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Belghazi K, Marcon N, Teshima C, Wang KK, Milano RV, Mostafavi N, Wallace MB, Kandel P, Mejía Pérez LK, Bourke MJ, Bahin F, Everson MA, Haidry R, Ginsberg GG, Ma GK, Koch AD, Ragunath K, Ortiz-Fernandez-Sordo J, di Pietro M, Seewald S, Weusten BL, Schoon EJ, Bisschops R, Bergman JJ, Pouw RE. Risk factors for serious adverse events associated with multiband mucosectomy in Barrett's esophagus: an international multicenter analysis of 3827 endoscopic resection procedures. Gastrointest Endosc 2020; 92:259-268.e2. [PMID: 32240684 DOI: 10.1016/j.gie.2020.03.3842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Multiband mucosectomy (MBM) is a widely used technique for the treatment of Barrett's esophagus (BE). However, large multicenter studies enabling a generalizable estimation of the risk of serious adverse events, such as perforation and postprocedural bleeding, are lacking. The aim of this study was to estimate the rate of, and risk factors for, serious adverse events associated with MBM. METHODS In this retrospective analysis, consecutive patients who underwent MBM for treatment of BE in 14 tertiary referral centers in Europe, the United States, Canada, and Australia were included. Primary outcomes were perforation and postprocedural bleeding rate. Potential risk factors were identified by logistic regression. RESULTS Between 2001 and 2016, a total of 3827 MBM procedures were performed in 2447 patients (84% male, mean age 66 years, median BE length C2M4). Perforation occurred in 17 procedures (0.4%; 95% confidence interval [CI], 0.3-0.7), of which 15 could be treated endoscopically or conservatively. Female gender was an independent risk factor for perforation (odds ratio [OR], 2.77; 95% CI, 1.02-7.57; P = .05). Postprocedural bleeding occurred after 35 procedures (0.9%; 95% CI, 0.6-1.3). The number of resections (OR, 1.15; 95% CI, 1.06-1.25; P < .001) was significantly associated with postprocedural bleeding. CONCLUSION The results of this study show that MBM for BE is safe with a low risk of serious adverse events. In addition, most of the adverse events could be managed endoscopically or conservatively. The number of resections was an independent risk factor for postprocedural bleeding.
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Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Norman Marcon
- Department of Gastroenterology, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Christopher Teshima
- Department of Gastroenterology, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Kenneth K Wang
- Department of Gastroenterology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Reza V Milano
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nahid Mostafavi
- Biostatistical Unit, Department of Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Pujan Kandel
- Department of Gastroenterology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Farzan Bahin
- Department of Gastroenterology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Martin A Everson
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Gregory G Ginsberg
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gene K Ma
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, Cancer Institute, Rotterdam, the Netherlands
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre & NIHR Biomedical Research Centre, Nottingham University Hospital, Nottingham, United Kingdom
| | - Jacobo Ortiz-Fernandez-Sordo
- Nottingham Digestive Diseases Centre & NIHR Biomedical Research Centre, Nottingham University Hospital, Nottingham, United Kingdom
| | | | - Stefan Seewald
- Department of Gastroenterology, GastroZentrum Hirslanden Zürich, Switzerland
| | - Bas L Weusten
- Department of Gastroenterology and Hepatology, St. Antonius hospital, Nieuwegein, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, UZ Leuven, KU Leuven, Belgium
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Pouw RE, Belghazi K, Bisschops R, Bergman JJGHM. Response. Gastrointest Endosc 2020; 91:457. [PMID: 32036953 DOI: 10.1016/j.gie.2019.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 10/15/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kamar Belghazi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, UZ Gasthuisberg Leuven, Leuven, Belgium
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Belghazi K, Schölvinck DW, van Berge Henegouwen MI, Gisbertz SS, Weusten BL, Meijer SL, Bergman JJ, Pouw RE. Results of a two-phased clinical study evaluating a new multiband mucosectomy device for early Barrett's neoplasia: a randomized pre-esophagectomy trial and a pilot therapeutic pilot study. Surg Endosc 2018; 33:2864-2872. [PMID: 30456511 PMCID: PMC6684496 DOI: 10.1007/s00464-018-6582-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 11/02/2018] [Indexed: 01/05/2023]
