Endoscopic Resection Of Visible Lesions Research Articles

Update on Endoscopic Dysplasia Surveillance in IBD.

As medical management of inflammatory bowel disease (IBD) makes great advances, most patients with IBD will have long life expectancies without need for total colectomy. With prolonged disease duration, however, there is increased risk of dysplasia leading to colorectal cancer (CRC). Multiple consensus and guideline documents have been published over the last decade with recommendations to optimize early detection and management of dysplastic lesions. Endoscopic technology has improved tremendously, even over the last few years. Previously invisible dysplasia has become visible in most cases with advanced imaging technologies that now allow for much clearer and more detailed mucosal inspection. New tools to facilitate endoscopic resection of visible lesions has also enabled patients to avoid colectomy, with resulting need to continue colon surveillance. There are limited or conflicting data leading to inconsistent recommendations regarding the need for random biopsies, the preferred endoscopic imaging technique and surveillance intervals after resection of dysplasia. Similarly, there remains significant variability in the application of guidelines into daily practice and availability of and training with advanced imaging technologies. Here, we present a narrative review of which patients are at highest risk for dysplasia, the current guidelines on surveillance colonoscopy, factors affecting optimal mucosal visualization, enhanced imaging techniques, standardized reporting terminologies for surveillance colonoscopy, endoscopic management of dysplasia, indications for colectomy, and briefly on future potential technologies to assist in dysplasia detection.

Meta-Analysis for Comparison between Antireflux Surgery With or Without Endoscopic Management of Barrett's Esophagus

Abstract Background: In patients with BE, anti-reflux surgery aims to sustainable control reflux symptoms and heal reflux induced esophageal mucosal inflammation and prevent progression of BE to adenocarcinoma. Endoscopic resection of visible lesions if any, followed by ablation of the rest of the BE epithelium is the current standard of care for management of BE with confirmed dysplasia. Although the current literature describes multiple endoscopic and anti-reflux techniques for the management of BE, there is no published evidence on the efficacy of anti-reflux surgery followed by endoscopic man-agement on the outcomes of BE. Aim of Study: The objective of this study was to compare between anti-reflux surgery with or without endoscopic man-agement of BE. Patients and Methods: In the present study, we searched Medline via PubMed, SCOPUS, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and Google Scholar. The search retrieved 2089 unique records. We then retained 57 potentially eligible records for full-texts screening. Finally, 6 studies were included. Results: In the present systematic review and meta-analysis, five studies reported the rates of recurrence. The overall effect estimates showed the rate of recurrence was 5.7% (95% CI 1.2-10.2%). In the present systematic review and meta-analysis, five studies reported the overall complica-tions rate. The overall effect estimates showed the overall complications rate was 7.3% (95% CI 4.1-10.6%), mainly stricture and perforation. Conclusion: Endoscopic procedures after anti-reflux surgery is a safe modality, with high rate of success in complete eradication of BE in symptomatic GERD patients, especially those with severe anatomical impairment in distal esophageal segment. As a concurrent procedure, endoscopic procedures may be beneficial in the terms of reducing the early recurrence rates, which seems to be important issue during the manage-ment of BE. By doing synchronous endoscopic procedures and fundoplication, one might observe a true anatomy of esophagogastric junction in its entirety and might be able to truly observe the distal extent of columnar esophagus.

Long-term outcomes after endoscopic treatment for Barrett’s neoplasia with radiofrequency ablation ± endoscopic resection: results from the national Dutch database in a 10-year period

ObjectiveRadiofrequency ablation (RFA)±endoscopic resection (ER) is the preferred treatment for early neoplasia in Barrett’s oesophagus (BE). We aimed to report short-term and long-term outcomes for all 1384 patients treated in...

