Randomized trial of argon plasma coagulation versus endoscopic surveillance for barrett esophagus after antireflux surgery: late results

Comparison of interventions for Barrett's esophagus: A network meta-analysis

BACKGROUND AND OBJECTIVE

Barrett's esophagus (BE) is a precancerous condition that has the potential to develop into esophageal cancer (EC). Currently, there is a wide range of management options available for individuals at different pathological stages in Barrett's esophagus (BE). However, there is currently a lack of knowledge regarding their comparative efficacy. To address this gap, we conducted a network meta-analysis of published randomized controlled trials to examine the comparative effectiveness of all regimens.

METHODS

Data extracted from eligible randomized controlled trials were utilized in a Bayesian network meta-analysis to examine the relative effectiveness of BE's treatment regimens and determine their ranking in terms of efficacy. The ranking probability for each regimen was assessed using the surfaces under cumulative ranking values. The outcomes under investigation were complete ablation of BE, neoplastic progression of BE, and complete eradication of dysplasia.

RESULTS

We identified twenty-three RCT studies with a total of 1675 participants, and ten different interventions. Regarding complete ablation of non-dysplastic BE, the comparative effectiveness ranking indicated that argon plasma coagulation (APC) was the most effective regimen, with the highest SUCRA value, while surveillance and PPI/H2RA were found to be the least efficacious regimens. For complete ablation of BE with low-grade dysplasia, high-grade dysplasia, or esophageal cancer, photodynamic therapy (PDT) had the highest SUCRA value of 94.1%, indicating it as the best regimen. Additionally, for complete eradication of dysplasia, SUCRA plots showed a trend in ranking PDT as the highest with a SUCRA value of 91.2%. Finally, for neoplastic progression, radiofrequency ablation (RFA) and surgery were found to perform significantly better than surveillance. The risk of bias assessment revealed that 6 studies had an overall high risk of bias. However, meta-regression with risk of bias as a covariate did not indicate any influence on the model. In terms of the Confidence in Network Meta-Analysis evaluation, a high level of confidence was found for all treatment comparisons.

CONCLUSION

Endoscopic surveillance alone or PPI/H2RA alone may not be sufficient for managing BE, even in cases of non-dysplastic BE. However, APC has shown excellent efficacy in treating non-dysplastic BE. For cases of BE with low-grade dysplasia, high-grade dysplasia, or esophageal cancer, PDT may be the optimal intervention as it can induce regression of BE metaplasia and prevent future progression of BE to dysplasia and EC.

Management of Long-Segment Barrett's Esophagus

Background: Gastroesophageal reflux disease is a common gastrointestinal disorder with one of its most feared complications being Barrett's esophagus (BE). Currently, most of the recommendations of BE management are driven by the level of dysplasia. However, the length of BE might also be related to the risk of dysplasia/malignant transformation. We aimed to determine the appropriate management of BE based on its length. Materials and Methods: A systematic literature review was conducted with searches made on PubMed, Embase, and Cochrane databases. Long-segment BE (LSBE) was defined as 3 cm or longer and short-segment BE (SSBE) as under 3 cm. Studies evaluating the behavior and management of SSBE and/or LSBE were included for analysis. Results: LSBE have greater risk of dysplasia or progression to esophageal adenocarcinoma compared to SSBE. Despite this greater risk, LSBE and SSBE are currently managed similarly based on the presence and degree of dysplasia. Endoscopic and ablative techniques may have higher level of success and less complications in SSBE, compared to LSBE. Decreasing time interval between surveillance may be a viable option for managing LSBE. Conclusions: Although many algorithms of monitoring and treatment of BE remain the same regardless of segment length, current evidence suggests that more aggressive management for LSBE might be needed due to its higher risk of malignant progression.

Development and application of a spray tip that enables electrocoagulation of a variety of tissues

BACKGROUND

Spray hemostasis is possible using a high-frequency power source from the tip of an electric scalpel; however, the difficulties regarding the uniformity and rapidity of the hemostasis surface remain. This study reports the development of a novel electrocoagulation device tip that can be used in endoscopic and robotic surgeries and can quickly coagulate and hemostat and easily adjust the extent of cauterization and hemostasis while minimizing the depth of thermal injury.

METHODS

The safety and efficacy of the hemostatic device were verified in a porcine model. A liver surface transection was conducted in vivo and the rapidity of the hemostatic effect of the device was observed. An extracted stomach, kidney, and liver were cauterized ex vivo by three operators with different surgical skills and the effects were analyzed pathologically. In addition, a sacrificed pig cadaver was used to achieve hemostasis at a renal transection site using the multi-spray endoscope tip.

