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Niu X, Wang N, Wang Y, Feng J, Li L, Han K, Chai N, Linghu E. Role of submucosal injection in radiofrequency ablation of gastric low-grade dysplasia: Effects on symptoms and outcomes. Chin Med J (Engl) 2024:00029330-990000000-01034. [PMID: 38602084 DOI: 10.1097/cm9.0000000000003080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Indexed: 04/12/2024] Open
Abstract
BACKGROUND To date, there is still a lack of standardized management strategies for gastric low-grade dysplasia (LGD), which is a direct neoplastic precancerous lesion and requires specifically superficial destruction. Radiofrequency ablation (RFA) is expected to be an effective method for gastric LGD, but post-RFA pain may affect patients' satisfaction and compliance. The current study aimed to evaluate the value of a submucosal injection prior to RFA (SI-RFA) for postoperative pain and treatment outcomes. METHODS Between October 2014 and July 2021, gastric LGDs without risk factors (size >2 cm, unclear boundary, and abnormal microsurface and microvascularity) undergoing regular RFA and SI-RFA were retrospectively analyzed. Postoperative pain scores, wound healing, and clinical efficacy were compared. Propensity score matching, stratified analysis, and multivariable logistic regression were performed to control the confounding variables. RESULTS One hundred and ninety-seven gastric LGDs in 151 patients received regular RFA. Forty-nine gastric LGDs in 36 patients received SI-RFA. Thirty-six pairs of patients were selected for the assessment of postoperative pain by propensity score matching. Compared to regular RFA, SI-RFA significantly decreased the degree and duration of postoperative pain (OR, 0.32; 95% CI, 0.13-0.84; P = 0.020), improved wound healing rate (80.0% [36/45] vs. 58.9% [89/151], P = 0.012), increased the complete ablation rate (91.8% [45/49] vs. 86.3% [170/197], χ2 = 1.094, P = 0.295), but correlated with higher rates of local recurrence and progression (25.6% [10/39] vs. 13.2% [18/136], χ2 = 3.471, P = 0.062; 8.3% [3/36] vs. 0.9% [1/116], P = 0.042). The multivariable logistic regression model confirmed that submucosal injection was associated with local recurrence (OR, 2.93; 95% CI, 1.13-7.58; P = 0.027). CONCLUSIONS Submucosal injections prior to RFA may reduce postoperative pain and scar formation while ensuring complete ablation of gastric LGD. However, local recurrence and progression should be considered seriously.
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Affiliation(s)
- Xiaotong Niu
- Medical School of Chinese PLA General Hospital, Beijing 100853, China
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Nanjun Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yan Wang
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
- Nankai University School of Medicine, Nankai University, Tianjin 300071, China
| | - Jia Feng
- Department of Gastroenterology, Bethune International Peace Hospital, ShijiaZhuang, Hebei 050082, China
| | - Longsong Li
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ke Han
- Medical School of Chinese PLA General Hospital, Beijing 100853, China
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Ningli Chai
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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Akizue N, Okimoto K, Hirotsu Y, Amemiya K, Kaneko T, Ohta Y, Taida T, Saito K, Matsumura T, Nishimura M, Matsushita K, Mochizuki H, Chiba T, Arai M, Kato J, Omata M, Kato N. Carcinogenic potential in regenerated mucosa after endoscopic resection of esophageal squamous cell carcinoma. J Gastroenterol Hepatol 2023; 38:1546-1551. [PMID: 37194195 DOI: 10.1111/jgh.16219] [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: 07/15/2022] [Revised: 11/04/2022] [Accepted: 05/03/2023] [Indexed: 05/18/2023]
Abstract
BACKGROUND AND AIM Little is known about genetic mutations in the regenerated mucosa (RM) after endoscopic resection (ER) of esophageal carcinoma. Thus, this study investigates the status of genetic variation in RM after ER of esophageal squamous cell carcinoma (ESCC). METHODS The study cohort included 19 patients with ESCC. We used an esophageal carcinoma panel to identify target sequences for squamous cell carcinoma (SCC), background mucosa (BM), and RM after ER of ESCC. We used OncoKB to check whether each mutation was a putative driver. RESULTS We identified 77 mutations of 32 genes in SCC, 133 mutations of 34 genes in BM, and 100 mutations of 29 genes in RM. Putative driver mutations were identified in 20 mutations in 14 cases in SCC, 16 mutations in 10 cases in BM, and 7 mutations in 11 cases in RM. The rate of putative driver mutations to total mutations was significantly lower in RM (26% in SCC vs 12% in BM vs 7% in RM, P = 0.009). Additionally, the rate of cases with TP53 putative driver mutations was significantly lower in RM (63% in SCC vs 37% in BM vs 16% in RM, P = 0.011). The percentage of putative driver mutations and the percentage of cases with a putative driver of TP53 were significantly lower in RM. CONCLUSION Esophageal RM after ER of ESCC could have a lower risk of carcinogenesis.
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Affiliation(s)
- Naoki Akizue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kenichiro Okimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yosuke Hirotsu
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Kenji Amemiya
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Tatsuya Kaneko
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Ohta
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Takashi Taida
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keiko Saito
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tomoaki Matsumura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Motoi Nishimura
- Division of Clinical Genetics and Proteomics, Department of Laboratory Medicine, Chiba University Hospital, Chiba, Japan
| | - Kazuyuki Matsushita
- Division of Clinical Genetics and Proteomics, Department of Laboratory Medicine, Chiba University Hospital, Chiba, Japan
| | - Hitoshi Mochizuki
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Japan
| | - Tetsuhiro Chiba
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Makoto Arai
- Department of Gastroenterology, Tokyo Women's Medical University Yachiyo Medical Center, Yachiyo, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Masao Omata
- Genome Analysis Center, Yamanashi Prefectural Central Hospital, Kofu, Japan
- Tokyo University, Tokyo, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Extension of early esophageal squamous cell neoplasia into ducts and submucosal glands and the role of endoscopic ablation therapy. Gastrointest Endosc 2021; 94:832-842.e2. [PMID: 33974941 DOI: 10.1016/j.gie.2021.04.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/27/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Early esophageal squamous cell neoplasia (ESCN) is preferably treated with en-bloc endoscopic resection. Ablation might be an alternative for flat ESCN, but ESCN extension along the epithelial lining of ducts and submucosal glands (SMGs) might jeopardize ablation efficacy. Clinical studies suggest that local recurrence might arise from such buried ESCN niches after ablation. We studied human endoscopic resection specimens of ESCN to quantify ESCN extension into ducts/SMGs and performed a prospective porcine study to evaluate the depth of radiofrequency ablation (RFA) and CryoBalloon ablation (CBA) into ducts/SMGs. METHODS Endoscopic submucosal dissection specimens of flat-type ESCN from a Japanese (n = 65) and Dutch cohort (n = 14) were evaluated for presence and neoplastic involvement of ducts/SMGs. Twenty-seven pigs were treated with circumferential RFA (c-RFA; n = 4), focal CBA (n = 20), and focal RFA (n = 3) with 4, 60, and 9 treatment areas, respectively. After prespecified survival periods (0 hours, 8 hours, 2 days, 5 days, and 28 days), treatment areas were evaluated for uniformity and depth of ablation and affected SMGs. RESULTS Neoplastic extension in ducts/SMGs was observed in most lesions: 58% (38/65) in the Japanese and 64% (9/14) in the Dutch cohort. In the animal study, 33% of SMGs (95% confidence interval, 28-50) were not affected after c-RFA, although the overlying epithelium was ablated. Focal RFA and CBA resulted in uniform ablations with effective treatment of all SMGs. CONCLUSIONS ESCN extends into ducts/SMGs in most patients. In an animal model, focal RFA and CBA effectively ablated SMGs, whereas c-RFA inadequately ablated SMGs. Given this potential reason for recurrence, endoscopic resection should remain the standard of care.
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Radiofrequency Ablation for Early Superficial Flat Esophageal Squamous Cell Neoplasia: A Comprehensive Review. Gastroenterol Res Pract 2020; 2020:4152453. [PMID: 32508911 PMCID: PMC7244955 DOI: 10.1155/2020/4152453] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Accepted: 04/27/2020] [Indexed: 12/17/2022] Open
Abstract
Esophageal squamous cell carcinoma comprises the majority of esophageal carcinoma in the Eastern Asia. The need of early detection of precancerous neoplastic lesions and cancer has been necessitated due to the probability of progression to the advanced stage and its poor prognosis. In recent times, many endoscopic modalities have come into practice for early detection and treatment. Endoscopic radiofrequency ablation (RFA) has been recommended as an efficient therapy in treating the dysplastic mucosa in Barrett's esophagus (BE). Its potential in reversing neoplastic lesions in squamous epithelium has been gradually explored. This article is aimed at reviewing the current evidence regarding the use of RFA on esophageal squamous cell neoplasia.
