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1
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Bredenoord AJ, Rancati F, Lin H, Schwartz N, Argov M. Normative values for esophageal functional lumen imaging probe measurements: A meta-analysis. Neurogastroenterol Motil 2022; 34:e14419. [PMID: 35665566 PMCID: PMC9786273 DOI: 10.1111/nmo.14419] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/28/2022] [Accepted: 05/05/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND The functional lumen imaging probe (Endoflip™) is increasingly used for evaluation of patients with esophageal symptoms. To improve the interpretation of Endoflip™ in clinical practice, normative values with appropriate cut-off values are required. METHODS Original clinical studies describing Endoflip™ use for measurements of esophageal motility in healthy adults were considered. Meta-analysis was performed based on published values. RESULTS A total of 17 articles were included in the systematic review, 15 of which were included in the meta-analysis, representing 154 unique subjects. At 40 ml distention, the 5th-95th and 10th-90th percentiles for esophagogastric junction distensibility index (EGJ-DI) were 1.96-10.95 mm2 /mmHg and 2.36-8.95 mm2 /mmHg, respectively. An EGJ-DI below 2 mm2 /mmHg was found in 5.4%, and below 3 mm2 /mmHg in 20.1% of healthy subjects. At 50 ml distention, the 5th-95th and 10th-90th percentiles for EGJ-DI are 2.86-10.66 mm2 /mmHg and 3.28-9.12 mm2 /mmHg, respectively (below 2 mm2 /mmHg: 0.6%, 3 mm2 /mmHg: 6.3%). The 5th-95th and 10th-90th percentiles for EGJ-DI at 60 ml distention were 3.06-8.14 mm2 /mmHg and 3.33-7.18 mm2 /mmHg, respectively (below 2 mm2 /mmHg: 0.0%, 3 mm2 /mmHg: 7%). A clear cut-off for lower values was identified while a large spread in values was observed for upper limits of normal for EGJ-DI for all filling volumes. CONCLUSIONS Given these observations, we recommend using a cut-off of 2 mm2 /mmHg for clinical practice, values below can be considered abnormal. Given that 5.4% of the healthy subjects will have an EGJ-DI below 2 mm2 /mmHg at 40 ml, we recommend using the 50 and 60 ml distention volumes. The clinical use of an upper limit for normality of EGJ-DI seems questionable.
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Affiliation(s)
- Albert J Bredenoord
- Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
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2
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Savarino E, di Pietro M, Bredenoord AJ, Carlson DA, Clarke JO, Khan A, Vela MF, Yadlapati R, Pohl D, Pandolfino JE, Roman S, Gyawali CP. Use of the Functional Lumen Imaging Probe in Clinical Esophagology. Am J Gastroenterol 2020; 115:1786-1796. [PMID: 33156096 PMCID: PMC9380028 DOI: 10.14309/ajg.0000000000000773] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The functional lumen imaging probe (FLIP) measures luminal dimensions using impedance planimetry, performed most often during sedated upper endoscopy. Mechanical properties of the esophageal wall and opening dynamics of the esophagogastric junction (EGJ) can be objectively evaluated in esophageal motor disorders, eosinophilic esophagitis, esophageal strictures, during esophageal surgery and in postsurgical symptomatic states. Distensibility index, the ratio of EGJ cross sectional area to intraballoon pressure, is the most useful FLIP metric. Secondary peristalsis from balloon distension can be displayed topographically as repetitive anterograde or retrograde contractile activity in the esophageal body, similar to high-resolution manometry. Real-time interpretation and postprocessing of FLIP metadata can complement the identification of esophageal outflow obstruction and achalasia, especially when findings are inconclusive from alternate esophageal tests in symptomatic patients. FLIP can complement the diagnosis of achalasia when manometry and barium studies are inconclusive or negative in patients with typical symptoms. FLIP can direct adequacy of disruption of the EGJ in achalasia when used during and immediately after myotomy and pneumatic dilation. Lumen diameter measured using FLIP in eosinophilic esophagitis and in complex strictures can potentially guide management. An abbreviated modification of the Grading of Recommendations Assessment, Development, and Evaluation was used to determine the quality of available evidence and recommendations regarding FLIP utilization. FLIP metrics that are diagnostic or suggestive of an abnormal motor pattern and metrics that define normal esophageal physiology were developed by consensus and are described in this review.
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Affiliation(s)
| | | | | | | | | | | | | | - Rena Yadlapati
- University of California in San Diego, La Jolla, California, USA
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3
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Desprez C, Roman S, Leroi AM, Gourcerol G. The use of impedance planimetry (Endoscopic Functional Lumen Imaging Probe, EndoFLIP ® ) in the gastrointestinal tract: A systematic review. Neurogastroenterol Motil 2020; 32:e13980. [PMID: 32856765 DOI: 10.1111/nmo.13980] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/03/2020] [Accepted: 08/05/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND PURPOSE The EndoFLIP® system is a method of delineating impedance and was first designed to investigate the characteristics of the esophago-gastric junction. In the last decade, its use was widened to investigate other sphincteric and non-sphincteric systems of the gastrointestinal tract. The objective of the present systematic review was to summarize the available data in literature on the use of the EndoFLIP® system in the gastrointestinal tract, including sphincteric and non-sphincteric regions. We performed a systematic review in accordance with recommendations for systematic review using PRISMA guidelines without date restriction, until June 2020, using MEDLINE-PubMed, Cochrane Library, and Google Scholar databases. Only articles written in English were included in the present review. Five hundred and six unique citations were identified from all database combined. Of those, 95 met the inclusion criteria. There was a lack of standardization among studies in terms of anesthetic drugs use, probe placement, and inflation protocol. In most cases, only small cohorts of patients were included. Most studies investigated the EGJ, with a potential use of the EndoFLIP® to identify a subgroup of patients with achalasia and for intraoperative assessment of treatment efficacy in achalasia. However, the use of EndoFLIP® in the esophageal body (esophageal panometry), other esophageal diseases (gastro-esophageal reflux disease, eosinophilic esophagitis), and other sphincter regions (anal canal, pylorus) will need further confirmatory studies. The EndoFLIP® system provides detailed geometric data of the gastrointestinal lumen but further works are needed to determine its use in clinical practice.
