Barrett’s Esophagus
Alessandro Repici
Digestive Endoscopy Unit
IRCCS Istituto Clinico Humanitas
Milano
goblets = Barrett‘s
no goblets = no Barrett‘s
Spechler SJ 2000
Definition of Barrett
Barrett‘s Definition
USA: specialized intestinal Metaplasia
UK/Japan: all columnar metaplasia
Europe: specialized intestin...
481 000 new cases (3.8% of the total) oesophageal cancer estimated in 2008
The sixth most common cause of death from cance...
Incidence of BE is increasing in men under
60 years
BE/1000 scop
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
1996...
EAC : lethal, rapidly rising incidence
J Natl Cancer Inst, June 2005
Relative incidence of Esophageal
AdenoCa/other malign...
Risk of progression may be lower
than previously thought
EAC incidence in NDBE
3.3 per 1000 patient years
Desai Gut 2012
Mortality in BE
Sikkema Clin Gastro Hepatology 2010
Key Features for the Endoscopic
Recognition of Barrett’s Esophagus
Locate gastro-oesophageal
junction
Recognise the squamo...
Endoscopic recognition of the
columnar lined esophagus
Endoscopic BE: Prague C&M Criteria
• Based on –
Circumference and
Maximum extent
• Patient with 5 cm
long Barrett’s, dista...
• Endoscopic surveillance using white-light endoscopy (WLE)
• Random 4-quadrant biopsies of every 1 to 2 cm of the BE
segm...
X
X
X
X
X
X
X
X
X
X
X X
Seattle Protocol
2cm
2cm
Disadvantages:
-Time consuming
-Risk of bleeding
-Poor adherence
-Costs f...
Praga & Seattle protocol
• Praga classification adopted in less 40%
• Seattle protocol adherence <50%
• Correct sampling a...
Barrett’s Inspection Time (BIT)
Longer BIT led to more HGD/EAC detection (p=0.001) despite
no difference in BE length (p=0...
What look for and how
• Mucosal irregularities/nodulesMucosal irregularities/nodules
– Acetic acid
– Methylene blue
– Elec...
- Sedation
- Esophagus should be carefully cleaned
- Scope gradually withdrawn in inflated fashion
- Esophagus should grad...
Retroversion
Examination in inflation & deflation
Where is the dysplasia?
Pech et.al. Endoscopy 2007;39:588-593Kariawasan et.al. GIE 2012;75:938-44
New endoscopic modalities to
detect early cancer in BE
CHROMOENDOSCOPY
AUTOFLUORESENCE
ENDOSCOPY
CONFOCAL
ENDOMICROSCOPY
O...
Acetic Acid
• Fortun: APT 2005-15% pts had histologic
upgrade with acetic acid
• Pohl: Endoscopy 2007—sensitivity 87% PV
3...
Disadvantages of Chromoendoscopy
• Operator-dependant
• Labor-intensive
• Requires the use of dyes
• Spraying catheters
• ...
The pathway to BE cancer
Low Grade Dysplasia
High Grade Dysplasia
Intramucosal cancer
→ Architectural changes
→ Architectu...
How dangerous is LGD?
• Low grade dysplasia has 3 - 6% 5yr cancer risk
• Grading dysplasia is difficult for pathologists
•...
110 LGD pts reviewed110 LGD pts reviewed
by 2 expert pathologistsby 2 expert pathologists
87 pts NDBE87 pts NDBE
(80%)(80%...
How dangerous is “real” LGD?
Treatment is related to different factors
• Grade/Stage of BE neoplasia
• Endoscopic morphology (flat vs nodular lesion)
•...
Ideal treatment for LGD (& NDBE)
• Safe (<1% SAE’s for LGD, <0,1 for NDBE)
• Effective (reducing cancer risk)
• Minimally ...
magnified
electrode
Controlled ablation depth by:Controlled ablation depth by:
• Bipolar balloon based electrodeBipolar ba...
