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Gallegos MMM, Gomes ILC, Brunaldi VO, Bestetti AM, Marques SB, Miyajima NT, Filho HMN, da Silva PHVA, Kum AST, Bernardo WM, de Moura EGH. Endoscopic submucosal dissection vs. endoscopic mucosal resection in the treatment of early Barrett's neoplasia: Systematic review and meta-analysis. Dig Endosc 2024; 36:1299-1311. [PMID: 39219530 DOI: 10.1111/den.14892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 07/04/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES Endoscopic resection is the preferred approach to treat early Barrett's neoplasia, reducing the need for surgical interventions. However, the best choice between endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) remains unclear. The study aimed to compare the efficacy and safety of EMR vs. ESD for early Barrett's neoplasia. METHODS An electronic search was conducted in MEDLINE, Central Cochrane, EMBASE, and LILACS until November 2023. Studies comparing ESD vs. EMR in the treatment of patients with early Barrett's neoplasia were included. This study was performed according to the Preferred Report Items for Systematic Reviews and Meta-Analyses guidelines. The ROBIN-I tool was used to analyze the risk of bias and GRADE to measure the quality of the evidence. RESULTS A total of 9352 patients from 15 observational studies were included. Patients undergoing ESD had significantly higher rates of en-bloc (odds ratio [OR] 25.96, 95% confidence interval [CI] 13.82, 48.74; I2 = 52%; P < 0.00001) and R0 (OR 5.10, 95% CI 3.29, 7.91; I2 = 73%; P < 0.00001) with a higher risk of adverse events, including bleeding, stricture formation, and perforation. In a subgroup analysis of patients who did not receive radiofrequency ablation, ESD had a lower recurrence rate than EMR (OR 0.22, 95% CI 0.05, 0.94; I2 = 88%; P = 0.04). CONCLUSION Endoscopic submucosal dissection is more effective than EMR in treating early Barrett's neoplasia at the expense of higher adverse events rates.
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Affiliation(s)
| | - Igor Logetto Caetité Gomes
- Gastrointestinal Endoscopy Unit, Clinical Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Vitor Ottoboni Brunaldi
- Gastrointestinal Endoscopy Unit, Clinical Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Alexandre Moraes Bestetti
- Gastrointestinal Endoscopy Unit, Clinical Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Sergio Barbosa Marques
- Gastrointestinal Endoscopy Unit, Clinical Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Nelson Tomio Miyajima
- Gastrointestinal Endoscopy Unit, Clinical Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
| | | | | | - Angelo So Taa Kum
- Gastrointestinal Endoscopy Unit, Clinical Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy Unit, Clinical Hospital, University of São Paulo School of Medicine, São Paulo, Brazil
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Teixeira-Farinha H, Béhal H, Cailliau E, Pasquer A, Duhamel A, Théréaux J, Chalret du Rieu M, Lefevre JH, Turner K, Mantziari S, Collet D, Piessen G, Gronnier C. Impact of primary endoscopic resection on oncological outcomes after esophagectomy for cancer: a retrospective propensity score-based cohort study. Surg Endosc 2024; 38:5169-5177. [PMID: 39039292 DOI: 10.1007/s00464-024-11077-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 07/08/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Esophageal cancer posed significant global health challenges, particularly due to poor survival rates, especially in advanced stages. Primary endoscopic resection had emerged as an alternative treatment for early esophageal cancer, aiming to preserve organ function and reduce surgical morbidity. METHODS This retrospective multicenter cohort study included 334 patients with early esophageal cancer (T1a-b, N0) from 30 French-speaking European centers between 2000 and 2010. Patients underwent either primary endoscopic resection followed by esophagectomy (E group, n = 36) or esophagectomy alone (S group, n = 298). Cox proportional hazards models adjusted for TNM stage and propensity score weighting were used to assess the impact of primary endoscopic resection on recurrence-free survival (RFS), overall survival (OS), and postoperative complications. RESULTS Primary endoscopic resection did not significantly influence RFS (adjusted HR 0.92, 95% CI 0.31 to 2.68, p = 0.88) or OS (adjusted HR 1.06, 95% CI 0.35 to 3.13, p = 0.92) compared to esophagectomy alone. Initial higher thromboembolic complications in the endoscopic resection group were not significant after adjustment (adjusted OR 4.73, 95% CI 0.34 to 64.27, p = 0.24). CONCLUSIONS Primary endoscopic resection followed by esophagectomy for early esophageal cancer did not alter oncological outcomes or overall survival in this retrospective cohort. These findings supported the role of primary endoscopic resection as a safe initial treatment strategy, warranting validation in larger prospective studies. REGISTRATION Our study was registered retrospectively on the Clinicaltrials.com website under the identifier NCT01927016. We acknowledge the importance of prospective registration and regret that this was not done before the commencement of the study.
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Affiliation(s)
- Hugo Teixeira-Farinha
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Bordeaux, France
- Department of Visceral Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Hélène Béhal
- Biostatistics Department, CHU Lille, 59000, Lille, France
| | | | - Arnaud Pasquer
- Digestive Surgery Department, Hospices Civils de Lyon, Hôpital Edouard Herriot, Lyon, France
| | - Alain Duhamel
- Biostatistics Department, CHU Lille, 59000, Lille, France
| | - Jérémie Théréaux
- Department of General, Digestive and Metabolic Surgery, La Cavale Blanche University Hospital, Brest, France
| | - Mael Chalret du Rieu
- Service de Chirurgie Bariatrique, Ramsay Générale de Santé, Clinique Des Cedres, Cornebarrieu, France
| | - Jérémie H Lefevre
- Department of Digestive and General Surgery, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Kathleen Turner
- Department of Gastrointestinal and Hepatic Surgery, Rennes University Hospital Center, Rennes, France
| | - Styliani Mantziari
- Department of Visceral Surgery, CHUV, University Hospital of Lausanne, Lausanne, Switzerland
| | - Denis Collet
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Bordeaux, France
- Faculty of Medicine, Bordeaux Ségalen University, Bordeaux, France
| | - Guillaume Piessen
- Department of Digestive and Oncological Surgery, Claude Huriez Hospital, CHU Lille, Lille, France
- CNRS, Inserm, UMR9020-U1277 - CANTHER - Cancer Heterogeneity Plasticity and Resistance to Therapies, CHU Lille, Univ. Lille, 59000, Lille, France
| | - Caroline Gronnier
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, Bordeaux, France.
- Faculty of Medicine, Bordeaux Ségalen University, Bordeaux, France.
- Oeso-Gastric Surgery Unit, Department of Digestive Surgery, Magellan Center, Bordeaux University Hospital, 33600, Pessac, France.
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Nammour T, Shah PM. Endoscopic Therapies for Early Stage Esophageal and Gastric Cancers. Surg Oncol Clin N Am 2024; 33:487-495. [PMID: 38789191 DOI: 10.1016/j.soc.2023.12.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Early detection of esophageal and gastric cancers offers the possibility of curative treatments with less-invasive interventions than traditional surgical approaches. This review highlights the main endoscopic therapeutic modalities used for early esophageal and gastric malignancies. Endoscopic resection techniques include endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). EMR is beneficial for smaller, well-defined lesions and involves resecting the superficial layer of the mucosa. In contrast, ESD permits en bloc resection of larger lesions, including those involving the superficial submucosa, offering precise histopathological assessments and reduced recurrence rates. As such, multidisciplinary collaboration is essential to achieve optimal outcomes.
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Affiliation(s)
- Tarek Nammour
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Pari M Shah
- Gastroenterology, Hepatology, and Nutrition Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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4
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Ebert MP, Fischbach W, Hollerbach S, Höppner J, Lorenz D, Stahl M, Stuschke M, Pech O, Vanhoefer U, Porschen R. S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:535-642. [PMID: 38599580 DOI: 10.1055/a-2239-9802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Affiliation(s)
- Matthias P Ebert
- II. Medizinische Klinik, Medizinische Fakultät Mannheim, Universitätsmedizin, Universität Heidelberg, Mannheim
- DKFZ-Hector Krebsinstitut an der Universitätsmedizin Mannheim, Mannheim
- Molecular Medicine Partnership Unit, EMBL, Heidelberg
| | - Wolfgang Fischbach
- Deutsche Gesellschaft zur Bekämpfung der Krankheiten von Magen, Darm und Leber sowie von Störungen des Stoffwechsels und der Ernährung (Gastro-Liga) e. V., Giessen
| | | | - Jens Höppner
- Klinik für Allgemeine Chirurgie, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Dietmar Lorenz
- Chirurgische Klinik I, Allgemein-, Viszeral- und Thoraxchirurgie, Klinikum Darmstadt, Darmstadt
| | - Michael Stahl
- Klinik für Internistische Onkologie und onkologische Palliativmedizin, Evang. Huyssensstiftung, Evang. Kliniken Essen-Mitte, Essen
| | - Martin Stuschke
- Klinik und Poliklinik für Strahlentherapie, Universitätsklinikum Essen, Essen
| | - Oliver Pech
- Klinik für Gastroenterologie und Interventionelle Endoskopie, Krankenhaus Barmherzige Brüder, Regensburg
| | - Udo Vanhoefer
- Klinik für Hämatologie und Onkologie, Katholisches Marienkrankenhaus, Hamburg
| | - Rainer Porschen
- Gastroenterologische Praxis am Kreiskrankenhaus Osterholz, Osterholz-Scharmbeck
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5
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Nguyen CL, Tovmassian D, Zhou M, Seyfi D, Gooley S, Falk GL. Durability of radiofrequency ablation for long-segment and ultralong-segment Barrett's esophagus over 10 years. Surg Endosc 2024; 38:1239-1248. [PMID: 38092973 DOI: 10.1007/s00464-023-10608-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/17/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Long-term durability data for radiofrequency ablation (RFA) to prevent esophageal adenocarcinoma in long-segment (LSBE) and ultralong-segment Barrett's esophagus (ULSBE) is lacking. This study aimed to determine 10-year cancer progression, eradication, and complication rates in LSBE and ULSBE patients treated with RFA. METHODS Single-surgeon prospective database of patients with LSBE (≥ 3 to < 8 cm) and ULSBE (≥ 8 cm) who underwent RFA (2001-2021) were retrospectively analyzed. Ten-year cancer progression calculated with Kaplan-Meier analysis. Eradication rates, including complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM), and rates of recurrence and complications, compared between LSBE and ULSBE groups. RESULTS Ten years after starting treatment, the cancer rate was 14.3% in 56 patients. CR-D and CR-IM rates were 87.5% and 67.9%, respectively. Relapse rates from CR-D were 1.8% and 3.6% from CR-IM. Eradication rates for dysplasia in LSBE and ULSBE patients (90.6% versus 83.3%) and IM (71.9% versus 62.5%) were not significantly different. ULSBE patients required higher mean number of ablation sessions for IM eradication (4.7 versus 3.7, p = 0.032), while complication rates including strictures (4.2% versus 6.2%), perforation (0 versus 0), and bleeding (4.2% versus 3.1%), were similar between ULSBE and LSBE patients, respectively. On multivariate analysis, shorter Barrett's segment and baseline low-grade dysplasia were associated with increased likelihood for eradication of IM and dysplasia. A total number of ablation sessions or endoscopic resections ≥ 3 was associated with reduced likelihood for eradication. CONCLUSION RFA was durable in maintaining dysplasia and IM eradication in both LSBE and ULSBE over 10 years, and with low complication rates. IM eradication was more difficult to achieve in ULSBE. Late development of cancer occurred in 14.3%.