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Yu X, van Munster SN, Zhang Y, Xue L, Fleischer DE, Weusten BLAM, Lu N, Dawsey SSM, Bergman JJGHM, Wang G. Durability of radiofrequency ablation for treatment of esophageal squamous cell neoplasia: 5-year follow-up of a treated cohort in China. Gastrointest Endosc 2019; 89:736-748.e2. [PMID: 30905354 PMCID: PMC7517876 DOI: 10.1016/j.gie.2018.10.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Accepted: 10/19/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Radiofrequency ablation (RFA) is an accepted treatment for flat Barrett's neoplasia. Less is known about RFA for esophageal squamous cell neoplasia (ESCN). Our group has reported several prospective studies of RFA for ESCN in China with promising results through 12 months of follow-up. In this cohort study we aimed to evaluate longer term outcomes after RFA for ESCN. METHODS Patients with flat unstained lesions (USLs) on Lugol's endoscopy containing moderate-/high-grade intraepithelial neoplasia (MGIN/HGIN) or mucosal cancer were treated with RFA every 3 months until complete remission (CR; no MGIN or a worse histologic grade). Patients with CR at 12 months (CR12) were included for follow-up and underwent annual Lugol's endoscopy with biopsy sampling and re-RFA for flat USLs. The clinical course of patients with persistent ESCN at 12 months (treatment failures) is also reported. RESULTS Among the 78 patients in CR12, 67 (86%) had sustained CR during a median of 48 months (interquartile range, 48-48) of follow-up and 5 endoscopies (interquartile range, 4-6). Recurrence occurred in 7 of 78 patients (9%; MGIN, n = 6; HGIN, n = 1); all lesions were managed with RFA. Four other patients (5%) had progression (to HGIN, n = 1; submucosal esophageal squamous cell carcinoma, n = 3). During follow-up protocol violations occurred in 46 of 78 patients (59%). Of the 12 treatment failures, progression occurred in 6. Overall, 2 patients developed subepithelial disease that was not visible after Lugol's endoscopy. Based on post-hoc analysis, the pink-color sign at baseline (a pink color change after Lugol's endoscopy) significantly predicted failure after RFA. CONCLUSIONS RFA is relatively easy to apply and can efficiently treat large areas with ESCN. Despite protocol violations that may have interfered with the efficacy of RFA in 59% of patients, most patients with CR12 had sustained CR during follow-up. However, some patients progressed to advanced disease and 2 developed subepithelial disease, not visible after Lugol's endoscopy. Based on currently available data, we advise the restriction of the use of RFA for flat MGIN and HGIN without the pink-color sign on Lugol's chromoendoscopy. (Clinical trial registration number: NCT02047305.).
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Affiliation(s)
- Xinying Yu
- Department of Endoscopy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Sanne N van Munster
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Yueming Zhang
- Department of Endoscopy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Liyan Xue
- Department of Pathology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - David E Fleischer
- Department of Gastroenterology & Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Bas L A M Weusten
- Department of Gastroenterology & Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands; Department of Gastroenterology & Hepatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Ning Lu
- Department of Pathology, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Sanford S M Dawsey
- Department of Cancer Epidemiology & Genetics, National Cancer Institute, Bethesda, Maryland, USA
| | - Jacques J G H M Bergman
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Guiqi Wang
- Department of Endoscopy, Cancer Institute and Hospital, Chinese Academy of Medical Sciences, Beijing, China
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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: 1.2] [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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Kristo I, Rieder E, Paireder M, Schwameis K, Jomrich G, Dolak W, Parzefall T, Riegler M, Asari R, Schoppmann SF. Radiofrequency ablation in patients with large cervical heterotopic gastric mucosa and globus sensation: Closing the treatment gap. Dig Endosc 2018; 30:212-218. [PMID: 28884487 DOI: 10.1111/den.12959] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 08/31/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Symptomatic cervical heterotopic gastric mucosa, also known as cervical inlet patch (CIP), may present in various shapes and causes laryngopharyngeal reflux (LPR). Unfortunately, argon plasma coagulation, standard treatment of small symptomatic CIP, is limited in large CIP mainly because of concerns of stricture formation. Therefore, we aimed to investigate radiofrequency ablation (RFA), a novel minimally invasive ablation method, in the treatment of CIP focusing on large symptomatic patches. METHODS Consecutive patients with macroscopic and histological evidence of large (≥20 mm diameter) heterotopic gastric mucosa were included in this prospective trial. Primary outcome was complete macroscopic and histological eradication rate of CIP. Secondary outcome measures were symptom improvement, quality of life, severity of LPR and adverse events. RESULTS Ten patients (females, n = 5) underwent RFA of symptomatic CIP. Complete histological and macroscopic eradication of CIP was observed in 80% (females, n = 4) of individuals after two ablations. Globus sensations significantly improved from median visual analog scale score 8 (5-9) at baseline to 1.5 (1-7) after first ablation and 1 (1-2) after final evaluation (P < 0.001). Mental health scores significantly increased from 41.4 (± 8.5) to 54.4 (± 4.4) after RFA (P = 0.007). LPR improved significantly (P = 0.005) with absence of strictures after a mean follow up of 1.9 (± 0.5) years. CONCLUSIONS This is the first study on RFA focusing on therapy of large symptomatic heterotopic gastric mucosa. Hereby, we demonstrate that this new technique can be successfully implemented in patients where treatment was limited so far (NCT03023280).
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Affiliation(s)
- Ivan Kristo
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Erwin Rieder
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Matthias Paireder
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Katrin Schwameis
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Gerd Jomrich
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
| | - Werner Dolak
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Parzefall
- Department of Otorhinolaryngology, Medical University of Vienna, Vienna, Austria
| | | | - Reza Asari
- Departments of Surgery, Medical University of Vienna, Vienna, Austria
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Navaneethan U, Thosani N, Goodman A, Manfredi M, Pannala R, Parsi MA, Smith ZL, Sullivan SA, Banerjee S, Maple JT. Radiofrequency ablation devices. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2017; 2:252-259. [PMID: 29905337 PMCID: PMC5992954 DOI: 10.1016/j.vgie.2017.06.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Key Words
- APC, argon plasma coagulation
- ASGE, American Society for Gastrointestinal Endoscopy
- BE, Barrett's esophagus
- CCA, cholangiocarcinoma
- CE-D, complete eradication of dysplasia
- CE-IM, complete eradication of intestinal metaplasia
- CI, confidence interval
- CPT, current procedural technology
- ESD, endoscopic submucosal dissection
- GAVE, gastric antral vascular ectasia
- HGD, high-grade dyplasia
- IMC, intramucosal carcinoma
- LGD, low-grade dysplasia
- NET, neuroendocrine tumors
- PDT, photodynamic therapy
- RF, radiofrequency
- RFA, radiofrequency ablation
- RP, radiation proctopathy
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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: 1.9] [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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Abstract
Although there are many unanswered questions with Barrett esophagus, we can safely say that the incidence is increasing, chemoprevention strategies for the prevention of Barrett metaplasia and its progression to adenocarcinoma may be in the offing, surveillance should be considered for all patients who are discovered to have Barrett esophagus, RFA is the treatment of choice for those with HGD and strongly considered in those with LGD, EMR should be the treatment of choice for patients with nodular high-grade Barrett esophagus, and, finally, vagal-sparing esophagectomy reserved for patients with persistent HGD or a strong suspicion of carcinoma, with consideration of a concomitant fundoplication.
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Affiliation(s)
- Mark Splittgerber
- Division of General Surgery, University of South Florida, Tampa, FL, USA
| | - Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, FL, USA.
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Patel A, Pathak R, Deshpande V, Patel SH, Wickremesinghe PC, Vadada D. Radiofrequency ablation using BarRx for the endoscopic treatment of radiation proctopathy: a series of three cases. Clin Exp Gastroenterol 2014; 7:453-60. [PMID: 25525377 PMCID: PMC4266256 DOI: 10.2147/ceg.s66534] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Radiation proctopathy is a complication of pelvic radiotherapy, which occurs in patients treated for carcinoma of the prostate, rectum, urinary bladder, cervix, uterus, and testes. If it presents within 6 weeks to 9 months after therapy, it is called acute radiation proctitis/proctopathy (ARP), and if it occurs 9 months to a year after treatment, it is classified as chronic radiation proctitis/proctopathy (CRP). CRP occurs in 5%–20% of patients receiving pelvic radiation, depending on the radiation dose and the presence or absence of chemotherapy. In many cases, CRP resolves spontaneously, but in some, it can lead to persistent rectal bleeding. Other symptoms of CRP include diarrhea, mucoid discharge, urgency, tenesmus, rectal pain, and fecal incontinence. Despite the availability of several therapies, many patients fail to respond, and continue to suffer in their quality of life. Radiofrequency ablation (RFA) is a newer endoscopic technique that uses radiofrequency energy to ablate tissue. This is an emerging way to treat radiation proctopathy and other mucosal telangiectasia. We present three cases of radiation proctopathy treated with RFA at our institute and review the literature on treatment modalities for CRP. We were also able to find 16 other cases of CRP that used RFA, and review their literature as well as literature on other treatment modalities.