Human Esophagus
Muscularis Mucosae
Submucosa
Muscularis Propria
GG
Surgical
Depth
PDT, APC &
Cryo Depth?
Lamina Propria
Ep...
Focal ablation – HALO90
system
A Randomized, Multicenter, Sham Controlled Trial of RF Ablation
• 128 patients with BE and dysplasia (LGD/HGD)
• Mean BE l...
How effective is RFA?
• RFA extensively studied for HGD and early ca
• Often combination of mucosectomy with RFA
• RFA has...
DEFINITION OF HGD AND EARLY CANCERDEFINITION OF HGD AND EARLY CANCER
ON BARRETT’S ESOPHAGUSON BARRETT’S ESOPHAGUS
High-gra...
A 42y old male with IM Ca on BE
How much frequent is HGD on flat Barrett?
• 150 cases of nodular lesions or focal abnormalities
• 143 flat mucosa
• Flat l...
Incidence of lymph node metastasesIncidence of lymph node metastases
Level of infiltrationLevel of infiltration Lymph node...
T1 m1-sm1 Esophageal Adenocarcinoma: a
very low risk of lymphatic dissemination
Westerterp M, Virchows Arch, 2005
*
* Diam...
Prevalence of T1b carcinoma at
esophagectomy for HGD-IMC
• Retrospective study, 60 pts. with HGD or IMC at biopsy.
• Pts. ...
Muscolaris
mucosae
The Paris Endoscopic Classification of Superficial Neoplastic Lesions
Gastrointest Endosc 2003
Cut-off ...
AGA Medical Position Statement
Recommend endoscopic therapy rather than
surveillance for confirmed HGD
Recommend EMR in pa...
The pathway to BE cancer
Low Grade Dysplasia
High Grade Dysplasia
Intramucosal cancer
→ Surveillance or
Radiofrequency
→ E...
Endoscopic approach for early EC is the most
effective and less expensive option:
a decision analysis model
The position o...
Staging of early neoplastic lesionsStaging of early neoplastic lesions
• Mucosal/submucosalMucosal/submucosal
• Isolated l...
Staging dysplasia/early neoplasiadysplasia/early neoplasia in BE
• HD/HR Endoscopy
• Chromoendoscopy and Electronic Chromo...
EC staging by EUS in 266 pts. who had
esophagectomy without induction-CT
• EUS erroneously classified T3-T4 in 42 pts (16%...
Accuracy of EUS in early EC
Proportion of correct
results
EUS
Accuracy
Mucosal
Invasion
Sub-Mucosal
Invasion
Chemaly, Endo...
EUS performance in EC:
overstaging and understaging
Pech O, Endoscopy, 2010
Reasons for poor EUS performance
• Microscopic definition of disease
• Hiatal ernia
• No water assistance
• Duplication of...
Endoscopic Resection (ER)
• ER allows for histological correlation, enabling optimal
selection of patients for endoscopic ...
Endoscopic Resection Techniques
• Standard snare resection
• Cap assisted resection
• Band-ligator assisted
• Submucosal d...
CAP-ASSISTED
WITH BAND-LIGATOR
ER-cap techniqueER-cap technique
Multi-Band Mucosectomy (DuetteR
)
How to chose the right approach
• Location
• Extension of the targeted area
• Presence of visible nodules
4 bleeding10033539Conio
None75472318Mino-
Kenudson
Not reported100452340Larghi
1 bleeding993550115Peck
2 stenosis100243428...
Randomized, controlled trial in tertiary-care and community-care centers.
Piecemeal ER was performed by using ER-cap (n 42...
In this intense, structured training program, the first 120 esophageal endoscopic resections performed by
six participants...
EMR of early cancer and high-grade dysplasia
at distal esophagus and GEJ
• 1120 ERs in 6 years (680 pts)
• Mortality 0
• M...
