Advanced Endoscopy Techniques
Jayant P.Talreja, M.D.
Gastrointestinal Specialists, Inc.
Bon Secours St. Mary’s Hospital
Acknowledgements
Christopher Thompson, MD
Marvin Ryou, MD
William Brugge, MD
David Forcione, MD
Brigham & Women’s Hospital
Massachusetts General Hospital
Harvard Medical School
Boston, MA
Objectives
• Discuss the endoscopic management of
Barrett’s Esophagus
• EUS-guided placement of fiducials
• Endoscopic management of bariatric
surgery complications
Case Presentation #1
HPI:
• 53 year old male with 8 month history of reflux symptoms
• Marginal benefit with omeprazole daily
• Despite lifestyle modifications – avoiding dietary triggers, late
meals
• No alarm symptoms – no dysphagia, weight loss
• Presented for outpatient EGD
Barrett’s esophagus
• In 1957 Norman Barrett, British thoracic surgeon,
described the “lower esophagus lined by columnar
epithelium.”
• Barrett’s esophagus is now defined as “metaplastic
change from squamous to columnar-lined epithelium
(including the presence of goblet cells), visible
endoscopically and confirmed histologically.”
• Barrett’s esophagus results from the reflux of gastric acid
and bile salts into the esophagus, and may be viewed as
an adaptive response in which stratified squamous
epithelium is replaced by potentially acid-resistant
columnar epithelium.
O’Donovan M, Fitzgerald R. Diag Histopath 2012
Noffsinger N. Atlas Nontumor Path. AFIP. 2007
Evolution of Barrett’s and Cancer
Injury
Acid & bile reflux
nitrous oxide
Genetics
Gender, race,
? other factors (cox-2)
Accumulate
Genetic
Changes
Kountourakis P, et al. Gastrointest Cancer Res 2012
Ong CA, et al. World J Gastroenterol, 2010
Barrett’s Prevalence Estimates
• 1.6% of general adult population (3.8 M)
–
Ronkainen J, et al. Prevalence of BE… Gastroenterology 2005;129:1825-31.
• 5.6% of general US adult population (13.1M)
–
Hayeck TJ, et al. The Prevalence of BE in the US (model)…Dis Esophagus 2010;23:451-7.
• 6.8% of persons over age 40 (8.3 M)
–
Rex DK, et al. Screening for Barrett’s... Gastroenterology 2003;125:1670-77.
U.S. Cancer Incidence
General Population
Cancer Incidence
Esophageal
3.0 per 100,000
Adenocarcinoma (0.003%)
Colorectal
Cancer
HGD Cohort
Cancer Incidence
Multiple
6,600 per 100,000
(6.6%)
2,200X
General Population Polyp Cohort
Cancer Incidence
Cancer Incidence
Multiple
45 per 100,000
(0.045%)
13X
http://www.seer.cancer.gov/ (accessed July 2, 2013)
Surveillance, Epidemiology and End Results (SEER)
Wani S, et al. Am J Gastroenterol 2009
Winawer SJ, et al. N Engl J Med 1993
580 per 100,000
(0.58%)
Risk multiple for developing
cancer conferred by HGD or polyp
versus risk of that cancer in
the general U.S. population
U.S. Cancer Incidence
General Population
Cancer Incidence
LGD Cohort
Cancer Incidence
Multiple
1,700 per 100,000
(1.7%)
560X
General Population
Cancer Incidence
Polyp Cohort
Cancer Incidence
Multiple
45 per 100,000
(0.045%)
580 per 100,000
(0.58%)
13X
Esophageal
3.0 per 100,000
Adenocarcinoma (0.003%)
Colorectal
Cancer
http://www.seer.cancer.gov/ (accessed July 2, 2013)
Surveillance, Epidemiology and End Results (SEER)
Wani S, et al. Am J Gastroenterol 2009
Winawer SJ, et al. N Engl J Med 1993
Risk multiple for developing
cancer conferred by LGD or polyp
versus risk of that cancer in
the general U.S. population
U.S. Cancer Incidence
General Population ND-BE Cohort
Cancer Incidence
Cancer Incidence
Esophageal
Adenocarcinoma
Colorectal
Cancer
3.0 per 100,000
(0.003%)
330 per 100,000
(0.33%)
General Population
Cancer Incidence
Polyp Cohort
Cancer Incidence
45 per 100,000
(0.045%)
580 per 100,000
(0.58%)
http://www.seer.cancer.gov/ (accessed July 2, 2013)
Surveillance, Epidemiology and End Results (SEER)
Desai TK, et al. Gut 2012
Winawer SJ, et al. N Engl J Med 1993
Multiple
110X
Multiple
13X
Risk multiple for developing
cancer conferred by NDBE or polyp
versus risk of that cancer in
the general U.S. population
Case Presentation #1
• Diagnostic EGD – by Prague Criteria the Barrett’s appearing
mucosa was measured at C5M6
• Top of the gastric folds seen at 40 cm
• Circumferential extent of Barrett’s terminated at 35 cm
• Maximum extent of Barrett’s terminated at 34 cm
• Prague Criteria – C5M6
• Biopsies taken with cold forceps
• Current consensus guidelines – 4 quadrant biopsies every 2 cm
• Directed biopsies at abnormal appearing regions (i.e. nodules)
• This patient had a total of 4 specimen jars – biopsies taken
every 2 cm and directed biopsies at nodular region
Case Presentation #1
• Biopsies of nodular region show high grade dysplasia
• Remaining biopsies show intestinal metaplasia consistent with
Barrett’s esophagus
• Follow up discussion with patient about significance of these
findings and options for the next step in management
• What can we offer this patient?