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Affiliation(s)
- Anish Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Rahul Pathak
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Vrushak Deshpande
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | - Sunil H Patel
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
| | | | - Deepak Vadada
- Department of Gastrointestinal Medicine, Richmond University Medical Center, Staten Island, NY, USA
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Cameron GR, Jayasekera CS, Williams R, Macrae FA, Desmond PV, Taylor AC. Detection and staging of esophageal cancers within Barrett's esophagus is improved by assessment in specialized Barrett's units. Gastrointest Endosc 2014; 80:971-83.e1. [PMID: 24929493 DOI: 10.1016/j.gie.2014.03.051] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 03/27/2014] [Indexed: 12/20/2022]
Abstract
BACKGROUND Identification and resection of mucosal abnormalities are critical in managing dysplastic Barrett's esophagus (BE) because these areas may harbor esophageal adenocarcinoma (EAC). OBJECTIVES To compare mucosal lesion and EAC detection rates in dysplastic BE in the community versus a BE unit and assess the impact of EMR on disease staging and management. DESIGN Prospective cohort study. SETTING Tertiary referral center. PATIENTS Patients with dysplastic BE. INTERVENTIONS Reassessment with high-definition white-light endoscopy (HD-WLE), narrow-band imaging (NBI), and Seattle protocol biopsies. EMR performed in lesions thought to harbor neoplasia. Review of referral histology and endoscopies. MAIN OUTCOME MEASUREMENTS Mucosal lesion and EAC detection rates in a BE unit versus the community. Impact of EMR on management. RESULTS Sixty-nine patients were referred (88% male; median age, 69 years). At referral, HD-WLE/NBI use was 57%/14%, and Seattle protocol adherence was 20%. Eighteen patients had intramucosal cancer. Lesions were detected in 65 patients in the BE unit versus 29 patients at referral (P < .001). EMR was performed in 47 patients. BE unit assessment confirmed EAC in all 18 patients and identified 10 additional patients (56% increased cancer detection, P = .036); all 10 had lesions identified in the BE unit (vs 3 identified at referral). EMR in these patients found submucosal cancer (n = 4) and intramucosal cancer (n = 6), resulting in esophagectomy (n = 4) and chemoradiotherapy (n = 1). LIMITATION Academic center. CONCLUSION BE assessment at a BE unit resulted in increased lesion and EAC detection. EMR of early cancers was critical in optimizing patient management. These data suggest that BE unit referral be considered in patients with dysplastic BE.
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Affiliation(s)
- Georgina R Cameron
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Chatura S Jayasekera
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; Royal Melbourne Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Richard Williams
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Finlay A Macrae
- Royal Melbourne Hospital, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Paul V Desmond
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew C Taylor
- St. Vincent's Hospital Melbourne, Melbourne, Victoria, Australia; University of Melbourne, Melbourne, Victoria, Australia
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Ribeiro A, Bejarano P, Livingstone A, Sparling L, Franceschi D, Ardalan B. Depth of injury caused by liquid nitrogen cryospray: study of human patients undergoing planned esophagectomy. Dig Dis Sci 2014; 59:1296-301. [PMID: 24395381 DOI: 10.1007/s10620-013-2991-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 12/09/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Cryotherapy using liquid nitrogen delivered endoscopically has been used for mucosal ablation of esophageal neoplasia. There are no data for the human esophagus on the depth of injury and effects of this technique. AIM Prospective study to examine the effect of treatment and depth of injury to the human esophagus of liquid nitrogen spray cryotherapy for subjects with esophageal neoplasia before planned esophagectomy. METHODS Liquid nitrogen spray cryoablation was performed seven days before scheduled esophagectomy for seven males with esophageal carcinoma. Subjects were assigned to either treatment of four cycles of 10 s each (group 1) or two cycles of 20 s each (group 2) applied to a 2-cm segment of healthy esophagus above the tumor area. Main outcomes measured were: mean depth of injury (mm); surface displaying mucosal ablation, and adverse events. RESULTS Mucosal destruction was similar for both groups (group 1, 95%; group 2, 93%; p = NS). Deeper injury was observed for group 2; mean depth was 5.4 mm compared with 4.0 mm for group 1. Cryonecrosis reached the submucosa for 60% (12/20) of subjects in group 1 versus 93% (14/15) of subjects in group 2 (p = 0.04, two-tailed Fisher's exact test). No serious adverse events occurred. No perforation was seen in the resected esophagus. CONCLUSION Mucosal ablation with liquid nitrogen spray cryotherapy was highly effective in inducing mucosal necrosis; the doses assessed had similar effects. Ablation reached the submucosa more often with longer spray time despite fewer treatment cycles.
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Affiliation(s)
- Afonso Ribeiro
- Division of Gastroenterology, Department of Surgery, University of Miami School of Medicine, Miami, FL, USA,
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Heartburn, Barrett's oesophagus and cancer: implications for primary care. Br J Gen Pract 2014; 64:120-1. [PMID: 24567627 DOI: 10.3399/bjgp14x677383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
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van Vilsteren FGI, Phoa KN, Alvarez Herrero L, Pouw RE, Sondermeijer CMT, Visser M, Ten Kate FJW, van Berge Henegouwen MI, Weusten BLAM, Schoon EJ, Bergman JJGHM. A simplified regimen for focal radiofrequency ablation of Barrett's mucosa: a randomized multicenter trial comparing two ablation regimens. Gastrointest Endosc 2013; 78:30-8. [PMID: 23528655 DOI: 10.1016/j.gie.2013.02.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Accepted: 02/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The currently recommended regimen for focal radiofrequency ablation (RFA) of Barrett's esophagus (BE) comprises 2 applications of energy, cleaning of the device and ablation zone, and 2 additional applications of energy. A simplified regimen may be of clinical utility if it is faster, easier, and equally safe and effective. OBJECTIVE To compare the efficacy of 2 focal RFA regimens. SETTING Three tertiary referral centers. PATIENTS Consecutive patients scheduled for focal RFA of BE with flat type BE with at least 2 BE islands or mosaic groups of islands were enrolled. INTERVENTIONS BE areas were paired: 1 area was randomized to the "standard" regimen (2 × 15 J/cm(2)-clean-2 × 15 J/cm(2)) or to the "simplified" regimen (3 × 15 J/cm(2)-no clean), allocating the second area automatically to the other regimen. The percentage of surface area regression of each area was scored at 2 months by the endoscopist (blinded). OUTCOME MEASURE Proportion of completely removed BE areas at 2 months. Calculated sample size was 46 pairs of BE areas using a noninferiority design. Noninferiority was defined as <20% difference in the paired proportions. RESULTS Forty-five equivalent pairs of BE areas were included in 41 patients. The proportion of completely removed BE areas at 2 months after focal RFA was 30 (67%) for standard and 33 (73%) for simplified. Noninferiority was demonstrated by a 7% difference (95% CI, -10.6 to +20.9). LIMITATIONS Tertiary referral centers. CONCLUSIONS The results of this multicenter randomized trial suggest that a simplified 3 × 15 J/cm(2) focal ablation regimen is not inferior to the standard regimen, regarding the endoscopic removal of residual Barrett islands.
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Estores D, Velanovich V. Barrett esophagus: epidemiology, pathogenesis, diagnosis, and management. Curr Probl Surg 2013; 50:192-226. [PMID: 23601575 DOI: 10.1067/j.cpsurg.2013.01.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Circumferential balloon-based radiofrequency ablation of Barrett's esophagus with dysplasia can be simplified, yet efficacy maintained, by omitting the cleaning phase. Clin Gastroenterol Hepatol 2013; 11:491-98.e1. [PMID: 23267867 DOI: 10.1016/j.cgh.2012.12.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2012] [Accepted: 12/10/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The current procedure for circumferential balloon-based radiofrequency ablation (c-RFA) for the removal of dysplastic Barrett's esophagus (BE) is labor intensive, comprising 2 ablation passes with a cleaning step to remove debris from the ablation zone and electrode. We compared the safety and efficacy of 3 different c-RFA ablation regimens. METHODS We performed a prospective trial of consecutive patients with flat-type BE with high-grade dysplasia. Fifty-seven patients (45 men; age, 64 ± 15 y; 28 with prior endoscopic resection) were assigned randomly to groups that underwent c-RFA with a double application of RFA (12 J/cm(2)). The standard group received c-RFA, with device removal and cleaning, followed by c-RFA; the simple-with-cleaning group underwent c-RFA, with device cleaning without removal, followed by c-RFA; and the simple-no-cleaning group received 2 applications of c-RFA, and the device was not removed or cleaned. The primary outcome was surface regression of BE 3 months later, graded by 2 blinded expert endoscopists. Calculated sample size was 57 patients, based on a noninferiority design. RESULTS Median BE surface regression at 3 months was 83% in the standard group, 78% in the simple-with-cleaning group, and 88% in the simple-no-cleaning group (P = .14). RF ablation time was 20 minutes (interquartile range [IQR], 18-25 min) for the standard group, 13 minutes (IQR, 11-15 min) for the simple-with-cleaning group, and 5 minutes (IQR, 5-9 min) for the simple-no-cleaning group (P < .01). The median number of introductions (RFA devices/endoscope) for the standard group was 7, vs 4 for the simple groups (P < .01). CONCLUSIONS This randomized, prospective study suggests that c-RFA is easier and faster, but equally safe and effective, when the cleaning phase between ablations is omitted or simplified. Trialregister.nl, NTR 2495.