• “Low-risk”: sm1, type I/II, no vascular or lymphatic
involvement, well or moderately differentiated
• 21 patients: 19 tr...
Combine endoscopic resection & ablationCombine endoscopic resection & ablation
The buried BE glands beneath squamousThe buried BE glands beneath squamous
epitheliumepithelium
A total of 47 patients’ in...
Endotherapy vs Surgery
This Cochrane review has indicated that there are
no randomised control trials to compare managemen...
Prasad A et al Gastroenterology 2009
Retrospective analysis of 178 patients treated by Endoscopy (132)
or Surgery 46
L'esofago di Barrett -  Gastrolearning®
L'esofago di Barrett -  Gastrolearning®
L'esofago di Barrett -  Gastrolearning®
L'esofago di Barrett -  Gastrolearning®
L'esofago di Barrett -  Gastrolearning®
L'esofago di Barrett -  Gastrolearning®
L'esofago di Barrett -  Gastrolearning®
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L'esofago di Barrett - Gastrolearning®

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Gastrolearning II modulo/11a lezione
L'esofago di Barrett
Dott. A. Repici - Istituto Clinico Humanitas, Milano

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  • The Fig on the right shows the relative rate of rise in the incidence of EAC in comparison to other carcinomas (breast, colon, lung, prostate). Compared to other tumors, the rate of rise in EAC is exponential. Animate with arrows
    The figure on the left shows the incidence in comparison to the mortality from EAC and unfortunately both are rising in parallel. This has not changed in the last 3 decades with the 5 year survival being less than 15-20% in cases diagnosed after the onset of symptoms. The rapidly rising incidence of a lethal tumor when diagnosed after the onset of symptoms provides the strongest impetus to attempts at screening and early diagnosis.
  • Finally the rates of progression to EAC are low with a recent metanalysis showing that the incidence of EAC was 6/1000 patient years of follow up. Even addition of HGD to this endpoint only increased the rate to 10/1000 patient years. The causes of death in subjects with BE further reinforce this. Causes of death in BE cohorts further reinforce this : EAC is a cause of death in only 7% of subjects with EAC with the majority dying of Cardiac, Pulmonary causes and other malignancies.
    Hence identification of BE has the potential of helping only a very small subset of the BE cohort
    Have we made any progress in overcoming these multiple limitations?
  • L'esofago di Barrett - Gastrolearning®

    1. 1. Barrett’s Esophagus Alessandro Repici Digestive Endoscopy Unit IRCCS Istituto Clinico Humanitas Milano
    2. 2. goblets = Barrett‘s no goblets = no Barrett‘s Spechler SJ 2000 Definition of Barrett
    3. 3. Barrett‘s Definition USA: specialized intestinal Metaplasia UK/Japan: all columnar metaplasia Europe: specialized intestinal Metaplasia
    4. 4. 481 000 new cases (3.8% of the total) oesophageal cancer estimated in 2008 The sixth most common cause of death from cancer with 406 000 deaths (5.4% of the total). More than 75% of the cases in developing countries are squamous More than 60% of the cases in western countries are adenoca 280 000 new cases of LGD and HGD BE are expected in 2012
    5. 5. Incidence of BE is increasing in men under 60 years BE/1000 scop 0.00 10.00 20.00 30.00 40.00 50.00 60.00 70.00 80.00 1996 1997 1998 1999 2000 2001 2002 2003 Man <60 Man >60 Vrouw <60 Vrouw >60 van Soest et al. Gut 2005
    6. 6. EAC : lethal, rapidly rising incidence J Natl Cancer Inst, June 2005 Relative incidence of Esophageal AdenoCa/other malignancies Disease specific incidence rates/ mortality of Esophageal AdenoCa
    7. 7. Risk of progression may be lower than previously thought EAC incidence in NDBE 3.3 per 1000 patient years Desai Gut 2012
    8. 8. Mortality in BE Sikkema Clin Gastro Hepatology 2010
    9. 9. Key Features for the Endoscopic Recognition of Barrett’s Esophagus Locate gastro-oesophageal junction Recognise the squamocolumnar junction Describe extent consistently
