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Rubenstein JH, Sawas T, Wani S, Eluri S, Singh S, Chandar AK, Perumpail RB, Inadomi JM, Thrift AP, Piscoya A, Sultan S, Singh S, Katzka D, Davitkov P. AGA Clinical Practice Guideline on Endoscopic Eradication Therapy of Barrett's Esophagus and Related Neoplasia. Gastroenterology 2024; 166:1020-1055. [PMID: 38763697 DOI: 10.1053/j.gastro.2024.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2024]
Abstract
BACKGROUND & AIMS Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Endoscopic eradication therapy (EET) can be effective in eradicating BE and related neoplasia and has greater risk of harms and resource use than surveillance endoscopy. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for the use of EET in BE and related neoplasia. METHODS The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the use of EET in patients with BE under the following scenarios: presence of (1) high-grade dysplasia, (2) low-grade dysplasia, (3) no dysplasia, and (4) choice of stepwise endoscopic mucosal resection (EMR) or focal EMR plus ablation, and (5) endoscopic submucosal dissection vs EMR. Clinical recommendations were based on the balance between desirable and undesirable effects, patient values, costs, and health equity considerations. RESULTS The panel agreed on 5 recommendations for the use of EET in BE and related neoplasia. Based on the available evidence, the panel made a strong recommendation in favor of EET in patients with BE high-grade dysplasia and conditional recommendation against EET in BE without dysplasia. The panel made a conditional recommendation in favor of EET in BE low-grade dysplasia; patients with BE low-grade dysplasia who place a higher value on the potential harms and lower value on the benefits (which are uncertain) regarding reduction of esophageal cancer mortality could reasonably select surveillance endoscopy. In patients with visible lesions, a conditional recommendation was made in favor of focal EMR plus ablation over stepwise EMR. In patients with visible neoplastic lesions undergoing resection, the use of either endoscopic mucosal resection or endoscopic submucosal dissection was suggested based on lesion characteristics. CONCLUSIONS This document provides a comprehensive outline of the indications for EET in the management of BE and related neoplasia. Guidance is also provided regarding the considerations surrounding implementation of EET. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.
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Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Tarek Sawas
- Division of Digestive and Liver Disease, University of Texas Southwestern, Dallas, Texas
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Swathi Eluri
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, Florida
| | - Shailendra Singh
- Division of Gastroenterology, West Virginia University, Morgantown, West Virginia; Advanced Center for Endoscopy, West Virginia University Medicine, Morgantown, West Virginia
| | - Apoorva K Chandar
- Digestive Health Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | | | - John M Inadomi
- Department of Internal Medicine, The University of Utah School of Medicine, Salt Lake City, Utah
| | - Aaron P Thrift
- Section of Epidemiology and Population Sciences, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | | | - Shahnaz Sultan
- Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, Minneapolis, Minnesota; Veterans Affairs Healthcare System, Minneapolis, Minnesota
| | - Siddharth Singh
- Division of Gastroenterology, University of California San Diego, La Jolla, California
| | - David Katzka
- Division of Gastroenterology and Hepatology, Columbia University, New York, New York
| | - Perica Davitkov
- Department of Medicine, Case Western Reserve University, Cleveland, Ohio; Division of Gastroenterology, Veterans Affairs Northeast Ohio Healthcare System, Cleveland, Ohio
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di Pietro M, Trudgill NJ, Vasileiou M, Longcroft-Wheaton G, Phillips AW, Gossage J, Kaye PV, Foley KG, Crosby T, Nelson S, Griffiths H, Rahman M, Ritchie G, Crisp A, Deed S, Primrose JN. National Institute for Health and Care Excellence (NICE) guidance on monitoring and management of Barrett's oesophagus and stage I oesophageal adenocarcinoma. Gut 2024; 73:897-909. [PMID: 38553042 PMCID: PMC11103346 DOI: 10.1136/gutjnl-2023-331557] [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: 11/16/2023] [Accepted: 02/15/2024] [Indexed: 05/12/2024]
Abstract
Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma, a cancer with very poor prognosis. The main risk factors for Barrett's oesophagus are a history of gastro-oesophageal acid reflux symptoms and obesity. Men, smokers and those with a family history are also at increased risk. Progression from Barrett's oesophagus to cancer occurs via an intermediate stage, known as dysplasia. However, dysplasia and early cancer usually develop without any clinical signs, often in individuals whose symptoms are well controlled by acid suppressant medications; therefore, endoscopic surveillance is recommended to allow for early diagnosis and timely clinical intervention. Individuals with Barrett's oesophagus need to be fully informed about the implications of this diagnosis and the benefits and risks of monitoring strategies. Pharmacological treatments are recommended for control of symptoms, but not for chemoprevention. Dysplasia and stage 1 oesophageal adenocarcinoma have excellent prognoses, since they can be cured with endoscopic or surgical therapies. Endoscopic resection is the most accurate staging technique for early Barrett's-related oesophageal adenocarcinoma. Endoscopic ablation is effective and indicated to eradicate Barrett's oesophagus in patients with dysplasia. Future research should focus on improved accuracy for dysplasia detection via new technologies and providing more robust evidence to support pathways for follow-up and treatment.