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Affiliation(s)
- Charlotte Desprez
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
| | - Sabine Roman
- Digestive Physiology Department, Hospices Civils de Lyon, Hopital H Herriot, Lyon, France
| | - Anne Marie Leroi
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
| | - Guillaume Gourcerol
- Digestive Physiology Department, Rouen University Hospital, Rouen, France
- Nutrition, Brain and Gut Laboratory, INSERM unit 1073, Rouen University Hospital, Rouen, France
- Clinical Investigation Center, CIC-CRB 1404, Rouen University Hospital, Rouen, France
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4
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Wu PI, Sloan JA, Kuribayashi S, Gregersen H. Impedance in the evaluation of the esophagus. Ann N Y Acad Sci 2020; 1481:139-153. [PMID: 32557676 DOI: 10.1111/nyas.14408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/09/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022]
Abstract
The aim of this paper is to review esophageal electrical impedance technologies and to discuss the use of these technologies for physiological measurements, diagnostics, and therapy of esophageal disease. In order to develop a better understanding of the pathophysiology of and improve the diagnosis of esophageal disorders, such as gastroesophageal reflux disease (GERD) and achalasia, several new diagnostic tests, including intraluminal impedance, esophageal mucosal impedance, and the functional luminal imaging probe, have been developed. These technologies have proven valuable for assessment of the esophagus in recent years. They provide information on esophageal flow properties, mucosal integrity, lumen shape, and distensibility in esophageal disorders, in particular for GERD and achalasia. Despite their promise and novel clinical studies, the potential of these technologies has been far from realized. New multidisciplinary approaches will contribute to our understanding and interpretation of esophageal impedance data and disease mechanisms.
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Affiliation(s)
- Peter I Wu
- Department of Gastroenterology and Hepatology, St George Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Joshua A Sloan
- Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Hans Gregersen
- GIOME, Department of Surgery, The Chinese University of Hong Kong, Hong Kong, China
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5
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Chen HM, Li BW, Li LY, Xia L, Chen XB, Shah R, Abdelfatah MM, Jain A, Cassani L, Massaad J, Keilin S, Cai Q. Functional lumen imaging probe in gastrointestinal motility diseases. J Dig Dis 2019; 20:572-577. [PMID: 31498966 DOI: 10.1111/1751-2980.12818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/19/2019] [Accepted: 09/06/2019] [Indexed: 12/11/2022]
Abstract
Dysfunction of gastrointestinal (GI) sphincters, including the lower esophageal sphincter (LES) at the esophagogastric junction (EGJ) and the pyloric sphincter, plays a vital role in GI motility disorders, such as achalasia, gastroesophageal reflux disease (GERD), gastroparesis, and fecal incontinence. Using multi-detector high-resolution impedance planimetry, the functional luminal imaging probe (FLIP) system measures simultaneous data on tissue distensibility and luminal geometry changes in the sphincter in a real-time manner. In this review we focus on the emerging data on FLIP, which can be used as an innovative diagnostic method during endoscopic or surgical procedures in GI motility disorders. Subsequent large, prospective, standardizing studies are needed to validate these findings before it can be put to routine clinical use.
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Affiliation(s)
- Hui Min Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bai Wen Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, Shanghai General Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Lian Yong Li
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, The People's Liberation Army 306th Hospital, Beijing, China
| | - Liang Xia
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi Province, China
| | - Xiang Bo Chen
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Department of Endoscopy, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou, Fujian Province, China
| | - Rushikesh Shah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohamed M Abdelfatah
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Anand Jain
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Lisa Cassani
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA.,Division of Digestive Diseases, Department of Medicine, Atlanta Veterans Affairs Medical Center, Decatur, GA, USA
| | - Julia Massaad
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Steve Keilin
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Qiang Cai
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
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6
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Hirano I, Pandolfino JE, Boeckxstaens GE. Functional Lumen Imaging Probe for the Management of Esophageal Disorders: Expert Review From the Clinical Practice Updates Committee of the AGA Institute. Clin Gastroenterol Hepatol 2017; 15:325-334. [PMID: 28212976 PMCID: PMC5757507 DOI: 10.1016/j.cgh.2016.10.022] [Citation(s) in RCA: 162] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/03/2016] [Accepted: 10/16/2016] [Indexed: 02/06/2023]
Abstract
The functional luminal imaging probe is a Food and Drug Administration-approved measurement tool used to measure simultaneous pressure and diameter to guide management of various upper gastrointestinal disorders. Additionally, this tool is also approved to guide therapy during bariatric procedures and specialized esophageal surgery. Although it has been commercially available since 2009 as the endolumenal functional lumen imaging probe (EndoFLIP), the functional luminal imaging probe has had limited penetrance into clinical settings outside of specialized centers. This is primarily because of a paucity of data supporting its utility in general practice and a lack of standardized protocols and data analysis methodology. However, data are accumulating that are providing guidance regarding emerging applications in the evaluation and management of foregut disorders. This clinical practice update describes the technique and reviews potential indications in achalasia, eosinophilic esophagitis, and gastroesophgeal reflux disease. Best Practice Advice 1: Clinicians should not make a diagnosis or treatment decision based on functional lumen imaging probe (FLIP) assessment alone. Best Practice Advice 2: FLIP assessment is a complementary tool to assess esophagogastric junction opening dynamics and the stiffness of the esophageal wall. Best Practice Advice 3: Utilization should follow distinct protocols and analysis paradigms based on the disease state of interest. Best Practice Advice 4: Clinicians should not utilize FLIP in routine diagnostic assessments of gastroesophageal reflux disease. Best Practice Advice 5: FLIP should not be used to diagnose eosinophilic esophagitis but may have a role in severity assessment and therapeutic monitoring.
