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Okubo Y, Ishihara R. Endoscopic Submucosal Dissection for Esophageal Cancer: Current and Future. Life (Basel) 2023; 13:life13040892. [PMID: 37109421 PMCID: PMC10140872 DOI: 10.3390/life13040892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 03/06/2023] [Accepted: 03/24/2023] [Indexed: 03/29/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) has been widely used to treat superficial esophageal cancer. The advantages of esophageal ESD include a high en bloc resection rate and accurate pathological diagnosis. It enables local resection of the primary tumor and accurate identification of the risk factors for lymph node metastasis, including depth, vascular invasion, and types of invasion. Even in cases with clinical T1b-SM cancer, ESD and additional treatment can achieve radical cure, depending on the risk of lymph node metastasis. Esophageal ESD will be increasingly vital in minimally invasive and effective esophageal cancer treatment. This article describes the current status and prospects of esophageal ESD.
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Motofei IG. Biology of cancer; from cellular and molecular mechanisms to developmental processes and adaptation. Semin Cancer Biol 2022; 86:600-615. [PMID: 34695580 DOI: 10.1016/j.semcancer.2021.10.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 09/21/2021] [Accepted: 10/10/2021] [Indexed: 02/07/2023]
Abstract
Cancer research has been largely focused on the cellular and molecular levels of investigation. Recent data show that not only the cell but also the extracellular matrix plays a major role in the progression of malignancy. In this way, the cells and the extracellular matrix create a specific local microenvironment that supports malignant development. At the same time, cancer implies a systemic evolution which is closely related to developmental processes and adaptation. Consequently, there is currently a real gap between the local investigation of cancer at the microenvironmental level, and the pathophysiological approach to cancer as a systemic disease. In fact, the cells and the matrix are not only complementary structures but also interdependent components that act synergistically. Such relationships lead to cell-matrix integration, a supracellular form of biological organization that supports tissue development. The emergence of this supracellular level of organization, as a structure, leads to the emergence of the supracellular control of proliferation, as a supracellular function. In humans, proliferation is generally involved in developmental processes and adaptation. These processes suppose a specific configuration at the systemic level, which generates high-order guidance for local supracellular control of proliferation. In conclusion, the supracellular control of proliferation act as an interface between the downstream level of cell division and differentiation, and upstream level of developmental processes and adaptation. Understanding these processes and their disorders is useful not only to complete the big picture of malignancy as a systemic disease, but also to open new treatment perspectives in the form of etiopathogenic (supracellular or informational) therapies.
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Affiliation(s)
- Ion G Motofei
- Department of Oncology/ Surgery, Carol Davila University, St. Pantelimon Hospital, Dionisie Lupu Street, No. 37, Bucharest, 020021, Romania.
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Kubota Y, Tanabe S, Ishido K, Yano T, Wada T, Watanabe A, Azuma M, Katada C, Koizumi W. Usefulness of argon plasma coagulation for superficial esophageal squamous cell neoplasia in patients at high risk or with limited endoscopic resectability. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:529-537. [PMID: 32897227 DOI: 10.5152/tjg.2020.19329] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND/AIMS Endoscopic resection is the standard treatment for superficial esophageal squamous-cell neoplasia (SESCN). However, we encounter patients in whom endoscopic resection is difficult to perform. We retrospectively studied the usefulness of argon plasma coagulation (APC) in patients with SESCN. MATERIALS AND METHODS The study comprised 45 patients with SESCN (81 lesions) who underwent APC in our hospital from March 1999 through August 2016. Clinicopathological characteristics, treatment time, the presence or absence of metastasis and recurrence, adverse events, and outcomes were studied. RESULTS The median follow-up was 40 months. The median age was 70 years. The tumor diameter was 10 mm or longer in 48 lesions and less than 10 mm in 33 lesions. The median treatment time was 22 minutes. The reasons for selecting APC were as follows: technical difficulty caused by the presence of metachronous multiple lesions in the radiation field after chemoradiotherapy or close proximity to the ulcer scar remaining after endoscopic treatment in 49 lesions (60.4%), and the presence of underlying diseases in 26 lesions (32.0%). Adverse events occurred in 2 patients (4.4%) who had hypoxemia due to over-sedation. Two lesions (2.5%) recurred locally but could be locally controlled by additional APC. No patient had metastasis or recurrence or died of esophageal neoplasia. The 3-year overall survival rate was 87.0%, and the 3-year recurrence-free survival rate was 97.2%. CONCLUSION APC can be a useful treatment option for SESCN in patients with a limited life expectancy, poor performance status, or technical difficulty in resection of superficial neoplasms.
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Affiliation(s)
- Yo Kubota
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Satoshi Tanabe
- Department of Advanced Medicine Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
| | - Kenji Ishido
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takafumi Yano
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Takuya Wada
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Akinori Watanabe
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Mizutomo Azuma
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Chikatoshi Katada
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Wasaburo Koizumi
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
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Peerally MF, Bhandari P, Ragunath K, Barr H, Stokes C, Haidry R, Lovat L, Smart H, Harrison R, Smith K, Morris T, de Caestecker JS. Radiofrequency ablation compared with argon plasma coagulation after endoscopic resection of high-grade dysplasia or stage T1 adenocarcinoma in Barrett's esophagus: a randomized pilot study (BRIDE). Gastrointest Endosc 2019; 89:680-689. [PMID: 30076843 DOI: 10.1016/j.gie.2018.07.031] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2018] [Accepted: 07/25/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic resection (ER) is safe and effective for Barrett's esophagus (BE) containing high-grade dysplasia (HGD) or mucosal adenocarcinoma (T1A). The risk of metachronous neoplasia is reduced by ablation of residual BE by using radiofrequency ablation (RFA) or argon plasma coagulation (APC). These have not been compared directly. We aimed to recruit up to 100 patients with BE and HGD or T1A confirmed by ER over 1 year in 6 centers in a randomized pilot study. METHODS Randomization was 1:1 to RFA or APC (4 treatments allowed at 2-month intervals). Recruitment, retention, dysplasia clearance, clearance of benign BE, adverse events, healthcare costs, and quality of life by using EQ-5D, EORTC QLQ-C30, or OES18 were assessed up to the end of the trial at 12 months. RESULTS Of 171 patients screened, 76 were randomized to RFA (n = 36) or APC (n = 40). The mean age was 69.7 years, and 82% were male. BE was <5 cm (n = 27), 5 to 10 cm (n = 45), and >10 cm (n = 4). Sixty-five patients completed the trial. At 12 months, dysplasia clearance was RFA 79.4% and APC 83.8% (odds ratio [OR] 0.7; 95% confidence interval [CI], 0.2-2.6); BE clearance was RFA 55.8%, and APC 48.3% (OR 1.4; 95% CI, 0.5-3.6). A total of 6.1% (RFA) and 13.3% (APC) had buried BE glands. Adverse events (including stricture rate after starting RFA 3/36 [8.3%] and APC 3/37 [8.1%]) and quality of life scores were similar, but RFA cost $27491 more per case than APC. CONCLUSION This pilot study suggests similar efficacy and safety but a cost difference favoring APC. A fully powered non-inferiority trial is appropriate to confirm these findings. (Clinical trial registration number: NCT01733719.).
