Re-epithelialisation of Barrett's oesophagus

Outcome of various treatments for posttransplant hepatitis B virus recurrence

BACKGROUND

Currently, no treatment guidelines are available for posttransplant hepatitis B virus (HBV) recurrence. We retrospectively evaluated the rate of clearance of hepatitis B surface antigen (HBsAg) from serum according to various treatment regimens in two large Korean liver transplantation centers.

METHODS

Between 1996 and 2008, HBV recurred in 59 patients among 933 HBV liver recipients (6.3 %). Patients with HBV recurrence were divided into four groups according to their treatment: group L (lamivudine-based therapy n = 21) and group N [new nucleos(t)ide analogue (NA)-based therapy, n = 38]. Intravenous hepatitis B immunoglobulin (ivHBIG) had been simultaneously administered to 10 patients in group L and 26 patients in group N. The mean posttransplant follow-up duration and time to HBV recurrence were 69 (14-152) months and 37 (3-120) months.

RESULTS

Overall, 22 patients (37.3 %) showed seronegative conversion of HBsAg for a median 8 months after treatment (range 1-15 months). The seroclearance rate was significantly higher in group N (n = 20, 52.6 %) than in group L (n = 2, 9.5 %) (p < 0.000). The time to seroconversion did not differ between group L (7 months, range 5-16) and group N (7 months, range 1-15) (p = 0.428). Subgroup analysis showed that the HBsAg seroconversion rate was much higher for patients given combined ivHBIG and new NAs (15/26 patients, 58.0 %) than the others (p = 0.006).

CONCLUSIONS

Seroclearance of HBsAg could be achieved using new NAs in half of the patients after posttransplant HBV recurrence. Combined ivHBIG may add a synergistic effect to new NAs for clearing HBsAg.

Advanced pathology under squamous epithelium on initial EMR specimens in patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma: implications for surveillance and endotherapy management

BACKGROUND

Prior studies report the presence of buried Barrett's epithelium under squamous mucosa after endoscopic ablative therapies for Barrett's esophagus (BE) with high-grade dysplasia (HGD) or intramucosal carcinoma (IMC). However, there still exists significant controversy about whether these glands represent a neoablative phenomenon or predate endoscopic therapy.

OBJECTIVE

To determine the prevalence of buried BE underneath squamous epithelium on initial mucosectomy specimens for complete Barrett's eradication EMR (CBE-EMR) for BE with HGD or IMC.

DESIGN

Retrospective double-blinded review.

SETTING

A tertiary-care academic referral center.

PATIENTS AND METHODS

Histopathology slides of all initial mucosectomy specimens for all patients who underwent CBE-EMR for BE with HGD or IMC at our center between August 2003 and February 2008 were reviewed retrospectively in a double-blinded fashion by 2 expert GI pathologists. None of the patients had undergone prior endoscopic ablative therapy for dysplastic BE.

MAIN OUTCOME MEASUREMENTS

The prevalence of buried BE underneath squamous epithelium in initial mucosectomy specimens from CBE-EMR for BE with HGD or IMC.

RESULTS

A total of 47 patients' initial mucosectomy slides were reviewed. The presence of Barrett's epithelium underneath the squamous resection margin (Z line) was identified in 13 of 47 patients (28%) at initial mucosectomy. The linear distance of the Barrett's epithelium from the resection's squamous margin ranged from 0.8 to 5.6 mm (mean 2.3 mm and median 1.9 mm). Histopathology revealed nondysplastic buried BE in 3 patients, HGD in 9 patients, and IMC in 1 patient. Thus, 10 of 13 patients (21% of 47 total) had buried glands with advanced pathology (HGD or IMC), whereas 3 of 13 (6% of 47 total) had specialized intestinal metaplasia without dysplasia.

LIMITATIONS

A single-center, modest study population size.

CONCLUSIONS

Our results revealed a significant prevalence of buried Barrett's epithelium with or without dysplasia under squamous mucosa (squamocolumnar junction) on initial mucosectomy specimens. Given the neoplastic potential of BE, the presence of these subsquamous BE glands may affect the extent and adequacy of mucosal resection margins. Based on these findings, surveillance biopsies and ablative therapy should extend to 1 cm proximal to the endoscopically determined squamocolumnar junction.

Stepwise radical endoscopic resection is effective for complete removal of Barrett's esophagus with early neoplasia: a prospective study

OBJECTIVES

Endoscopic therapy for early neoplasia in Barrett's esophagus (BE) is evolving rapidly. Aim of this study was to prospectively evaluate safety and efficacy of stepwise radical endoscopic resection (ER) of BE containing early neoplasia.

METHODS

Patients with early neoplasia (i.e., high-grade intraepithelial neoplasia or early cancer) in BE < or = 5 cm, without signs of submucosal infiltration or lymph node/distant metastases, were included. Patients underwent resection sessions (cap technique after submucosal lifting) with intervals of 6 wk.

RESULTS

Between January 2003 and December 2004, 39 consecutive patients were included. Therapy was discontinued in two patients due to unrelated comorbidity. Complete eradication of early neoplasia was achieved in all 37 treated patients in a median number of three sessions. Complete removal of all Barrett's mucosa was achieved in 33 (89%) patients: 4 patients (all had undergone APC [argon plasma coagulation]) were found to have small isles of Barrett's mucosa underneath neosquamous mucosa. Complications occurred in two out of 88 (2%) ER procedures: one asymptomatic perforation, one delayed bleeding. Symptomatic stenosis occurred in 10 of 39 (26%) patients and was effectively treated by endoscopic bougienage. During a median follow-up of 11 months, no patients died and none had recurrence of neoplasia or Barrett's mucosa.