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Affiliation(s)
| | - Nigel J Trudgill
- Department of Gastroenterology, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | | | - Gaius Longcroft-Wheaton
- Department of Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
- Department of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, UK
| | - Alexander W Phillips
- Department of Surgery, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - James Gossage
- Department of Gastrointestinal Surgery, St Thomas' Hospital, London, UK
| | - Philip V Kaye
- Department of Histopathology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Kieran G Foley
- Division of Cancer and Genetics, Cardiff University, Cardiff, Cardiff, UK
| | - Tom Crosby
- Department of Clinical Oncology, Velindre University NHS Trust, Cardiff, UK
| | - Sophie Nelson
- Kenmore Medical Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Muksitur Rahman
- National Institute for Health and Care Excellence, London, UK
| | - Gill Ritchie
- National Institute for Health and Care Excellence, London, UK
| | - Amy Crisp
- National Institute for Health and Care Excellence, London, UK
| | - Stephen Deed
- National Institute for Health and Care Excellence, London, UK
| | - John N Primrose
- Department of Surgery, University of Southampton, Southampton, UK
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Zhang Q, Li M, Jin X, Zhou R, Ying Y, Wu X, Jing J, Pan W. Comparison of interventions for Barrett's esophagus: A network meta-analysis. PLoS One 2024; 19:e0302204. [PMID: 38709808 PMCID: PMC11073690 DOI: 10.1371/journal.pone.0302204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 03/30/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Barrett's esophagus (BE) is a precancerous condition that has the potential to develop into esophageal cancer (EC). Currently, there is a wide range of management options available for individuals at different pathological stages in Barrett's esophagus (BE). However, there is currently a lack of knowledge regarding their comparative efficacy. To address this gap, we conducted a network meta-analysis of published randomized controlled trials to examine the comparative effectiveness of all regimens. METHODS Data extracted from eligible randomized controlled trials were utilized in a Bayesian network meta-analysis to examine the relative effectiveness of BE's treatment regimens and determine their ranking in terms of efficacy. The ranking probability for each regimen was assessed using the surfaces under cumulative ranking values. The outcomes under investigation were complete ablation of BE, neoplastic progression of BE, and complete eradication of dysplasia. RESULTS We identified twenty-three RCT studies with a total of 1675 participants, and ten different interventions. Regarding complete ablation of non-dysplastic BE, the comparative effectiveness ranking indicated that argon plasma coagulation (APC) was the most effective regimen, with the highest SUCRA value, while surveillance and PPI/H2RA were found to be the least efficacious regimens. For complete ablation of BE with low-grade dysplasia, high-grade dysplasia, or esophageal cancer, photodynamic therapy (PDT) had the highest SUCRA value of 94.1%, indicating it as the best regimen. Additionally, for complete eradication of dysplasia, SUCRA plots showed a trend in ranking PDT as the highest with a SUCRA value of 91.2%. Finally, for neoplastic progression, radiofrequency ablation (RFA) and surgery were found to perform significantly better than surveillance. The risk of bias assessment revealed that 6 studies had an overall high risk of bias. However, meta-regression with risk of bias as a covariate did not indicate any influence on the model. In terms of the Confidence in Network Meta-Analysis evaluation, a high level of confidence was found for all treatment comparisons. CONCLUSION Endoscopic surveillance alone or PPI/H2RA alone may not be sufficient for managing BE, even in cases of non-dysplastic BE. However, APC has shown excellent efficacy in treating non-dysplastic BE. For cases of BE with low-grade dysplasia, high-grade dysplasia, or esophageal cancer, PDT may be the optimal intervention as it can induce regression of BE metaplasia and prevent future progression of BE to dysplasia and EC.
