Abraham M. Panossian

Predictors of esophageal stricture formation post endoscopic mucosal resection.

Background/Aims Stricture formation is a common complication after endoscopic mucosal resection. Predictors of stricture formation have not been well studied. Methods We conducted a retrospective, observational, descriptive study by using a prospective endoscopic mucosal resection database in a tertiary referral center. For each patient, we extracted the age, sex, lesion size, use of ablative therapy, and detection of esophageal strictures. The primary outcome was the presence of esophageal stricture at follow-up. Multivariate logistic regression was used to analyze the association between the primary outcome and predictors. Results Of 136 patients, 27% (n=37) had esophageal strictures. Thirty-two percent (n=44) needed endoscopic dilation to relieve dysphagia (median, 2; range, 1 to 8). Multivariate logistic regression analysis showed that the size of the lesion excised is associated with increased odds of having a stricture (odds ratio, 1.6; 95% confidence interval, 1.1 to 2.3; p=0.01), when controlling for age, sex, and ablative modalities. Similarly, the number of lesions removed in the index procedure was associated with increased odds of developing a stricture (odds ratio, 2.3; 95% confidence interval, 1.3 to 4.2; p=0.007). Conclusions Stricture formation after esophageal endoscopic mucosal resection is common. Risk factors for stricture formation include large mucosal resections and the resection of multiple lesions on the initial procedure.

State of the art in the endoscopic imaging and ablation of Barrett's esophagus

Barretts esophagus is the result of long-term acid reflux and is a precursor to esophageal adenocarcinoma. Surgical resection of the esophagus has been the mainstay of treatment for high grade dysplasia and early cancer. However, recent advances in the endoscopic imaging and ablation technologies have made esophagectomy avoidable in patients with dysplasia and superficial neoplasia. In this article, we review the most relevant endoscopic imaging technologies, such as chromoendoscopy, narrow band and autofluorescence imaging, and confocal laser endomicroscopy. We also review the various endoscopic ablation technologies, such as endoscopic mucosal resection, photodynamic therapy, radiofrequency ablation, and cryotherapy. Finally, we focus on the studies that evaluate the efficacy of these imaging and ablation technologies in finding and eradicating neoplastic Barretts esophagus.

Survival in esophageal high-grade dysplasia/adenocarcinoma post endoscopic resection

BACKGROUND Endoscopic resection followed by ablative therapy is frequently used to treat esophageal high-grade dysplasia or early esophageal adenocarcinoma. AIMS To study outcomes in patients with high-grade dysplasia compared to those with esophageal adenocarcinoma after endoscopic resection. METHODS Retrospective, observational, descriptive, single-centre study from a prospective database. We extracted data from 116 endoscopic resections. Survival was plotted using Kaplan-Meier curves multivariable Cox-proportional hazard assess for possible predictors of survival post-endoscopic resection was performed. RESULTS 116 patients (64 esophageal adenocarcinoma, 52 high-grade dysplasia) underwent endoscopic resection from May 2003 to June 2010. Mean age was 71 ± 11 years for high-grade dysplasia and 72 ± 10 years for esophageal adenocarcinoma. Median follow-up was 17 months. Eighty-five patients had negative margins on endoscopic resection. Five-year survivals for high-grade dysplasia and esophageal adenocarcinoma were 86% (range 68-100%) and 78% (59-96%), respectively. Survival was not significantly different between groups (p=0.20). Overall mortality rate was 10.6% (9/85). At multivariable Cox regression increased Barretts oesophagus length was associated with worse survival (HR 1.18 [1.06-1.33], p=0.0039). Survival was not affected by the pathology before resection: HR 2.4 [95%CI, 0.70-8.4], p=0.16. CONCLUSIONS Survival in patients with high-grade dysplasia of the oesophagus is similar to those with esophageal adenocarcinoma. Longer Barretts oesophagus segments are associated with decreased survival.

Continuing Medical Education Questions: January 2010

A. Questionnaires have less sensitivity then biochemical test in screening for alcohol abuse. B. Th e CAGE questionnaire was developed for outpatients and focuses on short-term drinking behaviors. C. Th e AUDIT screen has a higher sensitivity and specifi city than shorter screening instruments. D. Screening for alcohol abuse/dependence is not important in the clinical setting. 3. Which one of the following statements is true regarding the treatment of alcoholic liver disease?