Among R0 resections, annual local recurrence rate during median 27 months was 0.5 %. CONCLUSION In expert hands, ESD allows safe removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter showed R1 resection margins in 50 %, yet only one third had persisting neoplasia at follow-up. To better stratify R1 patients with an indication for additional surgery, repeat endoscopy after healing of the ESD might be a helpful possible prognostic factor for residual cancer.
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Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Johan G J A Offerhaus
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Amsterdam UMC location AMC, Amsterdam, The Netherlands
| | - Lodewijk A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Ed B 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.,GROW: School for Oncology and Developmental Biology, Maastricht University, Maastricht, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Laurelle van Tilburg
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, Ijsselland Hospital, Capelle aan den Ijssel, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Kees C A Seldenrijk
- Department of Pathology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC location VUMC, Amsterdam, The Netherlands
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Endoscopic Management of Barrett's Esophagus. Dig Dis Sci 2022; 67:1469-1479. [PMID: 35226224 DOI: 10.1007/s10620-022-07395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/09/2022]
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Clinical Adverse Events and Device Failures Reported for the Captivator and Duette Endoscopic Mucosal Resection (EMR) Systems: A MAUDE Database Analysis. J Clin Gastroenterol 2022; 57:490-493. [PMID: 35470284 DOI: 10.1097/mcg.0000000000001704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/10/2022] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Endoscopic mucosal resection (EMR) is a widely used technique for the removal of precancerous or select cancerous mucosal-based lesions. Two systems used for EMR of upper gastrointestinal lesions are the Duette EMR kit and the Captivator EMR kit. The aim of this study is to analyze the reports submitted to the Food and Drug Administration's (FDA) Manufacturer and User Facility Device Experience (MAUDE) database for patient-related adverse events and device failures associated with these EMR kits. METHODS We analyzed postmarketing data from the FDA MAUDE from August 2004 to August 2021. RESULTS Eighty-four MAUDE reports were found in the study period from August 2004 to August 2021. In total, device issues comprised 36.9% of the reports (n=31) and patient adverse events comprised 63.09% of the reports (n=53). Device issues that were reported included, but were not limited to, band placement/deployment failure (8.1%), suture breakage (7.31%), and snare breakage (4.94%). Patient adverse events that were reported included, but were not limited to, bleeding (25.9%), perforation (7.31%), and snare breakage (4.94%). CONCLUSION Captivator EMR and Duette EMR have similar patterns of technical failure and clinical adverse events. More MAUDE reports exist for Duette EMR, possibly due to its longer duration of commercial availability.
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van Munster S, Nieuwenhuis E, Weusten BLAM, Alvarez Herrero L, Bogte A, Alkhalaf A, Schenk BE, Schoon EJ, Curvers W, Koch AD, van de Ven SEM, de Jonge PJF, Tang TJ, Nagengast WB, Peters FTM, Westerhof J, Houben MHMG, Bergman JJ, Pouw RE. Long-term outcomes after endoscopic treatment for Barrett's neoplasia with radiofrequency ablation ± endoscopic resection: results from the national Dutch database in a 10-year period. Gut 2022; 71:265-276. [PMID: 33753417 PMCID: PMC8762001 DOI: 10.1136/gutjnl-2020-322615] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 03/02/2021] [Accepted: 03/08/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Radiofrequency ablation (RFA)±endoscopic resection (ER) is the preferred treatment for early neoplasia in Barrett's oesophagus (BE). We aimed to report short-term and long-term outcomes for all 1384 patients treated in the Netherlands (NL) from 2008 to 2018, with uniform treatment and follow-up (FU) in a centralised setting. DESIGN Endoscopic therapy for early BE neoplasia in NL is centralised in nine expert centres with specifically trained endoscopists and pathologists that adhere to a joint protocol. Prospectively collected data are registered in a uniform database. Patients with low/high-grade dysplasia or low-risk cancer, were treated by ER of visible lesions followed by trimonthly RFA sessions of any residual BE until