Abstract
Background Multiband mucosectomy (MBM) is the preferred technique for piecemeal resection of early neoplastic lesions in Barrett’s esophagus (BE). The currently most widely used device for MBM is the Duette device. Recently, the Captivator EMR device has come available which might have practical advantages over the Duette device. Methods Phase I was a randomized pre-esophagectomy trial with a non-inferiority design aiming to compare EMR specimens obtained with the Captivator and the Duette device. Primary outcome: max diameter of the EMR specimens, secondary outcomes: min diameter, max thickness of the EMR specimens and resected submucosal stroma. Phase II were clinical pilot cases aiming to evaluate the feasibility of EMR using the Captivator device. Primary outcome was the successful EMR rate and secondary outcomes included procedure time and adverse events. Results Phase I: 24 EMR specimens (12 pairs) were obtained from six patients. The median max diameter of EMR specimens obtained with the Captivator device was 16 mm [IQR 12–21] versus 18 mm [IQR 13–23] for the Duette device. Non-inferiority of the max diameter of the Captivator specimens could not be demonstrated (median difference 1 mm, 95% CI − 3.26 to + 5.26). However, when using paired analysis, no significant difference was found (p 0.573). In addition, no statistically significant differences were found in the min diameter, max thickness of EMR specimens, and max thickness of resected submucosal stroma. Phase II: 5 BE patients with early neoplastic lesions were included. Successful EMR was achieved in 100%. Median procedure time was 33 min (IQR 25–39). One patient developed transient dysphagia, without signs of stenosis on endoscopy. Conclusions EMR of early Barrett’s neoplasia using the Captivator device is comparable to Duette EMR when looking at size of resected specimens. In the first patients, EMR using the Captivator was feasible, resulting in successful resection without acute adverse events.
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Affiliation(s)
- K Belghazi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D W Schölvinck
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - S S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B L Weusten
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Pouw RE, Beyna T, Belghazi K, Koch AD, Schoon EJ, Haidry R, Weusten BL, Bisschops R, Shaheen NJ, Wallace MB, Marcon N, Heise-Ginsburg R, Gotink AW, Wang KK, Leggett CL, Ortiz-Fernández-Sordo J, Ragunath K, DiPietro M, Pech O, Neuhaus H, Bergman JJ. A prospective multicenter study using a new multiband mucosectomy device for endoscopic resection of early neoplasia in Barrett's esophagus. Gastrointest Endosc 2018; 88:647-654. [PMID: 30220300 DOI: 10.1016/j.gie.2018.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/27/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Early neoplasia in Barrett's esophagus (BE) can be effectively and safely removed by endoscopic resection (ER) using multiband mucosectomy (MBM). This study aimed to document performance of a novel MBM device designed for improved visualization, easier passage of accessories, and better suction power compared with other marketed MBM devices. METHODS This international, single-arm, prospective registry in 14 referral centers (Europe, 10; United States, 3; Canada, 1) included patients with early BE neoplasia scheduled for ER. The primary endpoint was successful ER defined as complete resection of the delineated area in 1 procedure. Secondary outcomes were adverse events and procedure time. RESULTS A total of 332 lesions was included in 291 patients (248 men; mean age, 67 years [standard deviation, 9.6]). ER indication was high-grade dysplasia in 64%, early adenocarcinoma in 19%, lesion with low-grade dysplasia in 11%, and a lesion without definite histology in 6%. Successful ER was reached in 322 of 332 lesions (97%; 95% confidence interval [CI], 94.6%-98.4%). A perforation occurred in 3 of 332 procedures (.9%; 95% CI, .31%-2.62%), all were managed endoscopically, and patients were admitted with intravenous antibiotics during days 2, 3, and 9. Postprocedural bleeding requiring an intervention occurred in 5 of 332 resections (1.5%; 95% CI, .65%-3.48%). Dysphagia requiring dilatation occurred in 11 patients (3.8%; 95% CI, 2.1%-6.6%). Median procedure time was 16 minutes (interquartile range, 12.0-26.0). CONCLUSIONS In expert hands, the novel MBM device proved to be effective for resection of early neoplastic lesions in BE, with successful ER in 97% of procedures. Severe adverse events were rare and were effectively managed endoscopically or conservatively. (Clinical trial registration number: NCT02482701.).