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Affiliation(s)
- Chu Luan Nguyen
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - David Tovmassian
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Michael Zhou
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Doruk Seyfi
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia
| | - Suzanna Gooley
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia
| | - Gregory L Falk
- Department of Upper Gastrointestinal Surgery, Concord Repatriation General Hospital, Concord, NSW, 2139, Australia.
- Department of Surgery, The University of Sydney, Camperdown, NSW, 2050, Australia.
- Sydney Heartburn Clinic, Lindfield, NSW, 2070, Australia.
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Weusten BLAM, Bisschops R, Dinis-Ribeiro M, di Pietro M, Pech O, Spaander MCW, Baldaque-Silva F, Barret M, Coron E, Fernández-Esparrach G, Fitzgerald RC, Jansen M, Jovani M, Marques-de-Sa I, Rattan A, Tan WK, Verheij EPD, Zellenrath PA, Triantafyllou K, Pouw RE. Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2023; 55:1124-1146. [PMID: 37813356 DOI: 10.1055/a-2176-2440] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Abstract
MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.
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Affiliation(s)
- Bas L A M Weusten
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Department of Gastroenterology and Hepatology, St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, TARGID, Leuven, Belgium
| | - Mario Dinis-Ribeiro
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Massimiliano di Pietro
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Francisco Baldaque-Silva
- Advanced Endoscopy Center Carlos Moreira da Silva, Department of Gastroenterology, Pedro Hispano Hospital, Matosinhos, Portugal
- Division of Medicine, Department of Upper Gastrointestinal Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital and University of Paris, Paris, France
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, IMAD, Centre hospitalier universitaire Hôtel-Dieu, Nantes, Nantes, France
- Department of Gastroenterology and Hepatology, University Hospital of Geneva (HUG), Geneva, Switzerland
| | - Glòria Fernández-Esparrach
- Endoscopy Unit, Department of Gastroenterology, Hospital Clínic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Biomedical Research Network on Hepatic and Digestive Diseases (CIBEREHD), Barcelona, Spain
| | - Rebecca C Fitzgerald
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Marnix Jansen
- Department of Histopathology, University College London Hospital NHS Trust, London, UK
| | - Manol Jovani
- Division of Gastroenterology, Maimonides Medical Center, New York, New York, USA
| | - Ines Marques-de-Sa
- Department of Gastroenterology, Porto Comprehensive Cancer Center, and RISE@CI-IPOP (Health Research Network), Porto Portugal
| | - Arti Rattan
- Department of Gastroenterology, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - W Keith Tan
- Early Cancer Institute, University of Cambridge and Department of Gastroenterology, Cambridge University Hospitals NHS Trust, Cambridge, UK
| | - Eva P D Verheij
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
| | - Pauline A Zellenrath
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Konstantinos Triantafyllou
- Hepatogastroenterology Unit, Second Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Attikon University General Hospital, Athens, Greece
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam Gastroenterology, Endocrinology and Metabolism, Cancer Center Amsterdam, Amsterdam, The Netherlands
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S3-Leitlinie Diagnostik und Therapie der Plattenepithelkarzinome und Adenokarzinome des Ösophagus. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e209-e307. [PMID: 37285869 DOI: 10.1055/a-1771-6953] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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8
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van Munster SN, Frederiks CN, Nieuwenhuis EA, Alvarez Herrero L, Bogte A, Alkhalaf A, Schenk BE, Schoon EJ, Curvers WL, Koch AD, van de Ven SEM, de Jonge PJF, Tang TJ, Nagengast WB, Peters FTM, Westerhof J, Houben MHMG, Bergman JJGHM, Pouw RE, Weusten BLAM. Incidence and outcomes of poor healing and poor squamous regeneration after radiofrequency ablation therapy for early Barrett's neoplasia. Endoscopy 2022; 54:229-240. [PMID: 34062597 DOI: 10.1055/a-1521-6318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Endoscopic eradication therapy with radiofrequency ablation (RFA) is effective in most patients with Barrett's esophagus (BE). However, some patients experience poor healing and/or poor squamous regeneration. We evaluated incidence and treatment outcomes of poor healing and poor squamous regeneration. METHODS We included all patients treated with RFA for early BE neoplasia from a nationwide Dutch registry based on a joint treatment protocol. Poor healing (active inflammatory changes or visible ulcerations ≥ 3 months post-RFA), poor squamous regeneration (< 50 % squamous regeneration), and treatment success (complete eradication of BE [CE-BE]) were evaluated. RESULTS 1386 patients (median BE C2M5) underwent RFA with baseline low grade dysplasia (27 %), high grade dysplasia (30 %), or early cancer (43 %). In 134 patients with poor healing (10 %), additional time and acid suppression resulted in complete esophageal healing, and 67/134 (50 %) had normal squamous regeneration with 97 % CE-BE. Overall, 74 patients had poor squamous regeneration (5 %). Compared with patients with normal regeneration, patients with poor squamous regeneration had a higher risk for treatment failure (64 % vs. 2 %, relative risk [RR] 27 [95 % confidence interval [CI] 18-40]) and progression to advanced disease (15 % vs. < 1 %, RR 30 [95 %CI 12-81]). Higher body mass index, longer BE segment, reflux esophagitis, and < 50 % squamous regeneration after baseline endoscopic resection were independently associated with poor squamous regeneration in multivariable logistic regression. CONCLUSIONS In half of the patients with poor healing, additional time and acid suppression led to normal squamous regeneration and excellent treatment outcomes. In patients with poor squamous regeneration, however, the risk for treatment failure and progression to advanced disease was significantly increased.
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Affiliation(s)
- Sanne N van Munster
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Charlotte N Frederiks
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Auke Bogte
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Boudewijn E Schenk
- Department of Gastroenterology and Hepatology, Isala Clinics, Zwolle, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Steffi E M van de Ven
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Pieter J F de Jonge
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Thjon J Tang
- Department of Gastroenterology and Hepatology, IJsselland Hospital, Cappelle a/d IJssel, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Frans T M Peters
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, Groningen University, Groningen, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Hospital, Den Haag, the Netherlands
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands.,Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Condon A, Muthusamy VR. The evolution of endoscopic therapy for Barrett's esophagus. Ther Adv Gastrointest Endosc 2021; 14:26317745211051834. [PMID: 34708204 PMCID: PMC8543722 DOI: 10.1177/26317745211051834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/21/2021] [Indexed: 12/20/2022] Open
Abstract
Barrett’s esophagus is the condition in which a metaplastic columnar epithelium
replaces the stratified squamous epithelium that normally lines the distal
esophagus. The condition develops as a consequence of chronic gastroesophageal
reflux disease and predisposes the patient to the development of esophageal
adenocarcinoma. The diagnosis and management of Barrett’s esophagus have
undergone dramatic changes over the years and continue to evolve today.
Endoscopic eradication therapy has revolutionized the management of dysplastic
Barrett’s esophagus and early esophageal adenocarcinoma by significantly
reducing the morbidity and mortality associated with the prior gold standard of
therapy, esophagectomy. The purpose of this review is to highlight current
principles in the management and endoscopic treatment of this disease.
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Affiliation(s)
- Ashwinee Condon
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - V Raman Muthusamy
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
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10
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Betancourt-Cuellar SL, Benveniste MFK, Palacio DP, Hofstetter WL. Esophageal Cancer: Tumor-Node-Metastasis Staging. Radiol Clin North Am 2021; 59:219-229. [PMID: 33551083 DOI: 10.1016/j.rcl.2020.11.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Esophageal cancer is an uncommon malignancy that ranks sixth in terms of mortality worldwide. Squamous cell carcinoma is the predominant histologic subtype worldwide whereas adenocarcinoma represents the majority of cases in North America, Australia, and Europe. Esophageal cancer is staged using the American Joint Committee on Cancer and the International Union for Cancer Control TNM system and has separate classifications for the clinical, pathologic, and postneoadjuvant pathologic stage groups. The determination of clinical TNM is based on complementary imaging modalities, including esophagogastroduodenoscopy/endoscopic ultrasound; endoscopic ultrasound-fine-needle aspiration; computed tomography of the chest, abdomen, and pelvis; and fluorodeoxyglucose PET/computed tomography.