complete eradication of BE (CE-BE). Patients with ER alone were not included. RESULTS After ER (62% of cases; 43% low-risk cancers) and median 1 circumferential and 2 focal RFA (p25-p75 0-1; 1-2) per patient, CE-BE was achieved in 94% (1270/1348). Adverse events occurred in 21% (268/1386), most commonly oesophageal stenosis (15%), all were managed endoscopically. A total of 1154 patients with CE-BE were analysed for long-term outcomes. During median 43 months (22-69) and 4 endoscopies (1-5), 38 patients developed dysplastic recurrence (3%, annual recurrence risk 1%), all were detected as endoscopically visible abnormalities. Random biopsies from a normal appearing cardia showed intestinal metaplasia (IM) in 14% and neoplasia in 0%. A finding of IM in the cardia was reproduced during further FU in only 33%, none progressed to neoplasia. Frequent FU visits in the first year of FU were not associated with recurrence risk. CONCLUSION In a setting of centralised care, RFA±ER is effective for eradication of Barrett's related neoplasia and has remarkably low rates of dysplastic recurrence. Our data support more lenient FU intervals, with emphasis on careful endoscopic inspection. Random biopsies from neosquamous epithelium and cardia are of questionable value. NETHERLANDS TRIAL REGISTER NUMBER NL7039.
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Affiliation(s)
- Sanne van Munster
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
- Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Esther Nieuwenhuis
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Bas L A M Weusten
- Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Auke Bogte
- Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Alaa Alkhalaf
- Gastroenterology and Hepatology, Isala Klinieken, Zwolle, Overijssel, The Netherlands
| | - B E Schenk
- Gastroenterology and Hepatology, Isala Klinieken, Zwolle, Overijssel, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Wouter Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Arjun D Koch
- Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Tjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Ziekenhuis, Capelle aan den IJssel, Zuid-Holland, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Frans T M Peters
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Martin H M G Houben
- Gastroenterology and Hepatology, Haga Hospital, Den Haag, Zuid-Holland, The Netherlands
| | - Jacques Jghm Bergman
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Roos E Pouw
- Gastroenterology and Hepatology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
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Endoscopic Resection Without Subsequent Ablation Therapy for Early Barrett's Neoplasia: Endoscopic Findings and Long-Term Mortality. J Gastrointest Surg 2021; 25:67-76. [PMID: 33140322 PMCID: PMC7851009 DOI: 10.1007/s11605-020-04836-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/17/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION After endoscopic resection (ER) of neoplasia in Barrett's esophagus (BE), it is recommended to ablate the remaining BE to minimize the risk for metachronous disease. However, we report long-term outcomes for a nationwide cohort of all patients who did not undergo ablation of the remaining BE after ER for early BE neoplasia, due to clinical reasons or performance status. METHODS Endoscopic therapy for BE neoplasia in the Netherlands is centralized in 8 expert centers with specifically trained endoscopists and pathologists. Uniformity is ensured by a joint protocol and regular group meetings. We report all patients who underwent ER for a neoplastic lesion between 2008 and 2018, without further ablation therapy. Outcomes include progression during endoscopic FU and all-cause mortality. RESULTS Ninety-four patients were included with mean age 74 (± 10) years. ER was performed for low-grade dysplasia (LGD) (10%), high-grade dysplasia (HGD) (25%), or low-risk esophageal adenocarcinoma (EAC) (65%). No additional ablation was performed for several reasons; in 73 patients (78%), the main argument was expected limited life expectancy. Median C2M5 BE persisted after ER, and during median 21 months (IQR 11-51) with 4 endoscopies per patient, no patient progressed to advanced cancer. Seventeen patients (18%) developed HGD/EAC: all were curatively treated endoscopically. In total, 29/73 patients (40%) with expected limited life expectancy died due to unrelated causes during FU, none of EAC. CONCLUSION In selected patients, ER monotherapy with endoscopic surveillance of the residual BE is a valid alternative to eradication therapy with ablation.
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