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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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2
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Eusebi LH, Telese A, Cirota GG, Haidry R, Zagari RM, Bazzoli F, Ford AC. Effect of gastro-esophageal reflux symptoms on the risk of Barrett's esophagus: A systematic review and meta-analysis. J Gastroenterol Hepatol 2022; 37:1507-1516. [PMID: 35614860 PMCID: PMC9543729 DOI: 10.1111/jgh.15902] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Revised: 03/13/2022] [Accepted: 05/19/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Gastro-esophageal reflux (GER) is the main predisposing factor for Barrett's esophagus (BE). A more precise estimate of the association of GER symptoms with the risk of BE would be important to prioritize endoscopic screening. We conducted a systematic review and meta-analysis to examine this issue. METHODS MEDLINE, EMBASE, and EMBASE Classic were searched to identify cross-sectional studies that reported the prevalence of BE based on presence of GER symptoms. The prevalence of BE was compared according to presence or absence of GER symptoms using an odds ratio (OR), with a 95% confidence interval (CI). Specificity and sensitivity of GER symptoms for predicting BE was calculated. RESULTS Of 10,463 citations evaluated, 19 studies reported the prevalence of BE in 43,017 subjects. The pooled OR among individuals with weekly GER symptoms compared with those without was 1.67 (95% CI 1.30-2.15) for endoscopically suspected BE, and 2.42 (95% CI 1.59-3.68) for histologically confirmed BE. No significant association was found between weekly GER symptoms and the presence of short segment BE (OR 1.30; 95% CI 0.86-1.97), whereas a strong association was present with long segment BE, with an OR of 6.30 (95% CI 2.26-17.61). CONCLUSIONS Gastro-esophageal reflux symptoms are associated with an increased odds of BE, with a further increase when weekly symptoms are present. Overall, GER symptoms showed low sensitivity and specificity for predicting BE; however, a strong association was found between weekly GER symptoms and long segment BE, but not short segment BE, suggesting that it may be worth considering screening individuals with weekly GER symptoms to rule out long segment BE.
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Affiliation(s)
- Leonardo H Eusebi
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Andrea Telese
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - Giovanna G Cirota
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rehan Haidry
- Department of Gastroenterology, University College London Hospital (UCLH), London, UK
| | - R Maurizio Zagari
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Franco Bazzoli
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy.,Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alexander C Ford
- Leeds Institute of Medical Research at St. James's, University of Leeds, Leeds, UK.,Leeds Gastroenterology Institute, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Fedorova E, Watson TJ. Antireflux and Endoscopic Therapies for Barrett Esophagus and Superficial Esophageal Neoplasia. Surg Clin North Am 2021; 101:391-403. [PMID: 34048760 DOI: 10.1016/j.suc.2021.03.002] [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: 11/25/2022]
Abstract
Barrett esophagus (BE), defined as intestinal metaplasia of the distal esophageal mucosa, typically results from chronic gastroesophageal reflux disease and is the only known precursor of esophageal adenocarcinoma. The standard of care for the management of early esophageal neoplasia in the setting of BE has changed drastically over the past 15 years. Further investigation into diagnostic and therapeutic adjuncts will continue to improve our ability to control or cure BE before its advancement to a life-threatening malignancy.
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Affiliation(s)
- Ekaterina Fedorova
- MedStar Franklin Square Medical Center, 9000 Franklin Square Drive, Department of Surgery, Baltimore, MD 21237, USA
| | - Thomas J Watson
- MedStar Georgetown University Hospital, 3800 Reservoir Rd, NW, 4PHC Department of Surgery, Washington, DC 20007, USA.
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Furnari M, Telese A, Hann A, Lisotti A, Boškoski I, Eusebi LH. New Devices for Endoscopic Treatments in Gastroenterology: A Narrative Review. Curr Drug Metab 2020; 21:850-865. [PMID: 32703127 DOI: 10.2174/1389200221666200722145727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/04/2020] [Accepted: 06/02/2020] [Indexed: 12/07/2022]
Abstract
Endoscopy is in a period of continuous innovations in terms of image quality, endoscopes, post-processing software and lastly, application of Artificial Intelligence. Therapeutic boundaries have expanded, widening the grey zone between endoscopy and surgery, and increasing endoscopic approaches in clinical scenarios where, until a few years ago, surgery was the only option. New scopes and accessories have made it easier to access critical areas such as the biliary tree and the small bowel intestine. In the field of hepato-pancreato-biliary endoscopy (HPB), it is now possible to directly access the biliary ducts or cystic lesions though dedicated stents and scopes, rather than having to rely only on fluoroscopy and ultrasound, increasing the diagnostic and therapeutic options by applying a three-dimensional approach. This narrative review will give an overview of some of the most relevant emerging fields in luminal and HPB endoscopy, highlighting advantages and main limitations of the techniques, and providing considerations for future development.
