Endoscopic Ablation of Intraepithelial Neoplasia in Barrett's Patients

Abstract

Endoscopic Ablation of Intraepithelial Neoplasia in Barrett’s Patients Jelle Haringsma, Ilona Kerkhof, Jan Werner-Poley, Peter Siersema, Huug Tilanus, Ernst Kuipers Background: There is no generally accepted strategy for patients with intraepithelial neoplasia (IEN) in Barrett’s esophagus (BE). Esophagectomy is considered standard therapy for advanced cancer, and in many centers also for IEN. Surgical resection, however, carries considerable mortality and morbidity. Endoscopic ablation is developed as a minimally invasive organ-preserving therapy for IEN. There are limited data on outcome of such a strategy. We therefore aimed to determine the results of endoscopic ablation in patients referred for superficial neoplasia in BE. Methods: Prospective cohort study of all subjects with IEN referred to our tertiary center. 35 patients underwent endoscopic Mucosal Resection (EMR) of suspected BE lesions with a capped technique. In patients with high-grade neoplasia (Vienna class 4) endoscopic ablation was subsequently completed with Photodynamic Therapy (PDT) using 5-aminolevulinic acid 40 mg/kg at 633 nm 100J/ cm. Endoscopic biopsies were taken at 6 weeks, 3 mo and subsequently every 6 mo after PDT. Results: 56 patients (mean age 66 yrs, range 42-85) referred for superficial neoplasia in BE were evaluated. 7 patients with only low-grade IEN were followed. Primary surgical resection was performed in 10 of 49 patients based on endoscopic criteria, histological differentiation, and patient’s preference. 39 patients (80%) consented and were considered suitable for endoscopic ablation. Due to submucosal infiltration, poor differentiation and angio-invasion in the EMR specimen at histology, 5 were treated surgically, 4 were followed and 4 were treated otherwise. Endoscopic ablation was completed in 26. Of the latter group 21 patients had a sustained remission of severe neoplasia, 3 were subsequently treated surgically, 2 were followed. After a mean follow-up of 22 months, a total of 18/56 patients (32%) were operated upon. In 3 patients who had undergone EMR, no invasive cancer was found in the resection specimen. Operative mortality was 1/18 (5,5%). Three other patients died post-surgically: 1 from tumor recurrence, 2 from unrelated causes. Of 26 patients treated endoscopically, remission was sustained in 21 patients (81%). No major complications occurred. Conclusions: Endoscopic ablation can replace primary surgery in well-selected patients with severe intraepithelial neoplasia. Endoscopic ablation using EMR and PDT is safe and effective. Selection and endoscopic treatment of neoplasia in Barrett’s should be performed in expert centers. 495 A Randomized, Prospective Trial of Electrosurgical Incision Followed by Rabeprazole Versus Bougie Dilation Followed by Rabeprazole of Symptomatic Esophageal (Schatzki’s) Rings Jason C. Wills, Kristen Hilden, James DiSario, John C. Fang Background: Lower esophageal (Schatzki’s) rings are a common cause of solid food dysphagia. Standard treatment involves passage of a single large bougie to disrupt the ring but symptoms recur in the majority of patients. Electrosurgical incision of the ring may provide a longer duration of symptom improvement as suggested in a retrospective trial. Acid suppression has been shown to decrease the recurrence rate of peptic strictures but there is no data on the treatment of Schatzki’s rings. Aim: To compare the efficacy of bougie dilation to electrosurgical incision of symptomatic Schatzki’s rings at one year follow up in the presence of rabeprazole treatment. Methods: Forty-nine consecutive patients referred for endoscopic evaluation of dysphagia were randomized prior to EGD to Bougie dilation using a 52-54 French Maloney dilator or electrosurgical incision using a standard needle knife papillotome with 3-4 longitudinal incisions placed radially around the Schatzki’s ring. All patients completed validated GERD and dysphagia questionnaires at 0, 1, 3, 6, 9, and 12 months. All patients were placed on rabeprazole (20 mg/day) for the duration of the study. Analysis was made using Wilcoxon rank-sum (Mann-Whitney U) non-parametric test for independent samples (dysphagia score) and independent samples t-test (GERD scores and pH results). Results: Twenty-five patients underwent bougie dilation and 24 underwent electrosurgical incision. All patients had been followed for at least six months and an interim analysis was performed. There was one episode of bleeding in the incision group controlled with epinephrine injection. Dysphagia scores at 12 months decreased significantly in the incision group (median 5 / 0) compared with bougie group (median 7 / 3) (p Z 0.269). Both groups had significant improvement in GERD scores at 9 and 12 (p! 0.05). There was no difference in GERD improvement between the two groups at 12 (p Z 0.927). Conclusion: Electrosurgical incision of lower esophageal (Schatzki’s) rings is safe and offers similar improvement in dysphagia scores. Electrosurgical incision may offer more definitive relief of dysphagia (5/0) than bougie dilation (7/3) and require less frequent future interventions. Further follow up is needed. The addition of rabeprazole offered significant improvement in GERD scores in both groups.