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Eddi R, DePasquale JR. Radiofrequency ablation for the treatment of radiation proctitis: a case report and review of literature. Therap Adv Gastroenterol 2013; 6:69-76. [PMID: 23320051 PMCID: PMC3539292 DOI: 10.1177/1756283x12456895] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Radiation proctitis is a frequent complication of pelvic radiation for cancer. This condition can present acutely within several weeks of radiation, or chronically many months or years after radiation, leading to rectal bleeding and transfusion-dependent anemia. Various medical and endoscopic therapies have been described to treat this condition; however, some patients fail to respond to the current standard therapies. Here we present a case of refractory radiation proctitis, with suboptimal response to other therapies, treated successfully with a novel method, radiofrequency ablation.
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Affiliation(s)
- Rodney Eddi
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, 111 Central Avenue, Newark, NJ 07102, USA
| | - Joseph R. DePasquale
- Seton Hall University, School of Health and Medical Sciences – St. Michael’s Medical Center, Department of Medicine, Division of Gastroenterology, Newark, USA
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Endoscopic management of Barrett's esophagus: advances in endoscopic techniques. Dig Dis Sci 2012; 57:3055-64. [PMID: 22760590 DOI: 10.1007/s10620-012-2279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2012] [Accepted: 06/05/2012] [Indexed: 12/13/2022]
Abstract
Barrett's esophagus (BE) is a well-known premalignant condition that can be associated with the development of dysplasia and adenocarcinoma. In the past, esophagectomy was the standard treatment for patients with BE with high grade dysplasia (HGD) and early cancer (EC). However, esophagectomy is not necessarily the only treatment response to HGD and EC anymore. Over the past decade, a number of endoscopic therapies have been developed for management of BE. These include endoscopic mucosal resection, thermal ablation techniques that use laser irradiation, multipolar electrocoagulation, argon plasma coagulation, photodynamic therapy, and the recently developed cryotherapy and radiofrequency ablation.
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Abstract
Barrett's esophagus is a pathologic change of the normal squamous epithelium of the esophagus to specialized columnar metaplasia. Barrett's esophagus is a result of prolonged exposure of the esophagus to gastroduodenal refluxate. Although Barrett's itself is not symptomatic, and, in fact, patients with Barrett's esophagus may be completely asymptomatic, it does identify patients at higher risk of developing esophageal adenocarcinoma. Traditionally, antireflux surgery was reserved for patients with symptoms, because it was believed that antireflux surgery did not eliminate Barrett's esophagus and reduce cancer risk. Rationale for the treatment of Barrett's esophagus beyond treating symptoms of gastroesophageal reflux disease stems from the hope to decrease, if not eliminate, the risk of adenocarcinoma. Treatment options ranged from medical acid suppression without surveillance to resection. Ablation, particularly endoscopic radio-frequency ablation, has become the standard of care for Barrett's esophagus with high-grade dysplasia. It role in nondysplastic or low-grade dysplastic Barrett's is less clear. Combined endoscopic mucosal resection with ablation is effective in nodular high-grade Barrett's esophagus. Resection should be reserved for patients with persistent high-grade dysplasia despite multiple attempts at endoscopic ablation or resection or for patients with evidence of carcinoma.
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Affiliation(s)
- Vic Velanovich
- Division of General Surgery, University of South Florida, Tampa, Florida
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Green S, Bhandari P, DeCaestecker J, Barr H, Ragunath K, Jankowski J, Singh R, Longcroft-Wheaton G, Bennett C. Endoscopic therapies for the prevention and treatment of early esophageal neoplasia. Expert Rev Gastroenterol Hepatol 2011; 5:731-43. [PMID: 22017700 DOI: 10.1586/egh.11.80] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Esophageal cancers have traditionally been diagnosed late and prognosis has been dire. For many years the only real treatment option was esophagectomy with substantial morbidity and mortality. This situation has now changed dramatically. Improvements have been achieved in surgical outcomes and there is an array of new effective treatment options now available, particularly for the increasing proportion diagnosed with early-stage disease. Minimally invasive endoscopic therapies can now prevent, cure or palliate esophageal cancers. This article aims to investigate the role and evidence base for these new therapeutic options.
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Affiliation(s)
- Susi Green
- St Mark's Hospital, Northwick Park, Watford Road, Harrow, Middlesex, HA1 3UJ, UK.
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Goers TA, Leão P, Cassera MA, Dunst CM, Swanström LL. Concomitant endoscopic radiofrequency ablation and laparoscopic reflux operative results in more effective and efficient treatment of Barrett esophagus. J Am Coll Surg 2011; 213:486-92. [PMID: 21784666 DOI: 10.1016/j.jamcollsurg.2011.06.419] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2010] [Revised: 06/15/2011] [Accepted: 06/15/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Barrett esophagus (BE) caused by gastroesophageal reflux disease can lead to esophageal cancer. The success of endoscopic treatments with BE eradication depends on esophageal anatomy and post-treatment acid exposure. STUDY DESIGN Between January 2008 and December 2009, 10 patients were selected for combination treatment of BE using laparoscopic anti-reflux surgery and endoscopic radiofrequency ablation. Retrospective review of preoperative, procedural, and postoperative data was performed. RESULTS Seven study patients had a pathologic diagnosis of nondysplastic BE and 3 patients had a diagnosis of low-grade dysplasia. Average length of BE lesions was 6.4 ± 4.8 cm. Procedure time averaged 154.4 ± 46.4 minutes. At the time of surgery, the mean number of ablations performed was 4.39 ± 1.99. Six patients were noted to have major hiatal hernias requiring reduction. Five patients (80%) had 100% resolution of their BE at their first postoperative endoscopy. The remaining 3 patients had a ≥50% resolution and underwent subsequent endoscopic ablation. Symptomatic results revealed that 4 patients had substantial dysphagia to solids and other symptoms were minimal. Two patients were noted to have complications related to the ablative treatments. One stricture and 1 perforation were observed. CONCLUSIONS Endoscopic radiofrequency ablation of BE at the time of laparoscopic fundoplication is feasible and can effectively treat BE lesions. A single combined treatment can result in fewer overall procedures performed to obtain BE eradication.
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Affiliation(s)
- Trudie A Goers
- GI/Minimally Invasive Surgery Division, The Oregon Clinic, Portland, OR 97210, USA
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24
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Vienne A, Prat F. [Endoscopic treatments for Barrett oesophagus]. Presse Med 2011; 40:516-28. [PMID: 21474270 DOI: 10.1016/j.lpm.2011.02.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 02/07/2011] [Indexed: 11/25/2022] Open
Abstract
High grade dysplasia and superficial carcinomas (with no extension under muscularis mucosae) can be indications for endoscopic treatments of Barrett oesophagus. When an endoscopic treatment is considered, a gastroscopy with use of acetic acid and planimetry and the confirmation of high-grade dysplasia by a new examination after PPI treatment and a pathologic second confirmation is needed. For high-grade dysplasia in focalised and visible lesions, an endoscopic resection by EMR or ESD should be proposed: it allows a more accurate pathologic examination and can be an effective curative treatment. After endoscopic resection of visible high grade dysplasia lesions, a complete eradication of Barrett oesophagus may be proposed to prevent dysplasia recurrence. In case of extensive high-grade dysplasia or to eradicate Barrett oesophagus residual lesions, radiofrequency ablation is the preferred endoscopic technique. Photodynamic therapy may also be proposed for more invasive lesions or after other endoscopic techniques with mucosal scars. Surgical oesophagus resection is still recommended for diffuse high-grade dysplasia in young patients or in case of pathologic pejorative criteria in endoscopic resection specimen. In case of Low-grade dysplasia, either endoscopic surveillance should be performed every six or 12 months or radiofrequency ablation could be proposed in the yield of prospective studies.
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Affiliation(s)
- Ariane Vienne
- Assistance publique-Hôpitaux de Paris, hôpital Cochin, service de gastro-entérologie, 75014 Paris, France.
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Fernández-Esparrach G, Rodríguez-D'Jesús A. [Radiofrequency in the treatment of Barrett's esophagus]. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:35-40. [PMID: 21216043 DOI: 10.1016/j.gastrohep.2010.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 10/21/2010] [Indexed: 11/17/2022]
Abstract
Currently, there is ample evidence that endoscopic treatment of Barrett's esophagus (BE) and related neoplasms is safe and effective, suggesting that this approach should be preferred to esophagectomy in selected patients. Among new endoscopic tools, radiofrequency ablation is the latest to be developed. Due to its simplicity, effectiveness and safety, this technique may change the management of patients with BE since it appears to be effective not only in removing dysplasia but also in completely eradicating all Barrett's mucosa in most treated patients.
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Affiliation(s)
- Gloria Fernández-Esparrach
- Unidad de Endoscopia, Servicio de Gastroenterología, ICMDiM, Hospital Clínic, Universitat de Barcelona, CIBERehd, IDIBAPS, Barcelona, Spain.
