Medicine (St Vincent's) - Theses

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Author: Jayasekera, Chatura S. × End date: 2016 × Start date: 2012 × Type: Doctorate ×

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    Evaluating new technologies in the assessment and endoscopic management of Barrett’s oesophagus
    Jayasekera, Chatura S. ( 2012)
    The assessment and treatment of dysplastic Barrett’s oesophagus (BO) has evolved dramatically over the last decade. Recently, advances in endoscopic imaging techniques have enabled more accurate identification of subtle mucosal abnormalities and provide improved capacity to identify early cancers. This combined with advances in endoscopic resection and ablation techniques have resulted in excellent outcomes for individuals with high grade dysplasia (HGD) and intramucosal cancer (IMC) treated with endoscopic means alone. The aim of this work was to assess to efficacy and safety of these new technologies in the assessment and management of dysplastic BO. The first study assessed the accuracy of predicting HGD and IMC in mucosa predicted as being non dysplastic vs. dysplastic by high definition white light (HD WLE), Narrow band imaging (NBI) and confocal endomicroscopy (CEM). A prospective cohort study of 50 consecutive patients was performed. A prediction of likely histology was made for each biopsy point (4 quadrant every 1cm and any visible mucosal abnormality) firstly with HD WLE, then with NBI and finally CEM. 1190 individual biopsy points have been assessed (39 HGD and 52 IMC). For the detection of HGD/IMC the sensitivity, specificity and accuracy for HD WLE were 79.1%, 83.1% and 82.8%, for NBI were 89.0%, 80.1% and 81.4% and for CEM were 75.7%, 80.0% and 79.9% respectively. All mucosal points with IMC and all patients with HGD were detected by targeted biopsies guided by HD WLE and NBI without the need for random Seattle protocol biopsies. We then assessed the impact that endoscopic mucosal resection (EMR) had on the optimal staging and treatment of dysplastic BO. 71 consecutive patients referred for endoscopic management of dysplastic BO were included in the study. 48 patients had an EMR performed on a visible mucosal abnormality, resulting in upstaging in 20 patients (P= 0.0498). 33/48 patients had a lesion missed by their referring doctor, including 9 cancers. In 24/48 (50%) patients EMR was considered necessary for optimal treatment (12 patients with sub-mucosal invasion, were unsuitable for endoscopic therapy, 12 patients with IMC into the muscularis mucosa or lamina propria may not have been adequately treated by HALO radiofrequency ablation alone.) These results demonstrate the importance of EMR and secondly that a large proportion lesions are not identified by endoscopists in community practice. We finally assessed the rate of complete remission of intestinal metaplasia (CR-IM) at 12 months post commencement of HALO radiofrequency ablation (RFA) and secondly looked at factors that may predict resistance to HALO RFA. 92 patients at the time of analysis had been referred for endoscopic treatment of dysplastic BO of which 31 patients had reached the 12 month assessment. CR-IM was achieved in 25/31 patients (80%) within 12 months of the first HALO RFA treatment. A median of 3 therapeutic procedures (1 EMR and 2 HALO ablations sessions) were required to achieve CR-IM. Longer BO segments, median 9cm (range 5-14) predict failure to achieve CR-IM at 12 months (p = 0.04). Our study confirmed good success rates of combination endoscopic therapy comparable with other published studies.