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Affiliation(s)
- Ikuo Hirano
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - John E Pandolfino
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Guy E Boeckxstaens
- Department of Gastroenterology, Translational Research Center for Gastrointestinal Disorders, University Hospital Leuven, Catholic University of Leuven, Leuven, Belgium
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7
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Chen JW, Rubenstein JH. Esophagogastric junction distensibility assessed using the functional lumen imaging probe. World J Gastroenterol 2017; 23:1289-1297. [PMID: 28275309 PMCID: PMC5323454 DOI: 10.3748/wjg.v23.i7.1289] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2016] [Revised: 12/08/2016] [Accepted: 12/21/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess reference values in the literature for esophageal distensibility and cross-sectional area in healthy and diseased subjects measured by the functional lumen imaging probe (FLIP).
METHODS Systematic search and review of articles in Medline and Embase pertaining to the use of FLIP in the esophagus was conducted in accordance with the PRISMA guidelines. Cross-sectional area and distensibility at the esophagogastric junction (EGJ) were abstracted for normal subjects, achalasia, and gastroesophageal reflux disease (GERD) patients, stratified by balloon length and volume of inflation.
RESULTS Six achalasia studies (n = 154), 3 GERD (n = 52), and 5 studies including healthy controls (n = 98) were included in the systematic review. Normative data varied widely amongst studies of healthy volunteers. In contrast, studies in achalasia patients uniformly demonstrated low point estimates in distensibility ≤ 1.6 mm2/mmHg prior to treatment that increased to ≥ 3.4 mm2/mmHg following treatment at 40mL bag volume. In GERD patients, distensibility fell to the range of untreated achalasia (≤ 2.85 mm2/mmHg) following fundoplication.
CONCLUSION FLIP may be a useful tool in assessment of treatment efficacy in achalasia. The drastic drop in EGJ distensibility after fundoplication suggests that FLIP measurements need to be interpreted in the context of esophageal body motility and highlights the importance of pre-operative screening for dysmotility. Future studies using standardized FLIP protocol and balloon size are needed.
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8
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Savarino E, Ottonello A, Tolone S, Bartolo O, Baeg MK, Farjah F, Kuribayashi S, Shetler KP, Lottrup C, Stein E. Novel insights into esophageal diagnostic procedures. Ann N Y Acad Sci 2016; 1380:162-177. [PMID: 27681220 DOI: 10.1111/nyas.13255] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 08/12/2016] [Accepted: 08/22/2016] [Indexed: 12/14/2022]
Abstract
The 21st century offers new advances in diagnostic procedures and protocols in the management of esophageal diseases. This review highlights the most recent advances in esophageal diagnostic technologies, including clinical applications of novel endoscopic devices, such as ultrathin endoscopy and confocal laser endomicroscopy for diagnosis and management of Barrett's esophagus; novel parameters and protocols in high-resolution esophageal manometry for the identification and better classification of motility abnormalities; innovative connections between esophageal motility disorder diagnosis and detection of gastroesophageal reflux disease (GERD); impedance-pH testing for detecting the various GERD phenotypes; performance of distensibility testing for better pathophysiological knowledge of the esophagus and other gastrointestinal abnormalities; and a modern view of positron emission tomography scanning in metastatic disease detection in the era of accountability as a model for examining other new technologies. We now have better tools than ever for the detection of esophageal diseases and disorders, and emerging data are helping to define how well these tools change management and provide value to clinicians. This review features novel insights from multidisciplinary perspectives, including both surgical and medical perspectives, into these new tools, and it offers guidance on the use of novel technologies in clinical practice and future directions for research.
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Affiliation(s)
- Edoardo Savarino
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy.
| | - Andrea Ottonello
- Department of Surgical and Diagnostic Integrated Sciences, University of Genoa, Genoa, Italy
| | - Salvatore Tolone
- Division of General and Bariatric Surgery, Department of Surgery, Second University of Naples, Naples, Italy
| | - Ottavia Bartolo
- Division of Gastroenterology, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Myong Ki Baeg
- Division of Gastroenterology, Department of Internal Medicine, Catholic Kwandong University College of Medicine, International St. Mary's Hospital, Incheon, South Korea
| | - Farhood Farjah
- Division of Cardiothoracic Surgery, Surgical Outcomes Research Center, University of Washington, Seattle, Washington
| | - Shiko Kuribayashi
- Department of Gastroenterology and Hepatology, Gunma University Hospital, Maebashi, Japan
| | - Katerina P Shetler
- Division of Gastroenterology, Palo Alto Medical Foundation, Mountain View, California
| | - Christian Lottrup
- Department of Gastroenterology and Hepatology, Mech-Sense, Aalborg University Hospital, Aalborg, Denmark.,Department of Medicine, North Jutland Regional Hospital, Hjørring, Denmark
| | - Ellen Stein
- Division of Gastroenterology and Hepatology, Department of Medicine, Johns Hopkins University, Baltimore, Maryland
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9
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Macías-García F, Domínguez-Muñoz JE. Update on management of Barrett's esophagus. World J Gastrointest Pharmacol Ther 2016; 7:227-234. [PMID: 27158538 PMCID: PMC4848245 DOI: 10.4292/wjgpt.v7.i2.227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 10/15/2015] [Accepted: 02/16/2016] [Indexed: 02/06/2023] Open
Abstract
Barrett's esophagus (BE) is a common condition that develops as a consequence of gastroesophageal reflux disease. The significance of Barrett's metaplasia is that predisposes to cancer development. This article provides a current evidence-based review for the management of BE and related early neoplasia. Controversial issues that impact the management of patients with BE, including definition, screening, clinical aspects, diagnosis, surveillance, and management of dysplasia and early cancer have been assessed.
