Endoscopic laser ablation of nondysplastic Barrett's epithelium: is it worthwhile?

The clinical value of endoscopic ablation of nondysplastic Barrett's epithelium is controversial. It has been stated that ablation, combined with acid suppression or antireflux surgery, may reduce the risk of adenocarcinoma, thereby obviating the need for endoscopic surveillance in these patients. Eighteen symptomatic patients were enrolled in a prospective study of Nd:YAG laser ablation of Barrett's esophagus followed by treatment with proton pump inhibitors or antireflux surgery. All patients had intestinal metaplasia and no associated dysplasia or carcinoma. Laser treatment was performed with noncontact fibers and a power output of 60 watts. The mean number of treatment sessions was three (range 1 to 5), and the mean energy delivered during each session was 2800 joules (range 600 to 4800 joules). All patients were given a standard dose of omeprazole (40 mg/day) throughout the study period. In two patients a mild distal esophageal stricture occurred and required a single dilatation. Macroscopic and histologic eradication of the specialized columnar epithelium was documented in 8 of 12 patients with tongues of Barrett's metaplasia, in one of four patients with circumferential Barrett's metaplasia, and in two of two patients with short-segment Barrett's esophagus. In five patients (28%) only a partial ablation could be achieved despite repeated laser treatment. Two patients (11%), one with tongues and the other with circumferential Barrett's metaplasia, were considered nonresponders. Adenocarcinoma undermining regenerated squamous epithelium was found, 6 months after eradication, in one patient who underwent esophagogastric resection. Twelve patients agreed to undergo antireflux surgery. Over a mean follow-up period of 14 months (range 4 to 32 months), two patients presented with recurrent Barrett's metaplasia: one at 8 months after successful Nissen fundoplication and the other after 1 year of continuous omeprazole treatment. Progression of Barrett's metaplasia was found in two other patients receiving pharmacologic therapy in whom a partial response to laser treatment had been obtained. In conclusion, Nd:YAG laser therapy of nondysplastic Barrett's esophagus, performed in conjunction with omeprazole treatment and followed by antireflux surgery, allows a partial regression of specialized columnar epithelium in most patients. However, this is a time-consuming procedure that produced only temporary eradication, did not prove effective in reducing cancer risk, and did not obviate the need for endoscopic surveillance.

Lack of association between porphyria cutanea tarda and alpha 1-antitrypsin deficiency.

OBJECTIVE: To determine whether alpha 1-antitrypsin deficiency is involved in the pathogenesis of chronic liver disease in patients with porphyria cutanea tarda and in their recently described high prevalence of hepatitis C virus infection. DESIGN: Consecutive patients diagnosed as having porphyria cutanea tarda and chronic liver disease. SETTING: A northern Italian hospital. METHODS: alpha 1-antitrypsin phenotypes were characterized by isoelectric focusing and the results confirmed by DNA analysis in 63 Italian patients with porphyria cutanea tarda. RESULTS: alpha 1-antitrypsin phenotypes different from the normal one were found in 13% of the patients. This prevalence did not differ from that in control subjects (9%). Clinical characteristics of patients with porphyria cutanea tarda with normal or altered alpha 1-antitrypsin phenotype, including age of presentation of the disease, prevalence of hepatitis C virus infection, liver histology, prevalence of iron overload and hepatocellular carcinoma occurrence, did not differ significantly. CONCLUSION: alpha 1-antitrypsin does not seem to play a role in the pathogenesis of chronic liver disease and hepatitis C virus infection in patients with porphyria cutanea tarda. Patients in whom the two defects coexist do not have a more severe disease.

Endoscopic palliation of oesophageal cancer: results of a prospective comparison of Nd:YAG laser and ethanol injection.

OBJECTIVE: To evaluate the effectiveness of intratumoral alcohol injection compared with Nd:YAG laser in the treatment of unresectable fungating cancers of the oesophagus. DESIGN: Prospective, randomised clinical study. SETTING: University hospital, Italy. SUBJECTS AND INTERVENTIONS: 47 consecutive patients were randomly allocated to have endoscopic Nd:YAG laser treatment (n = 24), or intratumoural injection of 98% alcohol (n = 23). MAIN OUTCOME MEASURES: Morbidity, mortality, dysphagia score, survival. RESULTS: One patient in the laser group needed analgesic support during and after the treatment, whereas 18 (78%) of those treated with alcohol experienced mild pain and most of them required analgesics. An improvement of at least 2 points in the dysphagia score was noted in 21 patients (88%) in the laser group and in 18 in the alcohol group (78%). The mean dysphagia-free intervals between each treatment were 30 and 37 days, respectively. The median survival was 6 months in each group. There were no significant differences in the mean dysphagia scores of patients still alive. There were no complications in the laser group, but one oesophageal perforation occurred during the preliminary dilatation before the second session of alcohol injection. There were no procedure-related deaths. CONCLUSION: The two techniques allowed similar palliation of dysphagia and improvement of quality of life. Intratumoral injection of alcohol is an effective and inexpensive therapeutic option in the palliation of fungating oesophageal lesions.

Improving results of esophageal stenting: a study on 160 consecutive unselected patients.

BACKGROUND AND STUDY AIMS: Esophageal stenting is a valuable treatment in the management of malignant dysphagia. Recently, self-expanding stents have proved effective in reducing morbidity and mortality. The aim of this study was to evaluate the early and late results of esophageal stenting in a series of 160 consecutive unselected patients with unresectable esophageal and cardial carcinoma treated between November 1992 and December 1996. PATIENTS AND METHODS: The procedure was successful in 159 patients (99.4%). A traditional tube was employed in 84 patients (52.5%). Metallic self-expanding stents have been available since June 1993 and were used in 75 selected patients (46.9%). The tumor was located in the cervical, upper, middle and lower thoracic esophagus, and at the gastric cardia in 16, 16, 56, 22 and 34 patients, respectively. In the remaining 15 patients an esophagovisceral anastomosis was involved. Preoperative chemo- and/or radiotherapy were performed in 82 patients (51.3%). RESULTS: Overall hospital morbidity was 11.3% (18/159) and included four dislodgments, four incomplete expansions of a self-expanding stent, two perforations, two incomplete sealings of a malignant respiratory tract fistula, two hemorrhages, two persistent foreign body sensations, one arrhythmia and one aspiration pneumonia. Hospital mortality was 1.3% (2/159) and was recorded in patients who underwent traditional intubation. At discharge, dysphagia was improved at least 2 degrees in 152 patients (96.8%). The overall long-term morbidity was 23.5% (37/157). Mean survival after the procedure was 4.7 months. CONCLUSIONS: Intubation is a safe palliative procedure which can be performed with low morbidity and mortality rates. Self-expanding metallic stents have enhanced the indications and the outcomes of the procedure, resulting in the treatment of strictures where the placement of a traditional tube is difficult or technically impossible.