Real-World Safety and Efficacy of Fluid-Filled Dual Intragastric Balloon for Weight Loss

BACKGROUND & AIMS

Reshape Duo is a saline-filled dual, integrated intragastric balloon (IGB) approved by the Food and Drug Administration for weight loss in patients with obesity. In a prospective, randomized trial, obese patients who received the balloon had significantly greater percent excess weight loss (%EWL) compared with patients treated with diet and exercise alone. However, there are limited data on the real-world efficacy of the Reshape balloon.

METHODS

We performed a retrospective study of data collected from 2 academic centers and 5 private practices in which all patients paid for the IGB and follow-up visits out of pocket. The IGB was removed after 6 months. We collected data (demographic, medical, and laboratory) from 202 adults (mean age 47.8 ± 10.8 years; 83% female) with a baseline mean body mass index of 36.8 + 8.4 kg/m² who had IGB insertion for weight loss therapy, along with counselling on lifestyle modifications focused on diet and exercise. Primary outcomes were percent total body weight loss (%TBWL) and %EWL at 1, 3, 6, 9, and 12 months after the procedure.

RESULTS

Mean %TBWL at 1, 3, 6, 9 and 12 months was 4.8 ± 2.4%, 8.8 ± 4.3%, 11.4 ± 6.7%, 13.3 ± 7.8%, and 14.7 ± 11.8%, respectively. Data were available from 101 patients at 6 months and 12 patients at 12 months; 60.4% of patients achieved more than 10% TBWL and 55.4% had more than 25% EWL. Seventeen patients (8.4%) had esophageal tears during balloon insertion, with no intervention required. Thirteen patients (6.4%) had their IGB removed before the end of the 6-month treatment period. Nausea, vomiting, and abdominal pain were the most common adverse effects, occurring in 149 (73.8%), 99 (49%), and 51 (25.2%) patients. In one patient, the IGB migrated distally leading to small intestinal obstruction requiring surgical removal.

CONCLUSION

In a retrospective analysis of real-world patients who received the Reshape Duo IGB, we found it to be a safe and efficacious endoscopic method for producing weight loss, with most patients achieving greater than 10% TBWL at 6 months.

Late Recurrence of Barrett's Esophagus After Complete Eradication of Intestinal Metaplasia is Rare: Final Report From Ablation in Intestinal Metaplasia Containing Dysplasia Trial

BACKGROUND & AIMS

The goal of treatment for Barrett's esophagus (BE) with dysplasia is complete eradication of intestinal metaplasia (CEIM). The long-term durability of CEIM has not been well characterized, so the frequency and duration of surveillance are unclear. We report results from a 5-year follow-up analysis of patients with BE and dysplasia treated by radiofrequency ablation (RFA) in the randomized controlled Ablation of Intestinal Metaplasia Containing Dysplasia (AIM) trial.

METHODS

Participants for the AIM Dysplasia trial (18-80 years old) were recruited from 19 sites in the United States and had endoscopic evidence of non-nodular dysplastic BE ≤8 cm in length. Subjects (n = 127) were randomly assigned (2:1 ratio) to receive either RFA (entire BE segment ablated circumferentially) or a sham endoscopic procedure; patients in the sham group were offered RFA treatment 1 year later, and all patients were followed for 5 years. We collected data on BE recurrence (defined as intestinal metaplasia in the tubular esophagus) and dysplastic BE recurrence among patients who achieved CEIM. We constructed Kaplan-Meier estimates and applied parametric survival analysis to examine proportions of patients without any recurrence and without dysplastic recurrence.

RESULTS

Of 127 patients in the AIM Dysplasia trial, 119 received RFA and met inclusion criteria. Of those 119, 110 (92%) achieved CEIM. Over 401 person-years of follow-up (mean, 3.6 years per patient; range, 0.2-5.8 years), 35 of 110 (32%) patients had recurrence of BE or dysplasia, and 19 (17%) had dysplasia recurrence. The incidence rate of BE recurrence was 10.8 per 100 person-years overall (95% CI, 7.8-15.0); 8.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI, 4.9-14.0), and 13.5 per 100 person-years among patients with baseline high-grade dysplasia (95% CI 8.8-20.7). The incidence rate of dysplasia recurrence was 5.2 per 100 person-years overall (95% CI 3.3-8.2); 3.3 per 100 person-years among patients with baseline low-grade dysplasia (95% CI 1.5-7.2), and 7.3 per 100 person-years among patients with baseline high-grade dysplasia (95% CI 4.2-12.5). Neither BE nor dysplasia recurred at a constant rate. There was a greater probability of recurrence in the first year following CEIM than in the following 4 years combined.

CONCLUSIONS

In this analysis of prospective cohort data from the AIM Dysplasia trial, we found BE to recur after CEIM by RFA in almost one third of patients with baseline dysplastic disease; most recurrences occurred during the first year after CEIM. However, patients who achieved CEIM and remained BE free at 1 year after RFA had a low risk of BE recurrence. Studies are needed to determine when surveillance can be decreased or discontinued; our study did not identify any BE or dysplasia recurrence after 4 years of surveillance.

Development of a Fluorescence Detection System Using Optical Parametric Oscillator (OPO) Laser Excitation for in Vivo Diagnosis

In this work, the development and applications of a fluorescence detection system using optical parametric oscillator (OPO) laser excitation for in vivo disease diagnosis including oral carcinoma are described. The optical diagnosis system was based on an OPO laser for multi-wavelength excitation and time-resolved detection. The pulsed Nd-YAG-pumped OPO laser system (6 ns, 20 Hz) is compact and has a rapid, broad, and uniform tuning range. Time-gated detection of intensified charge-coupled device (ICCD) making use of external triggering was used to effectively eliminate the laser scattering and contribute to the highly sensitive in vivo measurements. Artificial tissue-simulating phantoms consisting of polystyrene microspheres and tissue fluorophores were tested to optimize the gating parameters. 51-ns gate width and 39-ns gate delays were determined to be the optimal parameters for sensitive detection. in vivo measurements with the optical diagnosis system were applied to esophagus, stomach, and small intestine using an endoscope in canine animal studies. The rapid tuning capability of the optical diagnosis system contributed greatly to the optimization of wavelength for the observation of porphyrin in the small intestine. When the small intestine was thoroughly washed with water, the emission band which corresponds to porphyrin disappeared. Based on this observation, it was concluded that the detected signal was yielded by porphyrin-containing bile secretion. Also, multispectral analyses using multiple excitations from 415 to 480 nm at 5 nm intervals confirmed the porphyrin detection in the small intestine. The optical diagnosis system was also applied to the detection of human xenograft of oral carcinoma in mice using 5-aminolevulinic acid (5-ALA) which is a photodynamic therapy (PDT) drug. Significant differences in protoporphyrin IX fluorescence intensity between normal and tumor tissue could be obtained 2 hours after the injection of 5-ALA into mice due to the preferential accumulation of 5-ALA in tumors. Results reported herein demonstrate potential capabilities of the LIF-OPO system for in vivo disease diagnosis.

CA11-19: a tumor marker for the detection of colorectal cancer

BACKGROUND AND AIM

Colorectal cancer (CRC) remains the second most frequent cause of cancer deaths in the United States. Blood tests using tumor-related antigens aid in diagnosing CRC. However, higher sensitivity and specificity are needed before an acceptable tumor antigen blood test for CRC is clinically useful. This study describes the diagnostic accuracy of an enzyme-linked immunosorbent assay for the CA11-19 serologic tumor antigen for the detection of CRC.

METHODS

Serum specimens were obtained from 522 colonoscopy-confirmed subjects in institutional review board-approved studies. Specimens were blind coded. CA11-19 levels were determined by using enzyme-linked immunosorbent assay analysis. The results were tabulated for categories of normal, hyperplastic polyps, benign GI, adenomatous polyps, and CRC based on their final diagnosis.

RESULTS

When a cutoff of 6.4 units/mL for normal is used, the CA11-19 level was elevated in 128 of 131 of CRC subjects, for an observed sensitivity of 98% (95% confidence interval, 93.1%-99.5%). Normal levels were found in 87% of normal subjects (90/103) and 83% of those with benign GI diseases (185/223). When combined, this yields an observed specificity of 84% (95% confidence interval, 80.0%-87.9%).

CONCLUSION

CA11-19 is a serologic tumor marker for the diagnosis of CRC with a sensitivity of 98% and specificity of 84%. This high sensitivity means that this test will detect 43 of 44 cases of CRC presented. For those older than 50 years of age, it has a positive predictive value of 3.6% and a negative predictive value of 99.98%. Additional prospective studies are needed to further clarify the use of CA11-19 as an aid in the diagnosis of CRC.