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10
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Lottrup C, Gregersen H, Liao D, Fynne L, Frøkjær JB, Krogh K, Regan J, Kunwald P, McMahon BP. Functional lumen imaging of the gastrointestinal tract. J Gastroenterol 2015; 50:1005-16. [PMID: 25980822 DOI: 10.1007/s00535-015-1087-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Accepted: 04/28/2015] [Indexed: 02/04/2023]
Abstract
This nonsystematic review aims to describe recent developments in the use of functional lumen imaging in the gastrointestinal tract stimulated by the introduction of the functional lumen imaging probe. When ingested food in liquid and solid form is transported along the gastrointestinal tract, sphincters provide an important role in the flow and control of these contents. Inadequate function of sphincters is the basis of many gastrointestinal diseases. Despite this, traditional methods of sphincter diagnosis and measurement such as fluoroscopy, manometry, and the barostat are limited in what they can tell us. It has long been thought that measurement of sphincter function through resistance to distension is a better approach, now more commonly known as distensibility testing. The functional lumen imaging probe is the first medical measurement device that purports in a practical way to provide geometric profiling and measurement of distensibility in sphincters. With use of impedance planimetry, an axial series of cross-sectional areas and pressure in a catheter-mounted allantoid bag are used for the calculation of distensibility parameters. The technique has been trialed in many valvular areas of the gastrointestinal tract, including the upper esophageal sphincter, the esophagogastric junction, and the anorectal region. It has shown potential in the biomechanical assessment of sphincter function and characterization of swallowing disorders, gastroesophageal reflux disease, eosinophilic esophagitis, achalasia, and fecal incontinence. From this early work, the functional lumen imaging technique has the potential to contribute to a better and more physiological understanding of narrowing regions in the gastrointestinal tract in general and sphincters in particular.
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Affiliation(s)
- Christian Lottrup
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark.
| | - Hans Gregersen
- GIOME and the Key Laboratory for Biorheological Science and Technology of Ministry of Education, Bioengineering College of Chongqing University, 83 Shabei Lu, 400044, Chongqing, China.
| | - Donghua Liao
- GIOME Academia, Department of Medicine, Aarhus University, Aarhus, Denmark
| | - Lotte Fynne
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Jens Brøndum Frøkjær
- Mech-Sense, Department of Radiology, Aalborg University Hospital, Aalborg, Denmark.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Klaus Krogh
- Neurogastroenterology Unit, Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Julie Regan
- Trinity Academic Gastroenterology Group, Tallaght Hospital, Dublin, Ireland
| | - Peter Kunwald
- Mech-Sense, Department of Gastroenterology and Hepatology, Aalborg University Hospital, Aalborg, Denmark
| | - Barry P McMahon
- GIOME and the Key Laboratory for Biorheological Science and Technology of Ministry of Education, Bioengineering College of Chongqing University, 83 Shabei Lu, 400044, Chongqing, China.,Trinity Academic Gastroenterology Group, Tallaght Hospital, Dublin, Ireland
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11
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Evaluation of esophageal motility after endoscopic submucosal dissection for superficial esophageal cancer. Eur J Gastroenterol Hepatol 2015. [PMID: 26225867 DOI: 10.1097/meg.0000000000000431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is a standard treatment for superficial esophageal cancer. Some patients complain of dysphagia after ESD even without any postoperative strictures. Although ineffective esophageal motility might be associated with dysphagia after ESD, its effect on esophageal motility after ESD remains unknown. Therefore, we aimed to elucidate esophageal motility after ESD and the cause of dysphagia using high-resolution manometry (HRM). PATIENTS AND METHODS Seventy-six patients (men/women, 64/12; mean age, 71.2 years) who had undergone ESD for superficial esophageal cancer were enrolled. The results of ESD were retrospectively investigated using endoscopic images from the ESD and patient questionnaire for dysphagia. Each patient underwent HRM, and the results were evaluated using metrics and contraction patterns, according to the Chicago classification. RESULTS Data were obtained from 71 patients. The circumferential mucosal defect ratio (β=0.284, P=0.017), number of ESD (β=0.346, P=0.003), and number of endoscopic balloon dilatations (EBDs) (β=0.416, P<0.001) were correlated with the number of weak contraction with large breaks on HRM. The circumferential mucosal defect (odds ratio=1.074, P<0.001) and number of EBDs (odds ratio=1.200, P=0.035) were also significant predictors for dysphagia after ESD. CONCLUSION Circumferential mucosal defect ratio, EBD, and repeated ESD were predictors for impaired esophageal motility after ESD. Because circumferential mucosal defect ratios and EBD were also correlated with dysphagia after ESD, impaired esophageal motility could explain dysphagia after ESD.
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12
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Ablative therapy for esophageal dysplasia and early malignancy: focus on RFA. BIOMED RESEARCH INTERNATIONAL 2014; 2014:642063. [PMID: 25140320 PMCID: PMC4129136 DOI: 10.1155/2014/642063] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 07/07/2014] [Indexed: 02/07/2023]
Abstract
Ablative therapies have been utilized with increasing frequency for the treatment of Barrett's esophagus with and without dysplasia. Multiple modalities are available for topical ablation of the esophagus, but radiofrequency ablation (RFA) remains the most commonly used. There have been significant advances in technique since the introduction of RFA. The aim of this paper is to review the indications, techniques, outcomes, and most common complications following esophageal ablation with RFA.