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Affiliation(s)
- Sonia L Betancourt-Cuellar
- Thoracic Imaging Department, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030-4009, USA.
| | - Marcelo F K Benveniste
- Thoracic Imaging Department, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1478, Houston, TX 77030-4009, USA
| | - Diana P Palacio
- Department of Medical Imaging, The University of Arizona - Banner Medical Center, 1501 North Campbell Avenue, PO BOX 245067, Tucson, AZ 85724, USA
| | - Wayne L Hofstetter
- Cardiothoracic Department, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1489, Houston, TX 77030-4009, USA
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11
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Endoscopic Resection Without Subsequent Ablation Therapy for Early Barrett's Neoplasia: Endoscopic Findings and Long-Term Mortality. J Gastrointest Surg 2021; 25:67-76. [PMID: 33140322 PMCID: PMC7851009 DOI: 10.1007/s11605-020-04836-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/17/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION After endoscopic resection (ER) of neoplasia in Barrett's esophagus (BE), it is recommended to ablate the remaining BE to minimize the risk for metachronous disease. However, we report long-term outcomes for a nationwide cohort of all patients who did not undergo ablation of the remaining BE after ER for early BE neoplasia, due to clinical reasons or performance status. METHODS Endoscopic therapy for BE neoplasia in the Netherlands is centralized in 8 expert centers with specifically trained endoscopists and pathologists. Uniformity is ensured by a joint protocol and regular group meetings. We report all patients who underwent ER for a neoplastic lesion between 2008 and 2018, without further ablation therapy. Outcomes include progression during endoscopic FU and all-cause mortality. RESULTS Ninety-four patients were included with mean age 74 (± 10) years. ER was performed for low-grade dysplasia (LGD) (10%), high-grade dysplasia (HGD) (25%), or low-risk esophageal adenocarcinoma (EAC) (65%). No additional ablation was performed for several reasons; in 73 patients (78%), the main argument was expected limited life expectancy. Median C2M5 BE persisted after ER, and during median 21 months (IQR 11-51) with 4 endoscopies per patient, no patient progressed to advanced cancer. Seventeen patients (18%) developed HGD/EAC: all were curatively treated endoscopically. In total, 29/73 patients (40%) with expected limited life expectancy died due to unrelated causes during FU, none of EAC. CONCLUSION In selected patients, ER monotherapy with endoscopic surveillance of the residual BE is a valid alternative to eradication therapy with ablation.
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Optimizing Outcomes with Radiofrequency Ablation of Barrett's Esophagus: Candidates, Efficacy and Durability. Gastrointest Endosc Clin N Am 2021; 31:131-154. [PMID: 33213792 DOI: 10.1016/j.giec.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The treatment of early Barrett's esophagus (BE) has undergone a paradigm shift from surgical subtotal esophagectomy to organ-saving endoluminal treatment. Over the past 15 years, several high-quality studies were conducted to assess safe oncological outcome of endoscopic resection of mucosal adenocarcinoma and high-grade dysplasia. It became clear that add-on ablative therapy with radiofrequency ablation (RFA) significantly reduces recurrence risk of neoplasia after resection. In this review, we highlight the most essential elements to optimize outcomes of RFA of BE, addressing the correct indication and patient selection in combination with the most efficient and safest treatment protocols to obtain long-term durability.
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13
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Pateria P, Chong A, Muwanwella N, Siah C, Kumarasinghe P, Raftopoulos S. To Investigate Outcomes In Endoscopic Management Of Early Oesophageal Adenocarcinoma In Barrett's Oesophagus: Experience At Three Australian Tertiary Centres. Intern Med J 2020; 52:633-639. [PMID: 33073906 DOI: 10.1111/imj.15104] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 09/05/2020] [Accepted: 10/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Barrett's oesophagus (BO) is known precursor of oesophageal adenocarcinoma (EAC). Early EAC includes T1a (invasion into mucosa) and T1b (invasion into submucosa but not muscularis propria). Endoscopic mucosal resection (EMR) provides accurate histological staging and definitive treatment for early EAC. Post EMR, the remaining Barrett's is eradicated with radiofrequency ablation (RFA). However, there is a paucity of long-term Australian data. AIMS To investigate the efficacy and long-term outcomes of EMR and RFA in management of early EAC. METHODS Retrospective analysis of patients early EAC treated endoscopically at three Western Australian tertiary centres, with at least 12-months follow-up, over last 10-years. RESULTS Sixty-seven patients with early EAC (61 T1a and 6 T1b) were treated with EMR. Complete Barrett's eradication was done by EMR in 31/67 patients whereas 36/67 patients underwent RFA for residual Barrett's. EMR changed pinch biopsy histology from HGD (n=33), HGD suspicious for IMC (n=5) and LGD (n=1) to early EAC in 58.2% (n=39) patients. During a mean follow-up of 37.2 months (IQR 20, 56), complete remission of dysplasia (CRD) and intestinal metaplasia (CRIM) was seen in 97% (n=65) and 89.5% (n=60) patients. One patient with T1b EAC underwent oesophagectomy. No cases developed metachronous EAC, progression to invasive adenocarcinoma or development of nodal/distant metastasis. Complications were endoscopically treated haematemesis (n=1) and strictures (n=16) requiring dilatations. 3 patients died due to causes unrelated to IMC. CONCLUSION EMR in conjunction with RFA is an effective and safe management for early EAC. EMR provides accurate staging and has low complication rates. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Puraskar Pateria
- Department of gastroenterology and hepatology, Fiona Stanley Hospital, 11, Robin Warren Dr, Murdoch, Western Australia, 6150
| | - Andre Chong
- Department of gastroenterology and hepatology, Fiona Stanley Hospital, 11, Robin Warren Dr, Murdoch, Western Australia, 6150
| | - Niroshan Muwanwella
- Department of gastroenterology and hepatology, Royal Perth Hospital, Victoria Square, Perth, Western Australia, 6000
| | - Chiang Siah
- Department of gastroenterology and hepatology, Royal Perth Hospital, Victoria Square, Perth, Western Australia, 6000
| | - Priyanthi Kumarasinghe
- Pathwest QEII Medical Centre, Hospital Avenue, Nedlands, Western Australia, 6009.,University of Western Australia, Crawley, Western Australia, 6009
| | - Spiro Raftopoulos
- Department of gastroenterology and hepatology, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, Western Australia, 6009.,University of Western Australia, Crawley, Western Australia, 6009
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14
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Endoscopic mucosal resection for early esophageal carcinoma is effective and safe but necessitates continued surveillance. Indian J Gastroenterol 2020; 39:487-494. [PMID: 33201442 DOI: 10.1007/s12664-020-01084-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Accepted: 07/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) is used for the treatment of early esophageal cancer (EEC). METHODS This a retrospective study aimed to study the efficacy, safety, and the recurrence rate of EEC following EMR. RESULTS Seventy-nine patients who had undergone EMR for early EEC (T1a andT1b lesions) from 2006 to 2015 were included. EMR alone was considered curative in 51 patients who had T1a lesion. Complete remission was achieved in 50 (98%) patients. Mean number of sessions of EMR was 1.14. Cancer recurred locally in 6 (12%) of 50 patients at a median follow-up of 48 (18-72) months. Endoscopic treatment alone achieved complete remission at last follow up in 47 of 50 patients (94%) who had initial EMR with complete remission, or in 47 of all 51 patients (92%) in whom EMR was considered curative for EC. The Kaplan-Meier cancer-free survival following complete remission with EMR was 94.2% at 1 year and 88.4% at 5 years. Patients with complete eradication of Barrett's had lower risk of recurrence of adenocarcinoma (AC) compared with patients who had persistent Barrett's (p = 0.01). EMR alone was not considered curative in 19 patients, 16 with T1b AC and 3 with T1a squamous cell carcinoma (SCC) invading the muscularis mucosa (m3). Two major adverse events were noted: delayed bleeding requiring hospitalization, and perforation that was closed endoscopically. CONCLUSION EMR is effective and safe for the management of early EC. The risk of cancer recurrence, albeit small, warrants surveillance. Complete eradication of Barrett's should be attempted in all patients after EMR of AC.
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Bennett C, Green S, DeCaestecker J, Almond M, Barr H, Bhandari P, Ragunath K, Singh R, Jankowski J. Surgery versus radical endotherapies for early cancer and high-grade dysplasia in Barrett's oesophagus. Cochrane Database Syst Rev 2020; 5:CD007334. [PMID: 32442322 PMCID: PMC7390331 DOI: 10.1002/14651858.cd007334.pub5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Barrett's oesophagus is one of the most common pre-malignant lesions in the world. Currently the mainstay of therapy is surgical management of advanced cancer but this has improved the five-year survival very little since the 1980s. As a consequence, improved survival relies on early detection through endoscopic surveillance programmes. Success of this strategy relies on the fact that late-stage pre-malignant lesions or very early cancers can be cured by intervention. Currently there is considerable controversy over which method is best: that is conventional open surgery or endotherapy (techniques involving endoscopy). OBJECTIVES We used data from randomised controlled trials (RCTs) to examine the effectiveness of endotherapies compared with surgery in people with Barrett's oesophagus, those with early neoplasias (defined as high-grade dysplasia (HGD) and those with early cancer (defined as carcinoma in-situ, superficially invasive, early cancer or superficial cancer T-1m (T1-a) and T-1sm (T1-b)). SEARCH METHODS We used the Cochrane highly sensitive search strategy to identify RCTs in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), ISI Web of Science, EBMR, Controlled Trials mRCT and ISRCTN, and LILACS, in July and August 2008. The searches were updated in 2009 and again in April 2012. SELECTION CRITERIA Types of studies: RCTs comparing endotherapies with surgery in the treatment of high-grade dysplasia or early cancer. All cellular types of cancer were included (i.e. adenocarcinomas, squamous cell carcinomas and more unusual types) but will be discussed separately. TYPES OF PARTICIPANTS patients of any age and either gender with a histologically confirmed diagnosis of early neoplasia (HGD and early cancer) in Barrett's or squamous lined oesophagus. Types of interventions; endotherapies (the intervention) compared with surgery (the control), all with curative intent. DATA COLLECTION AND ANALYSIS Reports of studies that meet the inclusion criteria for this review would have been analysed using the methods detailed in Appendix 9. MAIN RESULTS We did not identify any studies that met the inclusion criteria. In total we excluded 13 studies that were not RCTs but that compared surgery and endotherapies. AUTHORS' CONCLUSIONS This Cochrane review has indicated that there are no RCTs to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. The problems with such randomised methods are standardising surgery and endotherapies in all sites, standardising histopathology in all centres, assessing which patients are fit or unfit for surgery and making sure there are relevant outcomes for the study (i.e. long-term survival (over five or more years)) and no progression of HGD.
