Standard versus simplified radiofrequency ablation protocol for Barrett's esophagus: comparative analysis of the whole treatment pathway.

Background and study aims  The standard radiofrequency ablation (RFA) protocol for Barrett's esophagus (BE) encompasses an intermediary cleaning phase between two ablation sessions. A simplified protocol omitting the cleaning phase is less labor-intensive but equally effective in studies based on single ablation procedures. The aim of this study was to compare efficacy and safety of the standard and simplified RFA protocols for the whole treatment pathway for BE, including both circumferential and focal devices. Patients and methods  We performed a retrospective analysis of prospectively collected data on patients receiving RFA between January 2007 and August 2017 at two institutions. Outcomes assessed were: 1) complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM) at 18 months; and 2) rate of esophageal strictures. Results  One hundred forty-five patients were included of whom 73 patients received the standard and 72 patients received the simplified protocol. CR-D was achieved in 94.5 % and 95.8 % of patients receiving the standard and simplified protocol, respectively ( P  = 0.71). CR-IM was achieved in 84.9 % and 77.8 % of patients treated with the standard and simplified protocol, respectively ( P  = 0.27). Strictures were significantly more common among patients who received the simplified protocol (12.5 %) compared to the standard protocol (1.4 %; P  = 0.008). The median number of esophageal dilations was one. Conclusion  The simplified RFA protocol is as effective as the standard protocol in eradicating BE but carries a higher risk of strictures. This needs to be taken into account, particularly in patients with higher pretreatment risk of strictures, such as those with esophageal narrowing from previous endoscopic mucosal resection (EMR)

Neoadjuvant chemotherapy in oesophageal cancer

Neoadjuvant chemotherapy in oesophageal cancer has gained rapid favour in le United Kingdom over the past few years. It remains controversial outside the UK, with mixed results from clinical trials. The work in this thesis begins with a review of the literature on neoadjuvant chemotherapy, and of the antimetabolites and platinum agents used. The quantitative reverse transcriptase polymerase chain reaction (qRTPCR) used to identify molecular determinants of chemosensitivity is discussed followed by a look at the clinical experience of neoadjuvant chemotherapy at a single centre. Over the past six years 194 patients in Oxford have undergone neoadjuvant chemotherapy with cisplatin and 5-flurouracil. Six patients developed progressive disease, 12 patients stopped chemotherapy early, one patient died during chemotherapy and one patient had perforation of the oesophagus. Overall chemotherapy was well tolerated among patients with no significant increase in respiratory complications and anastomotic leak following the use of neoadjuvant chemotherapy. Following the advent of neoadjuvant chemotherapy, there has been a significant decrease in circumferential resection margin involvement, compared to historical controls. Locoregional recurrence and overall survival have also improved. Cox's multivariate analysis shows circumferential resection margin to be an independent prognostic factor for locoregional recurrence and overall survival.EThOS - Electronic Theses Online ServiceGBUnited Kingdo

Un-tutored training pathway to achieve competence in esophago-gastric endoscopic submucosal dissection in a Western center.

Background and Aims: Endoscopic submucosal dissection (ESD) has a long learning curve. We aimed to assess the efficacy of an ESD unsupervised training model for experienced endoscopists. Methods: Stepwise training included visit to high-volume center, unsupervised training on an ex-vivo porcine model and in-vivo human upper GI cases with anatomical progression. Performance measures: en-bloc resection, R0 resection, complication rates and operative time. Results: Following observation of 30 esophago-gastric ESDs and 15 un-tutored ex-vivo ESDs, five human cases of distal gastric ESDs were performed, followed by 55 unselected esophago-gastric cases. En-bloc and R0 resection rates were 93.0% and 80.7%, respectively. Operative time was 14.0 min/cm2 in stomach and 25.1 min/cm2 in esophagus, with evidence of learning curve for esophageal ESDs (first block 30.26 vs second block 14.81 min/cm2, p=0.01). Conclusions: Un-tutored training for esophago-gastric ESD is feasible and allows endoscopists, experienced in therapeutic endoscopy, to achieve the required standards towards competency

Comparative outcomes of radiofrequency ablation for Barrett's oesophagus with different baseline histology.

BACKGROUND: Radiofrequency ablation (RFA) is currently recommended for dysplastic Barrett's oesophagus (BO); however, there are limited data on treatment response when stratified by baseline histology. OBJECTIVE: The objective of this article is to evaluate RFA outcomes and durability for BO with different baseline histology. METHODS: Patients treated with RFA between 2007 and 2017 at a single institution were retrospectively included. Outcome measures were: (a) complete remission of dysplasia (CRD) and intestinal metaplasia (CRIM) at 18 months, (b) complication rate and (c) durability of CRD and CRIM. RESULTS: A total of 148 patients underwent RFA, of whom 113 completed the treatment protocol (21 low-grade dysplasia (LGD), 46 high-grade dysplasia (HGD) and 46 intramucosal carcinoma (IMC)). CRD and CRIM were achieved in 94.7% and 78.8% of patients, respectively. When stratified by baseline histology, there was no significant difference in CRD between groups (LGD, 95.2%; HGD, 95.7%; and IMC, 93.5%; p = 0.89). Similarly, there was no significant difference in CRIM between groups (LGD, 71.4%; HGD, 76.1% and IMC, 87.0%; p = 0.39). CRD and CRIM durability at 24 months for LGD, HGD and IMC were 100%, 97.7% and 100% (log rank p = 0.31), and 100%, 89.0% and 95.5%, respectively (log rank p = 0.62). CONCLUSION: Baseline histology is not a predictor of RFA response. Once CRD and CRIM are achieved, these effects are durable over time