Incidence of Esophageal Adenocarcinoma and Causes of Mortality After Radiofrequency Ablation of Barrett's Esophagus

BACKGROUND & AIMS

Radiofrequency ablation (RFA) is commonly used to treat Barrett's esophagus (BE). We assessed the incidence of esophageal adenocarcinoma (EAC) after RFA, factors associated with the development of EAC, and EAC-specific and all-cause mortality.

METHODS

We collected data for outcomes of patients who underwent RFA for BE from July 2007 through July 2011 from US multicenter RFA Patient Registry. Patients were followed until July 2014. Kaplan-Meier curves of EAC incidence were stratified by baseline histology. Crude EAC incidence and mortality (all-cause and EAC-specific) were calculated, and adjusted all-cause mortality was assessed. Logistic regression models were constructed to assess predictors of EAC and all-cause mortality.

RESULTS

Among 4982 patients, 100 (2%) developed EAC (7.8/1000 person-years [PY]) and 9 patients (0.2%) died of EAC (0.7/1000 PY) in a mean 2.7 ± 1.6 years. The incidence of EAC in nondysplastic BE was 0.5/1000 PY. Overall, 157 patients (3%) died during follow-up (all-cause mortality, 11.2/1000 PY). On multivariate logistic regression, baseline BE length (odds ratio, 1.1/ cm) and baseline histology (odds ratios, 5.8 and 50.3 for low-grade dysplasia and high-grade dysplasia [HGD] respectively) predicted EAC incidence. Among 9 EAC deaths, 6 (67%) had baseline HGD, and 3 (33%) had baseline intramucosal EAC. The most common causes of death were cardiovascular (15%) and extraesophageal cancers (15%). No deaths were associated with RFA.

CONCLUSIONS

Based on analysis of a multicenter registry of patients who underwent RFA of BE, less than 1% died from EAC. The incidence of EAC was markedly lower in this study than in other studies of disease progression, with the greatest absolute benefit observed in patients with HGD.

Sex and race and/or ethnicity differences in patients undergoing radiofrequency ablation for Barrett's esophagus: results from the U.S. RFA Registry

BACKGROUND

Little is known about differences in Barrett's esophagus (BE) characteristics by sex and race and/or ethnicity or these differences in response to radiofrequency ablation (RFA).

OBJECTIVE

We compared disease-specific characteristics, treatment efficacy, and safety outcomes by sex and race and/or ethnicity in patients treated with RFA for BE.

DESIGN

The U.S. RFA patient registry is a multicenter collaboration reporting processes and outcomes of care for patients treated with RFA for BE.

PATIENTS

Patients enrolled with BE.

INTERVENTIONS

RFA.

MAIN OUTCOME MEASUREMENTS

We assessed safety (stricture, bleeding, perforation, hospitalization), efficacy (complete eradication of intestinal metaplasia [CEIM]), complete eradication of dysplasia, and number of treatments to CEIM by sex and race and/or ethnicity.

RESULTS

Among 5521 patients (4052 men; 5126 white, 137 Hispanic, 82 African American, 40 Asian, 136 heritage not identified), women were younger (60.0 vs 62.1 years) and had shorter BE segments (3.2 vs 4.4 cm) and less dysplasia (37% vs 57%) than did men. Women were almost twice as likely to stricture (odds ratio 1.7; 95% confidence interval, 1.2-2.3). Although white patients were predominantly male, about half of African Americans and Asians with BE were female. African Americans and Asians had less dysplasia than white patients. Asians and African Americans had more strictures than did white patients. There were no sex or race differences in efficacy.

LIMITATIONS

Observational study with non-mandated paradigms, no central laboratory for reinterpretation of pathology.

CONCLUSION

In the U.S. RFA patient registry, women had shorter BE segments and less-aggressive histology. The usual tendency toward BE in men was absent in African Americans and Asians. Posttreatment stricture was more common among women and Asians. RFA efficacy did not differ by sex or race.

Durability and predictors of successful radiofrequency ablation for Barrett's esophagus

BACKGROUND & AIMS

After radiofrequency ablation (RFA), patients may experience recurrence of Barrett's esophagus (BE) after complete eradication of intestinal metaplasia (CEIM). Rates and predictors of recurrence after successful eradication have been poorly described.

METHODS

We used the US RFA Registry, a nationwide registry of BE patients receiving RFA, to determine rates and factors that predicted recurrence of intestinal metaplasia (IM). We assessed recurrence by Kaplan-Meier analysis for the overall cohort and by worst pretreatment histology. Characteristics associated with recurrence were included in a logistic regression model to identify independent predictors.

RESULTS

Among 5521 patients, 3728 had biopsies 12 months or more after initiation of RFA. Of these, 3169 (85%) achieved CEIM, and 1634 (30%) met inclusion criteria. The average follow-up period was 2.4 years after CEIM. IM recurred in 334 (20%) and was nondysplastic or indefinite for dysplasia in 86% (287 of 334); the average length of recurrent BE was 0.6 cm. In Kaplan-Meier analysis, more advanced pretreatment histology was associated with an increased yearly recurrence rate. Compared with patients without recurrence, patients with recurrence were more likely, based on bivariate analysis, to be older, have longer BE segments, be non-Caucasian, have dysplastic BE before treatment, and require more treatment sessions. In multivariate analysis, the likelihood for recurrence was associated with increasing age and BE length, and non-Caucasian race.

CONCLUSIONS

BE recurred in 20% of patients followed up for an average of 2.4 years after CEIM. Most recurrences were short segments and were nondysplastic or indefinite for dysplasia. Older age, non-Caucasian race, and increasing length of BE length were all risk factors. These risk factors should be considered when planning post-RFA surveillance intervals.

Prior fundoplication does not improve safety or efficacy outcomes of radiofrequency ablation: results from the U.S. RFA Registry

BACKGROUND

Ongoing gastroesophageal reflux may impair healing and re-epithelialization after radiofrequency ablation (RFA) of Barrett's esophagus (BE). Because prior fundoplication may improve reflux control, our aim was to assess the relationship between prior fundoplication and the safety/efficacy of RFA.

METHODS

We assessed the U.S. RFA Registry, a nationwide registry of BE patients receiving RFA at 148 institutions, to compare the safety and efficacy of ablation between those with prior fundoplication and those with medical management (proton pump inhibition).

RESULTS

Among 5,537 patients receiving RFA, 301 (5.4 %) had prior fundoplication. Of fundoplication subjects, 1.0 % developed stricture and 1.0 % were hospitalized after RFA. Rates of stricture, bleeding, and hospitalization were not statistically different (p = ns) between patients with and without prior fundoplication. Complete eradication of intestinal metaplasia and complete eradication of dysplasia were achieved in 71 % and 87 % of fundoplication patients, and 73 % and 87 % of patients without fundoplication, respectively (p = ns for both). Patients with prior fundoplication needed similar numbers of RFA sessions for eradication compared with those without fundoplication.

CONCLUSIONS

Radiofrequency ablation, with or without prior fundoplication, is safe and effective in eradicating BE. Prior fundoplication was associated with similar adverse event and efficacy rates when compared with medical management.

The effect of reactive atypia/inflammation on the laser-induced fluorescence diagnosis of non-dysplastic Barrett's esophagus

BACKGROUND AND OBJECTIVES

Differential Normalized Fluorescence (DNF) technique has been used to distinguish high-grade dysplasia from non-dysplastic Barrett's esophagus. This technology may assist gastroenterologists in targeting biopsies, reducing the number of biopsies using the standard protocol. In the presence of reactive atypia/inflammation, it becomes difficult for the pathologist to differentiate non-dysplastic Barrett's esophagus from Barrett's esophagus with low-grade dysplasia. Before DNF technique may be used to guide target biopsies, it is critical to know whether reactive atypia/inflammation in non-dysplastic Barrett's may result in false positives. This study was conducted to determine whether DNF technique is adversely affected by the presence of reactive atypia/inflammation in non-dysplastic Barrett's esophagus resulting in false positives.

