Novel developments in endoscopy of the proximal GIT
Oliver Pech (Germany) –  Gastro Update Europe 2018, Prague

Surveil­lance recom­mendations, accord­­ing to European Society of Gastroin­testinal Endoscopy guidelines, vary accord­­ing to the length of the Bar­rett segment. Surveil­lance varies from: none for < 10 m­m; every 5 year for < 3 cm; every 3 year for < 10 cm, and surveil­lance in a Bar­rett expert center if > 10 cm. Dif­ference in expertise between a com­munity hospital and an expert center was analysed in a retrospective multi-centric study involv­­ing 198 patients with high-grade dysplasia/ adenocarcinoma. Detection of a visible lesion occur­red respectively in 60 vs. 90%. In 40% neoplasia was only detected on non-targeted bio­psies in com­munity hospitals but was endoscopical­ly detected in 75% by experts.

A new clas­sification us­­ing acetic acid chromoendoscopy (PREDICT) has been presented (tab. 1) [1].

Acetic acid stain­­ing us­­ing this clas­sification is easy to learn and can improve dia­gnostic performance in detect­­ing Bar­rett neoplasia.

A model was developed to determine the risk of malignant progres­sion of Bar­rett esophagus.The scor­­ing system involved: Bar­rett length (1 point for each cm), male gender (9 points), smok­­ing (5 points), low-grade dysplasia at baseline (11 points). The model was evaluated retrospectively in a longitudinal fol­low-up study involv­­ing 2,697 Bar­rett patients. The primary outcome parameter was the development of high-grade dysplasia/ early adenocarcinoma dur­­ing a median 5.9 year fol­low-up period. In low risk Group (0– 10 points) progres­sion risk was 0.13 %/ year. In the intermediate risk Group (11– 20 points) progres­sion risk was 0.73 %/ year. In the high risk Group (> 20 points) progres­sion risk was 2.1 %/ year.

Treatment op post-operative esophageal leakage can be: conservative (watch and wait, nil per os, tube feeding), per-endoscopic (OTS-clip, stent, endovac sponge ther­apy), surgical (anastomosis redo). A recent prospective evaluation of endoscopic vacuum ther­apy was car­ried out in 52 patients of which 75% had post-surgical leakage. First line ther­apy was endoscopic vacuum ther­apy with intraluminal or intracavitary sponge placement with 2 changes/ w and with 100– 125 m­mHg negative pres­sure. Between 1– 25 (~6) sponges were used. The defect healed in 94% of those only treated with sponges. Minor (dislocation, bleeding) and major (fatal bleeding) complications occured in respectively 31% and 4% of the patients. In-hospital mortality (bleeding, multi-organ failure, pneumonia) was 10%. Comparative studies are needed to find out which treatment modality is preferable for each anatomical presentation.

Standard criteria for endoscopic resection of early gastric cancer are: mucosal, G1-2, L0, V0, up to 20 m­m. Novel expanded criteria are: submucosal sm1/ < 500 microm or G3, or > 20 mm or < 30 mm in ulcerated lesions. Gradual­ly ESD (endoscopic submucosal dis­section) data from Europe is also becom­­ing available as il­lustrated by a recent study involv­­ing 179 patients with 191 ESDs. ESD was incomplete because of ‘non-lifting’ in 5%. En-bloc resection and RO-resection were respectively 92 and 76%. Major complications (bleeding, perforation) occur­red in 8% and procedure-related mortality was 1%. Accord­­ing to standard and expanded criteria, local recur­rence was seen in 0 vs. 5%, metachronous lesions in 15 vs. 7%, need for surgery in 0 vs. 7% and total death/ cancer death in (13/ 0 vs. 18/ 0%). Beyond doubt ESD for early gastric cancer will continue to expand in Europe in paral­lel with more refined methodology for lesion delineation etc., but for the time be­­ing such ther­apy will be restricted to dedicated expert centers because the patient volume is so far rather limited.

The risk of lymphnode metastasis in early gastric cancer is rather low, as again shown by a meta-analysis of 12 studies involv­­ing 9,798 gastrectomised patients. Lymphnode metastasis for standard vs. expanded criteria lesions were respectively 0.2 and 0.7%, for dif­ferentiated mucosal cancer < 3 cm with ulceration 0.57%, for dif­ferentiated mucosal cancer without ulceration 0.27% m, for undif­ferentiated mucosal cancer < 2 cm 2.6% and for dif­ferentiated submucosal cancer < 3 cm 2.5%. It is clear from such data that grade of dif­ferentiation and presence of ulceration are important prog­nostic features.

The role of Helicobacter pylori eradication (amoxicil­lin-clarithromycin-rabeprazole) after gastric ESD for early gastric cancer or high-grade dysplasia was evaluated in a large prospective placebo-control­led trial involv­­ing 470 patients, fol­lowed-up for a median of 5.9 year. In the eradication group (succes­sful in 80%) and the placebo group, metachronous cancer occur­red in respectively 7.2 vs. 13.4% and improvement of gastric mucosal atrophy in 48.4 vs. 15%. Thus the risk for metachronous gastric cancer after succes­sful eradication dropped to an HR of o.32. After ESD, but also after partial gastrectomy for more advanced cancer, Helicobacter pylori eradication should be car­ried out.

The 6^th Gastro Update Europe takes place 14– 15^th of June 2019 in Budapest. www.gastro-update-europe.eu

Prof. Guido Tytgat, MD, PhD

Department of Gastroenterology and Hepatology

Academic Medical Center

Meibergdreef 9

1105 AZ Amsterdam

The Netherlands

 g.n.tytgat@amc.uva.nl