A prospective multicenter study to evaluate the impact of cryotherapy on dysphagia and quality of life in patients with inoperable esophageal cancer.

BACKGROUND: Dysphagia palliation in inoperable esophageal cancer continues to be a challenge. Self-expandable metal stents have been the mainstay of endoscopic palliation but have a significant risk of adverse events (AEs). Liquid nitrogen spray cryotherapy is an established modality that can be used with systemic therapy. This study reports the outcomes of cryotherapy, including dysphagia and quality of life (QoL), in patients receiving systemic therapy. METHODS: This was a prospective multicenter cohort study of adults with inoperable esophageal cancer who underwent cryotherapy. QoL and dysphagia scores before and after cryotherapy were compared. RESULTS: 55 patients received 175 cryotherapy procedures. After a mean of 3.2 cryotherapy sessions, mean QoL improved from 34.9 at baseline to 29.0 at last follow-up (P < 0.001) and mean dysphagia improved from 1.9 to 1.3 (P = 0.004). Patients receiving more intensive cryotherapy (≥ 2 treatments within 3 weeks) showed a significantly greater improvement in dysphagia compared with those not receiving intensive therapy (1.2 vs. 0.2 points; P = 0.003). Overall, 13 patients (23.6 %) received another intervention (1 botulinum toxin injection, 2 stent, 3 radiation, 7 dilation) for dysphagia palliation. Within the 30-day post-procedure period, there were three non-cryotherapy-related grade ≥ 3 AEs (all deaths). The median overall survival was 16.4 months. CONCLUSION: In patients with inoperable esophageal cancer receiving concurrent systemic therapy, adding liquid nitrogen spray cryotherapy was safe and associated with improvement in dysphagia and QoL without causing reflux. More intensive treatment showed a greater improvement in dysphagia and should be considered as the preferred approach.

Liquid nitrogen spray cryotherapy for dysphagia palliation in patients with inoperable esophageal cancer.

BACKGROUND AND AIMS: Dysphagia is a debilitating symptom in patients with inoperable esophageal cancer that contributes to poor quality of life and worsening nutritional status. The 2 most commonly used palliative modalities for dysphagia are radiation therapy and esophageal stent placement. However, radiation therapy is limited by adverse events (AEs) and total dose, and stent placement has a high rate of AEs, including reflux, migration, and chest pain. A relatively new modality of liquid nitrogen endoscopic spray cryotherapy has been described as salvage when other options have been exhausted and when patients are no longer receiving systemic therapy. We evaluated the safety and efficacy of cryotherapy as the primary modality for relieving dysphagia in inoperable esophageal cancer including patients receiving systemic cancer therapy. METHODS: This is a retrospective, multicenter, consecutive case series of 49 inoperable esophageal cancer patients undergoing palliative endoscopic cryotherapy at 4 specialized cancer centers from May 2014 to May 2016. The primary outcomes were change in dysphagia scores between pre- and postcryotherapy and AEs. Dysphagia was measured using a 5-point Likert scale: 0, no dysphagia; 1, dysphagia to solids; 2, dysphagia to semisolids; 3, dysphagia to liquids; 4, dysphagia to saliva. RESULTS: Thirty-nine men and 10 women with a mean age of 58 years underwent a total of 120 cryotherapy treatments. The mean dysphagia score improved significantly from 2.4 precryotherapy to 1.7 postcryotherapy (improvement of .7 points; P < .001). Minor AEs were seen in 6 of 120 (5.0%) cryotherapy treatments (1 intraprocedural and 5 postprocedural). In addition, 1 patient developed a severe intraprocedural AE of dilation-related perforation, whereas another patient developed a benign stricture requiring dilation. CONCLUSIONS: This preliminary retrospective study suggests that liquid nitrogen spray cryotherapy may be safe and effective for dysphagia palliation in inoperable esophageal cancer. Large prospective studies are needed to confirm these findings and identify patient and procedure characteristics associated with the greatest benefit.

Promising new therapies in advanced pancreatic adenocarcinomas.

Pancreatic ductal adenocarcinoma is a lethal disease due to late diagnosis, early metastasis and the lack of effective therapies. In patients with metastatic disease, 1-year survival ranges from 17 to 23% and 5-year survival is less than 5%. This necessitates an urgent need for developing more effective therapies. Targeting the neoplastic cells has been largely ineffective due to the dense stroma, which is a physical barrier for effective drug delivery and also a source for different factors that promote tumor progression and immunosuppression. In this review, we focus on understanding the complex biology of this tumor as it relates to the evaluation of previously failed molecularly targeted trials and review potential new therapies that are emerging in the treatment of metastatic pancreatic ductal adenocarcinoma.

Organ and function preservation in gastrointestinal cancer: Current and future perspectives on endoscopic ablation.