STUDY DESIGN/MATERIALS AND METHODS

Four hundred ten-nanometer laser light was used to induce autofluorescence of Barrett's mucosa in 49 patients. The clinical study included 37 males and 12 females. This was a blinded retrospective data analysis study. A total of 303 spectra were collected and matched to non-dysplastic Barrett's biopsy results. One hundred seventy-five spectra were collected from areas with a pathology of non-dysplastic Barrett's esophagus with reactive atypia/inflammation. One hundred twenty-eight spectra were collected from areas with non-dysplastic Barrett's esophagus without reactive changes/inflammation. The spectra were analyzed using the DNF Index at 480 nm and classified as positive or negative using the threshold of -0.75 × 10(-3).

RESULTS

Using DNF technique, 92.6% of non-dysplastic samples with reactive atypia/inflammation were classified correctly (162/175). 92.2% of non-dysplastic samples without reactive atypia/inflammation were classified correctly (118/128). Comparing the ratios of false positives among the two sample groups, there was not a statistically significant difference between the two groups.

CONCLUSION

Using DNF technique for classification of non-dysplastic Barrett's mucosa does not result in false-positive readings due to reactive atypia/inflammation. Target biopsies guided by DNF technique may drastically reduce the number of pinch biopsies using the standard biopsy protocol.

Durability of radiofrequency ablation in Barrett's esophagus with dysplasia

BACKGROUND & AIMS

Radiofrequency ablation (RFA) can eradicate dysplasia and intestinal metaplasia in patients with dysplastic Barrett's esophagus (BE), and reduce rates of esophageal adenocarcinoma. We assessed long-term rates of eradication, durability of neosquamous epithelium, disease progression, and safety of RFA in patients with dysplastic BE.

METHODS

We performed a randomized trial of 127 subjects with dysplastic BE; after cross-over subjects were included, 119 received RFA. Subjects were followed for a mean time of 3.05 years; the study was extended to 5 years for patients with eradication of intestinal metaplasia at 2 years. Outcomes included eradication of dysplasia or intestinal metaplasia after 2 and 3 years, durability of response, disease progression, and adverse events.

RESULTS

After 2 years, 101 of 106 patients had complete eradication of all dysplasia (95%) and 99 of 106 had eradication of intestinal metaplasia (93%). After 2 years, among subjects with initial low-grade dysplasia, all dysplasia was eradicated in 51 of 52 (98%) and intestinal metaplasia was eradicated in 51 of 52 (98%); among subjects with initial high-grade dysplasia, all dysplasia was eradicated in 50 of 54 (93%) and intestinal metaplasia was eradicated in 48 of 54 (89%). After 3 years, dysplasia was eradicated in 55 of 56 of subjects (98%) and intestinal metaplasia was eradicated in 51 of 56 (91%). Kaplan-Meier analysis showed that dysplasia remained eradicated in >85% of patients and intestinal metaplasia in >75%, without maintenance RFA. Serious adverse events occurred in 4 of 119 subjects (3.4%); the rate of stricture was 7.6%. The rate of esophageal adenocarcinoma was 1 per 181 patient-years (0.55%/patient-years); there was no cancer-related morbidity or mortality. The annual rate of any neoplastic progression was 1 per 73 patient-years (1.37%/patient-years).

CONCLUSIONS

In subjects with dysplastic BE, RFA therapy has an acceptable safety profile, is durable, and is associated with a low rate of disease progression, for up to 3 years.

Detection of dysplasia in Barrett's esophagus with in vivo depth-resolved nuclear morphology measurements

BACKGROUND & AIMS

Patients with Barrett's esophagus (BE) show increased risk of developing esophageal adenocarcinoma and are routinely examined using upper endoscopy with biopsy to detect neoplastic changes. Angle-resolved low coherence interferometry (a/LCI) uses in vivo depth-resolved nuclear morphology measurements to detect dysplasia. We assessed the clinical utility of a/LCI in the endoscopic surveillance of patients with BE.

METHODS

Consecutive patients undergoing routine surveillance upper endoscopy for BE were recruited at 2 endoscopy centers. A novel, endoscope-compatible a/LCI system measured the mean diameter and refractive index of cell nuclei in esophageal epithelium at 172 biopsy sites in 46 patients. At each site, an a/LCI measurement was correlated with a concurrent endoscopic biopsy specimen. Each biopsy specimen was assessed histologically and classified as normal, nondysplastic BE, indeterminate for dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). The a/LCI data from multiple depths were analyzed to evaluate its ability to differentiate dysplastic from nondysplastic tissue.

RESULTS

Pathology characterized 5 of the scanned sites as HGD, 8 as LGD, 75 as nondysplastic BE, 70 as normal tissue types, and 14 as indeterminate for dysplasia. The a/LCI nuclear size measurements separated dysplastic from nondysplastic tissue at a statistically significant (P < .001) level for the tissue segment 200 to 300 μm beneath the surface with an accuracy of 86% (147/172). A receiver operator characteristic analysis indicated an area under the curve of 0.91, and an optimized decision point gave 100% (13/13) sensitivity and 84% (134/159) specificity.

CONCLUSIONS

These preliminary data suggest a/LCI is accurate in detecting dysplasia in vivo in patients with BE.

Endoscopic radiofrequency ablation for Barrett's esophagus: 5-year outcomes from a prospective multicenter trial

BACKGROUND AND STUDY AIMS

The AIM-II Trial included patients with nondysplastic Barrett's esophagus (NDBE) treated with radiofrequency ablation (RFA). Complete eradication of NDBE (complete response-intestinal metaplasia [CR-IM]) was achieved in 98.4 % of patients at 2.5 years. We report the proportion of patients demonstrating CR-IM at 5-year follow-up.

PATIENTS AND METHODS

Prospective, multicenter US trial (NCT00489268). After endoscopic RFA of NDBE up to 6 cm, patients with CR-IM at 2.5 years were eligible for longer-term follow-up. At 5 years, we obtained four-quadrant biopsies from every 1 cm of the original extent of Barrett's esophagus. All specimens were reviewed by one expert gastrointestinal pathologist, followed by focal RFA and repeat biopsy if NDBE was identified. Primary outcomes were (i) proportion of patients demonstrating CR-IM at 5-year biopsy, and (ii) proportion of patients demonstrating CR-IM at 5-year biopsy or after the single-session focal RFA.

RESULTS

Of 60 eligible patients, 50 consented to participate. Of 1473 esophageal specimens obtained at 5 years 85 % contained lamina propria or deeper tissue (per patient, mean 30 , standard deviation [SD] 13). CR-IM was demonstrated in 92 % (46 / 50) of patients, while 8 % (4 / 50) had focal NDBE; focal RFA converted all these to CR-IM. There were no buried glands, dysplasia, strictures, or serious adverse events. Kaplan-Meier CR-IM survival analysis showed probability of maintaining CR-IM for at least 4 years after first durable CR-IM was 0.91 (95 % confidence interval [CI] 0.77 - 0.97) and mean duration of CR-IM was 4.22 years (standard error [SE] 0.12).

CONCLUSIONS

In patients with NDBE treated with RFA, CR-IM was demonstrated in the majority of patients (92 %) at 5-year follow-up, biopsy depth was adequate to detect recurrence, and all failures (4 / 4, 100 %) were converted to CR-IM with single-session focal RFA.

Biopsy depth after radiofrequency ablation of dysplastic Barrett's esophagus

BACKGROUND

After endoscopic radiofrequency ablation (RFA) of dysplastic Barrett's esophagus (BE), endoscopic biopsy samples are obtained to assess response to therapy. Whether these biopsies are of adequate depth to assess efficacy is unknown.

OBJECTIVE

To compare the depth of endoscopic biopsy samples after RFA with those of untreated controls and to determine the prevalence of subepithelial structures in endoscopic biopsy fragments.

DESIGN

Secondary analysis of the AIM Dysplasia Trial, a multicenter, randomized, sham-controlled study.

SETTING

Nineteen treatment centers.

PATIENTS

Subjects with dysplastic BE, either status post RFA or ablation naïve (sham).

MAIN OUTCOME MEASUREMENTS

The proportion of biopsy samples demonstrating subepithelial structures, stratified by tissue type (columnar vs squamous) in sham- and RFA-treated subjects.

RESULTS

A total of 5648 biopsy fragments were analyzed from 113 subjects (78 RFA, 35 sham; mean 50.0 fragments per subject). Most fragments (4653, 82.4%) contained subepithelium. Squamous biopsy samples from RFA and sham subjects demonstrated subepithelium at similar rates (78.4% vs 79.1%, respectively, P = not significant [NS]). Columnar biopsy samples from RFA and sham subjects also included subepithelium at similar rates (99.0% vs 98.8%, respectively, P = NS). Regardless of treatment assignment, more columnar than squamous biopsy samples demonstrated subepithelium (98.8% vs 78.5%, P < .001).

