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Kahn A, Priyan H, Dierkhising RA, Johnson ML, Lansing RM, Maixner KA, Wolfsen HC, Wallace MB, Ramirez FC, Fleischer DE, Leggett CL, Wang KK, Iyer PG. Outcomes of radiofrequency ablation by manual versus self-sizing circumferential balloon catheters for the treatment of dysplastic Barrett's esophagus: a multicenter comparative cohort study. Gastrointest Endosc 2021; 93:880-887.e1. [PMID: 32739482 DOI: 10.1016/j.gie.2020.07.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 07/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Radiofrequency ablation (RFA) is the preferred ablative modality for treating dysplastic Barrett's esophagus. The recently introduced self-sizing circumferential ablation catheter eliminates the need for a sizing balloon. Although it enhances efficiency, outcomes have not been compared with the previous manual-sizing catheter. We evaluated the comparative safety and efficacy of these 2 ablation systems in a large, multicenter cohort. METHODS Patients undergoing RFA at 3 tertiary care centers from 2005 to 2018 were included. Circumferential RFA was performed in a standard fashion, followed by focal RFA as needed. Outcomes were compared between the self-sizing and manual-sizing groups. The primary outcome was the rate of adverse events, including strictures, perforation, and bleeding. Secondary outcomes were procedure time and treatment efficacy, as assessed by rates and time to complete eradication of dysplasia (CE-D) and intestinal metaplasia (CE-IM). RESULTS Three hundred eighteen patients were included, 90 (28.3%) treated with the self-sizing catheter and 228 (71.7%) with the manual-sizing catheter. Twenty-one patients (6.6%) developed strictures (8 [8.9%] in the self-sizing group and 13 [5.7%] in the manual-sizing group, P = .32). Of the self-sizing strictures, 75% occurred at the 12J dose before widespread adoption of the current 10J treatment standard. One patient developed bleeding, and no perforations were encountered. Procedure time was significantly shorter in the self-sizing group. No significant differences were observed in rates of and time to CE-D and CE-IM. CONCLUSIONS These findings suggest that both systems are comparable in safety and efficacy. The use of the self-sizing system may enhance the efficiency of RFA for treating dysplastic Barrett's esophagus.
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Affiliation(s)
- Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Harshith Priyan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ross A Dierkhising
- Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Michele L Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ramona M Lansing
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kristyn A Maixner
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Francisco C Ramirez
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David E Fleischer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Klair JS, Jayaraj M, Chandrasekar VT, Priyan H, Law J, Murali AR, Singh D, Larsen M, Irani S, Kozarek R, Ross A, Krishnamoorthi R. ERCP with overtube-assisted enteroscopy in patients with Roux-en-Y gastric bypass anatomy: a systematic review and meta-analysis. Endoscopy 2020; 52:824-832. [PMID: 32492751 DOI: 10.1055/a-1178-9741] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Roux-en-Y gastric bypass (RYGB) anatomy is challenging. Overtube-assisted enteroscopy (OAE) is usually needed to perform ERCP in these patients. There is significant variation in the reported rates of success and adverse events across published studies. We performed a systematic review and meta-analysis to reliably estimate the pooled rates of success and adverse events. METHODS We performed a systematic search of multiple electronic databases through February 2020 to identify studies reporting outcomes of OAE-ERCP in post-RYGB patients. The pooled rates of enteroscopy success, technical success, and adverse events were estimated for OAE-ERCP. The pooled rates of success and adverse events were also estimated for ERCP using double-balloon enteroscopes (DBE) alone. RESULTS 10 studies reporting a total of 398 procedures were included in the meta-analysis. The pooled rates of enteroscopy and technical success of OAE-ERCP were 75.3 % (95 % confidence interval [CI] 64.5 - 83.6) and 64.8 % (95 %CI 53.1 - 74.9) respectively. The pooled rate of adverse events was 8.0 % (95 %CI 5.2 - 12.2). The pooled rates of enteroscopy and technical success of DBE-ERCP (four studies) were 83.5 % (95 %CI 68.3 - 92.2) and 72.5 % (95 %CI 52.3 - 86.4), respectively. The pooled rate of adverse events with DBE-ERCP was 9.0 % (95 %CI 5.4 - 14.5). Substantial heterogeneity was noted. CONCLUSIONS OAE-ERCP appears to be effective and safe in post-RYGB patients. Among the currently available techniques, OAE-ERCP is the least invasive approach in this challenging group of patients. Future studies comparing the effectiveness and safety of alternative novel techniques, such as endosonography-directed transgastric ERCP, with OAE-ERCP are needed.
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Affiliation(s)
- Jagpal Singh Klair
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Mahendran Jayaraj
- Division of Gastroenterology and Hepatology, University of Nevada School of Medicine, Las Vegas, Nevada, United States
| | | | - Harshith Priyan
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Joanna Law
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Arvind R Murali
- Division of Gastroenterology and Hepatology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
| | - Dhruv Singh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States
| | - Michael Larsen
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Shayan Irani
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Richard Kozarek
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Andrew Ross
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
| | - Rajesh Krishnamoorthi
- Digestive Disease Institute, Virginia Mason Medical Center, Seattle, Washington, United States
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Genere J, Priyan H, Wang K. Endoscopic submucosal dissection using a novel endoscopic articulating knife for clinical staging of early esophageal neoplasia. J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
114 Background: Clinical staging of early esophageal neoplasia traditionally involves histological confirmation and imaging with endoscopic ultrasound (EUS), CT, and PET which have low sensitivity and specificity for staging esophageal cancer (EC). Endoscopic submucosal dissection (ESD) therapy is traditionally used for treatment, but not diagnosis as it is felt to be technically challenging and have a high risk for complications. We applied a new articulating endoscopic knife that permits safe ESD (ESD-CC) to evaluate early neoplasia with potential curative resection. Methods: We performed a retrospective study of patients undergoing ESD to stage or treat suspected early EC (cT1-T2). Clinical stage was done by EUS, CT, and PET. Two expert GI pathologists reviewed all histology. Lesions were examined with high resolution white light endoscopy and narrow band imaging. ESD was done with 1:200,000 epinephrine and methylene blue dye injection for lifting and staining the submucosal space. A 5mm, scissors-like articulated knife was used to perform ESD and hemostasis. Complications during post-ESD observation or follow-up were recorded. Results: A total of 35 patients who underwent ESD-CC were included with median age 70 (IQR 12), 26 males (74%), and followed for a median 3.4 months (IQR 6.4). This group consisted of 32 potential adenocarcinomas and 3 squamous cell cancers. The clinical Pre-ESD diagnoses were cT1 EC (24, 69%) and suspected EC in Barrett’s esophagus (BE) (11, 31%). The cT1 EC cases had ESD staged at least T1b (5, 21%), T1a (11, 46%), EC in situ (1, 4%), and dysplastic BE (7, 29%). The suspected EC cases had ESD staged at least T1b (1, 9%), T1a (2, 18%), and DBE (8, 73%). ESD-CC up-staged 4 (11%), down-staged 10 (29%), and confirmed prior diagnosis in 21 (60%). No complications including bleeding, perforation, or stricture formation regardless of size of ESD, age of patient, or co-morbidities. Conclusions: Staging of early esophageal cancer can be improved using ESD with an articulating knife, without increase in complications. ESD may be used as a staging modality in early esophageal cancer.
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