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Porschen R, Fischbach W, Gockel I, Hollerbach S, Hölscher A, Jansen PL, Miehlke S, Pech O, Stahl M, Vanhoefer U, Ebert MPA. Updated German guideline on diagnosis and treatment of squamous cell carcinoma and adenocarcinoma of the esophagus. United European Gastroenterol J 2024; 12:399-411. [PMID: 38284661 PMCID: PMC11017771 DOI: 10.1002/ueg2.12523] [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] [Received: 05/30/2023] [Accepted: 11/21/2023] [Indexed: 01/30/2024] Open
Abstract
Diagnosis and therapy of esophageal carcinoma is challenging and requires a multidisciplinary approach. The purpose of the updated German guideline "Diagnosis and Treatment of Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus-version 3.1" is to provide practical and evidence-based advice for the management of patients with esophageal cancer. Recommendations were developed by a multidisciplinary expert panel based on an extensive and systematic evaluation of the published medical literature and the application of well-established methodologies (e.g. Oxford evidence grading scheme, grading of recommendations). Accurate diagnostic evaluation of the primary tumor as well as lymph node and distant metastases is required in order to guide patients to a stage-appropriate therapy after the initial diagnosis of esophageal cancer. In high-grade intraepithelial neoplasia or mucosal carcinoma endoscopic resection shall be performed. Whether endoscopic resection is the definitive therapeutic measure depends on the histopathological evaluation of the resection specimen. Esophagectomy should be performed minimally invasive or in combination with open procedures (hybrid technique). Because the prognosis in locally advanced esophageal carcinoma is poor with surgery alone, multimodality therapy is recommended. In locally advanced adenocarcinomas of the esophagus or esophagogastric junction, perioperative chemotherapy or preoperative radiochemotherapy should be administered. In locally advanced squamous cell carcinomas of the esophagus, preoperative radiochemotherapy followed by complete resection or definitive radiochemotherapy without surgery should be performed. In the case of residual tumor in the resection specimen after neoadjuvant radiochemotherapy and R0 resection of squamous cell carcinoma or adenocarcinoma, adjuvant immunotherapy with nivolumab should be given. Systemic palliative treatment options (chemotherapy, chemotherapy plus immunotherapy, immunotherapy alone) in unresectable or metastastic esophageal cancer depend on histology and are stratified according to PD-L1 and/or Her2 expression.
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Affiliation(s)
- Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus OsterholzOsterholz‐ScharmbeckGermany
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von MagenDarm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro‐Liga) e. V.GiessenGermany
| | - Ines Gockel
- Klinik für Viszeral‐, Transplantations‐, Thorax‐ und GefäßchirurgieLeipzigGermany
| | | | - Arnulf Hölscher
- Contilia Zentrum für SpeiseröhrenerkrankungenElisabeth Krankenhaus EssenEssenGermany
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für GastroenterologieVerdauungs‐ und StoffwechselkrankheitenBerlinGermany
| | | | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle EndoskopieKrankenhaus Barmherzige BrüderRegensburgGermany
| | - Michael Stahl
- Klinik für Internistische Onkologie & Onkologische PalliativmedizinEvang. Kliniken Essen‐MitteEssenGermany
| | - Udo Vanhoefer
- Klinik für Hämatologie und OnkologieKath. MarienkrankenhausHamburgGermany
| | - Matthias P. A. Ebert
- Medizinische Fakultät MannheimII. Medizinische KlinikUniversitätsmedizinUniversität HeidelbergMannheimGermany
- DKFZ‐Hector Krebsinstitut an der Universitätsmedizin MannheimMannheimGermany
- Molecular Medicine Partnership UnitEMBLHeidelbergGermany
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Ebert MP, Fischbach W, Hollerbach S, Höppner J, Lorenz D, Stahl M, Stuschke M, Pech O, Vanhoefer U, Porschen R. S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:535-642. [PMID: 38599580 DOI: 10.1055/a-2239-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthias P Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universitätsmedizin, Universität Heidelberg, Mannheim
- DKFZ-Hector Krebsinstitut an der Universitätsmedizin Mannheim, Mannheim
- Molecular Medicine Partnership Unit, EMBL, Heidelberg
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von Magen, Darm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro-Liga) e. V., Giessen
| | | | - Jens Höppner
- Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt
| | - Michael Stahl
- Klinik für Internistische Onkologie und onkologische Palliativmedizin, Evang. Huyssensstiftung, Evang. Kliniken Essen-Mitte, Essen
| | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Udo Vanhoefer
- Klinik für Hämatologie und Onkologie, Katholisches Marienkrankenhaus, Hamburg
| | - Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus Osterholz, Osterholz-Scharmbeck
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S2k-Leitlinie Gastroösophageale Refluxkrankheit und eosinophile Ösophagitis der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) – März 2023 – AWMF-Registernummer: 021–013. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:862-933. [PMID: 37494073 DOI: 10.1055/a-2060-1069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/28/2023]
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Endoscopic therapy replaces surgery for clinical T1 oesophageal cancer in the Netherlands: a nationwide population-based study. Surg Endosc 2023:10.1007/s00464-023-09914-x. [PMID: 36849563 DOI: 10.1007/s00464-023-09914-x] [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: 09/04/2022] [Accepted: 01/28/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Endoscopic resection for early oesophageal cancer was introduced around 2000 in the Netherlands. The scientific question was how the treatment and survival of early oesophageal and gastro-oesophageal junction cancer has changed over time in the Netherlands. METHODS Data were obtained from the nationwide population-based Netherlands Cancer Registry. All patients diagnosed with clinical in situ or T1 oesophageal or GOJ cancer without lymph node or distance metastasis during the study period (2000-2014) were extracted. Primary outcome parameters were the trends in treatment modalities over time and relative survival of each treatment regime. RESULTS A total of 1020 patients were diagnosed with a clinical in situ or T1 oesophageal or gastro-oesophageal junction cancer without lymph node or distance metastasis. The proportion of patients who received endoscopic treatment increased from 2.5% in 2000 to 58.1% in 2014. During the same period the proportion of patients who received surgery decreased from 57.5 to 23.1%. Five-year relative survival of all patients was 69%. Five-year relative survival after endoscopic therapy was 83% and after surgery 80%. Relative excess risk analyses showed no significant difference in survival between patients in the endoscopic therapy group and patients in the surgery group after adjustment for age, sex, clinical TNM classification, morphology and tumour location (RER 1.15; CI 0.76-1.75; p 0.76). CONCLUSION Our results demonstrate an increase in endoscopic treatment and a decrease of surgical treatment for in situ and T1 oesophageal/GOJ cancer between 2000-2014 in the Netherlands. The relative 5-year survival after endoscopic treatment is high (83%) and comparable with surgery (80%).
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Tanaka I, Hirasawa D, Saito H, Akahira J, Fujishima F, Matsuda T. Stepwise endoscopic submucosal dissection for circumferential Barrett's esophageal dysplasia and carcinoma: a case series. Endosc Int Open 2022; 10:E215-E221. [PMID: 35178340 PMCID: PMC8847047 DOI: 10.1055/a-1672-4122] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/17/2021] [Indexed: 11/21/2022] Open
Affiliation(s)
- Ippei Tanaka
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai-city, Miyagi, Japan
| | - Dai Hirasawa
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai-city, Miyagi, Japan
| | - Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai-city, Miyagi, Japan
| | - Junichi Akahira
- Department of Pathology, Sendai Kousei Hospital, Sendai-city, Miyagi, Japan
| | - Fumiyoshi Fujishima
- Department of Anatomic Pathology, Tohoku University School of Medicine, Sendai-city, Japan
| | - Tomoki Matsuda
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai-city, Miyagi, Japan
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Ehlken H, Schmitz R, Riethdorf S, Riethdorf L, Krause J, Karstens KF, Schrader J, Viol F, Giannou A, Sterlacci W, Vieth M, Clauditz T, Kähler C, Mann O, Izbicki JR, Huber S, Pantel K, Rösch T. Possible tumour cell reimplantation during curative endoscopic therapy of superficial Barrett's carcinoma. Gut 2022; 71:277-286. [PMID: 33441377 DOI: 10.1136/gutjnl-2020-322723] [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: 08/04/2020] [Revised: 12/10/2020] [Accepted: 12/18/2020] [Indexed: 12/08/2022]
Abstract
BACKGROUND AND AIMS Endoscopic resection has been established as curative therapy for superficial cancer arising from Barrett's oesophagus (BE); recurrences are very rare. Based on a case series with unusual and massive early recurrences, we analyse the issue of tumour cell reimplantation. METHODS This hypothesis was developed on the basis of two out of seven patients treated by circumferential (n=6) or nearly circumferential (n=1) en bloc and R0 endoscopic resection of T1 neoplastic BE. Subsequently, a prospective histocytological analysis of endoscope channels and accessories was performed in 2 phases (cytohistological analysis; test for cell viability) in 22 different oesophageal carcinoma patients undergoing endoscopy. Finally, cultures from two oesophageal adenocarcinoma cell lines were incubated with different triamcinolone concentrations (0.625-10 mg/mL); cell growth was determined on a Multiwell plate reader. RESULTS Cancer regrowth in the two suspicious cases (male, 78/71 years) occurred 7 and 1 months, respectively, after curative tumour resection. Subsequent surgery showed advanced tumours (T2) with lymph node metastases; one patient died. On cytohistological examinations of channels and accessories, suspicious/neoplastic cells were found in 4/10 superficial and in all 5 advanced cancers. Further analyses in seven further advanced adenocarcinoma cases showed viable cells in two channel washing specimens. Finally, cell culture experiments demonstrated enhanced tumour cell growth by triamcinolone after 24 hours compared with controls. CONCLUSIONS Tumour cell reimplanation from contaminated endoscopes and accessories is a possible cause of local recurrence after curative endoscopic therapy for superficial Barrett carcinoma; also, corticosteroid injection could have promoted tumour regrowth in these cases.
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Affiliation(s)
- Hanno Ehlken
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rüdiger Schmitz
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sabine Riethdorf
- Institute of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Jenny Krause
- Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karl-Frederick Karstens
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jörg Schrader
- Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabrice Viol
- Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anastasios Giannou
- Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Michael Vieth
- Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany
| | - Till Clauditz
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Kähler
- Institute of Pathology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Oliver Mann
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jakob R Izbicki
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samuel Huber
- Department of Internal Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Klaus Pantel
- Institute of Tumor Biology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Godat S, Marx M, Caillol F, Robert M, Autret A, Bories E, Pesenti C, Ratone JP, Schoepfer A, Poizat F, Giovannini M. Benefit of radiofrequency ablation after widespread endoscopic resection of neoplastic Barrett's esophagus in daily practice. Ann Gastroenterol 2022; 35:34-41. [PMID: 34987286 PMCID: PMC8713341 DOI: 10.20524/aog.2021.0685] [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: 10/09/2020] [Accepted: 03/02/2021] [Indexed: 11/25/2022] Open
Abstract
Background High-grade dysplasia (HGD) and intramucosal carcinoma (IMC) in Barrett’s esophagus (BE) are now well-established indications for endoscopic resection (ER). Radiofrequency ablation (RFA) can be combined with ER in case of flat or long-segment BE ablation. We report here our experience of complementary RFA after widespread ER of neoplastic BE in daily practice. Method We retrospectively reviewed data of 89 patients, treated between 2006 and 2013 by ER alone (group 1) or by ER combined with RFA (group 2). Results Fifty-five patients in group 1 (7F/48M, mean age 68 years) underwent widespread ER with eradication of residual non-dysplastic BE. Complete eradication of HGD/IMC and intestinal metaplasia (IM) was achieved in 32/32 (100%) and 48/55 (87.3%) patients, respectively. Thirty-four patients in group 2 (3F/31M, mean age 67 years) had a multimodal treatment strategy, with widespread ER followed by RFA. Mean Prague classification of BE in this group was significantly longer (C4.4M6.6 vs. C2.7M4.5, P<0.001). Complete eradication of HGD/IMC and non-dysplastic BE was confirmed in 26/27 (96.3%) and 20/34 (58.8%) patients, respectively. There was no significant difference between groups concerning adverse events (16.4% vs. 23.5%, P=0.58) or recurrence rate of HGD/IMC (9.1% vs. 14.7%, P=0.42). The mismatch rate between preoperative and final histological diagnosis was high in both groups, at 45.5% and 26.5%. Conclusions A combination of ER and RFA can treat significantly longer neoplastic BE than ER alone, with the same efficiency and safety. Widespread ER, in contrast, is the only method of obtaining a reliable histological diagnosis.