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Abstract
Esophageal cancer (EsC) is one of the least studied and deadliest cancers worldwide because of its extremely aggressive nature and poor survival rate. It ranks sixth among all cancers in mortality. In retrospective studies of EsC, smoking, hot tea drinking, red meat consumption, poor oral health, low intake of fresh fruit and vegetables, and low socioeconomic status have been associated with a higher risk of esophageal squamous cell carcinoma. Barrett's esophagus is clearly recognized as a risk factor for EsC, and dysplasia remains the only factor useful for identifying patients at increased risk, for the development of esophageal adenocarcinoma in clinical practice. Here, we investigated the epidemiologic patterns and causes of EsC. Using population based cancer data from the Surveillance, Epidemiology and End Results Program of the United States; we generated the most up-to-date stage distribution and 5-year relative survival by stage at diagnosis for 1998-2009. Special note should be given to the fact that esophageal cancer, mainly adenocarcinoma, is one of the very few cancers that is contributing to increasing death rates (20%) among males in the United States. To further explore the mechanism of development of EsC will hopefully decrease the incidence of EsC and improve outcomes.
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14
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Radiofrequency ablation of Barrett’s esophagus and early cancer within the background of the pathophysiology of the disease. Eur Surg 2012. [DOI: 10.1007/s10353-012-0183-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Rohof WO, Hirsch DP, Kessing BF, Boeckxstaens GE. Efficacy of treatment for patients with achalasia depends on the distensibility of the esophagogastric junction. Gastroenterology 2012; 143:328-35. [PMID: 22562023 DOI: 10.1053/j.gastro.2012.04.048] [Citation(s) in RCA: 209] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2012] [Revised: 04/02/2012] [Accepted: 04/24/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Many patients with persistent dysphagia and regurgitation after therapy have low or no lower esophageal sphincter (LES) pressure. Distensibility of the esophagogastric junction (EGJ) largely determines esophageal emptying. We investigated whether assessment of the distensibility of the EGJ is a better and more integrated parameter than LES pressure for determining efficacy of treatment for patients with achalasia. METHODS We measured distensibility of the EGJ using an endoscopic functional luminal imaging probe (EndoFLIP) in 15 healthy volunteers (controls; 8 male; age, 40 ± 4.1 years) and 30 patients with achalasia (16 male; age, 51 ± 3.1 years). Patients were also assessed by esophageal manometry and a timed barium esophagogram. Symptom scores were assessed using the Eckardt score, with a score <4 indicating treatment success. The effect of initial and additional treatment on distensibility and symptoms was evaluated in 7 and 5 patients, respectively. RESULTS EGJ distensibility was significantly reduced in untreated patients with achalasia compared with controls (0.7 ± 0.9 vs 6.3 ± 0.7 mm(2)/mm Hg; P < .001). In patients with achalasia, EGJ distensibility correlated with esophageal emptying (r = -0.72; P < .01) and symptoms (r = 0.61; P < .01) and was significantly increased with treatment. EGJ distensibility was significantly higher in patients successfully treated (Eckardt score <3) compared with those with an Eckardt score >3 (1.6 ± 0.3 vs 4.4 ± 0.5 mm(2)/mm Hg; P = .001). Even when LES pressure was low, EGJ distensibility could be reduced, which was associated with impaired emptying and recurrent symptoms. CONCLUSIONS EGJ distensibility is impaired in patients with achalasia and, in contrast to LES pressure, is associated with esophageal emptying and clinical response. Assessment of EGJ distensibility by EndoFLIP is a better parameter than LES pressure for evaluating efficacy of treatment for achalasia.
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Affiliation(s)
- Wout O Rohof
- Department of Gastroenterology & Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Bennett C, Vakil N, Bergman J, Harrison R, Odze R, Vieth M, Sanders S, Gay L, Pech O, Longcroft-Wheaton G, Romero Y, Inadomi J, Tack J, Corley DA, Manner H, Green S, Al Dulaimi D, Ali H, Allum B, Anderson M, Curtis H, Falk G, Fennerty MB, Fullarton G, Krishnadath K, Meltzer SJ, Armstrong D, Ganz R, Cengia G, Going JJ, Goldblum J, Gordon C, Grabsch H, Haigh C, Hongo M, Johnston D, Forbes-Young R, Kay E, Kaye P, Lerut T, Lovat LB, Lundell L, Mairs P, Shimoda T, Spechler S, Sontag S, Malfertheiner P, Murray I, Nanji M, Poller D, Ragunath K, Regula J, Cestari R, Shepherd N, Singh R, Stein HJ, Talley NJ, Galmiche JP, Tham TCK, Watson P, Yerian L, Rugge M, Rice TW, Hart J, Gittens S, Hewin D, Hochberger J, Kahrilas P, Preston S, Sampliner R, Sharma P, Stuart R, Wang K, Waxman I, Abley C, Loft D, Penman I, Shaheen NJ, Chak A, Davies G, Dunn L, Falck-Ytter Y, Decaestecker J, Bhandari P, Ell C, Griffin SM, Attwood S, Barr H, Allen J, Ferguson MK, Moayyedi P, Jankowski JAZ. Consensus statements for management of Barrett's dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process. Gastroenterology 2012; 143:336-346. [PMID: 22537613 PMCID: PMC5538857 DOI: 10.1053/j.gastro.2012.04.032] [Citation(s) in RCA: 284] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2011] [Revised: 03/26/2012] [Accepted: 04/06/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett's esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA. METHODS We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement. RESULTS Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated. CONCLUSIONS We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.