• Endoscopic mucosal resection
• Radiofrequency Ablation
Endoscopic Mucosal Resection
• endoscopic technique designed
to remove targeted superficial
tissue
• Indicated for nodular dysplasia
and superficial T1a
adenocarcinoma
• Distinct advantage is availability
of larger tissue specimens
• EMR for HGD and EAC is
successful in 91-98% of T1a
cancers
• Complications include bleeding,
perforation, and stricture
formation
Endoscopic Mucosal Resection
Case Presentation #1
• EMR of nodular region completed during subsequent endoscopy
• If initial biopsies had shown intramucosal carcinoma, staging
radial EUS would be performed prior to EMR to ensure
submucosal preservation
• Post-procedure recommendations:
– Clear liquid diet for 24 hours
– Soft solid diet for 72 hours
– PPI
– Carafate
– Consider liquid oxycodone
– Avoid non-essential NSAID’s for 14 days
– Hold Plavix for additional 5-7 days
– Restart ASA if CAD
– Repeat EGD in 2 months
Case Presentation #1
• Repeat EGD in 2 months shows well healed
EMR resection site with no residual nodularity
• Next step is to proceed to radiofrequency
ablation (RFA)
• An electrode mounted on a balloon catheter or
over the scope is used to deliver heat energy
directly to the diseased lining of the
esophagus.
• The energy delivered results in high
temperature heating (ablation) of the Barrett’s
lining.
• This tissue sloughs off over 48 to72 hours
following the procedure.
• Over a period of six to eight weeks, this tissue
is replaced by normal (squamous) lining.
Ablation Effect on Natural History
NDBE
LGD
HGD
Polyp
Natural
History
(53 studies)
0.6%
1.7%
6.6%
0.58%
After
Ablation
(65 studies)
0.16%
0.16%
1.7%
0.06%
NNT=45
NNT=13
NNT= 4
NNT= 38
Progression risk expressed as “Per-patient-per-year” (%) risk of developing EAC
NNT calculated on 5-year basis (number needed to treat to avoid one cancer over 5 years)
Wani S. Am J Gastro 2009
Winawer SJ. NEJM 1993
Proprietary Properties of RFA Lead to a
Precise Ablation Depth
Mechanisms
1. Tightly spaced electrodes (250 µm apart)
2. Proven pre-set energy & power densities
3. Generator turns off when a pre-determined resistance
level in the ablated tissues is reached (mean of 0.3s)
Ganz, Gastrointest Endosc, 2004
Dunkin, Surg Endosc 2006
Smith, Surg Endosc 2007
Case Presentation #2
HPI:
• 64 year old male with 6 month history of progressive dysphagia
• Unintentional weight loss of 12 pounds
• Longstanding smoker
• No significant reflux symptoms
• Presented for outpatient EGD
Bx: adenocarcinoma
Background
• Esophageal Cancer:
– Worldwide 5th most common cause of cancer related
death
– In US 4th leading cause of cancer mortality
• Resectability rate: 60%-90%
• Neo-adjuvant chemoradiation commonly
used
• 5-year overall survival rate of resectable
disease: 10% - 25%
Background
• Advances in XRT (IMRT, IGRT, PET-based
planning), particularly in esophageal CA
• However, these advances only as effective as
the accuracy with which target is known
• Esophagus represents cancer site affected by
one of the widest ranges of inter-observer
variability in tumor delineation1
• Endoscopic clipping has improved definition of
gross tumor volume during XRT sim2
1 Njeh
2
CF. J Med Phys. 2008
Pfau PR. J Clin Gastro. 2005
Clinical Need
• Accuracy & Precision of Tumor
Delineation
– Current paradigm entails:
• Baseline PET CT (FDG activity, bony landmarks,
surgical hardware)
• Endoscopy report (distance from incisors)
– Challenges of the current paradigm:
• Dynamic movement of viscera
• Respiratory variations & cardiac cycle
• Body habitus changes over treatment
Solution: Paint the Target
Fig 1: Fiducial marking proximal mass
Fig 2: PET shows optimal fiducial positioning