{"title":"Treatment of Barrett’s esophagus: a narrative review","authors":"Grace Nesheiwat, R. Carr, D. Molena, Laura Tang","doi":"10.21037/aoe-21-63","DOIUrl":"https://doi.org/10.21037/aoe-21-63","url":null,"abstract":"","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41520534","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2021-01-01DOI: 10.21037/AOE-2020-MTEC-08
L. Koggel, M. A. Lantinga, P. Siersema
Palliation of dysphagia forms the cornerstone in treating incurable esophageal cancer. The ultimate goal is to provide rapid and sustained relief of dysphagia. Optimal management is however a challenge as a single modality providing both rapid and sustained relief is not readily available. The two most commonly used modalities for palliative treatment of dysphagia include esophageal stent placement and radiotherapy. Treatment choice primarily depends on life-expectancy and dysphagia severity. Radiotherapy is preferred in those with a life-expectancy of more than three months as it is superior to stent placement with regard to effect duration. Regarding the former, short cycle external-beam radiotherapy (EBRT) is currently preferred over single-dose brachytherapy (BT) because of better clinical outcomes, lower toxicity and easier application. In contrast, if life-expectancy is less than three months, immediate relief of dysphagia is important and self-expandable metal stent (SEMS) placement is the preferred treatment. Although combining these two treatment modalities seems promising, evidence to support this is lacking. Placement of an irradiation stent has been suggested for patients with a reasonable life-expectancy, although placement requires a specifically-designed unit and experienced personnel. The research agenda should focus on further improving radiotherapy techniques, stent design, and effectiveness of combination therapy aiming to provide rapid and sustained dysphagia relief while maintaining quality of life.
{"title":"Palliation of malignant dysphagia: stent or radiotherapy?","authors":"L. Koggel, M. A. Lantinga, P. Siersema","doi":"10.21037/AOE-2020-MTEC-08","DOIUrl":"https://doi.org/10.21037/AOE-2020-MTEC-08","url":null,"abstract":"Palliation of dysphagia forms the cornerstone in treating incurable esophageal cancer. The ultimate goal is to provide rapid and sustained relief of dysphagia. Optimal management is however a challenge as a single modality providing both rapid and sustained relief is not readily available. The two most commonly used modalities for palliative treatment of dysphagia include esophageal stent placement and radiotherapy. Treatment choice primarily depends on life-expectancy and dysphagia severity. Radiotherapy is preferred in those with a life-expectancy of more than three months as it is superior to stent placement with regard to effect duration. Regarding the former, short cycle external-beam radiotherapy (EBRT) is currently preferred over single-dose brachytherapy (BT) because of better clinical outcomes, lower toxicity and easier application. In contrast, if life-expectancy is less than three months, immediate relief of dysphagia is important and self-expandable metal stent (SEMS) placement is the preferred treatment. Although combining these two treatment modalities seems promising, evidence to support this is lacking. Placement of an irradiation stent has been suggested for patients with a reasonable life-expectancy, although placement requires a specifically-designed unit and experienced personnel. The research agenda should focus on further improving radiotherapy techniques, stent design, and effectiveness of combination therapy aiming to provide rapid and sustained dysphagia relief while maintaining quality of life.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41480236","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
V. D. Plat, Emma L. van Toorenburg, R. V. van Wanrooij, David J. Heineman, J. Straatman, D. L. van der Peet, J. Luttikhold, F. Daams
{"title":"Preoperative anatomic considerations for a cervical or intrathoracic anastomosis: a retrospective cohort study","authors":"V. D. Plat, Emma L. van Toorenburg, R. V. van Wanrooij, David J. Heineman, J. Straatman, D. L. van der Peet, J. Luttikhold, F. Daams","doi":"10.21037/aoe-21-41","DOIUrl":"https://doi.org/10.21037/aoe-21-41","url":null,"abstract":"","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41723709","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: Endoscopic treatment of esophageal adenocarcinoma (EAC) and squamous cell cancer (ESCC) has gained importance over the last years. Early endoscopic detection has important prognostic and therapeutic implications because of the risk of lymph node metastasis even in early stages of disease. Endoscopic image enhancement techniques and virtual chromoendoscopy are helpful diagnostic tools for the detection of early neoplastic lesions. The characterization of mucosal and vascular pattern by using magnifying endoscopy and narrow band imaging (NBI) and embedding this information in classifications are useful in assessing neoplastic lesions and their invasion depth. For example, the Japanese Esophageal Society (JES) classification applies NBI in the evaluation and assessment of esophageal cancer. Both EAC and ESCC should be treated by en bloc resection whenever possible. Because of the higher risk of lymph node metastasis early ESCC should