Introduction

Cryoballoon ablation is a relatively novel method which can be used for the eradication of dysplastic Barrett esophagus (BE). While the focal cryoballoon ablation system has shown to be efficacious for BE of limited extent, the cryoballoon¹⁸⁰ ablation system (CBAS¹⁸⁰) is developed to treat longer BE segments by semi-circumferential ablation over 3cm in a single step. A prior first-in-human study demonstrated the feasibility of CBAS¹⁸⁰ treatment¹, yet the optimal dose needs to be determined. Therefore, in the current prospective multicenter study, we investigate CBAS¹⁸⁰ at lower dosages for patients with dysplastic BE. In addition, we report on the results of CBAS¹⁸⁰ followed by focal cryoballon ablation (fCBA).

Aims & Methods

A total of 50 patients with ablation naïve BE (C≤3 and M≥1) will be enrolled in six Dutch Barrett expert centers. Treatment consists of a full circumferential ablation over 3 cm of length, using two semi-circumferential ablations at a dose of 1.2 mm/sec. Follow-up consisted of follow-up phone calls at days 1, 7 and 30, a symptom diary during 14 days, and a follow-up endoscopy after 3 months. Outcomes included:
(1) technical success rate,
(2) BE regression percentage at follow-up scored by an independent adjudication committee and the treating endoscopist,
(3) incidence of adverse events,
(4) post-procedural pain (on a scale of 0-10), and
(5) post-procedural dysphagia (on a scale of 0-4).
Follow-up treatment consisted of fCBA treatments until complete eradication of visible BE was achieved, confirmed by biopsies from the neo-Z-line.

Results

So far, 25 patients (80% male; mean age 67) with a median BE length of C0M2 (p25-p75 C0-1M2-4) were included. Technical success rate was 92% (23/25). In two patients, treatment was technically unsuccessful due to unstable positioning of the balloon (n=1) or a device malfunction (n=1). Median procedure time was 14 (p25-p75 11-16) 4) minutes and median ablation time was 5 (p25-p75 3-5) minutes. All 23 successfully treated patients completed follow-up endoscopy at 3 months. Median BE regression was 90% (p25-p75 75%-100%) and 95% (p25-p75 75%-99%) as evaluated by the independent adjudication committee and the treating endoscopist, respectively. Overall, CBAS¹⁸⁰ adverse event rate was 8% (2/23), with one patient developing a esophageal stricture (1/23; 4%) resolved after a single endoscopic dilation. Another patient (1/23; 4%) experienced post-procedural bleeding, resulting in re-endoscopy without intervention. The CBAS¹⁸⁰ procedure was well tolerated with low post-procedural pain (median 2 [p25-p75 1-4] at day 1 and 0 [p25-p75 0-1] at day 7) and dysphagia (44% and 30% of patients with score ≥1 at day 1 and 7) scores.
So far, 22/23 patients were treated with fCBA in the follow-up phase, of whom and 4 are still under treatment. The remaining 18 patients achieved complete eradication of all visible BE after median 1 (p25-p75 1-3) fCBA treatments. Based on the histological assessment, a complete eradication of dysplasia and intestinal-metaplasia was achieved in all 18 patients. Two patients developed strictures requiring dilation (2 and 1 dilations, respectively) during the follow-up phase.

Conclusion

Based on these preliminary results, circumferential ablation with CBAS¹⁸⁰ at 1.2 mm/sec, followed by fCBA, emerges as an effective and safe procedure for dysplastic BE eradication in the hands of expert endoscopists. Further avenues for exploration should encompass the assessment of multiple CBAS¹⁸⁰ ablations stacked on top of each other in larger segments and the validation of outcomes in a larger patient cohort.

References

1. Overwater A, van Munster SN, Nagengast WB, et al. Novel cryoballoon 180° ablation system for treatment of Barrett’s esophagus-related neoplasia: a first-in-human study. Endoscopy. 2022;54(1):64-70. doi:10.1055/a-1381-7562

Disclosure

PENTAX medical consultancy services & spakker's fee

Introduction

Post infection disorders of gut-brain interaction (PI-DGBI) are a subset of chronic gastrointestinal disorders triggered by acute gastroenteritis. These conditions impose a significant burden on patients' quality of life.

Aims & Methods

This study aimed to determine the prevalence of PI-DGBI and assess associated risk factors among respondents to the Rome Foundation Global Epidemiology Study. Data were extracted from an online survey involving 54,127 participants across 26 countries. PI-DGBI diagnosis was established based on self-reported gastrointestinal symptoms following acute gastroenteritis. Statistical analyses included multivariate logistic regression to identify predictors of PI-DGBI and comparisons with DGBI not associated with infection.