LIMITATIONS

Biopsy samples were not individually mounted.

CONCLUSIONS

In both squamous and columnar tissue, endoscopic biopsy samples after RFA were as likely to demonstrate subepithelium as untreated controls. Almost 80% of all biopsy samples were adequate to evaluate for subsquamous intestinal metaplasia. The primary determinant of biopsy depth is the type of epithelium that underwent biopsy, with squamous less likely to yield subepithelium than columnar. Biopsy samples after RFA appear to be of adequate depth to assess response to therapy. (Clinical trial registration number NCT00282672.).

The case for endoscopic treatment of non-dysplastic and low-grade dysplastic Barrett's esophagus

Non-dysplastic mucosa (ND-) in Barrett's esophagus (BE) shows clonal molecular aberrations, loss of cell cycle control, and other features of "neoplasia." These changes occur prior to morphologic expression of neoplasia (dysplasia). Morphologic evaluation of dysplasia is fraught with error, and, as a result, often leads to false-negative and false-positive diagnoses. Early "crypt dysplasia" is difficult to detect, and is often missed in routine biopsy specimens. Some studies show substantial progression rates of low-grade dysplasia (LGD), and crypt dysplasia, to esophageal adenocarcinoma (EAC). Dysplasia, even when fully developed, may, in certain circumstances, be difficult to differentiate from non-dysplastic (regenerating) BE. Radiofrequency ablation (RFA) is a safe and effective method for removing mucosa at risk of cancer. Given the difficulties of dysplasia assessment in mucosal biopsies, and the molecular characteristics of ND-BE, this technique should be considered for treatment of all BE patients, including those with ND or LGD. Post-ablation neo-squamous epithelium reveals no molecular abnormalities, and is biologically stable. Given that prospective randomized controlled trials of ablative therapy for ND-BE aiming at reducing EAC incidence and mortality are unlikely to be completed in the near future, endoscopic ablation is a valid management option. The success of RFA in achieving safe, uniform, reliable, and predictable elimination of BE allows surgeons to combine fundoplication with RFA. Currently, there is no type of treatment for dysplastic or non-dysplastic BE that achieves a complete response in 100% of patients, eliminates all risk of developing cancer, results in zero adverse events, is less expensive in terms of absolute costs than surveillance, is durable for 20+ years, or eliminates the need for surveillance. Regardless, RFA shows established safety, efficacy, durability, and cost-effective profiles that should be considered in the management of patients with non-dysplastic or low-grade dysplastic BE.

Radiofrequency ablation in Barrett's esophagus with dysplasia

BACKGROUND

Barrett's esophagus, a condition of intestinal metaplasia of the esophagus, is associated with an increased risk of esophageal adenocarcinoma. We assessed whether endoscopic radiofrequency ablation could eradicate dysplastic Barrett's esophagus and decrease the rate of neoplastic progression.

METHODS

In a multicenter, sham-controlled trial, we randomly assigned 127 patients with dysplastic Barrett's esophagus in a 2:1 ratio to receive either radiofrequency ablation (ablation group) or a sham procedure (control group). Randomization was stratified according to the grade of dysplasia and the length of Barrett's esophagus. Primary outcomes at 12 months included the complete eradication of dysplasia and intestinal metaplasia.

RESULTS

In the intention-to-treat analyses, among patients with low-grade dysplasia, complete eradication of dysplasia occurred in 90.5% of those in the ablation group, as compared with 22.7% of those in the control group (P<0.001). Among patients with high-grade dysplasia, complete eradication occurred in 81.0% of those in the ablation group, as compared with 19.0% of those in the control group (P<0.001). Overall, 77.4% of patients in the ablation group had complete eradication of intestinal metaplasia, as compared with 2.3% of those in the control group (P<0.001). Patients in the ablation group had less disease progression (3.6% vs. 16.3%, P=0.03) and fewer cancers (1.2% vs. 9.3%, P=0.045). Patients reported having more chest pain after the ablation procedure than after the sham procedure. In the ablation group, one patient had upper gastrointestinal hemorrhage, and five patients (6.0%) had esophageal stricture.

CONCLUSIONS

In patients with dysplastic Barrett's esophagus, radiofrequency ablation was associated with a high rate of complete eradication of both dysplasia and intestinal metaplasia and a reduced risk of disease progression. (ClinicalTrials.gov number, NCT00282672.)

Squamous overgrowth is not a safety concern for photodynamic therapy for Barrett's esophagus with high-grade dysplasia

BACKGROUND & AIMS

Photodynamic therapy with porfimer sodium combined with acid suppression (PHOPDT) is used to treat patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD). A 5-year phase 3 trial was conducted to determine the extent of squamous overgrowth of BE with HGD after PHOPDT.

METHODS

Squamous overgrowth was compared in patients with BE with HGD randomly assigned (2:1) to receive PHOPDT (n=138) or 20 mg omeprazole twice daily (n=70). Patients underwent 4-quadrant jumbo esophageal biopsies every 2 cm throughout the pretreatment length of BE until 4 consecutive quarterly follow-up results were negative for HGD and then biannually up to 5 years or treatment failure. Endoscopies were reviewed by blinded gastroenterology pathologists.

RESULTS

Histologic assessment of 33,658 biopsies showed no significant difference (P> .05) in squamous overgrowth between groups when compared per patient (30% vs 33%) or per biopsy (0.5% vs 1.3%), or when the average number of biopsies with squamous overgrowth were compared per patient (0.48 vs 0.66). The highest grade of neoplasia per endoscopy was not found exclusively beneath squamous mucosa in any patient.

CONCLUSIONS

No difference was observed in squamous overgrowth between patients given PHOPDT plus omeprazole compared with only omeprazole. Squamous overgrowth did not obscure the most advanced neoplasia in any patient. Treatment of HGD with PHOPDT in patients with BE does not present a long-term risk of failure to detect subsquamous dysplasia or carcinoma.

Endoscopic ablation of Barrett's esophagus: a multicenter study with 2.5-year follow-up

BACKGROUND

For patients with Barrett's esophagus (BE), life-long surveillance endoscopy is recommended because of an elevated risk for developing dysplasia and esophageal adenocarcinoma. Various endoscopic therapies have been used to eradicate BE. Recently circumferential radiofrequency ablation has been used with encouraging short-term results.

OBJECTIVE

To provide longer follow-up and to assess the long-term safety and efficacy of step-wise circumferential ablation with the addition of focal ablation for BE.

DESIGN

Prospective, multicenter clinical trial (NCT00489268).

SETTING

Eight U.S. centers, between May 2004 and February 2007.

PATIENTS

Seventy subjects with 2 to 6 cm of BE and histologic evidence of intestinal metaplasia (IM).

INTERVENTIONS

Circumferential ablation was performed at baseline and repeated at 4 months if there was residual IM. Follow-up biopsy specimens were obtained at 1, 3, 6, 12, and 30 months. Specimens were reviewed by a central pathology board. Focal ablation was performed after the 12-month follow-up for histological evidence of IM at the 12-month biopsy (absolute indication) or endoscopic appearance suggestive of columnar-lined esophagus (relative indication). Subjects received esomeprazole for control of esophageal reflux.

MAIN OUTCOME MEASUREMENTS

Complete absence of IM per patient from biopsy specimens obtained at 12 and 30 months, defined as complete remission-IM (CR-IM).

RESULTS

At 12 months, CR-IM was achieved in 48 of 69 available patients (70% per protocol [PP], 69% intention to treat [ITT]). At 30 months after additional focal ablative therapy, CR-IM was achieved in 60 of 61 available patients (98% PP, 97% ITT). There were no strictures or buried glandular mucosa detected by the standardized biopsy protocol at 12 or 30 months, and there were no serious adverse events.

LIMITATIONS

This was an uncontrolled clinical trial with 2.5-year follow-up.

CONCLUSION

Stepwise circumferential and focal ablation resulted in complete eradication of IM in 98% of patients at 2.5-year follow-up.

Circumferential ablation of Barrett's esophagus that contains high-grade dysplasia: a U.S. Multicenter Registry

BACKGROUND

The management strategies for Barrett's esophagus (BE) that contains high-grade dysplasia (HGD) include intensive endoscopic surveillance, photodynamic therapy, thermal ablation, EMR, and esophagectomy.

OBJECTIVE

To assess the safety and effectiveness of endoscopic circumferential balloon-based ablation by using radiofrequency energy for treating BE HGD.