be treated endoscopically only up to a mucosal invasion depth of m2. Submucosal invasion especially deeper than 200 µm has a significant risk of lymph node metastasis. Endoscopic mucosal resection (EMR) should be performed if the lesion is smaller than 15 mm otherwise endoscopic submucosal dissection (ESD) is recommended. In early adenocarcinoma, these criteria can be extended if submucosal invasion is less than ≤ 500 µm (sm1) and the resected carcinoma is well or moderately differentiated, with a lesion size <3 cm and without lymphatic invasion. For early EAC larger than 15 mm, lesions suspicious for submucosal invasion or lesions with poor lifting, ESD is recommended. For well or moderately differentiated early squamous cell carcinoma (SCC) and early adenocarcinoma of the esophagus, curative resection is achieved if there is no lymphatic or vascular invasion. After endoscopic resection, additional endoscopic treatment options exist for example local ablative procedures such as radiofrequency ablation (RFA) for residual Barrett segments. 8
{"title":"Indications for endoscopic treatment of adenocarcinoma and squamous cell cancer of the esophagus","authors":"C. Fleischmann, A. Probst, H. Messmann","doi":"10.21037/aoe-2020-35","DOIUrl":"https://doi.org/10.21037/aoe-2020-35","url":null,"abstract":": Endoscopic treatment of esophageal adenocarcinoma (EAC) and squamous cell cancer (ESCC) has gained importance over the last years. Early endoscopic detection has important prognostic and therapeutic implications because of the risk of lymph node metastasis even in early stages of disease. Endoscopic image enhancement techniques and virtual chromoendoscopy are helpful diagnostic tools for the detection of early neoplastic lesions. The characterization of mucosal and vascular pattern by using magnifying endoscopy and narrow band imaging (NBI) and embedding this information in classifications are useful in assessing neoplastic lesions and their invasion depth. For example, the Japanese Esophageal Society (JES) classification applies NBI in the evaluation and assessment of esophageal cancer. Both EAC and ESCC should be treated by en bloc resection whenever possible. Because of the higher risk of lymph node metastasis early ESCC should be treated endoscopically only up to a mucosal invasion depth of m2. Submucosal invasion especially deeper than 200 µm has a significant risk of lymph node metastasis. Endoscopic mucosal resection (EMR) should be performed if the lesion is smaller than 15 mm otherwise endoscopic submucosal dissection (ESD) is recommended. In early adenocarcinoma, these criteria can be extended if submucosal invasion is less than ≤ 500 µm (sm1) and the resected carcinoma is well or moderately differentiated, with a lesion size <3 cm and without lymphatic invasion. For early EAC larger than 15 mm, lesions suspicious for submucosal invasion or lesions with poor lifting, ESD is recommended. For well or moderately differentiated early squamous cell carcinoma (SCC) and early adenocarcinoma of the esophagus, curative resection is achieved if there is no lymphatic or vascular invasion. After endoscopic resection, additional endoscopic treatment options exist for example local ablative procedures such as radiofrequency ablation (RFA) for residual Barrett segments. 8","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43897183","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background: Anastomotic complications resulting from inadequate perfusion of a gastric conduit have significant implications for patient undergoing esophagectomy. The primary aim of this study was to assess the feasibility and reliability of real time laser doppler imaging (LDI) to measure changes in gastric perfusion during oesophagectomy. The secondary aim was to assess whether there were differences in perfusion between patients with and without anastomotic complications. Methods: Using real time LDI, regional changes in perfusion were measured during construction of a gastric conduit in 20 patients undergoing oesophagectomy (14 male, 6 female, mean age 67, range 47–77 years). Results: There was a significant fall in perfusion for the whole stomach from 93.7% to 69.9% (P<0.001) during formation of the gastric conduit within the abdomen. There were marked regional differences within the stomach with the most significant reduction in perfusion at the fundus/tip of the conduit (54.4%), although perfusion fell significantly at all regions. Of note there was a stepwise degradation in perfusion as each named artery (or major branches thereof) was ligated. There was a further significant fall in perfusion at the fundus of 10.2% to 44.2% (P<0.001) after pull through of the conduit into the thorax or neck. There was a significant difference in perfusion at the tip of the gastric conduit in those patients suffering an anastomotic complication (Leak or stricture) compared to those without (28.5% vs. 52.6%, P<0.001). Perfusion was significantly lower in those patients who developed an anastomotic leak (25.0% vs. 49.0%, P<0.01) and the gradient of this fall was steeper after ligation of the left gastric artery when compared to patients without this complication. Conclusions: Real time non-invasive LDI provides valid and reliable measurements of gastric perfusion during oesophagectomy and could help identify patients at risk of anastomotic complications.