RESULTS

An increase in the number of tip terminals expanded the cauterization surface and shortened the cauterization time. In parenchymatous organs, uniform cauterization was possible without increasing the depth of thermal injury. The cauterization depth did not depend on the operator's skill, and the spray coagulation was safe. The variable spray tip allowed for simple hemostasis during open and laparoscopic surgeries.

CONCLUSIONS

This novel electrocoagulation device tip can be developed as a forceps that can change the spray range and can be used during laparoscopic and robotic surgeries.

ENDOSCOPIC ABLATION COMBINED WITH FUNDOPLICATION PLUS ACID SUPPRESSION-DUODENAL DIVERSION PROCEDURE FOR LONG SEGMENT BARRETT´S ESOPHAGUS: EARLY AND LONG-TERM OUTCOME

BACKGROUND:

The addition of endoscopic ablative therapy plus proton pump inhibitors or fundoplication is postulated for the treatment of patients with long-segment Barrett´s esophagus (LSBE); however, it does not avoid acid and bile reflux in these patients. Fundoplication with distal gastrectomy and Roux-en-Y gastrojejunostomy is proposed as an acid suppression-duodenal diversion procedure demonstrating excellent results at long-term follow-up. There are no reports on therapeutic strategy with this combination.

AIMS:

To determine the early and long-term results observed in LSBE patients with or without low-grade dysplasia who underwent the acid suppression-duodenal diversion procedure combined with endoscopic therapy.

METHODS:

Prospective study including patients with endoscopic LSBE using the Prague classification for circumferential and maximal lengths and confirmed by histological study. Patients were submitted to argon plasma coagulation (21) or radiofrequency ablation (31). After receiving treatment, they were monitored at early and late follow-up (5–12 years) with endoscopic and histologic evaluation.

RESULTS:

Few complications (ulcers or strictures) were observed after the procedure. Re-treatment was required in both groups of patients. The reduction in length of metaplastic epithelium was significantly better after radiofrequency ablation compared to argon plasma coagulation (10.95 vs 21.15 mms for circumferential length; and 30.96 vs 44.41 mms for maximal length). Intestinal metaplasia disappeared in a high percentage of patients, and histological long-term results were quite similar in both groups.

CONCLUSIONS:

Endoscopic procedures combined with fundoplication plus acid suppression with duodenal diversion technique to eliminate metaplastic epithelium of distal esophagus could be considered a good alternative option for LSBE treatment.

Hybrid APC in Combination With Resection for the Endoscopic Treatment of Neoplastic Barrett's Esophagus: A Prospective, Multicenter Study

INTRODUCTION

The current therapy of neoplastic Barrett's esophagus (BE) consists of endoscopic resection plus ablation, with radiofrequency ablation as the best studied technique. This prospective trial assesses a potential alternative, namely hybrid argon plasma ablation.

METHODS

Consecutive patients with neoplastic BE undergoing ablation after curative endoscopic resection (89.6%) or primarily were included into this prospective trial in 9 European centers. Up to 5 ablation sessions were allowed for complete eradication of BE (initial complete eradication of intestinal metaplasia [CE-IM]), by definition including BE-associated neoplasia, documented by 1 negative endoscopy with biopsies. The main outcome was the rate of initial CE-IM in intention-to-treat (ITT) and per-protocol (PP) samples at 2 years. The secondary end points were the rate of recurrence-free cases (sustained CE-IM) documented by negative follow-up endoscopies with biopsies and immediate/delayed adverse events.

RESULTS

One hundred fifty-four patients (133 men and 21 women, mean age 64 years) received a mean of 1.2 resection and 2.7 ablation sessions (range 1-5). Initial CE-IM was achieved in 87.2% of 148 cases in the PP analysis (ITT 88.4%); initial BE-associated neoplasia was 98.0%. On 2-year follow-up of the 129 successfully treated cases, 70.8% (PP) or 65.9% (ITT) showed sustained CE-IM; recurrences were mostly endoscopy-negative biopsy-proven BE epithelium and neoplasia in 3 cases. Adverse events were seen in 6.1%.

DISCUSSION

Eradication and recurrence rates of Barrett's intestinal metaplasia and neoplasia by means of hybrid argon plasma coagulation at 2 years seem to be within expected ranges. Final evidence in comparison to radiofrequency ablation can only be provided by a randomized comparative trial.

