Efficacy and safety outcomes of multimodal endoscopic eradication therapy in Barrett's esophagus-related neoplasia: a systematic review and pooled analysis.
OBJECTIVE
Focal EMR followed by radiofrequency ablation (f-EMR + RFA) and stepwise or complete EMR (s-EMR) are established strategies for eradication of Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC)/intramucosal carcinoma (IMC). The objective of this study was to derive pooled rates of efficacy and safety of individual methods in a large cohort of patients with BE and to indirectly compare the 2 methods.


METHODS
PubMed, Embase, Web of Science, Cochrane, and major conference proceedings were searched. A systematic review and pooled analysis were carried out to determine the following outcomes in patients with BE undergoing either f-EMR + RFA or s-EMR: (1) complete eradication rates of neoplasia (CE-N) and intestinal metaplasia (CE-IM); (2) recurrence rates of cancer (EAC), dysplasia, and IM; (3) incidence rates of adverse events. Mixed logistic regression was performed as an exploratory analysis to examine differences in outcomes between the 2 methods.


RESULTS
Nine studies (774 patients) of f-EMR + RFA and 11 studies (751 patients) of s-EMR were included. Patients undergoing f-EMR + RFA had high BE eradication rates (CE-N, 93.4%; CE-IM, 73.1%), whereas strictures occurred in 10.2%, bleeding in 1.1%, and perforations in 0.2% of patients. Recurrence of EAC, dysplasia, and IM was 1.4%, 2.6%, and 16.1%, respectively, in this group. Patients undergoing s-EMR also showed high BE eradication rates (CE-N, 94.9%; CE-IM, 79.6%) but a higher rate of adverse events (strictures in 33.5%, bleeding in 7.5%, and perforation in 1.3%). Recurrence of EAC, dysplasia, and IM was 0.7%, 3.3%, and 12.1%, respectively, in the s-EMR group. Mixed logistic regression showed that patients undergoing s-EMR might be more likely to develop esophageal strictures (odds ratio [OR], 4.73; 95% confidence interval [CI], 1.61-13.85; P = .005), perforation (OR, 7.00; 95% CI, 1.56-31.33; P = .01), and bleeding (OR, 6.88; 95% CI, 2.19-21.62; P = 0.001) compared with f-EMR + RFA.


CONCLUSIONS
In patients with HGD/EAC, f-EMR followed by RFA seems to be equally effective as and safer than s-EMR.
Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.
Madhav
M
Desai
Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.
Shreyas
S
Saligram
Gastroenterology and Hepatology, Loyola University Medical Center, Chicago, Illinois, USA.
Neil
N
Gupta
Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.
Prashanth
P
Vennalaganti
Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA.
Ajay
A
Bansal
Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA.
Abhishek
A
Choudhary
Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA.
Sreekar
S
Vennelaganti
Department of Biostatistics, University of Kansas Medical Center, Kansas City, Kansas, USA.
Jianghua
J
He
Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA.
Mohammad
M
Titi
Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy.
Roberta
R
Maselli
Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, Thomasville, Georgia, USA.
Bashar
B
Qumseya
Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA.
Mojtaba
M
Olyaee
Department of Gastroenterology and Hepatology, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.
Irwing
I
Waxman
Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy.
Alessandro
A
Repici
Department of Gastroenterology, Istituto Clinico Humanitas, Milan, Italy.
Cesare
C
Hassan
Division of Gastroenterology & Hepatology, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA; Department of Gastroenterology, Veteran Affairs Medical Center, Kansas City, Missouri, USA.
Prateek
P
Sharma
D000230:Adenocarcinoma / Q000601:surgery*; D001471:Barrett Esophagus / Q000601:surgery*; D017115:Catheter Ablation / Q000379:methods*; D003131:Combined Modality Therapy; D000069916:Endoscopic Mucosal Resection / Q000379:methods*; D004938:Esophageal Neoplasms / Q000601:surgery*; D004940:Esophageal Stenosis / Q000453:epidemiology; D004945:Esophagoscopy / Q000379:methods*; D006801:Humans; D016015:Logistic Models; D016017:Odds Ratio; D011183:Postoperative Complications / Q000453:epidemiology