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[This corrects the article DOI: 10.1016/j.jhepr.2019.10.006.].
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BACKGROUND AND AIMS: Studies have shown that hydrothermal duodenal mucosal ablation results in improved glycemic control. Recellularization via electroporation therapy (ReCET) is a novel endoscopic procedure that uses electroporation to induce cellular apoptosis and subsequent reepithelization. In this study, we aimed to eliminate exogenous insulin treatment in type 2 diabetes (T2D) patients through a single ReCET procedure combined with a glucagon-like peptide 1 receptor agonist. Feasibility, safety, and (dose) efficacy of ReCET were assessed. METHODS: This first-in-human study included patients with T2D on basal insulin (age, 28-75 years; body mass index, 24-40 kg/m2; glycosylated hemoglobin, ≤64 mmol/mol; C-peptide, ≥0.2 nmol/L). The electroporation dose was optimized during the study, starting with single 600 V and ending with double 750 V treatments. All patients underwent ReCET, after which insulin was discontinued and semaglutide (glucagon-like peptide-1 receptor agonist) was initiated. The primary endpoints were feasibility (procedure time [from catheter in to catheter out], technical success rate), safety, and efficacy (patients off insulin at 6 months; HbA1c, ≤58 mmol/mol). RESULTS: Fourteen patients underwent endoscopic ReCET. The median procedure time was 58 (interquartile range, 49-73) minutes. ReCET demonstrated a technical success rate of 100%. No device-related severe adverse events or severe hypoglycemic events were observed. At the 12-month follow-up, 12 (86%) patients remained off exogenous insulin therapy, with significant improvements in glycemic control and metabolic parameters. The 2 patients in whom insulin therapy was reintroduced both received ReCET at the lowest voltage (single 600 V). CONCLUSION: These results suggest that ReCET is feasible and safe. In combination with semaglutide, ReCET may be a promising therapeutic option to replace insulin therapy in selected T2D patients while improving glycemic control and metabolic health.
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High-risk T1 esophageal adenocarcinoma (HR-T1 EAC) is defined as T1 cancer, with one or more of the following histological criteria: submucosal invasion, poorly or undifferentiated cancer, and/or presence of lympho-vascular invasion. Esophagectomy has long been the only available treatment for these HR-T1 EACs and was considered necessary because of a presumed high risk of lymph node metastases up to 46%. However, endoscopic submucosal disscection have made it possible to radically remove HR-T1 EAC, irrespective of size, while leaving the esophageal anatomy intact. Parallel to this development, new publications demonstrated that the risk of lymph node metastases for HR-T1 EAC may be even <24%. Therefore, indications for endoscopic treatment of HR-T1 EAC are being reconsidered and current research aims at finding the optimal management strategy for this indication, where watchful waiting may proof to be an acceptable strategy in selected patients. In this review, we will discuss the latest developments in this field.
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Adenocarcinoma , Barrett Esophagus , Esophageal Neoplasms , Humans , Lymphatic Metastasis , Esophageal Neoplasms/surgery , Esophageal Neoplasms/pathology , Adenocarcinoma/surgery , Adenocarcinoma/pathology , Esophagoscopy , Esophagectomy/adverse effects , Barrett Esophagus/pathologyABSTRACT
BACKGROUND & AIMS: Follow-up (FU) strategies after endoscopic eradication therapy (EET) for Barrett's neoplasia do not consider the risk of mortality from causes other than esophageal adenocarcinoma (EAC). We aimed to evaluate this risk during long-term FU, and to assess whether the Charlson Comorbidity Index (CCI) can predict mortality. METHODS: We included all patients with successful EET from the nationwide Barrett registry in the Netherlands. Data were merged with National Statistics for accurate mortality data. We evaluated annual mortality rates (AMRs, per 1000 person-years) and standardized mortality ratio for other-cause mortality. Performance of the CCI was evaluated by discrimination and calibration. RESULTS: We included 1154 patients with a mean age of 64 years (±9). During median 59 months (p25-p75 37-91; total 6375 person-years), 154 patients (13%) died from other causes than EAC (AMR, 24.1; 95% CI, 20.5-28.2), most commonly non-EAC cancers (n = 58), cardiovascular (n = 31), or pulmonary diseases (n = 26). Four patients died from recurrent EAC (AMR, 0.5; 95% CI, 0.1-1.4). Compared with the general Dutch population, mortality was significantly increased for patients in the lowest 3 age quartiles (ie, age <71 years). Validation of CCI in our population showed good discrimination (Concordance statistic, 0.78; 95% CI, 0.72-0.84) and fair calibration. CONCLUSION: The other-cause mortality risk after successful EET was more than 40 times higher (48; 95% CI, 15-99) than the risk of EAC-related mortality. Our findings reveal that younger post-EET patients exhibit a significantly reduced life expectancy when compared with the general population. Furthermore, they emphasize the strong predictive ability of CCI for long-term mortality after EET. This straightforward scoring system can inform decisions regarding personalized FU, including appropriate cessation timing. (NL7039).