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Torsten Beyna
- Department of Gastroenterology and Hepatology, Evangelisches Krankenhaus, Düsseldorf, Germany
| | - Kamar Belghazi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Bas L Weusten
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Raf Bisschops
- Department of Gastroenterology, UZ Gasthuisberg, Leuven, Belgium
| | - Nicholas J Shaheen
- Department of Gastroenterology, University North Carolina Hospital, Chapel Hill, North Carolina, USA
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Norman Marcon
- Department of Gastroenterology, St Michaels Hospital, Toronto, Ontario, Canada
| | - Rachel Heise-Ginsburg
- Department of Gastroenterology and Hepatology, Evangelisches Krankenhaus, Düsseldorf, Germany
| | - Anniek W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Kenneth K Wang
- Department of Gastroenterology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Department of Gastroenterology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jacobo Ortiz-Fernández-Sordo
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | | | - Oliver Pech
- Department of Gastroenterology, St John of God Hospital, Regensburg, Germany
| | - Horst Neuhaus
- Department of Gastroenterology and Hepatology, Evangelisches Krankenhaus, Düsseldorf, Germany
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Belghazi K, Pouw RE, Bergman JJ. In the expanding arena of endoscopic management for Barrett's neoplasia, how should we fit in endoscopic submucosal dissection? Gastrointest Endosc 2018; 87:1394-1395. [PMID: 29759155 DOI: 10.1016/j.gie.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
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6
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Belghazi K, Pouw RE, Sondermeijer C, Meijer SL, Schoon EJ, Koch AD, Weusten B, Bergman J. A single-step sizing and radiofrequency ablation catheter for circumferential ablation of Barrett's esophagus: Results of a pilot study. United European Gastroenterol J 2018; 6:990-999. [PMID: 30228886 PMCID: PMC6137598 DOI: 10.1177/2050640618768919] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/26/2018] [Indexed: 11/21/2022] Open
Abstract
Background The 360 Express balloon catheter (360 Express) has the ability to self-adjust to the esophageal lumen, ensuring optimal tissue contact. Objective The objective of this article is to evaluate the efficacy and safety of the 360 Express for radiofrequency ablation (RFA) treatment of Barrett's esophagus (BE). Methods BE patients with low-grade dysplasia (LGD), high-grade dysplasia (HGD) or early cancer (EC) were included. Visible lesions were removed by endoscopic resection (ER) prior to RFA. RFA was performed with the 360 Express using the standard ablation regimen (12J/cm2–clean–12J/cm2). Primary outcome: BE regression percentage at three months. Secondary outcomes: procedure time, adverse events, complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM). Results Thirty patients (median BE C4M6) were included. Eight patients underwent ER prior to RFA. Median BE regression: 90%. Median procedure time: 31 minutes. Adverse events (13%): laceration (n = 1); atrial fibrillation (n = 1); vomiting and dysphagia (n = 1); dysregulated diabetes (n = 1). After subsequent treatment CE-D and CE-IM was achieved in 97% and 87%, respectively. In 10% a stenosis developed during additional treatment requiring a median of one dilation. Conclusion This study shows that circumferential RFA using the 360 Express may shorten procedure time, while maintaining efficacy compared to standard circumferential RFA.