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Affiliation(s)
- Sébastien Godat
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Mariola Marx
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Fabrice Caillol
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Maxime Robert
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Aurélie Autret
- Division of Biostatistics, Paoli-Calmettes Institute, Marseille, France (Aurélie Autret)
| | - Erwan Bories
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Christian Pesenti
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Jean Philippe Ratone
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
| | - Alain Schoepfer
- Division of Gastroenterology and Hepatology, CHUV, Lausanne, Switzerland (Sébastien Godat, Mariola Marx, Maxime Robert, Alain Schoepfer)
| | - Flora Poizat
- Division of Pathology, Paoli-Calmettes Institute, Marseille, France (Flora Poizat)
| | - Marc Giovannini
- Division of Gastroenterology, Paoli-Calmettes Institute, Marseille, France (Fabrice Caillol, Erwan Bories, Jean Philippe Ratone, Marc Giovannini)
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Predictors of recurrence of dysplasia or cancer in patients with dysplastic Barrett's esophagus following complete eradication of dysplasia: a single-center retrospective cohort study. Surg Endosc 2021; 36:5041-5048. [PMID: 34750708 DOI: 10.1007/s00464-021-08864-6] [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: 05/09/2021] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND AIMS Endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) for Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) are considered effective treatments for eradication of BE. Little is known about the impact of achieving complete eradication of intestinal metaplasia (CE-IM) following the complete eradication of neoplasia (CE-N), specifically if CE-IM reduces the risk of recurrent dysplasia. METHODS Retrospective cohort study of consecutive patients with BE and HGD or intramucosal cancer (IMC)-treated endoscopically at a tertiary referral center between 2001 and 2019. Association between CE-IM and recurrent dysplasia after CE-N was evaluated. RESULTS A total of 433 patients treated with EMR and/or RFA were included. Of these, 381 (88%) achieved CE-N, of which 345 (80%) had adequate follow-up for inclusion in the analysis. A total of 266 (77%) patients achieved CE-IM; with a median follow-up since initial treatment for HGD/IMC of 45.9 months (IQR 25.9, 93.1); 20 patients (5.8%) had recurrent dysplasia after achieving CE-N. Kaplan Meier survival curves revealed that time free of recurrence in those who achieved CE-IM was significantly higher (p = 0.002). In the multivariable analysis, CE-IM was associated with a significant lower hazard of recurrence (HR 0.2, 95% CI 0.1, 0.6), whereas the number of endoscopic treatments to achieve CE-N was associated with a significant higher hazard of recurrence (HR 1.1, 95% CI 1.0, 1.2). CONCLUSION Achieving CE-IM following CE-N reduces the risk of recurrent dysplasia and should be considered a treatment target among patients with BE undergoing endoscopic therapies for HGD or EAC.
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AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol Hepatol 2021; 19:2252-2261.e2. [PMID: 34224876 DOI: 10.1016/j.cgh.2021.06.045] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 02/07/2023]
Abstract
BEST PRACTICE ADVICE 1: For all procedures, especially procedures carrying an increased risk for perforation, a thorough discussion between the endoscopist and the patient (preferably together with the patient's family) should include details of the procedural techniques and risks involved. BEST PRACTICE ADVICE 2: The area of perforation should be kept clean to prevent any spillage of gastrointestinal contents into the perforation by aspirating liquids and, if necessary, changing the patient position to bring the perforation into a non-dependent location while minimizing insufflation of carbon dioxide to avoid compartment syndrome. BEST PRACTICE ADVICE 3: Use of carbon dioxide for insufflation is encouraged for all endoscopic procedures, especially any endoscopic procedure with increased risk of perforation. If available, carbon dioxide should be used for all endoscopic procedures. BEST PRACTICE ADVICE 4: All endoscopists should be aware of the procedures that carry an increased risk for perforation such as any dilation, foreign body removal, any per oral endoscopic myotomy (Zenker's, esophageal, pyloric), stricture incision, thermal coagulation for hemostasis or tumor ablation, percutaneous endoscopic gastrostomy, ampullectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), endoluminal stenting with self-expanding metal stent (SEMS), full-thickness endoscopic resection, endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy, endoscopic ultrasound (EUS)-guided biliary and pancreatic access, EUS-guided cystogastrostomy, and endoscopic gastroenterostomy using a lumen apposing metal stent (LAMS). BEST PRACTICE ADVICE 5: Urgent surgical consultation should be highly considered in all cases with perforation even when endoscopic repair is technically successful. BEST PRACTICE ADVICE 6: For all upper gastrointestinal perforations, the patient should be considered to be admitted for observation, receive intravenous fluids, be kept nothing by mouth, receive broad-spectrum antibiotics (to cover Gram-negative and anaerobic organisms), nasogastric tube (NGT) placement (albeit some exceptions), and surgical consultation. BEST PRACTICE ADVICE 7: For upper gastrointestinal tract perforations, a water-soluble upper gastrointestinal series should be considered to confirm the absence of continuing leak at the perforation site before initiating a clear liquid diet. BEST PRACTICE ADVICE 8: Endoscopic closure of esophageal perforations should be pursued when feasible, utilizing through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) for perforations <2 cm and endoscopic suturing for perforations >2 cm, reserving esophageal stenting with SEMS for cases where primary closure is not possible. BEST PRACTICE ADVICE 9: Endoscopic closure of gastric perforations should be pursued when feasible, utilizing TTSCs or OTSCs for perforations <2 cm and endoscopic suturing or combination of TTSCs and endoloop for perforations >2 cm. BEST PRACTICE ADVICE 10: For large type 1 duodenal perforations (lateral duodenal wall tear >3 cm), being cognizant of the difficulty in closing them endoscopically, urgent surgical consultation should be made while the feasibility of endoscopic closure is assessed. BEST PRACTICE ADVICE 11: Because type 2 periampullary (retroperitoneal) perforations are subtle and can be easily missed, the endoscopist should carefully assess the gas pattern on fluoroscopy to avoid delays in treatment and request a computed tomography scan if there is a concern for such a perforation; identified perforations of this type at the time of ERCP may be closed with TTSCs if feasible and/or by placing a fully covered SEMS into the bile duct across the ampulla. BEST PRACTICE ADVICE 12: For the management of large duodenal polyps, endoscopic mucosal resection (EMR) should only be performed by experienced endoscopists and endoscopic submucosal dissection (ESD) only by experts because both EMR and ESD in the duodenum require proficiency in resection and mucosal defect closure techniques to manage immediate and/or delayed perforations (caused by the proteolytic enzymes of the pancreas). BEST PRACTICE ADVICE 13: Endoscopists should be aware that colon perforations occurring during diagnostic colonoscopy are most commonly located in the sigmoid colon due to direct trauma from forceful advancement of the colonoscope. Such tears recognized at the time of colonoscopy may be closed by TTSCs or OTSCs if the bowel preparation is good and the patient is stable. BEST PRACTICE ADVICE 14: Although colon perforation is responsive to various endoscopic tools such as TTSC, OTSC, and endoscopic suturing, perforations in the right colon, especially in the cecum, have been relegated to using only TTSCs because of inability to reach the site of the perforation with an endoscopic suturing device or OTSC if the colon is tortuous or unclean. Recently a new suture-based device for defect closure has been introduced allowing deep submucosal and intramuscular enhanced fixation through a standard gastroscope or colonoscope. BEST PRACTICE ADVICE 15: Patients with perforations who are hemodynamically unstable or who have suffered a delayed perforation with peritoneal signs or frank peritonitis should be surgically managed without any attempt at endoscopic closure. BEST PRACTICE ADVICE 16: In any adverse event including perforation, it is paramount to ensure accurate documentation, prompt discussion with the patient and family, and swift reporting to the quality officer (or equivalent) and risk management team of the institution (in major adverse events).
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Desai M, Rösch T, Sundaram S, Chandrasekar VT, Kohli D, Spadaccini M, Hassan C, Repici A, Sharma P. Systematic review with meta-analysis: the long-term efficacy of Barrett's endoscopic therapy-stringent selection criteria and a proposal for definitions. Aliment Pharmacol Ther 2021; 54:222-233. [PMID: 34165205 DOI: 10.1111/apt.16473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/16/2021] [Accepted: 05/25/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Barrett's endoscopic therapy (BET) is well established for neoplasia in Barrett's oesophagus using a concept of complete eradication of all Barrett's. However, long-term efficacy is not known. AIMS To perform a systematic review and meta-analysis to examine long-term efficacy of BET for Barrett's neoplasia. METHODS Electronic databases were searched for studies meeting stringent criteria: (a) subjects with high-grade dysplasia and/or superficial adenocarcinoma who underwent BET (ablation ± endoscopic mucosal resection); (b) BET completion by confirmation of complete eradication of neoplasia (CE-N) and intestinal metaplasia (CE-IM) with systematic sampling and (c) clearly defined follow-up (endoscopy and biopsy) protocol of ≥2 years thereafter for detection of recurrence. Pooled estimates of CE-N and CE-IM after BET completion and follow-up were analysed. RESULTS Eight studies met the stringent criteria (n = 794, males 89%, age 64.6 years). Despite high efficacy of BET at therapy completion (CE-N: 95.9 [91.7-98.7]%; CE-IM: 90.9 [83-96.6]%), this declined (CE-N: 89 [73.4-98.2]%; CE-IM: 77.8 [65.6-88]%) over 3.4 years of follow-up. There was considerable heterogeneity. Only two studies reported a post-BET follow-up of >5 years (CE-IM 50 [41.5%-58.5]%). Higher person years of follow-up seem to correlate with decrease in BET efficacy. CONCLUSION Using stringent criteria for appropriate study selection with sufficient follow-up, a lack of high-quality controlled intervention trials becomes evident for assessment of long-term durable remission rates of BET despite initial high success rates. We plea for a uniform documentation of study details which could be used in future trials.
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Affiliation(s)
- Madhav Desai
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA.,Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
| | - Thomas Rösch
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Suneha Sundaram
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA
| | | | - Divyanshoo Kohli
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA
| | - Marco Spadaccini
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Cesare Hassan
- Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Alessandro Repici
- Digestive Endoscopy Unit, Division of Gastroenterology, Humanitas Clinical and Research Center, Milan, Italy
| | - Prateek Sharma
- Department of Gastroenterology, Kansas City VA Medical Center, Kansas City, MO, USA.,Department of Gastroenterology and Hepatology, University of Kansas School of Medicine, Kansas City, KS, USA
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12
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Abstract
Esophageal cancer (EC) often cannot be discovered in time because of its asymptomatic or symptom-atypical characteristics in early stage. The risk and probability of lymph node metastasis and distant metastasis increase correspondingly as the cancer aggressively invades deeper layers. Treatment regimens may be shifted to surgery and chemoradiotherapy (CRT) from endoscopic eradication therapy (EET) with poor quality of life and prognosis. It is imperative to identify dysplasia and EC early and enable early curative endoscopic treatments. Newer methods have been attempted in the clinical setting to achieve early detection at a more microscopic and precise level. Newer imaging techniques and artificial intelligence (AI) technology have been involved in targeted biopsies and will gradually unveil the visualization of pathology in the future. Early detection and diagnosis are the prerequisite to choose personal and precise treatment regimens. EET has also been undergoing development and improvement to benefit more patients as the first option or the firstly chosen alternative therapy, when compared with esophagectomy. More clinical studies are needed to provide more possibilities for EET.
