ENDOSCOPIC EVALUATION AND TREATMENT OF BARRETT ESOPHAGUS AND EARLY ESOPHAGEAL CANCER

DAYNA S. EARLY

Washington University, St. Louis, USA

Chronic gastroesophageal reflux disease (GERD) can lead to replacement of esophageal squamous mucosa by intestinal metaplasia, known commonly as Barrett’s esophagus (BE). BE mucosa can develop dysplasia, which can lead to esophageal adenocarcinoma (EAC). The risk of progression of BE to EAC depends on the dysplasia grade at diagnosis, where BE with no dysplasia progresses at approximately 0.27% per year, BE with low grade dysplasia (BE-LGD) progresses at 0.6% per year and BE with high grade dysplasia (BE-HGD) progresses in over 30%. Considering the poor prognosis of invasive EAC, endoscopic therapy has emerged as a safe and effective means of treating/eradicating dysplastic BE and intramucosal EAC (IM-EAC), thereby eliminating precancerous tissue. Endoscopic therapy of dysplastic BE and IM-EAC can be broadly divided into ablative therapies, which destroy BE mucosa, and mucosal resection, which removes BE mucosa. Several modalities have been used to ablate BE mucosa, including photodynamic therapy (PDT), argon plasma coagulation, radiofrequency ablation (RFA), and cryotherapy. Initial results with PDT were favorable, but it is rarely used due to photosensitivity caused by the photosensitizing agent and a high rate of strictures. APC is easy to use but can be cumbersome when treating long segment BE and is very superficial. The most commonly used ablative therapies currently are RFA and cryotherapy. Both are considered safe and effective, but there is a larger body of published data on RFA. RFA uses an endoscopically placed balloon, or a probe attached to the tip of the endoscope, both of which deliver radiofrequency energy via direct contact with mucosa. The RFA balloon can treat 3 cm of mucosa circumferentially and the probe can treat 2 x 1.3 cm. Long segment BE can be treated in one setting. After treatment cytoprotective therapy and vigorous acid suppression is used to allow regrowth of squamous mucosa once the ablated mucosa sloughs off. Retreatment after 3 months is often necessary for small islands that were missed on the initial treatment, and about 4 sessions is needed to completely eradicate a long segment of BE. A prospective randomized sham controlled study of BE-LGD and BE-HGD showed complete eradication of dysplastic BE (low grade and high grade) in 90.5% and 81% respectively and complete eradication of all BE mucosa in 77.4 %. A 3-year follow up study of a subset of the same cohort of patients demonstrated complete eradication of dysplastic BE (low grade and high grade) in 93% and complete eradication of all BE mucosa in 89%.The study was a crossover design, such that many patients randomized to sham were then treated with RFA. The overall rate of stricture long-term is 7.6% and progression from LGD to HGD or HGD or EAC occurred in 1.4%. Cryotherapy is a catheter based technique in which either liquid nitrogen or carbon dioxide is delivered by a catheter that sprays cryogen in a non-contact method onto mucosa in several “freeze-thaw” cycles to cause cellular death. Proponents of cryotherapy suggest there is a lower stricture rate since extracellular tissue is not destroyed, however this has not yet been shown in a prospective study. Similar to RFA, several sessions may be required to completely eliminate long segment BE, but cryotherapy appears to be well tolerated based on published data. Mucosal resection of BE has the advantages of removing dysplastic tissue. The risks of endoscopic mucosal resection (EMR) include bleeding, and for complete eradication by EMR the stricture rate is reported up to 37 %. There are several EMR techniques, with band ligation and cap-assisted being the most commonly used. With band ligation, a system is attached to the tip of the endoscope just as if variceal ligation were being performed. The area to be resected is suctioned into the cap and a band is deployed to create a pseudo-polyp. The pseudopolyp is then ensnared and resected. Multiple areas can be resected in one session and are retrieved with a net. With the cap-assisted technique, a clear cap is attached to the endoscope. The area to be resected is lifted with saline plus/minus methylene blue. A snare is then placed into a groove in the cap, the tissue is suctioned into the cap, ensnared and resected. Both techniques are effective at removing tissue to the depth of submucosa, with slightly larger pieces with cap-assisted EMR and slightly shorter procedure times with band ligation EMR.

While both ablative techniques and EMR are used for flat dysplastic BE, nodular or irregular BE mucosa should be resected by EMR to exclude invasive EAC. Although the yield is low, EUS is still recommended in order to exclude lymphadenopathy and submucosa or muscularis propria invasion, prior to embarking on endoscopic therapy of dysplastic BE or IM-EAC.

