Endoscopic Treatment of Early Barrett's Adenocarcinoma and Dysplasia: Focus on Submucosal Cancer.

BACKGROUND/AIMS: Eradication of early Barrett's neoplasia by endoscopic resection and radiofrequency ablation is safe and effective. In T1b adenocarcinoma, standard of care remains controversial. We investigated the therapeutic outcome between high-grade dysplasia (HGD)/mucosal adenocarcinoma and submucosal adenocarcinoma in Barrett's patients. We hypothesised similar outcome in low-risk (LR) T1b compared to T1a/HGD. METHODS: Patients with endoscopically treated Barrett's esophagus were included in a Swiss tertiary center cohort study. Primary outcome parameter was complete eradication of early neoplasia. Secondary outcome parameters were recurrence-free survival and safety of endoscopic treatment. RESULTS: Forty-eight patients (1 female) with median Barrett's length C4M6 and mean age of 66 years were included. Complete endoscopic eradication of HGD/T1a was achieved in 33 out of 35 and in 11 out of 13 T1b adenocarcinoma. During a median follow-up of 41 (interquartile range 28-63) months no systemic recurrence was observed in endoscopically treated HGD/T1a and LR -T1b and one in a high-risk T1b adenocarcinoma after surgery. Local recurrences were amenable to surgical or endoscopic re-treatment. No lymphnode metastasis was detected in initial staging with esophageal endosonography/positron emission tomography-CT. CONCLUSION: Comparable endoscopic eradication and recurrence rate were observed in HGD/T1a and LR T1b adenocarcinoma. Carefully selected LR T1b cancer may receive endoscopic treatment in an expert center without any negative impact on recurrence.

The role of single-balloon colonoscopy for patients with previous incomplete standard colonoscopy: Is it worth doing it?

BACKGROUND: The rate of cecal intubation is a well-recognized quality measure of successful colonoscopy. Infrequently, the standard colonoscopy techniques fail to achieve complete examination. The role of single-balloon overtube-assisted colonoscopy (SBC) in these situations has only been sparsely studied. This prospective single-center study aimed to investigate the technical success (rate of cecal intubation) and the diagnostic gain of SBC. METHODS: The study recruited consecutive patients with previous incomplete standard colonoscopy who were admitted for SBC at our tertiary center in Eastern Switzerland between February 2008 and October 2014. The primary outcome was defined as successful cecal intubation. Data on patient characteristics, indication, technical details of procedure, and outcome were collected prospectively. The Olympus enteroscope SIF-Q180 was used. RESULTS: The study included 100 consecutive patients (median age 70 years; range 38-87 years; 54 % female) who were examined using a single-balloon overtube-assisted technique. The cecal intubation rate was 98 % (98/100). The median time of total procedure was 54 min (range 15-119 min); the median time to reach the cecal pole was 27.5 min (range 4-92 min). Passage of the sigmoid colon was not possible in two cases with a fixed, angulated sigmoid colon. The diagnostic gain was 21 % regarding adenomatous polyps in the right colon. The complication rate was 2 % (2/100, minor) without need for surgery. CONCLUSIONS: This prospective patient cohort study shows that single-balloon colonoscopy is a safe and effective procedure to achieve a complete endoscopic examination in patients with a previous failed standard colonoscopy. A significant diagnostic and therapeutic gain in the right colon justifies additional procedure time.

Multipurpose use of the over-the-scope-clip system ("Bear claw") in the gastrointestinal tract: Swiss experience in a tertiary center.

AIM: To evaluate the outcome of over-the-scope-clip system (OTSC) for endoscopic treatment of various indications in daily clinical practice in Switzerland. METHODS: This prospective, consecutive case series was conducted at a tertiary care hospital from September 2010 to January 2014. Indications for OTSC application were fistulae, anastomotic leakage, perforation, unroofed submucosal lesion for biopsy, refractory bleeding, and stent fixation in the gastrointestinal (GI) tract. Primary technical success was defined as the adequate deployment of the OTSC on the target lesion. Clinical success was defined as resolution of the problem; for instance, no requirement for surgery or further endoscopic intervention. In cases of recurrence, retreatment of a lesion with a second intervention was possible. Complications were classified into those related to sedation, endoscopy, or deployment of the clip. RESULTS: A total of 28 OTSC system applications were carried out in 21 patients [median age 64 years (range 42-85), 33% females]. The main indications were fistulae (52%), mostly after percutaneous endoscopic gastrostomy tube removal, and anastomotic leakage after GI surgery (29%). Further indications were unroofed submucosal lesions after biopsy, upper gastrointestinal bleeding, or esophageal stent fixation. The OTSC treatments were applied either in the upper (48%) or lower (52%) GI tract. The mean lesion size was 8 mm (range: 2-20 mm). Primary technical success and clinical success rates were 85% and 67%, respectively. In 53% of cases, the suction method was used without accessories (e.g., twin grasper or tissue anchor). No endoscopy-related or OTSC-related complications were observed. CONCLUSION: OTSC is a useful tool for endoscopic closure of various GI lesions, including fistulae and leakages. Future randomized prospective multicenter trials are warranted.

Routine use of Hemospray for gastrointestinal bleeding: prospective two-center experience in Switzerland.

Hemospray (Cook Medical, Winston-Salem, North Carolina, USA) is a hemostatic agent recently introduced for the management of upper gastrointestinal bleeding (GIB). To date, there is little experience with this fairly new hemostatic tool. The aim of this case series was to reflect the use and effectiveness of Hemospray as a treatment option in GIB in everyday clinical practice at two tertiary referral centers. Consecutive patients (n = 16) with active GIB of various origins were treated with Hemospray. The rate of successful initial hemostasis was 93.75 % (15 /16; salvage therapy 92.85 % [13/14]; monotherapy 100 % [2 /2]). The rebleeding rate within 7 days was 12.5 % (2/16). One patient, in whom interventional radiology also failed, had to undergo surgery as salvage therapy. The effectiveness of Hemospray in the management of GIB in various clinical situations is promising. Future multicenter randomized prospective trials for clearly defined bleeding situations are needed for greater generalizability of case series findings.