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Affiliation(s)
- Manuele Furnari
- Department of Internal Medicine, Gastroenterology Unit, Policlinico IRCCS "San Martino", University of Genoa, Genoa, Italy
| | - Andrea Telese
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom
| | - Alexander Hann
- Interventional and Experimental Endoscopy (InExEn), Internal Medicine II, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Bologna, Italy
| | - Ivo Boškoski
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCSS, Rome, Italy
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Kumble LD, Silver E, Oh A, Abrams JA, Sonett JR, Hur C. Treatment of early stage (T1) esophageal adenocarcinoma: Personalizing the best therapy choice. World J Meta-Anal 2019; 7:406-417. [DOI: 10.13105/wjma.v7.i9.406] [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: 08/09/2019] [Revised: 10/03/2019] [Accepted: 10/19/2019] [Indexed: 02/06/2023] Open
Abstract
Esophagectomy is considered the primary form of management for esophageal adenocarcinoma (EAC); however, the surgery is associated with high rates of morbidity and mortality. For patients with early-stage EAC, endoscopic resection (ER) presents a potential curative treatment option that is less invasive and carries fewer risks procedure related risks, but it is associated with higher rates of cancer recurrence following the procedure. For some patients, age and comorbidities may prevent them from having esophagectomy as a treatment option, while other patients may be operative candidates but do not wish to undergo esophagectomy for a variety of reasons related to their values and preferences. Furthermore, while anxiety of cancer recurrence following ER may significantly diminish a patient’s quality of life (QOL), so might the morbidity surrounding esophagectomy. In addition to considering health status, patient preferences, and impacts on QOL, physicians and patients must also consider what treatments would be both beneficial and available to the patient, considering esophagectomy methods-minimally invasive vs open-or the use of chemoradiotherapy in addition to ER. Our article reviews and summarizes available treatment options for patients with early EAC and their potential effects on the health and wellbeing of patients based on the current data. We conclude with a request for more research of available options for early EAC patients, the conditions that determine when each option should be employed, and their effects not only on patient health but also QOL.
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Affiliation(s)
| | - Elisabeth Silver
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Aaron Oh
- General Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Julian A Abrams
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Joshua R Sonett
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
| | - Chin Hur
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, United States
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Quero G, Saccomandi P, Kwak JM, Dallemagne B, Costamagna G, Marescaux J, Mutter D, Diana M. Modular laser-based endoluminal ablation of the gastrointestinal tract: in vivo dose-effect evaluation and predictive numerical model. Surg Endosc 2018; 33:3200-3208. [PMID: 30456508 DOI: 10.1007/s00464-018-6603-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection allows for "en bloc" removal of early gastrointestinal neoplasms. However, it is technically demanding and time-consuming. Alternatives could rely on energy-based techniques. We aimed to evaluate a predictive numerical model of thermal damage to preoperatively define optimal laser settings allowing for a controlled ablation down to the submucosa, and the ability of confocal endomicroscopy to provide damage information. MATERIALS AND METHODS A Nd:YAG laser was applied onto the gastric mucosa of 21 Wistar rats on 10 spots (total 210). Power settings ranging from 0.5 to 2.5W were applied during 1-12 s, with a consequent energy delivery varying from 0.5 to 30 J. Out of the 210 samples, a total of 1050 hematoxilin-eosin stained slides were obtained. To evaluate thermal injury, the ratio between the damage depth (DD) over the mucosa and the submucosa thickness (T) was calculated. Effective and safe ablation was considered for a DD/T ratio ≤ 1 (only mucosal and submucosal damage). Confocal endomicroscopy was performed before and after ablation. A numerical model, using human physical properties, was developed to predict thermal damage. RESULTS No full-thickness perforations were detected. On histology, the DD/T ratio at 0.5 J was 0.57 ± 0.21, significantly lower when compared to energies ranging from 15 J (a DD/T ratio = 1.2 ± 0.3; p < 0.001) until 30 J (a DD/T ratio = 1.33 ± 0.31; p < 0.001). Safe mucosal and submucosal ablations were achieved applying energy between 4 and 12 J, never impairing the muscularis propria. Confocal endomicroscopy showed a distorted gland architecture. The predicted damage depth demonstrated a significant positive linear correlation with the experimental data (Pearson's r 0.85; 95% CI 0.66-0.94). CONCLUSIONS Low-power settings achieved effective and safe mucosal and submucosal ablation. The numerical model allowed for an accurate prediction of the ablated layers. Confocal endomicroscopy provided real-time thermal damage visualization. Further studies on larger animal models are required.
