Barrett's esophagus endoscopic therapy: Difference between revisions

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{{Barrett's esophagus}}
{{Barrett's esophagus}}


{{CMG}}; {{AE}}; {{AMK}}
{{CMG}}; {{AE}}; {{MKK}} {{AMK}}
 
==Overview==
==Overview==


==Endoscopic Therapy==
==Endoscopic Therapy==
[[Several]] [[endoscopic]] [[therapies]] [[are]] [[available]] [[to]] [[treat]] [[severe]] [[dysplasia]] [[and]] [[cancer]]. [[During]] [[these]] [[therapies]], [[the]] [[Barrett’s]] [[lining]] [[is]] [[destroyed]] [[or]] [[the]] [[portion]] [[of]] [[the]] [[lining]] [[that]] [[has]] [[dysplasia]] or [[cancer]] [[is]] [[cut]] [[out]]. [[The]] [[goal]] [[of]] [[the]] [[treatment]] [[is]] [[to]] [[encourage]] [[normal]] [[esophageal]] [[tissue]] [[to]] [[replace]] [[the]] [[destroyed]] [[Barrett’s]] [[lining]]. [[Endoscopic]] [[therapies]] [[are]] [[performed]] [[at]] [[specialty]] [[centers]] [[by]] [[physicians]] [[with]] [[expertise]] [[in]] [[these]] [[procedures]].
Endoscopic therapy is classified into two types:<ref name="pmid27169585">{{cite journal| author=Pophali P, Halland M| title=Barrett's oesophagus: diagnosis and management. | journal=BMJ | year= 2016 | volume= 353 | issue=  | pages= i2373 | pmid=27169585 | doi=10.1136/bmj.i2373 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=&cmd=prlinks&id=27169585  }} </ref><ref name="pmid20875123">{{cite journal |vauthors=Menon D, Stafinski T, Wu H, Lau D, Wong C |title=Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy |journal=BMC Gastroenterol |volume=10 |issue= |pages=111 |year=2010 |pmid=20875123 |pmc=2955687 |doi=10.1186/1471-230X-10-111 |url=}}</ref>
*'''[[Photodynamic therapy]] ([[PDT]])''' :  [[PDT]] [[uses]] [[a]] [[light-sensitizing]] [[agent]] [[called]] [[Photofrin]] [[and]] [[a]] [[laser]] [[to]] [[kill]] [[precancerous]] [[and]] [[cancerous]] [[cells]]. [[Photofrin]] [[is]] [[injected]] [[into]] [[a]] [[vein]] [[and]] [[the]] [[patient]] [[returns]] 48 [[hours]] [[later]]. [[The]] [[laser]] [[light]] [[is]] [[then]] [[passed]] [[through]] [[the]] [[endoscope]] [[and]] [[activates]] [[the]] [[Photofrin]] [[to]] [[destroy]] [[Barrett’s]] [[tissue]] [[in]] [[the]] [[esophagus]]. [[Complications]] [[of]] [[PDT]] [[include]] [[chest pain]], [[nausea]], [[sun]] [[sensitivity]] [[for]] [[several]] [[weeks]], [[and]] [[esophageal strictures]].
*Tissue acquiring therapies are:
*'''Endoscopic mucosal resection (EMR)''': EMR involves lifting the Barrett’s lining and injecting a solution under it or applying suction to it and then cutting it off. The lining is then removed through the endoscope. If EMR is used to treat cancer, an [[endoscopic ultrasound]] is done first to make sure the cancer involves only the top layer of esophageal cells. The ultrasound uses sound waves that bounce off the walls of the esophagus to create a picture on a monitor. Complications of EMR can include bleeding or tearing of the esophagus. EMR is sometimes used in combination with PDT.
**Endoscopic mucosal resection
**Endoscopic submucosal dissection
*Non-tissue acquiring or ablative therapies are:
**Radiofrequency ablation
**Photodynamic therapy
**Cryotherapy
**Argon plasma coagulation
 
