Faculty Bibliography

Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study is to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal adenocarcinoma. This study includes patients with esophageal adenocarcinoma who had failed or were not candidates for conventional therapy enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from 11 academic and community practices. Endoscopic spray cryotherapy was performed until biopsy proven local tumor eradication or until treatment was halted due to progression of disease, patient withdrawal or comorbidities. Eighty-eight patients with esophageal adenocarcinoma (median age 76, 80.7% male, mean length 5.1 cm) underwent 359 treatments (mean 4.4 per patient). Tumor stages included 39 with T1a, 25 with T1b, 9 with unspecified T1, and 15 with T2. Eighty-six patients completed treatment with complete response of intraluminal disease in 55.8%, including complete response in 76.3% for T1a, 45.8% for T1b, 66.2% for all T1, and 6.7% for T2. Mean follow-up was 18.4 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 12 of 88 patients (13.6%) but were present before spray cryotherapy in 3 of 12. This study suggests that endoscopic spray cryotherapy is a safe, well-tolerated, and effective treatment option for early esophageal adenocarcinoma.

Background: Volumetric laser endomicroscopy (VLE) is a second-generation optical coherence tomography system capable of rapidly scanning a large area of the esophagus to a depth of 3 mm and a resolution of 7 microns. Its ability to identify areas suspicious for dysplasia and neoplasia may alter the management of patients undergoing endoscopic treatment of Barrett's esophagus (BE). Our aim was to evaluate whether VLE findings affect clinical decision making, including whether to perform tissue sampling, when used in the same session as BE treatment. Methods: An interim analysis was performed for a US-based, multicenter Registry which prospectively collected demographic, endoscopic and histologic data from cases where VLE was used during the same endoscopy where field ablation of BE was being performed. All procedures were performed with the NvisionVLE system (Nine- Point Medical, Bedford, MA). Patients could be treatment naive or incompletely treated. Allowed treatments included radiofrequency ablation (RFA), cryo-ablation (Cryo) or argon plasma coagulation (APC). Patients who underwent VLE in the same session as endoscopic mucosal resection (EMR) were excluded, as these cases underwent a separate analysis. Results: Patient demographics and relevant medical history are summarized in Table 1. BE was seen on standard endoscopy in 80% (145/ 182) cases where RFA, Cryo or APC was performed at the time of the VLE. The depth or extent of disease identified on VLE was used to determine treatment modality in 68/182 cases (37%). When a focally suspicious lesion was identified and described on white light endoscopy (WLE) in 15% of procedures (27/182 procedures), VLE findings still guided treatment in 16/27 cases (59%). In procedures where focal lesions were identified by WLE/narrow band imaging (NBI) and VLE-guided biopsies were performed, 11/20 (55%) of biopsy results came back as disease (6/20 or 30% positive for dysplasia or cancer). In 3 cases where focal lesions were identified by WLE/NBI, and non-VLE targeted biopsies and/or random biopsies were performed, all tissue was negative for BE or cancer. Conclusion: VLE performed at the time of BE field ablation treatment provided multiple benefits to users within the Registry. Its ability to determine the depth and extent of disease influenced the choice of ablation modality in over a third of cases. Concomitant tissue sampling based on VLE images identified dysplasia or neoplasia in a third of these cases, whereas random or non- VLE targeted biopsies did not find any BE, dysplasia or neoplasia. VLE therefore provides an effective non-invasive tool for real-time optimization of ablative technique and management of BE patients. (Table Presented)

Methods and study aims: The incidence of esophageal cancer is rising despite increased surveillance efforts. Volumetric laser endomicroscopy (VLE) is a new endoscopic imaging tool that can allow for targeted biopsy of neoplasia in Barrett's esophagus. We report a series of 6 patients with long-segment Barrett's esophagus ( > 3 cm), who underwent a session of endoscopy with volumetric laser endomicroscopy, after a separate prior session of standard high-definition endoscopy with narrow band imaging (NBI) and random biopsies that did not reveal neoplasia. In all six patients, the first endoscopy was the index endoscopy diagnosing the Barrett's esophagus. All VLE exams were performed within 6 months of the previous endoscopy. In five patients, VLE-targeted biopsy resulted in upstaged disease/diagnosed dysplasia that then qualified the patient for endoscopic ablation therapy. In one patient, VLE localized a focus of intramucosal cancer that allowed for curative endoscopic mucosal resection. This case series shows that endoscopy with VLE can target neoplasia that cannot be localized by high-definition endoscopy with NBI and random biopsies.