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Affiliation(s)
- Giuseppe Quero
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Paola Saccomandi
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Department of Mechanical Engineering, Politecnico di Milano, Milan, Italy
| | - Jung-Myun Kwak
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Bernard Dallemagne
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Guido Costamagna
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Didier Mutter
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France. .,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France. .,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.
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Graham D, Sever N, Magee C, Waddingham W, Banks M, Sweis R, Al-Yousuf H, Mitchison M, Alzoubaidi D, Rodriguez-Justo M, Lovat L, Novelli M, Jansen M, Haidry R. Risk of lymph node metastases in patients with T1b oesophageal adenocarcinoma: A retrospective single centre experience. World J Gastroenterol 2018; 24:4698-4707. [PMID: 30416317 PMCID: PMC6224466 DOI: 10.3748/wjg.v24.i41.4698] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/29/2018] [Accepted: 10/15/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To assess clinical outcomes for submucosal (T1b) oesophageal adenocarcinoma (OAC) patients managed with either surgery or endoscopic eradication therapy.
METHODS Patients found to have T1b OAC following endoscopic resection between January 2008 to February 2016 at University College London Hospital were retrospectively analysed. Patients were split into low-risk and high-risk groups according to established histopathological criteria and were then further categorised according to whether they underwent surgical resection or conservative management. Study outcomes include the presence of lymph-node metastases, disease-specific mortality and overall survival.
RESULTS A total of 60 patients were included; 22 patients were surgically managed (1 low-risk and 21 high-risk patients) whilst 38 patients were treated conservatively (12 low-risk and 26 high-risk). Overall, lymph node metastases (LNM) were detected in 10 patients (17%); six of these patients had undergone conservative management and LNM were detected at a median of 4 mo after endoscopic mucosal resection (EMR). All LNM occurred in patients with high-risk lesions and this represented 21% of the total high-risk lesions. Importantly, there was no statistically significant difference in tumor-related deaths between those treated surgically or conservatively (P = 0.636) and disease-specific survival time was also comparable between the two treatment strategies (P = 0.376).
CONCLUSION T1b tumours without histopathological high-risk markers of LNM can be treated endoscopically with good out-comes. In selected patients, endoscopic therapy may be appropriate for high-risk lesions.
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Affiliation(s)
- David Graham
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
- Division of Surgery and Science, University College London, London WC1E 6BT, United Kingdom
| | - Nejc Sever
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
- Gastroenterology Department, University Medical Center Ljubljana, Slovenia
| | - Cormac Magee
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
- Department of Metabolism and Experimental Therapeutics, University College London, London WC1E 6BT, United Kingdom
| | - William Waddingham
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
- Division of Surgery and Science, University College London, London WC1E 6BT, United Kingdom
| | - Matthew Banks
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
| | - Rami Sweis
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
| | - Hannah Al-Yousuf
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
| | - Miriam Mitchison
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
| | - Durayd Alzoubaidi
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
| | | | - Laurence Lovat
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
- Division of Surgery and Science, University College London, London WC1E 6BT, United Kingdom
| | - Marco Novelli
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
| | - Marnix Jansen
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
- Division of Surgery and Science, University College London, London WC1E 6BT, United Kingdom
| | - Rehan Haidry
- GI Services, University College London Hospital, London NW1 2BU, United Kingdom
- Division of Surgery and Science, University College London, London WC1E 6BT, United Kingdom
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Abstract
RATIONALE Radiation enteritis (RE) is one of the serious complications caused by the radiotherapy and it can occur in any segment of the intestine, including small intestine, colon, and rectum. It can cause a number of serious problems of the intestine, such as chronic ulcers, bleeding, intestinal stenosis, intestinal fistula, and perforation. At present, there is no standard treatment guideline for the RE. PATIENT CONCERNS A 54-year-old male patient received surgery and chemotherapy for rectal cancer and radiofrequency ablation (RFA) for a single metastatic carcinoma of the liver. Three years later, he was diagnosed with recurrent lesion in the rectal anastomotic stoma and was treated with radiotherapy with a total dose of 70 Gy. Following this, he had persistent abdominal pain and diarrhea for 1 year. DIAGNOSES Colonoscopy confirmed a diagnosis of RE. INTERVENTIONS Since intestinal probiotics, intestinal mucosal protectants, antidiarrheal drugs, and other treatments were not effective; the patient was treated by RFA. OUTCOMES Clinical symptoms of the patient were gradually decreased after the RFA. Colonoscopy examination was performed 3 months later and intestinal mucosa was found to have healed well. LESSONS RFA is an effective treatment for patients with RE, and it is expected to be one of the standard treatments for the RE.