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Affiliation(s)
- Cathy Bennett
- Centre for Innovative Research Across the Life Course (CIRAL), Coventry University, Coventry, UK
| | - Susi Green
- Gastroenterology, Portsmouth Hospitals Trust, Cosham, UK
| | | | - Max Almond
- Department of Oesphogastric Surgery, Gloucestershire Royal Hospital, Gloucester, UK
| | - Hugh Barr
- Surgery, Gloucester Royal Hospital, Gloucester, UK
| | - Pradeep Bhandari
- Gastroenterology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Krish Ragunath
- Wolfson Digestive Diseases Centre, Queens Medical Centre, Nottingham University NHS Trust, Nottingham, UK
| | - Rajvinder Singh
- Gastroenterology, The Lyell McEwin Hospital, Elizabeth Vale, Australia
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Fountoulakis A, Souglakos J, Vini L, Douridas GN, Koumarianou A, Kountourakis P, Agalianos C, Alexandrou A, Dervenis C, Gourtsoyianni S, Gouvas N, Kalogeridi MA, Levidou G, Liakakos T, Sgouros J, Sgouros SN, Triantopoulou C, Xynos E. Consensus statement of the Hellenic and Cypriot Oesophageal Cancer Study Group on the diagnosis, staging and management of oesophageal cancer. Updates Surg 2019; 71:599-624. [DOI: 10.1007/s13304-019-00696-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 11/26/2019] [Indexed: 12/13/2022]
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Krill T, Baliss M, Roark R, Sydor M, Samuel R, Zaibaq J, Guturu P, Parupudi S. Accuracy of endoscopic ultrasound in esophageal cancer staging. J Thorac Dis 2019; 11:S1602-S1609. [PMID: 31489227 DOI: 10.21037/jtd.2019.06.50] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Since its advent in the 1980s endoscopic ultrasound (EUS) has played an important role in the diagnosis, staging, and therapeutic management of various gastrointestinal malignancies. EUS has emerged as a vital tool in the evaluation of esophageal cancer as it provides a detailed view of the layers of the esophageal wall and surrounding tissues. This permits determination of tumor invasion depth and local lymph node metastases. It is the most sensitive and specific method available for locoregional staging of esophageal cancer. The information obtained via EUS is vital in determining the appropriate diagnosis, prognosis, and treatment options. Thus, this article aims to present a review of the accuracy and utilization of EUS in the staging of esophageal cancer.
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Affiliation(s)
- Timothy Krill
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, USA
| | - Michelle Baliss
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Russel Roark
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Michael Sydor
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Jenine Zaibaq
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, USA
| | - Praveen Guturu
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, USA
| | - Sreeram Parupudi
- Department of Gastroenterology and Hepatology, University of Texas Medical Branch, Galveston, TX, USA
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19
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Pouw RE. Endoscopic resection of superficial esophageal adenocarcinoma: the Japanese point of view. Gastrointest Endosc 2019; 89:1129-1131. [PMID: 31104745 DOI: 10.1016/j.gie.2019.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/06/2019] [Indexed: 02/08/2023]
Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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20
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Zeki SS, Bergman JJ, Dunn JM. Endoscopic management of dysplasia and early oesophageal cancer. Best Pract Res Clin Gastroenterol 2018; 36-37:27-36. [PMID: 30551853 DOI: 10.1016/j.bpg.2018.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023]
Abstract
In the past decade there have been technological advances in Endoscopic Eradication Therapy (EET) for the management of patients with oesophageal neoplasia and early cancer. Multiple endoscopic techniques now exist for both squamous and Barrett's oesophagus associated neoplasia or early cancer. A fundamental aspect of endotherapy is removal of the target lesion by endoscopic mucosal resection, or endosopic submucosal dissection. Residual tissue is subsequently ablated to remove the risk of recurrence. The most validated technique for Barrett's oesophagus is radiofrequency ablation, but other techniques such as hybrid-APC and cryotherapy also show good results. This chapter will discuss the evolution of EET, and which patients are most likely to benefit. It will also explore the evidence behind the success of different techniques and provide practical advice on how to carry out the endoscopic techniques with a focus on radiofrequency ablation and endoscopic mucosal resection in particular.
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Affiliation(s)
- S S Zeki
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom.
| | - J J Bergman
- Dep. of Gastroenterology, Academic Medical Center, Amsterdam, Netherlands
| | - J M Dunn
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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21
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Feczko AF, Louie BE. Endoscopic Resection in the Esophagus. Thorac Surg Clin 2018; 28:481-497. [PMID: 30268294 DOI: 10.1016/j.thorsurg.2018.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The article is a review of the principles behind endoscopic resection of esophageal dysplasia and early cancers. The techniques of endoscopic mucosal resection and endoscopic submucosal dissection are reviewed, and the supporting literature compared. Endoscopic resection is compared with esophagectomy for the management of these lesions and current areas of controversy with regard to T1b lesions and gastroesophageal reflux following resection are addressed.
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Affiliation(s)
- Andrew F Feczko
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Avenue, Seattle, WA 98104, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Cancer Institute, 1101 Madison Avenue, Seattle, WA 98104, USA.
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22
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Malik S, Sharma G, Sanaka MR, Thota PN. Role of endoscopic therapy in early esophageal cancer. World J Gastroenterol 2018; 24:3965-3973. [PMID: 30254401 PMCID: PMC6148428 DOI: 10.3748/wjg.v24.i35.3965] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 07/23/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
Esophageal carcinoma is a highly lethal cancer associated with high morbidity and mortality. Esophageal squamous cell carcinoma and esophageal adenocarcinoma are the two distinct histological types. There has been significant progress in endoscopic diagnosis and treatment of early stages of cancer using resection and ablation techniques, as shown in several trials in the recent past. Earlier detection of esophageal cancer and advances in treatment modalities have lead to improvement in the 5-year survival from 5% to about 20% in the past decade. Endoscopic eradication therapy is the preferred modality of treatment in cancer limited to mucosal layer of the esophagus as there is very low risk of lymph node metastasis, leading to high cure rates, low risk of recurrence and with few adverse effects. The most common adverse events seen are strictures, bleeding and rarely perforation which can be endoscopically managed. In patients with recurrent advanced disease or invasive tumor, esophagectomy with lymph node dissection remains the mainstay of treatment. There is debate on post-endoscopic surveillance with some studies suggesting closer follow up with upper endoscopy every 6 mo for the first 1-2 years and then annually for the 3 years while others recommending the appropriate action only if symptoms or other abnormalities develop. Overall, the field of endoscopic therapy is still evolving and focus should be placed on careful patient selection using a multidisciplinary approach.
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Affiliation(s)
- Sonika Malik
- Department of Internal Medicine, Cleveland Clinic Akron General Medical Center, Akron, OH 44307, United States
| | - Gautam Sharma
- Department of Anesthesiology, University Hospitals, Cleveland, OH 44106, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology, Digestive Disease Surgery Institute, Cleveland Clinic, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology, Digestive Disease Surgery Institute, Cleveland Clinic, OH 44195, United States
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23
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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] [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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24
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Bourke MJ, Neuhaus H, Bergman JJ. Endoscopic Submucosal Dissection: Indications and Application in Western Endoscopy Practice. Gastroenterology 2018; 154:1887-1900.e5. [PMID: 29486200 DOI: 10.1053/j.gastro.2018.01.068] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Abstract
Endoscopic submucosal dissection was developed in Japan, early in this century, to provide a minimally invasive yet curative treatment for the large numbers of patients with early gastric cancer identified by the national screening program. Previously, the majority of these patients were treated surgically at substantial cost and with significant risk of short- and long-term morbidity. En-bloc excision of these early cancers, most with a limited risk of nodal metastasis, allowed complete staging of the tumor, stratification of the subsequent therapeutic approach, and potential cure. This transformative innovation changed the nature of endoscopic treatment for superficial mucosal neoplasia and, ultimately, for the first time allowed endoscopists to assert that the early cancer had been definitively cured. Subsequently, Western endoscopists have increasingly embraced the therapeutic possibilities offered by endoscopic submucosal dissection, but with some justifiable scientific caution. Here we provide an evidence-based critical appraisal of the role of endoscopic submucosal dissection in advanced endoscopic tissue resection.
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Affiliation(s)
- Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jacques J Bergman
- Academic Medical Centre, Department of Gastroenterology and Hepatology, Amsterdam, Netherlands
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25
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Barret M, Prat F. Diagnosis and treatment of superficial esophageal cancer. Ann Gastroenterol 2018; 31:256-265. [PMID: 29720850 PMCID: PMC5924847 DOI: 10.20524/aog.2018.0252] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 01/29/2018] [Indexed: 02/07/2023] Open
Abstract
Endoscopy allows for the screening, early diagnosis, treatment and follow up of superficial esophageal cancer. Endoscopic submucosal dissection has become the gold standard for the resection of superficial squamous cell neoplasia. Combinations of endoscopic mucosal resection and radiofrequency ablation are the mainstay of the management of Barrett’s associated neoplasia. However, protruded, non-lifting or large lesions may be better managed by endoscopic submucosal dissection. Novel ablation tools, such as argon plasma coagulation with submucosal lifting and cryoablation balloons, are being developed for the treatment of residual Barrett’s esophagus, since iatrogenic strictures still hamper the development of extensive circumferential resections in the esophagus. Optimal surveillance modalities after endoscopic resection are still to be determined. The assessment of the risk of lymph-node metastases, as well as of the need for additional treatments based on qualitative and quantitative histological criteria, balanced to the patient’s condition, requires a dedicated multidisciplinary team decision process. The need for trained endoscopists, expert pathologists and surgeons, and specialized multidisciplinary meetings underlines the role of expert centers in the management of superficial esophageal cancer.
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Affiliation(s)
- Maximilien Barret
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Paris, France
| | - Frédéric Prat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Paris, France
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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: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [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: 1.9] [Reference Citation Analysis] [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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28
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Schölvinck DW, Friedland S, Triadafilopoulos G, Valli T, van Berge Henegouwen MI, Bergman JJGHM, Weusten BLAM. Balloon-based esophageal cryoablation with a novel focal ablation device: dose-finding and safety in porcine and human models. Dis Esophagus 2017; 30:1-8. [PMID: 28881895 DOI: 10.1093/dote/dox019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Accepted: 03/03/2017] [Indexed: 12/11/2022]
Abstract
The new Cryoballoon Focal Ablation System (CbFAS), a through-the-scope catheter with battery-powered handle that delivers cryogenic fluid into an inflated balloon, differs from current cryotherapy methods used for treatment of Barrett's epithelium. In this dose-finding study, short- and long-term histopathological effects and safety of the CbFAS were evaluated. Cryoablations with (supra)therapeutic durations (4-24 seconds) were performed in pigs that survived for 12 or 48 hours or 4 or 28 days. Next, cryoablations (durations based on animal data) were performed in normal mucosa of esophageal cancer patients scheduled to undergo esophagectomy. The outcome parameters, the occurrence of any bleeding or perforation, the histological presence of edema, inflammation, and necrosis throughout the esophageal wall layers, were evaluated. A total of 60 cryoablations were performed in 11 pigs. 48 hour cryoablations with therapeutic durations (4-10 seconds) resulted in edema/inflammation as deep as the serosa and necrosis ranging from submucosa to serosa with a median depth of 3.2 mm. In 4 day cryoablations this was in the serosa, and muscularis tunica to serosa at a median depth of 4.5 mm, respectively. No necrosis or inflammation remained after 28 days, not even after supratherapeutic cryoablation (12-24 seconds). No acute or delayed bleeding or perforation was observed. Next, eight 6-second cryoablations were performed in four patients. Direct postablation mucosal necrosis was observed; after 4 days necrosis and inflammation was limited to the submucosa. CbFAS cryoablation penetrates deeply into the esophageal wall layers resulting in severe early ablation. After 4 weeks, little injury and no fibrosis remain, even after supratherapeutic durations of administration, suggesting that CbFAS combines deep ablation with a potentially favorable safety profile.