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Affiliation(s)
- Qinlin Zhang
- Department of Gastroenterology, Sanmen County People’s Hospital, Taizhou, Zhejiang, China
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Miya Li
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Xin Jin
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Ruhong Zhou
- Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Yize Ying
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Xueping Wu
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Jiyong Jing
- Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Wensheng Pan
- Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
- Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital of Hangzhou Medical College, Hangzhou, Zhejiang, China
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Lao SH, Huang JL, Wu LF. Barrett’s esophagus: Current challenges in diagnosis and treatment. WORLD CHINESE JOURNAL OF DIGESTOLOGY 2024; 32:267-275. [DOI: 10.11569/wcjd.v32.i4.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/28/2024]
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Gomes ILC, de Moura DTH, Ribeiro IB, Marques SB, de Sousa Carlos A, Nunes BCM, Hirsch BS, de Oliveira GHP, Trasolini RP, Bernardo WM, de Moura EGH. Cryotherapy versus radiofrequency ablation in the treatment of dysplastic Barrett's esophagus with or without early esophageal neoplasia: a systematic review and meta-analysis. Clin Endosc 2024; 57:181-190. [PMID: 38229440 PMCID: PMC10984752 DOI: 10.5946/ce.2023.065] [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: 02/27/2023] [Revised: 08/03/2023] [Accepted: 08/26/2023] [Indexed: 01/18/2024] Open
Abstract
BACKGROUND/AIMS Radiofrequency ablation (RFA) is the first-line therapy for dysplastic Barrett's esophagus (BE). Therefore, cryotherapy has emerged as an alternative treatment option. This study aimed to compare the efficacies of these two techniques based on the rates of complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D). Adverse events and recurrence have also been reported. METHODS An electronic search was conducted using the Medline (PubMed), Embase, LILACS, and Google Scholar databases until December 2022. Studies were included comparing cryotherapy and RFA for treating dysplastic BE with or without early esophageal neoplasia. This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. RESULTS Three retrospective cohort studies involving 627 patients were included. Of these, 399 patients underwent RFA, and 228 were treated with cryotherapy. There was no difference in CE-IM (risk difference [RD], -0.03; 95% confidence interval [CI], -0.25 to 0.19; p=0.78; I2=86%) as well as in CE-D (RD, -0.03; 95% CI, -0.15 to 0.09; p=0.64; I2=70%) between the groups. The absolute number of adverse events was low, and there was no difference in the recurrence rate. CONCLUSION Cryotherapy and RFA were equally effective in treating dysplastic BE, with or without early esophageal neoplasia.
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Affiliation(s)
- Igor Logetto Caetité Gomes
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sérgio Barbosa Marques
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Alexandre de Sousa Carlos
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Bruno Salomão Hirsch
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | - Roberto Paolo Trasolini
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil
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Weusten BLAM, Bisschops R, Dinis-Ribeiro M, di Pietro M, Pech O, Spaander MCW, Baldaque-Silva F, Barret M, Coron E, Fernández-Esparrach G, Fitzgerald RC, Jansen M, Jovani M, Marques-de-Sa I, Rattan A, Tan WK, Verheij EPD, Zellenrath PA, Triantafyllou K, Pouw RE. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2023; 55:1124-1146. [PMID: 37813356 DOI: 10.1055/a-2176-2440] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.
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Affiliation(s)
- Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Massimiliano di Pietro
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francisco Baldaque-Silva
- Advanced Endoscopy Center Carlos Moreira da Silva, Department of Gastroenterology, Pedro Hispano Hospital, Matosinhos, Portugal
- Division of Medicine, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, Centre hospitalier universitaire Hôtel-Dieu, Nantes, Nantes, France
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biomedical Research Network on Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
| | - Rebecca C Fitzgerald
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital NHS Trust, London, UK
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, New York, New York, USA
| | - Ines Marques-de-Sa
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Arti Rattan
- Department of Gastroenterology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - W Keith Tan
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pauline A Zellenrath
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
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Rubenstein JH, Stachler MD. TSP-9: A Barrett's Esophagus Biomarker Better Than Pathologists? Gastroenterology 2023; 165:1106-1107. [PMID: 37659675 DOI: 10.1053/j.gastro.2023.08.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 08/16/2023] [Indexed: 09/04/2023]
Affiliation(s)
- Joel H Rubenstein
- Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, Michigan; Cancer Control and Population Sciences Program, Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Matthew D Stachler
- Helen Diller Family Comprehensive Cancer Center, Department of Pathology, University of California San Francisco, San Francisco, California
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Knabe M, Wetzka J, Welsch L, Richl J, Michael F, Blößer S, Heilani M, Kronsbein H, May A. Radiofrequency ablation versus hybrid argon plasma coagulation in Barrett's esophagus: a prospective randomised trial. Surg Endosc 2023; 37:7803-7811. [PMID: 37605011 PMCID: PMC10520130 DOI: 10.1007/s00464-023-10313-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Accepted: 07/15/2023] [Indexed: 08/23/2023]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) and hybrid argon plasma coagulation (H-APC) are established thermal ablation techniques for eradicating Barrett's esophagus after endoscopic resection. This study aimed to compare RFA with H-APC in relation to safety, effectiveness and eradication rates. METHODS After endoscopic resection, patients were randomly assigned to H-APC or RFA. A simplified H-APC technique was applied at 60 W. RFA was used with a 90° focal catheter and a simplified protocol of 12 J/cm2 × 3 or with a Halo 360° balloon and 10 J/cm2/cleaning/10 J/cm2. Eradication rates and adverse events were recorded. Patients received follow-up examinations after 3, 6, 12 and 24 months. RESULTS One hundred and one patients were finally included in the study (RFA N = 47, H-APC N = 54). The median follow-up period for short-term was 6.0 (CI 5.4-6.9) months and for long term 21 (CI 19.2.5-22.7) months. In total 211 ablations were performed. The eradication rates after long-term follow-up were 74.2% in the RFA group and 82.9% in the H-APC group. Post-interventional pain was significantly greater in the RFA group, with a mean score of 4.56/10 and duration of 7.54 days, in comparison with a mean score of 2.07/10 over 3.59 days in the H-APC group. Stenoses requiring intervention were noted in 3.7% of patients in the H-APC arm and 14.9% of those in the RFA arm. CONCLUSIONS Both ablation techniques have good results in relation to the eradication rate, with a slightly better outcome in the H-APC group. The severity and duration of pain were significantly greater in the RFA group.