背景:胃导管灌注不足引起的吻合口并发症对食管切除术患者具有重要意义。本研究的主要目的是评估实时激光多普勒成像(LDI)测量食管切除术期间胃灌注变化的可行性和可靠性。次要目的是评估有无吻合口并发症的患者灌注是否有差异。方法:对20例食管切除术患者(男14例，女6例，平均年龄67岁，47 ~ 77岁)，应用实时LDI测量胃导管构建过程中的局部灌注变化。结果:胃管在腹腔内形成时，全胃灌注从93.7%下降到69.9% (P<0.001)。胃内存在明显的区域差异，尽管所有区域的灌注都明显下降，但胃底/导管尖端的灌注减少最为显著(54.4%)。值得注意的是，随着每条冠名动脉(或其主要分支)的结扎，灌注逐渐退化。将导管拉入胸腔或颈部后，眼底灌注进一步显著下降10.2% ~ 44.2% (P<0.001)。有吻合口并发症(瘘或狭窄)的患者与无吻合口并发症的患者胃管尖端灌注有显著差异(28.5% vs. 52.6%， P<0.001)。吻合口瘘患者的血流灌注明显降低(25.0% vs 49.0%， P<0.01)，结扎胃左动脉后的血流梯度比无吻合口瘘患者更陡。结论:实时无创LDI提供了有效可靠的食管切除术期间胃灌注测量，有助于识别有吻合口并发症风险的患者。
{"title":"Changes in gastric perfusion during oesophagectomy using real time laser doppler imaging may predict patients at risk of anastomotic complications","authors":"M. Kelly, J. Gossage","doi":"10.21037/AOE-20-39","DOIUrl":"https://doi.org/10.21037/AOE-20-39","url":null,"abstract":"Background: Anastomotic complications resulting from inadequate perfusion of a gastric conduit have significant implications for patient undergoing esophagectomy. The primary aim of this study was to assess the feasibility and reliability of real time laser doppler imaging (LDI) to measure changes in gastric perfusion during oesophagectomy. The secondary aim was to assess whether there were differences in perfusion between patients with and without anastomotic complications. Methods: Using real time LDI, regional changes in perfusion were measured during construction of a gastric conduit in 20 patients undergoing oesophagectomy (14 male, 6 female, mean age 67, range 47–77 years). Results: There was a significant fall in perfusion for the whole stomach from 93.7% to 69.9% (P<0.001) during formation of the gastric conduit within the abdomen. There were marked regional differences within the stomach with the most significant reduction in perfusion at the fundus/tip of the conduit (54.4%), although perfusion fell significantly at all regions. Of note there was a stepwise degradation in perfusion as each named artery (or major branches thereof) was ligated. There was a further significant fall in perfusion at the fundus of 10.2% to 44.2% (P<0.001) after pull through of the conduit into the thorax or neck. There was a significant difference in perfusion at the tip of the gastric conduit in those patients suffering an anastomotic complication (Leak or stricture) compared to those without (28.5% vs. 52.6%, P<0.001). Perfusion was significantly lower in those patients who developed an anastomotic leak (25.0% vs. 49.0%, P<0.01) and the gradient of this fall was steeper after ligation of the left gastric artery when compared to patients without this complication. Conclusions: Real time non-invasive LDI provides valid and reliable measurements of gastric perfusion during oesophagectomy and could help identify patients at risk of anastomotic complications.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46866985","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: Esophagectomy is the preferred treatment in advanced esophageal cancer, but the location of the anastomosis after esophagectomy is debatable. Here, we discuss leakage rates between cervical or intrathoracic anastomosis and complications related to fistulae. The aim of this review article is to describe the McKeown procedure with step-by-step cervical anastomosis. We also update evidence in the literature and discuss the experience of our institution. We report our experience with the cervical anastomosis in minimally invasive esophagectomy and performed a brief review of patients operated in our institution mainly related the rate of cervical fistulas. From 2009 to 2019, more than 345 esophagectomy with cervical anastomosis were performed, and fistula was diagnosed in 46 (13.3%). The spontaneous preferred locations of the liquid drainage after leakage were cervical (38/46, 82.6%), upper mediastinum (4/46, 8.7%), and mediastinum with mediastinitis (4/46, 8.7%). The main risk factors for anastomosis leak are gastric tube perfusion, obesity, heart failure, coronary heart disease, vascular disease, smoking, and cervical anastomosis. The literature shows different opinions and results based on surgeon and center experiences. The McKeown procedure is a feasible, standardized, and secure procedure. Anastomosis leak increases the morbidity and mortality and the frequency of anastomotic leakage in the literature. The rate is around 10% with low mortality.