Goals of endoscopic eradication therapy in Barrett’s esophagus: a narrative review

: Barrett’s esophagus is a premalignant condition, and endoscopic eradication therapy is indicated upon development of early neoplasia. Therapy consists of endoscopic resection for visible lesions, if present, followed by endoscopic ablation for remaining flat Barrett’s epithelium. Since Barrett’s esophagus with early neoplasia in itself is asymptomatic disease, the ultimate goal of endoscopic eradication therapy is to prevent progression to advanced cancer: a disease stage with limited treatment options and a poor prognosis. The preventive nature of endoscopic treatment may give rise to debate about the preferred endpoint to pursue. Establishment of a careful balance between the benefits of endoscopic eradication therapy against its risks, such as complications and other adverse events, may help to define the optimum endpoint for each individual patient. To date, various endpoints have been used in regular practice and different endpoints are used in clinical studies. The most important differences between these endpoints are whether all visible Barrett’s epithelium is eradicated or all dysplasia and cancer; and whether the endpoint is assessed on endoscopic examination only or with histologic confirmation. In this narrative review, we aim to evaluate these different endpoints of endoscopic eradication therapy with potential advantages and limitations, and present three clinical vignettes each with a different suggestion for an appropriate treatment endpoint.

Single-Step Treatment with Limited Endoscopic Resection and Cryoballoon Ablation Is Feasible and Safe in an Esophageal Porcine Model.

Treatment of Barrett's neoplasia consists of two steps: endoscopic resection of visible lesions with subsequent ablation of remaining Barrett's epithelium. However, extensive resection might hamper subsequent ablation due to stenosis. Combining both modalities in one session therefore offers potential advantages. Single-step treatment with radiofrequency ablation and resection appeared to be unsafe. To evaluate feasibility and safety of single-step treatment with cryoballoon ablation and endoscopic resection. Two single-step treatment regimens (15 treatment areas per regimen) were evaluated: (1) CRYO-EMR: four side-by-side focal ablations of 10seconds followed by resection in the treated area; (2) EMR-CRYO: resection followed by 10-s ablation targeted on the resection wound. Primary outcome for both regimens was safety (perforations, clinically relevant strictures) and for CRYO-EMR also feasibility of resection and histopathological evaluation. Secondly, all CRYO-EMR and esophageal resection specimens were histopathologically evaluated. Six female pigs were treated (five treatment areas per animal). During 28days of follow-up, no perforations or clinically relevant stenosis occurred. All resections were technically successful. For all CRYO-EMR specimens, histopathological evaluation was feasible with ablation effects present throughout all layers, while the architecture requisite for histopathological analysis remained intact. After 28days, histopathological evaluation of the esophagi was performed. For EMR-CRYO, post-treatment fibrosis was present throughout the submucosa. The muscularis propria was the deepest layer involved for CRYO-EMR. Single-step treatment with limited endoscopic resection and cryoballoon ablation is feasible and safe in a porcine model and justifies further evaluation in a clinical trial.

935 Salvage Hybrid APC After Failed Radiofrequency Ablation and Cryotherapy for Barrett’s Esophagus

INTRODUCTION: The frequency of Barrett’s esophagus (BE) has increased by a factor of more than 7 during the past four decades in the United States. It has been estimated that 5.6 percent of adults in the United States have Barrett's esophagus, although the large majority of cases go unrecognized. Endoscopic resection of visible lesions, followed by ablation of the rest of the BE epithelium is the current standard of care for management of BE with confirmed dysplasia and IMC. Today, the most readily use treatment for Barret’s esophagus is RFA and APC. None of the current methods are able to guarantee a complete ablation success of 100 %. Cryotherapy has become a salvage technique for patient that have failed RFA. There is limited data available to determine the efficacy and safety of this technique. For patients who failed RFA and Cryotherapy, there are limited options available. The aim of this study is to assess the efficacy and safety of hybrid APC in patients with BE dysplasia who failed RFA and cryotherapy.Hybrid APC can be an effective alternative adjunctive salvage tool to RFA and cryotherapy for patients in whom both of these techniques have failed. METHODS: This is a single center, retrospective cohort study at a tertiary medical center between 2010 and 2019 in patients with BE low-grade dysplasia (LGD) and high grade dysplasia (HGD) who failed RFA and cryotherapy treatment. Six patients with an average age of 63, and five out of six are males (84%) and five have persistent LGD (84%). Response was determined by complete eradication (CE). Six patients with persistent dysplasia and with incomplete response to RFA and cryotherapy were offered hybrid APC. The primary endpoint was CE after hybrid APC. RESULTS: A total of 6 patients underwent RFA and Cryotherapy for BE dysplasia. After an average of 4.5 RFA sessions and 2.7 Cryotherapy session none of the patient were able to reach CE. 5 patients with BE with LGD and 1 with HGD were offered H-APC after failure of reaching CE (average of 2.3 H-APC treatment). CE was reached in 100% of the patients who underwent H-APC. 6 months endoscopic surveillance has not shown any recurrence of BE or dysplasia. CONCLUSION: Patient with refractory dysplasia or recurrent dysplasia after failed eradication of salvage cryotherapy and radiofrequency ablation were offered hybrid APC. The data demonstrate a complete eradication in those patients who failed treatment with RFA and cryotherapy. Furthermore, there were no alternative outcome reported as of to date.