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Menon D, Stafinski T, Wu H, Lau D, Wong C. Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy. BMC Gastroenterol 2010; 10:111. [PMID: 20875123 PMCID: PMC2955687 DOI: 10.1186/1471-230x-10-111] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2010] [Accepted: 09/27/2010] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Recently, several new endoscopic treatments have been used to treat patients with Barrett's esophagus with high grade dysplasia. This systematic review aimed to determine the safety and effectiveness of these treatments compared with esophagectomy. METHODS A comprehensive literature search was undertaken to identify studies of endoscopic treatments for Barrett's esophagus or early stage esophageal cancer. Information from the selected studies was extracted by two independent reviewers. Study quality was assessed and information was tabulated to identify trends or patterns. Results were pooled across studies for each outcome. Safety (occurrence of adverse events) and effectiveness (complete eradication of dysplasia) were compared across different treatments. RESULTS The 101 studies that met the selection criteria included 8 endoscopic techniques and esophagectomy; only 12 were comparative studies. The quality of evidence was generally low. Methods and outcomes were inconsistently reported. Protocols, outcomes measured, follow-up times and numbers of treatment sessions varied, making it difficult to calculate pooled estimates.The surgical mortality rate was 1.2%, compared to 0.04% in 2831 patients treated endoscopically (1 death). Adverse events were more severe and frequent with esophagectomy, and included anastomotic leaks (9.4%), wound infections (4.1%) and pulmonary complications (4.1%). Four patients (0.1%) treated endoscopically experienced bleeding requiring transfusions. The stricture rate with esophagectomy (5.3%) was lower than with porfimer sodium photodynamic therapy (18.5%), but higher than aminolevulinic acid (ALA) 60 mg/kg PDT (1.4%). Dysphagia and odynophagia varied in frequency across modalities, with the highest rates reported for multipolar electrocoagulation (MPEC). Photosensitivity, an adverse event that occurs only with photodynamic therapy, was experienced by 26.4% of patients who received porfimer sodium.Some radiofrequency ablation (RFA) or argon plasma coagulation (APC) studies (used in multiple sessions) reported rates of almost 100% for complete eradication of dysplasia. But the study methods and findings were not adequately described. The other studies of endoscopic treatments reported similarly high rates of complete eradication. CONCLUSIONS Endoscopic treatments offer safe and effective alternatives to esophagectomy for patients with Barrett's esophagus and high grade dysplasia. Unfortunately, shortcomings in the published studies make it impossible to determine the comparative effectiveness of each of the endoscopic treatments.
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Affiliation(s)
- Devidas Menon
- Department of Public Health Sciences, University of Alberta, Room 3021, Research Transition Facility, 8308 114 Street, Edmonton, Alberta, T6G 2V2, Canada.
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Watson TJ. Radiofrequency ablation of Barrett's esophagus. J Gastrointest Surg 2010; 14 Suppl 1:S88-93. [PMID: 19816748 DOI: 10.1007/s11605-009-1012-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2009] [Accepted: 08/25/2009] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Barrett's esophagus (BE) is known to be due to chronic gastroesophageal reflux disease and is a precursor of esophageal adenocarcinoma. DISCUSSION The ability to eliminate BE is appealing, given the neoplastic potential of this condition and the continued increase in incidence of adenocarcinoma involving the esophagus and esophagogastric junction, a highly lethal disease. While a number of endoscopic technologies targeting metaplastic or neoplastic esophageal mucosa have been introduced into the clinical marketplace, most have not been widely adopted. Radiofrequency ablation recently was developed and holds appeal as a reliable, minimally invasive, inexpensive, and well-tolerated technique to destroy pathologic esophageal epithelium. CONCLUSION The available data show its efficacy and safety in the short-term, though more mature follow-up is needed to demonstrate its durability in the long-term and its cost-effectiveness in ultimately saving lives.
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Affiliation(s)
- Thomas J Watson
- Division of Thoracic and Foregut Surgery, Department of Surgery, University of Rochester School of Medicine and Dentistry, Rochester, NY 14642, USA.
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Abstract
BACKGROUND Treatments for Barrett's oesophagus, the precursor lesion of adenocarcinoma, are available but whether these therapies effectively prevent the development of adenocarcinoma, and in some cases eradicate the Barrett's oesophagus segment, remains unclear. OBJECTIVES To summarise, quantify and compare the efficacy of pharmacological, surgical and endoscopic treatments for the eradication of dysplastic and non-dysplastic Barrett's oesophagus and prevention of these states from progression to adenocarcinoma. SEARCH STRATEGY We searched CENTRAL (The Cochrane Library 2004, issue 4), MEDLINE (1966 to June 2008) and EMBASE (1980 to June 2008). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing medical, endoscopic or non-resectional surgical treatments for Barrett's oesophagus. The primary outcome measures were complete eradication of Barrett's and dysplasia at 12 months, and reduction in the number of patients progressing to cancer at five years or latest time point. DATA COLLECTION AND ANALYSIS Three authors independently extracted data and assessed the quality of the trials included in the analysis. MAIN RESULTS Sixteen studies, including 1074 patients, were included. The mean number of participants in the studies was small (n = 49; range 8 to 208). Most studies did not report on the primary outcomes. Medical and surgical interventions to reduce symptoms and sequelae of gastro-oesophageal reflux disease (GORD) did not induce significant eradication of Barrett's oesophagus or dysplasia. Endoscopic therapies (photodynamic therapy (PDT with aminolevulinic acid or porfimer sodium), argon plasma coagulation (APC) and radiofrequency ablation (RFA)) all induced regression of Barrett's oesophagus and dysplasia. The data for photodynamic therapy were heterogeneous with a mean eradication rate of 51% for Barrett's oesophagus and between 56% and 100% for dysplasia, depending on the treatment regimens. The variation in photodynamic therapy eradication rates for dysplasia was dependent on the drug, source and dose of light. Radiofrequency ablation resulted in eradication rates of 82% and 94% for Barrett's oesophagus and dysplasia respectively, compared to a sham treatment. Endoscopic treatments were generally well tolerated, however all were associated with some buried glands, particularly following argon plasma coagulation and photodynamic therapy, as well as photosensitivity and strictures induced by porfimer sodium based photodynamic therapy in particular. AUTHORS' CONCLUSIONS Despite their failure to eradicate Barrett's oesophagus, the role of medical and surgical interventions to reduce the troubling symptoms and sequelae of GORD is not questioned. Whether therapies for GORD reduce the cancer risk is not yet known. Ablative therapies have an increasing role in the management of dysplasia within Barrett's and current data would favour the use of radiofrequency ablation compared with photodynamic therapy. Radiofrequency ablation has been shown to yield significantly fewer complications than photodynamic therapy and is very efficacious at eradicating both dysplasia and Barrett's itself. However, long-term follow-up data are still needed before radiofrequency ablation can be used in routine clinical care without the need for very careful post-treatment surveillance. More clinical trial data and in particular randomised controlled trials are required to assess whether or not the cancer risk is reduced in routine clinical practice.
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Affiliation(s)
- Jonathan RE Rees
- Hutchison/MRC Research CentreMRC Cancer Cell UnitHills RoadCambridgeUKCB22 2XZ
| | - Pierre Lao‐Sirieix
- Hutchison/MRC Research CentreMRC Cancer Cell UnitHills RoadCambridgeUKCB22 2XZ
| | - Angela Wong
- Hutchison/MRC Research CentreMRC Cancer Cell UnitHills RoadCambridgeUKCB22 2XZ
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Ablation of Barrett's esophagus using the HALO radiofrequency ablation system. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2010.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Wani S, Sayana H, Sharma P. Endoscopic eradication of Barrett's esophagus. Gastrointest Endosc 2010; 71:147-66. [PMID: 19879565 DOI: 10.1016/j.gie.2009.07.026] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 07/18/2009] [Indexed: 01/03/2023]
Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri 64128-2295, USA
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Pouw RE, Wirths K, Eisendrath P, Sondermeijer CM, Ten Kate FJ, Fockens P, Devière J, Neuhaus H, Bergman JJ. Efficacy of radiofrequency ablation combined with endoscopic resection for barrett's esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8:23-9. [PMID: 19602454 DOI: 10.1016/j.cgh.2009.07.003] [Citation(s) in RCA: 234] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Revised: 06/28/2009] [Accepted: 07/01/2009] [Indexed: 12/27/2022]
Abstract
BACKGROUND & AIMS Radiofrequency ablation (RFA) is safe and effective for eradicating intestinal metaplasia and neoplasia in patients with Barrett's esophagus. We sought to assess the safety and efficacy of RFA in conjunction with baseline endoscopic resection for high-grade intraepithelial neoplasia (HGIN) and early cancer. METHODS This multicenter, prospective cohort study included 24 patients (mean age, 65 years; median Barrett's esophagus, 8 cm), with Barrett's esophagus of < or =12 cm containing HGIN or early cancer, from 3 European tertiary-care medical centers. Visible lesions were endoscopically resected, followed by serial RFA. Focal escape endoscopic resection was used if Barrett tissue persisted despite RFA. Complete response, defined as all biopsies negative for intestinal metaplasia and neoplasia, was assessed during endoscopy with 4-quadrant biopsies taken every 1 cm of the original Barrett's segment 2 months after the patient was last treated. RESULTS Twenty-three patients underwent pre-RFA endoscopic resection for visible lesions; 16 patients had early cancer and 7 patients had HGIN. The worst residual histology results, pre-RFA (after any endoscopic resection) were: HGIN (10 patients), low-grade intraepithelial neoplasia (11 patients), and intestinal metaplasia (3 patients). Neoplasia and intestinal metaplasia were eradicated in 95% and 88% of patients, respectively; after escape endoscopic resection in 2 patients, rates improved to 100% and 96%, respectively. Complications after RFA included melena (n = 1) and dysphagia (n = 1). After additional follow-up (median, 22 months; interquartile range, 17.2-23.8 months) no neoplasia recurred. CONCLUSIONS This European multicenter study to show that early neoplasia in Barrett's esophagus can be effectively and safely treated with RFA, in combination with prior endoscopic resection of visible lesions.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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Vassiliou MC, von Renteln D, Wiener DC, Gordon SR, Rothstein RI. Treatment of ultralong-segment Barrett's using focal and balloon-based radiofrequency ablation. Surg Endosc 2009; 24:786-91. [PMID: 19711128 DOI: 10.1007/s00464-009-0639-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 05/31/2009] [Accepted: 06/30/2009] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Endoscopic radiofrequency ablation (ERFA) is being evaluated as definitive treatment for patients with Barrett's esophagus (BE). Guidelines have yet to be developed for the application of this technology to patients with ultralong-segment BE (ULBE, > or = 8 cm). This study reports a single institution's experience with ERFA of ULBE. METHODS A retrospective review of patients with ULBE undergoing ERFA from August 2005 to February 2009 was conducted. The entire segment of intestinal metaplasia (IM) was treated at each session using balloon- and/or plate-based devices (BARRX Medical, Inc., Sunnyvale, CA). Retreatments, endoscopic mucosal resection (EMR), dilations, and biopsies were performed based on endoscopic findings. Surveillance was conducted according to standard guidelines. RESULTS Twenty-five patients (22 male) with a median age of 66 years [interquartile range (IQR) 57-74 years] were included. The length of BE treated was 10 cm (median; IQR 8-12 cm). Intramucosal carcinoma (IMC) was present in 3 patients, 15 had high-grade dysplasia (HGD), 6 had low-grade dysplasia (LGD), and 1 had IM without dysplasia. Complications for all 25 patients included hemorrhage (n = 1), stricture (n = 2), and nausea and vomiting (n = 2). Time from the initial procedure was such that 15 patients had postablation biopsies at least once. One patient with biopsies elected to undergo esophagectomy. Of these patients, 78.5% (11/14) had complete response (CR; no residual IM), two patients regressed from HGD to IM, and one patient with IMC had residual HGD and was treated with repeat EMR. The number of ablations in this group was 2.5 (median, IQR 2-3) during a median follow-up time of 20.3 months (IQR 10.4-29.2 months). CONCLUSION ERFA is safe and feasible in patients with ULBE and can be applied to the entire length of IM during one session. Eradication of BE can be achieved with few repeat ablations and continued, vigilant surveillance.