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Zemlyak AY, Pacicco T, Mahmud EM, Tsirline VB, Belyansky I, Walters A, Heniford BT. Radiofrequency ablation offers a Reliable Surgical Modality for the Treatment of Barrett's Esophagus with a Minimal Learning Curve. Am Surg 2012. [DOI: 10.1177/000313481207800717] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Radiofrequency ablation (RFA) has gained popularity as treatment for Barrett's esophagus. Inclusive series of patients from initiation of our Barrett's Therapy Program were studied. Review of patients undergoing RFA for Barrett's was performed from September 2008 to May 2011. Patients’ outcomes were recorded and analyzed using standard statistical methods. Seventy patients were treated. Average age was 61 (28–70); 80 per cent were male. Seventy-four per cent had dysplasia; 44 low-grade and eight high-grade. A total of 75.7 per cent of patients had long and 24.3 per cent had short segment Barrett's. Procedures per patient ranged from one to seven. Number of treatments in long- and short-segment groups were not different ( P = 0.11). The maximum number of treatments in the short-segment group was five with a median of three (44.3%). For long segment, the maximum of RFA procedures was seven, with a median of three (30.8%). Average procedure time was 20.8 minutes for long and 17.9 minutes for short segment. Mean follow-up was 16.1 (2–38) months. Complete response was accomplished in 81 per cent. There were 93.3 per cent of complete responders in the short-segment group versus 75 per cent in the long ( P = 0.24). Complications included dysphagia (1), transient chest and cervical pain (1), and abdominal pain (1). Comparing the first 25 per cent of the RFA procedures to the later 75 per cent or first 50 per cent to second 50 per cent, there was no difference in operative time or complications. Two patients recurred, both in the long-segment group. RFA is a safe and effective means to eradicate Barrett's. By measure of treatment time, complication rate, and efficacy of therapy, there is minimal or no “learning curve” for experienced endoscopists.
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Affiliation(s)
- Alla Y. Zemlyak
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Thomas Pacicco
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Ebrahem M. Mahmud
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Victor B. Tsirline
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Igor Belyansky
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - Amanda Walters
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
| | - B. Todd Heniford
- Division of Gastrointestinal Medicine, Charlotte Medical Clinic, Division of Gastrointestinal and Minimally Invasive Surgery, Carolinas Laparoscopic and Advanced Surgery Program, Carolinas Medical Center, Charlotte, North Carolina
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Komanduri S. Endoscopic therapies for Barrett's-associated dysplasia: a new paradigm for a new decade. Expert Rev Gastroenterol Hepatol 2012; 6:291-300. [PMID: 22646252 DOI: 10.1586/egh.12.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The emergence of endoscopic therapies for Barrett's esophagus (BE)-associated dysplasia has significantly altered the management of this complex disease. Over the past decade, there has been a paradigm shift from that of pure surveillance to a more therapeutic approach in eradicating dysplastic BE. This strategy includes less invasive options than esophagectomy for high-grade dysplasia and early eradication of confirmed low-grade dysplasia. Although multiple modalities exist for endoscopic therapy, endoscopic mucosal resection coupled with radiofrequency ablation appears to be the most effective therapy, with minimal complications. Recent advances in endoscopic eradication therapies for dysplastic BE have fueled excitement for a significant weapon against the rising incidence of esophageal cancer.
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Affiliation(s)
- Sri Komanduri
- Division of Gastroenterology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA.
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Ortiz-Fernández-Sordo J, Parra-Blanco A, García-Varona A, Rodríguez-Peláez M, Madrigal-Hoyos E, Waxman I, Rodrigo L. Endoscopic resection techniques and ablative therapies for Barrett's neoplasia. World J Gastrointest Endosc 2011; 3:171-182. [PMID: 21954414 PMCID: PMC3180609 DOI: 10.4253/wjge.v3.i9.171] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Revised: 07/04/2011] [Accepted: 08/15/2011] [Indexed: 02/05/2023] Open
Abstract
Esophageal adenocarcinoma is the most rapidly increasing cancer in western countries. High-grade dysplasia (HGD) arising from Barrett's esophagus (BE) is the most important risk factor for its development, and when it is present the reported incidence is up to 10% per patient-year. Adenocarcinoma in the setting of BE develops through a well known histological sequence, from non-dysplastic Barrett's to low grade dysplasia and then HGD and cancer. Endoscopic surveillance programs have been established to detect the presence of neoplasia at a potentially curative stage. Newly developed endoscopic treatments have dramatically changed the therapeutic approach of BE. When neoplasia is confined to the mucosal layer the risk for developing lymph node metastasis is negligible and can be successfully eradicated by an endoscopic approach, offering a curative intention treatment with minimal invasiveness. Endoscopic therapies include resection techniques, also known as tissue-acquiring modalities, and ablation therapies or non-tissue acquiring modalities. The aim of endoscopic treatment is to eradicate the whole Barrett's segment, since the risk of developing synchronous and metachronous lesions due to the persistence of molecular aberrations in the residual epithelium is well established.
