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Erschienen in: Current Treatment Options in Gastroenterology 1/2019

19.01.2019 | Esophagus (PG Iyer, Section Editor)

Challenges in Endoscopic Therapy of Dysplastic Barrett’s Esophagus

verfasst von: Aurada Cholapranee, MD, Arvind J Trindade, MD

Erschienen in: Current Treatment Options in Gastroenterology | Ausgabe 1/2019

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Abstract

Purpose of review

Barrett’s esophagus (BE) is the only known measurable factor associated with esophageal adenocarcinoma. The development of endoscopic eradication therapy (EET) has transformed the way BE is managed. Given the fairly recent development of EET, its role in BE is still evolving.

Recent findings

This paper discusses the challenges that endoscopists face at the preprocedural, intraprocedural, and postprocedural stages of BE management. These include challenges in risk stratification, dysplasia detection, ablation methods and dosimetry, choice of resection technique, and management of refractory disease.

Summary

Despite the advances in EET in BE, there remain challenges that this review focuses on. Future research into these challenges will optimize ablation techniques and strategies in the future.
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Zurück zum Zitat •• Pouw RE, Bergman JJ. Safety signal for the simple double ablation regimen when using the Barrx 360 express radiofrequency ablation balloon catheter. Gastroenterology. 2017;153:614 This is a letter to the editors commenting on the interim findings of an ongoing randomized controlled multicenter trial looking at the efficacy and safety of RFA balloon catheter ablation using a standard regimen (2 × 10 J/cm2 with cleaning) versus two simplified regimens a) 2 × 10J/cm2 without cleaning and b) 1 × 10 J/cm2. Their interim findings showed unexpectedly high rates of stricturing (17%) in the 2 × 10 J/cm2 group without cleaning compared with the other two treatment groups. •• Pouw RE, Bergman JJ. Safety signal for the simple double ablation regimen when using the Barrx 360 express radiofrequency ablation balloon catheter. Gastroenterology. 2017;153:614 This is a letter to the editors commenting on the interim findings of an ongoing randomized controlled multicenter trial looking at the efficacy and safety of RFA balloon catheter ablation using a standard regimen (2 × 10 J/cm2 with cleaning) versus two simplified regimens a) 2 × 10J/cm2 without cleaning and b) 1 × 10 J/cm2. Their interim findings showed unexpectedly high rates of stricturing (17%) in the 2 × 10 J/cm2 group without cleaning compared with the other two treatment groups.
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Zurück zum Zitat •• Pouw RE, et al. Simplified versus standard regimen for focal radiofrequency ablation of dysplastic Barrett’s oesophagus: a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol. 2018. https://doi.org/10.1016/S2468-1253(18)30157-2 A simplified RFA regimen of 3 × 15 J/cm2 without cleaning has been shown to be as effective as the standard regimen of 2 × 15 J/cm2 with cleaning; however, it has been showed to be associated with higher stricturing rates. This randomized non-inferiority study looks at a new lower radiofrequency energy regimen of 3 × 12J/cm2 without cleaning versus the standard regimen for focal treatments. The results of this study demonstrated that the lower energy simplified version was noninferior to the standard regimen with no increase in adverse events or stricturing. •• Pouw RE, et al. Simplified versus standard regimen for focal radiofrequency ablation of dysplastic Barrett’s oesophagus: a multicentre randomised controlled trial. Lancet Gastroenterol Hepatol. 2018. https://​doi.​org/​10.​1016/​S2468-1253(18)30157-2 A simplified RFA regimen of 3 × 15 J/cm2 without cleaning has been shown to be as effective as the standard regimen of 2 × 15 J/cm2 with cleaning; however, it has been showed to be associated with higher stricturing rates. This randomized non-inferiority study looks at a new lower radiofrequency energy regimen of 3 × 12J/cm2 without cleaning versus the standard regimen for focal treatments. The results of this study demonstrated that the lower energy simplified version was noninferior to the standard regimen with no increase in adverse events or stricturing.
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Zurück zum Zitat •• Solomon SS, et al. Liquid nitrogen spray cryotherapy is associated with less postprocedural pain than radiofrequency ablation in barrett’s esophagus: a multicenter prospective study. J Clin Gastroenterol. 2018. https://doi.org/10.1097/MCG.0000000000000999 This multicenter prospective study compared focal RFA with liquid nitrogen spray cryotherapy and found that RFA was associated with five times greater odds of pain immediately following the procedure as well as 48 hours postprocedure compared to cryotherapy. •• Solomon SS, et al. Liquid nitrogen spray cryotherapy is associated with less postprocedural pain than radiofrequency ablation in barrett’s esophagus: a multicenter prospective study. J Clin Gastroenterol. 2018. https://​doi.​org/​10.​1097/​MCG.​0000000000000999​ This multicenter prospective study compared focal RFA with liquid nitrogen spray cryotherapy and found that RFA was associated with five times greater odds of pain immediately following the procedure as well as 48 hours postprocedure compared to cryotherapy.