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Adenocarcinoma , Barrett Esophagus , Esophageal Neoplasms , Registries , Humans , Middle Aged , Male , Barrett Esophagus/surgery , Barrett Esophagus/mortality , Barrett Esophagus/pathology , Female , Netherlands/epidemiology , Aged , Esophageal Neoplasms/mortality , Esophageal Neoplasms/surgery , Incidence , Adenocarcinoma/mortality , Adenocarcinoma/surgery , Adenocarcinoma/pathology , Esophagoscopy/adverse effects , Cause of Death , Risk Assessment , Risk Factors , Treatment Outcome , Time Factors , ComorbidityABSTRACT
The metabolic syndrome (MetSyn) is currently one of the biggest global health challenges because of its impact on public health. MetSyn includes the cluster of metabolic disorders including obesity, high blood pressure, hyperglycemia, high triglyceride levels, and hepatic steatosis. Together, these abnormalities increase the cardiovascular risk of individuals and pose a threat to healthcare systems worldwide. To better understand and address this complex issue, recent research has been increasingly focusing on unraveling the delicate interplay between metabolic disorders and the intestines and more specifically our gut microbiome. The gut microbiome entails all microorganisms inhabiting the gastrointestinal tract and plays a pivotal role in metabolic processes and overall health of its host. Emerging evidence proves an association between the gut microbiome composition and aspects of MetSyn, such as obesity. Understanding these relationships is crucial because they offer valuable insights into the mechanisms underlying development and progression of metabolic disorders and possible treatment options. Yet, how should we interpret this relationship? This review focuses on the interplay between the gut and MetSyn. In addition, we have reviewed the existing evidence of the gut microbiome and its association with and impact on metabolic disorders, in an attempt to understand the complex interactions and nature of this association. We also explored potential therapeutic options targeting the gut to modify metabolic disorders and obesity.
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Gastrointestinal Microbiome , Metabolic Syndrome , Obesity , Humans , Metabolic Syndrome/microbiology , Gastrointestinal Microbiome/physiology , Obesity/microbiology , Intestines/microbiologyABSTRACT
BACKGROUND: This study evaluated the proportion of patients with residual neoplasia after endoscopic resection (ER) for Barrett's neoplasia with confirmed tumor-positive vertical resection margin (R1v). METHODS: This retrospective cohort study included patients undergoing ER for Barrett's neoplasia with histologically documented R1v since 2008 in the Dutch Barrett Expert Centers. We defined R1v as cancer cells touching vertical resection margins and Rx as nonassessable margins. Reassessment of R1v specimens was performed by experienced pathologists until consensus was reached regarding vertical margins. RESULTS: 101/110 included patients had macroscopically complete resections (17 T1a, 84 T1b), and 99/101 (98%) ER specimens were histologically reassessed, with R1v confirmed in 74 patients (75%), Rx in 16%, and R0 in 9%. Presence/absence of residual neoplasia could be assessed in 66/74 patients during endoscopic reassessment (52) and/or in the surgical resection specimen (14), and 33/66 (50%) had residual neoplasia. Residual neoplasia detected during endoscopy was always endoscopically visible and biopsies from a normal-appearing ER scar did not detect additional neoplasia. Of 25 patients who underwent endoscopic follow-up (median 37 months [interquartile range 12-50]), 4 developed local recurrence (16.0%), all detected as visible abnormalities. CONCLUSIONS: After ER with R1v, 50% of patients had no residual neoplasia. Histological evaluation of ER margins appears challenging, as in this study 75% of documented R1v cases were confirmed during reassessment. Endoscopic reassessment 8-12 weeks after ER seems to accurately detect residual neoplasia and can help to determine the most appropriate strategy for patients with R1v.