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Affiliation(s)
- Jacobo Ortiz-Fernández-Sordo
- Jacobo Ortiz-Fernández-Sordo, Adolfo Parra-Blanco, Endoscopy Unit, Department of Gastroenterology, Central University Hospital of Asturias, Celestino Villamil S/N, Oviedo 33006, Asturias, Spain
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Alvarez Herrero L, van Vilsteren FGI, Pouw RE, ten Kate FJW, Visser M, Seldenrijk CA, van Berge Henegouwen MI, Fockens P, Weusten BLAM, Bergman JJGHM. Endoscopic radiofrequency ablation combined with endoscopic resection for early neoplasia in Barrett's esophagus longer than 10 cm. Gastrointest Endosc 2011; 73:682-90. [PMID: 21292262 DOI: 10.1016/j.gie.2010.11.016] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 11/08/2010] [Indexed: 12/15/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) is safe and effective for eradicating Barrett's esophagus (BE) and BE-associated early neoplasia. Most RFA studies have limited the baseline length of BE (<10 cm), and therefore little is known about RFA for longer BE. OBJECTIVE To assess the safety and efficacy of RFA with or without prior endoscopic resection (ER) for BE ≥ 10 cm containing neoplasia. DESIGN Prospective trial. SETTING Two tertiary-care centers. PATIENTS This study involved consecutive patients with BE ≥ 10 cm with early neoplasia. INTERVENTION Focal ER for visible abnormalities, followed by a maximum of 2 circumferential and 3 focal RFA procedures every 2 to 3 months until complete remission. MAIN OUTCOME MEASUREMENTS Complete remission, defined as endoscopic resolution of BE and no intestinal metaplasia (CR-IM) or neoplasia (CR-neoplasia) in biopsy specimens. RESULTS Of the 26 patients included, 18 underwent ER for visible abnormalities before RFA. The ER specimens showed early cancer in 11, high-grade intraepithelial neoplasia (HGIN) in 6, and low-grade intraepithelial neoplasia (LGIN) in 1. The worst residual histology, before RFA and after any ER, was HGIN in 16 patients and LGIN in 10 patients. CR-neoplasia and CR-IM were achieved in 83% (95% confidence interval [CI], 63%-95%) and 79% (95% CI, 58%-93%), respectively. None of the patients had fatal or severe complications and 15% (95% CI, 4%-35%) had moderate complications. During a mean (± standard deviation) follow-up of 29 (± 9.1) months, no neoplasia recurred. LIMITATIONS Tertiary-care center, short follow-up. CONCLUSION ER for visible abnormalities, followed by RFA of residual BE is a safe and effective treatment for BE ≥ 10 cm containing neoplasia, with a low chance of recurrence of neoplasia or BE during follow-up.
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Affiliation(s)
- Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
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Boeckxstaens GE. Alterations confined to the gastro-oesophageal junction: the relationship between low LOSP, TLOSRs, hiatus hernia and acid pocket. Best Pract Res Clin Gastroenterol 2010; 24:821-9. [PMID: 21126696 DOI: 10.1016/j.bpg.2010.08.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Accepted: 08/28/2010] [Indexed: 01/31/2023]
Abstract
The gastro-oesophageal junction is a specialised segment of the gut designed to prevent reflux of gastric contents into the oesophagus. This task is fulfilled by two structures, i.e. the lower oesophageal sphincter and the crural diaphragm, which generate a high pressure zone. Especially during low pressure at the junction, as in case of long-lasting transient lower oesophageal sphincter relaxations, reflux can occur but mainly if a positive pressure gradient exists between stomach and the oesphagogastric junction. Although patients with gastro-oesophageal reflux disease have increased oesophageal acid exposure compared to controls, the number of transient relaxations is not increased compared to healthy controls. Instead, the risk to have acid reflux is at least doubled in patients, especially in those with a hiatal hernia, most likely as a result of the supradiaphragmatic position of the acid pocket. In hiatal hernia patients, the acid pocket is indeed often trapped in the hernia above the diaphragm. Which factors exactly determine the physical composition (liquid or gas) and the proximal extent of the refluxate however requires further research.
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Affiliation(s)
- Guy E Boeckxstaens
- Department of Gastroenterology, University Hospital of Leuven, Catholic University of Leuven, Belgium.
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Bisschops R. Optimal endoluminal treatment of Barrett's esophagus: integrating novel strategies into clinical practice. Expert Rev Gastroenterol Hepatol 2010; 4:319-33. [PMID: 20528119 DOI: 10.1586/egh.10.20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Endoluminal therapy has become the first-choice treatment over the last 5 years for early Barrett's neoplasia limited to the mucosa. Long-term follow-up data on endoscopic resection have demonstrated the oncological safety of endoscopic resection in comparison to surgery. However, there is a high rate of recurrent disease, which can be avoided using additional ablation of the remaining Barrett. Radiofrequency ablation was recently introduced as an efficacious means to ablate Barrett's epithelium with a better safety profile than older ablation techniques. Recent studies show that endoscopic resection can be safely combined with radiofrequency ablation for treating dysplastic Barrett's after removal of visible lesions. This constitutes a completely new treatment paradigm that will be integrated in routine clinical practice in the forthcoming years.
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Affiliation(s)
- Raf Bisschops
- University Hospital Leuven, Department of Gatsroenterology, 49 Herestraat, 3000 Leuven, Belgium.
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A systematic review of the evidence for radiofrequency ablation for Barrett's esophagus. Surg Endosc 2010. [PMID: 20464420 DOI: 10.1007/s00464-010-1087] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Radiofrequency ablation with the HALO system is a new option for the treatment of patients with Barrett's esophagus. This systematic review summarizes the results of all relevant publications on this topic to answer patient-relevant clinical questions and to evaluate the potential benefit and harm of this new therapy. METHODS A systematic literature search of MEDLINE and CENTRAL up to May 2009 was performed. To identify the relevant literature, references were evaluated by two reviewers independently. The inclusion criteria for the review required that studies investigated patients with Barrett's esophagus, used radiofrequency ablation as the intervention, and had a minimum follow-up period of 12 months. RESULTS A total of nine relevant observational studies (involving 429 patients) were identified. Complete eradication of Barrett's esophagus dysplasia and metaplasia was achieved respectively for 71-100% and for 46-100% of the patients. Only six cases of stenosis and one case of buried intestinal metaplasia were reported among all the patients. Only a few mild adverse events were reported. CONCLUSIONS Based on the evidence of observational studies, the summary of the current data suggests that radiofrequency ablation with the HALO system could be a promising method associated with a low complication rate, low risk of stricture formations, and a minor probability of buried glands. To evaluate the potential benefit at a higher level of evidence, randomized controlled trials (RCTs) involving a direct comparison with other more established endoscopic methods such as photodynamic therapy are necessary.