{"title":"McKeown—cervical anastomosis in minimally invasive esophagectomy","authors":"F. Takeda, R. Sallum, F. Fernandes, I. Cecconello","doi":"10.21037/AOE-21-11","DOIUrl":"https://doi.org/10.21037/AOE-21-11","url":null,"abstract":": Esophagectomy is the preferred treatment in advanced esophageal cancer, but the location of the anastomosis after esophagectomy is debatable. Here, we discuss leakage rates between cervical or intrathoracic anastomosis and complications related to fistulae. The aim of this review article is to describe the McKeown procedure with step-by-step cervical anastomosis. We also update evidence in the literature and discuss the experience of our institution. We report our experience with the cervical anastomosis in minimally invasive esophagectomy and performed a brief review of patients operated in our institution mainly related the rate of cervical fistulas. From 2009 to 2019, more than 345 esophagectomy with cervical anastomosis were performed, and fistula was diagnosed in 46 (13.3%). The spontaneous preferred locations of the liquid drainage after leakage were cervical (38/46, 82.6%), upper mediastinum (4/46, 8.7%), and mediastinum with mediastinitis (4/46, 8.7%). The main risk factors for anastomosis leak are gastric tube perfusion, obesity, heart failure, coronary heart disease, vascular disease, smoking, and cervical anastomosis. The literature shows different opinions and results based on surgeon and center experiences. The McKeown procedure is a feasible, standardized, and secure procedure. Anastomosis leak increases the morbidity and mortality and the frequency of anastomotic leakage in the literature. The rate is around 10% with low mortality.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42726608","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Endoscopic resection is a minimally-invasive treatment for superficial esophageal tumors compared with surgery or chemoradiation therapy. Endoscopic submucosal dissection (ESD) is a wellestablished method with accurate histological evaluation and favorable procedural outcomes. However, ESD requires a high level of skill, and is therefore technically challenging and time-consuming. Traction-assisted ESD has been introduced to facilitate ESD and provides adequate submucosal visualization and satisfactory tissue traction. We reviewed the scientific literature in English to evaluate the efficacy of traction-assisted ESD for esophageal lesions, including the clip-with-thread (CT) method and the submucosal tunneling (ST) method. The CT method is a simple and affordable technique that uses commercially available hemoclips. Two randomized controlled trials and two retrospective studies showed that the CT method resulted in shorter procedure times and reduced local injection compared with conventional ESD, and no cases of perforation. The ST method does not require specific devices and facilitates the procedure by securing a stable submucosal visual field and maintaining a submucosal liquid cushion. Two retrospective studies reported shorter procedure times with similar en bloc resection rates and complete resection rates using the ST method compared with conventional ESD. Although a combination of the ST method with the CT method seems to be effective for large lesions, its efficacy and safety should be confirmed by a largescale study. In the future, robotic traction has a great potential to be a breakthrough for esophageal ESD, providing appropriate and multi-directional traction to the lesions via an operator-controlled robotic arm. There is no doubt that traction assistance is key to facilitating esophageal ESD. Further studies are needed to elucidate the best method from the perspective of efficacy, safety, and cost.