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Affiliation(s)
- Hang Yang
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Wu Hou District, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Wu Hou District, China
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13
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Noordzij IC, Van Loon van de Ende MCM, Curvers WL, van Lijnschoten G, Huysentruyt CJ, Schoon EJ. Dysplasia in Random Biopsies from Barrett's Surveillance Is an Important Marker for More Severe Pathology. Dig Dis Sci 2021; 66:1957-1964. [PMID: 32661766 DOI: 10.1007/s10620-020-06463-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/30/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Although endoscopic recognition of dysplasia in Barrett's esophagus is difficult, experience in recognition of early neoplastic lesions is supposed to increase the detection of early neoplastic lesions. The aim of this study was to assess the significance of dysplasia in random biopsies in Barrett's esophagus, in the absence of reported visible lesions as well as the difference in final outcome of pathology. METHODS We retrospectively identified all patients with Barrett's esophagus with suspicion of dysplasia or early adenocarcinoma who were referred to our center between February 2008 and April 2016. We analyzed all endoscopy reports, pathology reports, and referral letters from 19 different hospitals. Patients were divided into two groups, based on the presence or absence of visible lesions reported upon referral. RESULTS In total, 170 patients diagnosed with dysplasia or adenocarcinoma were referred to our tertiary center. Ninety-one of these referred patients were referred with dysplasia or adenocarcinoma in random biopsies, without a reported lesion during endoscopy in the referral center. During endoscopic work-up at our center, a visible lesion was detected in 44 of these 91 patients (48.4%). After endoscopic work-up and treatment, adenocarcinoma was found in an additional 21 patients. Two of these patients were initially referred with low-grade dysplasia, and 19 patients were initially referred with high-grade dysplasia. The final pathology was upstaged in 35.8% of the patients. CONCLUSIONS The presence of any grade of dysplasia in random biopsies during surveillance in referral centers is a marker for more severe final pathology. Training in recognition of early neoplastic lesions in Barrett's esophagus imaging is recommended for endoscopists performing Barrett's surveillance.
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Affiliation(s)
- I C Noordzij
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - M C M Van Loon van de Ende
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - W L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - G van Lijnschoten
- PAMM (Laboratory of Pathology and Medical Microbiology), Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - C J Huysentruyt
- PAMM (Laboratory of Pathology and Medical Microbiology), Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
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14
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Spadaccini M, Belletrutti PJ, Attardo S, Maselli R, Chandrasekar VT, Galtieri PA, Fugazza A, Anderloni A, Carrara S, Pellegatta G, Hassan C, Sharma P, Repici A. Safety and efficacy of multiband mucosectomy for Barrett's esophagus: a systematic review with pooled analysis. Ann Gastroenterol 2021; 34:487-492. [PMID: 34276186 PMCID: PMC8276358 DOI: 10.20524/aog.2021.0620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/07/2021] [Indexed: 12/14/2022] Open
Abstract
Background According to guidelines, all visible lesions in Barrett’s esophagus (BE) should be endoscopically resected. Available methods of endoscopic resection include the cap-assisted technique and, more recently, multiband mucosectomy (MBM). Data on the efficacy and safety of MBM have yet to be systematically reviewed. We performed the first systematic review with pooled analysis to evaluate the outcomes of MBM in patients with BE. Methods Electronic databases (Medline, Scopus, EMBASE) were searched up to August 2019. Studies including patients with BE who underwent MBM were eligible. The primary outcome was the adverse events rate. Secondary outcomes were the proportions of complete resections and R0 resections. Outcomes were assessed by pooling data using a random or fixed-effect model, according to the degree of heterogeneity, to obtain a proportion with a 95% confidence interval. Results Fourteen studies were eligible (1334 procedures, 986 patients). The adverse event rate was 5.3%. Immediate and post-procedural bleeding, perforations and strictures occurred in 0.2%, 0.7%, 0.3% and 3.9% of procedures, respectively. Focal lesions were resected at a complete rate of 97.6% with an R0 resection rate of 94.1%. Conclusion MBM is a safe and effective technique for treating visible lesions in BE.
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Affiliation(s)
- Marco Spadaccini
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici).,Department of Biomedical Sciences, Humanitas University, MI, Italy (Marco Spadaccini, Alessandro Repici)
| | - Paul J Belletrutti
- Medicine Department, University of Calgary, Calgary, Canada (Paul J. Belletrutti)
| | - Simona Attardo
- Gastroenterology Unit "AOU Ospedale Maggiore della Carità", Novara, Italy (Simona Attardo)
| | - Roberta Maselli
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | | | - Piera Alessia Galtieri
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Alessandro Fugazza
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Andrea Anderloni
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Silvia Carrara
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Gaia Pellegatta
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici)
| | - Cesare Hassan
- Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy (Cesare Hassan)
| | - Prateek Sharma
- Gastroenterology and Hepatology "Kansas City VA Medical Center", USA (Viveksandeep Thoguluva Chandrasekar, Prateek Sharma)
| | - Alessandro Repici
- Endoscopy Unit "Humanitas Research Hospital", MI, Italy (Marco Spadaccini, Roberta Maselli, Piera Alessia Galtieri, Alessandro Fugazza, Andrea Anderloni, Silvia Carrara, Gaia Pellegatta, Alessandro Repici).,Department of Biomedical Sciences, Humanitas University, MI, Italy (Marco Spadaccini, Alessandro Repici)
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15
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Abou Ali E, Belle A, Hallit R, Terris B, Beuvon F, Leconte M, Dohan A, Leblanc S, Dermine S, Palmieri LJ, Coriat R, Chaussade S, Barret M. Management of esophageal strictures after endoscopic resection for early neoplasia. Therap Adv Gastroenterol 2021; 14:1756284820985298. [PMID: 33519974 PMCID: PMC7816530 DOI: 10.1177/1756284820985298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 11/26/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Endoscopic resection of extensive esophageal neoplastic lesions is associated with a high rate of esophageal stricture. Most studies have focused on the risk factors for post-endoscopic esophageal stricture, but data on the therapeutic management of these strictures are scarce. Our aim is to describe the management of esophageal strictures following endoscopic resection for early esophageal neoplasia. METHODS We included all patients with an endoscopic resection for early esophageal neoplasia followed by endoscopic dilatation at a tertiary referral center. We recorded the demographic, endoscopic, and histological characteristics, and the outcomes of the treatment of the strictures. RESULTS Between January 2010 and December 2019, we performed 166 endoscopic mucosal resections and 261 endoscopic submucosal dissections for early esophageal neoplasia, and 34 (8.0%) patients developed an esophageal stricture requiring endoscopic treatment. The indication for endoscopic resection was Barrett's neoplasia in 15/34 (44.1%) cases and squamous cell neoplasia (SCN) in 19/34 (55.9%) cases. The median [(interquartile range) (IQR)] number of endoscopic dilatations was 2.5 (2.0-4.0). Nine of 34 (26.5%) patients required only one dilatation, and 22/34 (65%) had complete dysphagia relief following three endoscopic treatment sessions. The median number of dilatations was significantly higher for SCN [3.0 (2-7); range 1-17; p = 0.02], and in the case of circumferential resection [4.0 (3.0-7.0); p = 0.03]. Endoscopic dilatation allowed a sustained dysphagia relief in 33/34 (97.0%) patients after a mean follow-up of 25.3 ± 22 months. CONCLUSION Refractory post-endoscopic esophageal stricture is a rare event. After a median of 2.5 endoscopic dilatations, 97.0% of patients were permanently relieved of dysphagia. Circumferential endoscopic esophageal resections should be considered when indicated.
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Affiliation(s)
- Einas Abou Ali
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
| | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Rachel Hallit
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Benoit Terris
- Department of Pathology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
| | - Frédéric Beuvon
- Department of Pathology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
| | - Mahaut Leconte
- Department of Digestive Surgery, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris France,University of Paris, Paris, France
| | - Anthony Dohan
- Department of Abdominal and Interventional Imaging, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
| | - Sarah Leblanc
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Solène Dermine
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
| | - Lola-Jade Palmieri
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
| | - Romain Coriat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France,University of Paris, Paris, France
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16
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Kumarasinghe MP, Armstrong M, Foo J, Raftopoulos SC. The modern management of Barrett's oesophagus and related neoplasia: role of pathology. Histopathology 2020; 78:18-38. [PMID: 33382493 DOI: 10.1111/his.14285] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022]
Abstract
Modern management of Barrett's oesophagus and related neoplasia essentially focuses upon surveillance to detect early low-risk neoplastic lesions and offering organ-preserving advanced endoscopic therapies, while traditional surgical treatments of oesophagectomy and lymph node clearance with or without chemoradiation are preserved only for high-risk and advanced carcinomas. With this evolution towards figless invasive therapy, the choice of therapy hinges upon the pathological assessment for risk stratifying patients into those with low risk for nodal metastasis who can continue with less invasive endoscopic therapies and others with high risk for nodal metastasis for which surgery or other forms of treatment are indicated. Detection and confirmation of neoplasia in the first instance depends upon endoscopic and pathological assessment. Endoscopic examination and biopsy sampling should be performed according to the recommended protocols, and endoscopic biopsy interpretation should be performed applying standard criteria using appropriate ancillary studies by histopathologists experienced in the pathology of Barrett's disease. Endoscopic resections (ERs) are both diagnostic and curative and should be performed by clinicians who are skilled with advanced endoscopic techniques. Proper preparation and handling of ERs are essential to assess histological parameters that dictate the curative nature of the procedure. Those parameters are adequacy of resection and risk of lymph node metastasis. The risk of lymph node metastasis is determined by depth invasion and presence of poor differentiation and lymphovascular invasion. Those adenocarcinomas with invasion up to muscularis mucosae (pT1a) and those with superficial submucosal invasion (pT1b) up to 500 µ with no poor differentiation and lymphovascular invasion and negative margins may be considered cured by endoscopic resections.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Michael Armstrong
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Jonathan Foo
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Spiro C Raftopoulos
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
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17
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Single-Step Treatment with Limited Endoscopic Resection and Cryoballoon Ablation Is Feasible and Safe in an Esophageal Porcine Model. Dig Dis Sci 2020; 65:3175-3183. [PMID: 31970611 DOI: 10.1007/s10620-020-06054-3] [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] [Received: 10/14/2019] [Accepted: 01/06/2020] [Indexed: 12/09/2022]
Abstract
BACKGROUND Treatment of Barrett's neoplasia consists of two steps: endoscopic resection of visible lesions with subsequent ablation of remaining Barrett's epithelium. However, extensive resection might hamper subsequent ablation due to stenosis. Combining both modalities in one session therefore offers potential advantages. Single-step treatment with radiofrequency ablation and resection appeared to be unsafe. AIMS To evaluate feasibility and safety of single-step treatment with cryoballoon ablation and endoscopic resection. METHODS Two single-step treatment regimens (15 treatment areas per regimen) were evaluated: (1) CRYO-EMR: four side-by-side focal ablations of 10 seconds followed by resection in the treated area; (2) EMR-CRYO: resection followed by 10-s ablation targeted on the resection wound. Primary outcome for both regimens was safety (perforations, clinically relevant strictures) and for CRYO-EMR also feasibility of resection and histopathological evaluation. Secondly, all CRYO-EMR and esophageal resection specimens were histopathologically evaluated. RESULTS Six female pigs were treated (five treatment areas per animal). During 28 days of follow-up, no perforations or clinically relevant stenosis occurred. All resections were technically successful. For all CRYO-EMR specimens, histopathological evaluation was feasible with ablation effects present throughout all layers, while the architecture requisite for histopathological analysis remained intact. After 28 days, histopathological evaluation of the esophagi was performed. For EMR-CRYO, post-treatment fibrosis was present throughout the submucosa. The muscularis propria was the deepest layer involved for CRYO-EMR. CONCLUSIONS Single-step treatment with limited endoscopic resection and cryoballoon ablation is feasible and safe in a porcine model and justifies further evaluation in a clinical trial.