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Affiliation(s)
- D W Schölvinck
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - S Friedland
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford
| | - G Triadafilopoulos
- Department of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford
| | - T Valli
- VDx Veterinary Diagnostics, Davis, California, United States of America
| | | | - J J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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29
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Abstract
The esophagus is one of the areas of the gastrointestinal tract, for which therapeutic concepts have changed the most over the last two decades. The most decisive advance is the development of endoscopic resection techniques for early esophageal carcinomas. These methods provide excellent short- and long-term results combined with very low morbidity and negligible mortality rates in comparison with surgical esophagectomy, especially in case of mucosal Barrett's adenocarcinoma. In addition, the endoscopic myotomy techniques in Zenker's diverticulum and spastic achalasia are new, attractive endoscopic treatment modalities.
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Affiliation(s)
- A May
- Bereichsleitung Gastroenterologie, Sana Klinikum Offenbach GmbH, Starkenburgring 66, 63069, Offenbach am Main, Deutschland.
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30
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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] [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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31
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Abstract
PURPOSE OF REVIEW Providing an overview on types of cryotherapy for esophageal application and their role in the management of Barrett's esophagus. RECENT FINDINGS Recent studies have involved multiple types of cryotherapy including cryospray techniques that use either liquid nitrogen or carbon dioxide as the cryogenic fluid, and the CryoBalloon focal ablation device that uses nitrous oxide. Overall, studies report cryotherapy to be safe and effective in eradicating Barrett's epithelium. However, substantial variations among these studies in design and outcomes preclude direct comparisons of the results. Moreover, little is known of the long-term outcomes of cryotherapy, with only one report describing 5-year follow-up of patients treated with liquid nitrogen cryospray. SUMMARY The concept of cryotherapy is appealing. By preserving the extracellular matrix and inducing anesthetic effects, cryotherapy has the potential to enable deeper ablations with less pain and a lower rate of stricture formation than radiofrequency ablation. To date, however, these potential benefits remain unproved. Prospective studies with clearly defined endpoints and longer follow-up are necessary to determine the role of cryotherapy in the management of patients with Barrett's esophagus.
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32
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Desai M, Saligram S, Gupta N, Vennalaganti P, Bansal A, Choudhary A, Vennelaganti S, He J, Titi M, Maselli R, Qumseya B, Olyaee M, Waxman I, Repici A, Hassan C, Sharma P. Efficacy and safety outcomes of multimodal endoscopic eradication therapy in Barrett's esophagus-related neoplasia: a systematic review and pooled analysis. Gastrointest Endosc 2017; 85:482-495.e4. [PMID: 27670227 DOI: 10.1016/j.gie.2016.09.022] [Citation(s) in RCA: 102] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 09/12/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Focal EMR followed by radiofrequency ablation (f-EMR + RFA) and stepwise or complete EMR (s-EMR) are established strategies for eradication of Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC)/intramucosal carcinoma (IMC). The objective of this study was to derive pooled rates of efficacy and safety of individual methods in a large cohort of patients with BE and to indirectly compare the 2 methods. METHODS PubMed, Embase, Web of Science, Cochrane, and major conference proceedings were searched. A systematic review and pooled analysis were carried out to determine the following outcomes in patients with BE undergoing either f-EMR + RFA or s-EMR: (1) complete eradication rates of neoplasia (CE-N) and intestinal metaplasia (CE-IM); (2) recurrence rates of cancer (EAC), dysplasia, and IM; (3) incidence rates of adverse events. Mixed logistic regression was performed as an exploratory analysis to examine differences in outcomes between the 2 methods. RESULTS Nine studies (774 patients) of f-EMR + RFA and 11 studies (751 patients) of s-EMR were included. Patients undergoing f-EMR + RFA had high BE eradication rates (CE-N, 93.4%; CE-IM, 73.1%), whereas strictures occurred in 10.2%, bleeding in 1.1%, and perforations in 0.2% of patients. Recurrence of EAC, dysplasia, and IM was 1.4%, 2.6%, and 16.1%, respectively, in this group. Patients undergoing s-EMR also showed high BE eradication rates (CE-N, 94.9%; CE-IM, 79.6%) but a higher rate of adverse events (strictures in 33.5%, bleeding in 7.5%, and perforation in 1.3%). Recurrence of EAC, dysplasia, and IM was 0.7%, 3.3%, and 12.1%, respectively, in the s-EMR group. Mixed logistic regression showed that patients undergoing s-EMR might be more likely to develop esophageal strictures (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.61-13.85; P = .005), perforation (OR, 7.00; 95% CI, 1.56-31.33; P = .01), and bleeding (OR, 6.88; 95% CI, 2.19-21.62; P = 0.001) compared with f-EMR + RFA. CONCLUSIONS In patients with HGD/EAC, f-EMR followed by RFA seems to be equally effective as and safer than s-EMR.
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Affiliation(s)
- Madhav Desai
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Shreyas Saligram
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Neil Gupta
- Gastroenterology and Hepatology, Loyola University Medical Center, Chicago, Illinois, USA
| | - Prashanth Vennalaganti
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Ajay Bansal
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Abhishek Choudhary
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Sreekar Vennelaganti
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Jianghua He
- Department of Biostatistics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Mohammad Titi
- Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
| | - Roberta Maselli
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - Bashar Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, Thomasville, Georgia, USA
| | - Mojtaba Olyaee
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Irwing Waxman
- Department of Gastroenterology and Hepatology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA
| | - Alessandro Repici
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - Cesare Hassan
- Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy
| | - Prateek Sharma
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA; Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA
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33
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Rosmolen WD, Nieuwkerk PT, Pouw RE, van Berge Henegouwen MI, Bergman JJGHM, Sprangers MAG. Quality of life and fear of cancer recurrence after endoscopic treatment for early Barrett's neoplasia: a prospective study. Dis Esophagus 2017; 30:1-9. [PMID: 27766707 DOI: 10.1111/dote.12512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Endoscopic therapy is the treatment of choice for high grade intraepithelial neoplasia (HGIN) or early cancer (≤T1sm1) in Barrett's esophagus (BE). We prospectively evaluated the effect of endoscopic treatment on quality of life (QOL) and fear of cancer (recurrence) and compared this with the effect of Barrett's surveillance or surgery. Patients treated endoscopically for early Barrett's neoplasia (n = 42, HGIN - T1sm1N0M0) were compared with three groups: patients with non-dysplastic BE undergoing surveillance (n = 44); patients treated surgically for early BE neoplasia (HGIN - T2N0M0, n = 21); patients treated surgically for advanced BE cancer (T1N1M0 - T3N1M0, n = 19). QOL (SF-36; EORTC-QLQ-C30; EORTC-QLQ-OES18) and fear of cancer recurrence (Worry of Cancer Scale [WOCS] and the Hospital Anxiety and Depression Scale [HADS]) were measured at baseline, 2 and 6 months after treatment. The endoscopic treatment group reported significantly better QOL in both physical and mental scales of SF-36 and EORTC-QLQ-C30 and less esophageal cancer related symptoms compared to both surgical groups. The endoscopic treatment group reported significant more worry for cancer recurrence (WOCS) compared to the early surgical group. Their scores on the WOCS were comparable with the scores of the advanced surgical group. Endoscopic treatment of early esophageal cancer has less negative impact on QOL and esophageal cancer symptoms than surgery. However, endoscopically treated patients worry as much about cancer recurrence as patients treated surgically for advanced cancer.
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Affiliation(s)
- Wilda D Rosmolen
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Mirjam A G Sprangers
- Department of Medical Psychology, Academic Medical Center, Amsterdam, The Netherlands
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34
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Manner H, Wetzka J, May A, Pauthner M, Pech O, Fisseler-Eckhoff A, Stolte M, Vieth M, Lorenz D, Ell C. Early-stage adenocarcinoma of the esophagus with mid to deep submucosal invasion (pT1b sm2-3): the frequency of lymph-node metastasis depends on macroscopic and histological risk patterns. Dis Esophagus 2017; 30:1-11. [PMID: 26952572 DOI: 10.1111/dote.12462] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The rate of lymph-node (LN) metastasis in early adenocarcinoma (EAC) of the esophagus with mid to deep submucosal invasion (pT1b sm2/3) has not yet been precisely defined. The aim of the this study was to evaluate the rate of LN metastasis in pT1b sm2/3 EAC depending on macroscopic and histological risk patterns to find out whether there may also be options for endoscopic therapy as in cancers limited to the mucosa and the upper third of the submucosa. A total of 1.718 pt with suspicion of EAC were referred for endoscopic treatment (ET) to the Dept. of Internal Medicine II at HSK Wiesbaden 1996-2010. In 230/1.718 pt, the suspicion (endoscopic ultrasound, EUS) or definitive diagnosis of pT1b EAC (ER/surgery) was made. Of these, 38 pt had sm2 lesions, and 69 sm3. Rate of LN metastasis was analyzed depending on risk patterns: histologically low-risk (hisLR): G1-2, L0, V0; histologically high-risk (hisHR): ≥1 criterion not fulfilled; macroscopically low-risk (macLR): gross tumor type I-II, tumor size ≤2 cm; macroscopically high-risk (macHR): ≥1 criterion not fulfilled; combined low-risk (combLR): hisLR+macLR; combined high-risk (combHR): at least 1 risk factor. LN rate was only evaluated in pt who had proven maximum invasion depth of sm2/sm3, and who in case of ET had a follow-up (FU) by EUS of at least 24 months. 23/38 pt with pT1b sm2 lesions and 39/69 pt with sm3 lesions fulfilled our inclusion criteria. In the pT1b sm2 group, rate of LN metastasis in the hisLR, hisHR, combLR, and combHR groups were 8.3% (1/12), 36.3% (4/11), 0% (0/5), and 27.8% (5/18). In the pT1b sm3 group, rate of LN metastasis in the hisLR, hisHR, combLR and combHR groups were 28.6% (2/7), 37.5% (12/32), 25% (1/4), and 37.1% (13/35). 30-day mortality of surgery was 1.7% (1/58 pt). In EAC with pT1b sm2/3 invasion, the frequency of LN metastasis depends on macroscopic and histological risk patterns. Surgery remains the standard treatment, because the rate of LN metastasis appears to be higher than the mortality risk of surgery. Whether a highly selected group of pT1b sm2 patients with a favourable risk pattern may be candidates for endoscopic therapy cannot be decided until the results of larger case volumes are available.