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Affiliation(s)
- Mohammad Farhad Peerally
- Digestive Diseases Centre, University Hospitals of Leicester NHS Trust, UK and Leicester Cancer Research Centre, College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester, United Kingdom
| | | | - Krish Ragunath
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Hugh Barr
- Gloucester Royal Hospital, Gloucester, United Kingdom
| | - Clive Stokes
- Gloucester Royal Hospital, Gloucester, United Kingdom
| | - Rehan Haidry
- University College Hospital, London, United Kingdom
| | | | - Howard Smart
- Royal Liverpool Hospital, Liverpool, United Kingdom
| | - Rebecca Harrison
- Department of Pathology, University Hospitals of Leicester NHS trust, Leicester, United Kingdom
| | - Karen Smith
- Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Tom Morris
- Leicester Clinical Trials Unit, University of Leicester, Leicester, United Kingdom
| | - John S de Caestecker
- Digestive Diseases Centre, University Hospitals of Leicester NHS Trust, UK and Leicester Cancer Research Centre, College of Medicine, Biological Sciences and Psychology, University of Leicester, Leicester, United Kingdom
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Singh T, Sanaka MR, Thota PN. Endoscopic therapy for Barrett’s esophagus and early esophageal cancer: Where do we go from here? World J Gastrointest Endosc 2018; 10:165-174. [PMID: 30283599 PMCID: PMC6162248 DOI: 10.4253/wjge.v10.i9.165] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 06/13/2018] [Accepted: 06/28/2018] [Indexed: 02/06/2023] Open
Abstract
Since Barrett’s esophagus is a precancerous condition, efforts have been made for its eradication by various ablative techniques. Initially, laser ablation was attempted in non-dysplastic Barrett’s esophagus and subsequently, endoscopic ablation using photodynamic therapy was used in Barrett’s patients with high-grade dysplasia who were poor surgical candidates. Since then, various ablative therapies have been developed with radiofrequency ablation having the best quality of evidence. Resection of dysplastic areas only without complete removal of entire Barrett’s segment is associated with high risk of developing metachronous neoplasia. Hence, the current standard of management for Barrett’s esophagus includes endoscopic mucosal resection of visible abnormalities followed by ablation to eradicate remaining Barrett’s epithelium. Although endoscopic therapy cannot address regional lymph node metastases, such nodal involvement is present in only 1% to 2% of patients with intramucosal adenocarcinoma in Barrett esophagus and therefore is useful in intramucosal cancers. Post ablation surveillance is recommended as recurrence of intestinal metaplasia and dysplasia have been reported. This review includes a discussion of the technique, efficacy and complication rate of currently available ablation techniques such as radiofrequency ablation, cryotherapy, argon plasma coagulation and photodynamic therapy as well as endoscopic mucosal resection. A brief discussion of the emerging technique, endoscopic submucosal dissection is also included.
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Affiliation(s)
- Tavankit Singh
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Madhusudhan R Sanaka
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
| | - Prashanthi N Thota
- Department of Gastroenterology and Hepatology, Cleveland Clinic, Cleveland, OH 44195, United States
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Dunn JM, Sui G, Anggiansah A, Wong T. Radiofrequency ablation of symptomatic cervical inlet patch using a through-the-scope device: a pilot study. Gastrointest Endosc 2016; 84:1022-1026.e2. [PMID: 27373671 DOI: 10.1016/j.gie.2016.06.037] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 06/17/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The cervical inlet patch (CIP) is an area of heterotopic gastric mucosa at the proximal esophagus, which can secrete both acid and mucus. Attributable symptoms include chronic globus sensation and sore throat. Previous studies have demonstrated improvement in symptoms after ablation using argon plasma coagulation. Our aim was to assess a through-the-scope radiofrequency ablation (RFA) catheter for ablation of symptomatic CIP. METHODS Ten patients with endoscopically and histologically proven CIP and symptoms of globus or sore throat were included in the study. An ablation protocol of 3 ablations at 12 J/cm2, without removal of coagulated tissue between ablations, was used. A maximum of 2 RFA sessions, 3 months apart, was allowed. A visual analog score was completed at baseline, 6 weeks (on proton pump inhibitor), 3 months (off proton pump inhibitor), and 12 months after treatment. RESULTS Mean patient age was 56 years (±3 years, standard error of the mean), 60% were men, and 80% were white. Barrett's esophagus was present in 50%. The mean number of CIPs was 2 (range, 1-4) with a median surface area of 2 cm2 (range, .5-14). After a median of 2 treatments, 80% achieved complete endoscopic and histologic resolution, with a mean follow-up of 14 months (range, 12-17). Globus, sore throat, and cough significantly improved from baseline (P < .05). No strictures or buried glands were identified. CONCLUSIONS This prospective pilot study demonstrates that RFA using a through-the-scope device is safe and effective for treating patients with symptomatic CIP. One-year follow-up data suggest the effect is durable.
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Affiliation(s)
- Jason Mark Dunn
- Department of Gastroenterology, Guy's and St. Thomas's Hospital NHS Trust, London, United Kingdom; Institute for Cancer Genetics and Informatics, Oslo University, Oslo, Norway
| | - Guiping Sui
- Department of Gastroenterology, Guy's and St. Thomas's Hospital NHS Trust, London, United Kingdom
| | - Angela Anggiansah
- Department of Gastroenterology, Guy's and St. Thomas's Hospital NHS Trust, London, United Kingdom
| | - Terence Wong
- Department of Gastroenterology, Guy's and St. Thomas's Hospital NHS Trust, London, United Kingdom
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Abstract
Electric discharge utilized for electrosurgery is studied by means of a recently developed method for the diagnostics of small-size atmospheric plasma objects based on Rayleigh scattering of microwaves on the plasma volume. Evolution of the plasma parameters in the near-electrode sheaths and in the positive column is measured and analyzed. It is found that the electrosurgical system produces a glow discharge of alternating current with strongly contracted positive column with current densities reaching 10(3) A/cm(2). The plasma electron density and electrical conductivities in the channel were found be 10(16) cm(-3) and (1-2) Ohm(-1) cm(-1), respectively. The discharge interrupts every instance when the discharge-driving AC voltage crosses zero and re-ignites again every next half-wave at the moment when the instant voltage exceeds the breakdown threshold.