Tu1124 - Risk Factors for Bleeding During Endoscopic Resection for Visible Lesions in Barrett's Esophagus

Introduction Endoscopic resection (ER) is the preferred initial treatment for early cancer and dyplasia with visible lesions arising in Barrett’s oesophagus (BE). An intra-procedural bleeding risk of 10% is typically quoted, with most controlled by endoscopic intervention. There is little data on risk factors for bleeding during oesophageal piecemeal ER. Studies on colonic polypectomy have shown older age and the presence of depressed lesions are associated with increased bleeding risk. Previous studies on gastric ESD have shown lesion size was the main risk factor. We sought to identify variables associated with an increased risk of bleeding. Methods Data were collected retrospectively for patients who had undergone ER for BE at a tertiary endotherapy centre between November 2012 – October 2017. Age, anticoagulant use, Paris classification of the lesion, number of ER specimens resected, and histology of the resected tissue were recorded. From 2015 an e-noting system was used to collect blood pressure readings pre, during and post procedure, and the highest mean arterial pressure (MAP) was calculated. Bleeding was classified as mild (controlled by snare tip), moderate (controlled by coagulation graspers/clips), or severe (necessitating admission). Patients who had a moderate or severe bleed were grouped for comparison. Results A total of 212 EMR procedures were performed in the study period. 144 were used for analysis as blood pressure recordings were available. Mean age was 71, and 76.4% were male. 28 patients bled during the procedure (19.4%), of which two had a bleed requiring admission (1.4%). There was no difference between the MAP in patients who bled during the procedure and those who did not. The mean number of ER specimens resected in total was 2.7 (range 1–12), with a greater number of resections in patients who suffered a moderate-severe bleed (3.4 vs 2.6, p=0.034). Both depressed lesions (Paris III) and pedunculated lesions (Paris Ip) conferred an increased risk of bleeding (p=0.002 and 0.011 respectively). Oesophageal cancers with a stage greater than T1b were associated with an increased bleeding risk (p=0.004). Conclusions In this study, bleeding risk was associated with the area of the ER, with a greater risk when more ER specimens were resected. Paris type Ip and III lesions conferred an increased risk of bleeding, as did resection of an oesophageal cancer with a stage greater than T1b. This may reflect increased angiogenesis associated with lymphovascular invasion. Age, sex, anticoagulant use and intra-procedural MAP made no difference to the risk of bleeding. Importantly all bleeds were controlled by endoscopic measures and mortality was zero. In Conclusion, in patients where a wide field ER is anticipated, caution with regards to bleeding and appropriate planning for cessation of haemorrhage with endoscopic techniques should be exercised.

Detection of lesions in dysplastic Barrett's esophagus by community and expert endoscopists.