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18
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Shimamura Y, Iwaya Y, Kobayashi R, Rodriguez de Santiago E, Muwanwella N, Raftopoulos S, Mosko JD, May GR, Kandel G, Kortan P, Marcon N, Teshima CW. Clinical and pathological predictors of failure of endoscopic therapy for Barrett's related high-grade dysplasia and early esophageal adenocarcinoma. Surg Endosc 2020; 35:5468-5479. [PMID: 32989547 DOI: 10.1007/s00464-020-08037-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/16/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIMS Multimodal endoscopic treatment for Barrett's esophagus (BE) related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) is safe and effective. However, there is a paucity of data to predict the response to endoscopic treatment. This study aimed to identify predictors of failure to achieve complete eradication of neoplasia (CE-N) and complete eradication of intestinal metaplasia (CE-IM). METHODS We performed a retrospective analysis of prospectively collected data of all HGD/EAC cases treated endoscopically at a tertiary referral center. Only patients with confirmed HGD/EAC from initial endoscopic mucosal resection (EMR) were included. Potential predictive variables including clinical characteristics, endoscopic features, and index histologic parameters of the EMR specimens were evaluated using multivariate Cox regression. RESULTS A total of 457 patients were diagnosed with HGD/EAC by initial EMR from January 2008 to January 2019. Of these, 366 patients who underwent subsequent endoscopic treatment with or without RFA were included. Cumulative incidence rates at 3 years for CE-N and CE-IM were 91.4% (95% CI 87.8-94.2%) and 66.8% (95% CI 61.2-72.3%), respectively during a median follow-up period of 35 months. BE segment of 3-10 cm (HR 0.45; 95% CI 0.36-0.57) and > 10 cm (HR 0.25; 95% CI 0.15-0.40) were independent clinical predictors associated with failure to achieve CE-N. With respect to CE-IM, increasing age (HR 0.88; 95% CI 0.78-1.00) was another predictor along with BE segment of 3-10 cm (HR 0.37; 95% CI 0.28-0.49) and > 10 cm (HR 0.15; 95% CI 0.07-0.30). Lymphovascular invasion increased the risk of CE-N and CE-IM failure in EAC cases. CONCLUSION Failure to achieve CE-N and CE-IM is associated with long-segment BE and other clinical variables. Patients with these predictors should be considered for a more intensive endoscopic treatment approach at expert centers.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada.
| | - Yugo Iwaya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Ryosuke Kobayashi
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramon Y Cajal, IRYCIS, Universidad de Alcala, Madrid, Spain
| | - Niroshan Muwanwella
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology and Hepatology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Jeffrey D Mosko
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gary R May
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Gabor Kandel
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Paul Kortan
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Norman Marcon
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Christopher W Teshima
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
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19
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Badgery H, Read M, Winter NN, Taylor ACF, Hii MW. The role of esophagectomy in the management of Barrett's esophagus with high-grade dysplasia. Ann N Y Acad Sci 2020; 1481:72-89. [PMID: 32812261 DOI: 10.1111/nyas.14439] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 06/12/2020] [Accepted: 06/24/2020] [Indexed: 12/19/2022]
Abstract
Barrett's esophagus (BE) with high-grade dysplasia (HGD) has previously been a routine indication for esophagectomy. Recent advances in endoscopic therapy have resulted in a shift away from surgery. Current international guidelines recommend endoscopic therapy for BE with HGD irrespective of recurrence or progression of dysplasia. Current guidelines do not address the ongoing role of esophagectomy as an adjunct in the setting of failed endoscopic therapy. This review examines the role of esophagectomy as an adjunct to endoscopy in the management of patients with BE and HGD, with a specific focus on patients with persistent, progressive, or recurrent disease, disease resistant to endoscopic therapy, in patients with concomitant esophageal pathology, and in those patients in whom lifelong surveillance may not be possible or desired.
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Affiliation(s)
- Henry Badgery
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Matthew Read
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Nicole N Winter
- Department of Upper Gastrointestinal Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Andrew C F Taylor
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, the University of Melbourne, Melbourne, Victoria, Australia
| | - Michael W Hii
- Department of Upper Gastrointestinal Surgery, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Surgery, The University of Melbourne, St Vincent's Hospital, Melbourne, Victoria, Australia
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20
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Adil MT, Al-Taan O, Rashid F, Munasinghe A, Jain V, Whitelaw D, Jambulingam P, Mahawar K. A Systematic Review and Meta-Analysis of the Effect of Roux-en-Y Gastric Bypass on Barrett's Esophagus. Obes Surg 2020; 29:3712-3721. [PMID: 31309524 DOI: 10.1007/s11695-019-04083-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Obesity is associated with a twofold risk of gastroesophageal reflux disease (GERD) and thrice the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) leads to weight loss and improvement of GERD in population with obesity, but its effect on BE is less clear. METHODS Bibliographic databases were searched systematically for relevant articles till January 31, 2019. Studies evaluating the effect of RYGB on BE with preoperative and postoperative endoscopy and biopsy were included. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was conducted using Mantel-Haenszel, random effects model and presented as risk difference (RD) or odds ratio (OR) with 95% confidence intervals. RESULTS Eight studies with 10,779 patients undergoing RYGB reported on 117 patients with BE with follow-up of > 1 year. Significant regression of BE after RYGB was observed (RD - 0.56.95% c.i. - 0.69 to - 0.43; P < 0.001). Subgroup analysis showed regression of both short-segment BE [ssBE] (RD - 0.51.95% c.i. - 0.68 to - 0.33; P < 0.001) and long-segment BE [lsBE] (RD - 0.46.95% c.i. - 0.71 to - 0.21; P < 0.001). RYGB also caused improvement in GERD in patients of BE (RD - 0.93, 95% c.i. - 1.04 to - 0.81; P < 0.001). RYGB was strongly associated with regression of BE compared with progression (OR 31.2.95% c.i. 11.37 to 85.63; P < 0.001). CONCLUSIONS RYGB leads to significant improvement of BE at > 1 year after surgery in terms of regression and resolution of the associated GERD. Both ssBE and lsBE improve after RYGB significantly.
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Affiliation(s)
- Md Tanveer Adil
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom.
| | - Omer Al-Taan
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Farhan Rashid
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Aruna Munasinghe
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Vigyan Jain
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Douglas Whitelaw
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Periyathambi Jambulingam
- Department of Upper GI and Bariatric Surgery, Luton and Dunstable University Hospital, Lewsey Road, Luton, LU4 0DZ, United Kingdom
| | - Kamal Mahawar
- Department of General Surgery, Sunderland Royal Hospital, Kayll Road, Sunderland, SR4 7TP, United Kingdom
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21
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Lampridis S, Mitsos S, Hayward M, Lawrence D, Panagiotopoulos N. The insidious presentation and challenging management of esophageal perforation following diagnostic and therapeutic interventions. J Thorac Dis 2020; 12:2724-2734. [PMID: 32642181 PMCID: PMC7330325 DOI: 10.21037/jtd-19-4096] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diagnostic and therapeutic interventions on the esophagus or adjacent organs are responsible for nearly half of all esophageal perforations. If not recognized at the time of the injury, iatrogenic esophageal perforations can present insidiously and lead to delay in diagnosis, thereby increasing morbidity and mortality. Acute clinical awareness is vital for prompt diagnosis, which is usually confirmed with contrast esophagography and contrast-enhanced computed tomography. After establishment of diagnosis, treatment should be promptly initiated and include fluid-volume resuscitation, cessation of oral intake, nasogastric tube insertion, broad-spectrum antibiotics and analgesia. Primary repair, when feasible, is the treatment of choice. Additional procedures beyond primary repair, such as relief of concomitant obstruction, may be necessary if there is underlying esophageal pathology. Drainage alone can be performed for perforations of the cervical esophagus that cannot be visualized. Esophageal T-tube placement or exclusion and diversion techniques are appropriate in clinically unstable patients and in cases where primary repair is precluded either due to preexisting esophageal disease or extensive esophageal damage. Esophagectomy should be performed in patients with malignancy, end-stage benign esophageal disease or extensive esophageal damage that precludes repair. Endoscopic techniques, including stenting, clipping or vacuum therapy, can be used in select cases. Finally, nonoperative management should be reserved for patients with contained esophageal perforations, limited extraluminal soilage and no evidence of systemic inflammation.
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Affiliation(s)
- Savvas Lampridis
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Sofoklis Mitsos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Martin Hayward
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - David Lawrence
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
| | - Nikolaos Panagiotopoulos
- Thoracic Surgery Department, University College London Hospitals, NHS Foundation Trust, London, UK
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22
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Ohki T, Yamamoto M. Esophageal regenerative therapy using cell sheet technology. Regen Ther 2020; 13:8-17. [PMID: 33490318 PMCID: PMC7794050 DOI: 10.1016/j.reth.2020.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 03/20/2020] [Accepted: 04/19/2020] [Indexed: 12/13/2022] Open
Abstract
We have been conducting research on esophageal regenerative therapy using cell sheet technology. In particular, in the endoscopic field, we have pushed forward clinical research on endoscopic transplantation of cultured autologous oral mucosal epithelial cell sheets to esophageal ulcer after endoscopic submucosal dissection (ESD). We started research in this direction using animal models in 2004 and performed clinical research in 2012 in collaboration with Nagasaki University and Karolinska Institute. Although in full-circumferential cases it was difficult to prevent esophageal stricture after ESD, there were no complications and stricture could be suppressed. The cell sheet technology is still in its infancy. However, we are convinced that it has a high potential for application in various areas of gastrointestinal science. In this review, we focus on the pre-clinical and clinical trial results obtained and on the theoretical aspects of (1) stricture prevention, (2) esophageal tissue engineering research, and (3) endoscopic transplantation, and review the esophageal regenerative therapy by cell sheet technology.
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Key Words
- CMC, carboxymethyl cellulose
- CPC, cell-processing center
- Cell sheet technology
- EBD, endoscopic balloon dilation
- ECM, extracellular matrix
- EMR, endoscopic mucosal dissection
- ESD, endoscopic submucosal dissection
- Endoscopic submucosal dissection (ESD)
- Endoscopic transplantation
- Esophageal stricture
- GMP, good manufacturing practice
- OMECS, oral mucosal epithelial cell sheet
- PGA, polyglycolic acid
- PIPAAm, poly(N-isopropylacrylamide)
- PVDF, polyvinylidene difluoride
- Regenerative medicine
- SEMS, self-expandable metallic stent
- TAC, triamcinolone
- Tissue-engineered oral mucosal
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Affiliation(s)
- Takeshi Ohki
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
- Institute of Advanced Biomedical Engineering and Science, Tokyo Women's Medical University (TWIns), 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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23
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Al-Asiry J, Lord R, Mohammed N. Management of spontaneous and iatrogenic perforations, leaks and fistulae of the upper gastrointestinal tract. Ther Adv Gastrointest Endosc 2020; 12:2631774519895845. [PMID: 31909396 PMCID: PMC6935768 DOI: 10.1177/2631774519895845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022] Open
Abstract
Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.