DESIGN

Multicenter U.S. registry.

SETTING

Sixteen academic and community centers; treatment period from September 2004 to March 2007.

PATIENTS

Patients with histologic evidence of intestinal metaplasia (IM) that contained HGD confirmed by at least 2 expert pathologists. A prior EMR was permitted, provided that residual HGD remained in the BE region for ablation.

INTERVENTION

Endoscopic circumferential ablation with follow-up esophageal biopsies to assess the histologic response to treatment.

OUTCOMES

Histologic complete response (CR) end points: (1) all biopsy specimen fragments obtained at the last biopsy session were negative for HGD (CR-HGD), (2) all biopsy specimens were negative for any dysplasia (CR-D), and (3) all biopsy specimens were negative for IM (CR-IM).

RESULTS

A total of 142 patients (median age 66 years, interquartile range [IQR] 59-75 years) who had BE HGD (median length 6 cm, IQR 3-8 cm) underwent circumferential ablation (median 1 session, IQR 1-2). No serious adverse events were reported. There was 1 asymptomatic stricture and no buried glands. Ninety-two patients had at least 1 follow-up biopsy session (median follow-up 12 months, IQR 8-15 months). A CR-HGD was achieved in 90.2% of patients, CR-D in 80.4%, and CR-IM in 54.3%.

LIMITATIONS

A nonrandomized study design, without a control arm, a lack of centralized pathology review, ablation and biopsy technique not standardized, and a relatively short-term follow-up.

CONCLUSIONS

Endoscopic circumferential ablation is a promising modality for the treatment of BE that contains HGD. In this multicenter registry, the intervention safely achieved a CR for HGD in 90.2% of patients at a median of 12 months of follow-up.

Photodynamic therapy of Barrett's esophagus: ablation of Barrett's mucosa and reduction in p53 protein expression after treatment

BACKGROUND

The effectiveness of photodynamic therapy (PDT) for ablation of high grade dysplasia (HGD) in Barrett's esophagus (BE) is typically reported histologically. Following successful PDT, Barrett's mucosa is replaced with neosquamous mucosa. The objective of this study was to compare the expression of p53 protein in neosquamous mucosa as compared to that in HGD samples not treated with PDT.

PATIENTS AND METHODS

The patients were divided into two groups. Group I patients (n = 12) had been treated with PDT for HGD and provided 23 biopsy samples of neosquamous mucosa. Group II patients (n = 10) had not received any ablative therapies for BE and provided 14 HGD samples. The immunohistochemical (IHC) staining for p53 protein was performed using mouse anti-human monoclonal antibody DO-1. The degree of p53 protein expression in the cell nuclei was scored using an established IHC scoring system (0 for negative samples and range of 2 to 8 for positive samples).

RESULTS

The HGD samples showed diffuse strong p53 staining. The median IHC score for HGD was 7.0. The median IHC score for neosquamous mucosa following PDT was 4.0, with positive scores indicating weak staining in the basal layer of the neosquamous samples. There was significantly lower p53 expression in the neosquamous samples compared to that in the HGD samples (p < 0.001).

CONCLUSION

Significantly lower p53 protein expression was detected in neosquamous mucosa of patients who had received PDT for HGD, suggesting a decreased risk for neoplastic progression after treatment.

Development of a synchronous fluorescence imaging system and data analysis methods

Although conventional autofluorescence spectroscopy, in which fluorescence emission spectra are recorded for fixed excitation wavelengths, has demonstrated good performance in tissue diagnosis, it suffers from prolonged data acquisition time and broad-band fluorescence features. Synchronous spectroscopy has been proposed to overcome the limitations of conventional fluorescence spectroscopy but has not been applied to imaging for tissue diagnosis in vivo. Our group has developed a synchronous fluorescence imaging system to combine the great diagnostic potential of synchronous spectroscopy and the large field of view of imaging for cancer diagnosis. This system has been tested in a mouse skin model to capture synchronous fluorescence images. A simple discriminant analysis method and a more complicated multi-variate statistical method have been developed to generate a single diagnostic image from a large number of raw fluorescence images. Moreover, it was demonstrated that the diagnostic image generated from synchronous data is comparable to that generated from full spectral data in classification accuracy.

Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high-grade dysplasia

BACKGROUND

Barrett's esophagus (BE) with high-grade dysplasia (HGD) is a risk factor for development of esophageal carcinoma. Photodynamic therapy (PDT) with Photofrin (PHO) has been used to eliminate HGD in BE.

OBJECTIVE

Our purpose was to compare PHOPDT plus omeprazole with omeprazole only (OM).

DESIGN

Five-year follow-up of a randomized, multicenter, multinational, pathology-blinded HGD trial.

SETTING

30 sites in 4 countries.

PATIENTS

208.

INTERVENTIONS

Patients with BE and HGD were randomized (2:1) to PHOPDT (n=138) or OM (n=70) into a 2-year trial followed up for 3 more years. PHOPDT patients received 2 mg/kg PHO intravenously followed by endoscopic laser light exposure of Barrett's mucosa at a wavelength of 630 nm within 40 to 50 hours to a maximum of 3 courses at least 90 days apart. Both groups received 20 mg of OM twice daily. Pathologists at one center assessed biopsy specimens in a blinded fashion.

MAIN OUTCOME MEASUREMENT

HGD ablation status over 5 years of follow-up.

RESULTS

At 5 years PHOPDT was significantly more effective than OM in eliminating HGD (77% [106/138] vs 39% [27/70], P<.0001). A secondary outcome measure preventing progression to cancer showed a significant difference (P=.027) with about half the likelihood of cancer occurring in PHOPDT (21/138 [15%]) compared with OM (20/70 [29%]), with a significantly (P=.004) longer time to progression to cancer favoring PHOPDT.

LIMITATIONS

Not all patients were available for follow-up.

CONCLUSIONS

This 5-year randomized trial of BE patients with HGD demonstrates that PHOPDT is a clinically and statistically effective therapy in producing long-term ablation of HGD and reducing the potential impact of cancer compared with OM.

Improving efficiencies in the GI practice of endoscopic ambulatory surgery center

The practice of gastroenterology is undergoing sweeping changes that demand improvements in efficiency and effectiveness within the practice and ambulatory endoscopy centers. This article discusses core principles of practice and endoscopic ambulatory surgery center function and management that lead to the improvements in the delivery of efficient, quality care.

Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett's esophagus: 1-year follow-up of 100 patients

OBJECTIVE

To assess the dose-response, safety, and efficacy of circumferential endoscopic ablation of Barrett's esophagus (BE) by using an endoscopic balloon-based ablation device (HALO360 System).

DESIGN

This study was conducted in 2 serial phases (dosimetry phase and effectiveness phase) to evaluate a balloon-based ablation device that delivers a pre-set amount of energy density (J/cm2) to BE tissue. The dosimetry phase evaluated the dose-response and the safety of delivering 6 to 12 J/cm2. The effectiveness phase used 10 J/cm2 (delivered twice [x2]) for all patients, followed by EGD with biopsies at 1, 3, 6, and 12 months. A second ablation procedure was performed if BE was present at 1 or 3 months. Patients received esomeprazole 40 mg twice a day for 1 month after ablation, and 40 mg every day thereafter. Postablation symptoms were quantified by using a 14-day symptom diary (scale, 0-100). A complete response (CR) was defined as all biopsy specimens negative for BE at 12 months.

SETTING

Eight U.S. centers, between September 2003 and September 2005.

PATIENTS

Patients were 18 to 75 years of age, with a diagnosis of BE (without dysplasia), with histopathology reconfirmation of the diagnosis within 6 months of enrollment.

RESULTS

In the dosimetry phase, 32 patients (29 men; mean age, 56.8 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 3. There were no dose-related serious adverse events, and the outcomes at 1 and 3 months permitted the selection of 10 J/cm2 (x2) for the subsequent effectiveness phase of the study. In the effectiveness phase, 70 patients (52 men, 18 women; mean age, 55.7 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 4. At 12 months (n = 69; mean, 1.5 sessions), a CR for BE was achieved in 70% of patients. There were no strictures and no buried glandular mucosa in either study phase (4306 biopsy fragments evaluated).

CONCLUSIONS

Circumferential ablation of nondysplastic BE by using this balloon-based ablation device can be performed with no subsequent strictures or buried glands and with complete elimination of BE in 70% of patients at 1-year follow-up.