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Affiliation(s)
- Mate Knabe
- Department of Gastroenterology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany.
| | - Jens Wetzka
- Department of Medicine I, Asklepios Paulinen Klinik Wiesbaden, Wiesbaden, Germany
| | - Lukas Welsch
- Department of Gastroenterology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Johannes Richl
- Department of Gastroenterology, Sana Klinikum GmbH Offenbach, Offenbach, Germany
| | - Florian Michael
- Department of Gastroenterology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Sandra Blößer
- Department of Medicine I, Asklepios Paulinen Klinik Wiesbaden, Wiesbaden, Germany
| | - Myriam Heilani
- Department of Gastroenterology, Goethe University Frankfurt, University Hospital, Frankfurt am Main, Germany
| | - Holger Kronsbein
- Department of Gastroenterology, Facility Bielefeld-Bethel, University Hospital Ostwestfalen-Lippe, Bielefeld, Germany
| | - Andrea May
- Department of Medicine I, Asklepios Paulinen Klinik Wiesbaden, Wiesbaden, Germany
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9
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Eusebi LH, Telese A, Castellana C, Engin RM, Norton B, Papaefthymiou A, Zagari RM, Haidry R. Endoscopic Management of Dysplastic Barrett's Oesophagus and Early Oesophageal Adenocarcinoma. Cancers (Basel) 2023; 15:4776. [PMID: 37835470 PMCID: PMC10571849 DOI: 10.3390/cancers15194776] [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: 08/23/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Barrett's oesophagus is a pathological condition whereby the normal oesophageal squamous mucosa is replaced by specialised, intestinal-type metaplasia, which is strongly linked to chronic gastro-oesophageal reflux. A correct endoscopic and histological diagnosis is pivotal in the management of Barrett's oesophagus to identify patients who are at high risk of progression to neoplasia. The presence and grade of dysplasia and the characteristics of visible lesions within the mucosa of Barrett's oesophagus are both important to guide the most appropriate endoscopic therapy. In this review, we provide an overview on the management of Barrett's oesophagus, with a particular focus on recent advances in the diagnosis and recommendations for endoscopic therapy to reduce the risk of developing oesophageal adenocarcinoma.
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Affiliation(s)
- Leonardo Henry Eusebi
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Andrea Telese
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Division of Surgery and Interventional Science, University College London, London NW1 2BU, UK
| | - Chiara Castellana
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Rengin Melis Engin
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Benjamin Norton
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Department of Gastroenterology, University College London Hospital (UCLH), London NW1 2BU, UK;
- Centre for Obesity Research, Department of Medicine, Rayne Institute, University College London, London NW1 2BU, UK
| | - Apostolis Papaefthymiou
- Department of Gastroenterology, University College London Hospital (UCLH), London NW1 2BU, UK;
| | - Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
- Esophagus and Stomach Organic Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Rehan Haidry
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Division of Surgery and Interventional Science, University College London, London NW1 2BU, UK
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10
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Barret M. Low-grade dysplasia on Barrett's esophagus: visible or not ? Endosc Int Open 2023; 11:E816-E817. [PMID: 37664789 PMCID: PMC10473885 DOI: 10.1055/a-2145-5564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023] Open
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11
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Spadaccini M, Alfarone L, Chandrasekar VT, Maselli R, Capogreco A, Franchellucci G, Massimi D, Fugazza A, Colombo M, Carrara S, Facciorusso A, Bhandari P, Sharma P, Hassan C, Repici A. What Is "Cold" and What Is "Hot" in Mucosal Ablation for Barrett's Oesophagus-Related Dysplasia: A Practical Guide. Life (Basel) 2023; 13:life13041023. [PMID: 37109552 PMCID: PMC10142767 DOI: 10.3390/life13041023] [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: 01/31/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
Over the last two decades, endoscopic eradication therapy has been established as the therapeutic strategy of choice for patients with Barrett's oesophagus-related dysplasia and early oesophageal adenocarcinoma. With a multimodal approach, ablative therapies have been highly effective in achieving remarkable eradication rates of metaplastic epithelium with an acceptable adverse event rate. Among ablative techniques, radiofrequency ablation is currently considered as the first-line option as its efficacy and safety are strongly supported by relevant data. Nevertheless, radiofrequency ablation is costly, and not universally available, or applicable to every situation. Moreover, primary failure and recurrence rates are not negligible. In the last few years, cryotherapy techniques and hybrid argon plasma coagulation have been increasingly assessed as potential novel ablative therapies. Preliminary data have been promising and suggest that they may even have a role as first-line options, alternatively to radiofrequency ablation. The aim of this review is to provide a practical guide for the ablation of Barrett's oesophagus, with emphasis on the different ablative options.
