Curative criteria for endoscopic treatment of oesophageal adenocarcinoma

The incidence of oesophageal adenocarcinoma has been increasing rapidly in the Western world. A well-known risk factor for developing this type of tumour is reflux disease, which can cause metaplasia from the squamous cell mucosa to columnar epithelium (Barrett's Oesophagus) which can progress to dysplasia and eventually adenocarcinoma. With the rise of the incidence of oesophageal adenocarcinoma, research on the best way to manage this disease is of great importance and has changed treatment modalities over the last decades. The gold standard for superficial adenocarcinoma has shifted from surgical to endoscopic management when certain criteria are met. This review will discuss the different curative criteria for endoscopic treatment of oesophageal adenocarcinoma.</p

Curative criteria for endoscopic treatment of oesophageal adenocarcinoma

The incidence of oesophageal adenocarcinoma has been increasing rapidly in the Western world. A well-known risk factor for developing this type of tumour is reflux disease, which can cause metaplasia from the squamous cell mucosa to columnar epithelium (Barrett's Oesophagus) which can progress to dysplasia and eventually adenocarcinoma. With the rise of the incidence of oesophageal adenocarcinoma, research on the best way to manage this disease is of great importance and has changed treatment modalities over the last decades. The gold standard for superficial adenocarcinoma has shifted from surgical to endoscopic management when certain criteria are met. This review will discuss the different curative criteria for endoscopic treatment of oesophageal adenocarcinoma.</p

Endoscopic resection for residual oesophageal neoplasia after definitive chemoradiotherapy

Definitive chemoradiation is the recommended treatment for locally advanced, irresectable oesophageal cancer and a valid alternative to neoadjuvant chemoradiotherapy (CRT) with surgery in oesophageal squamous cell cancer (OSCC) patients. In case of locoregional recurrence, salvage treatment can be considered in fit and resectable patients. Salvage surgery is a valid option but associated with significant morbidity. Therefore, for tumors confined to the mucosa or submucosal layers endoscopic resection is a good and less-invasive alternative. Over the last decade several case-series have demonstrated a high technical success rate of endoscopic treatment after definitive CRT. In this review we summarize the clinical outcomes and challenges of endoscopic treatment of early recurrence after definitive CRT in oesophageal cancer.</p

Endoscopic resection for residual oesophageal neoplasia after definitive chemoradiotherapy

Definitive chemoradiation is the recommended treatment for locally advanced, irresectable oesophageal cancer and a valid alternative to neoadjuvant chemoradiotherapy (CRT) with surgery in oesophageal squamous cell cancer (OSCC) patients. In case of locoregional recurrence, salvage treatment can be considered in fit and resectable patients. Salvage surgery is a valid option but associated with significant morbidity. Therefore, for tumors confined to the mucosa or submucosal layers endoscopic resection is a good and less-invasive alternative. Over the last decade several case-series have demonstrated a high technical success rate of endoscopic treatment after definitive CRT. In this review we summarize the clinical outcomes and challenges of endoscopic treatment of early recurrence after definitive CRT in oesophageal cancer.</p

Increased risk of oesophageal squamous cell carcinoma development

The incidence of oesophageal squamous cell carcinoma accounts for almost 85 % of all oesophageal cancers worldwide. Patients with oesophageal cancer can present with clinical symptoms including dysphagia, weight loss, retrosternal discomfort or regurgitation. Nevertheless, most cancers remain asymptomatic and thereby undetected until the cancer has reached advanced or even incurable stages. This results in poor prognosis and relatively low long-term survival rates. The identification of patients at high risk for oesophageal cancer development is therefore an important cornerstone in the detection of oesophageal cancer in early and curable stages. This group contains patients with a history of cancer in the aerodigestive tract, squamous dysplasia, certain lifestyle aspects, three types of genetic syndromes, caustic or radiation induced injury to the oesophagus and achalasia. In this review, we evaluate different risk factors for the development of oesophageal squamous cell carcinoma and discuss whether screening of these patients might be justified.</p

A Steep Early Learning Curve for Endoscopic Submucosal Dissection in the Live Porcine Model

Background: Endoscopic submucosal dissection (ESD) is a demanding procedure requiring high level of expertise. ESD training programs incorporate procedures with live animal models. This study aimed to assess the early learning curve for performing ESD on live porcine models by endoscopists without any or with limited previous ESD experience. Methods: In a live porcine model ESD workshop, number of resections, completeness of the resections, en bloc resections, adverse events, tutor intervention, type of knife, ESD time and size of resected specimens were recorded. ESD speed was calculated. Results: A total of 70 procedures were carried out by 17 trainees. The percentage of complete resections, en bloc resections and ESD speed increased from the first to the latest procedures (88.2%-100%, 76.5%-100%, 8.6-31.4 mm2/min, respectively). The number of procedures in which a trainee needed tutor intervention and the number of adverse events also decreased throughout the procedures (4 to 0 and 6 to 0, respectively). During the workshop, when participants changed to a different type of knife, ESD speed slightly decreased (18.5 mm2/min to 17.0 mm2/min) and adverse events increased again (0-2). Conclusions: Through successive procedures, complete resections, en bloc resections, and ESD speed improve whereas adverse events decrease, supporting the role of the live porcine model in the preclinical learning phase. Changing ESD knives has a momentarily negative impact on the learning curve.</p

Training in endoscopic mucosal resection and endoscopic submucosal dissection: face, content and expert validity of the live porcine model