The escalating prevalence of gastrointestinal cancers underscores the urgency for transformative approaches. Current treatment costs amount to billions of dollars annually, combined with the risks and comorbidities associated with invasive surgery. This highlights the importance of less invasive alternatives with organ preservation being a central aspect of the treatment paradigm. The current standard of care typically involves neoadjuvant systemic therapy followed by surgical resection. There is a growing interest in organ preservation approaches by way of minimizing extensive surgical resections. Endoscopic ablation has proven to be useful in precursor lesions, as well as in palliative cases of unresectable disease. More recently, there has been an increase in reports on the utility of adjunct endoscopic ablative techniques for downstaging disease as well as contributing to non-surgical complete clinical response. This expansive field within endoscopic oncology holds great potential for advancing patient care. By addressing challenges, fostering collaboration, and embracing technological advancements, the gastrointestinal cancer treatment paradigm can shift towards a more sustainable and patient-centric future emphasizing organ and function preservation. This editorial examines the evolving landscape of endoscopic ablation strategies, emphasizing their potential to improve patient outcomes. We briefly review current applications of endoscopic ablation in the esophagus, stomach, duodenum, pancreas, bile ducts, and colon.

Optimal Management of Dysphagia in Patients with Inoperable Esophageal Cancer: Current Perspectives.

The majority of patients with esophageal cancer are diagnosed at an advanced, incurable stage. Palliation of symptoms, specifically dysphagia, is a crucial component to improve quality of life and optimize nutritional status. Despite multiple available treatment modalities, there is not one accepted or recommended to be the preferred treatment option. Palliative management is often decided by a multidisciplinary team considering factors including local availability, preference, patient life expectancy, and symptom severity. Systemic therapies such as chemotherapy are the most commonly used palliative modalities. Oncologists are most familiar with radiation for dysphagia palliation, especially for advanced metastatic cancer patients with good performance status. One common approach used by endoscopist is self-expandable metal stents. This is preferred for patients with short-term survival and poor functional status as it provides rapid relief of dysphagia. Cryotherapy is a relatively new endoscopic ablative modality and appears to be a promising option for dysphagia palliation, but more data is needed for wider adoption. This review summarizes the current literature on endoscopic and non-endoscopic treatment options for malignant dysphagia.

Diet and cognition in chronic liver disease.

PURPOSE OF REVIEW: The spectrum of neurocognitive impairment in cirrhosis spans a continuum of minimal hepatic encephalopathy (MHE) to overt hepatic encephalopathy (OHE), the pathophysiology of which remains incompletely understood. The current available evidence, however, suggests that nutrition plays an important role in its development and points to the fact that malnutrition increases the morbidity and mortality of patients with cirrhosis. This review incorporates recent findings published in the last 2 years within the evolution of evidence regarding the role dietary manipulation can play in the comprehensive management of patients with cirrhosis and cognitive dysfunction. RECENT FINDINGS: In patients with cirrhosis it is important to prevent starvation physiology which occurs after few hours of caloric deprivation as compared to 3 days in noncirrhotics. This can be accomplished by making sure that cirrhotic patients have daily breakfast and a late evening snack. In addition, probiotics and symbiotics are well tolerated and improve cognitive function in patients with MHE. SUMMARY: The long-time held belief that protein restriction is needed to improve encephalopathy has no scientific basis but remains widely practiced. Branched-chain amino acids supplement may be helpful in patients who continue to suffer from OHE despite treatment of precipitating events and pharmacologic treatment with lactulose and rifaximin. Preventing starvation physiology and supplementing the diet with prebiotics and symbiotics are helpful in patients with MHE.

Isolated Colonic Metastasis From Esophageal Adenocarcinoma.

Esophageal cancer is an aggressive and highly lethal malignancy that has a high death-to-incidence ratio approaching 0.90. We present a 60-year-old man with a history of Barrett's esophagus, presented with dysphagia. An upper endoscopy with biopsy confirmed invasive esophageal adenocarcinoma (EAC). Workup, including positron emission tomography scan, showed no evidence of metastasis. A preoperative colonoscopy showed a nodule in the ascending colon that was proven later to be a metastatic lesion from the esophageal primary tumor. Esophageal adenocarcinoma with an isolated colonic metastasis is an extremely rare presentation of esophageal metastasis. These metastatic lesions may not be detected by the positron emission tomography scan.

Management of malignant biliary diseases by the use of peroral and percutaneous cholangioscopy.

BACKGROUND AND AIMS: The single-operator digital cholangioscope has allowed visual access to the biliary tree and the ability to perform selective biopsies. This has significantly improved our diagnostic yield in bile-duct disorders. Cholangioscopy requires specialized equipment and expertise. It is especially challenging in altered anatomy for various reasons, including difficulty in accessing the biliary tree, difficulty in maintaining endoscope position, and difficulty in using ERCP specialized tools. In addition, the use of cholangioscopy in interventional procedures has been very limited. In this video, we demonstrate some of the diagnostic and therapeutic uses of percutaneous cholangioscopy in patients with altered anatomy of the biliary tree. METHODS: Percutaneous cholangioscopy was performed in 3 different procedures in 2 patients with altered anatomy of the biliary tree. The first was for the diagnosis of a distally located malignant biliary stricture, the second was for management of hemobilia, and the third was for biliary stent placement. RESULTS: Technical and clinical success was achieved in all 3 situations. There were no procedure-related adverse events. CONCLUSION: The use of percutaneous cholangioscopy in altered anatomy for diagnostic and therapeutic uses is safe and effective and may prove very useful in selected unusual conditions.