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Affiliation(s)
- Jamal Al-Asiry
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Richard Lord
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Noor Mohammed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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24
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Gabr A. Sealing the hole: endoscopic management of acute gastrointestinal perforations. Frontline Gastroenterol 2020; 11:55-61. [PMID: 31885841 PMCID: PMC6914298 DOI: 10.1136/flgastro-2018-101136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/03/2019] [Accepted: 02/16/2019] [Indexed: 02/04/2023] Open
Abstract
Acute perforations are one of the recognised complications of both diagnostic and therapeutic gastrointestinal (GI) endoscopy. The incidence rate varies according to the type of procedure and the anatomical location within the GI tract. For decades, surgical treatment has been the standard of care, but endoscopic closure has become a more popular approach, due to feasibility and the reduction of the burden of surgery. Various devices are available now such as through-the-scope clips, over-the-scope clips, endoscopic suturing devices, stents, bands and omental patch. All have been tested in studies done on humans or animal models, with a reasonable overall technical and clinical success rate, proving efficiency and feasibility of endoscopic closure. The choice of which device to use depends on the site and the size of the perforation. It also depends on availability of thee device and the endoscopist's experience. A number of factors that could predict success of endoscopic closure or favour surgical treatment have been suggested in different studies. After successful endoscopic closure, patients are usually kept nil by mouth and receive antibiotics for a duration that varied between different studies.
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Affiliation(s)
- Ahmed Gabr
- Gastroenterology, Palestine Hospital, Cairo, Egypt
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25
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Abstract
Traditionally, early esophageal cancer (i.e., cancer limited to the mucosa or superficial submucosa) was managed surgically; the gastroenterologist's role was primarily to diagnose the tumor. Over the last decade, advances in endoscopic imaging, ablation, and resection techniques have resulted in a paradigm shift-diagnosis, staging, treatment, and surveillance are within the endoscopist's domain. Yet, there are few reviews that provide a focused, evidence-based approach to early esophageal cancer, and highlight areas of controversy for practicing gastroenterologists. In this manuscript, we will discuss the following: (1) utility of novel endoscopic technologies to identify high-grade dysplasia and early esophageal cancer, (2) role of endoscopic resection and imaging to stage early esophageal cancer, (3) endoscopic therapies for early esophageal cancer, and (4) indications for surgical and multidisciplinary management.
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26
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Sanghi V, Amin H, Sanaka MR, Thota PN. Resection of early esophageal neoplasms: The pendulum swings from surgical to endoscopic management. World J Gastrointest Endosc 2019; 11:491-503. [PMID: 31798770 PMCID: PMC6885444 DOI: 10.4253/wjge.v11.i10.491] [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: 06/11/2019] [Revised: 08/09/2019] [Accepted: 09/11/2019] [Indexed: 02/06/2023] Open
Abstract
Esophageal cancer is a highly lethal disease and is the sixth leading cause of cancer related mortality in the world. The standard treatment is esophagectomy which is associated with significant morbidity and mortality. This led to development of minimally invasive, organ sparing endoscopic therapies which have comparable outcomes to esophagectomy in early cancer. These include endoscopic mucosal resection and endoscopic submucosal dissection. In early squamous cell cancer, endoscopic submucosal dissection is preferred as it is associated with cause specific 5-year survival rates of 100% for M1 and M2 tumors and 85% for M3 and SM1 tumors and low recurrence rates. In early adenocarcinoma, endoscopic resection of visible abnormalities is followed by ablation of the remaining flat Barrett’s mucosa to prevent recurrences. Radiofrequency ablation is the most widely used ablation modality with others being cryotherapy and argon plasma coagulation. Focal endoscopic mucosal resection followed by radiofrequency ablation leads to eradication of neoplasia in 93.4% of patients and eradication of intestinal metaplasia in 73.1% of patients. Innovative techniques such as submucosal tunneling with endoscopic resection are developed for management of submucosal tumors of the esophagus. This review includes a discussion of various endoscopic techniques and their clinical outcomes in early squamous cell cancer, adenocarcinoma and submucosal tumors. An overview of comparison between esophagectomy and endoscopic therapy are also presented.
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Affiliation(s)
- Vedha Sanghi
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Hina Amin
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
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27
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Stricture Prevention after Extensive Endoscopic Submucosal Dissection of Neoplastic Barrett's Esophagus: Individualized Oral Steroid Prophylaxis. Gastroenterol Res Pract 2019; 2019:2075256. [PMID: 31110516 PMCID: PMC6487109 DOI: 10.1155/2019/2075256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 02/24/2019] [Accepted: 03/24/2019] [Indexed: 02/07/2023] Open
Abstract
Introduction Endoscopic resection (ER) exceeding ≥75% of the esophageal circumference is accompanied with a high stricture risk regardless of the resection method. The ideal strategy for stricture prevention is not well defined today. Different approaches have been reported but data are limited to the resection of squamous cell neoplasia. The aim of this study was to assess the efficacy of an individualized oral steroid regimen to prevent strictures after extensive ER in neoplastic Barrett's esophagus (NBE). Materials and Methods Over a 50-month period, endoscopic submucosal dissection (ESD) was performed in 193 patients with NBE. 23 patients with resections exceeding 75% of the circumference were included. 19 resection ulcers were noncircumferential (NCR) while 4 were circumferential (CR). Stricture prevention was performed using oral prednisolone starting with a daily dose of 50 mg and standard tapering over 8 weeks (50/40/30/25/20/15/10/5 mg). Tapering was individualized according to the ulcer healing process (assessed endoscopically in the first tapering period and before stopping the steroids). Data were analyzed retrospectively. Results Stricture rates were 5.3% (1/19) for NCR and 100% (4/4) for CR (p < 0.001). The only stricture in the NCR group was seen in a patient who had stopped steroids without any reason after few days. 12/19 patients received standard tapering over 8 weeks (63.1%). According to the individual ulcer healing, treatment was prolonged to 9-10 weeks in 4/19 (21.1%) and shortened to 7 weeks in another 2/19 (10.5%). After CR, all patients needed endoscopic balloon dilatation (median 6.5 sessions; range 3-14 sessions for 8-40 weeks). Side effects of the steroid therapy were not noted. Conclusion Oral prednisolone therapy with an endoscopy-based individualized tapering regimen is effective in avoiding strictures after NCR of Barrett's neoplasia. After CR, the stricture risk is not sufficiently decreased. CR should be restricted to circumferential neoplasia which is a very rare scenario in neoplastic BE.
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28
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van Munster SN, Pouw RE, Bergman JJGHM. Randomized studies for Barrett's ablation: just because we can doesn't mean we should. Gastrointest Endosc 2019; 89:690-692. [PMID: 30902198 DOI: 10.1016/j.gie.2018.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 11/07/2018] [Indexed: 02/08/2023]
Affiliation(s)
- Sanne Noortje van Munster
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
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29
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Abstract
Endoscopic resection for early esophageal cancer is a very precise endoscopic surgical technique and having experience in endoscopic resection is mandatory to perform these kinds of procedures safely. In case of adequate resection and favorable histological outcome, long-term prognosis of the patient is excellent. The basic principle for endoscopic treatment of early adenocarcinoma is based on the fact that the risk of lymph node metastasis gradually increases with the depth of invasion. Inspection and evaluation of all mucosal and submucosal lesions need to be done carefully before endoscopic resection. Endoscopic resection of mucosal (T1m1-3) and superficial submucosal (T1sm1) adenocarcinoma can be curative as well as for superficial mucosal (T1m1-m2) squamous cell carcinoma. In Paris type I lesions in Barrett's esophagus and for early squamous cell carcinoma endoscopic submucosal dissection (ESD) is the preferred option. The risk of severe adverse events associated with endoscopic resection are low. Most adverse events are managed endoscopically and can be treated conservatively. Endoscopic radiofrequency ablation is the most widely used ablation technique for Barrett's epithelium and highly effective to achieve full remission of dysplasia and intestinal metaplasia. The role of radiofrequency ablation in the treatment armamentarium in squamous cell carcinoma of the esophagus has still to be determined.
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Affiliation(s)
- Irma C Noordzij
- Department of Gastroenterology and Hepatology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Cancer Institute, Catharina Hospital, Eindhoven, The Netherlands
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30
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Baldaque-Silva F, Marques M, Andrade AP, Sousa N, Lopes J, Carneiro F, Macedo G. Endoscopic submucosal dissection of gastrointestinal lesions on an outpatient basis. United European Gastroenterol J 2019; 7:326-334. [PMID: 31080617 DOI: 10.1177/2050640618823874] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 12/12/2018] [Indexed: 12/13/2022] Open
Abstract
Background Endoscopic submucosal dissection (ESD) is usually associated with hospital admission. Objectives To evaluate, prospectively, the feasibility, safety and efficacy of outpatient gastrointestinal ESD. Methods Patients with suitable lesions were invited to participate. Those that dwelt more than 1 hour from the hospital, lived alone, had severe co-morbidities, were <18 years old, had duodenal lesions, or that had ESD-related complications were admitted. The remaining patients were discharged if no complications were detected. A patients' inquiry was performed. Results Of the 164 ESD patients, 122 were outpatient-based, corresponding to 115 patients, 47% male and mean age 63 ± 12 years-old. Outpatients tended to be younger, female, to have gastric lesions, less advanced lesions, and shorter and less complicated ESDs (all p < 0.05). Outpatients' mean tumour size was 38 mm, en bloc and R0 resection rates were 88 and 78%, respectively. Seven ESD outpatients (5.7%) had complications: delayed bleeding (n = 4), pneumonitis (n = 2) or emphysema (n = 1), all managed conservatively. Colorectal location of the lesions was predictive of hospital admission (p = 0.03). In total, 97% of patients were satisfied with the outpatient strategy. Conclusion Risks of ambulatory ESD are low and complications can be successfully managed. This strategy has high patient satisfaction. More studies are needed to evaluate its implications on costs and patients' management.
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Affiliation(s)
- Francisco Baldaque-Silva
- Department of Digestive Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden.,Department of Gastroenterology, São João University Hospital, Porto, Portugal
| | - Margarida Marques
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
| | | | - Nuno Sousa
- Department of Biomedical Sciences and Medicine, University of Algarve, Faro, Portugal
| | - Joanne Lopes
- Department of Pathology, São João University Hospital, Porto, Portugal
| | - Fatima Carneiro
- Department of Pathology, São João University Hospital, Porto, Portugal.,Institute of Molecular Pathology and Immunology, University of Porto, Porto, Portugal
| | - Guilherme Macedo
- Department of Gastroenterology, São João University Hospital, Porto, Portugal
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31
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Zeki SS, Bergman JJ, Dunn JM. Endoscopic management of dysplasia and early oesophageal cancer. Best Pract Res Clin Gastroenterol 2018; 36-37:27-36. [PMID: 30551853 DOI: 10.1016/j.bpg.2018.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023]
Abstract
In the past decade there have been technological advances in Endoscopic Eradication Therapy (EET) for the management of patients with oesophageal neoplasia and early cancer. Multiple endoscopic techniques now exist for both squamous and Barrett's oesophagus associated neoplasia or early cancer. A fundamental aspect of endotherapy is removal of the target lesion by endoscopic mucosal resection, or endosopic submucosal dissection. Residual tissue is subsequently ablated to remove the risk of recurrence. The most validated technique for Barrett's oesophagus is radiofrequency ablation, but other techniques such as hybrid-APC and cryotherapy also show good results. This chapter will discuss the evolution of EET, and which patients are most likely to benefit. It will also explore the evidence behind the success of different techniques and provide practical advice on how to carry out the endoscopic techniques with a focus on radiofrequency ablation and endoscopic mucosal resection in particular.