Background and aims Endoscopic treatment of Barrett's esophagus (BE) consists of endoscopic resection of visible lesions followed by radiofrequency ablation (RFA) for any remaining flat BE. Because RFA is only justified in flat BE, detection of neoplastic lesions (high grade dysplasia [HGD] and early adenocarcinoma [EAC]) is crucial. We hypothesized that the detection of visible lesions containing HGD or EAC would be superior in BE expert centers compared with community hospitals, thereby supporting centralization of therapy for BE-related neoplasia. Methods Patients referred with histologically proven HGD or EAC to two Dutch BE expert centers were included. Referral letters, and endoscopy and pathology reports were reviewed for the description of the BE, presence of lesions, and histopathological analysis of target and random tissue sampling. Primary outcome was the endoscopic detection rate of lesions containing histopathologically proven neoplasia (HGD and/or EAC) in community and expert centers. Results There were 198 patients referred from 37 community hospitals (median referral time 55 days [interquartile range 33 - 85]). Detection rates for visible lesions were 60 % in community centers (75 % in patients with a biopsy diagnosis of EAC, 47 % in HGD) and 87 % in expert centers (98 % in EAC, 75 % in HGD); P < 0.001. Even with HGD/EAC on random biopsies from the index endoscopy, the yield at repeat endoscopy was < 50 % in community hospitals. In 79 patients referred solely because of random biopsy results, a lesion requiring endoscopic resection or surgery was found in 76 % by the expert endoscopists. Conclusions Endoscopists at community hospitals detect neoplastic lesions at a significantly lower rate. These data support the value of BE expert centers for work-up and further treatment of BE.

Single-session endoscopic resection and focal radiofrequency ablation for short-segment Barrett’s esophagus with early neoplasia

The management of early neoplasia in Barrett's esophagus (BE) requires endoscopic resection of visible lesions, followed by radiofrequency ablation (RFA) of the remaining BE. We evaluated the safety and efficacy of combining endoscopic resection and focal RFA in a single endoscopic session in patients with early BE neoplasia. This was a retrospective analysis of patients with early BE neoplasia and a visible lesion undergoing combined endoscopic resection and focal RFA in a single session. Consecutive ablation procedures were performed every 8 to 12 weeks until complete endoscopic and histologic eradication of dysplasia and intestinal metaplasia were reached. Forty patients were enrolled, with a median C1M2 BE segment, a visible lesion with a median diameter of 15mm, and invasive carcinoma in 68% of cases. Endoscopic resection was performed by using the multiband mucosectomy technique in 80% of cases, and the Barrx(90) catheter (Barrx Medical, Sunnyvale, Calif) was used for focal ablation. When an intention-to-treat analysis was used, both complete remission of all neoplasia and intestinal metaplasia were 95% after a median follow-up of 19 months. Stenoses occurred in 33% of cases and were successfully managed with a median number of 2 dilations. In 43% of patients, 1 single-session treatment resulted in complete histologic remission of intestinal metaplasia. Combining endoscopic resection and focal RFA in a single session appears to be effective. Less-aggressive RFA regimens could limit the adverse event rates.

Good Results with Ablation of Barrett Esophagus with Low-Grade Dysplasia

For high-grade dysplasia and intramucosal esophageal adenocarcinoma (EAC), endoscopic resection of visible lesions followed by radiofrequency ablation

Radiofrequency ablation and endoscopic resection in a single session for Barrett’s esophagus containing early neoplasia: a feasibility study