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Barrett Esophagus , Esophageal Neoplasms , Margins of Excision , Neoplasm, Residual , Humans , Barrett Esophagus/pathology , Barrett Esophagus/surgery , Male , Female , Retrospective Studies , Aged , Middle Aged , Esophageal Neoplasms/surgery , Esophageal Neoplasms/pathology , Esophagoscopy/methods , Endoscopic Mucosal Resection , Netherlands , Adenocarcinoma/surgery , Adenocarcinoma/pathology , BiopsyABSTRACT
BACKGROUND: Although endoscopic submucosal dissection (ESD) is established as first-choice treatment for early esophageal squamous cell carcinoma (ESCC) worldwide, most data are derived from Asian studies. We aimed to evaluate the long-term outcomes of ESD for patients with early ESCC in a Western cohort. METHODS: In this retrospective cohort study, patients with early ESCC amenable to ESD were included from four tertiary referral hospitals in the Netherlands between 2012 and 2017. All ESD procedures were performed by experienced endoscopists, after which the decision for additional treatment was made on a per-patient basis. Outcomes were curative resection rate, ESCC-specific survival, and overall survival. RESULTS: Of 68 included patients (mean age 69 years; 34 males), ESD was technically successful in 66 (97%; 95%CI 93%-100%), with curative resection achieved in 34/66 (52%; 95%CI 39%-64%). Among patients with noncurative resection, 15/32 (47%) underwent additional treatment, mainly esophagectomy (n = 10) or definitive chemoradiation therapy (n = 4). Endoscopic surveillance was preferred in 17/32 patients (53%), based on severe comorbidities or patient choice. Overall, 31/66 patients (47%) died during a median follow-up of 66 months; 8/31 (26%) were ESCC-related deaths. The 5-year overall and ESCC-specific survival probabilities were 62% (95%CI 52%-75%) and 86% (95%CI 77%-96%), respectively. CONCLUSION: In this Western cohort with long-term follow-up, the effectiveness and safety of ESD for early ESCC was confirmed, although the rate of noncurative resections was substantial. Irrespective of curative status, the long-term prognosis of these patients was limited mainly due to competing mortality.
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Endoscopic Mucosal Resection , Esophageal Neoplasms , Esophageal Squamous Cell Carcinoma , Humans , Endoscopic Mucosal Resection/methods , Endoscopic Mucosal Resection/adverse effects , Male , Female , Aged , Esophageal Neoplasms/surgery , Esophageal Neoplasms/mortality , Esophageal Neoplasms/pathology , Retrospective Studies , Esophageal Squamous Cell Carcinoma/surgery , Esophageal Squamous Cell Carcinoma/mortality , Esophageal Squamous Cell Carcinoma/pathology , Middle Aged , Netherlands , Esophagectomy/methods , Esophagectomy/adverse effects , Treatment Outcome , Survival Rate , Aged, 80 and over , Neoplasm StagingABSTRACT
BACKGROUND AND AIMS: The duodenum has been shown to play a key role in glucose homeostasis. Duodenal mucosal resurfacing (DMR) is an endoscopic procedure for patients with type 2 diabetes (T2D) in which the duodenal mucosa is hydrothermally ablated. DMR improves glycemic control, but the underlying mechanisms remain unclear. Here, we report changes in glucoregulatory hormones and indices of insulin sensitivity and beta cell function after DMR. METHODS: We included 28 patients on noninsulin glucose-lowering medications who underwent open-label DMR and a mixed meal test (MMT) in Revita-1 or Revita-2 studies. Inclusion criteria were a hemoglobin A1c from 7.6% to 10.4% and a body mass index of 24 to 40 kg/m2. Baseline and 3-month MMT data included plasma glucose, insulin, C-peptide, glucagon-like peptide-1 (GLP-1), and gastric inhibitory polypeptide (GIP) concentrations. Glucoregulatory hormones, insulin sensitivity indices (Homeostatic Model Assessment for Insulin Resistance [HOMA-IR], Matsuda index [MI], and hepatic insulin resistance) and beta cell function (insulinogenic index, disposition index [DI], and insulin secretion rate [ISR]) were assessed. RESULTS: Fasting insulin, glucagon, and C-peptide decreased significantly. Insulin sensitivity (HOMA-IR, MI, and hepatic insulin resistance) and beta cell function (DI and ISR) all improved significantly. Declines in postprandial glucose, mainly driven by a decrease in fasting levels, and in postprandial glucagon were observed, whereas GLP-1 and GIP did not change. CONCLUSIONS: Insulin sensitivity and insulin secretion improved 3 months after DMR. It is unlikely that incretin changes are responsible for improved glucose control after DMR. These data add to the growing evidence validating the duodenum as a therapeutic target for patients with T2D. (Clinical trial registration numbers: NCT02413567 and NCT03653091.).