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Affiliation(s)
- S S Zeki
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom.
| | - J J Bergman
- Dep. of Gastroenterology, Academic Medical Center, Amsterdam, Netherlands
| | - J M Dunn
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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32
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Malik S, Sharma G, Sanaka MR, Thota PN. Role of endoscopic therapy in early esophageal cancer. World J Gastroenterol 2018; 24:3965-3973. [PMID: 30254401 PMCID: PMC6148428 DOI: 10.3748/wjg.v24.i35.3965] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
Esophageal carcinoma is a highly lethal cancer associated with high morbidity and mortality. Esophageal squamous cell carcinoma and esophageal adenocarcinoma are the two distinct histological types. There has been significant progress in endoscopic diagnosis and treatment of early stages of cancer using resection and ablation techniques, as shown in several trials in the recent past. Earlier detection of esophageal cancer and advances in treatment modalities have lead to improvement in the 5-year survival from 5% to about 20% in the past decade. Endoscopic eradication therapy is the preferred modality of treatment in cancer limited to mucosal layer of the esophagus as there is very low risk of lymph node metastasis, leading to high cure rates, low risk of recurrence and with few adverse effects. The most common adverse events seen are strictures, bleeding and rarely perforation which can be endoscopically managed. In patients with recurrent advanced disease or invasive tumor, esophagectomy with lymph node dissection remains the mainstay of treatment. There is debate on post-endoscopic surveillance with some studies suggesting closer follow up with upper endoscopy every 6 mo for the first 1-2 years and then annually for the 3 years while others recommending the appropriate action only if symptoms or other abnormalities develop. Overall, the field of endoscopic therapy is still evolving and focus should be placed on careful patient selection using a multidisciplinary approach.
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Affiliation(s)
- Sonika Malik
- Department of Internal Medicine, Cleveland Clinic Akron General Medical Center, Akron, OH 44307, United States
| | - Gautam Sharma
- Department of Anesthesiology, University Hospitals, Cleveland, OH 44106, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Digestive Disease Surgery Institute, Cleveland Clinic, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology, Digestive Disease Surgery Institute, Cleveland Clinic, OH 44195, United States
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33
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Urbanska AM, Ponnazhagan S, Mozafari M. Pathology, Chemoprevention, and Preclinical Models for Target Validation in Barrett Esophagus. Cancer Res 2018; 78:3747-3754. [PMID: 29959150 DOI: 10.1158/0008-5472.can-18-0206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 04/13/2018] [Accepted: 05/22/2018] [Indexed: 11/16/2022]
Abstract
Despite esophageal adenocarcinoma (EAC) being the most widespread among gastrointestinal cancers, with an 11-fold increase in the risk of cancer for patients with Barrett esophagus (BE), its prognosis is still poor. There is a critical need to better perceive the biology of cancer progression and identification of specific targets that are the hallmark of BE's progression. This review explores the established animal models of BE, including genetic, surgical and nonsurgical approaches, potential chemoprevention targets, and the reasoning behind their applications to prevent Barrett-related EAC. The key methodological features in the design feasibility of relevant studies are also discussed. Cancer Res; 78(14); 3747-54. ©2018 AACR.
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Affiliation(s)
- Aleksandra M Urbanska
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Medical Center, New York, New York
| | | | - Masoud Mozafari
- Bioengineering Research Group, Nanotechnology and Advanced Materials Department, Materials and Energy Research Center (MERC), Tehran, Iran. .,Cellular and Molecular Research Center, Iran University of Medical Sciences, Tehran, Iran.,Department of Tissue Engineering and Regenerative Medicine, Faculty of Advanced Technologies in Medicine, Iran University of Medical Sciences, Tehran, Iran
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34
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Pouw RE, Künzli HT, Bisschops R, Sondermeijer CM, Koch AD, Didden P, Gotink AW, Schoon EJ, Curvers WL, Bergman JJGHM, Weusten BLAM. Simplified versus standard regimen for focal radiofrequency ablation of dysplastic Barrett's oesophagus: a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol 2018; 3:566-574. [PMID: 29934224 DOI: 10.1016/s2468-1253(18)30157-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 04/19/2018] [Accepted: 04/23/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND For focal radiofrequency ablation of Barrett's oesophagus, a simplified regimen (3 × 15 J/cm2, without cleaning) has proven to be as effective as the standard regimen (2 × 15 J/cm2, followed by cleaning, followed by 2 × 15 J/cm2). However, this simplified regimen seemed to be associated with a higher stenosis rate. Therefore, we lowered the radiofrequency energy and hypothesised that this new simplified regimen would be as effective and safe as the standard regimen. METHODS This randomised non-inferiority trial included patients with dysplastic Barrett's oesophagus or residual Barrett's oesophagus after endoscopic resection or circumferential radiofrequency ablation, in five European tertiary referral centres. Patients were randomly assigned (1:1) to the new simplified regimen (3 × 12 J/cm2, without cleaning) or the standard regimen, with variable block sizes of four, six, and eight patients, stratified by participating hospital. Focal radiofrequency ablation was done every 3 months, up to a maximum of three treatments, until all Barrett's oesophagus was eradicated. The primary outcome was complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments, assessed in the intention-to-treat population. Non-inferiority was assessed on the basis of the difference between groups in the median percentage of Barrett's oesophagus surface regression, with a non-inferiority margin of -15%. This study is registered with www.trialregister.nl, number NTR4994, and is completed. FINDINGS Between March 25, 2015, and July 25, 2016, 84 patients were randomly assigned to treatment: 44 to receive the simplified regimen and 40 to receive the standard regimen. One patient assigned to the simplified regimen and four assigned to the standard regimen were excluded because they weree found not to be eligible; therefore the final intention-to-treat population consisted of 43 patients in the simplified ablation group and 36 in the standard ablation group. Complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments was achieved in 32 (74%, 95% CI 59-87) patients treated with the simplified protocol, versus 30 (83%, 95% CI 67-94) patients treated with the standard protocol (p=0·34). Median Barrett's oesophagus surface regression after two focal radiofrequency ablation sessions was 98% (IQR 95-100) in the simplified regimen group and 100% (97-100) in the standard regimen group. The difference between medians was 2% (95% CI -0·562 to 3·162); thus the simplified regimen was deemed non-inferior to the standard regimen. Stenoses requiring dilatation were observed in four (9%) of 43 patients in the simplified regimen group and four (11%) of 36 in the standard regimen group. Post-procedural bleeding requiring repeat endoscopy occurred in one (2%) patient in the simplified ablation group and three (8%) patients in the standard ablation group. One patient (2%) in the simplified treatment group died 36 days after the second radiofrequency ablation procedure, due to an unknown cause. INTERPRETATION Based on the results of this study, we conclude that the simplified regimen is the preferred regimen for focal radiofrequency ablation of Barrett's oesophagus. FUNDING None.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Hannah T Künzli
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Carine M Sondermeijer
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Paul Didden
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Anniek W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands.
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Sami SS, Haboubi HN, Ang Y, Boger P, Bhandari P, de Caestecker J, Griffiths H, Haidry R, Laasch HU, Patel P, Paterson S, Ragunath K, Watson P, Siersema PD, Attwood SE. UK guidelines on oesophageal dilatation in clinical practice. Gut 2018; 67:1000-1023. [PMID: 29478034 PMCID: PMC5969363 DOI: 10.1136/gutjnl-2017-315414] [Citation(s) in RCA: 78] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 01/03/2018] [Accepted: 01/14/2018] [Indexed: 01/10/2023]
Abstract
These are updated guidelines which supersede the original version published in 2004. This work has been endorsed by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG) under the auspices of the oesophageal section of the BSG. The original guidelines have undergone extensive revision by the 16 members of the Guideline Development Group with representation from individuals across all relevant disciplines, including the Heartburn Cancer UK charity, a nursing representative and a patient representative. The methodological rigour and transparency of the guideline development processes were appraised using the revised Appraisal of Guidelines for Research and Evaluation (AGREE II) tool.Dilatation of the oesophagus is a relatively high-risk intervention, and is required by an increasing range of disease states. Moreover, there is scarcity of evidence in the literature to guide clinicians on how to safely perform this procedure. These guidelines deal specifically with the dilatation procedure using balloon or bougie devices as a primary treatment strategy for non-malignant narrowing of the oesophagus. The use of stents is outside the remit of this paper; however, for cases of dilatation failure, alternative techniques-including stents-will be listed. The guideline is divided into the following subheadings: (1) patient preparation; (2) the dilatation procedure; (3) aftercare and (4) disease-specific considerations. A systematic literature search was performed. The Grading of Recommendations Assessment, Develop-ment and Evaluation (GRADE) tool was used to evaluate the quality of evidence and decide on the strength of recommendations made.
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Affiliation(s)
- Sarmed S Sami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Hasan N Haboubi
- Cancer Biomarker Group, Swansea Medical School, Swansea University, Swansea, UK
| | - Yeng Ang
- Department of GI Sciences, University of Manchester, Manchester, UK,Salford Royal NHS Foundation Trust, Salford, UK
| | - Philip Boger
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospitals NHS Trust, Portsmouth, UK
| | - John de Caestecker
- Digestive Diseases Centre, University Hospitals of Leicester, Leicester, UK
| | - Helen Griffiths
- Department of Gastroenterology, Wye Valley NHS Trust, Wye Valley, UK
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, UK
| | - Hans-Ulrich Laasch
- Department of Radiology, The Christie NHS Foundation Trust, Manchester, UK
| | - Praful Patel
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Stuart Paterson
- Department of Gastroenterology, NHS Forth Valley, Stirling, UK
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Centre, Queens Medical Centre, Belfast, UK
| | - Peter Watson
- Faculty of Medicine Health and Life Sciences, Queen’s University Belfast, Belfast, UK
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Bourke MJ, Neuhaus H, Bergman JJ. Endoscopic Submucosal Dissection: Indications and Application in Western Endoscopy Practice. Gastroenterology 2018; 154:1887-1900.e5. [PMID: 29486200 DOI: 10.1053/j.gastro.2018.01.068] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Abstract
Endoscopic submucosal dissection was developed in Japan, early in this century, to provide a minimally invasive yet curative treatment for the large numbers of patients with early gastric cancer identified by the national screening program. Previously, the majority of these patients were treated surgically at substantial cost and with significant risk of short- and long-term morbidity. En-bloc excision of these early cancers, most with a limited risk of nodal metastasis, allowed complete staging of the tumor, stratification of the subsequent therapeutic approach, and potential cure. This transformative innovation changed the nature of endoscopic treatment for superficial mucosal neoplasia and, ultimately, for the first time allowed endoscopists to assert that the early cancer had been definitively cured. Subsequently, Western endoscopists have increasingly embraced the therapeutic possibilities offered by endoscopic submucosal dissection, but with some justifiable scientific caution. Here we provide an evidence-based critical appraisal of the role of endoscopic submucosal dissection in advanced endoscopic tissue resection.