Porfimer sodium photodynamic therapy for management of Barrett's esophagus with high-grade dysplasia

Porfimer sodium photodynamic therapy (ps-PDT) for Barrett's esophagus is a powerful endoscopic treatment that can eliminate high-grade dysplasia (HGD) and Barrett's mucosa and reduce the risk of development of cancer in these patients. Ps-PDT typically results in destruction of Barrett's esophagus in the majority of the treated area. However, residual small island of Barrett's mucosa may persist after PDT. Therefore, adjuvant thermal ablation should be available during follow-up endoscopies for ablation of residual islands of Barrett's mucosa. PDT should be applied concurrent with effective proton pump inhibitor therapy. This article provides a practical guide for application of porfimer sodium balloon PDT for management of Barrett's esophagus with HGD. Recommendations are provided for patient selection and screening, delivery of PDT to include light dosimetry, methodology for follow-up endoscopies, as well as discussing the potential side effects and complications.

Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett's esophagus: international, partially blinded, randomized phase III trial

BACKGROUND

Barrett's esophagus (BE) may lead to high-grade dysplasia (HGD) and adenocarcinoma. The objective was to examine the impact of treating patients with BE and with HGD by using porfimer sodium (POR) and photodynamic therapy (PDT) for ablating HGD and reducing the incidence of esophageal adenocarcinoma.

METHODS

The design was a multicenter, partially blinded (pathology), randomized clinical trial conducted in patients with BE who have HGD. There were 30 contributing centers. A total of 485 patients were screened, with 208 in the intent-to-treat population and 202 in the safety population. Patients were randomized on a 2:1 basis to compare PDT with POR plus omeprazole (PORPDT) with omeprazole only (OM). The main outcome measurement was complete HGD ablation occurring at any time during the study period.

RESULTS

There was a significant difference (p < 0.0001) in favor of PORPDT (106/138 [77%]) compared with OM (27/70 [39%]) in complete ablation of HGD at any time during the study period. The occurrence of adenocarcinoma in the PORPDT group (13%) (n=18) was significantly lower (p < 0.006) compared with the OM group (28%) [corrected] (n=20). The safety profile showed 94% of patients in the PORPDT group and 13% of patients in the OM group had treatment-related adverse effects. The limitations of the study were that PDT therapy may have had to be applied more than once and that patients spent more time in treatment. The patients and the physicians were not blinded to the treatment.

CONCLUSIONS

PORPDT in conjunction with omeprazole is an effective therapy for ablating HGD in patients with BE and in reducing the incidence of esophageal adenocarcinoma.

An Educational Tool for Photodynamic Therapy of Barrett Esophagus With High-Grade Dysplasia

Photodynamic therapy using a centering balloon was recently approved by the Food and Drug Administration for ablation of Barrett esophagus with high-grade dysplasia. This article is an educational tool for the photodynamic therapy team, addressing four important steps involved with photodynamic therapy: screening for potential patients, patient education, treatment using the centering balloon, and follow-up after treatment. Each step ensures proper care for the patient requiring photodynamic therapy.

Optimization of light dosimetry for photodynamic therapy of Barrett's esophagus: efficacy vs. incidence of stricture after treatment

BACKGROUND

Photodynamic therapy (PDT) may be used to ablate high-grade dysplasia/early stage cancer (HGD/T1) in patients with Barrett's esophagus. PDT may result in esophageal stricture. This nonrandomized, unblinded, dose de-escalation study in consecutive patients was designed to determine the lowest light dose effective for ablation of HGD/T1 while reducing the incidence of stricture.

METHODS

A total of 113 patients received an injection of porfimer sodium (2 mg/kg). Three days later, 630 nm light was delivered by using a 20-mm-diameter PDT balloon at doses of 115 J/cm (n=59), 105 J/cm (n=18), 95 J/cm (n=17), or 85 J/cm (n=19). Treatment efficacy was determined by obtaining biopsy specimens of the treated area 3 months later. The incidence of stricture was determined by the need for esophageal dilation to treat dysphagia. A stricture was considered severe if 6 or more dilations were required.

RESULTS

The incidence of severe stricture was related to the light dose. At 115 J/cm, 15.3% of patients developed severe strictures compared with 5.3% to 5.6% of those treated with the lower doses. At a light dose of 115 J/cm, 17.0% of patients had residual HGD/T1. Light doses of 105 J/cm, 95 J/cm, and 85 J/cm resulted in residual HGD/T1 in 33.3%, 29.4%, and 31.6% of patients, respectively. None of the observations were statistically significant.

CONCLUSIONS

Decreasing the light dose below 115 J/cm appeared to result in a reduced incidence rate of severe stricture but higher relative frequencies of residual HGD/T1 in Barrett's esophagus.

What is the best management strategy for high grade dysplasia in Barrett's oesophagus? A cost effectiveness analysis

BACKGROUND

Multiple treatment strategies for subjects with high grade dysplasia (HGD) in Barrett's oesophagus (BO) have been suggested. However, it is unclear which of these strategies provides the greatest life expectancy, and the costs associated with the management strategies are unknown.

AIM

To compare the efficacy and cost effectiveness of competing management strategies for BO with HGD.

METHODS

We created a decision analysis model in Data 4.0 to assess possible treatment strategies for BO with HGD. The strategies included: (1) no preventative strategy, (2) elective surgical oesophagectomy, (3) endoscopic ablation, and (4) surveillance endoscopy. The base case was a healthy 50 year old White male with an initial diagnosis of BO with HGD. The model allowed for complications of surgery, including death. Ablative therapy could cause stricture or perforation. Pathological misinterpretation was allowed, and modelled after reported rates. Estimates were derived from the literature for the rate of progression of HGD to cancer and for complication rates for the various treatment modalities. The endoscopic ablation arm was modelled as photodynamic therapy. Sensitivity analyses were performed over a wide range of cancer incidences, complication rates, and procedure costs.

RESULTS

Endoscopic ablation was the most effective strategy, yielding 15.5 discounted quality adjusted life years (dQALY), compared with 15.0 for endoscopic surveillance and 14.9 for oesophagectomy. No preventative strategy was the most inexpensive option, yielding an average cost per quality adjusted life year of US dollars 54 (44) per dQALY, but resulted in high rates of cancer. Endoscopic surveillance dominated oesophagectomy, being both less costly and more effective. The condition of extended dominance occurred when comparing endoscopic ablation to endoscopic surveillance because, although the total costs of ablation were greater than those of surveillance, it was less expensive to buy an additional life year using endoscopic ablation than endoscopic surveillance. The incremental cost effectiveness ratio when moving from no therapy to ablative therapy was a reasonable US dollars 25 621/dQALY (21 009/dQALY). Sensitivity analysis demonstrated that when yearly rates of progression to cancer from HGD exceeded 30%, oesophagectomy became the most cost effective option.

CONCLUSIONS

A strategy of endoscopic ablation provided the longest quality adjusted life expectancy for BO with HGD. Although endoscopic surveillance was less expensive than endoscopic ablation, it was associated with shorter survival. Optimal utilisation of healthcare resources may be achieved with endoscopic ablative therapy for BO with HGD.

Perforation during colonoscopy in endoscopic ambulatory surgical centers

BACKGROUND

Perforation as a complication of colonoscopy is estimated to occur in 0.01% to 0.3% of procedures, but the frequency in ambulatory settings is unknown. This study determined the number of perforations occurring within a network of endoscopic ambulatory surgery centers.

METHODS

A total of 116,000 colonoscopies were performed within one network of 45 endoscopic ambulatory surgery centers in the United States during 1999. All identified perforations were reported to the network clinical director and reviewed by a panel of 3 gastroenterologists.

RESULTS

There were 37 (0.03%) perforations; 27 in women and 10 in men. Median patient age was 75 years (range 39-87 years); 18 patients (49%) had diverticular disease and 20 (54%) had a history of pelvic or colonic surgery. Twenty-four (65%) procedures were diagnostic, and 13 (35%) were therapeutic. The most common site of perforation was the sigmoid colon (62%); followed by the ascending colon (16%); cecum, transverse colon, and splenic flexure (11%); and rectum, anastomotic, or unknown (11%). The time to diagnosis ranged from immediate to 72 hours (29 <1 hour, 8 >1 hour). All patients were hospitalized; 35 (95%) underwent exploratory laparotomy, and 2 (5%) were treated conservatively. No patient died.

CONCLUSIONS

Reported perforations for procedures performed in endoscopic ambulatory surgery centers occurred most frequently during diagnostic colonoscopy in older woman with a history of surgery or diverticular disease. Reported perforations in endoscopic ambulatory surgery centers were uncommon.