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Enestvedt BK, Ginsberg GG. Advances in endoluminal therapy for esophageal cancer. Gastrointest Endosc Clin N Am 2013; 23:17-39. [PMID: 23168117 DOI: 10.1016/j.giec.2012.10.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Advances in endoscopic therapy have resulted in dramatic changes in the way early esophageal cancer is managed as well as in the palliation of dysphagia related to advanced esophageal cancer. Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are effective therapies for accurate histopathologic staging and provide a potential for complete cure. Mucosal ablative techniques (radiofrequency ablation and cryotherapy) are effective adjuncts to EMR and ESD and reduce the occurrence of synchronous and metachronous lesions within the Barrett esophagus. The successes of these techniques have made endoscopic therapy the primary means of management of early esophageal cancer.
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Affiliation(s)
- Brintha K Enestvedt
- Division of Gastroenterology, Temple University, Philadelphia, PA 19140, USA.
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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: 2.5] [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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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: 2.5] [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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Wolfsen HC. Endoluminal therapy for esophageal disease: an introduction. Gastrointest Endosc Clin N Am 2010; 20:1-10, v. [PMID: 19951790 DOI: 10.1016/j.giec.2009.07.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
This introductory article summarizes decades of research from many dedicated gastrointestinal endoscopists. It provides a background to Barrett esophagus (BE), exploring the risk of progression to dysplasia and esophageal adenocarcinoma. Two premalignant conditions, BE and colon adenoma, are compared, including their progression to esophageal adenocarcinoma and colon and rectal carcinoma, respectively. A comparison of the risks of surgical treatment and post-surgical complications of these cancers and of the strikingly different paradigms for their prevention is presented. The article concludes with the rationale for endoscopic treatment of Barrett disease.
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Affiliation(s)
- Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL 32224, USA.
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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: 1.8] [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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Goulet CJ, Disario JA, Emerson L, Hilden K, Holubkov R, Fang JC. In vivo evaluation of argon plasma coagulation in a porcine model. Gastrointest Endosc 2007; 65:457-62. [PMID: 17321247 DOI: 10.1016/j.gie.2006.09.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 09/07/2006] [Indexed: 12/13/2022]
Abstract
BACKGROUND Argon plasma coagulation (APC) is a noncontact form of monopolar electrocautery. One purported advantage of APC includes a limit to the depth of injury. It is unclear from previous studies whether the depth of injury is limited to superficial tissue layers with the settings used in clinical practice. OBJECTIVE To evaluate the depth and the area of APC-induced injury by using new modes of APC delivery in an in vivo porcine model in the setting of colonoscopy. DESIGN Blinded quasi-experiment. SUBJECTS Six swine. INTERVENTION Colonoscopy with the swine under general anesthesia, with application of APC in 2 different pulsed modes and varying power settings and duration of application. MAIN OUTCOME MEASUREMENTS Surface area and depth of colonic mucosal injury. Qualitative histologic analysis of each site of APC application was performed on formalin-fixed specimens after euthanizing the swine. RESULTS Muscularis propria injury occurred in 22% of lesions with 10 W, 62% of lesions with 20 W, 86% of lesions with 40 W, and 80% of lesions with 60 W. Muscularis propria injury occurred in 42% of lesions at 1 second, 66% of lesions at 3 seconds, and 69% of lesions at 5 seconds. Depth of injury was significantly correlated with total energy delivered (P = .001, r = 0.75). Surface area was significantly associated with total energy delivered (P < .001, r = 0.81). LIMITATIONS This study was performed in distal swine colon rather than human colon. Colon tissue response to APC injury may differ from swine to human colon. The application distance from the APC probe to the colonic tissue may have varied between applications. CONCLUSIONS Muscularis propria injury occurs across a broad range of clinically used APC settings. The frequency of deep injury and the surface area of the lesion increases with total energy delivered. The lowest power settings (10-20 W) and the shortest durations have the lowest risk of deep tissue injury.
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Affiliation(s)
- Christopher J Goulet
- GI Division, University of Utah Health Sciences Center, 30 N 1900 E., Salt Lake City, UT 84132, USA
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Hubbard N, Velanovich V. Endoscopic endoluminal radiofrequency ablation of Barrett's esophagus in patients with fundoplications. Surg Endosc 2007; 21:625-8. [PMID: 17364152 DOI: 10.1007/s00464-007-9199-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2006] [Accepted: 12/12/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Endoscopic endoluminal radiofrequency ablation using the Barrx device is a new technique to treat Barrett's esophagus. This procedure has been used in patients who have not had antireflux surgery. This report is presents an early experience of the effects of endoluminal ablation on the reflux symptoms and completeness of ablation in post-fundoplication patients. METHODS Seven patients who have had either a laparoscopic or open Nissen fundoplication and Barrett's esophagus underwent endoscopic endoluminal ablation of the Barrett's metaplasia using the Barrx device (Barrx Medical, Sunnyvale, CA). Preprocedure, none of the patients had significant symptoms related to gastroesophageal reflux disease. One to two weeks after the ablation, patients were questioned as to the presence of symptoms. Preprocedure and postprocedure, they completed the GERD-HRQL symptom severity questionnaire (best possible score, 0; worst possible score, 50). Patients had follow-up endoscopy to assess completeness of ablation 3 months after the original treatment. RESULTS All patients completed the ablation without complications. No patients reported recurrence of their GERD symptoms. The median preprocedure total GERD-HRQL score was 2, compared to a median postprocedure score of 1. One patient had residual Barrett's metaplasia at 3 months follow-up, requiring re-ablation. CONCLUSIONS This preliminary report of a small number of patients demonstrates that endoscopic endoluminal ablation of Barrett's metaplasia using the Barrx device is safe and effective in patients who have already undergone antireflux surgery. There appears to be no disruption in the fundoplication or recurrence of GERD-related symptoms. Nevertheless, longer-term follow-up with more patients is needed.
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Affiliation(s)
- N Hubbard
- Division of General Surgery, K-8, Henry Ford Hospital, 2799 West Grand Blvd., Detroit, Michigan 48202-2689, USA
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Abstract
This article reviews methods to minimize the complications associated with endoscopic therapy for patients with Barrett's esophagus. To place this discussion in context, the natural history of Barrett's esophagus and the risks associated with progression to dysplasia and invasive carcinoma are reviewed. Operative esophageal resection traditionally is recommended for patients with Barrett's high-grade dysplasia and early carcinoma, and these surgical risks also are reviewed. Finally, all currently approved and commercially available methods for endoscopic ablation and resection of Barrett's disease are categorized according to their application methods of ablation: focal ablation, field ablation, and mucosal resection. The clinical experience with these devices is reviewed with their associated adverse events and complications. Caveats, concerns, and recommendations are discussed to help minimize the complications associated with the use of these important technologies that hold the promise of removing or destroying Barrett's disease to prevent the development of invasive carcinoma.