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9
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Mkarimi M, Mashimo H. Advanced Imaging for Barrett's Esophagus and Early Neoplasia: Surface and Subsurface Imaging for Diagnosis and Management. Curr Gastroenterol Rep 2018; 20:54. [PMID: 30302571 DOI: 10.1007/s11894-018-0661-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW Esophageal adenocarcinoma bears one of the fastest rising incidence of any cancers and generally arises in the setting of gastroesophageal reflux and Barrett's esophagus. However, early detection of neoplasia can be challenging since most patients are asymptomatic until they progress to more advanced and less curable stages, and early dysplastic lesions can be small, multifocal, and difficult to detect. Clearly, new imaging tools are needed in light of sampling error associated with random biopsies, the current standard of practice. RECENT FINDINGS Advances in endoscopic imaging including virtual chromoendoscopy, confocal laser endomicroscopy, and subsurface imaging with optical coherence tomography have ushered in a new era for detecting subtle neoplastic lesions. Moreover, in light of esophagus-sparing treatments for neoplastic lesions, such tools are likely to guide ablation and follow-up management. While there is no ideal single imaging modality to facilitate improved detection, staging, ablation, and follow-up of patients with dysplastic Barrett's esophagus, new advances in available technology, the potential for multimodal imaging, and the use of computer-aided diagnosis and biomarkers all hold great promise for improving detection and treatment.
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Affiliation(s)
- Mansoureh Mkarimi
- VA Boston Healthcare, Harvard Medical School, 1400 VFW Parkway, West Roxbury, MA, 02132, USA
| | - Hiroshi Mashimo
- VA Boston Healthcare, Harvard Medical School, 1400 VFW Parkway, West Roxbury, MA, 02132, USA.
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10
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Riegler M, Kristo I, Nikolic M, Rieder E, Schoppmann SF. Update on the management of Barrett's esophagus in Austria. Eur Surg 2017; 49:282-287. [PMID: 29250106 PMCID: PMC5725510 DOI: 10.1007/s10353-017-0504-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 11/20/2017] [Indexed: 01/27/2023]
Abstract
Background Barrett’s esophagus (BE) is the premalignant manifestation of gastroesophageal reflux disease (GERD). Radiofrequency ablation (RFA) with and without endoscopic resection (ER) is a novel treatment for BE. Methods Here we present a single-center update of the recommendations of a recent (June 2015) interdisciplinary expert panel meeting on the management of BE with dysplasia as well as cancer-positive and cancer-negative BE. We conducted a PubMed search of studies published in 2016 and 2017 on the topic of BE and RFA. Results Our update reconfirms that BE positive for T1a cancer as well as low- and high-grade dysplasia justifies the use of RFA ± ER, offering an 80–100% rate of BE clearance. RFA ± ER of dysplastic BE is tenfold more effective for cancer prevention when compared with surveillance. Risk factors for recurrence and follow-up treatments include baseline histopathology (dysplasia/T1a cancer), esophagitis, hiatal hernia >3 cm, smoking habits, BE segments >3 cm, and >10 years of GERD symptoms. A baseline diagnosis for dysplasia and T1a cancer should include a second expert pathologist opinion. Recent data justify the use of RFA for nondysplastic BE only in controlled clinical trials. Antireflux surgery can be offered to those with function-test-proven, GERD-symptom-positive BE before, during, or after RFA ± ER. Additionally, there is growing evidence that the intake of a sugar-rich diet is positively correlated with the development of GERD, BE, and cancer. Conclusion RFA ± ER should be offered for dysplastic BE and T1a cancer after ER as well as for nondysplastic BE with additional risk factors in controlled trials. Antireflux surgery can be offered to patients with function-test-proven GERD-symptom-positive BE. Diet considerations should be included in the management of GERD and BE.