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Affiliation(s)
- K Belghazi
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Cmt Sondermeijer
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - S L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - A D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC-University Medical Center, Rotterdam, the Netherlands
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jjghm Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
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Künzli HT, Belghazi K, Pouw RE, Meijer SL, Seldenrijk CA, Weusten B, Bergman J. Endoscopic management and follow-up of patients with a submucosal esophageal adenocarcinoma. United European Gastroenterol J 2018; 6:669-677. [PMID: 30083328 PMCID: PMC6068782 DOI: 10.1177/2050640617753808] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 12/03/2017] [Indexed: 12/31/2022] Open
Abstract
Introduction The risk of lymph node metastases (LNM) in submucosal esophageal adenocarcinoma (EAC) patients is subject to debate. These patients might be treated endoscopically if the risk of LNM appears to be low. Objective The objective of this article is to evaluate the outcome of patients who underwent an endoscopic resection (ER) and subsequent endoscopic follow-up for a submucosal EAC. Methods All patients who underwent ER for submucosal EAC between January 2012 and August 2016 and were subsequently managed with endoscopic follow-up were retrospectively identified. Primary outcome was the number of patients diagnosed with LNM; secondary outcomes included intraluminal recurrences. Results Thirty-five patients (median age 68 years) were included: 17 low-risk (submucosal invasion <500 microns, G1–G2, no lymphovascular invasion (LVI)), and 18 high-risk (submucosal invasion >500 microns, and/or G3–G4, and/or LVI, and/or a tumor-positive deep resection margin (R1)) EACs. After a median follow-up of 23 (IQR 15–43) months, in which patients underwent a median of six (IQR 4–8) endoscopies and a median of four (IQR 2–8) endoscopic ultrasound procedures, none of the included patients were diagnosed with LNM. Five (14%) patients developed a local intraluminal recurrence a median of 18 (IQR 11–21) months after baseline ER that were treated endoscopically. Conclusions In 35 patients with a submucosal EAC, no LNM were found during a median follow-up of 23 months. Endoscopic therapy may be an alternative for surgery in selected patients with a submucosal EAC.
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Affiliation(s)
- H T Künzli
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - K Belghazi
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - S L Meijer
- Department of Pathology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - C A Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Blam Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jjghm Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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Belghazi K, van Vilsteren FGI, Weusten BLAM, Meijer SL, Bergman JJGHM, Pouw RE. Long-term follow-up results of stepwise radical endoscopic resection for Barrett's esophagus with early neoplasia. Gastrointest Endosc 2018; 87:77-84. [PMID: 28455160 DOI: 10.1016/j.gie.2017.04.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 04/09/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Stepwise radical endoscopic resection (SRER) has shown to be effective in eradicating Barrett's esophagus (BE) and its associated dysplasia. The aim of this study was to assess the long-term durability after successful SRER for early Barrett's neoplasia. METHODS Patients treated with SRER for BE ≤5 cm with high-grade dysplasia (HGD) or early cancer (EC) and who had reached complete eradication of intestinal metaplasia (CE-IM) and neoplasia (CE-neo) were included. Primary outcomes were recurrence of neoplasia (HGD/EC), recurrence of dysplasia (indefinite for dysplasia included), and recurrence of endoscopically visible BE. Secondary outcomes were buried Barrett's glands, IM in biopsy specimens obtained distal to a normal-appearing neo-squamocolumnar junction (neo-SCJ), need for retreatment, and sustained CE-IM and CE-neo at the last follow-up endoscopy. RESULTS Seventy-three patients were included (64 men; mean age, 66 years; median BE, C2M3). Median follow-up was 76 months. Recurrence of neoplasia was observed in 1 patient (T1bN0M0) after 129 months of follow-up and was treated with curative surgery (annual incidence of .22% per patient-year of follow-up). In 4 patients, recurrence of dysplasia was found (.87% per patient-year of follow-up). Twelve patients had recurrent endoscopically visible BE after a median follow-up of 22 months (2.6% per patient-year of follow-up), mostly small islands or tongues. Five patients had a single finding of buried Barrett's glands (1.1% per patient-year of follow-up), and 27 patients (5.9% per patient-year of follow-up) showed IM in biopsy specimens just distal to the neo-SCJ, which was not reproduced in 56%. Retreatment was performed in 9 patients. CE-IM and CE-neo (excluding IM in the neo-SCJ) at the last follow-up endoscopy was seen in 95% and 97% of patients, respectively. CONCLUSIONS This study presents the longest published follow-up data on SRER to date. The 6-year outcomes show that successful SRER is a durable treatment for BE ≤5 cm with HGD/EC.