Argon plasma coagulation for Barrett's esophagus with low-grade dysplasia: a randomized trial with long-term follow-up on the impact of power setting and proton pump inhibitor dose

BACKGROUND

This study evaluated the impact of power setting and proton pump inhibitor (PPI) dose on efficacy and safety of argon plasma coagulation (APC) of Barrett's esophagus (BE) with low-grade dysplasia (LGD). METHODS : 71 patients were randomized to APC with power set at 90 W or 60 W followed by 120 mg or 40 mg omeprazole. The primary outcome was the rate of complete (endoscopic and histologic) ablation of BE at 6 weeks. Secondary outcomes included safety and long-term efficacy. RESULTS : Complete ablation rate in the 90 W/120 mg, 90 W/40 mg, and 60 W/120 mg groups was 78 % (18/23; 95 % confidence interval [CI] 61-95), 60 % (15/25; 95 %CI 41-79), 74 % (17/23; 95 %CI 56-92), respectively, at 6 weeks and 70 % (16/23; 95 %CI 51-88), 52 % (13/25; 95 %CI 32-72), and 65 % (15/23; 95 %CI 46-85) at 2 years post-treatment (differences not significant). Additional APC was required in 28 patients (23 residual and 5 recurrent BE). At median follow-up of 108 months, 66/71 patients (93 %; 95 %CI 87-99) maintained complete ablation. No high-grade dysplasia or adenocarcinoma developed. Overall, adverse events (97 % mild) did not differ significantly between groups. Chest pain/discomfort was more frequent in patients receiving 90 W vs. 60 W power (P < 0.001). One patient had esophageal perforation and two developed stenosis.

CONCLUSIONS

APC power setting and PPI dose did not impact efficacy and safety of BE ablation. Complete ablation of BE with LGD was durable in > 90 % of patients, without any evidence of neoplasia progression in the long term.

Screening for esophageal adenocarcinoma and precancerous conditions (dysplasia and Barrett's esophagus) in patients with chronic gastroesophageal reflux disease with or without other risk factors: two systematic reviews and one overview of reviews to inform a guideline of the Canadian Task Force on Preventive Health Care (CTFPHC)

BACKGROUND

Two reviews and an overview were produced for the Canadian Task Force on Preventive Health Care guideline on screening for esophageal adenocarcinoma in patients with chronic gastroesophageal reflux disease (GERD) without alarm symptoms. The goal was to systematically review three key questions (KQs): (1) The effectiveness of screening for these conditions; (2) How adults with chronic GERD weigh the benefits and harms of screening, and what factors contribute to their preferences and decision to undergo screening; and (3) Treatment options for Barrett's esophagus (BE), dysplasia or stage 1 EAC (overview of reviews).

METHODS

Bibliographic databases (e.g. Ovid MEDLINE®) were searched for each review in October 2018. We also searched for unpublished literature (e.g. relevant websites). The liberal accelerated approach was used for title and abstract screening. Two reviewers independently screened full-text articles. Data extraction and risk of bias assessments were completed by one reviewer and verified by another reviewer (KQ1 and 2). Quality assessments were completed by two reviewers independently in duplicate (KQ3). Disagreements were resolved through discussion. We used various risk of bias tools suitable for study design. The GRADE framework was used for rating the certainty of the evidence.

RESULTS

Ten studies evaluated the effectiveness of screening. One retrospective study reported no difference in long-term survival (approximately 6 to 12 years) between those who had a prior esophagogastroduodenoscopy and those who had not (adjusted HR 0.93, 95% confidence interval (CI) 0.58-1.50). Though there may be higher odds of a stage 1 diagnosis than a more advanced diagnosis (stage 2-4) if an EGD had been performed in the previous 5 years (OR 2.27, 95% CI 1.00-7.67). Seven studies compared different screening modalities, and showed little difference between modalities. Three studies reported on patients' unwillingness to be screened (e.g. due to anxiety, fear of gagging). Eleven systematic reviews evaluated treatment modalities, providing some evidence of early treatment effect for some outcomes.

CONCLUSIONS

Little evidence exists on the effectiveness of screening and values and preferences to screening. Many treatment modalities have been evaluated, but studies are small. Overall, there is uncertainty in understanding the effectiveness of screening and early treatments.

SYSTEMATIC REVIEW REGISTRATIONS

PROSPERO (CRD42017049993 [KQ1], CRD42017050014 [KQ2], CRD42018084825 [KQ3]).

Endoscopic therapy for confirmed low-grade dysplasia in Barrett's esophagus

Barrett's esophagus (BE) is a premalignant condition characterized by replacement of the esophageal lining with metastatic columnar epithelium. To date, the management in case of confirmed low-grade dysplasia (LGD) remains controversial. In this article we summarize the available endoscopic options and their results in terms of efficacy and safety in the treatment of confirmed LGD in BE.