    10. 10. Endoscopic recognition of the columnar lined esophagus
    11. 11. Endoscopic BE: Prague C&M Criteria • Based on – Circumference and Maximum extent • Patient with 5 cm long Barrett’s, distal 2 cm circumferential and proximal 3 cm in form of a tongue Barrett’s: C2M5 C2 M5 Sharma P et al, Gastroenterology 2006
    12. 12. • Endoscopic surveillance using white-light endoscopy (WLE) • Random 4-quadrant biopsies of every 1 to 2 cm of the BE segment (Seattle protocol) • Targeted biopsies of any endoscopically visible lesions Bennett C, Vakil N, Bergman J, et al. Consensus statements for management of Barrett’s dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process. Gastroenterology 2012;143:336–46
    13. 13. X X X X X X X X X X X X Seattle Protocol 2cm 2cm Disadvantages: -Time consuming -Risk of bleeding -Poor adherence -Costs for the health care BSG guidelines 2005; Wang KK, AmJG 2008; Spechler SJ, Gastro 2011 Curvers WL, Eur J Gastro Hep 2008; Abrams JA, Clin Gastro Hep 2009, Wani S, Gastroenterology 2011
    14. 14. Praga & Seattle protocol • Praga classification adopted in less 40% • Seattle protocol adherence <50% • Correct sampling and collection of specimens 35% • High Res/Def scope used randomly • Only those centers with research interest in BE showed excellent compliance Sharma P, DDW 2012
    15. 15. Barrett’s Inspection Time (BIT) Longer BIT led to more HGD/EAC detection (p=0.001) despite no difference in BE length (p=0.10) Gupta N et al. GIE 2012
    16. 16. What look for and how • Mucosal irregularities/nodulesMucosal irregularities/nodules – Acetic acid – Methylene blue – Electronic chromoendoscopy • Pit patternPit pattern – Methylene blue and electronic chromo • Vascular patternVascular pattern – Electronic chromoendoscopy
    17. 17. - Sedation - Esophagus should be carefully cleaned - Scope gradually withdrawn in inflated fashion - Esophagus should gradually be deflated to reveal any irregularities maybe stretched out during inflation - Special attention at area between 12 and 6 o’clock - Inspect in retroflexed position when hiatal hernia Careful and dedicated technique Curvers WL; Endoscopy 2008 Sharma P; IMAGE 2012  “look longer, biopsy less”  “look 2 minutes x cm of Barrett” !!!
    18. 18. Retroversion
    19. 19. Examination in inflation & deflation
    20. 20. Where is the dysplasia? Pech et.al. Endoscopy 2007;39:588-593Kariawasan et.al. GIE 2012;75:938-44
    21. 21. New endoscopic modalities to detect early cancer in BE CHROMOENDOSCOPY AUTOFLUORESENCE ENDOSCOPY CONFOCAL ENDOMICROSCOPY OPTICAL COHERENCE TOMOGRAPHY HIGH RESOLUTION MICRO ENDOSCOPY ENDOCYTOOSCOPY
    22. 22. Acetic Acid • Fortun: APT 2005-15% pts had histologic upgrade with acetic acid • Pohl: Endoscopy 2007—sensitivity 87% PV 39% • Curvers: Gastro 2008—no increased yield of AA over HRE • Longcroft-Wheaton: CGH 2010-specificity 80% sensitivity : 95% • Pohl: AJG 2010: Sensitivity 97% specificity 66%
    23. 23. Disadvantages of Chromoendoscopy • Operator-dependant • Labor-intensive • Requires the use of dyes • Spraying catheters • Unequal distribution of dye
    24. 24. The pathway to BE cancer Low Grade Dysplasia High Grade Dysplasia Intramucosal cancer → Architectural changes → Architectural changes Cellular changes → Architectural changes Cellular changes Macroscopic changes
    25. 25. How dangerous is LGD? • Low grade dysplasia has 3 - 6% 5yr cancer risk • Grading dysplasia is difficult for pathologists • Is low-grade always low-grade? • Amsterdam Gut Club Barrett registry – More than 3000 pts in 16 hospitals – 110 LGD cases diagnosed between ’00-’06
    26. 26. 110 LGD pts reviewed110 LGD pts reviewed by 2 expert pathologistsby 2 expert pathologists 87 pts NDBE87 pts NDBE (80%)(80%) 13 pts Indef13 pts Indef (12%)(12%) 10 pts LGD10 pts LGD (8%)(8%) 60% HGD/Ca60% HGD/Ca60% HGD/Ca60% HGD/CaNo HGD/CaNo HGD/Ca No HGD/CaNo HGD/Ca Median FU of 42 monthsMedian FU of 42 monthsMedian FU of 42 monthsMedian FU of 42 months Pouw et al, GIE 2010
    27. 27. How dangerous is “real” LGD?