Endoscopic resection with radiofrequency ablation (RFA) 6 weeks later safely and effectively eradicates Barrett's esophagus with high grade dysplasia (HGD) and early cancer. After widespread endoscopic resection, related scarring may hamper balloon-based circumferential RFA (c-RFA). However c-RFA immediately followed by endoscopic resection in the same session might avoid the impact of scarring and reduce laceration and stenosis risk. We aimed to assess the feasibility of such an approach. Patients with Barrett's esophagus ≥ 3 cm and ≥ 1 visible lesion (HGD/early cancer) were included. Visible lesions were marked with cautery, and c-RFA (12 J/cm2) was delivered using two applications and a cleaning step, followed by resection of the delineated area. Outcome measures were surface regression of Barrett's esophagus at 3 months, need for subsequent c-RFA, complications, and quality of resection specimens. 24 patients (20 men, 4 women; mean age 68 years, standard deviation [SD] 12; Barrett's esophagus median length C6M8) underwent single-session c-RFA + endoscopic resection, providing a median of 4 (interquartile range [IQR] 2 - 6) resection specimens (early cancer 18 patients; HGD 6). Complications included 1 perforation, 4 bleedings, and 5 stenoses; all were managed endoscopically. Specimens allowed assessment of neoplasia depth, differentiation, and lymphatic/vascular invasion. Median Barrett's esophagus surface regression at 3 months was 95 %. No patient required a second c-RFA procedure and 40 % required repeat endoscopic resection for visible lesions. Complete response for neoplasia was achieved in 100 % and complete response for intestinal metaplasia (CR-IM) in 95 %. c-RFA followed by endoscopic resection in the same session is feasible, but technically demanding and associated with a substantial rate of complications and repeat endoscopic resection. This approach should be reserved for selected cases in expert centers, with endoscopic resection and RFA 6 - 8 weeks later remaining the standard combined approach.

Endoscopic management of Barrett esophagus

Endoscopy has a vital role in the diagnosis, screening, surveillance and treatment of Barrett esophagus. Over the past few decades, tremendous advances have been made in endoscopic technology, and the management of dysplasia and early cancer in Barrett esophagus has changed radically from being surgical to organ-sparing endoscopic therapy. Proper endoscopic techniques and systematic biopsy protocols improve dysplasia detection, and endoscopic surveillance improves outcomes in patients with Barrett esophagus and dysplasia. Endoscopic treatment can be tissue acquiring (as in endoscopic mucosal resection and endoscopic submucosal dissection) or ablative (as with photodynamic therapy, radiofrequency ablation and cryotherapy). Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective. Shared decision-making between the patient and physician is important while considering treatment for dysplasia in Barrett esophagus. Issues such as durability of response, importance of subsquamous Barrett epithelium and the optimal management strategy in patients with low-grade dysplasia and nondysplastic Barrett esophagus need to be studied further. Development of safer wide-field resection techniques, which would effectively remove all Barrett esophagus and obviate the need for long-term surveillance, is needed.

Efficacy of Radiofrequency Ablation Combined With Endoscopic Resection for Barrett's Esophagus With Early Neoplasia

Radiofrequency ablation (RFA) is safe and effective for eradicating intestinal metaplasia and neoplasia in patients with Barrett's esophagus. We sought to assess the safety and efficacy of RFA in conjunction with baseline endoscopic resection for high-grade intraepithelial neoplasia (HGIN) and early cancer. This multicenter, prospective cohort study included 24 patients (mean age, 65 years; median Barrett's esophagus, 8 cm), with Barrett's esophagus of < or =12 cm containing HGIN or early cancer, from 3 European tertiary-care medical centers. Visible lesions were endoscopically resected, followed by serial RFA. Focal escape endoscopic resection was used if Barrett tissue persisted despite RFA. Complete response, defined as all biopsies negative for intestinal metaplasia and neoplasia, was assessed during endoscopy with 4-quadrant biopsies taken every 1 cm of the original Barrett's segment 2 months after the patient was last treated. Twenty-three patients underwent pre-RFA endoscopic resection for visible lesions; 16 patients had early cancer and 7 patients had HGIN. The worst residual histology results, pre-RFA (after any endoscopic resection) were: HGIN (10 patients), low-grade intraepithelial neoplasia (11 patients), and intestinal metaplasia (3 patients). Neoplasia and intestinal metaplasia were eradicated in 95% and 88% of patients, respectively; after escape endoscopic resection in 2 patients, rates improved to 100% and 96%, respectively. Complications after RFA included melena (n = 1) and dysphagia (n = 1). After additional follow-up (median, 22 months; interquartile range, 17.2-23.8 months) no neoplasia recurred. This European multicenter study to show that early neoplasia in Barrett's esophagus can be effectively and safely treated with RFA, in combination with prior endoscopic resection of visible lesions.