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24
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A systematic review of the evidence for radiofrequency ablation for Barrett's esophagus. Surg Endosc 2010; 24:2935-43. [PMID: 20464420 DOI: 10.1007/s00464-010-1087-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2009] [Accepted: 03/11/2010] [Indexed: 12/28/2022]
Abstract
BACKGROUND Radiofrequency ablation with the HALO system is a new option for the treatment of patients with Barrett's esophagus. This systematic review summarizes the results of all relevant publications on this topic to answer patient-relevant clinical questions and to evaluate the potential benefit and harm of this new therapy. METHODS A systematic literature search of MEDLINE and CENTRAL up to May 2009 was performed. To identify the relevant literature, references were evaluated by two reviewers independently. The inclusion criteria for the review required that studies investigated patients with Barrett's esophagus, used radiofrequency ablation as the intervention, and had a minimum follow-up period of 12 months. RESULTS A total of nine relevant observational studies (involving 429 patients) were identified. Complete eradication of Barrett's esophagus dysplasia and metaplasia was achieved respectively for 71-100% and for 46-100% of the patients. Only six cases of stenosis and one case of buried intestinal metaplasia were reported among all the patients. Only a few mild adverse events were reported. CONCLUSIONS Based on the evidence of observational studies, the summary of the current data suggests that radiofrequency ablation with the HALO system could be a promising method associated with a low complication rate, low risk of stricture formations, and a minor probability of buried glands. To evaluate the potential benefit at a higher level of evidence, randomized controlled trials (RCTs) involving a direct comparison with other more established endoscopic methods such as photodynamic therapy are necessary.
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Vassiliou MC, von Renteln D, Wiener DC, Gordon SR, Rothstein RI. Treatment of ultralong-segment Barrett's using focal and balloon-based radiofrequency ablation. Surg Endosc 2010; 24:786-791. [PMID: 19711128 DOI: 10.1007/s00464-009-0639-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Revised: 05/31/2009] [Accepted: 06/30/2009] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Endoscopic radiofrequency ablation (ERFA) is being evaluated as definitive treatment for patients with Barrett's esophagus (BE). Guidelines have yet to be developed for the application of this technology to patients with ultralong-segment BE (ULBE, > or = 8 cm). This study reports a single institution's experience with ERFA of ULBE. METHODS A retrospective review of patients with ULBE undergoing ERFA from August 2005 to February 2009 was conducted. The entire segment of intestinal metaplasia (IM) was treated at each session using balloon- and/or plate-based devices (BARRX Medical, Inc., Sunnyvale, CA). Retreatments, endoscopic mucosal resection (EMR), dilations, and biopsies were performed based on endoscopic findings. Surveillance was conducted according to standard guidelines. RESULTS Twenty-five patients (22 male) with a median age of 66 years [interquartile range (IQR) 57-74 years] were included. The length of BE treated was 10 cm (median; IQR 8-12 cm). Intramucosal carcinoma (IMC) was present in 3 patients, 15 had high-grade dysplasia (HGD), 6 had low-grade dysplasia (LGD), and 1 had IM without dysplasia. Complications for all 25 patients included hemorrhage (n = 1), stricture (n = 2), and nausea and vomiting (n = 2). Time from the initial procedure was such that 15 patients had postablation biopsies at least once. One patient with biopsies elected to undergo esophagectomy. Of these patients, 78.5% (11/14) had complete response (CR; no residual IM), two patients regressed from HGD to IM, and one patient with IMC had residual HGD and was treated with repeat EMR. The number of ablations in this group was 2.5 (median, IQR 2-3) during a median follow-up time of 20.3 months (IQR 10.4-29.2 months). CONCLUSION ERFA is safe and feasible in patients with ULBE and can be applied to the entire length of IM during one session. Eradication of BE can be achieved with few repeat ablations and continued, vigilant surveillance.
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Affiliation(s)
- Melina C Vassiliou
- Division of General Surgery, Montreal General Hospital, McGill University Health Centre, 1650 Cedar Ave., L9-518, Montreal, QC, H3G 1A4, Canada.
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Ablation of Barrett's esophagus using the HALO radiofrequency ablation system. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2010. [DOI: 10.1016/j.tgie.2010.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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van Vilsteren FGI, Bergman JJGHM. Endoscopic therapy using radiofrequency ablation for esophageal dysplasia and carcinoma in Barrett's esophagus. Gastrointest Endosc Clin N Am 2010; 20:55-74, vi. [PMID: 19951794 DOI: 10.1016/j.giec.2009.07.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Radiofrequency ablation (RFA) is a novel and promising treatment modality for treatment of Barrett's esophagus (BE) with high-grade dysplasia or early carcinoma. RFA can be used as a single-modality therapy for flat-type mucosa or as a supplementary therapy after endoscopic resection of visible abnormalities. The treatment protocol consists of initial circumferential ablation using a balloon-based electrode, followed by focal ablation of residual Barrett's epithelium. RFA is less frequently associated with stenosis and buried glandular mucosa as are other ablation techniques and has shown to be safe and effective in the treatment of patients with BE and early neoplasia. In this article, the technical background, current clinical experience, and future prospects of RFA are evaluated.
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Affiliation(s)
- Frederike G I van Vilsteren
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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