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Blood Glucose , Diabetes Mellitus, Type 2 , Duodenum , Gastric Inhibitory Polypeptide , Glucagon-Like Peptide 1 , Insulin Resistance , Insulin-Secreting Cells , Insulin , Intestinal Mucosa , Female , Humans , Male , Middle Aged , Blood Glucose/metabolism , C-Peptide/blood , C-Peptide/metabolism , Diabetes Mellitus, Type 2/metabolism , Duodenum/surgery , Duodenum/metabolism , Endoscopic Mucosal Resection/methods , Gastric Inhibitory Polypeptide/metabolism , Glucagon/metabolism , Glucagon-Like Peptide 1/metabolism , Glycated Hemoglobin/metabolism , Insulin/metabolism , Insulin-Secreting Cells/metabolism , Intestinal Mucosa/metabolism , Intestinal Mucosa/surgery , Pilot ProjectsABSTRACT
BACKGROUND AND AIMS: Circumferential endoscopic submucosal dissection (cESD) in the esophagus has been reported to be feasible in small Eastern case series. We assessed the outcomes of cESD in the treatment of early esophageal squamous cell carcinoma (ESCC) in Western countries. METHODS: We conducted an international study at 25 referral centers in Europe and Australia using prospective databases. We included all patients with ESCC treated with cESD before November 2022. Our main outcomes were curative resection according to European guidelines and adverse events. RESULTS: A total of 171 cESDs were performed on 165 patients. En bloc and R0 resections rates were 98.2% (95% confidence interval [CI], 95.0-99.4) and 69.6% (95% CI, 62.3-76.0), respectively. Curative resection was achieved in 49.1% (95% CI, 41.7-56.6) of the lesions. The most common reason for noncurative resection was deep submucosal invasion (21.6%). The risk of stricture requiring 6 or more dilations or additional techniques (incisional therapy/stent) was high (71%), despite the use of prophylactic measures in 93% of the procedures. The rates of intraprocedural perforation, delayed bleeding, and adverse cardiorespiratory events were 4.1%, 0.6%, and 4.7%, respectively. Two patients died (1.2%) of a cESD-related adverse event. Overall and disease-free survival rates at 2 years were 91% and 79%. CONCLUSIONS: In Western referral centers, cESD for ESCC is curative in approximately half of the lesions. It can be considered a feasible treatment in selected patients. Our results suggest the need to improve patient selection and to develop more effective therapies to prevent esophageal strictures.