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Affiliation(s)
- Melina C Vassiliou
- Division of General Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Ave., L9-518, Montreal, QC, H3G 1A4, Canada.
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Inadomi JM, Somsouk M, Madanick RD, Thomas JP, Shaheen NJ. A cost-utility analysis of ablative therapy for Barrett's esophagus. Gastroenterology 2009; 136:2101-2114.e1-6. [PMID: 19272389 PMCID: PMC2693449 DOI: 10.1053/j.gastro.2009.02.062] [Citation(s) in RCA: 152] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Revised: 02/17/2009] [Accepted: 02/20/2009] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Recommendations for patients with Barrett's esophagus (BE) include endoscopic surveillance with esophagectomy for early-stage cancer, although new technologies to ablate dysplasia and metaplasia are available. This study compares the cost utility of ablation with that of endoscopic surveillance strategies. METHODS A decision analysis model was created to examine a population of patients with BE (mean age 50), with separate analyses for patients with no dysplasia, low-grade dysplasia (LGD), or high-grade dysplasia (HGD). Strategies compared were no endoscopic surveillance; endoscopic surveillance with ablation for incident dysplasia; immediate ablation followed by endoscopic surveillance in all patients or limited to patients in whom metaplasia persisted; and esophagectomy. Ablation modalities modeled included radiofrequency, argon plasma coagulation, multipolar electrocoagulation, and photodynamic therapy. RESULTS Endoscopic ablation for patients with HGD could increase life expectancy by 3 quality-adjusted years at an incremental cost of <$6,000 compared with no intervention. Patients with LGD or no dysplasia can also be optimally managed with ablation, but continued surveillance after eradication of metaplasia is expensive. If ablation permanently eradicates >or=28% of LGD or 40% of nondysplastic metaplasia, ablation would be preferred to surveillance. CONCLUSIONS Endoscopic ablation could be the preferred strategy for managing patients with BE with HGD. Ablation might also be preferred in subjects with LGD or no dysplasia, but the cost effectiveness depends on the long-term effectiveness of ablation and whether surveillance endoscopy can be discontinued after successful ablation. As further postablation data become available, the optimal management strategy will be clarified.
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Affiliation(s)
- John M. Inadomi
- Division of Gastroenterology, San Francisco General Hospital, San Francisco, CA, GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Ma Somsouk
- Division of Gastroenterology, San Francisco General Hospital, San Francisco, CA, GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Ryan D. Madanick
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jennifer P. Thomas
- GI Health Outcomes, Policy and Economics (HOPE) Research Program, Department of Medicine, University of California, San Francisco, San Francisco, CA
| | - Nicholas J. Shaheen
- Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Department of Medicine, University of North Carolina, Chapel Hill, NC
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Fernando HC, Murthy SC, Hofstetter W, Shrager JB, Bridges C, Mitchell JD, Landreneau RJ, Clough ER, Watson TJ. The Society of Thoracic Surgeons practice guideline series: guidelines for the management of Barrett's esophagus with high-grade dysplasia. Ann Thorac Surg 2009; 87:1993-2002. [PMID: 19463651 DOI: 10.1016/j.athoracsur.2009.04.032] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 03/27/2009] [Accepted: 04/01/2009] [Indexed: 02/08/2023]
Abstract
The management of Barrett's esophagus with high-grade dysplasia is controversial. The standard of care has traditionally been esophagectomy. However, a number of treatment options aimed at esophageal preservation are increasingly being utilized by many centers. These esophageal-sparing approaches include endoscopic surveillance, mucosal ablation, and endoscopic mucosal resection. In this guideline we review the best evidence supporting these commonly used strategies for high-grade dysplasia to better define management and guide future investigation.
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Affiliation(s)
- Hiran C Fernando
- Boston University School of Medicine and Department of Cardiothoracic Surgery, Boston Medical Center, Boston, Massachussetts 02118, USA.
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Pouw RE, Gondrie JJ, Rygiel AM, Sondermeijer CM, ten Kate FJ, Odze RD, Vieth M, Krishnadath KK, Bergman JJ. Properties of the neosquamous epithelium after radiofrequency ablation of Barrett's esophagus containing neoplasia. Am J Gastroenterol 2009; 104:1366-73. [PMID: 19491850 DOI: 10.1038/ajg.2009.88] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Endoscopic radiofrequency ablation (RFA) eradicates intestinal metaplasia and intraepithelial neoplasia associated with Barrett's esophagus (BE), restoring an endoscopically normal neosquamous epithelium (NSE). We evaluated the post-RFA NSE for genetic abnormalities and buried glandular mucosa. METHODS Eligible patients underwent RFA for BE containing early cancer and/or high-grade intraepithelial neoplasia with subsequent complete histological reversion to normal NSE. At baseline, the BE was sampled by brush cytology and biopsies. At least 2 months after RFA, the NSE was sampled by brush cytology, keyhole biopsies, and endoscopic resection. The untreated squamous epithelium was biopsied as a control. The baseline BE and post-RFA NSE were evaluated for immunohistochemical expression of Ki-67 and p53, and genetic abnormalities (DNA-fluorescent in situ hybridization: chromosome 1 and 9, p16 and p53). In addition, biopsy depth was compared for biopsies from the NSE and untreated squamous epithelium. The presence of buried glandular mucosa in NSE was assessed with primary and keyhole biopsy, and endoscopic resection. RESULTS All pretreatment specimens from all 22 patients showed abnormalities on immunohistochemical staining and fluorescent in situ hybridization, whereas all post-RFA NSE specimens were normal. All the post-RFA biopsies from the NSE contained full epithelia, whereas 37% contained lamina propria, a finding no different from biopsies from untreated squamous epithelium (36% lamina propria). Deeper keyhole biopsies contained lamina propria in 51%. All endoscopic resection specimens contained submucosa, whereas no biopsy or endoscopic resection specimen contained buried glandular mucosa. CONCLUSIONS Rigorous evaluation of the post-RFA NSE in patients who, at baseline, had BE containing early cancer high-grade intraepithelial neoplasia, showed neither persistent genetic abnormalities nor buried glandular mucosa.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Zhou C, Adler DC, Becker L, Chen Y, Tsai TH, Figueiredo M, Schmitt JM, Fujimoto JG, Mashimo H. Effective treatment of chronic radiation proctitis using radiofrequency ablation. Therap Adv Gastroenterol 2009; 2:149-156. [PMID: 20593010 DOI: 10.1177/1756283x08103341] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Endoscopic argon plasma coagulation and bipolar electrocautery are currently preferred treatments for chronic radiation proctitis, but ulcerations and strictures frequently occur. Radiofrequency ablation (RFA) has been successful for mucosal ablation in the esophagus. Here we report the efficacy of RFA with the BarRx Halo(90) system in three patients with bleeding from chronic radiation proctitis. In all cases, the procedure was well tolerated and hemostasis was achieved after 1 or 2 RFA sessions. Re-epithelialization of squamous mucosa was observed over areas of prior hemorrhage. No stricturing or ulceration was seen on follow-up up to 19 months after RFA treatment. Real-time endoscopic optical coherence tomography (EOCT) visualized epithelialization and subsurface tissue microvasculature pre- and post-treatment, demonstrating its potential for follow-up assessment of endoscopic therapies.