Endoscopic management of colovaginal fistulas in advanced cancer patients.

BACKGROUND AND AIMS: Colovaginal fistula (CVF) in cancer patients can cause significant morbidity. In addition to causing local symptoms and infections, the constant stool leakage contributes to a poor quality of life, psychological distress, and possible social isolation. Patients with CVFs often have advanced disease, poor nutrition, and complex anatomy, making them poor candidates for major surgical interventions. Advancement in endoscopic tools has made endoscopic management possible. Endoscopic management is less invasive, is associated with prompt recovery, and can significantly improve the quality of life of patients and possibly allow them to resume systemic therapy. METHODS: In this video case series, 3 cases of CVF patients treated endoscopically are presented to demonstrate the use of the currently available tools and techniques. The strategy used for the closure of the 3 CVFs was dependent on the size and etiology of the fistulas. RESULTS: Technical and clinical success was achieved in all 3 situations. There were no procedure-related adverse events. CONCLUSION: These cases demonstrate the use of the cap to perform vaginal endoscopy; the use of the over-the-scope clips, covered stents, and endoscopic suturing; and how they can facilitate the closure of fistulas in patients who are poor surgical candidates.

Safety of endoscopy in cancer patients on antiangiogenic agents: A retrospective multicenter outcomes study.

BACKGROUND/AIMS: The use of antiangiogenic agents (AAs) in cancer treatment has increased because they offer survival benefit in combination with cytotoxic chemotherapy. Given their potential to cause gastrointestinal (GI) perforation and bleeding, it is currently recommended that AAs be held for 28 days before and after surgery. However, there are no specific guidelines which address their use around endoscopic procedures because data regarding the safety of endoscopy in cancer patients while on AAs is scarce despite the fact that these patients often require endoscopy. This study investigated the safety of endoscopy in cancer patients receiving AAs. METHODS: This is a retrospective multicenter study of a consecutive case series of 445 cancer patients undergoing endoscopy within 31 days of administration of AAs at 5 specialized cancer centers between April 2008 and August 2014. Endoscopies were classified into two different categories based on the risk of GI bleeding and perforation: low and high. The primary outcome measures were procedure-related adverse events (AEs) and death within 30 days of endoscopy. The severity of AEs was classified according to the common terminology criteria for adverse events (CTCAE) version 4.0. The incidence of AEs and mortality was calculated using the total number of patients as the denominator. RESULTS: 445 cancer patients with a mean age of 54 years underwent a total of 545 endoscopies. Median time duration from AAs to endoscopy was 11 days. Of 545 endoscopic procedures, 398 (73%) were low-risk and 147 (27%) were high-risk. There were 3 procedure-related AEs: esophageal perforation (grade 3) two days after an EGD, pancreatitis (grade 5) a day after failed ERCP, and bleeding from the gastrostomy site (grade 1) two days after an EGD. Of 445 patients, 29 (6.5%) died within 30 days of the procedure with no deaths deemed procedure-related. The most common causes of death were terminal cancer (n = 10), hepatic decompensation (n = 5) and sepsis (n = 4). CONCLUSION: In this retrospective study, the rate of endoscopy-related AEs in patients on AAs appears to be low when performed in specialized cancer centers. However, future prospective studies are needed to confirm this finding.

A retrospective matched cohort study evaluating the effects of percutaneous endoscopic gastrostomy feeding tubes on nutritional status and survival in patients with advanced gastroesophageal malignancies undergoing systemic anti-cancer therapy.

BACKGROUND: Many patients with cancer or other systemic illnesses can experience malnutrition. One way to mitigate malnutrition is by insertion of a percutaneous endoscopic gastrostomy feeding tube (PEG tube). The goal of this retrospective matched cohort study is to evaluate if PEG tube placement improved nutritional status and overall survival (OS) in advanced gastroesophageal (GE) cancer patients who are undergoing anti-neoplastic therapy. METHODS: GE cancer patients who were treated and evaluated by a nutritionist and had at least 2 nutritionist follow-up visits were identified. Patients with PEG tube were matched to patients that did not undergo PEG placement (non-PEG). Clinical characteristics, GE symptoms reported at nutrition follow-up visits, and OS were recorded. RESULTS: 20 PEG and 18 non-PEG cases met criteria for further analyses. After correction for multiple testing, there were no OS differences between PEG and non-PEG, treatment naive and previously treated. However, PEG esophageal carcinoma has statistically significant inferior OS compared with non-PEG esophageal carcinoma. PEG placement did not significantly reduce the proportion of patients with weight loss between the initial nutrition assessment and 12-week follow-up. CONCLUSIONS: In this small study, PEG placement had inferior OS outcome for GE esophageal carcinoma, no improvement in OS for other evaluated groups, and did not reduce weight loss between baseline and 12-week follow-up. Unless there is prospective randomized trial that can show superiority of PEG placement in this population, PEG placement in this group cannot be endorsed.