===Clinical practice guidelines===
According to the American College of Gastroenterology, indication for the endoscopic therapy in Barrett's esophagus patients are:<ref name="pmid26526079">{{cite journal| author=Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology| title=ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. | journal=Am J Gastroenterol | year= 2016 | volume= 111 | issue= 1 | pages= 30-50; quiz 51 | pmid=26526079 | doi=10.1038/ajg.2015.322 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26526079  }} </ref><ref name="pmid22798736">{{cite journal |vauthors=Amano Y, Kinoshita Y |title=Barrett esophagus: perspectives on its diagnosis and management in asian populations |journal=Gastroenterol Hepatol (N Y) |volume=4 |issue=1 |pages=45–53 |year=2008 |pmid=22798736 |pmc=3394474 |doi= |url=}}</ref>
*Patients with nodularity in Barrett’s esophagus segment should undergo [[endoscopic]] mucosal resection (EMR) of the nodular lesion(s) as the initial diagnostic and therapeutic maneuver. Histologic assessment of the endoscopic mucosal resection specimen should guide further therapy. In subjects with endoscopic mucosal resection specimens demonstrating high-grade dysplasia or intramucosal carcinoma, endoscopic ablative therapy of the remaining Barrett's esophagus should be performed.
*In patients with endoscopic mucosal resection specimens demonstrating neoplasia at a deep margin, residual neoplasia should be assumed, and surgical, systemic, or additional endoscopic therapies should be considered.
*Endoscopic ablative therapies should not be routinely applied to patients with nondysplastic Barrett's esophagus because of their low risk of progression to esophageal adenocarcinoma. Endoscopic eradication therapy is the procedure of choice for patients with confirmed low-grade dysplasia and confirmed high-grade dysplasia
*In patients with T1a esophageal adenocarcinoma, endoscopic therapy is the preferred therapeutic approach, being both effective and well tolerated.
*In patients with T1b esophageal adenocarcinoma, consultation with multidisciplinary surgical oncology team should occur before embarking on endoscopic therapy. In such patients, endoscopic therapy may be an alternative strategy to esophagectomy, especially in those with superficial (sm1) disease with a well-differentiated neoplasm lacking lymphovascular invasion, as well as those who are poor surgical candidates.
*Routine staging of patients with nodular Barrett's esophagus with endoscopic ultrasound or other imaging modalities before EMR has no demonstrated benefit. Given the possibility of over- and understanding, findings of these modalities should not preclude the performance of endoscopic mucosal resection to stage-early neoplasia.
*In patients with the known T1b disease, Endoscopic ultrasound may have a role in assessing and sampling regional lymph nodes, given the increased prevalence of lymph node involvement in these patients compared with the less advanced disease.
*In patients with dysplastic Barrett's esophagus who are to undergo endoscopic ablative therapy for the nonnodular disease, radiofrequency ablation is currently the preferred endoscopic ablative therapy.
 
===Trails===
Among patients with low-grade dysplasia, radiofrequency ablation reduced progression to high grade dysplasia.<ref name="pmid24668102">Phoa KN, van Vilsteren FG, Weusten BL, Bisschops R, Schoon EJ, Ragunath K et al. (2014) [https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&retmode=&cmd=prlinks&id=24668102 Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial.] ''JAMA'' 311 (12):1209-17. [http://dx.doi.org/10.1001/jama.2014.2511 DOI:10.1001/jama.2014.2511] PMID: [https://pubmed.gov/24668102 24668102]</ref>


==References==
==References==

Latest revision as of 18:23, 8 July 2018

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: ; Manpreet Kaur, MD [2] Amresh Kumar MD [3]

Overview

Endoscopic Therapy

Endoscopic therapy is classified into two types:[1][2]