In summary, endoscopic therapy of BE and IM-EAC is safe and effective at eradicating dysplastic and neoplastic tissue. Both ablative techniques and EMR have been studied and possess advantages and disadvantages. The advantages of ablative techniques are ease of performance, low risk of bleeding and stricture and acceptance by patients. The disadvantages of ablative techniques are its superficial nature and inability to remove dysplastic tissue. Conversely, the main advantage of EMR is the ability to resect dysplastic tissue, but is associated with a higher stricture rate and potential for bleeding. Nodular BE should always be treated with EMR, not only for a deeper resection, but also to provide adequate diagnostic tissue to exclude invasive EAC.

Endoscopic therapy for BE continues to evolve and will likely remain in the forefront of therapy for dysplastic BE and IM-EAC. Further study is needed to determine if endoscopic therapy of BE reduces the incidence and mortality from invasive EAC, and to determine if ablative techniques or EMR are the preferred treatment for flat dysplastic BE.

DATA OF REGULATORY SYSTEM AMONG PATIENTS WITH GASTROESOPHAGEAL REFLUX DISEASE

M.T. EFENDIEVA

Russian scientific centre of restorative medicine and balneology, Moscow, RUSSIA

Introduction: Formation of gastroesophageal reflux disease (GERD) is determined by a number of factors, but it is generally acknowledged, that initial mechanism is an insufficiency of lower esophageal sphincter (LES) due to disorders of neurohumoral regulation. One of transmitters of neurohumoral influences on to esophageal motility is a vasoactive intestinal peptide (VIP) which inhibits esophageal motility and lowers tonus of lower esophageal sphincter. Disorders of emotional and vegetative spheres take a significant part among numerous hypothesis of GERD’s origin.
Materials and investigation methods: A group being under investigation consisted of 60 GERD patients, 18 men and 42 women, age - from 21 to 48.

Estimation of vegetative nervous system’s state according to results of variability of heart rhythm (VHR) by means of spectral analysis in frame of 24-hour ECG monitoring. To investigate neurohumoral regulation of LES, a level of VIP in blood serum was determined by immune-enzyme method.

Results: Spectral analysis of wave structure of heart rhythm among GERD patients revealed disbalance of vegetative regulation with prevalence of central mechanisms of regulation and less high frequency waves which is an indicator or lowering of vagus influences.

Determining of VIP level revealed its valid increase in serum of GERD patients.

Conclusion: Data reflecting disorders of neurohumoral regulation of lower esophageal sphincter and disbalance of vegetative regulation in GERD patients contribute to understanding of pathogenesis of disease and may be used for elaboration of effective treatment methods of this cathegory of patients.

ENDOSCOPIC ASSESSMENT OF THE PATHOLOGY IN PATIENTS WITH REFLUX-ESOPHAGITIS

V.M.EFENDIYEV, T.M.ALIYEV, R.M.BABAYEV

AzSATID named after A.Aliyev, Baku, AZERBAIJAN

Difference of complaints in patients with reflux-esophagitis, other diseases of the digestive tract (gastric and duodenal ulcer, cholecystitis, gastric and esophageal cancer, cardiospasm etc.), coronary insufficiency, diaphragmatic disease, its associated course and masking create certain difficulties in the correct and timely detection of the disease. Moreover, after a number of operations in esophagus and cardiac orifice, development of reflux-esophagitis in patients is observed that necessitates endoscopic assessments of the pathology for the determination o the treatment tactics in such patients. For this purpose were involved 820 patients to the study within the recent 10 years. The study was carried out by fiber-optic endoscope of “Olympus” company. It was found out during the investigation that the reason of reflux-esophagitis in was hiatal hernia (HH), in 108 patients - shortening of esophagus with HH, in 36 patients – cardiofundal hiatal hernia, in 52 patients – isolated insufficiency of cardiac orifice, in 82 patients – cardiac insufficiency after manipulation and surgical intervention in lower 1/3 of the cardiac orifice and esophagus, in 96 patients – peptic structure of esophagus, in 43 patients – esophageal diverticulum with HH, in 41 patients – tumor of esophagus or cardiac orifice with HH. According to the severity degree in 398 patients - I grade, in 208 patients- II grade, in 115 patients - III grade, and in 99 patients - IV grade reflux-esophagitis was determined. Functional change of the esophageal wall (enlargement of the esophageal cavity, segmental spasm etc.) was observed in 147 patients. It was concluded by comparing clinical pattern of the disease with obtained endoscopic results, that intensity of clinical symptoms do not always correspond to the severity rate of esophagitis. In 31 patients with reflux-esophagitis no pathologies of the mucous coat of esophagus during the esophagoscopy were found. On the other hand, clinical presentations were not obviously expressed in a part of patients with severe injuries of the mucosal coat of the esophagus. Moreover, joint endoscopic examination and biopsy is necessary for the determination of treatment tactics of secondary reflux-esophagitis developed after o number of manipulations and operations conducted in the esophagus and cardiac orifice. As compared with other examination methods, esophagoscopy makes it possible to collect detailed information about the degree of injury of the mucous coat of the esophagus during secondary reflux-esophagitis.

Date: 2014-12-28; view: 886