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Affiliation(s)
- M Riegler
- Reflux Medical Vienna, Vienna, Austria
| | - I Kristo
- Department of Surgery, Upper-GI-Service, Comprehensive Cancer Center, GET-Unit, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - M Nikolic
- Department of Surgery, Upper-GI-Service, Comprehensive Cancer Center, GET-Unit, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - E Rieder
- Department of Surgery, Upper-GI-Service, Comprehensive Cancer Center, GET-Unit, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - S F Schoppmann
- Department of Surgery, Upper-GI-Service, Comprehensive Cancer Center, GET-Unit, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
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11
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Saccomandi P, Quero G, Costamagna G, Diana M, Marescaux J. Effects of Nd:YAG laser for the controlled and localized treatment of early gastrointestinal tumors: Preliminary in vivo study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:4533-4536. [PMID: 29060905 DOI: 10.1109/embc.2017.8037864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endoscopic submucosal dissection (ESD) is a minimally invasive technique allowing for the removal of early gastrointestinal (GI) tumors, widely considered as a valid alternative to conventional surgery. However, ESD is technically demanding, and potentially severe complications, such as bleeding and perforation, may occur. Energy-based techniques (e.g., radiofrequency ablation) might offer a potential alternative to ESD. However, their use mandates the ability to predict the damage induced and to identify a "signature" of the complete ablation, without the need for a physical specimen. Ideally, an energy-based procedure should be tunable in order to limit the ablation to the superficial layers, namely mucosa (M) and submucosa (SM), without injuring the muscularis propria (MP), thereby minimizing GI perforation. This experimental study aims to investigate thermal damage induced by Nd:YAG laser on the gastric wall, at different laser settings such as power (P) and time (t). Laser ablation was performed on the stomach wall of 6 Wistar rats. Two powers (2.5W and 1.0W) and 3 exposure times (12s, 6s and 2s) were tested, for a total of 30 ablations. Histological analysis allowed to assess thermal damage, in terms of damage depth (DD) and identification of involved layers. The ratio (R) between DD and the total depth (TD) of target layers (M+SM) was used as an index to evaluate the effectiveness of laser settings. At P=2.5W, MP was damaged (R>1) in the majority of cases (11/15). At P=1.0W, MP was preserved in all tests (R<;1), and rarely (4/15) did the damage reach the whole SM (R=1). Histopathological analysis evidenced that tissue damage was strongly related to the variable tissue thickness. These preliminary results seem to support the fact that endoscopic tunable laser ablation is feasible with a consistent damage/power correlation. Further tests are required to optimize the settings for applications on early GI tumors.
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Hoffman A, Manner H, Rey JW, Kiesslich R. A guide to multimodal endoscopy imaging for gastrointestinal malignancy - an early indicator. Nat Rev Gastroenterol Hepatol 2017; 14:421-434. [PMID: 28611477 DOI: 10.1038/nrgastro.2017.46] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Multimodality imaging is an essential aspect of endoscopic surveillance for the detection of neoplastic lesions, such as dysplasia or intramucosal cancer, because it improves the efficacy of endoscopic surveillance and therapeutic procedures in the gastrointestinal tract. This approach reveals mucosal abnormalities that cannot be detected by standard endoscopy. Currently, these imaging techniques are divided into those for primary detection and those for targeted imaging and characterization, the latter being used to visualize areas of interest in detail and permit histological evaluation. This Review outlines the use of virtual chromoendoscopy, narrow-band imaging, autofluorescence imaging, optical coherence tomography, confocal endomicroscopy and volumetric laser endomicroscopy as new imaging techniques for diagnostic investigation of the gastrointestinal tract. Insights into use of multimodal endoscopic imaging for early disease detection, in particular for pre-malignant lesions, in the oesophagus, stomach and colon are described.
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Affiliation(s)
- Arthur Hoffman
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany
| | - Henrik Manner
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany
| | - Johannes W Rey
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany
| | - Ralf Kiesslich
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Ludwig-Erhard-Strasse 100, 65199 Wiesbaden, Germany
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