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Affiliation(s)
- H Manner
- Department of Internal Medicine II, HSK Hospital, Teaching Hospital of the University Medicine of Mainz, Wiesbaden, Germany
| | - J Wetzka
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - A May
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - M Pauthner
- Department of General and Visceral Surgery, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - O Pech
- Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
| | | | - M Stolte
- Institute of Pathology, Kulmbach Hospital, Germany
| | - M Vieth
- Institute of Pathology, Bayreuth Hospital, Germany
| | - D Lorenz
- Department of General and Visceral Surgery, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
| | - C Ell
- Department of Internal Medicine II/IV, Sana Klinikum Offenbach, Teaching Hospital of the University Medicine of Frankfurt, Germany
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35
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Wang Z, Lu H, Wu L, Yuan B, Liu J, Shi H, Wang F. Long-term outcomes of endoscopic multiband mucosectomy for early esophageal squamous cell neoplasia: a retrospective, single-center study. Gastrointest Endosc 2016; 84:893-899. [PMID: 27108060 DOI: 10.1016/j.gie.2016.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Accepted: 04/07/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Endoscopic multiband mucosectomy (EMBM) has been used to treat early Barrett's esophagus and esophagogastric junction neoplasia, yet it is seldom reported for the treatment of early esophageal squamous cell neoplasia. Here we retrospectively evaluated the feasibility, safety, and efficacy of EMBM for early esophageal squamous cell neoplasia. METHODS A total of 125 patients were included in the study. Lesions were delineated using electrocoagulation and resected using the EMBM technique. The primary outcomes were local recurrence and adverse events. Secondary outcomes were histology of the endoscopic resection specimens, specimen area, and speed of resection. All patients were followed up endoscopically. RESULTS There were 135 esophageal lesions, of which 40 were pathologically diagnosed as low-grade intraepithelial neoplasia, 57 as high-grade intraepithelial neoplasia, 34 as early esophageal cancer, and 4 as squamous epithelium without neoplasia. No severe adverse events were observed, except for 1 perforation, which was treated by application of clips. The median follow-up was 27.75 months. Three patients had local recurrence and were endoscopically treated again. Local recurrence rate was 2.4% (3/125). No deaths occurred during the follow-up. All specimens were visible with a dividing rule, and the mean specimen area was 4.63 cm2. Mean operation time was 31.2 ± 17.4 minutes. Mean speed of resection was 6.74 min/cm2. CONCLUSIONS EMBM seems to be effective and safe for patients with early esophageal squamous cell neoplasia. The long-term recurrence rate is low.
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Affiliation(s)
- Zhenkai Wang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Heng Lu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Lin Wu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Boshi Yuan
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Jiong Liu
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Hui Shi
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
| | - Fangyu Wang
- Department of Gastroenterology and Hepatology, Jinling Hospital, Nanjing, Jiangsu Province, China
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36
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Künzli HT, van Berge Henegouwen M, Gisbertz S, Seldenrijk C, Kuijpers K, Bergman J, Wiezer M, Weusten B. Thoracolaparoscopic dissection of esophageal lymph nodes without esophagectomy is feasible in human cadavers and safe in a porcine survival study. Dis Esophagus 2016; 29:649-55. [PMID: 26228037 DOI: 10.1111/dote.12395] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
High-risk early esophageal adenocarcinoma (i.e. submucosal invasion >500 nm, poor differentiation, and/or presence of lymphovascular invasion) is currently treated with esophagectomy with lymph node (LN) dissection given the high rates of LN metastases. However, esophagectomy is associated with substantial morbidity and mortality. Endoscopic radical resection followed by thoracolaparoscopic LN dissection without concomitant esophagectomy could be an alternative. The study aim was to evaluate the feasibility and safety of thoracolaparoscopic dissection of esophageal LNs in a preclinical setting. (i) In human cadavers, thoracolaparoscopic dissection of LNs involved in drainage of the esophagus was performed. Subsequently, esophagectomy was performed to be able to detect retained LNs. Outcome parameters included the number of dissected LNs, the number of retained LNs in the esophagectomy specimen (ES), and technical success. (ii) In swine, thoracolaparoscopic LN dissection was also performed. After the procedure, the swine survived for 28 days. Thereafter, the swine were sacrificed and esophagectomy was performed. Outcome parameters included the presence of ischemia and/or stenosis in the ES and other complications. (i) In five human cadavers, a median of 26 LNs (interquartile range 22-46) were dissected. In two ES, one retained LN was found: one high paraesophageal, one low paraesophageal. Technical success rate was 100%. (ii) None of the seven porcine ES showed signs of ischemia or stenosis. One swine died because of ventricular fibrillation during surgery; during follow up no complications were observed. Thoracolaparoscopic dissection of LNs involved in the drainage of the esophagus is feasible in human cadavers and swine. The porcine survival study suggests that the esophageal vascularity is not severely compromised by the procedure. As anatomy differs between swine and humans, safety of the procedure will have to be investigated thoroughly before applying this new technique as the treatment of choice.
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Affiliation(s)
- H T Künzli
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | | | - S Gisbertz
- Department of Surgery, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - C Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - K Kuijpers
- Department of Pathology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - M Wiezer
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - B Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
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Schölvinck DW, Bergman JJGHM, Visser M, Weusten BLAM. Circumferential cryoablation in a strictured esophagus: a feasibility and dose-finding study in a porcine model after inducing stenosis by endoscopic mucosal resection. Dis Esophagus 2016; 29:528-36. [PMID: 26315973 DOI: 10.1111/dote.12379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In the treatment of early esophageal Barrett's neoplasia, radiofrequency ablation may be hindered by stenosis due to prior endoscopic resection (ER). The flexible balloon-based circumferential CryoBalloon Ablation System (CBAS) may overcome this problem by the conformability of the compliant balloon which might enable circumferential cryoablation in a stenosis. The aim of the current study was to evaluate the feasibility of the CBAS as well as the dose-response effect of cryoablation in a strictured esophagus model. In six pigs, a stenosis was induced by ER (3 cm in length, 75% of circumference) in the proximal, mid, and distal esophagus. After 28 days, cryoablation with the CBAS was performed, with the length of ablation time (6, 8, or 10 seconds) randomly assigned per stricture location within the esophagus. Four days post-ablation, the esophagi were harvested for histopathological assessment of the percentage of the total circumference affected by cryoablation and the maximum depth of necrosis. At 28 days, all 18 ER areas had transformed into strictures with ±50% of its original diameter remaining. In 9 of 18 strictures, more than one attempt for cryoablation was necessary due to displacement of the balloon. Histopathological evaluation showed a wide range in circumferential uniformity (0-100%) and maximum necrosis depth (epithelium to external proper muscle layer) of cryoablation, both independent of ablation times. Deepest ablation effects were seen at the center of the resection-induced scar. This first generation CryoBalloon Focal Ablation System was not feasible for ablation within severe stenoses, since it results in inconsistent circumferential uniformity of cryoablation with subsequent differences in depth of ablation. Further research with a next generation CBAS in a more realistic stricture model is warranted.
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Affiliation(s)
- D W Schölvinck
- Department of Gastroenterology and Hepatology, St Antonius Hospital, 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
| | - M Visser
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Schölvinck D, Künzli H, Meijer S, Seldenrijk K, van Berge Henegouwen M, Bergman J, Weusten B. Management of patients with T1b esophageal adenocarcinoma: a retrospective cohort study on patient management and risk of metastatic disease. Surg Endosc 2016; 30:4102-13. [PMID: 27357927 DOI: 10.1007/s00464-016-5071-y] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2016] [Accepted: 06/21/2016] [Indexed: 12/23/2022]
Abstract
BACKGROUND Esophagectomy for submucosal (T1b) esophageal adenocarcinoma (EAC) is performed in order to optimize patient outcomes given the risk of concurrent lymph node metastases (LNM). However, not seldom, comorbidity precludes these patients from surgery. Therefore, the aim of our study was to assess the course of follow-up after treatment in submucosal EAC patients undergoing surgery versus conservative therapy and to evaluate the incidence of metastatic disease. METHODS Between 2001 and 2012, all patients undergoing diagnostic endoscopic resection for EAC in two centers were reviewed. Only patients with histopathologically proven submucosal tumor invasion were included. Submucosal EACs were divided into tumors that were removed radically (R0) and irradically (R1). Subsequently, in the R0 group, EACs were classified as either low risk (LR; submucosal invasion <500 nm, G1-G2, no LVI) or high risk (HR; deep submucosal invasion >500 nm, G3-G4 and/or LVI). Metastatic disease was defined as LNM in surgical resection specimen and/or evidence of malignant disease during follow-up (FU). RESULTS Sixty-nine patients with a submucosal EAC were included [23 R1-resections and 46 R0-resection (14 R0-LR and 32 R0-HR)]. Twenty-six patients underwent surgical treatment (1 R0-LR, 12 R0-HR and 13 R1). None of the 14 R0-LR patients developed metastatic disease after a median FU of 60 months. In the R0-HR group and R1 group, metastatic disease was diagnosed in 16 and 30 % of patients, respectively. Surgical patients tended to have a better overall survival than non-surgical patients (p = 0.09). Tumor-related deaths, however, were 12 % in both groups. CONCLUSIONS In LR submucosal EAC, the risk of metastatic disease appears to be very low. In deep submucosal EAC (either R0- or R1-resection), the rate of metastatic disease is lower than reported in earlier surgical series. Given the reasonable disease-free survival and high background mortality, conservative management of these patients seems to be a valid alternative for surgery in selected cases.