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Affiliation(s)
- Herbert C Wolfsen
- Mayo Clinic College of Medicine, 200 First Street S.W., Rochester, MN 55905, USA.
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Wolfsen HC. Endoprevention of esophageal cancer: endoscopic ablation of Barrett's metaplasia and dysplasia. Expert Rev Med Devices 2006; 2:713-23. [PMID: 16293098 DOI: 10.1586/17434440.2.6.713] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
This review describes the use of endoscopic therapy for the treatment of Barrett's disease and the prevention of esophageal carcinoma, predominantly a disease of older white men. While the term endoprevention may be novel, gastroenterologists have been using endoscopic techniques to prevent colon cancer for decades. For the endoprevention of Barrett's carcinoma, the regulatory approval for the use of porfimer sodium photodynamic therapy was an important milestone, as this treatment has been proven to safely ablate Barrett's glandular epithelium, including high-grade dysplasia, and significantly decrease the risk for the development of invasive cancer in several single-center studies, a prospective multicenter randomized controlled study using expert centralized histopathology analysis and long-term single-center results. Newer methods of mucosal ablation, such as the radiofrequency balloon, have been developed for the treatment of patients with Barrett's metaplasia or dysplasia. These newly developed techniques are able to treat large fields of glandular epithelium in a short treatment procedure using safe, effective, durable methods for the complete ablation of Barrett's metaplasia and low-grade dysplasia. These techniques may finally allow the interventional gastrointestinal endoscopist to prevent the development of esophageal carcinoma, just as colonoscopy with polypectomy has prevented colon cancer. However, it will be critically important to document the safety, durability and efficacy of these devices. Ultimately, the impact of successful Barrett's ablation on the incidence of Barrett's carcinoma, and the need for postablation surveillance endoscopy must be determined.
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Affiliation(s)
- Herbert C Wolfsen
- Mayo Clinic, Division of Gastroenterology and Hepatology, 6A Davis Building, 4500 San Pablo Road, Jacksonville, FL 32224, USA.
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Abstract
With the increase in the rate of esophageal adenocarcinoma in the United States and the Western world matched with the high morbidity and mortality of esophagectomy, there is an increasing need for new and effective techniques to treat and prevent esophageal adenocarcinoma. A wide variety of endoscopic mucosal ablative techniques have been developed for early esophageal neoplasia. However, long-term control of neoplasic risk has not been demonstrated. Most studies show that specialized intestinal metaplasia may persist underneath neo-squamous mucosa, posing a risk for subsequent neoplastic progression. In this article we review current published literature on endoscopic therapies for the management of Barrett's esophagus.
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Affiliation(s)
- Ronald W Yeh
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Alway Building M-211, CA 94305, USA.
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20
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Affiliation(s)
- Philippa E Claydon
- Department of Surgery, Royal Hallamshire Hospital, Sheffield, United Kingdom
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21
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Weston AP, Sharma P, Banerjee S, Mitreva D, Mathur S. Visible endoscopic and histologic changes in the cardia, before and after complete Barrett's esophagus ablation. Gastrointest Endosc 2005; 61:515-21. [PMID: 15812402 DOI: 10.1016/s0016-5107(05)00131-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Adverse events associated with the thermal ablation of Barrett's esophagus (BE) include the generation of gastric mucosa buried beneath the neosquamous regrowth, and unrecognized development and growth of adenocarcinomas. No reports exist regarding the endoscopic appearance and histology of the cardia before and after BE ablation. The aim of our study was to assess the relative frequency of the occurrence of visible endoscopic and histologic changes in the cardia, before and after complete BE ablation. METHODS A subset analysis of patients with uncomplicated BE, BE with dysplasia, or early carcinoma, who had been enrolled into one of 4 ongoing prospective studies of mucosal ablation, was examined. Eighty-two patients were identified who entered a BE ablation study, with 75 of these completing BE mucosal ablation. Cardia biopsy specimens were taken in all patients before ablation and serially after BE ablation. Cardia histology was graded by using the modified Sydney System for gastritis. RESULTS Before ablation, cardia nodules were noted in 3, cardia intestinal metaplasia (IM) in 7 (8.5%), and none harbored cardia dysplasia. Postablation surveillance ranged from 3 to 75 months (mean 31.1 months [19.5]). Six subjects (8%) developed cardia nodules during surveillance; cardia IM was found in 21(28%), with 17 of these being a new finding (incidence of 25%). Cardia low-grade dysplasia incidence was 1.3% and high-grade dysplasia was 4% after BE ablation. CONCLUSIONS The pathophysiology of the abnormal cardia histology and the endoscopic lesions (nodules) is unclear, but endoscopic surveillance of not only the neosquamous epithelium but also the cardia should be considered after ablation, especially in those high-grade dysplasia and early adenocarcinoma BE patients.
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Affiliation(s)
- Allan P Weston
- Kansas City VAMC, Cancer Center, Kansas City, Missouri, USA
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22
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Madisch A, Miehlke S, Bayerdorffer E, Wiedemann B, Antos D, Sievert A, Vieth M, Stolte M, Schulz H. Long-term follow-up after complete ablation of Barrett’s esophagus with argon plasma coagulation. World J Gastroenterol 2005; 11:1182-6. [PMID: 15754401 PMCID: PMC4250710 DOI: 10.3748/wjg.v11.i8.1182] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To report the long-term outcome of patients after complete ablation of non-neoplastic Barrett’s esophagus (BE) with respect to BE relapse and development of intraepithelial neoplasia or esophageal adenocarcinoma.
METHODS: In 70 patients with histologically proven non-neoplastic BE, complete BE ablation was achieved by argon plasma coagulation (APC) and high-dose proton pump inhibitor therapy (120 mg omeprazole daily). Sixty-six patients (94.4%) underwent further surveillance endoscopy. At each surveillance endoscopy four-quadrant biopsies were taken from the neo-squamous epithelium at 2 cm intervals depending on the pre-treatment length of BE mucosa beginning at the neo-Z-line, and from any endoscopically suspicious lesion.