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Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Bas L A M Weusten
- Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, the Netherlands
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Belghazi K, Bergman JJGHM, Pouw RE. Management of Nodular Neoplasia in Barrett's Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection. Gastrointest Endosc Clin N Am 2017; 27:461-470. [PMID: 28577767 DOI: 10.1016/j.giec.2017.02.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Endoscopic resection has proven highly effective and safe in the removal of focal early neoplastic lesions in Barrett's esophagus and is considered the cornerstone of endoscopic treatment. Several techniques are available for endoscopic resection in Barrett's esophagus. The most widely used technique for piecemeal resection of early Barrett's neoplasia is the ligate-and-cut technique. Newer techniques such as endoscopic submucosal dissection may also play a role in the treatment of neoplastic Barrett's esophagus. Treatment of early Barrett's neoplasia should be centralized and limited to expert centers with a high-volume load and sufficient expertise in the detection and treatment of esophageal neoplasia.
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Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, Amsterdam 1105 AZ, The Netherlands.
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Barret M, Belghazi K, Weusten BLAM, Bergman JJGHM, Pouw RE. Single-session endoscopic resection and focal radiofrequency ablation for short-segment Barrett's esophagus with early neoplasia. Gastrointest Endosc 2016; 84:29-36. [PMID: 26769410 DOI: 10.1016/j.gie.2015.12.034] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 12/15/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS The management of early neoplasia in Barrett's esophagus (BE) requires endoscopic resection of visible lesions, followed by radiofrequency ablation (RFA) of the remaining BE. We evaluated the safety and efficacy of combining endoscopic resection and focal RFA in a single endoscopic session in patients with early BE neoplasia. METHODS This was a retrospective analysis of patients with early BE neoplasia and a visible lesion undergoing combined endoscopic resection and focal RFA in a single session. Consecutive ablation procedures were performed every 8 to 12 weeks until complete endoscopic and histologic eradication of dysplasia and intestinal metaplasia were reached. RESULTS Forty patients were enrolled, with a median C1M2 BE segment, a visible lesion with a median diameter of 15 mm, and invasive carcinoma in 68% of cases. Endoscopic resection was performed by using the multiband mucosectomy technique in 80% of cases, and the Barrx(90) catheter (Barrx Medical, Sunnyvale, Calif) was used for focal ablation. When an intention-to-treat analysis was used, both complete remission of all neoplasia and intestinal metaplasia were 95% after a median follow-up of 19 months. Stenoses occurred in 33% of cases and were successfully managed with a median number of 2 dilations. In 43% of patients, 1 single-session treatment resulted in complete histologic remission of intestinal metaplasia. CONCLUSIONS Combining endoscopic resection and focal RFA in a single session appears to be effective. Less-aggressive RFA regimens could limit the adverse event rates.
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Affiliation(s)
- Maximilien Barret
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Kamar Belghazi
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands; Department of Gastroenterology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
In the last few decades, endoscopic treatment of early neoplastic lesions in the esophagus has established itself as a valid and less invasive alternative to surgical resection. Endoscopic resection (ER) is the cornerstone of endoscopic therapy. Next to the curative potential of ER, by removing neoplastic lesions, ER may also serve as a diagnostic tool. The relatively large tissue specimens obtained with ER enable accurate histological staging of a lesion, allowing for optimal decision-making for further patient management. ER was pioneered in Japan, mainly for the resection of gastric lesions and squamous esophageal neoplasia, and also Western countries have been increasingly implementing ER in the treatment of early gastroesophageal neoplasia, mostly associated with Barrett's esophagus (BE). In BE, however, there is still a risk of metachronous lesions in the remainder of the Barrett's after focal ER. Additional treatment of all Barrett's mucosa is therefore advised. Currently, the most effective method for this is by using radiofrequency ablation (RFA). This review will provide an overview of indications for ER and RFA. Key Messages and Conclusions: Endoscopic management of early esophageal neoplasia is a safe and valid alternative to surgery and is nowadays the treatment of choice. ER is the mainstay of endoscopic management of early esophageal neoplasia since it allows for removal of neoplastic lesions and provides a large tissue specimen for histological evaluation. In case of early neoplasia in BE, focal ER should be complemented by eradication of the remaining Barrett's mucosa. RFA has proven to be a safe and effective modality to achieve complete eradication of Barrett's mucosa.