  • Tissue acquiring therapies are:
    • Endoscopic mucosal resection
    • Endoscopic submucosal dissection
  • Non-tissue acquiring or ablative therapies are:
    • Radiofrequency ablation
    • Photodynamic therapy
    • Cryotherapy
    • Argon plasma coagulation

Clinical practice guidelines

According to the American College of Gastroenterology, indication for the endoscopic therapy in Barrett's esophagus patients are:[3][4]

  • Patients with nodularity in Barrett’s esophagus segment should undergo endoscopic mucosal resection (EMR) of the nodular lesion(s) as the initial diagnostic and therapeutic maneuver. Histologic assessment of the endoscopic mucosal resection specimen should guide further therapy. In subjects with endoscopic mucosal resection specimens demonstrating high-grade dysplasia or intramucosal carcinoma, endoscopic ablative therapy of the remaining Barrett's esophagus should be performed.
  • In patients with endoscopic mucosal resection specimens demonstrating neoplasia at a deep margin, residual neoplasia should be assumed, and surgical, systemic, or additional endoscopic therapies should be considered.
  • Endoscopic ablative therapies should not be routinely applied to patients with nondysplastic Barrett's esophagus because of their low risk of progression to esophageal adenocarcinoma. Endoscopic eradication therapy is the procedure of choice for patients with confirmed low-grade dysplasia and confirmed high-grade dysplasia
  • In patients with T1a esophageal adenocarcinoma, endoscopic therapy is the preferred therapeutic approach, being both effective and well tolerated.
  • In patients with T1b esophageal adenocarcinoma, consultation with multidisciplinary surgical oncology team should occur before embarking on endoscopic therapy. In such patients, endoscopic therapy may be an alternative strategy to esophagectomy, especially in those with superficial (sm1) disease with a well-differentiated neoplasm lacking lymphovascular invasion, as well as those who are poor surgical candidates.
  • Routine staging of patients with nodular Barrett's esophagus with endoscopic ultrasound or other imaging modalities before EMR has no demonstrated benefit. Given the possibility of over- and understanding, findings of these modalities should not preclude the performance of endoscopic mucosal resection to stage-early neoplasia.
  • In patients with the known T1b disease, Endoscopic ultrasound may have a role in assessing and sampling regional lymph nodes, given the increased prevalence of lymph node involvement in these patients compared with the less advanced disease.
  • In patients with dysplastic Barrett's esophagus who are to undergo endoscopic ablative therapy for the nonnodular disease, radiofrequency ablation is currently the preferred endoscopic ablative therapy.

Trails

Among patients with low-grade dysplasia, radiofrequency ablation reduced progression to high grade dysplasia.[5]

References

  1. ↑ Pophali P, Halland M (2016). "Barrett's oesophagus: diagnosis and management". BMJ. 353: i2373. doi:10.1136/bmj.i2373. PMID 27169585.
  2. ↑ Menon D, Stafinski T, Wu H, Lau D, Wong C (2010). "Endoscopic treatments for Barrett's esophagus: a systematic review of safety and effectiveness compared to esophagectomy". BMC Gastroenterol. 10: 111. doi:10.1186/1471-230X-10-111. PMC 2955687. PMID 20875123.
  3. ↑ Shaheen NJ, Falk GW, Iyer PG, Gerson LB, American College of Gastroenterology (2016). "ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus". Am J Gastroenterol. 111 (1): 30–50, quiz 51. doi:10.1038/ajg.2015.322. PMID 26526079.
  4. ↑ Amano Y, Kinoshita Y (2008). "Barrett esophagus: perspectives on its diagnosis and management in asian populations". Gastroenterol Hepatol (N Y). 4 (1): 45–53. PMC 3394474. PMID 22798736.
  5. ↑ Phoa KN, van Vilsteren FG, Weusten BL, Bisschops R, Schoon EJ, Ragunath K et al. (2014) Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial. JAMA 311 (12):1209-17. DOI:10.1001/jama.2014.2511 PMID: 24668102

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