    28. 28. Treatment is related to different factors • Grade/Stage of BE neoplasia • Endoscopic morphology (flat vs nodular lesion) • Extension of the neoplasia (multifocal vs single dysplatic area) • Site of the BE • Extension of the BE • Previous treatments
    29. 29. Ideal treatment for LGD (& NDBE) • Safe (<1% SAE’s for LGD, <0,1 for NDBE) • Effective (reducing cancer risk) • Minimally invasive • Obviating need for future surveillance • Not more expensive than ??? yrs of surveillance • EMR? MBM? PDT? RFA? Cryo?
    30. 30. magnified electrode Controlled ablation depth by:Controlled ablation depth by: • Bipolar balloon based electrodeBipolar balloon based electrode • Fixed energy densityFixed energy density • Fixed powerFixed power • Automated RF deliveryAutomated RF delivery
    31. 31. Human Esophagus Muscularis Mucosae Submucosa Muscularis Propria GG Surgical Depth PDT, APC & Cryo Depth? Lamina Propria Epithelium Keys to Endotherapy: 1.Uniform mucosal removal 2.Controlled depth of ablation RFA Depth EMR/ESD Depth
    32. 32. Focal ablation – HALO90 system
    33. 33. A Randomized, Multicenter, Sham Controlled Trial of RF Ablation • 128 patients with BE and dysplasia (LGD/HGD) • Mean BE length 5 cm; 12 month follow up IM Eradication (n=127) LGD Eradication (n=64) HGD Eradication (n=63) 2% 23% 19% 77% * 90% * 81% * Patients % 0 10 20 30 40 50 60 70 80 90 100 SHAM RFA p<0.001 Shaheen N et al. NEJM 2009
    34. 34. How effective is RFA? • RFA extensively studied for HGD and early ca • Often combination of mucosectomy with RFA • RFA has excellent results in expert hands • RFA is only a small part of patient care – High quality endoscopy (team + equipment) – Expert pathology – Counselling – .........
    35. 35. DEFINITION OF HGD AND EARLY CANCERDEFINITION OF HGD AND EARLY CANCER ON BARRETT’S ESOPHAGUSON BARRETT’S ESOPHAGUS High-grade dysplasia exhibits more severe cytologic atypia and greater architectural complexity than does low-grade, but the cutoff between low-grade and high-grade dysplasia is difficult to define. In high grade dysplasia the neoplastic glands are irregularly shaped and are more crowded, separated only by thin strands of fibrovascular tissue.