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Affiliation(s)
- Chao Zhou
- Department of Electrical Engineering and Computer Science and Research Laboratory of Electronics Massachusetts Institute of Technology, Cambridge, MA, USA
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Endoscopic endoluminal radiofrequency ablation of Barrett’s esophagus: initial results and lessons learned. Surg Endosc 2009; 23:2175-80. [DOI: 10.1007/s00464-009-0364-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2008] [Revised: 11/24/2008] [Accepted: 01/12/2009] [Indexed: 02/07/2023]
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Eldaif SM, Lin E, Singh KA, Force SD, Miller DL. Radiofrequency ablation of Barrett's esophagus: short-term results. Ann Thorac Surg 2009; 87:405-10; discussion 410-1. [PMID: 19161747 DOI: 10.1016/j.athoracsur.2008.11.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2007] [Revised: 11/03/2008] [Accepted: 11/10/2008] [Indexed: 01/12/2023]
Abstract
BACKGROUND The presence of Barrett's esophagus (BE) increases the risk of esophageal cancer. Total regression of BE is uncommon with medication or laparoscopic fundoplication, and endoscopic techniques to obliterate BE have varied results. This study evaluated the early results of a balloon-based catheter radiofrequency ablation (RFA) system in patients with medically refractory reflux symptoms and biopsy-proven BE. METHODS The medical records of 27 consecutive patients who underwent RFA for BE from March 2005 through January 2007 were reviewed. Esophagogastroduodenoscopy was performed before ablation to document presence of BE and no cancer and at 8 weeks after the RFA to assess the presence of residual BE. RESULTS Mean patient age was 53.6 +/- 12.5 years; 16 (59%) were men. The average length of the Barrett segment treated was 4.6 +/- 4.7 cm. Two patients (7.4%) had low-grade dysplasia. No patient had high-grade dysplasia and cancer. There was no periprocedural morbidity or at follow-up, no postprocedure dysphagia or stricture. In all patients, the BE was completely replaced with normal squamous epithelium. Symptoms regressed in 16 patients (60%) with RFA and proton pump inhibitor therapy. Eleven required an antireflux procedure for persistent symptoms. CONCLUSIONS Short-term results show that RFA for BE is safe and achieves 100% replacement of intestinal metaplasia. RFA of BE combined with fundoplication may be offered to patients with BE and medically refractory reflux symptoms. Long-term endoscopic surveillance is needed to determine if the risk of cancer is reduced with this bimodality therapy.
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Affiliation(s)
- Shady M Eldaif
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Sharma VK, Jae Kim H, Das A, Wells CD, Nguyen CC, Fleischer DE. Circumferential and focal ablation of Barrett's esophagus containing dysplasia. Am J Gastroenterol 2009; 104:310-7. [PMID: 19174783 DOI: 10.1038/ajg.2008.142] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Dysplasia in a Barrett's esophagus (BE) is associated with an increased risk for developing esophageal adenocarcinoma. Ablation using the HALO system has shown promise for the treatment of BE with dysplasia. The objective of this study was to assess the safety and efficacy of a stepwise regimen of circumferential and focal ablation using the HALO system for the treatment of BE with dysplasia. METHODS BE patients with low-grade dysplasia (LGD) or high-grade dysplasia (HGD) were enrolled. Primary circumferential ablation was followed every 3 months by further circumferential ablation or focal ablation until complete endoscopic eradication of BE was achieved. At 3- or 6-month intervals, depending on baseline grade, targeted and four quadrant random biopsies were obtained to assess the histological response to ablation. A complete response (CR) is defined as all biopsies negative for intestinal metaplasia (IM) (CR-IM) or dysplasia (CR-D) at last available follow-up. RESULTS A total of 63 patients were treated (57 men; median age 71 years; median BE length 5 cm), with worst grade of dysplasia being LGD (n=39) and HGD (n=24). Follow-up is available for 62 patients (median 24 months). Overall, CR-IM is 79% and CR-D is 89%. For the LGD cohort, CR-IM is 87% and CR-D is 95%. For the HGD cohort, CR-IM is 67% and CR-D is 79%. CONCLUSIONS Stepwise circumferential and focal ablation of BE containing dysplasia appears to be a safe and effective intervention, achieving a CR for dysplasia in 95% and 79% of LGD and HGD patients, respectively.
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Affiliation(s)
- Virender K Sharma
- 1Esophageal Clinic, Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Scottsdale, Arizona 85259, USA.
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Smith CD. Surgical therapy for gastroesophageal reflux disease: indications, evaluation, and procedures. Gastrointest Endosc Clin N Am 2009; 19:35-48, v-vi. [PMID: 19232279 DOI: 10.1016/j.giec.2008.12.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Gastroesophageal reflux is a very common condition, and surgery remains a reasonable options in select patients. Successful surgical care for GERD depends on proper patient selection, workup and operative technique. This manuscript reviews surgical care for GERD.
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Affiliation(s)
- C Daniel Smith
- Department of Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Bronner MP, Overholt BF, Taylor SL, Haggitt RC, Wang KK, Burdick JS, Lightdale CJ, Kimmey M, Nava HR, Sivak MV, Nishioka N, Barr H, Canto MI, Marcon N, Pedrosa M, Grace M, Depot M. Squamous overgrowth is not a safety concern for photodynamic therapy for Barrett's esophagus with high-grade dysplasia. Gastroenterology 2009; 136:56-64; quiz 351-2. [PMID: 18996379 DOI: 10.1053/j.gastro.2008.10.012] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2008] [Revised: 09/26/2008] [Accepted: 10/02/2008] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Photodynamic therapy with porfimer sodium combined with acid suppression (PHOPDT) is used to treat patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD). A 5-year phase 3 trial was conducted to determine the extent of squamous overgrowth of BE with HGD after PHOPDT. METHODS Squamous overgrowth was compared in patients with BE with HGD randomly assigned (2:1) to receive PHOPDT (n=138) or 20 mg omeprazole twice daily (n=70). Patients underwent 4-quadrant jumbo esophageal biopsies every 2 cm throughout the pretreatment length of BE until 4 consecutive quarterly follow-up results were negative for HGD and then biannually up to 5 years or treatment failure. Endoscopies were reviewed by blinded gastroenterology pathologists. RESULTS Histologic assessment of 33,658 biopsies showed no significant difference (P> .05) in squamous overgrowth between groups when compared per patient (30% vs 33%) or per biopsy (0.5% vs 1.3%), or when the average number of biopsies with squamous overgrowth were compared per patient (0.48 vs 0.66). The highest grade of neoplasia per endoscopy was not found exclusively beneath squamous mucosa in any patient. CONCLUSIONS No difference was observed in squamous overgrowth between patients given PHOPDT plus omeprazole compared with only omeprazole. Squamous overgrowth did not obscure the most advanced neoplasia in any patient. Treatment of HGD with PHOPDT in patients with BE does not present a long-term risk of failure to detect subsquamous dysplasia or carcinoma.
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Adler DG, Chand B, Conway JD, Diehl DL, Kantsevoy SV, Kwon RS, Mamula P, Shah RJ, Wong Kee Song LM, Tierney WM. Mucosal ablation devices. Gastrointest Endosc 2008; 68:1031-42. [PMID: 19028211 DOI: 10.1016/j.gie.2008.06.018] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 06/17/2008] [Indexed: 02/08/2023]
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Fleischer DE, Overholt BF, Sharma VK, Reymunde A, Kimmey MB, Chuttani R, Chang KJ, Lightdale CJ, Santiago N, Pleskow DK, Dean PJ, Wang KK. Endoscopic ablation of Barrett's esophagus: a multicenter study with 2.5-year follow-up. Gastrointest Endosc 2008; 68:867-76. [PMID: 18561930 DOI: 10.1016/j.gie.2008.03.008] [Citation(s) in RCA: 151] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2007] [Accepted: 03/03/2008] [Indexed: 01/03/2023]
Abstract
BACKGROUND For patients with Barrett's esophagus (BE), life-long surveillance endoscopy is recommended because of an elevated risk for developing dysplasia and esophageal adenocarcinoma. Various endoscopic therapies have been used to eradicate BE. Recently circumferential radiofrequency ablation has been used with encouraging short-term results. OBJECTIVE To provide longer follow-up and to assess the long-term safety and efficacy of step-wise circumferential ablation with the addition of focal ablation for BE. DESIGN Prospective, multicenter clinical trial (NCT00489268). SETTING Eight U.S. centers, between May 2004 and February 2007. PATIENTS Seventy subjects with 2 to 6 cm of BE and histologic evidence of intestinal metaplasia (IM). INTERVENTIONS Circumferential ablation was performed at baseline and repeated at 4 months if there was residual IM. Follow-up biopsy specimens were obtained at 1, 3, 6, 12, and 30 months. Specimens were reviewed by a central pathology board. Focal ablation was performed after the 12-month follow-up for histological evidence of IM at the 12-month biopsy (absolute indication) or endoscopic appearance suggestive of columnar-lined esophagus (relative indication). Subjects received esomeprazole for control of esophageal reflux. MAIN OUTCOME MEASUREMENTS Complete absence of IM per patient from biopsy specimens obtained at 12 and 30 months, defined as complete remission-IM (CR-IM). RESULTS At 12 months, CR-IM was achieved in 48 of 69 available patients (70% per protocol [PP], 69% intention to treat [ITT]). At 30 months after additional focal ablative therapy, CR-IM was achieved in 60 of 61 available patients (98% PP, 97% ITT). There were no strictures or buried glandular mucosa detected by the standardized biopsy protocol at 12 or 30 months, and there were no serious adverse events. LIMITATIONS This was an uncontrolled clinical trial with 2.5-year follow-up. CONCLUSION Stepwise circumferential and focal ablation resulted in complete eradication of IM in 98% of patients at 2.5-year follow-up.