CONCLUSIONS

Stepwise radical ER is effective for selected patients with early neoplasia in BE; provides optimal histopathological diagnosis; and may reduce recurrence rate, since all mucosa at risk is effectively removed. Use of APC should be limited to prevent buried Barrett's mucosa. Methods for prevention of stenosis should be developed.

Endoscopic ablation of Barrett's oesophagus: a randomized-controlled trial of photodynamic therapy vs. argon plasma coagulation

BACKGROUND

Barrett's oesophagus is the major risk factor for oesophageal adenocarcinoma. 5-Aminlevulinic acid-induced photodynamic therapy and argon plasma coagulation have been shown to be effective for ablating Barrett's oesophagus, but a comparative trial of these two modalities has not been reported.

AIMS

To compare photodynamic therapy and argon plasma coagulation for the ablation of Barrett's oesophagus.

METHODS

A total of 68 patients (54 male, 14 female; median age 61) with Barrett's oesophagus were randomized to photodynamic therapy (n = 34) or argon plasma coagulation (n = 34). Photodynamic therapy was performed using 5-aminlevulinic acid (30 mg/kg) and red light. Argon plasma coagulation was administered at a power setting of 65 W. Multiple treatment sessions were performed, with follow-up to 24 months.

RESULTS

All patients showed a macroscopic reduction in the area of Barrett's oesophagus. This was greatest in the argon plasma coagulation group with 33 of 34 (97%) ablated, compared with 17 of 34 (50%) in the photodynamic therapy group; in the remainder, there was a reduction in the length of Barrett's oesophagus (median 50%, range: 5-90). Buried glands were found in 24% of photodynamic therapy patients, and in 21% of argon plasma coagulation patients. The median follow-up is 12 months (range: 6-24).

CONCLUSIONS

Photodynamic therapy and argon plasma coagulation are both effective for ablating Barrett's oesophagus. Argon plasma coagulation appears more effective than photodynamic therapy, but the impact of both on carcinoma development requires larger studies with long-term follow-up.

Comparison of high- vs low-dose 5-aminolevulinic acid for photodynamic therapy of Barrett's esophagus

BACKGROUND

Barrett's esophagus is the major risk factor for esophageal adenocarcinoma, the incidence of which is increasing rapidly in the Western world. Aminolevulinic acid for photodynamic therapy (ALA-PDT) is effective in the treatment of Barrett's esophagus, but controversy exists regarding optimum ALA dosage. The aim of this study was to establish the optimum dosage regime for ALA-PDT for Barrett's esophagus.

METHODS

Twenty-five patients with Barrett's esophagus were randomized to receive 30 (low-dose) or 60 (high-dose) mg/kg oral ALA at 4 or 6 h or 30 mg/kg in two fractions 4 and 6 h before PDT. PDT was standardized using red (635 nm) light. Biopsy specimens were taken for protoporphyrin IX (PpIX) quantification. Endoscopy was repeated 4 weeks later.

RESULTS

All patients showed a macroscopic response, with squamous re-epithelialization. This response was greatest in the 30 mg/kg and fractionated ALA groups. There was no significant difference in response between dosing 4 or 6 h prior to PDT. Tissue levels of PpIX were similar for all dosage groups and were not predictive of clinical response. Side effects were more common with the higher dose of ALA.

CONCLUSION

Low-dose ALA-PDT appears to be a safe protocol for the ablation of Barrett's esophagus.

Prospective randomized controlled trial of argon plasma coagulation ablation vs. endoscopic surveillance of patients with Barrett's esophagus after antireflux surgery

BACKGROUND

Argon plasma coagulation is one of several techniques used to ablate Barrett's esophagus. This study assessed the efficacy and safety of argon plasma coagulation in the ablation of Barrett's esophagus in patients who have undergone antireflux surgery.

METHODS

A total of 40 patients with Barrett's esophagus who had undergone a fundoplication were entered into a prospective, randomized, unblinded study comparing argon plasma coagulation with endoscopic surveillance. Treatment was repeated until either no Barrett's epithelium remained or a maximum of 6 treatment sessions.

RESULTS

One month after the final treatment, complete ablation was achieved in 12 patients. In the remaining 8, a reduction of over 95% was observed. One patient died at 9 months of an unrelated cause. At 1 year, one patient with residual Barrett's epithelium regressed completely, while relapse of Barrett's esophagus was seen in another because of fundoplication failure. Buried glands were observed in 35% patients at 1 month, but only 5% at 1 year. Dysplasia was never seen. In the surveillance group, partial regression was observed in 11 patients, and, in 3 with short-segment Barrett's esophagus, regression was complete. The length of Barrett's esophagus increased in two patients. Two had low-grade dysplasia initially, but this was not evident at 1 year. Overall, complete ablation was achieved in 12 of 19 (63%) patients in the ablation group and 3 of 20 (15%) in the surveillance group (p<0.01).

CONCLUSIONS

Argon plasma coagulation of Barrett's esophagus is safe and effective. The effects are durable, and buried glands may resolve with time. Long-term follow-up is required to assess the impact of argon plasma coagulation on cancer risk.