RESULTS: The median follow-up of 66 patients was 51 mo (range 9-85 mo) giving a total of 280.5 patient years. A mean of 6 biopsies were taken during surveillance endoscopies. In 13 patients (19.7%) tongues or islands suspicious for BE were found during endoscopy. In 8 of these patients (12.1%) non-neoplastic BE relapse was confirmed histologically giving a histological relapse rate of 3% per year. In none of the patients, intraepithelial neoplasia nor an esophageal adenocarcinoma was detected. Logistic regression analysis identified endoscopic detection of islands or tongues as the only positive predictor of BE relapse (P = 0.0004).
CONCLUSION: The long-term relapse rate of non-neoplastic BE following complete ablation with high-power APC is low (3% per year).
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Affiliation(s)
- Ahmed Madisch
- Medical Department I, Technical University Hospital, Fetscherstr. 74, D-01307 Dresden, Germany.
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23
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Dulai GS, Jensen DM, Cortina G, Fontana L, Ippoliti A. Randomized trial of argon plasma coagulation vs. multipolar electrocoagulation for ablation of Barrett's esophagus. Gastrointest Endosc 2005; 61:232-40. [PMID: 15729231 DOI: 10.1016/s0016-5107(04)02576-3] [Citation(s) in RCA: 90] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic ablation of Barrett's esophagus has been described in which various thermocoagulation modalities are used in combination with a high dose of a proton pump inhibitor. No randomized comparison of ablation strategies has been published. METHODS Referred patients were screened to identify those with Barrett's esophagus 2 to 7 cm in length, without high-grade dysplasia or cancer. Included patients received pantoprazole (40 mg twice a day), followed by randomization to treatment with argon plasma coagulation (APC) or multipolar electrocoagulation (MPEC). The primary outcome measure was the number of treatment sessions required for endoscopic ablation. RESULTS Of 235 patients screened, 52 were randomized. The mean length of Barrett's esophagus was 3.1 cm in the MPEC group vs. 4.0 cm in the APC group (p = 0.03). Otherwise, the treatment groups were similar with regard to baseline characteristics. The mean number of treatment sessions required for endoscopic ablation was 2.9 for MPEC vs. 3.8 for APC (p = 0.04) in an intention-to-treat analysis (p = 0.249, after adjustment for the difference in length of Barrett's esophagus). The proportion of patients in which ablation was endoscopically achieved proximal to the gastroesophageal junction was 88% for the MPEC group vs. 81% for the APC group (p = 0.68) and histologically achieved in 81% for MPEC vs. 65% for APC (p = 0.21). The mean time required for the first treatment session was 6 minutes with MPEC vs. 10 minutes with APC (p = 0.01) in per protocol analysis. There was no serious adverse event, but transient moderate to severe upper-GI symptoms occurred after MPEC in 8% vs. 13% after APC (p = 0.64). Conclusions Although there were no statistically significant differences, ablation of Barrett's esophagus with pantoprazole and MPEC required numerically fewer treatment sessions, and endoscopic and histologic ablation was achieved in a greater proportion of patients compared with treatment with pantoprazole and APC.
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24
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Ganz RA, Utley DS, Stern RA, Jackson J, Batts KP, Termin P. Complete ablation of esophageal epithelium with a balloon-based bipolar electrode: a phased evaluation in the porcine and in the human esophagus. Gastrointest Endosc 2004; 60:1002-10. [PMID: 15605025 DOI: 10.1016/s0016-5107(04)02220-5] [Citation(s) in RCA: 116] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the endoscopic and the histologic effects of a balloon-based bipolar radiofrequency electrode for ablation of porcine and human esophageal epithelium. METHODS All procedures were performed with a balloon-based, bipolar radiofrequency system that creates a circumferential, thin-layer epithelial ablation zone within the esophagus. In Phase I, multiple ablations were created in 10 farm swine, followed by acute euthanasia and histologic assessment for completeness of epithelial removal and ablation depth. In Phase II, multiple ablations were created in 19 farm swine, with varying power and energy density, followed by endoscopy at 2 and 4 weeks to assess stricture formation. In Phase III, 3 ablations were created in 12 farm swine, with varying energy density (5, 8, 10, 12, 15, or 20 J/cm 2 ) at 350 W. Animals were euthanized at 48 hours. Histologic examination determined the percentage of epithelium removed and the ablation depth. In Phase IV, 3 patients underwent esophageal epithelial ablation before esophagectomy, creating separate lesions proximal to the tumor. Completeness of epithelial ablation and ablation depth was quantified histologically. RESULTS In Phase I, complete removal of esophageal epithelium was achieved at energy density settings of 9.7 to 29.5 J/cm 2 . In Phase II, 9.7 and 10.6 J/cm 2 produced no stricture, whereas more than 20 J/cm 2 produced a stricture in every case. In Phase III, 8-20 J/cm 2 resulted in 100% epithelial ablation. Five and 8 J/cm 2 spared the muscularis mucosae, whereas 10 J/cm 2 caused injury to the muscularis mucosae but preserved the submucosa. In Phase IV, histologic examination demonstrated full-thickness epithelial removal in areas of electrode contact. Ablation extended only to the muscularis mucosae, without injury to submucosa. CONCLUSIONS In the porcine and the human esophagus, circumferential, full-thickness ablation of epithelium without direct injury to the submucosa is possible and was well tolerated. In all cases, depth of ablation was linearly related to energy density of treatment.
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Affiliation(s)
- Robert A Ganz
- Gastroenterology, Abbott-Northwestern Hospital, Chicago Avenue and 26th Street, Minneapolis, MN 55407, USA
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25
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Pinotti AC, Cecconello I, Filho FM, Sakai P, Gama-Rodrigues JJ, Pinotti HW. Endoscopic ablation of Barrett's esophagus using argon plasma coagulation: a prospective study after fundoplication. Dis Esophagus 2004; 17:243-6. [PMID: 15361098 DOI: 10.1111/j.1442-2050.2004.00415.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The aim of the prospective clinical study presented here is to test the effectiveness of a multimode approach consisting of argon plasma coagulation combined with laparoscopic fundoplication in the management of Barrett's esophagus. Argon plasma coagulation was performed in 19 patients with Barrett's esophagus who had previously undergone surgical antireflux treatment. The mean follow-up time was 17 months, ranging between 6 and 27 months. Squamous epithelium was completely restored in all patients. In 68.4% of cases two sessions were required. The most frequent complications were chest discomfort and retrosternal pain. In 11 patients the symptoms lasted 3 days and in six cases persisted for a longer period, requiring analgesic medication. Short-term dysphagia and odynophagia were observed in four patients.
