Presentations in Endoscopy


Radiofrequency Ablation in Barrett Esophagus Associated With Durable Epithelial Reversion

For many patients with dysplastic Barrett esophagus (BE), treatment with radiofrequency ablation (RFA) is associated with complete eradication of dysplasia and intestinal metaplasia, though the durability of eradication has not been well defined. Moreover, the efficacy of RFA in patients without complete eradication at 1 year is not known. The randomized, sham-controlled AIM Dysplasia Trial evaluated RFA plus surveillance versus surveillance alone in patients with dysplastic BE. Following stratification by degree of dysplasia and length of BE (<4 vs 4-8 cm), patients were randomly assigned 2:1 to RFA or sham treatment. Patients in the active treatment arm received step-wise circumferential and focal RFA. All enrolled patients underwent surveillance with biopsy every 3 months for high-grade disease or every 6 months for low-grade disease. Patients in the active arm received continued surveillance, whereas those in the control arm were offered RFA. After 1 year, 65 of 78 patients in the RFA arm (83%) had attained a complete response for intestinal metaplasia (CR-IM). These patients were a median of 66 years old; 85% were male; the mean BE length was 4.7 cm; and 34 patients had high-grade disease. Of the 13 patients with persistent BE at 1 year, the median age was 67; 92% were male; the mean BE length was 6.0 cm; 7 patients (54%) had high-grade disease; and 12 patients (92%) had multifocal dysplasia. The investigators conducted additional follow-up to evaluate the durability of CR-IM and the feasibility of response in patients not attaining CR-IM after 1 year. After a follow-up of 2 years in 62 RFA-treated patients attaining CR-IM at 1 year, CR-IM was maintained in 59 patients (95.2% in a per-protocol analysis/90.8% in an intent-to-treat analysis). In the remaining 3 patients, who had 5-6-cm, multifocal, high-grade disease at baseline, the dysplasia grade had improved at Year 2. In the 13 patients with persistent BE at 1 year, 11 patients (84.6%) achieved CR-IM at 2 years, with an average of 1.2 focal RFA sessions during the second year. Finally, a 3-year follow-up of patients with CR-IM at Year 1 showed durable responses, with maintenance of CR-IM in 13 of 13 evaluable patients.

Use Patterns in a Computed Tomography Colonography Colorectal Cancer Screening Program

Modeling studies have suggested that the introduction of computed tomography colonography (CTC) screening could lead to a reduction in the use of optical colonos-copies. However, this hypothesis has not been evaluated. In 2004, the University of Wisconsin was the first US institution to gain third-party payer coverage of CTC for colorectal cancer screening in average-risk individuals. In the current analysis, Benson and colleagues analyzed the uptake of a CTC screening program and its effect on optical colonoscopies in individuals 50-75 years of age over a 5-year period. The researchers compared screening rates from 2003 (the year before the approval of open-access third party-covered CTC) to 2008 (5 years after the program initiation). Use of CTC screening peaked in the third quarter of 2005 with 307 CTC examinations and declined to 203 examinations in the fourth quarter of 2008. Conversely, use of screening optical colonoscopy increased significantly from 2003 to 2008 from an average of 555 to 995 screenings per quarter (P<.001). Over the same time period, the number of total optical colonoscopies performed in this population increased from 1,104 to 1,976 (P<.001). The number of therapeutic colonoscopies performed per quarter did not increase significantly from 2003 to 2009 (463 vs 490; P=.36). Overall, colorectal cancer screening examinations of any type increased significantly from 2003 to 2008, from 555 to 1,187 examinations per quarter (P<.001). In 2009, CTC accounted for only 8.5% of all screenings, indicating that optical colonoscopy remains the primary screening method. The authors concluded that the introduction of the CTC screening program was not associated with a reduction in the use of optical colonoscopy; rather, there was an overall increase of screenings performed during the time period.
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So Many Advances in Medicine, So Many Yet to Come