Endoscopic Therapy for Barrett’s Esophagus Technique is Everything

1. Endoscopic Therapy for Barrett’s Esophagus
Technique is Everything
Sri Komanduri MD MS
Director of Interventional Endoscopy
Associate Professor of Medicine
Section of Gastroenterology
Feinberg School of Medicine
Northwestern University

2. Endoscopes
 Must use high
definition endoscope
with narrow band
imaging to adequately
delineate suspicious
areas

3. Invasive
Adenocarcinoma
High-grade
dysplasia
Low-grade
dysplasia
Barrett's
metaplasia
Chronic
inflammation
Squamous
esophagus
Accumulate
Genetic
Changes
Injury
Acid & bile reflux
nitrous oxide
Genetics
Gender, race,
? other factors (cox-2)
Evolution of Barrett’s

4. HALO Ablation Catheters
HALO360+
HALO90HALO60
HALOULTRA

5. Circumferential Ablation
Focal Ablation
Courtesy of Covidien Medical

6. Endoscopic images of RFA

9. EMR

10. Layers of the Gastrointestinal Tract
Image Courtesy of Dr. Roy Soetikno

11. Cap-based EMR
 A cap is fitted to the distal tip of the
endoscope allowing suction of a limited
amount of tissue for subsequent
resection
 Comes with a specialty “soft” snare

12. Band Ligation EMR
 Band is applied in the similar manner to
variceal banding
 A pseudopolyp is then created
 The muscularis propria retracts from the
band and thus is not entrapped
 Aim for below the band to ensure
complete resection

13. Band versus Cap
 Have been compared in two prospective studies
– Size of lesions obtained with band is smaller, but depth is not
– Increased complications with cap technique (3/39 with perforation
in cap group, none in band group)

14. Early Esophageal Adenocarcinoma
Risk of lymph node metastases:
• Tis (intraepithelial,HGD) 0
• T1a (intramucosal) 1-2%
• T1b (submucosal) 25%
Hulscher, et al. N Engl J Med 2002;347:1662-1669
Dunbar, Spechler. Am J Gastroenterol 2012;107:850-62

15. Choice of Treatment in Barrett’s is Dependent on Depth
of Disease
Konda VJ, AJG, 2012

16. Efficacy of Circumferental EMR vs. Focal EMR+RFA for
Barrett’s Neoplasia
Circumferential EMR versus Focal EMR+RFA
SRER
(n=25)
ER/RFA
(n=22)
Complete Response -
Neoplasia
100% 96%
Complete Response –
Intestinal Metaplasia
92% 96%
Stricture Formation 88%* 14%*
Therapeutic Sessions 6* 3*
* P < 0.05

17. EMR is not just for “Nodules”
Interobserver Agreement for Mucosal Biopsies and EMR Specimens
Pathology EMR, κ (95% CI), strength of
agreement
Biopsy, κ (95% CI), strength of
agreaement
P value
EAC 0.68(0.63–0.73),substantial 0.71(0.66–0.76),substantial .3
HGD 0.43(0.38–0.48),moderate 0.35(0.3–0.4),fair .018
LGD/IND 0.33(0.28–0.39),fair 0.22(0.17–0.27),fair <.001
NDBE 0.51(0.46–0.56),moderate 0.57(0.52–0.62),moderate .09
Wani S, CGH, 2010

18. Efficacy and Safety of EMR/RFA
• 169 patients with HGD/IMC
– 65 EMR/RFA (nodular dysplasia)
– 104 RFA alone (flat dyplasia)
• EMR/RFA
– CR-D: 94% and CR-IM: 88%
– Strictures: 4/4%
• RFA Alone
– CR-D: 82%, CR-IM: 77%
– Strictures: 7.7%
• DDW 2013: EURO II Final: 132 pts HGD/IMC: 92% CR-D, 87% CR-IM
Take Home Point: This study further validates algorithm of EMR/RFA for nodular
HGD/IMC and RFA for flat disease. Both are safe and effective
Kim H. et al, Gastroint Endoscopy 2012

19. Histologic Caveats for EMR
 Deep resection margin
 Submucosal Invasion
 Lymphovascular invasion
 Tumor differentiation
 Lateral Margin
 Most of these can be determined en bloc or piecemeal
 **More local recurrence post piecemeal (rare)

20.  138 patients EMR for dysplastic BE
 31 % change in diagnosis
– 10% Upstage to EAC, 20% downstage
 EMR is an essential staging and therapeutic modality for EET dysplastic BE
or early esophageal cancer

21. Safety of EMR for HGD
Tomizawa Y et al Am J Gastro 2013

22. RFA
Patient Pearls
• Proper Consent and Discussion Prior is Priceless
• Prepare the patients mentally for pain
• There should be a clear understanding that this a
treatment for Barrett’s NOT GERD
• Involve your surgeons or multifocal HGD/IMC
• Spend some time on post-RFA diet
• A picture is always worth a 1000 words…
• Give them your cell phone number

23. RFA
Clinical Pearls
• Proper Patient Selection/Team Selection
• See All Patients in Clinic first
• MAC is ideal
• Give ample time in patients post EMR
• Stringent protocol for anticoagulation/antiplatelet tx
• Acid suppression is essential (ph/impedance)
• Avoid early endoscopy
• Meet with patients after CR-IM to establish long term GERD plan

24. RFA
Technical Pearls
• Listen to your rep!
• Follow the IFU’s to a tee (Despite intuition)
• Take time sizing
• The smallest measurement is the best one! (Mostly)
• The ULTRA focal ablation device may provide better therapy for some
patients 1st treatment
• Respect the Hiatal Hernia. Make sure the patient understands the fight is not
over after CR, it actually has just begun…

25. RFA
Technical Pearls
• There is a feeling that focal ablation is “easier”. Proper focal therapy
is much more difficult than the 360
• Be meticulous at every step. No cutting corners!
– Confirmation of pathology
– Measurements
– Utilization of mucomyst and NBI
– Cleaning of “all” the coagulum
– Sizing the entire 12+ centimeters
– Good final look and photo documentation
– The Big Brother Theory: Ask for Help

26. Ablation Does not treat GERD

27. RFA Timeline
It is a commitment
Clinic
RFA or
EMR
RFA RFA Biopsy Clinic
2 months 2 months 2 months 1 month
• Your patients should be aware of this timeline. On average they will spend
the next 6-8 months with you
• At least one clinic visit and a minimum of 3 endoscopic procedures
• This is not a one and done
1 month

28. RFA for GAVE

29. RFA for GAVE
Prospective study

30. RFA for AVM’s

31. RFA for Squamous Cell HGIN

32. Endoscopic Therapy of Barrett’s Esophagus:
Take Home Points
 Should I be treating?
 Time commitment
 Training and education
 Proper patient selection
 HGD (EMR skill and EUS availability)
 Access to Multidisciplinary team
 Then Yes!
 The future: Let’s move on from who to ablate and see the forrest from the
trees:
 Biomarkers
 Screening: Transnasal endoscopy, Cytosponge,…

33. Endoscopic Therapy of Barrett’s Esophagus:
Take Home Points
 Are we ready to treat everyone? No!
 Are we ready to treat selectively? Yes!
– Almost all with HGD (EMR/RFA)
– Most with confirmed LGD (RFA)
– Some with NDBE with clinical factors indicating increased risk
 Buried glands and Recurrence:
 Imperative to have proper EMR technique (wide and often!)
 Physiologic testing for incomplete responders to RFA