Lois L. Hemminger

Prospective, Controlled Tandem Endoscopy Study of Narrow Band Imaging for Dysplasia Detection in Barrett's Esophagus

BACKGROUND & AIMS High-resolution endoscopy with narrow band imaging (NBI) enhances the visualization of mucosal glandular and vascular structures. This study assessed whether narrow band targeted biopsies could detect advanced dysplasia using fewer biopsy samples compared with standard resolution endoscopy. METHODS We conducted a prospective, blinded, tandem endoscopy study in a tertiary care center with 65 patients with Barretts esophagus undergoing evaluation for previously detected dysplasia. Standard resolution endoscopy was used first to detect visible lesions. Narrow band endoscopy was then used by another gastroenterologist to detect and biopsy areas suspicious for dysplasia. The lesions initially detected by standard resolution endoscopy were then disclosed and biopsied, after biopsy of the lesions targeted with NBI. Finally, random 4-quadrant biopsies were taken throughout the segment of Barretts mucosa. RESULTS Higher grades of dysplasia were found by NBI in 12 patients (18%), compared with no cases (0%) in whom standard resolution white light endoscopy with random biopsy detected a higher grade of histology (P < .001). Correspondingly, narrow band directed biopsies detected dysplasia in more patients (n = 37; 57%) compared with biopsies taken using standard resolution endoscopy (n = 28; 43%). In addition, more biopsies were taken using standard resolution endoscopy with random biopsy compared with narrow band targeted biopsies (mean 8.5 versus 4.7; P < .001). CONCLUSIONS In patients evaluated for Barretts esophagus with dysplasia, NBI detected significantly more patients with dysplasia and higher grades of dysplasia with fewer biopsy samples compared with standard resolution endoscopy.

Barrett's esophagus is common in older men and women undergoing screening colonoscopy regardless of reflux symptoms.

BACKGROUND:Although Barretts esophagus (BE) is the precursor of esophageal adenocarcinoma (ACA), most patients with ACA present outside of a BE surveillance program. This could be due to undiagnosed symptomatic GER and BE or BE/ACA occurring in patients without reflux symptoms. We have, therefore, studied the prevalence of BE and symptom status in older patients referred for colonoscopy.METHODSAll patients referred for outpatient colonoscopy were eligible if they were at least 65 yr old and had not previously undergone esophagoscopy. After informed consent, the patients completed detailed GER questionnaires. During the research endoscopy, the endoscopist recorded the squamocolumnar junction (SCJ) as either long-segment BE (LSBE), short-segment BE (SSBE), or normal. If the SCJ was felt to be “irregular” the endoscopist was asked to predict, in their judgment, if BE was present. All patients had biopsies below the SCJ, which were examined by a gastrointestinal pathologist who was blinded to the endoscopic findings.RESULTSBE esophagus was present in 50 of the 300 patients studied (16.7%). BE was more common in men (35 of 161, 21.7%) than in women (15 of 139, 10.8%) (p < 0.025). GERD symptoms were reported in 106 patients (35%) and BE was present in 19.8% of symptomatic and 14.9% of asymptomatic cases (NS). The majority of the BE in this study was less than 3 cm in length (92%). The questionnaires did not predict the presence of BE.CONCLUSIONSBE is common in unscreened male and female patients at least 65 yr of age who are referred for colonoscopy. Men were more likely than women to have BE although it occurred in both sexes. Reflux symptoms were fairly common but a poor predictor of BE.

Clinical experience of patients undergoing photodynamic therapy for Barrett's dysplasia or cancer

Introduction : Barretts oesophagus is the most important risk factor in the increase in incidence of oesophageal adenocarcinoma. Photodynamic therapy using porfimer sodium is the only approved endoscopic treatment for use in patients with Barretts high‐grade dysplasia.

