Joep J. Gondrie

Stepwise radical endoscopic resection for eradication of Barrett's oesophagus with early neoplasia in a cohort of 169 patients

Background and Aims Endoscopic resection is safe and effective to remove early neoplasia (ie,high-grade intra-epithelial neoplasia/early cancer) in Barretts oesophagus. To prevent metachronous lesions during follow-up, the remaining Barretts oesophagus can be removed by stepwise radical endoscopic resection (SRER). The aim was to evaluate the combined experience in four tertiary referral centres with SRER to eradicate Barretts oesophagus with early neoplasia. Methods Design: Retrospective cohort study. Setting: Four tertiary referral centres. Participants: 169 patients (151 males, age 64 years (IQR 57–71), Barretts oesophagus 3 cm (IQR 2–5)) with early neoplasia in Barretts oesophagus ≤5 cm, without deep submucosal infiltration or lymph node metastases, treated by SRER between January 2000 and September 2006. Intervention: Endoscopic resection every 4–8 weeks, until complete endoscopic and histological eradication of Barretts oesophagus and neoplasia. Results According to intention-to-treat analysis complete eradication of all neoplasia and all intestinal metaplasia by the end of the treatment phase was reached in 97.6% (165/169) and 85.2% (144/169) of patients, respectively. One patient had progression of neoplasia during treatment and died of metastasised adenocarcinoma (0.6%). After median follow-up of 32 months (IQR 19–49), complete eradication of neoplasia and intestinal metaplasia was sustained in 95.3% (161/169) and 80.5% (136/169) of patients, respectively. Acute, severe complications occurred in 1.2% of patients, and 49.7% of patients developed symptomatic stenosis. Conclusions SRER of Barretts oesophagus ≤5 cm containing early neoplasia appears to be an effective treatment modality with a low rate of recurrent lesions during follow-up. The procedure, however, is technically demanding and is associated with oesophageal stenosis in half of the patients.

Properties of the Neosquamous Epithelium After Radiofrequency Ablation of Barrett's Esophagus Containing Neoplasia

OBJECTIVES:Endoscopic radiofrequency ablation (RFA) eradicates intestinal metaplasia and intraepithelial neoplasia associated with Barretts esophagus (BE), restoring an endoscopically normal neosquamous epithelium (NSE). We evaluated the post-RFA NSE for genetic abnormalities and buried glandular mucosa.METHODS:Eligible patients underwent RFA for BE containing early cancer and/or high-grade intraepithelial neoplasia with subsequent complete histological reversion to normal NSE. At baseline, the BE was sampled by brush cytology and biopsies. At least 2 months after RFA, the NSE was sampled by brush cytology, keyhole biopsies, and endoscopic resection. The untreated squamous epithelium was biopsied as a control. The baseline BE and post-RFA NSE were evaluated for immunohistochemical expression of Ki-67 and p53, and genetic abnormalities (DNA–fluorescent in situ hybridization: chromosome 1 and 9, p16 and p53). In addition, biopsy depth was compared for biopsies from the NSE and untreated squamous epithelium. The presence of buried glandular mucosa in NSE was assessed with primary and keyhole biopsy, and endoscopic resection.RESULTS:All pretreatment specimens from all 22 patients showed abnormalities on immunohistochemical staining and fluorescent in situ hybridization, whereas all post-RFA NSE specimens were normal. All the post-RFA biopsies from the NSE contained full epithelia, whereas 37% contained lamina propria, a finding no different from biopsies from untreated squamous epithelium (36% lamina propria). Deeper keyhole biopsies contained lamina propria in 51%. All endoscopic resection specimens contained submucosa, whereas no biopsy or endoscopic resection specimen contained buried glandular mucosa.CONCLUSIONS:Rigorous evaluation of the post-RFA NSE in patients who, at baseline, had BE containing early cancer high-grade intraepithelial neoplasia, showed neither persistent genetic abnormalities nor buried glandular mucosa.

Stepwise radiofrequency ablation of Barrett's esophagus preserves esophageal inner diameter, compliance, and motility

BACKGROUND AND AIM Stepwise endoscopic circumferential and focal radiofrequency ablation is safe and effective for the eradication of Barretts esophagus. In contrast to other techniques, radiofrequency ablation appears to avoid significant esophageal scarring or stenosis. Our aim was to evaluate whether radiofrequency ablation has an adverse effect on esophageal function in patients treated for Barretts esophagus containing intramucosal cancer and/or high-grade dysplasia. METHODS Twelve patients with Barretts esophagus containing intramucosal cancer or high-grade dysplasia were included in the study. After endoscopic resection of visible abnormalities, stepwise circumferential and focal ablation were performed every 2 months up to a maximum of five sessions. Measurement of the inner diameter was performed at 1-cm intervals in the distal esophagus. Manometry was performed using a water-perfused sleeve catheter. Compliance was evaluated using the functional lumen imaging probe (FLIP), measuring eight cross-sectional areas within a saline-filled bag with two pressure side holes, one proximal to and one inside the bag. Esophageal sizing, manometry, and compliance were recorded in patients at baseline and at least 2 months after the final ablation session. In addition, FLIP and manometry measurements were performed in 10 healthy volunteers. RESULTS All patients achieved complete eradication of dysplasia and Barretts esophagus, without severe complications or ablation-related stenoses. The esophageal diameter was unchanged by the ablation. Lower esophageal sphincter pressure and length and esophageal contraction amplitude before and after ablation were not significantly different. Baseline compliance was significantly different between healthy volunteers and Barretts esophagus patients. Compliance was not, however, significantly changed by ablation. CONCLUSIONS Stepwise circumferential and focal ablation of Barretts esophagus is an effective and safe treatment modality for early Barretts neoplasia that appears to preserve the functional characteristics of the esophagus.

Successful balloon-based radiofrequency ablation of a widespread early squamous cell carcinoma and high-grade dysplasia of the esophagus: a case report

BACKGROUND For selected patients with high-grade dysplasia (HGD) and/or early esophageal squamous cell cancer (ESCC), endoscopic therapy represents a nonsurgical treatment option. For widespread lesions, however, current endoscopic treatment modalities (eg, endoscopic resection, argon plasma coagulation, photodynamic therapy) are associated with considerable drawbacks, of which esophageal stricturing is the most significant. Balloon-based radiofrequency (RF) ablation (HALO System) is a promising technology for endoscopic treatment of Barretts esophagus, and may also play a role in treating widespread HGD and early ESCC. OBJECTIVE We describe a case report of balloon-based RF ablation for HGD and early ESCC. DESIGN Case report. SETTING Tertiary care institution, Academic Medical Center, Amsterdam, The Netherlands. PATIENT A 66-year-old male with a 35-mm large, flat-type ESCC with surrounding HGD. INTERVENTION Balloon-based RF ablation (HALO System). MAIN OUTCOME MEASUREMENTS Endoscopic and histological eradication of HGD and ESCC, and adverse events. RESULTS RF ablation resulted in complete endoscopic and histological eradication of HGD and ESCC without adverse events such as dysphagia or esophageal narrowing. LIMITATIONS Single patient report, limited follow-up. CONCLUSIONS This is the first report of balloon-based RF ablation for esophageal HGD and early ESCC. The treatment resulted in complete eradication of a 35-mm flat ESCC with no adverse events. This suggests that this ablation technique deserves further study for the management of widespread HGD or flat-type ESCC.