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Affiliation(s)
- Marco Spadaccini
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Ludovico Alfarone
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | | | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Antonio Capogreco
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Gianluca Franchellucci
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Davide Massimi
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Alessandro Fugazza
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Matteo Colombo
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Silvia Carrara
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, 71122 Foggia, Italy
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, UK
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, MO 66045, USA
| | - Cesare Hassan
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
| | - Alessandro Repici
- Department of Biomedical Sciences, Humanitas University, 20089 Rozzano, Italy
- Digestive Endoscopy Unit, Department of Endoscopy, Humanitas Research Hospital, IRCCS, Via Manzoni 56, 20089 Rozzano, Italy
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12
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Mathiesen M, Holm J, Thorsteinsson M. Radio frequency ablation of dysplastic Barrett's esophagus: Outcomes of a single-center registry. Scand J Surg 2023:14574969231151378. [PMID: 36756673 DOI: 10.1177/14574969231151378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Barrett's esophagus (BE) is associated with an increased risk of esophageal adenocarcinoma. The use of radio frequency ablation (RFA) for complete eradication of BE with confirmed low-grade dysplasia (LGD) or high-grade dysplasia (HGD) has been promising in multicenter trials. Our aim was to evaluate the safety and efficacy outcomes associated with RFA for patients with BE and LGD/HGD in a single-center setting. METHODS This was a retrospective single-center study conducted at Department of Surgery and Transplantation, Rigshospitalet, Denmark. Data were collected from all patients who had undergone RFA for LGD or HGD from January 2014 to December 2018. Effectiveness outcomes were based on histology: complete eradication of dysplasia (CE-D), defined as all esophageal biopsies being negative for dysplasia at the last biopsy session, and complete eradication of intestinal metaplasia (CE-IM) defined as esophageal biopsies being without intestinal metaplasia. Safety outcomes were based on the proportion of complications to the RFA treatment. RESULTS A total of 107 patients were identified during the follow-up period (75% men, median age = 65 years); 83% had LGD and 17% had HGD. The median follow-up was 25 months. After the last RFA treatment, CE-D was achieved in 89%. CE-D and CE-IM were achieved in 60%. Complications occurred in 6.5% of the patients. CONCLUSIONS In patients with BE and confirmed LGD or HGD, RFA was associated with a high rate of CE-D and a low risk of complications. The observed safety and efficacy outcomes were comparable with those previously reported in multicenter trials, showing that the Danish treatment of BE with LGD and HGD is comparable with those of larger European expert centers.
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Affiliation(s)
- Molly Mathiesen
- Department of Surgery and TransplantationRigshospitaletCopenhagen University Hospital, Copenhagen ØDenmark
| | - Jakob Holm
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Thorsteinsson
- Department of Surgery and Transplantation, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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13
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Weiss S, Pellat A, Corre F, Abou Ali E, Belle A, Terris B, Leconte M, Dohan A, Chaussade S, Coriat R, Barret M. Predictive factors of radiofrequency ablation failure in the treatment of dysplastic Barrett's esophagus. Clin Res Hepatol Gastroenterol 2023; 47:102065. [PMID: 36494071 DOI: 10.1016/j.clinre.2022.102065] [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: 10/02/2022] [Revised: 11/29/2022] [Accepted: 12/05/2022] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Radiofrequency ablation (RFA) has become the recommended endoscopic treatment for flat dysplastic Barrett's esophagus. However, the outcomes of this treatment are variable across European countries. Our aim was to report the results of a French high-volume center, and to investigate factors associated with treatment failure. METHODS We conducted a single-center retrospective study from a prospectively collected database from 2011 to 2020, including all consecutive patients treated with RFA for flat dysplastic Barrett's esophagus. The primary endpoint was the failure rate of esophageal radiofrequency treatment, defined as either persistence of intestinal metaplasia at the end of treatment, or neoplastic progression during RFA. RESULTS 96 patients treated with a median of four RFA sessions for a mean C5M6 Barrett's esophagus were included in the analysis. Complete eradication of intestinal metaplasia and dysplasia were achieved in 59% and 79% of patients, respectively, resulting in a treatment failure rate of 41%. Ten patients experienced neoplastic progression during treatment. We recorded 14% of post-RFA esophageal strictures, all successfully treated by endoscopic dilatation. Univariate analysis identified the length of Barrett's esophagus and the absence of hiatal hernia as predictive factors for treatment failure, however not confirmed in multivariate analysis. CONCLUSION In our experience, RFA of flat dysplastic Barrett's esophagus had a 41% treatment failure rate. The length of the Barrett's segment might be associated with treatment failure. Although our results confirm a role for RFA in the management of dysplastic Barrett's esophagus, the treatment failure rate was higher than expected. This suggest that endoscopists, even in high-volume centers, should receive specific training in RFA.