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Endoscopic Mucosal Resection , Esophageal Neoplasms , Esophageal Squamous Cell Carcinoma , Humans , Esophageal Squamous Cell Carcinoma/surgery , Esophageal Neoplasms/pathology , Endoscopic Mucosal Resection/methods , Esophagoscopy/methods , Treatment Outcome , Retrospective StudiesSubject(s)
Barrett Esophagus , Esophageal Neoplasms , Humans , Barrett Esophagus/diagnosis , Pathologists , BiomarkersABSTRACT
BACKGROUND & AIMS: Low-grade dysplasia (LGD) is associated with an increased risk of progression in Barrett's esophagus (BE); however, the diagnosis of LGD is limited by substantial interobserver variability. Multiple studies have shown that an objective tissue systems pathology test (TissueCypher Barrett's Esophagus Test, TSP-9), can effectively predict neoplastic progression in patients with BE. This study aimed to compare the risk stratification performance of the TSP-9 test vs benchmarks of generalist and expert pathology. METHODS: A blinded cohort study was conducted in the screening cohort of a randomized controlled trial of patients with BE with community-based LGD. Biopsies from the first endoscopy with LGD were assessed by the TSP-9 test and independently reviewed by 30 pathologists from 5 countries per standard practice. The accuracy of the test and the diagnoses in predicting high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) were compared. RESULTS: A total of 154 patients with BE (122 men), mean age 60.9 ± 9.8 years were studied. Twenty-four patients progressed to HGD/EAC within 5 years (median time of 1.7 years) and 130 did not progress to HGD/EAC within 5 years (median 7.8 years follow-up). The TSP-9 test demonstrated higher sensitivity (71% vs mean 63%, range 33%-88% across 30 pathologists), than the pathology review in detecting patients who progressed (P = .01186). CONCLUSIONS: The TSP-9 test outperformed the pathologists in risk stratifying patients with BE with LGD. Care guided by the test can provide an effective solution to variable pathology review of LGD, improving health outcomes by upstaging care to therapeutic intervention for patients at high risk for progression, while reducing unnecessary interventions in low-risk patients.
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INTRODUCTION: Low-grade dysplasia (LGD) in Barrett's esophagus (BE) is associated with an increased risk of progression to high-grade dysplasia or esophageal adenocarcinoma. However, because of substantial interobserver variability in the diagnosis of LGD, a patient's management plan and health outcome depend largely on which pathologist reviews their case. This study evaluated the ability of a tissue systems pathology test that objectively risk stratifies patients with BE (TissueCypher, TSP-9) to standardize management in a manner consistent with improved health outcomes for patients with BE. METHODS: A total of 154 patients with BE with community-based LGD from the prospectively followed screening cohort of the SURF trial were studied. Management decisions were simulated 500 times with varying generalist (n = 16) and expert (n = 14) pathology reviewers to determine the most likely care plan with or without use of the TSP-9 test for guidance. The percentage of patients receiving appropriate management based on the known progression/nonprogression outcomes was calculated. RESULTS: The percentage of patients with 100% of simulations resulting in appropriate management significantly increased from 9.1% for pathology alone, to 58.4% when TSP-9 results were used with pathology, and further increased to 77.3% of patients receiving appropriate management when only TSP-9 results were used. Use of the test results also significantly increased the consistency of management decisions for patients when their slides were reviewed by different pathologists ( P < 0.0001). DISCUSSION: Management guided by the TSP-9 test can standardize care plans by increasing the early detection of progressors who can receive therapeutic interventions, while also increasing the percentage of nonprogressors who can avoid unnecessary therapy and be managed by surveillance alone.
Subject(s)
Barrett Esophagus , Esophageal Neoplasms , Precancerous Conditions , Humans , Barrett Esophagus/diagnosis , Barrett Esophagus/therapy , Barrett Esophagus/epidemiology , Precancerous Conditions/pathology , Disease Progression , Esophageal Neoplasms/diagnosis , Esophageal Neoplasms/therapy , Esophageal Neoplasms/epidemiology , Hyperplasia , Outcome Assessment, Health CareABSTRACT
BACKGROUND: Recently, endoscopic vacuum therapy (EVT) was introduced as treatment for anastomotic leakage after upper gastrointestinal (GI) surgery. The aim of this study was to describe the initial experience with EVT for anastomotic leakage after upper GI surgery in a tertiary referral center. METHODS: Patients treated with EVT for anastomotic leakage after upper GI surgery were included retrospectively (January 2018-June 2021) and prospectively (June 2021-October 2021). The primary end point was the EVT success rate. Secondary end points included mortality and adverse events. RESULTS: 38 patients were included (31 men; mean age 66 years): 27 had undergone an esophagectomy with gastric conduit reconstruction and 11 a total gastrectomy with esophagojejunal anastomosis. EVT was successful in 28 patients (74â%, 95â%CI 57â%-87â%). In 10 patients, EVT failed: deceased owing to radiation pneumonitis (nâ=â1), EVT-associated complications (nâ=â2), and defect closure not achieved (nâ=â7). Mean duration of successful EVT was 33 days, with a median of six EVT-related endoscopies. Median hospital stay was 45 days. CONCLUSION: This initial experience with EVT for anastomotic leakage after upper GI surgery demonstrated a success rate of 74â%. EVT is a promising therapy that could prevent further major surgery. More experience with the technique and its indications will likely improve success rates in the future.