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Affiliation(s)
| | | | - Roos E. Pouw
- *Roos E. Pouw, MD, PhD, Department of Gastroenterology and Hepatology Academic Medical Center Meibergdreef 9, NL-1105 AZ Amsterdam (The Netherlands) E-Mail
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Belghazi K, Cipollone I, Bergman JJGHM, Pouw RE. Current Controversies in Radiofrequency Ablation Therapy for Barrett's Esophagus. Curr Treat Options Gastroenterol 2016; 14:1-18. [PMID: 26891725 PMCID: PMC4783441 DOI: 10.1007/s11938-016-0080-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OPINION STATEMENT Barrett's esophagus (BE) is the most important risk factor for esophageal adenocarcinoma. Through the sequence of no dysplasia to low-grade dysplasia (LGD) and high-grade dysplasia (HGD), eventually early cancer (EC) may develop. The risk of neoplastic progression is relatively low, 0.5-0.9 % per patient per year. However, once diagnosed, esophageal adenocarcinoma is often irresectable, and 5-year survival is only 15 %. Therefore, non-dysplastic BE patients are kept under endoscopic surveillance to detect early neoplasia in a curable stage. In case of LGD confirmed by an expert pathologist, risk of neoplastic progression is high. In these confirmed LGD patients, prophylactic ablation using radiofrequency ablation (RFA) of the Barrett's segment has proven to significantly reduce risk of neoplastic progression. Once patients are diagnosed with HGD or EC, they have a clear indication for endoscopic treatment. The cornerstone for endoscopic management of early Barrett's neoplasia is endoscopic resection of mucosal abnormalities. Endoscopic resection (ER) provides a large tissue specimen for accurate histological evaluation to select those patients for further endoscopic management, who have neoplasia limited to the mucosa, well to moderately differentiated and without lymph-vascular invasion. After ER, the remainder of the Barrett's mucosa can be eradicated with RFA, to prevent occurrence of metachronous lesions.
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Affiliation(s)
- Kamar Belghazi
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Ilaria Cipollone
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jacques J G H M Bergman
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Roos E Pouw
- Academic Medical Center, Department of Gastroenterology and Hepatology, Room C2-329, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Schölvinck DW, Belghazi K, Pouw RE, Curvers WL, Weusten BLAM, Bergman JJGHM. In vitro assessment of the performance of a new multiband mucosectomy device for endoscopic resection of early upper gastrointestinal neoplasia. Surg Endosc 2015; 30:471-479. [PMID: 26017906 PMCID: PMC4735249 DOI: 10.1007/s00464-015-4222-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Accepted: 05/14/2015] [Indexed: 01/14/2023]
Abstract
Background and study aims
Multiband mucosectomy (MBM) is widely used for the endoscopic resection of early neoplasia in the upper gastrointestinal tract. A new MBM-device may have advantages over the current MBM-device with improved visualization, easier passage of accessories, and higher suction power due to different trip wire and cap. Methods Rubber bands were released one by one for both MBM-devices while endoscopic images were collected. First, free endoscopic view was assessed by computer-assisted measurements (quantitative) and by ranking the images by a panel of 11 endoscopists (qualitative). Second, using a visual analog scale, three ‘blinded’ endoscopists assessed introduction and advancement of three types of endoscopic devices through the working channel of a diagnostic endoscope with the MBM-devices assembled. Third, suction power was evaluated by a manometer attached to the cap of the assembled MBM-devices in four endoscopes. Negative pressures were measured after 5 and 10 s of suction and repeated five times. The passage and suction experiments were performed with dry trip wires and repeated after soaking with bloody, mucous fluids. Results With all bands present, endoscopic views were 90 and 40 % in the new and current MBM-device, respectively. With the release of more bands, differences slowly disappeared. The panel scored a better endoscopic view in the new MBM-device (p = 0.03). Passage of all accessories was considered significantly easier in the new MBM-device. With the associated snare in the working channel, suction power was significantly better with the new MBM-device. Conclusion Compared to the currently available MBM-device, the new MBM-device provides improved endoscopic visibility, smoother passage of accessories, and higher suction power.
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Affiliation(s)
- D W Schölvinck
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands.
| | - K Belghazi
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - W L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - J J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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