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Affiliation(s)
- Simon Weiss
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France
| | - Anna Pellat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Felix Corre
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Einas Abou Ali
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France
| | - Benoit Terris
- Department of Pathology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Mahaut Leconte
- Department of Digestive Surgery, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Anthony Dohan
- Department of Abdominal and Interventional Imaging, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Romain Coriat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, France; Université de Paris Cité, France.
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van Munster SN, Nieuwenhuis E, Bisschops R, Willekens H, Weusten BLAM, Herrero LA, Bogte A, Alkhalaf A, Schenk EBE, Schoon EJ, Curvers W, Koch AD, de Jonge PJF, Tang TJ, Nagengast WB, Westerhof J, Houben MHMG, Bergman JJGHM, Pouw RE. Development and External Validation of a Model to Predict Complex Treatment After Radiofrequency Ablation for Barrett's Esophagus With Early Neoplasia. Clin Gastroenterol Hepatol 2022; 20:2495-2504.e5. [PMID: 35292379 DOI: 10.1016/j.cgh.2022.02.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/25/2022] [Accepted: 02/16/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Endoscopic eradication therapy for Barrett's esophagus (BE)-related neoplasia is safe and leads to complete eradication in the majority of patients. However, a subgroup will experience a more complex treatment course with a risk for failure or disease progression. Early identification of these patients may improve patient counseling and treatment outcomes. We aimed to develop a prognostic model for a complex treatment course. METHODS We collected data from a nationwide registry that captures outcomes for all patients undergoing endoscopic eradication therapy for early BE neoplasia. A complex treatment course was defined as neoplastic progression, treatment failure, or the need for endoscopic resection during the radiofrequency ablation treatment phase. We developed a prognostic model using logistic regression. We externally validated our model in an independent registry. RESULTS A total of 1386 patients were included, of whom 78 (6%) had a complex treatment course. Our model identified patients with a BE length of 9 cm or longer with a visible lesion containing high-grade dysplasia/cancer, and patients with less than 50% squamous conversion after radiofrequency ablation were identified as high risk for a complex treatment. This applied to 8% of the study population and included 93% of all treatment failures and 76% of all patients with advanced neoplastic progression. The model appeared robust in multiple sensitivity analyses and performed well in external validation (area under the curve, 0.84). CONCLUSIONS We developed a prognostic model that identified patients with a BE length of 9 cm or longer and high-grade dysplasia/esophageal adenocarcinoma and those with poor squamous regeneration as high risk for a complex treatment course. The good performance in external validation suggests that it may be used in clinical management (Netherlands Trial Register: NL7039).
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Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, The Netherlands; Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Esther Nieuwenhuis
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Koninklijke Universiteit Leuven, Belgium
| | - Hilde Willekens
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Koninklijke Universiteit Leuven, Belgium
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands; Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Ed B E Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, The Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands; GROW School for Oncology and Developmental Biology, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Wouter Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter Jan F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Tjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Cappelle aan den Ijssel, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, The Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, The Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, The Netherlands.
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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15
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Wani S, Souza RF, Durkalski VL, Serrano J, Hamilton F, Shaheen NJ. Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett's Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications. Gastroenterology 2022; 163:556-562.e4. [PMID: 35679951 PMCID: PMC9398991 DOI: 10.1053/j.gastro.2022.05.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/17/2022] [Accepted: 05/30/2022] [Indexed: 12/02/2022]
Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rhonda F. Souza
- Department of Medicine, Center for Esophageal Diseases, Baylor University Medical Center and Center for Esophageal Research, Baylor Scott & White Research Institute, Dallas, Texas
| | - Valerie L. Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Jose Serrano
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive Kidney Diseases, National Institute of Health, Bethesda, Maryland
| | - Frank Hamilton
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive Kidney Diseases, National Institute of Health, Bethesda, Maryland
| | - Nicholas J. Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
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16
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Cotton CC, Eluri S, Shaheen NJ. Management of Dysplastic Barrett's Esophagus and Early Esophageal Adenocarcinoma. Gastroenterol Clin North Am 2022; 51:485-500. [PMID: 36153106 PMCID: PMC10173367 DOI: 10.1016/j.gtc.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
While patients with Barrett's esophagus without dysplasia may benefit from endoscopic surveillance, those with low-grade dysplasia may be managed with either endoscopic surveillance or endoscopic eradication. Patients with Barrett's esophagus with high-grade dysplasia and/or intramucosal adenocarcinoma will generally require endoscopic eradication therapy. The management of Barrett's esophagus with dysplasia and early esophageal adenocarcinoma is predominantly endoscopic, with multiple effective methods available for the resection of raised neoplasia and ablation of flat neoplasia. High-dose proton-pump inhibitor therapy is advised during the treatment of Barrett's esophagus with dysplasia and early esophageal adenocarcinoma. After the endoscopic eradication of Barrett's esophagus and associated neoplasia, surveillance is required for the diagnosis and retreatment of recurrence or progression.