Ablation Therapy for Barrett's Esophagus: New Rules for Changing Times

PURPOSE OF REVIEW

In this review, we discuss different endoscopic techniques in the eradication of Barrett's esophagus (BE) as well as some controversies in the field of treatment.

RECENT FINDINGS

Patients with T1a esophageal adenocarcinoma and BE of high-grade dysplasia should undergo endoscopic ablative therapy. The most studied technique to date is radiofrequency ablation. It can be combined with endoscopic mucosal resection in cases containing nodular and flat lesions. Cryotherapy and APC have shown promise with good efficacy and safety profiles so far, but are not mainstream as more studies are needed. Surveillance is still required post-ablation since recurrence is common. Low-grade dysplasia can be treated with either endo-ablative therapy or surveillance. Non-dysplastic BE treatment is controversial and so far, only surveillance is recommended. Research is ongoing to better risk stratify these patients. Our ability to diagnose and treat BE has come a long way in the past few years with the goal of preventing its progression into malignancy. The advent of endoscopic techniques in the eradication of BE has provided a less invasive and safer modality of treatment as compared to surgical esophagectomy. Data in the form of randomized trials and high-volume registries has provided good evidence to support the efficacy of these techniques and their long-term durability.

Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma

Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.

Barrett’s oesophagus: Evidence from the current meta-analyses

Guidelines have been published regarding the management of Barrett’s oesophagus (columnar-lined oesophagus). These have examined the role of surveillance in an effort to detect dysplasia and early cancer. The guidelines have provided criteria for enrolment into surveillance and some risk stratification with regard to surveillance interval. The research basis for the decisions reached with regard to cancer risk is weak and this manuscript has examined the available data published from meta-analyses up to 25^th April 2013 (much of which has been published since the guidelines and their most recent updates have been written). There were 9 meta-analyses comparing patients with Barrett’s oesophagus to control populations. These have demonstrated that Barrett’s oesophagus is more common in males than females, in subjects who have ever smoked, in subjects with obesity, in subjects with prolonged symptoms of gastro-oesophageal reflux disease, in subjects who do not have infection with Helicobacter pylori and in subjects with hiatus hernia. These findings should inform public health measures in reducing the risk of Barrett’s oesophagus and subsequent surveillance burden and cancer risk. There were 8 meta-analyses comparing different groups of patients with Barrett’s oesophagus with regard to cancer risk. These have demonstrated that there was no statistically significant benefit of antireflux surgery over medical therapy, that endoscopic ablative therapy was effective in reducing cancer risk that there was similar cancer risk in patients with Barrett’s oesophagus independent of geographic origin, that the adenocarcinoma incidence in males is twice the rate in females, that the cancer risk in long segment disease showed a trend to be higher than in short segment disease, that there was a trend for higher cancer risk in low-grade dysplasia over non-dysplastic Barrett’s oesophagus, that there is a lower risk in patients with Helicobacter pylori infection and that there is a significant protective effect of aspirin and statins. There were no meta-analyses examining the role of intestinal metaplasia. These results demonstrate that guidance regarding surveillance based on the presence of intestinal metaplasia, segment length and the presence of low-grade dysplasia has a weak basis, and further consideration should be given to gender and helicobacter status, ablation of the metaplastic segment as well as the chemoprotective role of aspirin and statins.

Meta-analysis of endoscopic therapy for low-grade dysplasia in Barrett's oesophagus

Background

The optimal management of patients with Barrett's-associated low-grade dysplasia (LGD) is unclear. The objective of this study was to identify systematically all reports of endoscopic treatment of LGD, and to assess outcomes in terms of disease progression, eradication of dysplasia and intestinal metaplasia, and complication rates.

Methods

A systematic review of articles reporting endoscopic treatment of LGD was conducted in accordance with PRISMA guidelines. MEDLINE and Embase databases were searched to identify the relevant literature. Rates of complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D) were reported. The pooled incidence of progression to cancer was calculated following endoscopic therapy.

Results

Thirty-seven studies met the inclusion criteria, reporting outcomes of endoscopic therapy for 521 patients with LGD. The pooled incidence of progression to cancer was 3·90 (95 per cent confidence interval (c.i.) 1·27 to 9·10) per 1000 patient-years. CE-IM and CE-D were achieved in 67·8 (95 per cent c.i. 50·2 to 81·5) and 88·9 (83·9 to 92·5) per cent of patients respectively. The commonest adverse event was stricture formation.