    36. 36. A 42y old male with IM Ca on BE
    37. 37. How much frequent is HGD on flat Barrett? • 150 cases of nodular lesions or focal abnormalities • 143 flat mucosa • Flat lesions were associated with a reduced risk of HGD or invasive cancer
    38. 38. Incidence of lymph node metastasesIncidence of lymph node metastases Level of infiltrationLevel of infiltration Lymph node (N)Lymph node (N) IM esophagusIM esophagus (Adenoca)(Adenoca) 0.3-0.5%0.3-0.5% IM esophagus (SCC)IM esophagus (SCC) 8%8% Sm1 (Adenoca)Sm1 (Adenoca) 2%2% Sm1 (SCC)Sm1 (SCC) 10-14%10-14% Endoscopic management of BE: rationaleEndoscopic management of BE: rationale
    39. 39. T1 m1-sm1 Esophageal Adenocarcinoma: a very low risk of lymphatic dissemination Westerterp M, Virchows Arch, 2005 * * Diameter of Node+: 12 mm
    40. 40. Prevalence of T1b carcinoma at esophagectomy for HGD-IMC • Retrospective study, 60 pts. with HGD or IMC at biopsy. • Pts. with endoscopic evidence of mass and with EUS evidence of sm invasion were excluded Wang V.S., Gastrointestinal Endoscopy, 2009
    41. 41. Muscolaris mucosae The Paris Endoscopic Classification of Superficial Neoplastic Lesions Gastrointest Endosc 2003 Cut-off limit 500 µ m sm mp Barrett’s Esophagus ENDOSCOPY SURGERY sm1sm1
    42. 42. AGA Medical Position Statement Recommend endoscopic therapy rather than surveillance for confirmed HGD Recommend EMR in patients with visible lesions Strong recommendation Strong recommendation Gastroenterology March 2011
    43. 43. The pathway to BE cancer Low Grade Dysplasia High Grade Dysplasia Intramucosal cancer → Surveillance or Radiofrequency → EMR or Radiofrequency or Combination of ER and RF → EMR or ESD or Radiofrequency or Combination of ER and RF or Surgery
    44. 44. Endoscopic approach for early EC is the most effective and less expensive option: a decision analysis model The position of the threshold is determined by 5-year survival rate after endoscpic therapy among N+ pts: 10%, 20%, 25% Pohl H., Gastrointestinal Endoscopy , 2009
    45. 45. Staging of early neoplastic lesionsStaging of early neoplastic lesions • Mucosal/submucosalMucosal/submucosal • Isolated lesion/multifocal lesionsIsolated lesion/multifocal lesions • Nodes involvementNodes involvement • Distant metastasisDistant metastasis
    46. 46. Staging dysplasia/early neoplasiadysplasia/early neoplasia in BE • HD/HR Endoscopy • Chromoendoscopy and Electronic Chromoendoscopy • Radial EUS • HF miniprobes EUS • Linear EUS with FNA for nodes Mucosal Resection may be considered a strategic staging modality
    47. 47. EC staging by EUS in 266 pts. who had esophagectomy without induction-CT • EUS erroneously classified T3-T4 in 42 pts (16%) • EUS is insesitive for N+, but with high specificity • EUS is completely insensitive for M+ Gregory Zuccaro, Am J Gastroenterol, 2005
    48. 48. Accuracy of EUS in early EC Proportion of correct results EUS Accuracy Mucosal Invasion Sub-Mucosal Invasion Chemaly, Endoscopy 2008 62 13 75/102 73.5 % May , Gut 2004 62 12 74/93 79.6% Larghi, GIE 2005 9 NA 9/15 60.0%
    49. 49. EUS performance in EC: overstaging and understaging Pech O, Endoscopy, 2010
    50. 50. Reasons for poor EUS performance • Microscopic definition of disease • Hiatal ernia • No water assistance • Duplication of muscolaris mucosae
    51. 51. Endoscopic Resection (ER) • ER allows for histological correlation, enabling optimal selection of patients for endoscopic treatment. • However, after focal ER for early Barrett neoplasia, metachronous lesions are observed in 30% during follow-up.