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Anastomotic Leak , Negative-Pressure Wound Therapy , Male , Humans , Aged , Anastomotic Leak/etiology , Anastomotic Leak/surgery , Retrospective Studies , Negative-Pressure Wound Therapy/methods , Endoscopy/adverse effects , Gastrectomy/adverse effects , Esophagectomy/adverse effectsABSTRACT
Introduction: Endoscopic vacuum therapy (EVT) has gained a greater role in management of transmural defects in the upper gastrointestinal (GI) tract, including anastomotic leakage and esophageal perforation (e.g. Boerhaave syndrome and iatrogenic causes). The vacuum-stent is a new treatment modality, combining the benefits of EVT and an intraluminal stent. Patients and methods: This prospective case series describes the first ten cases of a transmural defect in the upper GI tract treated with a vacuum-stent in a tertiary referral center. All patients signed informed consent for prospective registration of relevant data on treatment and outcomes in a specially designed database. Outcome parameters were successful closure of the defect, number of endoscopies, duration of treatment and adverse events. Results: In total, ten patients treated with a vacuum-stent were included. Eight patients had anastomotic leakage after esophageal resection, of whom six were treated with vacuum-sponge and vacuum-stent, and two with vacuum-stent only. One patient had Boerhaave syndrome, treated with vacuum-sponge and vacuum-stent, and one had an iatrogenic perforation during pneumodilation for achalasia, treated with vacuum-stent only. Success rate was 100%, requiring a median of 5 (IQR 3-12) EVT-related endoscopies with a treatment course of median 18 (IQR 12-59) days. One patient developed an esophageal stricture, but no other vacuum-stent related adverse events were observed. Conclusion: The vacuum-stent, which combines benefits of EVT and an intraluminal stent, shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. Future studies should point out whether this device can prevent major (re-)surgery in these patients.
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BACKGROUND: Selective lymphadenectomy using sentinel node-navigated surgery (SNNS) might offer a less invasive alternative to esophagectomy in patients with high-risk T1 esophageal adenocarcinoma (EAC). The aim of this study was to evaluate the feasibility and safety of a new treatment strategy, consisting of radical endoscopic resection of the tumor followed by SNNS. METHODS: In this multicenter pilot study, ten patients with a radically resected high-risk pT1cN0 EAC underwent SNNS. A hybrid tracer of technetium-99m nanocolloid and indocyanine green was injected endoscopically around the resection scar the day before surgery, followed by preoperative imaging. During surgery, sentinel nodes (SNs) were identified using a thoracolaparoscopic gammaprobe and fluorescence-based detection, and subsequently resected. Endpoints were surgical morbidity and number of detected and resected (tumor-positive) SNs. RESULTS: Localization and dissection of SNs was feasible in all ten patients (median 3 SNs per patient, range 1-6). The concordance between preoperative imaging and intraoperative detection was high. In one patient (10%), dissection was considered incomplete after two SNs were not identified intraoperatively. Additional peritumoral SNs were resected in four patients (40%) after fluorescence-based detection. In two patients (20%), a (micro)metastasis was found in one of the resected SNs. One patient experienced neuropathic thoracic pain related to surgery, while none of the patients developed functional gastroesophageal disorders. CONCLUSIONS: SNNS appears to be a feasible and safe instrument to tailor lymphadenectomy in patients with high-risk T1 EAC. Future research with long-term follow-up is warranted to determine whether this esophageal preserving strategy is justified for high-risk T1 EAC.