Conclusion

Reports of endoscopic therapy were heterogeneous and follow-up periods were short. There is a high likelihood of historical overdiagnosis of LGD. Endoscopic therapy, particularly radiofrequency ablation, appears safe and effective at eradicating LGD, but does not eliminate the risk of progression to cancer.

Ablation of Barrett's oesophagus: towards improved outcomes for oesophageal cancer?

Barrett's oesophagus is the major risk factor for the development of oesophageal adenocarcinoma. The management of Barrett's oesophagus entails treating reflux symptoms with acid-suppressing medication or surgery (fundoplication). However, neither form of anti-reflux therapy produces predictable regression, or prevents cancer development. Patients with Barrett's oesophagus usually undergo endoscopic surveillance, which aims to identify dysplastic changes or cancer at its earliest stage, when treatment outcomes should be better. Alternative endoscopic interventions are now available and are suggested for the treatment of early cancer and prevention of progression of Barrett's oesophagus to cancer. Such treatments could minimize the risks associated with oesophagectomy. The current status of these interventions is reviewed. Various endoscopic interventions have been described, but with long-term outcomes uncertain, they remain somewhat controversial. Radiofrequency ablation of dysplastic Barrett's oesophagus might reduce the risk of cancer progression, although cancer development has been reported after this treatment. Endoscopic mucosal resection (EMR) allows a 1.5-2 cm diameter piece of oesophageal mucosa to be removed. This provides better pathology for diagnosis and staging, and if the lesion is confined to the mucosa and fully excised, EMR can be curative. The combination of EMR and radiofrequency ablation has been used for multifocal lesions, but long-term outcomes are unknown. The new endoscopic interventions for Barrett's oesophagus and early oesophageal cancer have the potential to improve clinical outcomes, although evidence that confirms superiority over oesphagectomy is limited. Longer-term outcome data and data from larger cohorts are required to confirm the appropriateness of these procedures.

Molecular biomarkers and ablative therapies for Barrett's esophagus

Barrett's esophagus is the major risk factor for esophageal adenocarcinoma. Endoscopic interventions that ablate Barrett's esophagus mucosa lead to replacement with a new squamous (neosquamous) mucosa, but it can be difficult to achieve complete ablation. Knowing whether cancer is less likely to develop in neosquamous mucosa or residual Barrett's esophagus after ablation is critical for determining the efficacy of treatment. This issue can be informed by assessing biomarkers that are associated with an increased risk of progression to adenocarcinoma. Although there are few postablation biomarker studies, evidence suggests that neosquamous mucosa may have a reduced risk of adenocarcinoma in patients who have been treated for dysplasia or cancer, but some patients who do not have complete eradication of nondysplastic Barrett's esophagus may still be at risk. Biomarkers could be used to optimize endoscopic surveillance strategies following ablation, but this needs to be assessed by clinical studies and economic modeling.

Ablative therapies for Barrett's esophagus

Barrett's esophagus has gained increased clinical attention because of its association with esophageal adenocarcinoma, a cancer with increasing incidence and poor survival rates. The goals of ablating Barrett's esophagus are to decrease esophageal cancer rates and to improve overall survival and quality of life. Different techniques have been developed and tested for their effectiveness eradicating Barrett's epithelium. This review assesses the literature associated with different ablative techniques. The safety and efficacy of different techniques are discussed. This review concludes with recommendations for the clinician, including specific strategies for patient care decisions for patients with Barrett's esophagus with varying degrees of dysplasia.

Barrett's esophagus: endoscopic treatments I

The following on endoscopic treatments of Barrett's esophagus includes commentaries on indications for endoscopic treatments; endo-luminal plication procedures; the cellular modifications induced by the endoscopic ablation therapies; eradication by banding without resection; the evaluation of complete ablation; recurrence after ablation; association of antireflux surgery; radiofrequency ablation; and nondysplastic Barrett's esophagus.

Endoscopic resection techniques and ablative therapies for Barrett's neoplasia

Esophageal adenocarcinoma is the most rapidly increasing cancer in western countries. High-grade dysplasia (HGD) arising from Barrett's esophagus (BE) is the most important risk factor for its development, and when it is present the reported incidence is up to 10% per patient-year. Adenocarcinoma in the setting of BE develops through a well known histological sequence, from non-dysplastic Barrett's to low grade dysplasia and then HGD and cancer. Endoscopic surveillance programs have been established to detect the presence of neoplasia at a potentially curative stage. Newly developed endoscopic treatments have dramatically changed the therapeutic approach of BE. When neoplasia is confined to the mucosal layer the risk for developing lymph node metastasis is negligible and can be successfully eradicated by an endoscopic approach, offering a curative intention treatment with minimal invasiveness. Endoscopic therapies include resection techniques, also known as tissue-acquiring modalities, and ablation therapies or non-tissue acquiring modalities. The aim of endoscopic treatment is to eradicate the whole Barrett's segment, since the risk of developing synchronous and metachronous lesions due to the persistence of molecular aberrations in the residual epithelium is well established.