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Affiliation(s)
- Dirk Schölvinck
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Hannah Künzli
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sybren Meijer
- Department of Pathology, Academic Medical Center Amsterdam, Amsterdam, The Netherlands
| | - Kees Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands
| | | | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, Nieuwegein, The Netherlands. .,Department of Gastroenterology and Hepatology, Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Krishnamoorthi R, Singh S, Ragunathan K, Katzka DA, Wang KK, Iyer PG. Risk of recurrence of Barrett's esophagus after successful endoscopic therapy. Gastrointest Endosc 2016; 83:1090-1106.e3. [PMID: 26902843 PMCID: PMC4937826 DOI: 10.1016/j.gie.2016.02.009] [Citation(s) in RCA: 76] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 02/02/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Previous estimates of incidence of intestinal metaplasia (IM) recurrence after achieving complete remission of IM (CRIM) through endoscopic therapy of Barrett's esophagus (BE) have varied widely. We performed a systematic review and meta-analysis of studies to estimate an accurate recurrence risk after CRIM. METHODS We performed a systematic search of multiple literature databases through June 2015 to identify studies reporting long-term follow-up after achieving CRIM through endoscopic therapy. Pooled incidence rate (IR) of recurrent IM, dysplastic BE, and high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC) per person-year of follow-up after CRIM was estimated. Factors associated with recurrence were also assessed. RESULTS We identified 41 studies that reported 795 cases of recurrence in 4443 patients over 10,427 patient-years of follow-up. This included 21 radiofrequency ablation studies that reported 603 cases of IM recurrence in 3186 patients over 5741 patient-years of follow-up. Pooled IRs of recurrent IM, dysplastic BE, and HGD/EAC after radiofrequency ablation were 9.5% (95% CI, 6.7-12.3), 2.0% (95% CI, 1.3-2.7), and 1.2% (95% CI, .8-1.6) per patient-year, respectively. When all endoscopic modalities were included, pooled IRs of recurrent IM, dysplastic BE, and HGD/EAC were 7.1% (95% CI, 5.6-8.6), 1.3% (95% CI, .8-1.7), and .8% (95% CI, .5-1.1) per patient-year, respectively. Substantial heterogeneity was noted. Increasing age and BE length were predictive of recurrence; 97% of recurrences were treated endoscopically. CONCLUSIONS The incidence of recurrence after achieving CRIM through endoscopic therapy was substantial. A small minority of recurrences were dysplastic BE and HGD/EAC. Hence, continued surveillance after CRIM is imperative. Additional studies with long-term follow-up are needed.
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Affiliation(s)
- Rajesh Krishnamoorthi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Siddharth Singh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Karthik Ragunathan
- Department of Internal Medicine, University of Illinois College of Medicine, Peoria, Illinois, USA
| | - David A. Katzka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K. Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G. Iyer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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40
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Belghazi K, Bergman J, Pouw RE. Endoscopic Resection and Radiofrequency Ablation for Early Esophageal Neoplasia. Dig Dis 2016; 34:469-75. [PMID: 27333327 PMCID: PMC5296892 DOI: 10.1159/000445221] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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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41
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Phoa KN, Pouw RE, Bisschops R, Pech O, Ragunath K, Weusten BLAM, Schumacher B, Rembacken B, Meining A, Messmann H, Schoon EJ, Gossner L, Mannath J, Seldenrijk CA, Visser M, Lerut T, Seewald S, ten Kate FJ, Ell C, Neuhaus H, Bergman JJGHM. Multimodality endoscopic eradication for neoplastic Barrett oesophagus: results of an European multicentre study (EURO-II). Gut 2016; 65:555-62. [PMID: 25731874 DOI: 10.1136/gutjnl-2015-309298] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 02/07/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Focal endoscopic resection (ER) followed by radiofrequency ablation (RFA) safely and effectively eradicates Barrett's oesophagus (BO) containing high-grade dysplasia (HGD) and/or early cancer (EC) in smaller studies with limited follow-up. Herein, we report long-term outcomes of combined ER and RFA for BO (HGD and/or EC) from a single-arm multicentre interventional study. DESIGN In 13 European centres, patients with BO ≤ 12 cm with HGD and/or EC on 2 separate endoscopies were eligible for inclusion. Visible lesions (<2 cm length; <50% circumference) were removed with ER, followed by serial RFA every 3 months (max 5 sessions). Follow-up endoscopy was scheduled at 6 months after the first negative post-treatment endoscopic control and annually thereafter. OUTCOMES complete eradication of neoplasia (CE-neo) and intestinal metaplasia (CE-IM); durability of CE-neo and CE-IM (once achieved) during follow-up. Biopsy and resection specimens underwent centralised pathology review. RESULTS 132 patients with median BO length C3M6 were included. After entry-ER in 119 patients (90%) and a median of 3 RFA (IQR 3-4) treatments, CE-neo was achieved in 121/132 (92%) and CE-IM in 115/132 patients (87%), per intention-to-treat analysis. Per-protocol analysis, CE-neo and CE-IM were achieved in 98% and 93%, respectively. After a median of 27 months following the first negative post-treatment endoscopic control, neoplasia and IM recurred in 4% and 8%, respectively. Mild-to-moderate adverse events occurred in 25 patients (19%); all managed conservatively or endoscopically. CONCLUSIONS In patients with early Barrett's neoplasia, intensive multimodality endotherapy consisting of ER combined with RFA is safe and highly effective, and the treatment effect appears to be durable during mid-term follow-up. TRIAL REGISTRATION NUMBER NTR 1211, http://www.trialregister.nl.
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Affiliation(s)
- K Nadine Phoa
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
| | - Oliver Pech
- Department of Internal Medicine II, Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Krish Ragunath
- Department of Gastroenterology, Queens Medical Centre, Nottingham, UK
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Brigitte Schumacher
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Bjorn Rembacken
- Department of Gastroenterology, The General Infirmary at Leeds, Leeds, UK
| | - Alexander Meining
- Department of Gastroenterology, Klinikum rechts der Isar, Munich, Germany
| | - Helmut Messmann
- Department of Gastroenterology, Augsburg Hospital, Augsburg, Germany
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Liebwin Gossner
- Department of Internal Medicine II, Karlsruhe Hospital, Karlsruhe, Germany
| | - Jayan Mannath
- Department of Gastroenterology, Queens Medical Centre, Nottingham, UK
| | - C A Seldenrijk
- Department of Pathology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Mike Visser
- Department of Pathology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Toni Lerut
- Department of Gastroenterology, University Hospitals Leuven, Leuven, Vlaams Brabant, Belgium
| | - Stefan Seewald
- Department of Interdisciplinary Endoscopy, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Fiebo J ten Kate
- Department of Pathology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
| | - Christian Ell
- Department of Internal Medicine II, Dr. Horst-Schmidt-Kliniken, Wiesbaden, Germany
| | - Horst Neuhaus
- Department of Gastroenterology, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jacques J G H M Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre-University of Amsterdam, Amsterdam, the Netherlands
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Management of Barrett's esophagus: Screening to newer treatments. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2016. [DOI: 10.1016/j.rgmxen.2016.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Thoguluva Chandrasekar V, Vennalaganti P, Sharma P. Management of Barrett's esophagus: From screening to newer treatments. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2016; 81:91-102. [PMID: 26964773 DOI: 10.1016/j.rgmx.2015.07.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 07/15/2015] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus is a premalignant condition of the esophagus in which the squamous epithelium of the lower end of the esophagus is replaced with columnar epithelium. Since the incidence of esophageal adenocarcinoma is on the rise, the major gastroenterology societies have come up with their recommendations for screening and surveillance. Specific factors like obesity, white race, age over 50 years, early age of onset of GERD, smoking and hiatal hernia have been identified as increasing the risk of Barrett's esophagus and adenocarcinoma. The diagnosis requires both endoscopic identification of columnar-lined mucosa and histological confirmation with biopsy. Most medical societies recommend screening people with GERD and other risk factors with endoscopy, but other alternatives employing less invasive methods are currently being studied. Surveillance strategies vary depending on the endoscopic findings and the Seattle biopsy protocol with random 4-quadrant sampling is recommended. Biomarkers have shown promising results, but more studies are needed in the future. White light endoscopy is the standard practice, but other advanced imaging modalities have shown variable results and hence more studies are awaited for further validation. Endoscopic eradication techniques, including both resection and ablation, have shown good but variable results for treating dysplastic lesions confined to the mucosa. Resection procedures to remove visible lesions followed by ablation of the dysplastic mucosa have shown the best results with higher eradication rates and lower recurrence rates. Surgical management is reserved for lesions with sub-mucosal invasion and lymph node spread with increased risk of metastasis.
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Affiliation(s)
| | - P Vennalaganti
- Department of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas city, Missouri, EE. UU
| | - P Sharma
- Department of Gastroenterology, Hepatology and Motility, University of Kansas Medical Center, Kansas city, Missouri, EE. UU..
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Swager AF, Boerwinkel DF, de Bruin DM, Faber DJ, van Leeuwen TG, Weusten BL, Meijer SL, Bergman JJ, Curvers WL. Detection of buried Barrett's glands after radiofrequency ablation with volumetric laser endomicroscopy. Gastrointest Endosc 2016; 83:80-8. [PMID: 26124075 DOI: 10.1016/j.gie.2015.05.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/20/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The prevalence and clinical relevance of buried Barrett's glands (BB) after radiofrequency ablation (RFA) in Barrett's esophagus (BE) are debated. Recent optical coherence tomography studies demonstrated a high prevalence of BBs. Direct histological correlation, however, has been lacking. Volumetric laser endomicroscopy (VLE) is a second-generation optical coherence tomography system capable of scanning a large surface of the esophageal wall layers with low-power microscopy resolution. The aim was to evaluate whether post-RFA subsquamous glandular structures (SGSs), detected with VLE, actually correspond to BBs by pursuing direct histological correlation with VLE images. METHODS In vivo VLE was performed to detect SGSs in patients with endoscopic regression of BE post-RFA. A second in vivo VLE scan was performed to confirm correct delineation of the SGSs. After endoscopic resection, the specimens were imaged ex vivo with VLE. Extensive histological sectioning of SGS areas was performed, and all histology slides were evaluated by an expert BE pathologist. RESULTS Seventeen patients underwent successful in vivo VLE (histological diagnosis before endoscopic treatment: early adenocarcinoma in 8 patients and high-grade dysplasia in 9). In 4 of 17 patients, no SGSs were identified during VLE, and a random resection was performed. In the remaining 13 patients (76%), VLE detected SGS areas, which were all confirmed on a second in vivo VLE scan and subsequently resected. Most SGSs identified by VLE corresponded to normal histological structures (eg, dilated glands and blood vessels). However, 1 area containing BBs was found on histology. No specific VLE features to distinguish between BBs and normal SGSs were identified. CONCLUSIONS VLE is able to detect subsquamous esophageal structures. One area showed BBs beneath endoscopically normal-appearing neosquamous epithelium; however, most post-RFA SGSs identified by VLE correspond to normal histological structures. ( CLINICAL TRIAL REGISTRATION NUMBER NTR4056.).