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Affiliation(s)
- Cary C Cotton
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4153, Chapel Hill, NC 27599-7080, USA
| | - Swathi Eluri
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4142, Chapel Hill, NC 27599-7080, USA
| | - Nicholas J Shaheen
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4150, Chapel Hill, NC 27599-7080, USA.
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Abstract
IMPORTANCE Barrett esophagus is characterized by the replacement of normal esophageal squamous cell epithelium with columnar metaplasia and affects approximately 5% of people in the US and approximately 1% worldwide. Approximately 3% to 5% of patients with Barrett esophagus will be diagnosed with esophageal adenocarcinoma in their lifetime. OBSERVATIONS Barrett esophagus affects approximately 2.3% to 8.3% of people with gastroesophageal reflux disease (GERD) and approximately 1.2% to 5.6% of people without GERD. Characteristics associated with Barrett esophagus include older age (prevalence of approximately 1.1% in individuals older than 50 years compared with 0.3% in those 50 years or younger), male sex, and smoking (prevalence of approximately 12% in people who smoke cigarettes compared with 1.1% in those who do not smoke cigarettes). The histopathology of Barrett esophagus progresses from metaplasia to dysplasia and, without treatment, can progress to adenocarcinoma. People with Barrett esophagus have approximately a 0.2% to 0.5% annual rate of developing esophageal adenocarcinoma. Management of Barrett esophagus primarily consists of acid-suppressive medications to reduce underlying GERD symptoms and surveillance endoscopy every 3 to 5 years. In patients with Barrett esophagus and dysplasia or early cancer, endoscopic therapy consisting of resection and ablation successfully treats 80% to 90% of patients. CONCLUSIONS AND RELEVANCE Barrett esophagus affects approximately 5% of people in the US and approximately 1% worldwide and is associated with an increased risk of esophageal adenocarcinoma. First-line therapy for Barrett esophagus consists of proton-pump inhibitors for control of reflux symptoms, but their role in chemoprevention is unclear. Surveillance with upper endoscopy is recommended by practice guidelines to monitor for progression to esophageal adenocarcinoma, but randomized clinical trials are lacking.
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Affiliation(s)
- Prateek Sharma
- University of Kansas School of Medicine, VA Medical Center, Kansas City, Kansas
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18
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Srinivasan S, Sharma P. Real-world data for endoscopic therapy in LGD: not looking so good. Gut 2022; 71:1457-1458. [PMID: 34330785 DOI: 10.1136/gutjnl-2021-324544] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 07/01/2021] [Indexed: 12/08/2022]
Affiliation(s)
- Sachin Srinivasan
- Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, Missouri, USA.,University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Prateek Sharma
- University of Kansas Medical Center, Kansas City, Kansas, USA .,Kansas City VA Medical Center, Kansas City, Missouri, USA
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Maione F, Chini A, Maione R, Manigrasso M, Marello A, Cassese G, Gennarelli N, Milone M, De Palma GD. Endoscopic Diagnosis and Management of Barrett's Esophagus with Low-Grade Dysplasia. Diagnostics (Basel) 2022; 12:diagnostics12051295. [PMID: 35626450 PMCID: PMC9141542 DOI: 10.3390/diagnostics12051295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 02/05/2023] Open
Abstract
Barrett’s Esophagus is a common condition associated with chronic gastroesophageal reflux disease. It is well known that it has an association with a higher incidence of esophageal adenocarcinoma, but this neoplastic transformation is first preceded by the onset of low and high-grade dysplasia. The evaluation of low grade dysplastic esophageal mucosa is still controversial; although endoscopic surveillance is preferred, several minimally invasive endoscopic therapeutic approaches are available. Endoscopic mucosal resection and radiofrequency ablation are the most used endoscopic treatments for the eradication of low-grade dysplasia, respectively, for nodular and flat dysplasia. Novel endoscopic treatments are cryotherapy ablation and argon plasma coagulation, that have good rates of eradication with less complications and post-procedural pain.
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Affiliation(s)
- Francesco Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
- Correspondence: (F.M.); (R.M.)
| | - Alessia Chini
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Rosa Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
- Correspondence: (F.M.); (R.M.)