Barrett's esophagus

Barrett's esophagus is an acquired metaplastic abnormality in which the normal stratified squamous epithelium lining of the esophagus is replaced by an intestinal-like columnar epithelium. While in itself a benign and asymptomatic disorder, the clinical importance of this relatively common condition relates to its role as a precursor lesion to esophageal adenocarcinoma, the incidence of which has dramatically increased in Western populations in recent years. Although known to arise as a consequence of chronic gastroesophageal reflux, the cellular and molecular mechanisms underlying development Barrett's esophagus and its progression to cancer remain unclear.

MicroRNA-196a & microRNA-101 expression in Barrett's oesophagus in patients with medically and surgically treated gastro-oesophageal reflux

BACKGROUND

Proton pump inhibitor (PPI) medication and surgical fundoplication are used for the control of gastro-oesophageal reflux in patients with Barrett's oesophagus, but differ in their effectiveness for both acid and bile reflux. This might impact on the inflammatory processes that are associated with progression of Barrett's oesophagus to cancer, and this may be evident in the gene expression profile and microRNA expression pattern in Barrett's oesophagus mucosa. We hypothesised that two miRNAs with inflammatory and oncogenic roles, miR-101 and miR-196a, are differentially expressed in Barrett's oesophagus epithelium in patients with reflux treated medically vs. surgically.

FINDINGS

Mucosal tissue was obtained at endoscopy from patients with Barrett's oesophagus whose reflux was controlled by proton pump inhibitor (PPI) therapy (n = 20) or by fundoplication (n = 19). RNA was extracted and the expression of miR-101 and miR-196a was measured using real-time reverse transcription - polymerase chain reaction. There were no significant differences in miR-101 and miR-196a expression in Barrett's oesophagus epithelium in patients treated by PPI vs. fundoplication (p = 0.768 and 0.211 respectively). Secondary analysis showed a correlation between miR-196a expression and Barrett's oesophagus segment length (p = 0.014).

CONCLUSION

The method of reflux treatment did not influence the expression of miR-101 and miR-196a in Barrett's oesophagus. This data does not provide support to the hypothesis that surgical treatment of reflux better prevents cancer development in Barrett's oesophagus. The association between miR-196a expression and Barrett's oesophagus length is consistent with a tumour promoting role for miR-196a in Barrett's oesophagus.

Advances in endoscopic diagnosis and treatment of Barrett's esophagus

Barrett's esophagus (BE) is defined as abnormal specialized columnar metaplasia with intestinalization in place of the normal squamous esophageal epithelium. Gastroesophageal reflux disease is a known risk factor for BE; nonetheless BE is also detected in asymptomatic individuals. Other risk factors for BE include smoking, male gender, age over 50 and obesity. Patients diagnosed with BE (without dysplasia) are recommended to undergo endoscopic surveillance every 3-5 years. Advances in imaging techniques (such as narrow band imaging, autofluorescence imaging and confocal laser endomicroscopy) have the potential to improve the detection of dysplasia and early cancer, thus making surveillance a more cost-effective endeavor. Patients with high grade dysplasia (HGD) and early cancer have a high rate of progression to invasive adenocarcinoma and traditionally these patients were treated with esophagectomy. The rapid advancement of endoscopic therapeutic techniques along with a low risk of complications have made endoscopic therapy an acceptable alternative to an esophagectomy in patients with HGD and early cancer. Several endoscopic treatment techniques such as endoscopic mucosal resection, multipolar electrocoagulation, photodynamic therapy, argon plasma coagulation, cryotherapy, and radiofrequency ablation have been studied for endoscopic treatment.

Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy

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.

Treatment of ultralong-segment Barrett's using focal and balloon-based radiofrequency ablation

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.

Treatment for Barrett's oesophagus

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.