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Affiliation(s)
- A C Pinotti
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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26
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Affiliation(s)
- John J Vargo
- Department of Gastroenterology and Hepatology, The Cleveland Clinic Foundation, Ohio 44195, USA
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27
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Ackroyd R, Tam W, Schoeman M, Devitt PG, Watson DI. Prospective randomized controlled trial of argon plasma coagulation ablation vs. endoscopic surveillance of patients with Barrett's esophagus after antireflux surgery. Gastrointest Endosc 2004; 59:1-7. [PMID: 14722539 DOI: 10.1016/s0016-5107(03)02528-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Roger Ackroyd
- University of Adelaide, Department of Surgery and Gastroenterology Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia
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28
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Affiliation(s)
- Glenn M Eisen
- Department of Medicine, Oregon Health Sciences University, Portland, Oregon 97239, USA
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29
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Fennerty MB. Endoscopic ablation of Barrett's related neoplasia: what is the evidence supporting its use? Gastrointest Endosc 2003; 58:246-9. [PMID: 12872094 DOI: 10.1067/mge.2003.359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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30
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Abstract
The clinical applicability of the experimental data discussed previously remains questionable, and results of clinical studies on chemoprevention in Barrett's esophagus are needed. The utility of selectively targeting acid exposure, ODC, and COX-2 is not clear, and elucidation of that role will be facilitated by a better understanding of the contribution of these factors in the development of Barrett's cancers. The insights already gained into the basic mechanisms of acid exposure, ODC, and COX-2 in the pathogenesis of Barrett's esophagus and esophageal adenocarcinoma hold promise for the development of future therapies aimed at these molecular targets and their signaling pathways. In preclinical studies, the ability of COX-2 selective NSAIDs and DFMO to inhibit carcinogenesis is encouraging. Results of well-designed, prospective clinical studies, however, are still needed to establish the efficacy of potent acid suppression, COX-2 inhibitors, and DFMO in the prevention of this malignancy.
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Affiliation(s)
- Rhonda F Souza
- Division of Gastroenterology, Dallas VA Medical Center, Dallas, TX 75216, USA.
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31
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Affiliation(s)
- Helen Lantz
- University of Wisconsin Medical School, Milwaukee, Wisconsin, USA
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32
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Franchimont D, Van Laethem JL, Devière J. Argon plasma coagulation in Barrett's esophagus. Gastrointest Endosc Clin N Am 2003; 13:457-66. [PMID: 14629102 DOI: 10.1016/s1052-5157(03)00040-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Despite the availability of many clinical trials, there is no evidence that APC has any role in the management of Barrett's esophagus. Ablation therapy is not indicated for nondysplastic Barrett's esophagus (and this is true, whatever the technique used), and it should not be performed outside of a carefully designed and approved clinical trial. Indeed, these patients have a low risk of cancer, and there is no evidence that Barrett's esophagus ablation will be of any benefit for these patients. In some cases, APC could be of some help, especially for treating short segments of dysplastic Barrett's esophagus. In this field, however, it competes with the growing indication of mucosectomy, which clearly offers advantages in terms of treatment's quality control assessment.
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Affiliation(s)
- Denis Franchimont
- Gastroenterology Department, Hôpital Erasme-Université Libre de Bruxelles, Brussels, Belgium
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33
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Affiliation(s)
- M Jung
- Innere Abteilung, St.-Hildegardis-Krankenhaus Mainz.
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34
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Cipolletta L, Bianco MA, Rotondano G, Marmo R, Meucci C, Piscopo R. Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: preliminary results of a prospective randomized trial. Gastrointest Endosc 2002. [PMID: 12297759 DOI: 10.1016/s0016-5107(02)70428-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series. The aim of this study was to determine whether argon plasma coagulation is effective in reducing variceal recurrence after endoscopic variceal ligation. METHODS Thirty patients with cirrhosis, a history of acute esophageal variceal bleeding, and eradication of varices by endoscopic variceal ligation were randomized to argon plasma coagulation (16 patients) or observation (14 patients). The 2 groups were similar with respect to all background variables including age, Child-Pugh score, presence of gastric varices, and degree of portal hypertensive gastropathy. In the argon plasma coagulation group, the entire esophageal mucosa 4 to 5 cm proximal to the esophagogastric junction was thermocoagulated circumferentially with argon plasma coagulation in 1 to 3 sessions performed at weekly intervals. Endoscopy was performed every 3 months to check for recurrence of varices in both groups. RESULTS During the course of the study, no serious complication was noted. After argon plasma coagulation, transient fever occurred in 13 patients and 8 complained of dysphagia or retrosternal pain/discomfort. Mean follow-up for all patients was 16 months (range 9-28 months). No recurrence of varices or variceal hemorrhage was observed in the argon plasma coagulation group, whereas varices recurred in 42.8% (6/14) of the patients in the control group (p < 0.04) and bleeding recurred in 7.2% (1/14). CONCLUSIONS Argon plasma coagulation of the distal esophageal mucosa after eradication of esophageal varices by endoscopic variceal ligation is safe and effective for reducing the rate of variceal recurrence.
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Affiliation(s)
- Livio Cipolletta
- U.O. di Gastroenterologia, Asl NA5-Ospedale Maresca, Torre del Greco, Italy
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35
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Abstract
Barrett's esophagus is a prevalent, premalignant condition affecting the gastroesophageal junction and distal esophagus. Ablation plus antireflux therapy has recently been advocated to prevent the development of adenocarcinoma or to treat those unfit or unwilling to undergo esophagectomy. The present article, based on a search of Medline/ISI databases and cross-referencing of relevant articles, reviews the literature on this subject. A number of techniques have been used to remove the affected mucosa, including laser, electrocoagulation, argon plasma coagulation and photodynamic therapy but, as yet, none has been shown to be superior. Depending on the method used, ablation results in complete removal of Barrett's esophagus in approximately one third of patients and a partial response in nearly two-thirds. The resultant squamous mucosa is apparently 'normal' but may regress. To promote and maintain regeneration, antireflux therapy must be sufficient to reduce repetitive injury to the esophageal mucosa. Whether ablation reduces the cancer risk or delays its occurrence is unknown, though recent data suggests benefit. Complications are infrequent and usually mild. Regular follow-up endoscopy and deep biopsies continue to be necessary. Careful data from much larger populations with long-term follow-up is required before ablation reaches the stage of broad clinical application.
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Affiliation(s)
- S J Walker
- Blackpool Victoria Hospital NHS Trust, Blackpool, UK.
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36
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Abstract
The incidence of adenocarcinoma of the esophagus has increased dramatically over recent years. Because Barrett's epithelium is recognized as a risk factor for adenocarcinoma there is an interest in reversing this metaplasia. A number of endoscopic methods of destruction of esophageal columnar epithelium have been described. The purpose of this article is to review the currently available methods of managing Barrett's epithelium with particular reference to the role of ablative therapy in reducing the risk of adenocarcinoma.