{"title":"Endoscopic submucosal dissection for large early squamous cell carcinoma—traction assisted methods","authors":"M. Yoshida","doi":"10.21037/aoe-2020-34","DOIUrl":"https://doi.org/10.21037/aoe-2020-34","url":null,"abstract":"Endoscopic resection is a minimally-invasive treatment for superficial esophageal tumors compared with surgery or chemoradiation therapy. Endoscopic submucosal dissection (ESD) is a wellestablished method with accurate histological evaluation and favorable procedural outcomes. However, ESD requires a high level of skill, and is therefore technically challenging and time-consuming. Traction-assisted ESD has been introduced to facilitate ESD and provides adequate submucosal visualization and satisfactory tissue traction. We reviewed the scientific literature in English to evaluate the efficacy of traction-assisted ESD for esophageal lesions, including the clip-with-thread (CT) method and the submucosal tunneling (ST) method. The CT method is a simple and affordable technique that uses commercially available hemoclips. Two randomized controlled trials and two retrospective studies showed that the CT method resulted in shorter procedure times and reduced local injection compared with conventional ESD, and no cases of perforation. The ST method does not require specific devices and facilitates the procedure by securing a stable submucosal visual field and maintaining a submucosal liquid cushion. Two retrospective studies reported shorter procedure times with similar en bloc resection rates and complete resection rates using the ST method compared with conventional ESD. Although a combination of the ST method with the CT method seems to be effective for large lesions, its efficacy and safety should be confirmed by a largescale study. In the future, robotic traction has a great potential to be a breakthrough for esophageal ESD, providing appropriate and multi-directional traction to the lesions via an operator-controlled robotic arm. There is no doubt that traction assistance is key to facilitating esophageal ESD. Further studies are needed to elucidate the best method from the perspective of efficacy, safety, and cost.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43590973","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: Esophageal adenocarcinoma is an aggressive disease that is often treated with trimodality therapy for locoregionally advanced cases. However, about a quarter of these patients are found to have pathologic complete response (pCR) on resection, which raises the question of whether we can avoid esophagectomy in favor of active surveillance in patients who appear to have a complete response on clinical evaluation after neoadjuvant chemoradiation (nCRT). Two prospective trials—the SANO trial and ESOSTRATE trial—are currently ongoing in an attempt to study this question. While awaiting the results of these trials, in order to consider active surveillance as a viable alternative to upfront surgery, we must understand the accuracy of clinical tools currently used to evaluate for pCR, establish safe, efficient and reliable surveillance protocols, and finally, understand the risk of selecting either strategy. Currently available clinical tools include FDG-PET/CT, CT with IV contrast of the chest and abdomen, MRI, endoscopy with biopsy and endoscopic ultrasound. None of these modalities has been found to be reliable to independently predict pCR, and although MRI may perform better than other studies, nearly all the available data is from small scale feasibility studies. Recognizing these limits, the SANO group developed a novel technique of bite-on-bite biopsy which appears to perform better than preexisting methods (74% sensitivity and 77% specificity for residual tumor detection). However, outside of the SANO group publications, there is virtually no data regarding this technique at this time. In the meanwhile, the risk balance of either approach continues to evolve. Esophagectomy and its perioperative management continue to evolve with improved short- and long-term outcomes and improved survivorship. The objective estimation of a specific patient’s perioperative risk continues to be elusive and therefore heavily relies on subjective evaluations by clinicians. On the other hand, delayed (salvage) esophagectomy is often found to have increased morbidity, and there is no clear data establishing the safest and most effective active surveillance protocol. At this point, we find that our current ability to detect true pCR and predict outcomes after either surgery or surveillance is limited, which severely diminishes the safety of active surveillance for patients with clinical complete response. As we await the results from the aforementioned trials, any decision made in a patient with clinical complete response after nCRT must be individualized, keeping in mind the goals of care for any given patient but recognizing the limits of available data and high stakes.