    52. 52. Endoscopic Resection Techniques • Standard snare resection • Cap assisted resection • Band-ligator assisted • Submucosal dissection
    53. 53. CAP-ASSISTED WITH BAND-LIGATOR
    54. 54. ER-cap techniqueER-cap technique
    55. 55. Multi-Band Mucosectomy (DuetteR )
    56. 56. How to chose the right approach • Location • Extension of the targeted area • Presence of visible nodules
    57. 57. 4 bleeding10033539Conio None75472318Mino- Kenudson Not reported100452340Larghi 1 bleeding993550115Peck 2 stenosis100243428May 1 bleeding100131317Buttar None100171525Nijhawan 1 bleeding97141235Ell ComplicationsCompleteb Response Recurrencea % F-up (mo) # Patients Authors a Metachronous/recurrent lesions b End of f-up after multimodality (EMR-APC-PDT) treatment Larghi et al., Gastrointest Endosc Clin N Am 2007 EMR for HGD or IMC (visible lesions)
    58. 58. Randomized, controlled trial in tertiary-care and community-care centers. Piecemeal ER was performed by using ER-cap (n 42) or MBM (n 42). Outcome Measurements: Safety, efficacy, procedure time, costs. Results: Procedure time (34 vs 50 minutes; P .02) and costs (€240 vs €322; P .01) were significantly less with MBM compared with ER-cap. MBM resulted in smaller resection specimens than ER-cap (18 13 mm vs 20 15 mm; P .01). Maximum thicknesses of specimens and resected submucosa were not significantly different. There were no clinically relevant bleeding episodes. Four perforations occurred, 3 with ER- cap, 1 with MBM Rouw PE, GIE 2011
    59. 59. In this intense, structured training program, the first 120 esophageal endoscopic resections performed by six participants were associated with a 5.0% perforation rate5.0% perforation rate. Although perforations were adequately managed, performingperforming 20 endoscopic resections may not be20 endoscopic resections may not be sufficient to reachsufficient to reach the peak of the learning curve in endoscopic resection Van Vilsterein FGI, et al Endoscopy 2012
    60. 60. EMR of early cancer and high-grade dysplasia at distal esophagus and GEJ • 1120 ERs in 6 years (680 pts) • Mortality 0 • Major complications 1.1% (13 patients) Perforation 1 Bleeding 10 (epinephrine, clip) Stenosis 8 (bougienage) • 5-yr survival rate 79% Ell C, UEGW 2010
    61. 61. • “Low-risk”: sm1, type I/II, no vascular or lymphatic involvement, well or moderately differentiated • 21 patients: 19 treated by endoscopy • Complete remission obtained in 95% (18/19) over 5.3 months • ER is associated with favorable outcomes even in case of “low-risk” submucosal Barrett Cancer. Manner H et al AJG 2008
    62. 62. Combine endoscopic resection & ablationCombine endoscopic resection & ablation
    63. 63. The buried BE glands beneath squamousThe buried BE glands beneath squamous epitheliumepithelium A total of 47 patients’ initial mucosectomy slides were reviewed Buried BE underneath the squamous resection margin was identified in 13/47 patients (28%) The linear distance of the Barrett’s epithelium from the resection’s squamous margin ranged from 0.8 to 5.6 mm (mean 2.3 mm and median 1.9 mm). Histopathology revealed nondysplastic buried BE in 3 patients, HGD in 9 patients, and IMC in 1 patient. Chenneat J et al GIE 2010
    64. 64. Endotherapy vs Surgery This Cochrane review has indicated that there are no randomised control trials to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency The problems with such randomised methods are: 1)Standardising surgery and endotherapy 2)Standardising histopathology 3)Assessing which patients are fit or unfit for surgery 4)At least 5 years survival Cochrane Database Syst Rev Apr 2009
    65. 65. Prasad A et al Gastroenterology 2009 Retrospective analysis of 178 patients treated by Endoscopy (132) or Surgery 46

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