ESOFAGO DI BARRETT TERAPIA MEDICA & ENDOSCOPICA Massimo Conio Sanremo Massimo Conio Sanremo.
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Transcript of ESOFAGO DI BARRETT TERAPIA MEDICA & ENDOSCOPICA Massimo Conio Sanremo Massimo Conio Sanremo.
Barrett's Esophagus & HGDBarrett's Esophagus & HGDStrategiesStrategies
Barrett's Esophagus & HGDBarrett's Esophagus & HGDStrategiesStrategies
Passive: surveillance
Active: endotherapysurgerychemoprevention
Passive: surveillance
Active: endotherapysurgerychemoprevention
Barrett's Esophagus & HGDBarrett's Esophagus & HGDBarrett's Esophagus & HGDBarrett's Esophagus & HGD
58 patients follow-up: 10 years
26% invasive cancer 27% “regression”
58 patients follow-up: 10 years
26% invasive cancer 27% “regression”
Gastroenterology 1996
ChemopreventionChemopreventionChemopreventionChemoprevention
COX-2 inhibition
Prostaglandins enhance: Proliferation Angiogenesis Invasiveness Apoptosis inhibition
COX-2 inhibition
Prostaglandins enhance: Proliferation Angiogenesis Invasiveness Apoptosis inhibition
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Years of follow-up
Dys
plas
ia r
ate
%
El-Serag et al., Am J Gastroenterol 2004
0
10
20
30
40
50
60
70
80No PPI Therapy
PPI Therapy
Esophagectomy (40% simultaneous foci of intramucosal cancer) Morbidity 48% Mortality 2-3%
Barrett’s Esophagus with High-Grade Dysplasia
SCJSCJ
SCJSCJ
SCJSCJ
Barrett's Esophagus;Histologic Maps of Surgical Resections
Barrett's Esophagus;Histologic Maps of Surgical Resections
Barrett's, no dysplasiaLow-grade dysplasiaHigh-grade dysplasiaAdenocarcinoma
CP1109264-27
Photodynamic therapy (PDT)sodium porfimer (Photofrin®)5-aminolevulinic acid
ThermalLaser (Nd:YAG, KTP)Argon Plasma Coagulator (APC)MPEC
MechanicalUltrasonicMicrowave
Cryotherapy
Endoscopic Ablative Therapies For Barrett’s Esophagus With HGD
Esophagus: Japanese dataEsophagus: Japanese data
About 1000 patients
• “En-bloc” (< 3 cm) CR 100%• Piecemeal ( 3 cm) CR 86% (N1:
23%)
About 1000 patients
• “En-bloc” (< 3 cm) CR 100%• Piecemeal ( 3 cm) CR 86% (N1:
23%)
5-year survival 97.9% (surgery: 98%)
Visible nodular abnormalities
Comorbidities/Advanced age
Efficacy to be determined
Endoscopic Mucosal Resection (EMR)Barrett’s Esophagus
Oblique aspiration mucosectomy device
Attached to tip of conventional endoscope.
Tanabe et al. Gastrointest Endosc, 2004
GROUP A GROUP B
N. Sessions (mean)* 1.3 0.6 2.8 2.0
Complete remission* 97% 59%
Complications 1 spurting 1 oozing*statistically significant
EMR in Barrett’s esophagus with HGD
Ell et al., Gastroenterology 2000
EMR in Barrett’s esophagusEMR in Barrett’s esophagus
Change in the diagnosis: 44%
32% up-staging
Change in the diagnosis: 44%
32% up-staging
Nijhawan et al., Gastrointest Endosc 2000
May 2000 – December 2003:
39 pts (mean age 62.8±11.4 yrs)
Mucosal abnormalities: 36
EUS 20-MHz
May 2000 – December 2003:
39 pts (mean age 62.8±11.4 yrs)
Mucosal abnormalities: 36
EUS 20-MHz
EMR for High-Grade Dysplasia and Intramucosal Cancer
Conio, Repici, Cestari, World J Gastroenterol 2005
Histology of lesionsHistology of lesions
Histology Pre-EMR Post-EMR
LGD - 5 (12.8%)HGD 35 (89.7%) 27 (69.2%)IM. AC 4 (10.3%) 2 (5.1%)Invasive AC - 5 (12.8%)
Change of the original diagnosis 25.6%
EMR for HGD and/or Intramucosal CancerEMR for HGD and/or Intramucosal Cancer
AC sm 3 AC >> Surgery (no residual disease) 2 AC >> Follow-up (cancer free)
ComplicationsBleeding 4 patients (endoscopic treatment) Follow-up (median 20 months)1 recurrence (HGD) >> EMR
AC sm 3 AC >> Surgery (no residual disease) 2 AC >> Follow-up (cancer free)
ComplicationsBleeding 4 patients (endoscopic treatment) Follow-up (median 20 months)1 recurrence (HGD) >> EMR
EMR and PDT in Barrett’s esophagusEMR and PDT in Barrett’s esophagus
Downstaging: 8 (47%)Follow-up 13 months: CR 16 (94%)
Complications: stricture 30%bleeding 6%
Downstaging: 8 (47%)Follow-up 13 months: CR 16 (94%)
Complications: stricture 30%bleeding 6%
Buttar, Gastrointest Endosc 2001
17 patients (EMR 1 cm) (PDT 200J/cm2)
Circumferential EMRCircumferential EMR
Multifocal HGD & IM cancer
5 “visible” and 7 “no visible” lesions Circumferential BE: median length 5 cmComplications: 4/31 EMR sessions (bleeding) Follow-up: no recurrences (median 9 mo)
Multifocal HGD & IM cancer
5 “visible” and 7 “no visible” lesions Circumferential BE: median length 5 cmComplications: 4/31 EMR sessions (bleeding) Follow-up: no recurrences (median 9 mo)
Seewald et al., Gastrointest Endosc 2003
Circumferential EMR in Barrett’s EsophagusCircumferential EMR
in Barrett’s Esophagus
21 pts (19 T1N0; 2 T0N0) EUS 20-MHz Polypectomy snare & saline Circumferential BE: median length 5 cm Complications: 4/21 (bleeding) Follow-up: 2/21 (mean 18 months)
21 pts (19 T1N0; 2 T0N0) EUS 20-MHz Polypectomy snare & saline Circumferential BE: median length 5 cm Complications: 4/21 (bleeding) Follow-up: 2/21 (mean 18 months)
Giovannini et al., Endoscopy 2004
1st endoscope: lifting
2nd endoscope: cutting
Kuwano et al., Ann Surg 2004
Double Endoscopic Intraluminal Operation
(DEILO)
SummarySummary
Surveillance finds dysplasia or early cancer New endoscopic diagnostic method EMR: long term results awaited EMR for non-dysplastic Barrett’s
Surveillance finds dysplasia or early cancer New endoscopic diagnostic method EMR: long term results awaited EMR for non-dysplastic Barrett’s