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Abstract
High-grade dysplasia is the last stage before the development of adenocarcinoma. Despite the fact that the lesion is not yet invasive, it has tremendous potential to become malignant. The approach to the disease has clinicians divided between immediate intervention with surgical resection or continued endoscopic surveillance proof of the unclear natural history. Much knowledge has been acquired recently regarding application of surveillance and outcomes of esophageal resection. Also, many endoscopic techniques for treating high-grade dysplasia have been studied in depth. Results on their safety, efficacy, and complication rates have recently become available. This review analyzes the progress in the understanding and treatment of high-grade dysplasia during the past 24 to 36 months and examines how this new information plays a role in the disease's treatment algorithm.
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Roorda AK, Triadafilopoulos G. Circumferential and focal radiofrequency ablation for the treatment of Barrett's esophagus. Expert Rev Gastroenterol Hepatol 2008; 2:627-34. [PMID: 19072339 DOI: 10.1586/17474124.2.5.627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This invited profile summarizes the technical aspects and clinical trial results related to the use of circumferential and focal radiofrequency ablation in the management algorithm for Barrett's esophagus. What makes this relatively new endoscopic intervention unique is its promising safety and efficacy profile reported in published clinical trials. This technology appears to have overcome many of the limitations of prior endoscopic ablative modalities, and is thus garnering a role in the management of this disease state.
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Affiliation(s)
- Andrew K Roorda
- Section of Digestive Diseases, Department of Medicine, West Virginia University School of Medicine PO Box 9161 Morgantown, WV 26506-9161, USA.
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Pouw RE, Gondrie JJ, Sondermeijer CM, ten Kate FJ, van Gulik TM, Krishnadath KK, Fockens P, Weusten BL, Bergman JJ. Eradication of Barrett esophagus with early neoplasia by radiofrequency ablation, with or without endoscopic resection. J Gastrointest Surg 2008; 12:1627-36; discussion 1636-7. [PMID: 18704598 DOI: 10.1007/s11605-008-0629-1] [Citation(s) in RCA: 91] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2008] [Accepted: 07/16/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND Radiofrequency ablation is safe and effective for complete eradication of nondysplastic Barrett esophagus (BE). The aim was to report the combined results of two published and two ongoing studies on radiofrequency ablation of BE with early neoplasia, as presented at SSAT presidential plenary session DDW 2008. METHODS Enrolled patients had BE < or = 12 cm with early neoplasia. Visible lesions were endoscopically resected. A balloon-based catheter was used for circumferential ablation and an endoscope-based catheter for focal ablation. Ablation was repeated every 2 months until the entire Barrett epithelium was endoscopically and histologically eradicated. RESULTS Forty-four patients were included (35 men, median age 68 years, median BE 7 cm). Thirty-one patients first underwent endoscopic resection [early cancer (n = 16), high-grade dysplasia (n = 12), low-grade dysplasia (n = 3)]. Worst histology remaining after resection was high-grade (n = 32), low-grade (n = 10), or no (n = 2) dysplasia. After ablation, complete histological eradication of all dysplasia and intestinal metaplasia was achieved in 43 patients (98%). Complications following ablation were mucosal laceration at resection site (n = 3) and transient dysphagia (n = 4). After 21 months of follow-up (interquartile range 10-27), no dysplasia had recurred. CONCLUSIONS Radiofrequency ablation, with or without prior endoscopic resection for visible abnormalities, is effective and safe in eradicating BE and associated neoplasia.
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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Ganz RA, Overholt BF, Sharma VK, Fleischer DE, Shaheen NJ, Lightdale CJ, Freeman SR, Pruitt RE, Urayama SM, Gress F, Pavey DA, Branch MS, Savides TJ, Chang KJ, Muthusamy VR, Bohorfoush AG, Pace SC, DeMeester SR, Eysselein VE, Panjehpour M, Triadafilopoulos G. Circumferential ablation of Barrett's esophagus that contains high-grade dysplasia: a U.S. Multicenter Registry. Gastrointest Endosc 2008; 68:35-40. [PMID: 18355819 DOI: 10.1016/j.gie.2007.12.015] [Citation(s) in RCA: 198] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2007] [Accepted: 12/11/2007] [Indexed: 02/08/2023]
Abstract
BACKGROUND The management strategies for Barrett's esophagus (BE) that contains high-grade dysplasia (HGD) include intensive endoscopic surveillance, photodynamic therapy, thermal ablation, EMR, and esophagectomy. OBJECTIVE To assess the safety and effectiveness of endoscopic circumferential balloon-based ablation by using radiofrequency energy for treating BE HGD. DESIGN Multicenter U.S. registry. SETTING Sixteen academic and community centers; treatment period from September 2004 to March 2007. PATIENTS Patients with histologic evidence of intestinal metaplasia (IM) that contained HGD confirmed by at least 2 expert pathologists. A prior EMR was permitted, provided that residual HGD remained in the BE region for ablation. INTERVENTION Endoscopic circumferential ablation with follow-up esophageal biopsies to assess the histologic response to treatment. OUTCOMES Histologic complete response (CR) end points: (1) all biopsy specimen fragments obtained at the last biopsy session were negative for HGD (CR-HGD), (2) all biopsy specimens were negative for any dysplasia (CR-D), and (3) all biopsy specimens were negative for IM (CR-IM). RESULTS A total of 142 patients (median age 66 years, interquartile range [IQR] 59-75 years) who had BE HGD (median length 6 cm, IQR 3-8 cm) underwent circumferential ablation (median 1 session, IQR 1-2). No serious adverse events were reported. There was 1 asymptomatic stricture and no buried glands. Ninety-two patients had at least 1 follow-up biopsy session (median follow-up 12 months, IQR 8-15 months). A CR-HGD was achieved in 90.2% of patients, CR-D in 80.4%, and CR-IM in 54.3%. LIMITATIONS A nonrandomized study design, without a control arm, a lack of centralized pathology review, ablation and biopsy technique not standardized, and a relatively short-term follow-up. CONCLUSIONS Endoscopic circumferential ablation is a promising modality for the treatment of BE that contains HGD. In this multicenter registry, the intervention safely achieved a CR for HGD in 90.2% of patients at a median of 12 months of follow-up.
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Affiliation(s)
- Robert A Ganz
- Minnesota Gastroenterology, Plymouth, Minnesota 55446, USA
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Seibel EJ, Carroll RE, Dominitz JA, Johnston RS, Melville CD, Lee CM, Seitz SM, Kimmey MB. Tethered capsule endoscopy, a low-cost and high-performance alternative technology for the screening of esophageal cancer and Barrett's esophagus. IEEE Trans Biomed Eng 2008; 55:1032-42. [PMID: 18334395 DOI: 10.1109/tbme.2008.915680] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Esophageal cancer is currently the fastest growing cancer in the United States. To help combat the recent rise in morbidity, our laboratory has developed a low-cost tethered capsule endoscope system (TCE) aimed at improving early detection of esophageal cancer. The TCE contains a resonant fiberoptic laser scanner (1.6 mm O.D.) which fits into 6.4-mm easy-to-swallow capsule at the distal tip. The tethered portion contains a single mode optical fiber multiplexed to three laser diodes at the proximal end. This design offers two main advantages over current endoscope technology. First, because of its small size, the TCE can be swallowed with minimal patient discomfort, thereby obviating sedation. Second, by imaging via directed laser light, the TCE is strategically positioned to employ several burgeoning laser-based diagnostic technologies, such as narrow-band, hyperspectral, and fluorescence imaging. It is believed that the combination of such imaging techniques with novel biomarkers of dysplasia will greatly assist in identifying precancerous conditions such as Barrett's esophagus (BE). As the probe is swallowed, the fiber scanner captures high resolution, wide-field color images of the gastroesophageal junction (500 lines at 0.05-mm resolution) currently at 15-Hz frame rate. Video images are recorded as the capsule is slowly retracted by its tether. Accompanying software generates panoramic images from the video output by mosaicing individual frames to aid in pattern recognition. This initial report describes the rationale for the unique TCE system design, results from preliminary testing in vitro and in vivo, and discussion on the merits of this new platform technology as a basis for developing a low-cost screening program for esophageal cancer.
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Affiliation(s)
- Eric J Seibel
- Department of Mechanical Engineering, University of Washington, Human Photonics Lab, Box 352600, Seattle, WA 98195, USA.
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