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Alessandra Marello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Nicola Gennarelli
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
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20
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Martínez-Domínguez SJ, Lanas Á, Domper-Arnal MJ. Esófago de Barrett, hacia la mejora de la práctica clínica. Med Clin (Barc) 2022; 159:92-100. [DOI: 10.1016/j.medcli.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/07/2022] [Accepted: 02/08/2022] [Indexed: 02/07/2023]
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Endoscopic Management of Barrett's Esophagus. Dig Dis Sci 2022; 67:1469-1479. [PMID: 35226224 DOI: 10.1007/s10620-022-07395-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2022] [Indexed: 12/09/2022]
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22
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Choi KKH, Sanagapalli S. Barrett’s esophagus: Review of natural history and comparative efficacy of endoscopic and surgical therapies. World J Gastrointest Oncol 2022; 14:568-586. [PMID: 35321279 PMCID: PMC8919017 DOI: 10.4251/wjgo.v14.i3.568] [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: 05/22/2021] [Revised: 11/12/2021] [Accepted: 02/16/2022] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is the precursor to esophageal adenocarcinoma (EAC). Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately, invasive neoplasia. Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates. This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier, and potentially curative stage. The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy (EET) for management of dysplastic and early neoplastic BE, and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence. This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage, and the effectiveness of interventions in attenuating the risk posed by its natural history. Key findings were as follows. Non-dysplastic Barrett’s is associated with extremely low risk of progression, and interventions cannot be justified. The annual risk of cancer progression in low grade dysplasia is between 1%-3%; EET can be offered though evidence for its benefit remains confined to highly select settings. High-grade dysplasia progresses to cancer in 5%-10% per year; EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication. Risk of nodal metastases in intramucosal cancer is 2%-4%, which is comparable to operative mortality rate, so EET is usually preferred. Submucosal cancer is associated with nodal metastases in 14%-41% hence surgery remains standard of care, except for select situations.
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Affiliation(s)
- Kevin Kyung Ho Choi
- AW Morrow Gastroenterology Liver Centre, Royal Prince Alfred Hospital, Sydney 2050, NSW, Australia
| | - Santosh Sanagapalli
- Department of Gastroenterology, St Vincent’s Hospital, Darlinghurst 2010, NSW, Australia
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Wang Y, Ma B, Yang S, Li W, Li P. Efficacy and Safety of Radiofrequency Ablation vs. Endoscopic Surveillance for Barrett’s Esophagus With Low-Grade Dysplasia: Meta-Analysis of Randomized Controlled Trials. Front Oncol 2022; 12:801940. [PMID: 35296005 PMCID: PMC8920305 DOI: 10.3389/fonc.2022.801940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/08/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Aims Barrett’s esophagus with low-grade dysplasia (BE-LGD) carries a risk of progression to Barrett’s esophagus with high-grade dysplasia (BE-HGD) and esophageal adenocarcinoma (EAC). Radiofrequency ablation (RFA) appears to be a safe and efficacious method to eradicate Barrett’s esophagus. However, a confirmed consensus regarding treatment of BE-LGD with RFA vs. endoscopic surveillance is lacking. Therefore, this study aimed to elucidate the efficacy and safety for RFA vs. endoscopic surveillance in decreasing the risk of BE-LGD progression to BE-HGD or EAC. Methods Relevant studies published before May 1, 2021 were identified by searching relevant medical databases. The primary outcome was the rate of progression BE-LGD to HGD and/or EAC after treatment with RFA and endoscopic surveillance. The secondary outcome was the rate of complete eradication of dysplasia (CE-D) and complete eradication of intestinal metaplasia (CE-IM) after treatment with RFA and endoscopic surveillance. Adverse events were also extracted and evaluated. Results Three randomized controlled trials were eligible for analysis. The pooled estimate of rate of neoplastic progression of BE-LGD to HGD or EAC was much lower in the RFA group than the endoscopic surveillance group (RR, 0.25; 95% CI, 0.07–0.93; P = 0.04), with moderate heterogeneity (I2 = 55%). Subgroup analysis based on progression grade was performed. The pooled rate of progression of BE-LGD to HGD was much lower in the RFA group than the endoscopic surveillance group (RR, 0.25; 95% CI, 0.07–0.71; P = 0.01), with low heterogeneity (I2 = 15%). Although the pooled risk of progression of BE-LGD to EAC was slightly lower in the RFA group than the endoscopic surveillance group (RR, 0.56; 95% CI, 0.05–6.76), the result was not statistically significant (P = 0.65). RFA also was associated a higher rate of CE-D and CE-IM both at the end of endoscopic treatment and during follow-up. However, the rate of adverse events was slightly higher after RFA treatment. Conclusion RFA decreases the risk of BE-LGD progression to BE-HGD. However, given the uncertain course of LGD and the potential for esophageal stricture after RFA, treatment options should be fully considered and weighed. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021266128, identifier PROSPERO (CRD42021266128).
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Affiliation(s)
- Yizi Wang
- Department of Obstetrics and Gynecology, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Yizi Wang,
| | - Bin Ma
- Department of Colorectal Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital and Institute, Shenyang, China
| | - Shize Yang
- Department of Thoracic Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Wenya Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, Shenyang, China
| | - Peiwen Li
- Department of Thoracic Surgery, The First Hospital of China Medical University, Shenyang, China
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