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Affiliation(s)
- P Urosevic
- The University of Melbourne, Department of Clinical and Biomedical Sciences, The Geelong Hospital, Victoria, Australia
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37
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Shami VM, Waxman I. Endoscopic treatment of early gastroesophageal malignancy. Curr Opin Gastroenterol 2002; 18:587-94. [PMID: 17033338 DOI: 10.1097/00001574-200209000-00011] [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] [Indexed: 12/10/2022]
Abstract
With the routine use of endoscopy, gastroesophageal cancers, which were often diagnosed in the symptomatic and incurable state, are now being diagnosed at earlier stages. Treatment of early-stage upper gastrointestinal cancers has evolved tremendously. Endoscopic therapy has been employed for early-stage lesions in an attempt to avoid the high morbidity and mortality associated with current curative procedures such as esophagectomy. These new endoscopic techniques include endoscopic mucosal resection, photodynamic therapy, electrocoagulation, and laser therapy. Exciting and novel endoscopic therapeutic options in diagnosing and treating early gastroesophageal cancers are the focus of this review.
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Affiliation(s)
- Vanessa M Shami
- Section of Endoscopy and Therapeutics, University of Chicago, Chicago, Illinois 60637, USA
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39
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Norton ID, Wang L, Levine SA, Burgart LJ, Hofmeister EK, Yacavone RF, Gostout CJ, Petersen BT. In vivo characterization of colonic thermal injury caused by argon plasma coagulation. Gastrointest Endosc 2002; 55:631-6. [PMID: 11979242 DOI: 10.1067/mge.2002.123418] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Argon plasma coagulation has been rapidly accepted for endoscopic obliteration of vascular lesions and superficial tumors. Depth of injury is thought to be limited through preferential discharge of energy to nondesiccated tissue. However, argon plasma coagulation-induced injury has not been well characterized. The aim of this study was to characterize argon plasma coagulation-induced colonic injury by using a porcine model. METHODS Laparotomy was performed in 6 female swine and the colon exteriorized with the subjects under general anesthesia. Lesions were made with an argon plasma coagulation probe held perpendicular and 2 mm from the mucosa. Variables studied were as follows: power (45 W, 60 W, and 75 W) and duration (1, 2, or 3 seconds; n = 11 for each power/duration combination). Injury was graded as either superficial or deep, involving the muscularis propria. RESULTS Circular muscle layer injury correlated closely with power (p = 0.02), duration (p = 0.001), and total energy delivered (r = 0.977). Longitudinal muscle damage was associated with duration of burn (p = 0.001) and total energy delivered (r = 0.855), but correlated poorly with power (p = 0.40). No perforations occurred. Submucosal injection of saline solution had a protective effect with reductions in circular (90% to 10%, p = 0.002) and longitudinal muscle injury (50% to 0%, p = 0.1). CONCLUSIONS Injury to the muscularis propria occurs at recommended settings for argon plasma coagulation. Injury correlates with power setting, duration of burn, and total energy delivery. Protective arcing to nondesiccated tissue does not appear to be significant in vivo. Submucosal injection of saline solution protects against deep injury.
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Affiliation(s)
- Ian D Norton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota 55905, USA
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40
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Abstract
Barrett's esophagus is an acquired condition resulting from severe esophageal mucosal injury. It still remains unclear why some patients with gastroesophageal reflux disease develop Barrett's esophagus whereas others do not. The diagnosis of Barrett's esophagus is established if the squamocolumnar junction is displaced proximal to the gastroesophageal junction and if intestinal metaplasia is detected by biopsy. Despite this seemingly simple definition, diagnostic inconsistencies remain a problem, especially in distinguishing short segment Barrett's esophagus from intestinal metaplasia of the gastric cardia. Barrett's esophagus would be of little importance were it not for its well-recognized association with adenocarcinoma of the esophagus. The incidence of esophageal adenocarcinoma continues to increase and the 5-year survival rate for this cancer remains dismal. However, cancer risk for a given patient with Barrett's esophagus is lower than previously estimated. Current strategies for improved survival in patients with esophageal adenocarcinoma focus on cancer detection at an early and potentially curable stage. This can be accomplished either by screening more patients for Barrett's esophagus or with endoscopic surveillance of patients with known Barrett's esophagus. Current screening and surveillance strategies are inherently expensive and inefficient. New techniques to improve the efficiency of cancer surveillance are evolving rapidly and hold the promise to change clinical practice in the future. Treatment options include aggressive acid suppression, antireflux surgery, chemoprevention, and ablation therapy, but there is still no clear consensus on the optimal treatment for these patients.
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Affiliation(s)
- Gary W Falk
- Department of Gastroenterology, Center for Swallowing and Esophageal Disorders, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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41
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Fennerty MB. Barrett's-related esophageal cancer: has the final hurdle been cleared, now paving the way for human chemoprevention trials? Gastroenterology 2002; 122:1172-5. [PMID: 11910370 DOI: 10.1053/gast.2002.32753] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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Pacifico RJ, Wang KK. Role of mucosal ablative therapy in the treatment of the columnar-lined esophagus. CHEST SURGERY CLINICS OF NORTH AMERICA 2002; 12:185-203. [PMID: 11901929 DOI: 10.1016/s1052-3359(03)00073-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
With the high prevalence of gastroesophageal reflux-like symptoms in the United States and the association between GERD symptoms and the premalignant condition of BE, there is more and more demand for new and efficacious techniques to treat BE. A wide variety of endoscopic mucosal ablative techniques have been developed with promising initial results. Long-term control of neoplastic risk, however, has not been demonstrated, and most studies demonstrate that there is still potentially some intestinal mucosa present underneath squamous mucosa. Currently, more study is needed to determine which patient groups require therapy of any kind and to determine which therapies would be the most efficacious. Genetic markers may aid in identification of subgroups that are at risk for cancer and help to identify those who would respond to mucosal therapy. Even in patients who have HGD, subgroups of patients who have focal HGD have been found to have better prognosis than those who have more widespread HGD. Currently, there is sufficient information to consider mucosal ablative techniques in patients who are not good surgical candidates. Photodynamic therapy, APC, KTP, Nd:YAG and argon lasers, MPEC, and EMR may provide good alternatives, depending on the degree of dysplasia, the extent of disease, and the age of the patient. Photodynamic therapy and Nd:YAG laser therapy have been applied to more neoplastic lesions, whereas KTP:YAG, APC, and multipolar coagulation have been successful in nondysplastic Barrett's mucosa. In the future, there will be more information to justify the application of mucosal ablative therapy in selected patients.
