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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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Libânio D, Pimentel-Nunes P, Bastiaansen B, Bisschops R, Bourke MJ, Deprez PH, Esposito G, Lemmers A, Leclercq P, Maselli R, Messmann H, Pech O, Pioche M, Vieth M, Weusten BLAM, Fuccio L, Bhandari P, Dinis-Ribeiro M. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy 2023; 55:361-389. [PMID: 36882090 DOI: 10.1055/a-2031-0874] [Citation(s) in RCA: 28] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
ESGE suggests conventional endoscopic submucosal dissection (ESD; marking and mucosal incision followed by circumferential incision and stepwise submucosal dissection) for most esophageal and gastric lesions. ESGE suggests tunneling ESD for esophageal lesions involving more than two-thirds of the esophageal circumference. ESGE recommends the pocket-creation method for colorectal ESD, at least if traction devices are not used. The use of dedicated ESD knives with size adequate to the location/thickness of the gastrointestinal wall is recommended. It is suggested that isotonic saline or viscous solutions can be used for submucosal injection. ESGE recommends traction methods in esophageal and colorectal ESD and in selected gastric lesions. After gastric ESD, coagulation of visible vessels is recommended, and post-procedural high dose proton pump inhibitor (PPI) (or vonoprazan). ESGE recommends against routine closure of the ESD defect, except in duodenal ESD. ESGE recommends corticosteroids after resection of > 50 % of the esophageal circumference. The use of carbon dioxide when performing ESD is recommended. ESGE recommends against the performance of second-look endoscopy after ESD. ESGE recommends endoscopy/colonoscopy in the case of significant bleeding (hemodynamic instability, drop in hemoglobin > 2 g/dL, severe ongoing bleeding) to perform endoscopic hemostasis with thermal methods or clipping; hemostatic powders represent rescue therapies. ESGE recommends closure of immediate perforations with clips (through-the-scope or cap-mounted, depending on the size and shape of the perforation), as soon as possible but ideally after securing a good plane for further dissection.
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Affiliation(s)
- Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute - Porto, Portugal.,MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Porto, Portugal
| | - Pedro Pimentel-Nunes
- Department of Surgery and Physiology, Faculty of Medicine, University of Porto, FMUP, Porto, Portugal.,Gastroenterology, Unilabs, Portugal
| | - Barbara Bastiaansen
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology & Metabolism, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, Sydney, Australia.,Western Clinical School, University of Sydney, Sydney, Australia
| | - Pierre H Deprez
- Department of Hepatogastroenterology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Gianluca Esposito
- Department of Surgical and Medical Sciences and Translational Medicine, Sant'Andrea Hospital, Sapienza University of Rome, Italy
| | - Arnaud Lemmers
- Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, CUB Erasme Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Philippe Leclercq
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Roberta Maselli
- Department of Biomedical Sciences, Humanitas University, Milan, Italy. Endoscopy Unit, Humanitas Clinical and Research Center IRCCS, Rozzano, Italy
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brueder Regensburg, Germany
| | - Mathieu Pioche
- Endoscopy and Gastroenterology Unit, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Michael Vieth
- Institute of Pathology, Friedrich-Alexander University Erlangen-Nuremberg, Klinikum Bayreuth, Bayreuth, Germany
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.,University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Lorenzo Fuccio
- Department of Medical and Surgical Sciences, Gastroenterology Unit, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, UK
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute - Porto, Portugal.,MEDCIDS, Faculty of Medicine, University of Porto, Porto, Portugal.,Porto Comprehensive Cancer Center (Porto.CCC) & RISE@CI-IPOP (Health Research Network), Porto, Portugal
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Barret M, Doridot L, Le Gall M, Beuvon F, Jacques S, Pellat A, Belle A, Abou Ali E, Dhooge M, Leblanc S, Camus M, Nicco C, Coriat R, Chaussade S, Batteux F, Prat F. Mechanisms of esophageal stricture after extensive endoscopic resection: a transcriptomic analysis. Endosc Int Open 2023; 11:E149-E156. [PMID: 36741340 PMCID: PMC9894697 DOI: 10.1055/a-2000-8801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022] Open