Results

Of 21,713 individuals with at least one DGBI, 987 (10.5%) were classified as having PI-DGBI. PI-DGBI prevalence varied geographically, with the highest rates in Asia (7.1%) and Latin America (6.4%) (Table 1). PI-DGBI group was composed by more males (46.8% vs 40.9% in those without PI-DGBI (p<0.001) and younger subjects (age<40 years old 61.1% vs 46.1, p<0.001). The majority of PI-DGBI group lived in an urban area (94.8%) instead of a rural area (without PI-DGBI 91.1%, p<0.001). A higher rate of individuals with PI-DGBI live on a farm with animals (3.4% vs 1.8% in those without PI-DGBI, p<0.001). A lower rate of subjects with PI-DGBI have running water on tap (89.4% vs 93.4%, p<0.001) and electric power (93.3% vs 95.9%, p<0.001) at home. Patients with PI-DGBI reported more frequently anxiety (40% vs 27.5%) and depression (37.9% vs 26.5%) compared to patients without PI-DGBI.
Younger age [Odd ratio (OR) 1.97], anxiety (OR 1.76), and higher somatic symptom scores (OR 1.14) were risk factors for PI-DGBI, while female gender (OR 0.79) and rural living (0.56) were protective. Patients with PI-DGBI reported more severe psychological and physical health impairments and distinct gastrointestinal profiles, including higher rates of functional dyspepsia (32.2%), irritable bowel syndrome (23.5%), and anorectal disorders (35.3%).

Table 1. Prevalence of PI-DGBI by region.

Conclusion

PI-DGBI represents a significant subset of DGBI, with distinct sociodemographic and clinical characteristics. These findings highlight the role of acute gastroenteritis in triggering the onset of long-term gastrointestinal disorders and underscore the need for targeted interventions to mitigate its impact on patient health.

Introduction

Endoscopic submucosal dissection (ESD) is an effective treatment for superficial esophageal cancer, but postoperative stenosis remains a significant concern. Particularly, probability of the stenosis is less investigated in cases with a 50%-75% circumferential mucosal defect.

Aims & Methods

This study aimed to identify influential factors for postoperative stenosis after the moderate circumferential resection in esophageal ESD. This multi-center retrospective observational study analyzed data from 513 patients across 19 institutions who underwent esophageal ESD from April 2018 to March 2022 and showed 50% to 75% of the circumferential mucosal defect. We firstly overviewed the current status on the postoperative stenosis, the steroid use, and postoperative adverse events in these patients. Subsequently, we identified influential factors for postoperative stenosis. Patients were categorized into stenosis and no stenosis groups, and univariate and multivariate analyses were performed for each parameter. We further investigated influential factors of stenosis in two cohorts: steroid and no steroid groups. Finally, the parameters were compared between the steroid and no steroid groups to assess the tendency of the steroid use in general practice.

Results

Postoperative stenosis was observed in 28 cases (5%). Univariate analysis comparing the stenosis group (n = 28) and no stenosis group (n = 485) revealed significant differences in the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), defect circumference (p =0.01), and procedure duration (p = 0.02). There was no significant difference in the steroid use between two groups. Multivariate analyses identified history of prior endoscopic treatment close to the lesion (p = 0.01, odds ratio [OR], 5.10), cervical esophageal lesions (p = 0.03, OR, 3.97), large circumferential defect (p <0.01, OR, 3.78), and longer procedure duration (p <0.01, OR, 3.83) as independent risk factors for stenosis formation. Among the steroid group, significant associations of the postoperative stenosis were revealed with the prior endoscopic treatment near the lesion (p = 0.02), cervical esophageal location (p = 0.04), and >5/8 of defect circumference (p = 0.02). In the no steroid group, only the procedure duration (p = 0.01) showed a significant difference between the stenosis and non-stenosis groups. Comparison between the steroid (n = 223) and no steroid groups (n = 290) revealed significant differences in the prior endoscopic treatment near the lesion (p <0.01), cervical esophageal lesions (p <0.01), and resected specimen dimensions (p <0.01). The stenosis rates were 7% in the steroid group and 4% in the no steroid group, without a significant difference. No significant difference in adverse events was observed between the two groups.

Conclusion

In esophageal ESD with a 50%-75% circumferential mucosal defect, the steroid was used in over 40% of patients, and postoperative stenosis still occurred in 5%. Because wider circumference, location of the cervical esophagus, prior endoscopic treatment close to the lesion, and prolonged operative time were identified as independent risk factors on the stenosis, steroid therapy should be preferred in these cases. Particularly, lesions with a history of endoscopic treatment, on cervical esophagus, and with >5/8 of defect circumference should require more aggressive countermeasures than currently applied.