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Affiliation(s)
- Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jacques J Bergman
- Academic Medical Centre, Department of Gastroenterology and Hepatology, Amsterdam, Netherlands
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Belghazi K, Pouw RE, Sondermeijer C, Meijer SL, Schoon EJ, Koch AD, Weusten B, Bergman J. A single-step sizing and radiofrequency ablation catheter for circumferential ablation of Barrett's esophagus: Results of a pilot study. United European Gastroenterol J 2018; 6:990-999. [PMID: 30228886 PMCID: PMC6137598 DOI: 10.1177/2050640618768919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/26/2018] [Indexed: 11/21/2022] Open
Abstract
Background The 360 Express balloon catheter (360 Express) has the ability to self-adjust to the esophageal lumen, ensuring optimal tissue contact. Objective The objective of this article is to evaluate the efficacy and safety of the 360 Express for radiofrequency ablation (RFA) treatment of Barrett's esophagus (BE). Methods BE patients with low-grade dysplasia (LGD), high-grade dysplasia (HGD) or early cancer (EC) were included. Visible lesions were removed by endoscopic resection (ER) prior to RFA. RFA was performed with the 360 Express using the standard ablation regimen (12J/cm2–clean–12J/cm2). Primary outcome: BE regression percentage at three months. Secondary outcomes: procedure time, adverse events, complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM). Results Thirty patients (median BE C4M6) were included. Eight patients underwent ER prior to RFA. Median BE regression: 90%. Median procedure time: 31 minutes. Adverse events (13%): laceration (n = 1); atrial fibrillation (n = 1); vomiting and dysphagia (n = 1); dysregulated diabetes (n = 1). After subsequent treatment CE-D and CE-IM was achieved in 97% and 87%, respectively. In 10% a stenosis developed during additional treatment requiring a median of one dilation. Conclusion This study shows that circumferential RFA using the 360 Express may shorten procedure time, while maintaining efficacy compared to standard circumferential RFA.
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Affiliation(s)
- K Belghazi
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Cmt Sondermeijer
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - S L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - A D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jjghm Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
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Subramaniam S, Kandiah K, Chedgy F, Meredith P, Longcroft-Wheaton G, Bhandari P. The safety and efficacy of radiofrequency ablation following endoscopic submucosal dissection for Barrett's neoplasia. Dis Esophagus 2018; 31:4683665. [PMID: 29211875 DOI: 10.1093/dote/dox133] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Indexed: 12/11/2022]
Abstract
The current standard of treating early Barrett's neoplasia is resection of visible lesions using endoscopic mucosal resection (EMR) followed by ablative therapy to the Barrett's segment. There is increasing evidence to support the use of endoscopic submucosal dissection (ESD) where en-bloc resection and lower recurrence rates may be achieved. However, ESD is associated with deep submucosal dissection when compared to EMR. This may increase the risk of complications including stricture formation with subsequent radiofrequency ablation (RFA) therapy. The aim of this study is to compare the safety and efficacy of RFA following EMR and ESD as well as when RFA was used without prior endoscopic resection. The primary outcome measure was complication rates. Clearance of dysplasia (CRD) and clearance of intestinal metaplasia (CRIM) were secondary outcomes. A retrospective analysis of a cohort of 91 patients referred for RFA from a single academic tertiary center was performed. The choice of endoscopic resection method was tailored according to the lesion type and morphology. Focal and circumferential ablation was performed after initial follow up endoscopy postresection. Patients proceeded straight to RFA in the absence of any visible lesions. In this study, the ESD group had a higher proportion of cancers compared to the EMR cohort (74.1% vs. 30.2%, P < 0.01) prior to RFA. All complications post RFA occurred in the groups with previous endoscopic resection. There was no significant difference in the total complication rate (7.4% vs. 9.3%, P = 0.78) and stricture formation rate (3.7% vs. 9.3%, P = 0.38) between the ESD and EMR groups. CRD was achieved in 96.3% in the ESD group, 88.4% in the EMR group, and all patients in the RFA alone group. CRIM rates were similar in the EMR and ESD groups (81.4% vs. 85.2%) but higher in the RFA alone group (90.5%). In conclusion, RFA following ESD is very effective and not associated with an increased risk of complications compared to EMR. This supports the application of RFA in the treatment algorithm of patients undergoing ESD for Barrett's neoplasia.
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Affiliation(s)
| | | | | | - P Meredith
- Research & Innovation, Queen Alexandra Hospital, Portsmouth, United Kingdom
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Efficacy, Durability, and Safety of Complete Endoscopic Mucosal Resection of Barrett Esophagus: A Systematic Review and Meta-Analysis. J Clin Gastroenterol 2018; 52:210-216. [PMID: 28134635 DOI: 10.1097/mcg.0000000000000800] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
GOALS To report the rate of eradication and recurrence of both neoplasia and intestinal mucosa and the rate of adverse events for complete endoscopic resection (CER) of Barrett esophagus (BE). BACKGROUND There is limited composite data on the clinical efficacy of CER of BE with high-grade dysplasia or neoplasia. STUDY We performed a systematic review and meta-analysis of cohort studies that reported the clinical outcome of patients with BE who underwent CER and had at least 15-month follow-up after the time of elimination of BE. Main outcome of interests were pooled estimated rates of complete eradication of intestinal metaplasia and neoplasia, recurrence of intestinal metaplasia and neoplasia, and incidence of esophageal stricture, bleeding, and perforation. RESULTS We identified 8 studies reporting on 676 patients (high-grade dysplasia 54%) that met our criteria. Pooled estimated rates of complete eradication of intestinal metaplasia and complete eradication of intestinal neoplasia were 85.0% [95% confidence interval (CI), 79.4%-89.2%] and 96.6% (95% CI, 94.0%-98.1%), respectively, and rates of recurrence of intestinal metaplasia and recurrence of intestinal neoplasia were 15.7% (95% CI, 8.0%-28.4%) and 5.8% (95% CI, 3.9%-8.6%), respectively. Estimated incidences of adverse events were stricture 37.4 (95% CI, 24.4%-52.6%), bleeding 7.9% (95% CI, 4.4%-13.8%) and perforation 2.3% (95% CI, 1.3%-4.1%). CONCLUSIONS CER achieves an 85% complete eradication rate of BE with recurrent rate of neoplasia of 6%. Estimated rate of postprocedural stricture was 37.4%. On the basis of this high rate of adverse events and significant heterogeneity in the studies included, the present meta-analysis cannot endorse CER as sole therapy for BE.
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Shimamura Y, Iwaya Y, Goda K, Teshima CW. Endoscopic treatment of Barrett's esophagus: What can we learn from the Western perspective? Dig Endosc 2018; 30:182-191. [PMID: 28816408 DOI: 10.1111/den.12950] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Accepted: 08/14/2017] [Indexed: 02/08/2023]
Abstract
The incidence of Barrett's esophagus (BE)-related neoplasia in Western countries has increased in the past several decades and, even in Eastern countries, it appears to be increasing. Endoscopic therapies are the first-line treatment for BE-related neoplasia; however, there is still no standardized treatment strategy. Most of the data have been published from Western countries where the ultimate goal of treatment is complete eradication of BE mucosa removing subtle synchronous lesions and preventing metachronous neoplasia. A multimodality approach that combines endoscopic resection and radiofrequency ablation (RFA) has been widely accepted in the West. In contrast, the lack of access to RFA treatment in the East has meant that endoscopic resection is the only feasible option. There is a wide divergence in treatment strategies for BE-related neoplasia between the East and the West. It is very important to consider these basic differences in the context of the currently available evidence to date. Therefore, the purpose of this article is to review the recent literature and to provide an overview of the endoscopic treatment options for BE.
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Affiliation(s)
- Yuto Shimamura
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada.,Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yugo Iwaya
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Kenichi Goda
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Christopher W Teshima
- Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
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McLaren PJ, Dolan JP. Surgical Treatment of High-Grade Dysplasia and Early Esophageal Cancer. World J Surg 2018; 41:1712-1718. [PMID: 28258451 DOI: 10.1007/s00268-017-3958-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The treatment of early-stage esophageal cancer and high-grade dysplasia of the esophagus has changed significantly in recent years. Many early tumors that were traditionally treated with esophagectomy can now be resected with endoscopic therapy alone. These new endoscopic modalities can offer similar survival outcomes without the associated morbidity of a major operation. However, a number of these cases may still require surgical intervention as the best treatment option. METHODS The current scientific literature, national and international guidelines were reviewed for recommendations regarding optimal treatment of early esophageal malignancy. RESULTS The primary advantage of surgery over endoscopic treatment lies in the reduced risk of recurrence as well as the ability to assess harvested lymph nodes for regional disease. We recommend that esophageal tumors that have invaded into the submucosa (T1b) or beyond should be treated with an esophagectomy. In addition, dysplastic lesions and cancers that demonstrate poorly differentiated pathology or lymphovascular or perineural invasion should be surgically resected. Finally, large tumors, multifocal lesions, tumors within a long segment of Barrett's esophagus, tumors adjacent to a hiatal hernia, tumors that cannot be resected enbloc with endoscopic techniques should also be treated with an esophagectomy. CONCLUSIONS When performed at high-volume centers in experienced hands, esophagectomy can have consistently good outcomes for high-grade dysplasia and early esophageal cancers, and should be considered as a treatment option.
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Affiliation(s)
- Patrick J McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA
| | - James P Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, 3181 Sam Jackson Park Rd., Portland, OR, 97239, USA.
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Belghazi K, van Vilsteren FGI, Weusten BLAM, Meijer SL, Bergman JJGHM, Pouw RE. Long-term follow-up results of stepwise radical endoscopic resection for Barrett's esophagus with early neoplasia. Gastrointest Endosc 2018; 87:77-84. [PMID: 28455160 DOI: 10.1016/j.gie.2017.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/09/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Stepwise radical endoscopic resection (SRER) has shown to be effective in eradicating Barrett's esophagus (BE) and its associated dysplasia. The aim of this study was to assess the long-term durability after successful SRER for early Barrett's neoplasia. METHODS Patients treated with SRER for BE ≤5 cm with high-grade dysplasia (HGD) or early cancer (EC) and who had reached complete eradication of intestinal metaplasia (CE-IM) and neoplasia (CE-neo) were included. Primary outcomes were recurrence of neoplasia (HGD/EC), recurrence of dysplasia (indefinite for dysplasia included), and recurrence of endoscopically visible BE. Secondary outcomes were buried Barrett's glands, IM in biopsy specimens obtained distal to a normal-appearing neo-squamocolumnar junction (neo-SCJ), need for retreatment, and sustained CE-IM and CE-neo at the last follow-up endoscopy. RESULTS Seventy-three patients were included (64 men; mean age, 66 years; median BE, C2M3). Median follow-up was 76 months. Recurrence of neoplasia was observed in 1 patient (T1bN0M0) after 129 months of follow-up and was treated with curative surgery (annual incidence of .22% per patient-year of follow-up). In 4 patients, recurrence of dysplasia was found (.87% per patient-year of follow-up). Twelve patients had recurrent endoscopically visible BE after a median follow-up of 22 months (2.6% per patient-year of follow-up), mostly small islands or tongues. Five patients had a single finding of buried Barrett's glands (1.1% per patient-year of follow-up), and 27 patients (5.9% per patient-year of follow-up) showed IM in biopsy specimens just distal to the neo-SCJ, which was not reproduced in 56%. Retreatment was performed in 9 patients. CE-IM and CE-neo (excluding IM in the neo-SCJ) at the last follow-up endoscopy was seen in 95% and 97% of patients, respectively. CONCLUSIONS This study presents the longest published follow-up data on SRER to date. The 6-year outcomes show that successful SRER is a durable treatment for BE ≤5 cm with HGD/EC.