Abstract
Background and study aims Esophageal stricture is the most frequent adverse event after endoscopic resection for early esophageal neoplasia. Currently available treatments for the prevention of esophageal stricture are poorly effective and associated with major adverse events. Our aim was to identify transcripts specifically overexpressed or repressed in patients who have developed a post-endoscopic esophageal stricture, as potential targets for stricture prevention. Patients and methods We conducted a prospective single-center study in a tertiary endoscopy center. Patients scheduled for an endoscopic resection and considered at risk of esophageal stricture were offered inclusion in the study. The healthy mucosa and resection bed were biopsied on Days 0, 14, and 90. A transcriptomic analysis by microarray was performed, and the differences in transcriptomic profile compared between patients with and without esophageal strictures. Results Eight patients, four with esophageal stricture and four without, were analyzed. The mean ± SD circumferential extension of the mucosal defect was 85 ± 11 %. The transcriptomic analysis in the resection bed at day 14 found an activation of the interleukin (IL)-1 group (Z score = 2.159, P = 0.0137), while interferon-gamma (INFγ) and NUPR1 were inhibited (Z score = -2.375, P = 0.0022 and Z score = -2.333, P = 0.00131) in the stricture group. None of the activated or inhibited transcripts were still significantly so in any of the groups on Day 90. Conclusions Our data suggest that IL-1 inhibition or INFγ supplementation could constitute promising targets for post-endoscopic esophageal stricture prevention.
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Affiliation(s)
- Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France,Université de Paris, France,INSERM U1016, Institut Cochin, Paris, France
| | - Ludivine Doridot
- Université de Paris, France,INSERM U1016, Institut Cochin, Paris, France,Department of Immunology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France
| | - Morgane Le Gall
- 3P5 Proteom’IC facility, Université de Paris, Institut Cochin, INSERM, CNRS, F-75014, France
| | - Frédéric Beuvon
- Genomʼic CNRS UMR8104, Paris, France,Department of Pathology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, Paris, France
| | | | - Anna Pellat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France,Université de Paris, France
| | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France
| | - Einas Abou Ali
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France
| | - Marion Dhooge
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France
| | - Sarah Leblanc
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France,Department of Gastroenterology, Jean Mermoz Private Hospital, Lyon, France
| | - Marine Camus
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France,Department of Gastroenterology, St Antoine Hospital, Assistance Publique – Hôpitaux de Paris, France
| | - Carole Nicco
- Université de Paris, France,INSERM U1016, Institut Cochin, Paris, France
| | - Romain Coriat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France,Université de Paris, France,INSERM U1016, Institut Cochin, Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France,Université de Paris, France
| | - Frédéric Batteux
- Université de Paris, France,INSERM U1016, Institut Cochin, Paris, France,Department of Immunology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France
| | - Frédéric Prat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique – Hôpitaux de Paris, France,Université de Paris, France,INSERM U1016, Institut Cochin, Paris, France
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Fukami N. Endoscopic Submucosal Dissection in the Esophagus: Indications, Techniques, and Outcomes. Gastrointest Endosc Clin N Am 2023; 33:55-66. [PMID: 36375886 DOI: 10.1016/j.giec.2022.09.003] [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: 02/04/2023]
Abstract
Endoscopic submucosal dissection (ESD) is well-accepted endoscopic resection modality for esophageal lesions with benefits in certain situations. ESD offers potential cure for early esophageal cancer and detailed pathologic information for risk stratification. Techniques are mostly standardized, and the use of traction method is encouraged. Indication and proper techniques of ESD in esophageal disease and clinical outcomes will be discussed in this article with pearls for care planning and management during periprocedural period.
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Affiliation(s)
- Norio Fukami
- Mayo Clinic College of Medicine and Science, Mayo Clinic Arizona, 13400 E Shea Boulevard, Scottsdale, AZ 85259, USA.