Photodynamic therapy for Barrett's esophagus with dysplasia and/or early stage carcinoma: long-term results

BACKGROUND

Photodynamic therapy has been shown to eliminate Barrett's dysplasia. This report presents long-term follow-up data after photodynamic therapy of Barrett's esophagus with high-grade dysplasia, low-grade dysplasia, or early stage carcinoma.

METHODS

Porfimer-photodynamic therapy was performed in 103 patients. The Nd:YAG laser was used to photoablate small areas of residual or untreated Barrett's mucosa. Acid suppression was maintained in all patients (omeprazole, 20 mg twice a day).

RESULTS

Mean follow-up was 50.65 (SD 20.57) months (range 2-122 months). For the 82 patients not lost to follow-up, mean follow-up was 58.5 (12.89) months (range 41-132 months). After photodynamic therapy, the length of Barrett's mucosa decreased by a mean of 6.92 cm (range 1-22 cm). Of the 65 patients with high-grade dysplasia, 60 (94%) had elimination of high-grade dysplasia. Three (4.6%) patients developed subsquamous adenocarcinoma. Subsquamous, nondysplastic, metaplastic epithelium was found in 4 patients (4.9%). Strictures occurred in 18% with one session of photodynamic therapy, and 50% with two treatments, 30% overall. For the 103 patients, intention-to-treat success rates were 92.9%, 77.5%, and 44.4% for, respectively, low-grade dysplasia, high-grade dysplasia, and early stage carcinoma groups.

CONCLUSION

Porfimer-photodynamic therapy with supplemental Nd:YAG photoablation and continuous treatment with omeprazole reduces the length of Barrett's mucosa, eliminates high-grade dysplasia, and, by comparison with historical data, may reduce the expected frequency of carcinoma.

A corporate partner in the endoscopic ambulatory surgery center. A business relationship that works

Although doubts persist in the minds of some, physician owners-developers of EASCs are increasingly entering into long-term business relationships with a CP by jointly developing an EASC or by selling a controlling financial interest in their EASC to the CP. In exchange, the physicians benefit through improved quality of care, increased patient and physician satisfaction, and enhanced EASC revenues.

Revenue enhancement for the practice and the endoscopic ambulatory surgery center

Gastroenterologists, like all physicians, are attempting to control more of the services they provide by developing programs that enhance quality of care and practice revenues, reduce physician stress, and improve the physician's quality of life. Many opportunities exist to accomplish these goals, including those discussed in this article. The overriding feature of any such activity, however, must always meet the criteria of improving patient care.

Photodynamic therapy using Verteporfin (benzoporphyrin derivative monoacid ring A, BPD-MA) and 630 nm laser light in canine esophagus

BACKGROUND AND OBJECTIVE

Verteporfin is a new photosensitizer with short-term skin photosensitivity. The objective of this preclinical study was to find the light dose that effectively ablates canine esophageal mucosa when delivered 30 minutes after Verteporfin injection.

STUDY DESIGN/MATERIALS AND METHODS

Verteporfin was administered intravenously (0.75 mg/kg). 630 nm light from KTP/Dye laser was delivered using an esophageal Photodynamic therapy (PDT) balloon. In Phase I study, animals were treated 30 minutes after drug injection using 40, 60, and 80 J/cm to find the desired light dose. Using results from phase I and application of reciprocity principle (light dose vs. plasma concentration of drug), additional light doses were calculated for delivery at other times. In phase II, animals were treated at 15, 60, and 120 minutes, using the calculated light doses of 60, 145, and 200 J/cm, respectively. Animals were followed for 2 days to 4 weeks.

RESULTS

In Phase I, 80 J/cm at 30 minutes induced total mucosal ablation. In Phase II, light doses of 60, 145, and 200 J/cm induced similar mucosal injuries when delivered at 15, 60, and 120 minutes, respectively.

CONCLUSIONS

Effective mucosal ablation in canine esophagus was achieved using Verteporfin and 630 nm light doses of 60, 80, 145, and 200 J/cm when delivered at 15, 30, 60, and 120 minutes after the drug injection, respectively.

Evaluating treatments of Barrett's esophagus that shows high-grade dysplasia

Thermal ablation and surgery are currently indicated for the treatment of Barrett's esophagus that shows high-grade dysplasia. Recent clinical thought is that photodynamic therapy (PDT), a nonsurgical ablative therapy, along with proton pump inhibitor therapy, may be able to eliminate Barrett's esophagus with less morbidity and mortality, and perhaps at a lower cost, than other current treatments. PDT is currently under investigation for this indication. The principles of ablative therapy, complications of PDT, treatment results, the best candidates for PDT, and the workup strategy are discussed.

Results of photodynamic therapy for ablation of dysplasia and early cancer in Barrett's esophagus and effect of oral steroids on stricture formation

OBJECTIVE

The primary goal of this study was to investigate whether oral steroids would reduce the incidence of stricture formation after photodynamic therapy (PDT) in Barrett's patients. The effect of balloon window length, pretreatment of nodules, retreatment of skipped areas, and subsequent PDT on the incidence of strictures was also investigated. The ultimate goal of treatment was elimination of dysplasia, early cancer, and Barrett's mucosa.

METHODS

A total of 60 patients were injected with Photofrin (2 mg/kg). Patients were randomized to receive PDT (n = 30) or PDT and oral prednisone (n = 30). Two days later, 630 nm light (KTP/dye laser) was delivered using a 5- or 7-cm windowed balloon at a light dose of 200 or 175 J/cm. The majority of patients received 200 J/cm using a 7-cm balloon. Nodules were pretreated with a short diffuser at a dose of 50-75 J/cm. Additional light was delivered to skipped areas 2-3 days later. Endoscopies were conducted every 3-6 months to evaluate the response. Residual or recurrent Barrett's was treated using neodymium:aluminum-yttrium-garnet (Nd:YAG) laser (small areas) or was retreated with PDT.

RESULTS

The effect of steroids on the incidence of strictures was analyzed in patients receiving a single treatment with a light dose of 200 J/cm using a 7- cm balloon. There was no reduction in the incidence of strictures in patients receiving PDT and steroids (29%) compared to those receiving PDT alone (16%). Treatment using a 7-cm balloon caused more strictures (31%) than treatments using a 5-cm balloon (7%). Pretreatment of nodules or retreatment of skipped areas did not increase strictures. Patients receiving subsequent PDT had a higher incidence of strictures. Cancer was eliminated in all patients. High-grade dysplasia was eliminated in 41 of 43 patients (96%). Barrett's mucosa was totally eliminated in 25 of 60 patients (42%).

CONCLUSIONS

Oral prednisone after PDT did not reduce the incidence of strictures. Subsequent PDT and longer balloon window were associated with higher incidence of strictures. PDT followed by thermal ablation of small islands eliminated dysplasia, early cancer, and Barrett's mucosa.

Light sources and delivery devices for photodynamic therapy in the gastrointestinal tract

This article provides discussion on different light sources and light delivery devices used for photodynamic therapy of a variety of gastrointestinal malignancies. Different laser and nonlaser sources are discussed with emphasis on most commonly used clinical units. The discussion of light delivery devices is divided into several sections, each reviewing the evolution of fiberoptic delivery devices for different gastrointestinal malignancy. A discussion is provided on power meters and wavelength calibration devices used to assure proper light dosimetry. Finally, a short discussion is provided on a technique used to improve endoscopic monitoring of photodynamic therapy procedure during the treatment.

Photodynamic therapy for Barrett's esophagus: cardiac effects

BACKGROUND AND OBJECTIVE

Atrial fibrillation has been reported following esophageal photodynamic therapy. This study presents the results of serial cardiac testing following photodynamic therapy for patients with Barrett's esophagus and with dysplasia or early carcinoma.

STUDY DESIGN/MATERIALS AND METHODS

Twelve patients were treated using photodynamic therapy. Serum creatinine phosphokinase and lactic dehydrogenase isoenzyme levels were determined pretreatment and 24, 48, and 72 hours after treatment. Electrocardiograms were obtained before and 48 hours after treatment. A rhythm strip was obtained 1 week posttreatment. Clinical assessment for cardiac arrhythmias occurred daily following therapy.

RESULTS

Transient atrial fibrillation was noted in one patient during a follow-up endoscopy. However, no significant or permanent abnormality was noted in cardiac enzymes or electrocardiograms.

CONCLUSION

No permanent electrocardiographic changes or significant abnormalities in cardiac enzymes were detected following esophageal photodynamic therapy in patients with or without histories of cardiac disease. Delivery of esophageal PDT is not associated with permanent adverse cardiac effects.