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Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Bas L A M Weusten
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, the Netherlands
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di Pietro M, Canto MI, Fitzgerald RC. Endoscopic Management of Early Adenocarcinoma and Squamous Cell Carcinoma of the Esophagus: Screening, Diagnosis, and Therapy. Gastroenterology 2018; 154:421-436. [PMID: 28778650 PMCID: PMC6104810 DOI: 10.1053/j.gastro.2017.07.041] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 12/16/2022]
Abstract
Because the esophagus is easily accessible with endoscopy, early diagnosis and curative treatment of esophageal cancer is possible. However, diagnosis is often delayed because symptoms are not specific during early stages of tumor development. The onset of dysphagia is associated with advanced disease, which has a survival at 5 years lower than 15%. Population screening by endoscopy is not cost-effective, but a number of alternative imaging and cell analysis technologies are under investigation. The ideal screening test should be inexpensive, well tolerated, and applicable to primary care. Over the past 10 years, significant progress has been made in endoscopic diagnosis and treatment of dysplasia (squamous and Barrett's), and early esophageal cancer using resection and ablation technologies supported by evidence from randomized controlled trials. We review the state-of-the-art technologies for early diagnosis and minimally invasive treatment, which together could reduce the burden of disease.
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Affiliation(s)
| | - Marcia I Canto
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland
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Fujii-Lau LL, Cinnor B, Shaheen N, Gaddam S, Komanduri S, Muthusamy VR, Das A, Wilson R, Simon VC, Kushnir V, Mullady D, Edmundowicz SA, Early DS, Wani S. Recurrence of intestinal metaplasia and early neoplasia after endoscopic eradication therapy for Barrett's esophagus: a systematic review and meta-analysis. Endosc Int Open 2017; 5:E430-E449. [PMID: 28573176 PMCID: PMC5451278 DOI: 10.1055/s-0043-106578] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/15/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Conflicting data exist with regard to recurrence rates of intestinal metaplasia (IM) and dysplasia after achieving complete eradication of intestinal metaplasia (CE-IM) in Barrett's esophagus (BE) patients. AIM (i) To determine the incidence of recurrent IM and dysplasia achieving CE-IM and (ii) to compare recurrence rates between treatment modalities [radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) vs stepwise complete EMR (SRER)]. METHODS A systematic search was performed for studies reporting on outcomes and estimates of recurrence rates after achieving CE-IM. Pooled incidence [per 100-patient-years (PY)] and risk ratios with 95 %CI were obtained. Heterogeneity was measured using the I2 statistic. Subgroup analyses, decided a priori, were performed to explore heterogeneity in results. RESULTS A total of 39 studies were identified (25-RFA, 13-SRER, and 2 combined). The pooled incidence of any recurrence was 7.5 (95 %CI 6.1 - 9.0)/100 PY with a pooled incidence of IM recurrence rate of 4.8 (95 %CI 3.8 - 5.9)/100 PY, and dysplasia recurrence rate of 2.0 (95 %CI 1.5 - 2.5)/100 PY. Compared to the SRER group, the RFA group had significantly higher overall [8.6 (6.7 - 10.5)/100 PY vs. 5.1 (3.1 - 7)/100 PY, P = 0.01] and IM recurrence rates [5.8 (4.3 - 7.3)/100 PY vs. 3.1 (1.7 - 4)/100 PY, P < 0.01] with no difference in recurrence rates of dysplasia. Significant heterogeneity between studies was identified. The majority of recurrences were amenable to repeat endoscopic eradication therapy (EET). CONCLUSION The results of this study demonstrate that the incidence rates of overall, IM, and dysplasia recurrence rates post-EET are not inconsiderable and reinforce the importance of close surveillance after achieving CE-IM.
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Affiliation(s)
| | - Birtukan Cinnor
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | - Srinivas Gaddam
- Washington University School of Medicine, St. Louis, MO, USA
| | - Srinadh Komanduri
- Feinberg School of Medicine Northwestern University, Chicago, IL, USA
| | | | - Ananya Das
- Arizona Center for Digestive Health, Gilbert, AZ, USA
| | - Robert Wilson
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | | | | | - Daniel Mullady
- Washington University School of Medicine, St. Louis, MO, USA
| | | | - Dayna S. Early
- Washington University School of Medicine, St. Louis, MO, USA
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, CO, USA,Corresponding author Sachin Wani, MD Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CenterMail Stop F7351635 Aurora CourtRm 2.031AuroraCO 80045USA+1-720-848-2749
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Efficacy and safety outcomes of multimodal endoscopic eradication therapy in Barrett's esophagus-related neoplasia: a systematic review and pooled analysis. Gastrointest Endosc 2017; 85:482-495.e4. [PMID: 27670227 DOI: 10.1016/j.gie.2016.09.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Focal EMR followed by radiofrequency ablation (f-EMR + RFA) and stepwise or complete EMR (s-EMR) are established strategies for eradication of Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC)/intramucosal carcinoma (IMC). The objective of this study was to derive pooled rates of efficacy and safety of individual methods in a large cohort of patients with BE and to indirectly compare the 2 methods. METHODS PubMed, Embase, Web of Science, Cochrane, and major conference proceedings were searched. A systematic review and pooled analysis were carried out to determine the following outcomes in patients with BE undergoing either f-EMR + RFA or s-EMR: (1) complete eradication rates of neoplasia (CE-N) and intestinal metaplasia (CE-IM); (2) recurrence rates of cancer (EAC), dysplasia, and IM; (3) incidence rates of adverse events. Mixed logistic regression was performed as an exploratory analysis to examine differences in outcomes between the 2 methods. RESULTS Nine studies (774 patients) of f-EMR + RFA and 11 studies (751 patients) of s-EMR were included. Patients undergoing f-EMR + RFA had high BE eradication rates (CE-N, 93.4%; CE-IM, 73.1%), whereas strictures occurred in 10.2%, bleeding in 1.1%, and perforations in 0.2% of patients. Recurrence of EAC, dysplasia, and IM was 1.4%, 2.6%, and 16.1%, respectively, in this group. Patients undergoing s-EMR also showed high BE eradication rates (CE-N, 94.9%; CE-IM, 79.6%) but a higher rate of adverse events (strictures in 33.5%, bleeding in 7.5%, and perforation in 1.3%). Recurrence of EAC, dysplasia, and IM was 0.7%, 3.3%, and 12.1%, respectively, in the s-EMR group. Mixed logistic regression showed that patients undergoing s-EMR might be more likely to develop esophageal strictures (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.61-13.85; P = .005), perforation (OR, 7.00; 95% CI, 1.56-31.33; P = .01), and bleeding (OR, 6.88; 95% CI, 2.19-21.62; P = 0.001) compared with f-EMR + RFA. CONCLUSIONS In patients with HGD/EAC, f-EMR followed by RFA seems to be equally effective as and safer than s-EMR.
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Old OJ, Isabelle M, Barr H. Staging Early Esophageal Cancer. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 908:161-81. [PMID: 27573772 DOI: 10.1007/978-3-319-41388-4_9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Staging esophageal cancer provides a standardized measure of the extent of disease that can be used to inform decisions about therapy and guide prognosis. For esophageal cancer, the treatment pathways vary greatly depending on stage of disease, and accurate staging is therefore crucial in ensuring the optimal therapy for each patient. For early esophageal cancer (T1 lesions), endoscopic resection can be curative and simultaneously gives accurate staging of depth of invasion. For tumors invading the submucosa or more advanced disease, comprehensive investigation is required to accurately stage the tumor and assess suitability for curative resection. A combined imaging approach of computed tomography (CT), positron emission tomography (PET), and endoscopic ultrasound (EUS) offers complementary diagnostic information and gives the greatest chance of accurate staging. Staging laparoscopy can identify peritoneal disease and small superficial liver lesions that could be missed on CT or PET, and alters management in up to 20 % of patients. Optical diagnostic techniques offer the prospect of further extending the possibilities of endoscopic staging in real time. Optical coherence tomography can image superficial lesions and could provide information on depth of invasion for these lesions. Real-time lymph node analysis using optical diagnostics such as Raman spectroscopy could be used to support immediate endoscopic therapy without waiting for results of cytology or further investigations.
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Affiliation(s)
- O J Old
- Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucester, UK. .,Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucester, UK.
| | - M Isabelle
- Biophotonics Research Unit, Gloucestershire Royal Hospital, Gloucester, UK
| | - H Barr
- Upper GI Surgery Department, Gloucestershire Royal Hospital, Gloucester, UK
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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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Koutsoumpas A, Wang LM, Bailey AA, Gillies R, Marshall R, Booth M, Sgromo B, Maynard N, Braden B. Non-radical, stepwise complete endoscopic resection of Barrett's epithelium in short segment Barrett's esophagus has a low stricture rate. Endosc Int Open 2016; 4:E1292-E1297. [PMID: 27995191 PMCID: PMC5161117 DOI: 10.1055/s-0042-118282] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2016] [Accepted: 09/13/2016] [Indexed: 12/16/2022] Open
Abstract
Background and aims: Radical endoscopic excision of Barrett's epithelium performing 4 - 6 endoscopic resections during the same endoscopic session results in complete Barrett's eradication but has a high stricture rate (40 - 80 %). Therefore radiofrequency ablation is preferred after endoscopic mucosal resection (EMR) of visible nodules. We investigated the clinical outcome of non-radical, stepwise endoscopic mucosal resection with a maximum of two endoscopic resections per endoscopic session. Methods: We analysed our prospectively maintained database of patients undergoing esophageal EMR for early neoplasia in Barrett's esophagus from 2009 to 2014. EMR was performed using a maximum of two band ligation mucosectomies per endoscopic session; thereafter, follow-up was 3-monthly and EMR was repeated as required for Barrett's eradication. Results: In total, 118 patients underwent staging EMR for early Barrett's neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumor stages or were managed conservatively. The remaining 91 patients with high grade dysplasia (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months. Remission of dysplasia/neoplasia was achieved in 95.6 % after 12 months treatment. Stepwise endoscopic Barrett's resection resulted in complete Barrett's eradication in 36/91 patients (39.6 %) in a mean of four sessions; 40/91 patients (44.0 %) had a short circumferential Barrett's segment (< 3 cm). In this group, repeated EMR achieved complete Barrett's excision in 85.0 %. One patient developed a stricture (1.1 %), one a delayed bleeding, and there were no perforations. Conclusion: In patients with a short Barrett's segment, non-radical endoscopic Barrett's resection at the time of scheduled endoscopy follow-up allows complete Barrett's eradication with very low stricture rate.
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Affiliation(s)
- Andreas Koutsoumpas
- Translational Gastroenterology Unit, Oxford
University Hospitals, Oxford, UK
| | - Lai Mun Wang
- Department of Pathology, Oxford University
Hospitals NHS Foundation Trust, Oxford, UK
| | - Adam A. Bailey
- Translational Gastroenterology Unit, Oxford
University Hospitals, Oxford, UK
| | - Richard Gillies
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Robert Marshall
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Michael Booth
- Department of Surgery, Royal Berkshire
Hospital, Reading, Berkshire, UK
| | - Bruno Sgromo
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Nick Maynard
- Department of Upper GI Surgery, Oxford
University Hospitals, Oxford, UK
| | - Barbara Braden
- Translational Gastroenterology Unit, Oxford
University Hospitals, Oxford, UK,Corresponding author Professor Barbara
Braden Consultant
GastroenterologistTranslational Gastroenterology
UnitOxford University
HospitalsOxfordOX3
9DUUK+44-1865-228763
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Neuhaus H. Prevention of strictures after endoscopic resection of esophageal neoplasia. Gastrointest Endosc 2016; 84:614-7. [PMID: 27633356 DOI: 10.1016/j.gie.2016.05.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 05/30/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
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McLaren PJ, Dolan JP. Esophagectomy as a Treatment Consideration for Early-Stage Esophageal Cancer and High-Grade Dysplasia. J Laparoendosc Adv Surg Tech A 2016; 26:757-762. [DOI: 10.1089/lap.2016.29010.pjm] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Affiliation(s)
- Patrick J. McLaren
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
| | - James P. Dolan
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health and Science University, Portland, Oregon
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