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Probst A, Ebigbo A, Eser S, Fleischmann C, Schaller T, Märkl B, Schiele S, Geissler B, Müller G, Messmann H. Endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: long-term follow-up in a Western center. Clin Endosc 2023; 56:55-64. [PMID: 36634965 PMCID: PMC9902687 DOI: 10.5946/ce.2022.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 04/29/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND/AIMS Endoscopic submucosal dissection (ESD) has been established as a treatment modality for superficial esophageal squamous cell carcinoma (ESCC). Long-term follow-up data are lacking in Western countries. The aim of this study was to analyze long-term survival in a Western center. METHODS Patients undergoing ESD for ESCC were included. The analysis was performed retrospectively using a prospectively collected database. RESULTS R0 resection rate was 96.7% (59/61 lesions in 58 patients). Twenty-seven patients (46.6%) fulfilled the curative resection criteria (M1/M2) (group A), 11 patients (19.0%) had M3 lesions without lymphovascular invasion (LVI) (group B), and 20 patients (34.5%) had lesions with submucosal invasion or LVI (group C). Additional treatment was recommended after non-curative resection. It was not performed in 20/31 patients (64.5%), mainly because of comorbidities (75%). Twenty-nine out of 58 (50.0%) patients died during a mean follow-up of 3.7 years. Death was related to ESCC in 17.2% (5/29) of patients. The disease-specific survival rate after curative resection was 100%. Overall survival rates after 5 years were 61.5%, 63.6% and 28.1% for groups A, B, and C, respectively. The overall survival was significantly worse after non-curative resection (p=0.038). CONCLUSION Non-curative resection is frequent after ESD for ESCC in Western patients. The long-term prognosis is limited and mainly determined by comorbidity. Early diagnosis and pre-interventional assessments need to be improved.
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Affiliation(s)
- Andreas Probst
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany,Correspondence: Andreas Probst Department of Gastroenterology, University Hospital Augsburg, Stenglinstraße 2, 86156 Augsburg, Germany E-mail:
| | - Alanna Ebigbo
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Stefan Eser
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Carola Fleischmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
| | - Tina Schaller
- Institute of Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany
| | - Bruno Märkl
- Institute of Pathology and Molecular Diagnostics, University Hospital Augsburg, Augsburg, Germany
| | - Stefan Schiele
- Institute of Mathematics and Computational Statistics, University of Augsburg, Augsburg, Germany
| | - Bernd Geissler
- Department of General, Visceral and Transplant Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Gernot Müller
- Institute of Mathematics and Computational Statistics, University of Augsburg, Augsburg, Germany
| | - Helmut Messmann
- Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
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Mathies D, Oyama T, Steinbrück I, Dumoulin FL. Topical oro-dispersible budesonide tablets for stricture prevention after near circumferential ESD for esophageal squamous cell cancer - a case report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:454-456. [PMID: 33735916 DOI: 10.1055/a-1409-1076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic resection is the treatment of choice for early esophageal cancers. However, resections comprising more than 70-80 % of the circumference are associated with a high risk of stricture formation. Currently, repetitive local injections and/or systemic steroids are given for prevention. CASE REPORT We present here the case of a 78-year-old male patient who had a near circumferential endoscopic submucosal dissection for a pT1a mm, L0, V0, R0, G2 esophageal squamous cell cancer. At the end of endoscopic resection, 80 mg of triamcinolone was injected locally. The patient was then treated with oro-dispersible budesonide tablets (2 × 1 mg/day) and nystatin (4 × 100 000 I.E.) for 8 weeks. This treatment resulted in complete healing without any stricture formation and did not result in any complications. DISCUSSION Treatment with orodispersible budesonide tablets could help prevent strictures after large endoscopic resections in the esophagus.
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Affiliation(s)
- Daniel Mathies
- Department of Medicine and Gastroenterology, Academic Teaching Hospital, University of Bonn, Bonn, Germany
| | - Tsuneo Oyama
- Department of Endoscopy, Saku Central Hospital Advanced Care Center, Saku, Nagano, Japan
| | - Ingo Steinbrück
- Department of Medicine, Academic Teaching Hospital, University of Freiburg, Freiburg, Germany
| | - Franz Ludwig Dumoulin
- Department of Medicine and Gastroenterology, Academic Teaching Hospital, University of Bonn, Bonn, Germany
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