{"title":"Surgery versus active surveillance in clinical complete response","authors":"Giye Choe, D. Molena","doi":"10.21037/AOE-2020-20","DOIUrl":"https://doi.org/10.21037/AOE-2020-20","url":null,"abstract":": Esophageal adenocarcinoma is an aggressive disease that is often treated with trimodality therapy for locoregionally advanced cases. However, about a quarter of these patients are found to have pathologic complete response (pCR) on resection, which raises the question of whether we can avoid esophagectomy in favor of active surveillance in patients who appear to have a complete response on clinical evaluation after neoadjuvant chemoradiation (nCRT). Two prospective trials—the SANO trial and ESOSTRATE trial—are currently ongoing in an attempt to study this question. While awaiting the results of these trials, in order to consider active surveillance as a viable alternative to upfront surgery, we must understand the accuracy of clinical tools currently used to evaluate for pCR, establish safe, efficient and reliable surveillance protocols, and finally, understand the risk of selecting either strategy. Currently available clinical tools include FDG-PET/CT, CT with IV contrast of the chest and abdomen, MRI, endoscopy with biopsy and endoscopic ultrasound. None of these modalities has been found to be reliable to independently predict pCR, and although MRI may perform better than other studies, nearly all the available data is from small scale feasibility studies. Recognizing these limits, the SANO group developed a novel technique of bite-on-bite biopsy which appears to perform better than preexisting methods (74% sensitivity and 77% specificity for residual tumor detection). However, outside of the SANO group publications, there is virtually no data regarding this technique at this time. In the meanwhile, the risk balance of either approach continues to evolve. Esophagectomy and its perioperative management continue to evolve with improved short- and long-term outcomes and improved survivorship. The objective estimation of a specific patient’s perioperative risk continues to be elusive and therefore heavily relies on subjective evaluations by clinicians. On the other hand, delayed (salvage) esophagectomy is often found to have increased morbidity, and there is no clear data establishing the safest and most effective active surveillance protocol. At this point, we find that our current ability to detect true pCR and predict outcomes after either surgery or surveillance is limited, which severely diminishes the safety of active surveillance for patients with clinical complete response. As we await the results from the aforementioned trials, any decision made in a patient with clinical complete response after nCRT must be individualized, keeping in mind the goals of care for any given patient but recognizing the limits of available data and high stakes.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45937616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
: The relationship of the upper esophageal sphincter (UES) and gastroesophageal reflux is not well established. The phenomenon of refluxate violation of the UES has been well documented. Laryngopharyngeal reflux (LPR) which occurs when the refluxate has breached the UES has been linked to various atypical reflux symptoms, including laryngitis, hoarseness, chronic cough, asthma, aspiration pneumonia, and globus. This paper aims to review existing research on both physiologic and pathological UES functions related to reflux. The vagally mediated esophago-upper sphincter contraction reflex prevents oropharyngeal reflux while the esophago-upper sphincter relaxation reflex (EURR) allows gas venting. The UES responds to liquid refluxate with a contractile response in healthy, supine subjects. This mechanism serves to protect the respiratory tract and is distinct from the UES belch relaxation reflex. This response is innate and likely diminishes with age. Deficient esophago-upper sphincter contraction reflex and hyper-attenuated EURR have been linked with symptoms of supra-esophageal reflux disease (SERD). When this type of reflux leads to symptoms and other pharyngeal, laryngeal or airway pathology, it is considered SERD. Artificial augmentation of UES pressure has been proposed as a therapeutic option for the prevention of SERD. These findings have been reproduced in subsequent studies and correlate with a reduction in regurgitation and extraesophageal symptoms.
{"title":"The upper esophageal sphincter in gastroesophageal reflux disease","authors":"Michelle Lippincott, V. Velanovich","doi":"10.21037/AOE-21-3","DOIUrl":"https://doi.org/10.21037/AOE-21-3","url":null,"abstract":": The relationship of the upper esophageal sphincter (UES) and gastroesophageal reflux is not well established. The phenomenon of refluxate violation of the UES has been well documented. Laryngopharyngeal reflux (LPR) which occurs when the refluxate has breached the UES has been linked to various atypical reflux symptoms, including laryngitis, hoarseness, chronic cough, asthma, aspiration pneumonia, and globus. This paper aims to review existing research on both physiologic and pathological UES functions related to reflux. The vagally mediated esophago-upper sphincter contraction reflex prevents oropharyngeal reflux while the esophago-upper sphincter relaxation reflex (EURR) allows gas venting. The UES responds to liquid refluxate with a contractile response in healthy, supine subjects. This mechanism serves to protect the respiratory tract and is distinct from the UES belch relaxation reflex. This response is innate and likely diminishes with age. Deficient esophago-upper sphincter contraction reflex and hyper-attenuated EURR have been linked with symptoms of supra-esophageal reflux disease (SERD). When this type of reflux leads to symptoms and other pharyngeal, laryngeal or airway pathology, it is considered SERD. Artificial augmentation of UES pressure has been proposed as a therapeutic option for the prevention of SERD. These findings have been reproduced in subsequent studies and correlate with a reduction in regurgitation and extraesophageal symptoms.","PeriodicalId":72217,"journal":{"name":"Annals of esophagus","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44508122","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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