Complications of Endoscopy of the Upper Gastrointestinal Tract: A Single-Center Experience

OBJECTIVE To evaluate prospectively the complications that occurred during consecutive endoscopies of the upper gastrointestinal tract. PATIENTS AND METHODS We evaluated all endoscopies of the upper gastrointestinal tract (except endoscopic retrograde cholangiopancreatography and endosonography) performed at the Ambulatory Surgical Center at the Mayo Clinic in Jacksonville, Fla, between January 1999 and June 2002. A staff gastroenterologist with or without a trainee performed these procedures. Therapeutic procedures included esophageal band ligation, injection sclerotherapy, botulinum toxin injection, extended upper endoscopy, pneumatic balloon dilation, endoscopic mucosal resection, and endoscopic ablation using thermal laser, argon beam coagulator, or photodynamic therapy. All complications were tabulated prospectively as per mandatory state licensure reporting. RESULTS Complications after diagnostic endoscopy of the upper gastrointestinal tract were related to anesthesia in 2 of the 12,841 patients. Perforations in 5 patients were associated with esophageal dilation (2), resection of duodenal lesions (2), or passage of a side-viewing instrument into the duodenum (1). No deaths occurred. CONCLUSIONS Diagnostic endoscopy of the upper gastrointestinal tract is safe, with a complication rate of less than 1 per 5000 cases. Therapeutic endoscopy increases the risk of complications. Compared with complication rates published previously, our results from a single center indicate a favorable reduction in complications related to endoscopy of the upper gastrointestinal tract.

Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma.

Background: Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas. Materials and Methods: All patients with Barrett’s esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT. Results: In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia. Conclusions: The use of EMR resection in Barrett’s high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett’s mucosal adenocarcinoma. EMR should be strongly considered for Barrett’s dysplasia patients being evaluated for endoscopic ablation therapy.

Photodynamic therapy for Barrett's esophagus and high grade dysplasia: results of a patient satisfaction survey.

There are few data available describing the experience of patients who have undergone photodynamic therapy with porfimer sodium for Barrett’s esophagus. We describe the results of a satisfaction survey reported by 16 of 18 patients (11 men, 5 women; median age 75 years; median response at 27 months after treatment) treated with photodynamic therapy for Barrett’s esophagus with high-grade dysplasia. Treatments were performed on an outpatient basis although two patients required clinic visits for intravenous fluids. Subjects reported their most significant post-treatment problem was odynophagia or dysphagia (75%), which was best treated with a hydrocodone bitartrate and acetaminophen elixir (75%). Cutaneous photosensitivity persisted for a median of six weeks; two patients had phototoxic reactions requiring clinic evaluation and treatment. All but two patients reported swallowing problems lasting a median of four weeks, and weight loss (median 6.8 kg). All patients indicated they would again choose photodynamic therapy if they were faced with a similar choice of endoscopic treatment versus surgery for Barrett’s esophagus with high-grade dysplasia. These results indicate a generally high level of satisfaction in patients who have been treated with porfimer sodium photodynamic therapy for Barrett’s esophagus with high-grade dysplasia.

The role of surveillance endoscopy and endosonography after endoscopic ablation of high-grade dysplasia and carcinoma of the esophagus

Barretts esophagus (BE) with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) is at risk of recurrence. The efficacy of endoscopic ultrasound (EUS) for surveillance after PDT is unknown. Our objective was to determine if EUS is superior to esophagogastroduodenoscopy (EGD) and/or CT scan for surveillance of BE neoplasia after PDT. The study was designed as a retrospective review with the setting as a tertiary referral center. Consecutive patients with BE with HGD or carcinoma in situ treated with PDT were followed with EUS, CT scan and EGD with jumbo biopsies every 1 cm at 3, 4, or 6-month intervals. Exclusion criteria was < 6 months of follow up and/or < 2 EUS procedures. Main outcome measurements were residual or recurrent disease discovered by any method. Results showed that 67/97 patients met the inclusion criteria (56 men and 11 women). Median follow-up was 16 months. Recurrent or residual adenocarcinoma (ACA) was detected in four patients during follow-up. EGD with random biopsies or targeted nodule biopsies detected three patients. EUS with endoscopic mucosal resection of the nodule confirmed T1 recurrence in one of these three. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA (fine needle aspiration) confirmed adenocarcinoma. There were two deaths, one related to disease progression and one unrelated. The rate of recurrent/persistent ACA after PDT was 4/67 = 6%. EUS did not detect disease when EGD and CT were normal. Limitations of this study include non-blinding of results and preferential status of non-invasive imaging (CT) over EUS. Our experience suggests that EUS has little role in the surveillance of these patients, unless discrete abnormalities are found on EGD or cross-sectional imaging.