Introduction: Endoscopic mucosal resection and endoscopic submucosal dissection are demanding procedures. This study aims to establish face, content and expert validity of the live porcine model in performing endoscopic mucosal resection, endoscopic submucosal dissection, complication management and to assess it as a training tool. Material and methods: Tutors and trainees participating in live porcine model endoscopic mucosal resection and endoscopic submucosal dissection workshops filled out a questionnaire regarding the realism of the model compared to human setting and its role as a learning tool. A 10-point Likert scale was used. Results: Ninety-one endoscopists (13 tutors; 78 trainees) were involved in four workshops. Median global classifications for the realism of the life porcine model ranged between 7.0–8.0 (interquartile range 5.0–9.0). Procedures resembled human cases with a median of 9.0 (8.0–9.0) for oesophageal multiband endoscopic mucosal resection; 8.5 (8.0–9.0) for oesophageal endoscopic submucosal dissection; 9.0 (8.0–10.0) for gastric endoscopic submucosal dissection; and 9.0 (8.5–9.75 and 8.0–9.69) for complication detection and management. The animal model as a learning tool had median scores of 9.0 (7.0–10.0) considering how procedures are performed; 9.0–9.5 (8.0–10.0) for usefulness for beginners; and 9.0–10.0 (5.0–10.0) regarding it a prerequisite. Conclusions: Training in a live porcine model was considered very realistic compared to the human setting and was highly appreciated as a learning tool. This is the first study to establish face, content and expert validity of the live porcine model in performing multiband endoscopic mucosal resection, oesophageal and gastric endoscopic submucosal dissection. The validation of this model provides the rationale to incorporate it into formal teaching programmes.info:eu-repo/semantics/publishedVersio

Influence of a novel classification of the papilla of Vater on the outcome of needle-knife fistulotomy for biliary cannulation

BACKGROUND: Existing proposed classification systems for the Papilla of Vater (PV) suboptimally account for all relevant, encountered PV appearances, are too complex or have not been assessed for intra- or interobserver variability. We proposed a novel endoscopic classification system for PV, determined its inter- and intraobserver rates and used the classification system to assess whether the success and complications of needle-knife fistulotomy (NKF) are influenced by the morphology of the PV. METHODS: The classification system was developed by expert endoscopists. To evaluate the inter- and intraobserver agreement, an online questionnaire was sent to 20 endoscopists from several countries (10 experts and 10 nonexperts) that included 50 images of papillae of Vater divided among various categories. Four weeks later, a second survey, with the images from the first questionnaire randomly reordered, was sent to the same endoscopists. The inter- and intraobserver agreements among the experts and nonexperts was calculated. Using the proposed classification system, all 361 consecutive patients who underwent NKF for biliary access to a naïve papilla were prospectively enrolled in the study. RESULTS: The novel classification system comprises 7 categories: type I, flat type, lacking an oral protrusion; type IIA, prominent tubular nonpleated type, with an oral protrusion and  2 transverse folds over the oral protrusion; type IIC: prominent bulging type, with an enlarged and bulging oral protrusion; type IIIA, diverticular-intradiverticular type, with a papillary orifice inside the diverticulum; type IIIB: diverticular-diverticular border type, with a papillary orifice less than 2 cm from the diverticular border; type IV: unclassified papilla, with no morphology classified in the other categories. The interobserver agreement between experts was substantial (K = 0.611, 95% CI 0.498-0.709) and was higher than that between nonexperts (K = 0.516; 95% CI 0.410-0.636). The intraobserver agreement was substantial among both experts (K = 0,651; 95% CI 0.586-0.715) and nonexperts (K = 0.646, 95% CI 0.615-0.677). In a multivariate model, type IIIA and IIIB were the only independent risk factors for difficult rescue NKF biliary cannulation (P = 0.003 and P = 0.019, respectively), and type I and type IIB were the only independent risk factors for a prolonged cannulation time using NKF (P < 0.001 and P = 0.005, respectively). CONCLUSIONS: The novel endoscopic classification system for PV is highly reproducible among experienced ERCPists according to the substantial level of agreement between experts. However, nonexperts require further training in its use. Using the novel classification system, we identified different types of papillae significantly associated with a lower efficacy of NKF and a prolonged time to obtain successful biliary cannulation using NKF.publishersversionpublishe

Endoscopic submucosal dissection for early esophageal squamous cell carcinoma:long-term results from a Western cohort

Background Although endoscopic submucosal dissection (ESD) is established as first-choice treatment for early esophageal squamous cell carcinoma (ESCC) worldwide, most data are derived from Asian studies. We aimed to evaluate the long-term outcomes of ESD for patients with early ESCC in a Western cohort. Methods In this retrospective cohort study, patients with early ESCC amenable to ESD were included from four tertiary referral hospitals in the Netherlands between 2012 and 2017. All ESD procedures were performed by experienced endoscopists, after which the decision for additional treatment was made on a per-patient basis. Outcomes were curative resection rate, ESCC-specific survival, and overall survival. Results Of 68 included patients (mean age 69 years; 34 males), ESD was technically successful in 66 (97%; 95%CI 93%-100%), with curative resection achieved in 34/66 (52%; 95%CI 39%-64%). Among patients with noncurative resection, 15/32 (47%) underwent additional treatment, mainly esophagectomy (n = 10) or definitive chemoradiation therapy (n = 4). Endoscopic surveillance was preferred in 17/32 patients (53%), based on severe comorbidities or patient choice. Overall, 31/66 patients (47%) died during a median follow-up of 66 months; 8/31 (26%) were ESCC-related deaths. The 5-year overall and ESCC-specific survival probabilities were 62% (95%CI 52%-75%) and 86% (95%CI 77%-96%), respectively. Conclusion In this Western cohort with long-term follow-up, the effectiveness and safety of ESD for early ESCC was confirmed, although the rate of noncurative resections was substantial. Irrespective of curative status, the long-term prognosis of these patients was limited mainly due to competing mortality