Background: Although surgery is traditionally the standard of care for esophageal cancer, esophagectomy carries significant morbidity and mortality. Alternative endoscopic therapies are needed for patients who are not candidates for conventional treatment. The objective of this study was to assess the safety, efficacy, and tolerability of spray cryotherapy of esophageal cancer. Methods: This study includes patients enrolled retrospectively and prospectively in an open-label registry and patients in a retrospective cohort from twelve academic and community practices. Endoscopic spray cryotherapy was performed until local tumor eradication was confirmed by biopsy or until treatment was halted due to progression of disease, patient withdrawal or co-morbidities. Results: One-hundred and eight patients (median age 75.5, 79.6% male, 93.5% adenocarcinoma, mean length 5.2 cm) underwent 442 treatments (mean 4.2 per patient). Tumor stages included 40 with T1a, 27 with T1b, 10 with unspecified T1, 15 with T2, and 16 with no T stage reported. One-hundred and six patients completed treatment with complete response of intraluminal disease in 54.7%, including complete response in 74.4% for T1a, 50% for T1b, 65.3% for all T1, 6.7% for T2, and 50% for those with no T stage reported. Mean follow-up was 17.3 months. There were no deaths or perforations related to spray cryotherapy. Strictures developed in 11 of 108 patients (10.2%) but were present before spray cryotherapy in 3 of 11. Conclusions: This study suggests that endoscopic spray cryotherapy is safe, well tolerated and effective for early esophageal cancer in patients who are not candidates for conventional therapy

Objectives: Colonoscopy is the gold standard for colon cancer screening and prevention. Several new technologies have recently emerged in order to better assist gastroenterologists in their evaluation of the colonic mucosa to find and remove polyps during screening and surveillance colonoscopies. The ARC EndoCuff is a disposable plastic device with soft, hair-like projections that is placed at the tip of the colonoscope prior to the procedure (Image 1.). The device helps to stabilize the tip of the colonoscope and assists in flattening the folds of the colonic mucosa in order to better evaluate proximal colonic folds. We performed a retrospective chart review of patients who underwent screening and surveillance colonoscopy with and without EndoCuff. The aim of our study was to assess whether EndoCuff was more effective at detecting polyps and adenomas. Methods: Patients were retrospectively analyzed at a tertiary care medical center, urban and suburban outpatient practices from September 2013 thru November 2013. Only screening and surveillance colonoscopies were included. Based on previous learning curve results, the first 4 EndoCuff procedures for each operator were excluded. A comparison group was matched to Endocuff cases based on indication. Colonoscopy reports were retrospectively reviewed to obtain demographic information, total polyps and adenomas removed. This was used to calculate overall ADR and ADR by colon location (right vs. left). Paired t-tests were performed to assess for significance between EndoCuff and comparison group with respect to total polyps and adenomas removed and ADR. Results: 165 patients received EndoCuff and 153 patients underwent standard colonoscopy. Average polyps detected per patient in the EndoCuff group was 1.31 vs. 0.82 in standard colonoscopy (p=<0.001). Similar results were also observed in average adenoma per patient 0.8 vs 0.38 (p=<0.001). The ADR was highest amongst patients who underwent EndoCuff compared to standard colonoscopy (46.6% vs. 30.0%, p=0.!

A 50-year-old male was initially thought to have familial adenomatous polyposis (FAP) after innumerable small nodules in the upper GI tract were discovered upon endoscopic retrograde cholangiopancreatography for common bile duct stone extraction. ERCP was unsuccessful due to inability to find the major papilla amongst the nodules found in the duodenum. Biopsy of the nodules was consistent with nodular lymphoid hyperplasia. The patient was later found to have common variable immunodeficiency.

Purpose: Barrett's esophagus (BE) with high grade dysplasia (HGD) has the potential to progress to esophageal cancer if left untreated. Endoscopic ablation is an acceptable form of therapy oft en done with radiofrequency ablation (RFA). There is a subset of patients who continue to have persistent disease despite therapy and may benefit from low-pressure liquid nitrogen cryotherapy. Methods: A retrospective cohort of patients initially treated with RFA, but continued to have BE- HGD were analyzed in this study. Variables included patient demographics, initial BE length, total RFA sessions, degree of persistent BE after RFA, and results after cryotherapy. Results: A total of 12 patients were treated with RFA followed by cryotherapy for BE-HGD. The mean age was 69 years (range 53-84 years) and all were males. The mean BE segment was 5.6 cm (range 1-13 cm). In 25% (n=3) of BE-HGD patients endoscopic mucosal resection was done prior to ablation. The mean number of RFA sessions were 2.1 (range 1-4 treatments). In 11/12 (92%) patients BE-HGD persisted after RFA therapy based on biopsies. One patient was downgraded to BE without dysplasia. Patients were then treated with cryotherapy ablation for a mean of 2.3 treatments (range 1-5 treatments). Dosimetry freeze time had a mean of 19 seconds (range 10-30 seconds) repeated 2.6 cycles (range 2-4 cycles) per treatment session. Post cryotherapy biopsies of previous BE-HGD patients were available in 7/12 patients. Complete eradication of BE-HGD was seen in 4/7 patients and these patients were biopsy negative. Two patients only had BE without dysplasia and one patient was downgraded to low grade dysplasia based on biopsies. The remaining five patients demonstrated endoscopic improvement, but biopsies were still pending at time of analysis. Conclusion: There appears to be a subset of patients who fail RFA ablation for BE-HGD. Low pressure liquid nitrogen should be considered for refractory BE-HGD patients who fail RFA. Futures studies are needed to better define the role of cryotherapy for the endoscopic treatment of BE with dysplasia