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Affiliation(s)
- Rodney J Pacifico
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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43
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Weinstein WM. The prevention and treatment of dysplasia in gastroesophageal reflux disease: The results and the challenges ahead. J Gastroenterol Hepatol 2002; 17 Suppl:S113-24. [PMID: 12000598 DOI: 10.1046/j.1440-1746.17.s1.9.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Wilfred M Weinstein
- Department of Medicine, UCLA Center for the Health Sciences, 90095-1684, USA.
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44
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Abstract
Barrett's esophagus is a complication of chronic gastroesophageal reflux disease and is characterized by replacement of the normal squamous mucosa in the distal esophagus with metaplastic columnar mucosa. It is the premalignant lesion for adenocarcinoma of the distal esophagus and the esophagogastric junction. Treatment of Barrett's esophagus includes controlling the underlying reflux with either proton pump inhibitor therapy or antireflux surgery. However, neither pharmacological nor surgical treatment has resulted in reversal of the metaplastic mucosa. Failure of conventional treatments has led to endoscopic ablation therapies-injury to the Barrett's esophagus with different forms of energy in combination with acid suppression. This article reviews the current status of different therapies for endoscopic reversal of Barrett's esophagus.
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Affiliation(s)
- P Sharma
- Department of Medicine, University of Kansas School of Medicine, Kansas City, Missouri 64128, USA
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Rice TW, Blackstone EH, Goldblum JR, DeCamp MM, Murthy SC, Falk GW, Ormsby AH, Rybicki LA, Richter JE, Adelstein DJ. Superficial adenocarcinoma of the esophagus. J Thorac Cardiovasc Surg 2001; 122:1077-90. [PMID: 11726882 DOI: 10.1067/mtc.2001.113749] [Citation(s) in RCA: 114] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Experience with treatment and outcome of superficial adenocarcinoma of the esophagus is limited. The purpose of this study was to evaluate the results of surgical management and identify predictors of survival. METHODS Between September 1985 and December 1999, 122 patients underwent resection. Eighty-nine percent were men (mean age 63 +/- 10 years; range 35-83 years). Sixty (49%) patients were in endoscopic surveillance programs and 48 (39%) had the preoperative diagnosis of high-grade dysplasia. Forced expiratory volume in 1 second was less than 2 L in 12 (12%). Seventy-five (61%) patients underwent transhiatal esophagectomy. Pathologic stage was N1 in 8 (7%). Pulmonary complications necessitating reintubation (respiratory failure) occurred in 10 (8%) patients. Time-related survival models were developed for decision-making (preoperative), prognosis (operative), and hospital care (postoperative). RESULTS Operative mortality was 2.5%. Survival at 1, 5, and 10 years was 89%, 77%, and 68%. Preoperative decision-making factors associated with ideal outcome were 1-second forced expiratory volume of more than 2 L, surveillance, preoperative diagnosis of high-grade dysplasia, and planned transhiatal esophagectomy. Prognosis was decreased in younger patients and in those with N1 disease. Postoperative respiratory failure increased mortality. CONCLUSIONS Surgery is the treatment of choice for superficial adenocarcinoma of the esophagus. The ideal patient has a preoperative diagnosis of high-grade dysplasia found at surveillance, good pulmonary function, and undergoes a transhiatal esophagectomy. Discovery of N1 disease or development of postoperative respiratory failure reduces the benefits of surgery.
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Affiliation(s)
- T W Rice
- Department of Thoracic and Cardiovascular Surgery, The Center for Swallowing and Esophageal Disorders, The Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
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Campo R, Brullet E. [Endoscopic ablation of Barrett's epithelium]. GASTROENTEROLOGIA Y HEPATOLOGIA 2001; 24:403-8. [PMID: 11674961 DOI: 10.1016/s0210-5705(01)70209-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- R Campo
- Endoscopia Digestiva, UDIAT-CD, Corporació Parc Taulí, Sabadell.
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Fennerty MB, Triadafilopoulos G. Barrett's-related esophageal adenocarcinoma: is chemoprevention a potential option? Am J Gastroenterol 2001; 96:2302-5. [PMID: 11513166 DOI: 10.1111/j.1572-0241.2001.04033.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Review the rationale behind secondary prevention of Barrett's related esophageal adenocarcinoma and critically appraise the emerging literature regarding prevention of neoplasia in Barrett's esophagus with antisecretory and/or cyclo-oxygenase inhibition therapy. METHODS The existing English language literature regarding secondary cancer prevention in patients with Barrett's esophagus is reviewed and its potential clinical implications discussed. RESULTS There is biologic plausibility to pursue "chemoprevention" trials with antisecretory and/or cyclo-oxygenase inhibition therapy in patients with Barrett's esophagus. CONCLUSION Chemoprevention trials using potent antisecretory therapy coupled with cyclo-oxygenase 2 inhibition are warranted and may provide a means of decreasing the occurrence of cancer and cancer-related mortality in this disease.
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Affiliation(s)
- M B Fennerty
- Division of Gastroenterology, Oregon Health Sciences University, Portland 97201-3098, USA
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49
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Sáenz R, Silva C, Navarro A. Ablation with argon plasma coagulator (APC) for Barrett's esophagus. Am J Gastroenterol 2001; 96:1662-3. [PMID: 11374734 DOI: 10.1111/j.1572-0241.2001.03833.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Endoscopic ablative therapies for esophageal diseases have been used for palliation of inoperable esophageal cancer, but their use in eradication of early esophageal cancer and Barrett's esophagus (with and without dysplasia) has been reported in recent publications. Pharmacologic and surgical treatment of reflux symptoms in patients with Barrett's esophagus has not consistently reversed the metaplastic epithelium. This has led investigators to try different modalities of local injury to the columnar mucosa in an acid-reduced environment. Endoscopic reversal of Barrett's esophagus (visual replacement of columnar mucosa by squamous mucosa) is more readily achievable than complete histologic reversal. Preliminary data show that endoscopic reversal of Barrett's esophagus can be achieved, but intestinal metaplasia underlying the new squamous mucosa is reported in almost all series. Incidence of adenocarcinoma in patients with Barrett's without dysplasia is probably so low that endoscopic ablation as a therapy cannot be advocated outside of study protocols. Endoscopic therapy as a definitive treatment for patients with high-grade dysplasia (HGD) and/or early adenocarcinoma holds promise, especially in older patients with comorbid illnesses. Future long-term randomized studies are needed to determine whether ablative therapies can provide an alternative approach for patients with HGD and early cancer. Advanced cancers that are not resectable for cure can be effectively treated by endoscopic therapy for palliation of dysphagia.
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Affiliation(s)
- P Sharma
- University of Kansas School of Medicine, Veterans Affairs Medical Center, 4801 East Linwood Boulevard, Kansas City, MO 64128-2295, USA.
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