Endoscopic ablation therapy: imaging and advanced technology in action

Management of high grade dysplasia in Barrett's oesophagus with underlying oesophageal varices: A retrospective study

BACKGROUND

Endoscopic treatment of Barrett's oesophagus leading to high grade dysplasia with oesophageal varices may lead to bleeding complications.

AIMS

Estimate effectiveness of endoscopic band-ligation in oesophageal varices patients treated for high grade dysplasia, and compare to endoscopically treated non-oesophageal varices high grade dysplasia patients.

METHODS

Retrospective comparative study. All 8 high grade dysplasia patients with varices who were treated initially with band-ligation at Mayo Clinic between 8/1/1999 and 2/28/2014 were compared with reference group of 52 high grade dysplasia patients treated endoscopically.

RESULTS

One high grade dysplasia patients patient with oesophageal varices (12.5%) achieved complete remission of intestinal metaplasia defined by at least one followup endoscopy with normal biopsies, and 3 (37.5%) achieved complete remission of dysplasia defined by at least one followup endoscopy with non-dysplastic biopsies. 39 (75.0%) endomucosal resection/radiofrequency ablation patients experienced at least one followup endoscopy with normal biopsies, and 49 (94.2%) experienced non-dysplastic biopsies. Both of these endpoints occurred significantly more often in the endomucosal resection/radiofrequency ablation group compared to the high grade dysplasia with oesophageal varices group (p=0.016 and p=0.025, respectively).

CONCLUSIONS

High grade dysplastic Barrett's can be safely managed with band-ligation. However, resolution of Barrett's epithelium is rarely achieved with banding alone.

Predictors of esophageal stricture formation post endoscopic mucosal resection

BACKGROUND/AIMS

Stricture formation is a common complication after endoscopic mucosal resection. Predictors of stricture formation have not been well studied.

METHODS

We conducted a retrospective, observational, descriptive study by using a prospective endoscopic mucosal resection database in a tertiary referral center. For each patient, we extracted the age, sex, lesion size, use of ablative therapy, and detection of esophageal strictures. The primary outcome was the presence of esophageal stricture at follow-up. Multivariate logistic regression was used to analyze the association between the primary outcome and predictors.

RESULTS

Of 136 patients, 27% (n=37) had esophageal strictures. Thirty-two percent (n=44) needed endoscopic dilation to relieve dysphagia (median, 2; range, 1 to 8). Multivariate logistic regression analysis showed that the size of the lesion excised is associated with increased odds of having a stricture (odds ratio, 1.6; 95% confidence interval, 1.1 to 2.3; p=0.01), when controlling for age, sex, and ablative modalities. Similarly, the number of lesions removed in the index procedure was associated with increased odds of developing a stricture (odds ratio, 2.3; 95% confidence interval, 1.3 to 4.2; p=0.007).

CONCLUSIONS

Stricture formation after esophageal endoscopic mucosal resection is common. Risk factors for stricture formation include large mucosal resections and the resection of multiple lesions on the initial procedure.

Survival in esophageal high-grade dysplasia/adenocarcinoma post endoscopic resection

BACKGROUND

Endoscopic resection followed by ablative therapy is frequently used to treat esophageal high-grade dysplasia or early esophageal adenocarcinoma.

AIMS

To study outcomes in patients with high-grade dysplasia compared to those with esophageal adenocarcinoma after endoscopic resection.

METHODS

Retrospective, observational, descriptive, single-centre study from a prospective database. We extracted data from 116 endoscopic resections. Survival was plotted using Kaplan-Meier curves multivariable Cox-proportional hazard assess for possible predictors of survival post-endoscopic resection was performed.

RESULTS

116 patients (64 esophageal adenocarcinoma, 52 high-grade dysplasia) underwent endoscopic resection from May 2003 to June 2010. Mean age was 71 ± 11 years for high-grade dysplasia and 72 ± 10 years for esophageal adenocarcinoma. Median follow-up was 17 months. Eighty-five patients had negative margins on endoscopic resection. Five-year survivals for high-grade dysplasia and esophageal adenocarcinoma were 86% (range 68-100%) and 78% (59-96%), respectively. Survival was not significantly different between groups (p=0.20). Overall mortality rate was 10.6% (9/85). At multivariable Cox regression increased Barrett's oesophagus length was associated with worse survival (HR 1.18 [1.06-1.33], p=0.0039). Survival was not affected by the pathology before resection: HR 2.4 [95%CI, 0.70-8.4], p=0.16.

CONCLUSIONS

Survival in patients with high-grade dysplasia of the oesophagus is similar to those with esophageal adenocarcinoma. Longer Barrett's oesophagus segments are associated with decreased survival.

Barrett's esophagus: endoscopic treatments I

The following on endoscopic treatments of Barrett's esophagus includes commentaries on indications for endoscopic treatments; endo-luminal plication procedures; the cellular modifications induced by the endoscopic ablation therapies; eradication by banding without resection; the evaluation of complete ablation; recurrence after ablation; association of antireflux surgery; radiofrequency ablation; and nondysplastic Barrett's esophagus.

Variation in Barrett's esophageal wall thickness: is it associated with histology or segment length?

GOALS

To measure esophageal wall thickness (EWT) with endoscopic ultrasound (EUS) in patients with and without Barrett's esophagus (BE).

BACKGROUND

Segment length and histology are used to evaluate BE. The development of varying depths of ablation therapy has renewed interest in using EUS for BE.

STUDY

In this prospective study, EWT measurements were taken from the balloon-mucosal interface to the outer most hyper-echoic line. These measurements were correlated with the highest grade of BE dysplasia and segment length, and then compared with the measurements from control group.

RESULTS

Between 2004 to 2007, 76 BE patients (69 men, mean age 68 y, 4 ND, 14 low-grade dysplasia, 52 high-grade dysplasia, 6 carcinoma in situ) and 53 normal controls (18 men, mean age 60 y) underwent EUS. The mean EWT was 2.4 mm for controls, 3.1 mm for nondysplastic BE, 3.2 mm for low-grade dysplasia, 3.4 mm for high-grade dysplasia, and 3.9 mm for carcinoma in situ. In the control group of 53 patients, the mean EWT was 2.4 mm. Compared with normal controls, the mean EWT was significantly greater in all histologic subgroups of BE patients (P<0.001). No statistically significant correlation was seen between EWT and BE histology grade. There were no correlations between age, gender, or BE segment length and EWT (P=0.55).

CONCLUSIONS

EWT is greater among patients with BE compared with control patients; however, there were no systematic differences in EWT were found among BE patients, based on histology and segment length.