Prospective randomized trial of argon plasma coagulation ablation versus endoscopic surveillance of Barrett's esophagus in patients treated with antisecretory medication

Argon plasma coagulation (APC) has been used to ablate Barrett's esophagus, however, its role in the management of non-dysplastic Barrett's esophagus is uncertain. The purpose of this study is to determine the efficacy of endoscopic argon plasma coagulation (APC) for ablation of Barrett's esophagus in a prospective randomized controlled trial in two university teaching hospitals. Fifty-seven patients using proton pump inhibitor (PPI) medication and with Barrett's esophagus were randomized to undergo either ablation using endoscopic argon plasma coagulation (APC) or ongoing surveillance. Fifty-one patients underwent endoscopy at 12 months. Endoscopic argon plasma coagulation (APC) versus surveillance endoscopy was studied. Endoscopy and histopathological appearances of Barrett's esophagus at 12 months follow-up was also studied. Initially, at least 95% ablation of the metaplastic mucosa was achieved in 25 of the 26 treated patients. At 12 months, 14 of 23 APC patients had at least 95% regression, and nine of 23 had complete regression of Barrett's esophagus. No surveillance patient had more than 95% regression. The length of Barrett's esophagus shortened significantly after APC (mean 3.0 vs. 0.5 cm). Significant regression of Barrett's esophagus follows ablation with APC, although complete regression was achieved in less than half. The role of APC ablation of non-dysplastic Barrett's esophagus remains uncertain.

Mucosal ablation of Barrett esophagus

The management of Barrett esophagus is evolving with the emergence of new endoscopic technologies. Traditionally, patients with high-grade dysplasia or cancer were referred for esophagectomy. However, with the advent of endoscopic ablative therapies for Barrett esophagus, the treatment paradigm has shifted. Patients with high-grade dysplasia and intramucosal carcinoma are increasingly offered esophagus-sparing therapies. Endoscopic ablative therapies can be categorized into tissue-acquiring and non-tissue-acquiring modalities. Visible lesions in the setting of dysplasia should be treated with a tissue-acquiring modality to stage and resect the lesion appropriately. One or more modalities may be used to eradicate the entire region of affected esophagus totally. Total eradication treats all of the at-risk epithelium and, therefore, treats any metachronous or synchronous lesions. Success of treatment may be gauged by complete remission of cancer, dysplasia, or Barrett esophagus. In addition to procedure-related complications, the risk of residual Barrett esophagus or subsquamous Barrett esophagus remains to be addressed. Endoscopic surveillance and acid suppression is still currently required after ablation.

Treatment of Barrett's esophagus with high-grade dysplasia

The incidence of esophageal adenocarcinoma is increasing in the USA, now accounting for at least 4% of US cancer-related deaths. Barrett's esophagus is the main risk factor for the development of esophageal adenocarcinoma. The annual incidence of development of adenocarcinoma in Barrett's esophagus is approximately 0.5% per year, representing at least a 30-40-fold increase in risk from the general population. High-grade dysplasia is known to be the most important risk factor for progression to adenocarcinoma. Traditionally, esophagectomy has been the standard treatment for Barrett's esophagus with high-grade dysplasia. This practice is supported by studies revealing unexpected adenocarcinoma in 29-50% of esophageal resection specimens for high-grade dysplasia. In addition, esophagectomy employed prior to tumor invasion of the muscularis mucosa results in 5-year survival rates in excess of 80%. Although esophagectomy can result in improved survival rates for early-stage cancer, it is accompanied by significant morbidity and mortality. Recently, more accurate methods of surveillance and advances in endoscopic therapies have allowed scientists and clinicians to develop treatment strategies with lower morbidity for high-grade dysplasia. Early data suggests that carefully selected patients with high-grade dysplasia can be managed safely with endoscopic therapy, with outcomes comparable to surgery, but with less morbidity. This is an especially attractive approach for patients that either cannot tolerate or decline surgical esophagectomy. For patients that are surgical candidates, high-volume centers have demonstrated improved morbidity and mortality rates for esophagectomy. The addition of laparoscopic esophagectomy adds a less invasive surgical resection to the treatment armanentarium. Esophagectomy will remain the gold-standard treatment of Barrett's esophagus with high-grade dysplasia until clinical research validates the role of endoscopic therapies. Current treatment strategies for Barrett's esophagus with high-grade dysplasia will be reviewed.

MicroRNA-143 and -205 expression in neosquamous esophageal epithelium following Argon plasma ablation of Barrett's esophagus

INTRODUCTION

Ablation of Barrett's esophagus using Argon plasma coagulation (APC) is usually followed by the formation of a neosquamous epithelium. Investigating simple columnar or stratified squamous epithelium associated cytokeratin and microRNA (miRNA) expression in neo-squamous epithelium could help determine the identity and stability of the neosquamous epithelium.