Salvage photodynamic therapy for persistent esophageal cancer after chemoradiation therapy

BACKGROUND Locally advanced esophageal cancer may not be completely eradicated after chemoradiation therapy (CRT) and further treatment options are limited. Since 1998, we have used porfimer sodium photodynamic therapy (PDT) for inoperable patients with persistent mucosal carcinoma after CRT. METHODS Seven patients have undergone PDT after CRT: median age 75 (range 68-85), four patients male, three patients female. After upper endoscopy with biopsies documented neoplasm after CRT, patients were evaluated with contrast-enhanced computed tomography of the chest and abdomen as well as endoscopic ultrasound to confirm persistence/recurrence of only mucosal disease. RESULTS Two patients had squamous carcinoma while five patients had Barretts adenocarcinoma (Barretts median segment length=8cm; range 5-10cm). PDT was performed after infusion of 2mg/kg porfimer sodium using a median light dose of 150J/cm (range 100-200) using the bare fiber method. After PDT, all patients developed strictures requiring dilation (median number of dilations required=5, range 1-18). These patients have subsequently been followed with endoscopy every 3-6 months (mean follow up=30 months, range 12-50 months). After an initial response, the two patients with squamous cell carcinoma have subsequently been found to have recurrent disease and are being treated with erlotinib. The other five patients treated for Barretts carcinoma have remained disease free although one had died 33 months from metastatic colon cancer. CONCLUSION In selected patients, PDT may be useful in the treatment of persistent/recurrent mucosal esophageal cancer after incomplete response to CRT.

Variation in Barrett's esophageal wall thickness: Is it associated with histology or segment length?

Goals To measure esophageal wall thickness (EWT) with endoscopic ultrasound (EUS) in patients with and without Barretts esophagus (BE). Background Segment length and histology are used to evaluate BE. The development of varying depths of ablation therapy has renewed interest in using EUS for BE. Study In this prospective study, EWT measurements were taken from the balloon-mucosal interface to the outer most hyper-echoic line. These measurements were correlated with the highest grade of BE dysplasia and segment length, and then compared with the measurements from control group. Results Between 2004 to 2007, 76 BE patients (69 men, mean age 68 y, 4 ND, 14 low-grade dysplasia, 52 high-grade dysplasia, 6 carcinoma in situ) and 53 normal controls (18 men, mean age 60 y) underwent EUS. The mean EWT was 2.4 mm for controls, 3.1 mm for nondysplastic BE, 3.2 mm for low-grade dysplasia, 3.4 mm for high-grade dysplasia, and 3.9 mm for carcinoma in situ. In the control group of 53 patients, the mean EWT was 2.4 mm. Compared with normal controls, the mean EWT was significantly greater in all histologic subgroups of BE patients (P<0.001). No statistically significant correlation was seen between EWT and BE histology grade. There were no correlations between age, gender, or BE segment length and EWT (P=0.55). Conclusions EWT is greater among patients with BE compared with control patients; however, there were no systematic differences in EWT were found among BE patients, based on histology and segment length.

Resource Utilization and Procedure Parameters for the Stretta Procedure: Comparison with Endoscopic Ultrasonography and Colonoscopy

BACKGROUND No data are available regarding resource utilization of the Stretta procedure and its impact on endoscopy units in comparison with other endoscopy procedures. METHODS This observational cohort study compared the demographic data and procedural parameters for our first 13 cases undergoing the Stretta procedure, with similar endoscopic colonoscopy and ultrasonography (EUS) cases. RESULTS The characteristics of the patients were similar among these groups. The patients undergoing the Stretta procedure required significantly more sedative medication than those undergoing colonoscopy or EUS. The Stretta procedure time and recovery time were significantly longer than the colonoscopy procedure time and recovery time. The Stretta procedure time was also significantly longer than the EUS procedure time, but the Stretta recovery time was not significantly longer than the EUS recovery time. CONCLUSIONS Although this study is small and not randomized, it provides useful information regarding how endoscopic procedures compare with one another. Furthermore, these findings have implications for determining endoscopy unit staffing, work equivalency, and appropriate reimbursement.