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Affiliation(s)
- Anne-Fré Swager
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - David F Boerwinkel
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Daniel M de Bruin
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - Dirk J Faber
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ton G van Leeuwen
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bas L Weusten
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Biomedical Engineering, Academic Medical Center, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
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Sharma P, Katzka DA, Gupta N, Ajani J, Buttar N, Chak A, Corley D, El-Serag H, Falk GW, Fitzgerald R, Goldblum J, Gress F, Ilson DH, Inadomi JM, Kuipers EJ, Lynch JP, McKeon F, Metz D, Pasricha PJ, Pech O, Peek R, Peters JH, Repici A, Seewald S, Shaheen NJ, Souza RF, Spechler SJ, Vennalaganti P, Wang K. Quality indicators for the management of Barrett's esophagus, dysplasia, and esophageal adenocarcinoma: international consensus recommendations from the American Gastroenterological Association Symposium. Gastroenterology 2015; 149:1599-606. [PMID: 26296479 PMCID: PMC4820399 DOI: 10.1053/j.gastro.2015.08.007] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The development of and adherence to quality indicators in gastroenterology, as in all of medicine, is increasing in importance to ensure that patients receive consistent high-quality care. In addition, government-based and private insurers will be expecting documentation of the parameters by which we measure quality, which will likely affect reimbursements. Barrett's esophagus remains a particularly important disease entity for which we should maintain up-to-date guidelines, given its commonality, potentially lethal outcomes, and controversies regarding screening and surveillance. To achieve this goal, a relatively large group of international experts was assembled and, using the modified Delphi method, evaluated the validity of multiple candidate quality indicators for the diagnosis and management of Barrett's esophagus. Several candidate quality indicators achieved >80% agreement. These statements are intended to serve as a consensus on candidate quality indicators for those who treat patients with Barrett's esophagus.
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Affiliation(s)
- Prateek Sharma
- University of Kansas School of Medicine, Kansas City, Kansas; Veterans Affairs Medical Center, Kansas City, Missouri.
| | | | - Neil Gupta
- Department of Gastroenterology and Hepatology, Loyola University Medical Center, Maywood, Illinois
| | - Jaffer Ajani
- University of Texas, Anderson Cancer Center, Houston, Texas
| | | | - Amitabh Chak
- Case Western Reserve University, Cleveland, Ohio
| | - Douglas Corley
- Kaiser Permanente Northern California, Oakland, California
| | | | - Gary W. Falk
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rebecca Fitzgerald
- MRC Cancer Cell Unit, Hutchison-MRC Research Center and University of Cambridge, Cambridge, UK
| | - John Goldblum
- Anatomic Pathology, The Cleveland Clinic, Cleveland, Ohio
| | - Frank Gress
- State University of New York at Downstate Medical Center, New York, New York
| | - David H. Ilson
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - John M. Inadomi
- University of Washington Medical Center, Seattle, Washington
| | | | - John P. Lynch
- University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frank McKeon
- National University Health System, Singapore and University of Connecticut, Farmington, Connecticut
| | - David Metz
- University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Oliver Pech
- Kranhenhaus Barmherzige Brüder, Regensburg, Germany
| | - Richard Peek
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Nicholas J. Shaheen
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Rhonda F. Souza
- University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas
| | - Stuart J. Spechler
- University of Texas Southwestern Medical Center and VA North Texas Healthcare System, Dallas, Texas
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Balmadrid B, Hwang JH. Endoscopic resection of gastric and esophageal cancer. Gastroenterol Rep (Oxf) 2015; 3:330-8. [PMID: 26510452 PMCID: PMC4650978 DOI: 10.1093/gastro/gov050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/23/2015] [Indexed: 12/18/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) techniques have reduced the need for surgery in early esophageal and gastric cancers and thus has lessened morbidity and mortality in these diseases. ESD is a relatively new technique in western countries and requires rigorous training to reproduce the proficiency of Asian countries, such as Korea and Japan, which have very high complete (en bloc) resection rates and low complication rates. EMR plays a valuable role in early esophageal cancers. ESD has shown better en bloc resection rates but it is easier to master and maintain proficiency in EMR; it also requires less procedural time. For early esophageal adenocarcinoma arising from Barrett’s, ESD and EMR techniques are usually combined with other ablative modalities, the most common being radiofrequency ablation because it has the largest dataset to prove its success. The EMR techniques have been used with some success in early gastric cancers but ESD is currently preferred for most of these lesions. ESD has the added advantage of resecting into the submucosa and thus allowing for endoscopic resection of more aggressive (deeper) early gastric cancer.
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Affiliation(s)
- Bryan Balmadrid
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
| | - Joo Ha Hwang
- Division of Gastroenterology, University of Washington, Seattle, WA, USA
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Endoscopic mucosal resection of early oesophageal neoplasia in patients requiring anticoagulation: is it safe? Surg Endosc 2015; 30:2390-5. [PMID: 26307599 DOI: 10.1007/s00464-015-4489-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2015] [Accepted: 08/01/2015] [Indexed: 01/14/2023]
Abstract
BACKGROUND AND AIM Endoscopic mucosal resection (EMR) has become the standard treatment for early oesophageal neoplasia. The mucosal defect caused by EMR usually takes several weeks to heal. Despite guidelines on high-risk endoscopic procedures in patients on anticoagulation, evidence is lacking whether EMR is safe in such patients. We investigated the immediate and delayed bleeding risk in patients undergoing diagnostic or therapeutic oesophageal EMR comparing patients requiring warfarin anticoagulation with a control group. METHODS Warfarin was stopped 5 days before the planned EMR and restarted on the evening following the procedure. Patients with high-risk conditions, such as recent pulmonary thromboemboli, received bridging with low molecular weight heparin. All EMRs were performed when the INR was <1.5. Bleeding events on the day of the EMR and within 3 months post-procedure were documented. RESULTS One hundred and seventeen consecutive patients with early oesophageal neoplasia were included. Sixty-eight EMRs were performed in 15 patients requiring anticoagulation. One patient on warfarin was readmitted 10 days after EMR with haematemesis and melaena. Out of 400 EMRs in 102 controls, 26 immediate bleeding events occurred requiring endoscopic intervention. One delayed bleeding event (melaena) occurred in the control group. The number of bleeding events did not differ between groups [p = 0.99; odds ratio 1.01 (0.30-3.44)], neither for acute (p = 0.76) nor delayed bleeding (p = 0.24). CONCLUSION EMR of early oesophageal neoplasia can be safely performed in patients requiring anticoagulation when warfarin is discontinued 5 days before the endoscopic intervention and reinstituted on the evening of the procedure day.
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Rubenstein JH, Shaheen NJ. Epidemiology, Diagnosis, and Management of Esophageal Adenocarcinoma. Gastroenterology 2015; 149:302-17.e1. [PMID: 25957861 PMCID: PMC4516638 DOI: 10.1053/j.gastro.2015.04.053] [Citation(s) in RCA: 255] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 03/27/2015] [Accepted: 04/02/2015] [Indexed: 02/06/2023]
Abstract
Esophageal adenocarcinoma (EAC) is rapidly increasing in incidence in Western cultures. Barrett's esophagus is the presumed precursor lesion for this cancer. Several other risk factors for this cancer have been described, including chronic heartburn, tobacco use, white race, and obesity. Despite these known associations, most patients with EAC present with symptoms of dysphagia from late-stage tumors; only a small number of patients are identified by screening and surveillance programs. Diagnostic analysis of EAC usually commences with upper endoscopy followed by cross-sectional imaging. Endoscopic ultrasonography is useful to assess the local extent of disease as well as the involvement of regional lymph nodes. T1a EAC may be treated endoscopically, and some patients with T1b disease may also benefit from endoscopic therapy. Locally advanced disease is generally managed with esophagectomy, often accompanied by neoadjuvant chemoradiotherapy or chemotherapy. The prognosis is based on tumor stage; patients with T1a tumors have an excellent prognosis, whereas few patients with advanced disease have long-term survival.
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Affiliation(s)
- Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Ann Arbor, Michigan; Barrett's Esophagus Program, Division of Gastroenterology, Department of Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Nicholas J Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Singh R, Yeap SP, Cheong KL. Detection and characterization of early malignancy in the esophagus: what is the best management algorithm? Best Pract Res Clin Gastroenterol 2015; 29:533-44. [PMID: 26381300 DOI: 10.1016/j.bpg.2015.06.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 05/11/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023]
Abstract
Barrett's esophagus is a known precursor for esophageal adenocarcinoma. Early detection of dysplasia provides a window of opportunity for curative intervention. Several image-enhanced technologies have been developed to improve visualization of neoplasia. These however have not been found to be superior to the standard four quadrant random biopsy protocol. Patients are risk-stratified based on the degree of dysplasia found on biopsies and undergo either surveillance or treatment. Endoscopic therapy has become the mainstay of treatment for early neoplasia.
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Affiliation(s)
- Rajvinder Singh
- The Lyell McEwin Hospital & University of Adelaide Endoscopy Unit, Haydown Road, Elizabeth Vale, SA 5112, Australia.
| | - Sze Pheh Yeap
- The Lyell McEwin Hospital & University of Adelaide Endoscopy Unit, Haydown Road, Elizabeth Vale, SA 5112, Australia
| | - Kuan Loong Cheong
- The Lyell McEwin Hospital & University of Adelaide Endoscopy Unit, Haydown Road, Elizabeth Vale, SA 5112, Australia
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Pech O. Endoscopic therapy of high-grade dysplasia and intramucosal adenocarcinoma: 2 small steps for the endoscopists but a fine step forward for the patient. Gastrointest Endosc 2015; 81:1167-9. [PMID: 25864893 DOI: 10.1016/j.gie.2015.01.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 01/22/2015] [Indexed: 12/20/2022]
Affiliation(s)
- Oliver Pech
- Department of Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brüder (St. John of God Hospital), Teaching Hospital of the University of Regensburg, Regensburg, Germany
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