METHODS

Nine patients underwent ablation of Barrett's esophagus with APC. Biopsies were collected from Barrett's esophagus mucosa and proximal normal squamous epithelium before ablation, and from neosquamous and normal squamous epithelium after ablation. Additional esophageal mucosal biopsies from ten nonrefluxing subjects were used as a reference. RNA was extracted and real-time polymerase chain reaction was used to measure the expression of the cytokeratins CK-8 and CK-14 and the microRNAs miR-143 and miR-205.

RESULTS

CK-8 and miR-143 expression were significantly higher in Barrett's esophagus mucosa, compared to neosquamous and normal squamous epithelium before and after APC, whereas miRNA-205 and CK-14 expression was significantly lower in Barrett's esophagus mucosa compared to all categories of squamous mucosa. The expression of CK-8, CK-14, miR-205, and miR-143 was similar between neosquamous epithelium compared to normal squamous epithelium in patients with Barrett's esophagus. Only miR-143 expression was significantly higher in neosquamous and normal squamous epithelium before and after APC compared to normal squamous epithelium from control subjects (p < 0.004).

CONCLUSIONS

The expression levels of cytokeratins and miRNAs studied in post-ablation neosquamous epithelium and normal squamous epithelium in patients with Barrett's esophagus are similar. In patients with Barrett's esophagus, miR-143 expression is still elevated in both neosquamous mucosa, and the squamous mucosa above the metaplastic segment, suggesting that this mucosa may not be normal; i.e., it is different to that seen in subjects without Barrett's esophagus. miR-143 could promote a Barrett's epithelium gene expression pattern, and this could have a role in development of Barrett's esophagus.

Treatment of gastrointestinal diseases with second-generation argon plasma coagulation: an analysis of 260 cases

AIM: To investigate the safety and efficacy of the second-generation argon plasma coagulation (VIO APC) for gastrointestinal diseases.

METHODS: During 2007-09-14/2008-10-22, 260 patients were treated using VIO APC in a total of 289 sessions. For various indications, the new VIO APC device was used. Safety and efficacy of VIO APC were recorded after each individual treatment session.

RESULTS: The mean number of treatment sessions required using VIO APC in various indications was 1.11 ± 0.31. In the palliative treatment of gastric adenocarcinoma, it was 2.50; in endoscopic hemostasis, it was 1.23; in the treatment of colorectal polypi, it was 1.15, in the treatment of upper gastrointestinal polypi, it was 1.03, in the management of self-expand stent overgrowth or tumor stenosis, it was 1.17; in the ablation of Barrett's esophagus, it was 1.13; in the ablation of gastric dysplasia, gastritis verrucosa, gastric xanthelasma and gastric or duodenal liparomphalus, only 1 session was needed. Minor complications (pain, dysphagia/odynophagia, asymptomatic gas accumulation in the intestinal wall) were observed in 10.1%-20% sessions, but no major complications (hemorrhage, perforation, stenosis) were observed.

CONCLUSION: VIO APC is effective and safe for various gastrointestinal conditions. It can be widely applied to daily endoscopic treatment.

A systematic review and meta-analysis of the treatment for Barrett's esophagus

As evidence-based strategies to the clinical management of Barrett's esophagus (BE) are lacking, we have carried out a systematic review and meta-analysis of all published randomized controlled trials with the aim of evaluating the value of different approaches in the treatment of BE. Searches were conducted in the databases PUBMED, EMBASE, and Cochrane Library. Thirteen randomized clinical trials that fulfilled the inclusion criteria and addressed the clinical questions of this analysis were assessed in more detail. Based on our search, neither the pharmacological nor surgical therapies currently available for reflux appear to achieve complete regression of BE and the elimination of the cancer risk associated with it. In contrast, endoscopic ablative techniques are capable of achieving endoscopic and histological reversal of BE, with ablation by argon plasma coagulation (APC) appearing to be more effective than treatment with photodynamic therapy (PDT) [odds ratio (OR) 3.46, 95% confidence interval (CI) 1.67-7.81, P = 0.0008]. There was no statistically significant difference between APC and multipolar electrocoagulation (MPEC) in terms of the efficacy to achieve regression of BE (OR 2.01, 95% CI 0.77-5.23, P = 0.15). In conclusion, there have been only a limited number of randomized controlled trials that compare treatments for BE. The pharmacological therapy, antireflux surgery, and endoscopic ablative techniques are promising in terms of treating BE, but the studies carried out to date have had no adequate power to assess the effect of treatment on reducing and preventing progression to adenocarcinoma.