Subject(s)
Adenocarcinoma , Sentinel Lymph Node Biopsy , Humans , Sentinel Lymph Node Biopsy/methods , Feasibility Studies , Pilot Projects , Lymph Node Excision/methods , Indocyanine Green , Adenocarcinoma/diagnostic imaging , Adenocarcinoma/surgery , Adenocarcinoma/pathology , Lymph Nodes/pathologyABSTRACT
BACKGROUND: Current surveillance for Barrett's esophagus (BE), consisting of four-quadrant random forceps biopsies (FBs), has an inherent risk of sampling error. Wide-area transepithelial sampling (WATS) may increase detection of high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). In this multicenter randomized trial, we aimed to evaluate WATS as a substitute for FB. METHODS: Patients with known BE and a recent history of dysplasia, without visible lesions, at 17 hospitals were randomized to receive either WATS followed by FB or vice versa. All WATS samples were examined, with computer assistance, by at least two experienced pathologists at the CDx Diagnostics laboratory. Similarly, all FBs were examined by two expert pathologists. The primary end point was concordance/discordance for detection of HGD/EAC between the two techniques. RESULTS: 172 patients were included, of whom 21 had HGD/EAC detected by both modalities, 18 had HGD/EAC detected by WATS but missed by FB, and 12 were detected by FB but missed by WATS.âThe detection rate of HGD/EAC did not differ between WATS and FB (Pâ=â0.36). Using WATS as an adjunct to FB significantly increased the detection of HGD/EAC vs. FB alone (absolute increase 10â% [95â%CI 6â% to 16â%]). Mean procedural times in minutes for FB alone, WATS alone, and the combination were 6.6 (95â%CI 5.9 to 7.1), 4.9 (95â%CI 4.1 to 5.4), and 11.2 (95â%CI 10.5 to 14.0), respectively. CONCLUSIONS: Although the combination of WATS and FB increases dysplasia detection in a population of BE patients enriched for dysplasia, we did not find a statistically significant difference between WATS and FB for the detection of HGD/EAC as single modality.
Subject(s)
Adenocarcinoma , Barrett Esophagus , Esophageal Neoplasms , Precancerous Conditions , Humans , Barrett Esophagus/complications , Barrett Esophagus/diagnosis , Barrett Esophagus/epidemiology , Esophageal Neoplasms/diagnosis , Esophageal Neoplasms/etiology , Esophageal Neoplasms/epidemiology , Adenocarcinoma/diagnosis , Adenocarcinoma/etiology , Adenocarcinoma/epidemiology , Hyperplasia , Precancerous Conditions/pathology , Disease ProgressionABSTRACT
BACKGROUND: Radiofrequency ablation (RFA) is effective for eradication of Barrett's esophagus (BE) neoplasia, but little is known on the course of pain and dysphagia after RFA. We aimed to describe the course of post-RFA symptoms and to identify possible associated risk factors. METHODS: In this multicenter, observational cohort study, all RFA procedures registered in a prospective database were included. Patient and treatment characteristics were collected from medical records and patients self-registered post-procedural symptoms in electronic symptom diaries for 14 days. Mixed model regression was used for the analyses. RESULTS: In total, 255 diaries were completed. Post-RFA pain was reported for 95â% (95â%CI 93-98) of procedures (median duration 14 days; 25th-75th percentiles [p25-p75] 11-14) and major pain for 64â% (95â%CI 58-69; median duration 8 days, p25-p75 3-13). Post-procedural pain significantly increased with BE length, younger age, and no prior ablation. Dysphagia was present after 83â% (95â%CI 79-88) of procedures (median duration 13 days, p25-p75 9-14). The risk of dysphagia decreased with age and increased when patients experienced more pain. CONCLUSIONS: RFA treatment for BE-related neoplasia seems a significant burden for patients, and post-procedural symptoms should be taken into account when counseling patients before starting endoscopic eradication therapy.
