Endoprevention of esophageal cancer: endoscopic ablation of Barrett's metaplasia and dysplasia

Colonoscopy: Preparation and Potential Complications

Colonoscopy is a fairly common test that serves both diagnostic and therapeutic purposes. It has been considered the gold standard in colorectal cancer screening for several years. Due to the nature of the examination, various types of complications may occur. The purpose of this analysis is to describe the various complications related to the period of preparation for colonoscopy among hospitalized patients, including life-threatening ones, in order to know how to avoid complications while preparing for a colonoscopy. We analyzed the nursing and medical reports of 9962 patients who were prepared for colonoscopy between 2005 and 2016. The frequency of various side effects associated with intensive bowel cleansing prior to colonoscopy was assessed. In justified cases, additional medical data were collected from patients, their families or from other doctors providing advice to patients after complications. Out of 9962 patients prepared for colonoscopy, 180 procedures were discontinued due to complications and side effects, and in these cases no colonoscopy was performed. The most common complications were: vomiting; epistaxis; loss of consciousness with head injury; abdominal pain; acute diarrhea; symptoms of choking; heart rhythm disturbances; dyspnea; fractures of limbs and hands; acute coronary syndrome; hypotension; hypertension; cerebral ischemia; severe blood glucose fluctuations; increased muscle contraction and allergic reactions. In addition to the documentation of our own research, several works of other research groups were also analyzed. Currently, the literature does not provide data on the frequency and type of complications in the preparation period for colonoscopy. The advantage of our work is the awareness of the possibility of serious complications and postulating the necessary identification of threats. Individualization of the recommended procedures and increased supervision of patients undergoing bowel cleansing procedure, we hope, will reduce the occurrence of complications and side effects.

Comparison of endoscopic treatment modalities for Barrett's neoplasia

BACKGROUND

There are few data comparing endoscopic treatment outcomes for Barrett's esophagus (BE).

OBJECTIVE

To compare treatment outcomes in BE patients treated with radiofrequency ablation (RFA), RFA after EMR, and porfimer sodium photodynamic therapy (Ps-PDT).

DESIGN

Retrospective, observational study.

SETTING

Single tertiary center between 2001 and 2013.

PATIENTS

A total of 342 BE patients treated with RFA (n = 119), EMR+RFA (n = 98), and Ps-PDT (n = 125).

MAIN OUTCOME MEASUREMENTS

Rates of complete remission of intestinal metaplasia (CRIM), BE recurrence, and adverse events.

RESULTS

Baseline BE high-grade dysplasia (HGD) and adenocarcinoma were more common in the Ps-PDT group (89%) compared with the EMR-RFA (70%) and RFA (37%) groups. At a median follow-up of 14.2 months, 173 patients (50.6%) achieved CRIM. CRIM was significantly more common in Ps-PDT patients compared with RFA (P < .001) and EMR-RFA (P < .001) patients on multivariable analysis. In patients who achieved CRIM, the rates of subsequent BE recurrence were relatively similar among the 3 groups. Although the rates of bleeding were similar, strictures were less common in RFA patients (2.4%) compared with EMR-RFA (13.3%, P = .001) and Ps-PDT (10.4%, P =.043) patients.

CONCLUSION

This study of endoscopic treatment for Barrett's dysplasia and neoplasia found that complete remission was achieved more often and more rapidly after Ps-PDT with similar disease recurrence rates compared with EMR or RFA. Adverse events were more common after EMR and Ps-PDT. Further studies are required to determine which ablation and resection techniques are ideally suited for each BE patient.

Photodynamic Therapy for Barrett's Esophagus and Esophageal Carcinoma

This paper reviews the use of photodynamic therapy (PDT) in patients with Barrett's esophagus and esophageal carcinoma. We describe the history of PDT, mechanics, photosensitizers for PDT in patients with esophageal disease. Finally, we discuss its utility and limitations in this setting.

The role of photodynamic therapy in the esophagus

Photodynamic therapy (PDT) is a drug and device therapy using photosensitizer drugs activated by laser light for mucosal ablation. Porfimer sodium PDT has been used extensively with proven long-term efficacy and durability for the ablation of Barrett esophagus and high-grade dysplasia. and early esophageal adenocarcinoma. However, continued use is hampered by an associated stricture risk and prolonged photosensitivity (4-6 weeks). Promising single-center European studies using other forms of PDT, such as aminolevulinic acid PDT, have not been replicated elsewhere, limiting the widespread use of other forms of PDT. Future use of PDT in esophageal disease depends on the development of improved dosimetry and patient selection to optimize treatment outcomes, while minimizing adverse events and complications.

Endoluminal therapy for esophageal disease: an introduction

This introductory article summarizes decades of research from many dedicated gastrointestinal endoscopists. It provides a background to Barrett esophagus (BE), exploring the risk of progression to dysplasia and esophageal adenocarcinoma. Two premalignant conditions, BE and colon adenoma, are compared, including their progression to esophageal adenocarcinoma and colon and rectal carcinoma, respectively. A comparison of the risks of surgical treatment and post-surgical complications of these cancers and of the strikingly different paradigms for their prevention is presented. The article concludes with the rationale for endoscopic treatment of Barrett disease.

Barrett's esophagus: where do we stand?