Acid suppression and reepithelialization after ablation of Barrett's esophagus

The role of acid reflux in the development of esophageal columnar epithelium was first described in the early 1970s in the canine esophageal reflux model. In the presence of acid reflux, columnar epithelium developed at the site of induced esophageal mucosal injury. When reflux was suppressed, most epithelium reverted back to squamous mucosa. Similar findings in human patients with Barrett's esophagus (BE) who were treated with laser ablation were first described in 1993. While acid suppression with antireflux surgery or proton pump inhibitors (PPIs) has proven insufficient to completely reverse BE, ablation of the lesion followed by acid suppression may be a promising option. Although at least one report disputes the importance of complete acid suppression following mucosal ablation of BE, most investigators use full-dose PPI therapy following ablation, in the belief that full acid suppression provides an environment that allows the esophageal progenitor cell to develop squamous mucosa. This article provides a review of the literature to date regarding ablative therapies and acid suppression for patients with BE.

Characteristics of best gastroenterology practices

OBJECTIVE

As health care costs continue to rise, competition among providers is increasing. Although this competition is currently based on price, quality of care will become an increasingly important issue. One popular method to assess quality is by comparing physicians' performance with that of a representative group of physicians, in a process called benchmarking. The purpose of this study was to survey private practice gastroenterologists to identify the practice characteristics, so-called "best practices," associated with high-quality health care delivery to provide data for use as benchmarks.

METHODS

Three hundred randomly selected gastroenterology practices were surveyed regarding practice demographics, administration, financial management, and use of outcomes techniques by mail questionnaire. Analogous questionnaires were completed by representatives of the gastroenterology practices comprising the Gastroenterology Practice Management Group, LLC (GMPG).

RESULTS

One hundred and eighty-two (61%) of the 300 eligible practices responded to the questionnaire. Increasing differences between survey and benchmark GPMG practices were observed as the complexity of quality measures increased. Among structure measures, the groups were similar. By contrast, significant differences were observed between survey and benchmark groups with regards to outcomes measures such as the use of practice guidelines, continuous quality improvement, and outcomes assessment.

CONCLUSIONS

These results provide a snapshot of gastroenterology practices across the country and can be used as a benchmark for quality assessment purposes to compare with one's practice, suggesting areas for change or improvement. It seems clear that the defining characteristic of best gastroenterology practices is the demonstration of quality patient care. It also appears that many practices' efforts in this regard could be increased.

Results of photodynamic therapy in Barrett's esophagus: A review

Barrett's esophagus is associated with an increased occurrence of mucosal dysplasia and adenocarcinoma in the specialized glandular mucosa, with a 30- to 52-fold increase in the occurrence of esophageal cancer compared with the normal population. An alternative to esophagectomy as a treatment modality is needed because of the high morbidity and mortality associated with it. Photodynamic therapy offers an alternative nonsurgical therapy that eliminates dysplasia and superficial cancer, and reduces Barrett's mucosa while reducing the risks and costs compared with those of esophagectomy. The use of photodynamic therapy in the ablation of Barrett's mucosa is reviewed.

Photodynamic therapy for Barrett's esophagus: follow-up in 100 patients

BACKGROUND

This report presents clinical results of photodynamic therapy in patients with Barrett's esophagus and dysplasia or superficial esophageal cancer.

METHODS

One hundred patients including 13 with superficial cancers were treated. Light (630 nm) was endoscopically delivered to the esophageal mucosa by a diffuser or a windowed esophageal centering balloon. Nd:YAG laser was required to ablate small residual areas of Barrett's mucosa during-long-term follow-up. Patients were maintained on omeprazole and were followed for 4 to 84 months (mean 19 months).

RESULTS

Conversion of approximately 75% to 80% of treated Barrett's mucosa to normal squamous epithelium was found in all patients; complete elimination of Barrett's mucosa was noted in 43 patients. Dysplasia was eliminated in 78 patients. Dysplasia developed during follow-up in 11 of 48 patients in untreated Barrett's mucosa requiring additional therapy. Ten of the 13 malignancies were ablated. Esophageal strictures occurred in 34%. Use of longer centering balloons reduced the incidence of strictures.

CONCLUSION

Photodynamic therapy alone or with Nd:YAG laser thermal ablation combined with long-term acid inhibition provides an effective endoscopic therapy to (1) eliminate Barrett's mucosal dysplasia and superficial esophageal cancer and (2) reduce the extent of and, in some cases, eliminate Barrett's mucosa.

Laser-induced fluorescence for esophageal cancer and dysplasia diagnosis

A method using laser-induced fluorescence (LIF) for in vivo cancer diagnosis of the esophagus is described. Autofluorescence of normal and malignant tissues was measured directly using a fiberoptic probe inserted through an endoscope. The measurements were performed in vivo during routine endoscopy. Measurement of the fluorescence signal from the tissue was performed using laser excitation at 410 nm. The methodology was applied to differentiate normal and malignant tumors of the esophagus. The results of this LIF approach were compared with histopathology results of the biopsy samples and indicated excellent agreement in the classification of normal and malignant tumors for the samples investigated. The LIF procedure could lead to the development of a rapid and cost-effective technique for cancer diagnosis.

Physician profiling and capitated income distribution

Increasingly, gastroenterologists are addressing the practice issues of physician profiling and capitation. This article describes a method to easily create practice-generated physician profiles that are used in quality of care management and contracting decisions. These profiles are also used as part of a method for capitation revenue distribution that is described and that has been used by the author's practice for over 3 years. This capitation revenue distribution methodology properly rewards the provision of cost-effective care and bonuses desirable to physician-patient relationships, while protecting against under- or over-utilization.

Photodynamic therapy for Barrett's esophagus

In summary, in a group of 55 patients with Barrett's esophagus and dysplasia, the authors have reported the ablation of seven superficial cancers, the elimination of dysplasia in 42 of the 55 patients, the complete elimination of Barrett's mucosa in 16 patients, and the reduction of the extent of Barrett's mucosa in all patients who were treated with PDT and were maintained on long-term omeprazole. Repeated PDT sessions were required in some patients to accomplish elimination of dysplasia. Esophageal strictures occurred in 53% of patients, but were treated satisfactorily with dilation. Current results using 5- and 7-cm centering balloons has shown a dramatic reduction in the incidence of stricture formation. Mucosal injury with these balloons is less than with diffusers or shorter balloons that require overlapping of treated areas. The authors are carefully following the patients treated with longer PDT balloons to evaluate the long-term effects on dysplasia. Lugol's staining is an important technique to identify residual patches of Barrett's mucosa following PDT. Small residual patches of Barrett's mucosa can be successfully destroyed with Nd: YAG laser therapy. The authors' results indicate that PDT alone or in combination with thermal ablation can eliminate superficial cancers, dysplasia, and Barrett's mucosa in many patients with Barrett's esophagus.

Photodynamic therapy in Barrett's esophagus

OBJECTIVES

This report presents clinical results using photodynamic therapy for dysplasia and superficial esophageal cancer in Barrett's esophagus.

METHODS

Forty-five (45) patients with Barrett's esophagus and dysplasia were treated with photodynamic therapy using sodium porfimer 2.0 mg/kg as the photosensitizing drug. Fifteen patients also had 16 superficial esophageal cancers (0-1.5 cm; Tis-T2, N-0, M-0). Red light (630 nm) was delivered to the esophageal mucosa by a diffuser inserted through the endoscope or via a windowed esophageal centering balloon designed to improve targeted delivery of light during photodynamic therapy. Patients were maintained on omeprazole and were followed for 6-62 months following photodynamic therapy.

RESULTS

Photodynamic therapy produced mucosal damage in treated areas. Ablation of dysplastic or malignant mucosa was followed by healing and conversion of approximately 75-80% of treated Barrett's mucosa to normal squamous epithelium in all patients. Complete elimination of Barrett's epithelium was found in 16 patients. Areas of dysplasia were eliminated in 35 of the 45 patients. All 16 malignancies were ablated. No cancer recurrence was found in follow-up. Healing was associated with esophageal strictures in 58%, which were treated successfully by esophageal dilation in all patients.

CONCLUSION

Photodynamic therapy combined with long-term acid inhibition provides an effective endoscopic therapy to (1) eliminate Barrett's mucosal dysplasia and superficial esophageal cancer and (2) reduce the amount of and, in some cases, eliminate Barrett's mucosa.