74.
Zurück zum Zitat • van Munster SN, et al. Focal cryoballoon versus radiofrequency ablation of dysplastic Barrett’s esophagus: impact on treatment response and postprocedural pain. Gastrointest Endosc. 2018. https://doi.org/10.1016/j.gie.2018.06.015 This multicenter cohort study looked at the efficacy as well as the degree of postprocedural pain in focal cryoballoon therapy versus RFA. This study found no difference in efficacy for treatment of short-segment BE. However, cryotherapy was associated with less reported pain as well as fewer analgesic use compared with RFA. • van Munster SN, et al. Focal cryoballoon versus radiofrequency ablation of dysplastic Barrett’s esophagus: impact on treatment response and postprocedural pain. Gastrointest Endosc. 2018. https://​doi.​org/​10.​1016/​j.​gie.​2018.​06.​015 This multicenter cohort study looked at the efficacy as well as the degree of postprocedural pain in focal cryoballoon therapy versus RFA. This study found no difference in efficacy for treatment of short-segment BE. However, cryotherapy was associated with less reported pain as well as fewer analgesic use compared with RFA.
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Zurück zum Zitat • Visrodia K, et al. Cryotherapy for persistent Barrett’s esophagus after radiofrequency ablation: a systematic review and meta-analysis. Gastrointest Endosc. 2018;87:1396–1404.e1 This meta-analysis of 11 studies and 148 patients looked at the efficacy of cryoablation as salvage therapy in patients with persistent BE despite prior initial RFA treatment. The study found that cryotherapy successfully achieved CE-D and CE-IM (76% and 46% respectively) in this patient population.CrossRefPubMedPubMedCentral • Visrodia K, et al. Cryotherapy for persistent Barrett’s esophagus after radiofrequency ablation: a systematic review and meta-analysis. Gastrointest Endosc. 2018;87:1396–1404.e1 This meta-analysis of 11 studies and 148 patients looked at the efficacy of cryoablation as salvage therapy in patients with persistent BE despite prior initial RFA treatment. The study found that cryotherapy successfully achieved CE-D and CE-IM (76% and 46% respectively) in this patient population.CrossRefPubMedPubMedCentral
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Zurück zum Zitat •• Komanduri S, et al. recurrence of Barrett’s esophagus is rare following endoscopic eradication therapy coupled with effective reflux control. Am J Gastroenterol. 2017;112:556–66 This 2017 study found that concurrent use of PPI with RFA was associated with a lower number of required RFA sessions to achieve CE-IM as well as lower disease recurrence rates following eradiation therapy.CrossRefPubMed •• Komanduri S, et al. recurrence of Barrett’s esophagus is rare following endoscopic eradication therapy coupled with effective reflux control. Am J Gastroenterol. 2017;112:556–66 This 2017 study found that concurrent use of PPI with RFA was associated with a lower number of required RFA sessions to achieve CE-IM as well as lower disease recurrence rates following eradiation therapy.CrossRefPubMed
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Zurück zum Zitat • Krishnan K, et al. Increased risk for persistent intestinal metaplasia in patients with Barrett’s esophagus and uncontrolled reflux exposure before radiofrequency ablation. Gastroenterology. 2012;143:576–81 This study demonstrated that ongoing mild reflux despite twice a day PPI therapy before initiation of RFA was associated with persistent IM after BE ablation. The study also showed an association between the size of the hiatal hernia and length of BE with persistent IM after RFA.CrossRefPubMedPubMedCentral • Krishnan K, et al. Increased risk for persistent intestinal metaplasia in patients with Barrett’s esophagus and uncontrolled reflux exposure before radiofrequency ablation. Gastroenterology. 2012;143:576–81 This study demonstrated that ongoing mild reflux despite twice a day PPI therapy before initiation of RFA was associated with persistent IM after BE ablation. The study also showed an association between the size of the hiatal hernia and length of BE with persistent IM after RFA.CrossRefPubMedPubMedCentral
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Zurück zum Zitat Skrobić O, Simić A, Radovanović N, Ivanović N, Micev M, Peško P. Significance of Nissen fundoplication after endoscopic radiofrequency ablation of Barrett’s esophagus. Surg Endosc. 2016;30:3802–7.CrossRefPubMed Skrobić O, Simić A, Radovanović N, Ivanović N, Micev M, Peško P. Significance of Nissen fundoplication after endoscopic radiofrequency ablation of Barrett’s esophagus. Surg Endosc. 2016;30:3802–7.CrossRefPubMed
Metadaten
Titel
Challenges in Endoscopic Therapy of Dysplastic Barrett’s Esophagus
verfasst von
Aurada Cholapranee, MD
Arvind J Trindade, MD
Publikationsdatum
19.01.2019
Verlag
Springer US
Erschienen in
Current Treatment Options in Gastroenterology / Ausgabe 1/2019
Print ISSN: 1092-8472
Elektronische ISSN: 1534-309X
DOI
https://doi.org/10.1007/s11938-019-00215-8

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