Subject(s)
Barrett Esophagus , Catheter Ablation , Deglutition Disorders , Esophageal Neoplasms , Radiofrequency Ablation , Humans , Barrett Esophagus/surgery , Deglutition Disorders/etiology , Deglutition Disorders/surgery , Catheter Ablation/adverse effects , Catheter Ablation/methods , Treatment Outcome , Esophageal Neoplasms/surgery , Esophageal Neoplasms/etiology , Radiofrequency Ablation/adverse effects , Radiofrequency Ablation/methods , Pain/etiology , Esophagoscopy/methodsABSTRACT
BACKGROUND & AIMS: Although random histological sampling from the esophagogastric junction (EGJ) after complete eradication of Barrett's esophagus (BE) is recommended, its clinical relevance is questionable. This study aimed to assess the incidence and long-term outcomes of findings from random EGJ biopsies in a nationwide cohort with long-term follow-up. METHODS: We included all patients with successful endoscopic eradication therapy (EET), defined as complete endoscopic eradication of all visible BE (CE-BE), for early BE neoplasia from the Dutch registry. Patients were treated and followed-up in 9 expert centers according to a joint protocol. Outcomes included the incidence of intestinal metaplasia (IM) at the EGJ (EGJ-IM) and the association between IM and visible (dysplastic) BE recurrence. RESULTS: A total of 1154 patients were included with a median follow-up of 43 months (interquartile range, 22-69 months). At the time of CE-BE, persisting EGJ-IM was found in 7% of patients (78/1154), which was reproduced during further follow-up in 46% of patients (42/78). No significant association existed between persisting EGJ-IM at CE-BE and recurrent non-dysplastic or dysplastic BE (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.63-2.13 and HR, 0.73; 95% CI, 0.17-3.06, respectively). Among patients with no EGJ-IM at the time of CE-BE (1043/1154; 90%), EGJ-IM recurred in 7% (72/1043) after a median of 21 months (interquartile range, 15-36 months), and was reproduced during further follow-up in 26% of patients (19/72). No association was found between recurrent EGJ-IM and non-dysplastic or dysplastic recurrence (HR, 1.18; 95% CI, 0.67-2.06 and HR, 0.27; 95% CI, 0.04-1.96, respectively). CONCLUSION: Because EGJ-IM was not associated with a higher risk for recurrent disease, we recommend to consider abandoning random EGJ sampling after successful EET, under the condition that care is provided in expert centers, and the esophagus, including the EGJ, is carefully inspected (Netherlands Trial Register, NL7309).
Subject(s)
Barrett Esophagus , Catheter Ablation , Esophageal Neoplasms , Humans , Barrett Esophagus/surgery , Barrett Esophagus/pathology , Clinical Relevance , Neoplasm Recurrence, Local/epidemiology , Esophagogastric Junction/pathology , Biopsy , Metaplasia/pathology , Esophagoscopy , Esophageal Neoplasms/pathology , Treatment OutcomeABSTRACT
BACKGROUND: Cervical anastomotic strictures after esophagectomy cause significant disease burden. We aimed to study the technical feasibility and safety of intensive endoscopic therapy. METHODS: In this pilot study, we included 15 patients with an untreated benign cervical anastomotic stricture after esophagectomy. Intensive endoscopic therapy comprised three endoscopic modalities: in- and excision using a needle-knife, intralesional steroid injections and bougie dilation. In two endoscopic procedures, the stricture was dilated up to a luminal diameter of 18 mm. Patients were followed up to 6 months. RESULTS: A luminal diameter of 18 mm was achieved in 13 of 15 patients (87%) after two endoscopic procedures. No major adverse events related to the investigational treatment occurred. Median dysphagia scores significantly improved from 2 (IQR, interquartile range, 2-3) at baseline to 0 (IQR 0-1) after 14 days (p < 0.001). Eleven (73%) patients developed recurrent symptoms of dysphagia requiring a median of 1 (IQR 0-3) additional endoscopic dilation procedure. CONCLUSIONS: Achieving a luminal diameter of 18 mm in two procedures with intensive endoscopic therapy was technically feasible and effective in reducing dysphagia rapidly in patients with a cervical anastomotic stricture after esophagectomy. No major adverse events related to the investigational treatment were observed.