Barrett's esophagus (BE) is a precursor for esophageal adenocarcinoma, which has an increased incidence rate over the last few decades. Its importance stems from the poor five-year survival of esophageal adenocarcinoma and current data that suggest a survival benefit when surveillance programs are implemented. In this review, we will cover the pathophysiology and natural history of BE and the different endoscopic findings. The prevalence of BE in different geographic areas and the incidence of high-grade dysplasia and adenocarcinoma in this patient population is reviewed. Recent recommendation for screening and surveillance of BE has been covered in this review as well as the efficacy of nonconventional imaging modalities and endoscopic ablation therapies.

Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett's Esophagus

BACKGROUND & AIMS

High-resolution endoscopy with narrow band imaging (NBI) enhances the visualization of mucosal glandular and vascular structures. This study assessed whether narrow band targeted biopsies could detect advanced dysplasia using fewer biopsy samples compared with standard resolution endoscopy.

METHODS

We conducted a prospective, blinded, tandem endoscopy study in a tertiary care center with 65 patients with Barrett's esophagus undergoing evaluation for previously detected dysplasia. Standard resolution endoscopy was used first to detect visible lesions. Narrow band endoscopy was then used by another gastroenterologist to detect and biopsy areas suspicious for dysplasia. The lesions initially detected by standard resolution endoscopy were then disclosed and biopsied, after biopsy of the lesions targeted with NBI. Finally, random 4-quadrant biopsies were taken throughout the segment of Barrett's mucosa.

RESULTS

Higher grades of dysplasia were found by NBI in 12 patients (18%), compared with no cases (0%) in whom standard resolution white light endoscopy with random biopsy detected a higher grade of histology (P < .001). Correspondingly, narrow band directed biopsies detected dysplasia in more patients (n = 37; 57%) compared with biopsies taken using standard resolution endoscopy (n = 28; 43%). In addition, more biopsies were taken using standard resolution endoscopy with random biopsy compared with narrow band targeted biopsies (mean 8.5 versus 4.7; P < .001).

CONCLUSIONS

In patients evaluated for Barrett's esophagus with dysplasia, NBI detected significantly more patients with dysplasia and higher grades of dysplasia with fewer biopsy samples compared with standard resolution endoscopy.

Endoluminal therapy for Barrett's esophagus

This article reviews methods to minimize the complications associated with endoscopic therapy for patients with Barrett's esophagus. To place this discussion in context, the natural history of Barrett's esophagus and the risks associated with progression to dysplasia and invasive carcinoma are reviewed. Operative esophageal resection traditionally is recommended for patients with Barrett's high-grade dysplasia and early carcinoma, and these surgical risks also are reviewed. Finally, all currently approved and commercially available methods for endoscopic ablation and resection of Barrett's disease are categorized according to their application methods of ablation: focal ablation, field ablation, and mucosal resection. The clinical experience with these devices is reviewed with their associated adverse events and complications. Caveats, concerns, and recommendations are discussed to help minimize the complications associated with the use of these important technologies that hold the promise of removing or destroying Barrett's disease to prevent the development of invasive carcinoma.

Influence of EAP chemotherapy combined with local radiotherapy on the prognosis and interleukin-2 system of esophageal cancer patients with bone metastasis

AIM: To observe the changes of interleukin-2 (IL-2) system and prognosis of esophageal cancer patients with bone metastasis after EAP chemotherapy combined with local radiotherapy.

METHODS: A total of 66 advanced esophageal cancer patients with bone metastasis were divided into 2 groups. One group received ⁶⁰Co local radiotherapy in combination with the regimen of intravenous chemotherapy at normal dosage of EAP (VP₁₆100 mg/m², topmycine 4 mg/m² and carboplatin 60 mg/m²), and the other group only received intravenous chemotherapy. The levels of IL-2, IL-2 receptor and soluble IL-2 receptor were detected before and after treatment.

RESULTS: The short-term efficacy and 1-year survival rate were significantly higher in the patients with combined treatment than those in the controls (93.93% vs 36.36%, P < 0.01; 90.90% vs 54.54%, P < 0.01). Moreover, the levels of IL-2, IL-2 receptor, soluble IL-2 receptor were also markedly higher in the former (23.6 ± 3.12, 23.1 ± 3.14, 771.4 ± 11.32 ng/L vs 44.1 ± 4.07, 53.2 ± 5.24, 123.2 ± 9.34 ng/L, P < 0.01).

CONCLUSION: Intravenous chemotherapy in combination with radiotherapy can significantly improve the levels of IL-2, IL-2 receptor, and soluble IL-2 receptor as well as the prognosis of esophageal cancer patients with bone metastasis.

Thermal ablation of Barrett's esophagus: a heated debate

A study reported in this issue of the American Journal of Gastroenterology has explored the efficacy of high-power argon plasma coagulation (APC) for the eradication of nonneoplastic Barrett's epithelium. Complete eradication was achieved in 77% of 48 patients, with a 10% rate of major complications including hemorrhage, esophageal stricture, and esophageal perforation. Although these observations indicate that high-power APC can eradicate Barrett's epithelium in some patients, it is not clear that this expensive and hazardous therapy conveys any clinical benefit. Even if one makes the substantial leap of faith that APC can decrease the risk of cancer in Barrett's esophagus, that risk is so small for patients without dysplasia that the number needed to treat is unacceptably large. Available data do not support the routine application of endoscopic ablative therapy for patients who have Barrett's esophagus without dysplasia.