Hello, my name is Raman Muthusamy, I'm the Medical Director of Endoscopy for the UCLA Health System, and in honor of this being Esophageal Cancer Awareness Month, this video tip will be on best practices and quality indicators for endoscopic eradication of Barrett's esophagus. Endoscopic eradication therapy is defined as a combination of resection and ablative techniques to achieve complete eradication of all Barrett's epithelium. Most commonly, we use two major techniques. Ablation techniques, which include radiofrequency ablation, cryoablation, which can be done with liquid nitrogen or nitrous oxide in a balloon, or argon plasma coagulation with or without submucosal injection of liquid. Reception techniques typically include endoscopic mucosal resection, EMR, and occasionally ESD, endoscopic submucosal dissection for larger lesions or those with concern of submucosal involvement. These are some pictures showing the variety of ablation techniques, RFA at the top left, cryo spray therapy at the top right, cryo balloon at the bottom right, and at the bottom left you can see a submucosal injection of liquid followed by argon plasma coagulation to minimize the risk of deep injury and stricturing. Endoscopic mucosal resection has traditionally been formed in one of two ways, either with a cap assistance, which provides larger specimens in a variety of shapes and caps, but is technically more difficult due to the need for preloading a snare, and also carries an increased risk for perforation and injection is recommended. Rapid mucosectomy is a simple and familiar technique with injection being optional. More rapid and this can be overlapped to create confluent defects. It's also been shown to be safer, although the specimen size of each individual specimen is typically smaller, between 1.5 to 2 centimeters. EMR can change the diagnosis in up to 45% of cases when it is performed compared to biopsies. It also plays an important role in staging, as we see that high-grade dysplasia and intramucosal cancer can be effectively treated endoscopically, but those patients who have more than T1A cancer, in other words, those involving submucosa have higher risks of lymph node metastases and are better served by surgery. Here's an example of an EMR of a T1A esophageal cancer, where you see a lesion on the 9 o'clock position that underwent multiband mucosectomy, followed by eight weeks later under high-definition white light imaging, evidence of neosquamous epithelium at the site of the prior cancer, and on narrowband imaging, you can see that as well on the bottom. Putting it all together, we typically use a combination of mucosal resection of all visible lesions, followed by ablation, a flat Barrett's esophagus, and you see the lesion on the right here in a region of Barrett's esophagus, and then the patient after EMR and ablation with complete eradication of all Barrett's esophagus. It is important to know that if you're having difficulty in achieving eradication, or potentially even in patients at risk for developing recurrence, it's important to consider how well the pH is being controlled. If there's concern of issues of compliance or adequate acid suppression, consideration of a pH and or impedance study can be performed, and in those patients with a positive study, PPI use can be optimized, and in rare cases, fund application may even be indicated to help achieve eradication. A variety of quality metrics have been developed and adopted by both the ACG and the ASGE on best practices for endoscopic eradication therapy. The approved metrics really cover three major areas. Pre-procedure metrics include having a dysplasia diagnosed that is made by a GI pathologist or confirmed by a second pathologist. Centers performing endoscopic eradication therapy should have a high-definition white light scope available and be able to perform mucosal ablation and endoscopic mucosal resection or other resection techniques, ideally with the same endoscopist. Resection should also be done of the risk benefits and alternatives of EET prior to initiating this process. Intra-procedurally, the landmarks and length of BE should be documented, ideally using the Prague grading system. The presence or absence of visible lesion should be reported, ideally using a Paris classification, and Barrett's esophagus segment should be inspected carefully using high-definition white light endoscopy, and complete resection, defined as either on-block or piecemeal resection, should be performed in anyone with identified visible lesions. Among patients undergoing eradication therapy, a defined interval for the subsequent procedure should be documented, and the outcome metric should be that those patients who start endoscopic eradication therapy should achieve complete eradication of all neoplasia in 80% by 18 months, and 70% should have all of their Barrett's epithelium eradicated by 18 months. Finally, post-procedure metrics include, among patients who achieve CEIM, recommendation for appropriate endoscopic surveillance. When that surveillance is performed, biopsy should be obtained of any visible mucosal abnormalities that are seen. Anti-reflux regimen should be recommended after EET, as this can be a predictor of recurrence when adequate acid suppression is not achieved, and adverse events should be tracked and documented. This is a 2018 ASG guideline on endoscopic eradication therapy, and this, again, highlights many of the best practices just mentioned. Confirm with expert pathology, review the diagnosis, perform a careful exam under high-definition white light, and make sure that there's no esophagitis. Perform resection of all visible lesions, including raised and flat, and if the pathology found is high-grade dysplasia, T1A cancer, or low-grade dysplasia, then a resection of all visible lesions, followed by ablation of flat barrett's epithelium, is appropriate. In those identified with submucosal cancer, surgical referral should be made for consideration of esophagectomy. What have we learned regarding EET? We should resect all visible lesions, flat or nodular. We should consider submucosal injection to assess these lesions if depressed lesions lift. EUS has a limited value in assessing the T stage. Its primary role is to assess for malignant adenopathy in known or suspected cancers. Multiband mucosectomy is likely the preferred EMR method due to safety and efficacy compared to the CAP method and or ESD. Lifting agents really are optional for the vast majority of EMR, and that we must eliminate all barrett's epithelium, typically by ablation of flat, non-dysplastic barretts after resection of all visible lesions. Finally, control of pH is critical to achieving and maintaining eradication. I hope you found this brief review useful in your ongoing efforts to provide endoscopic eradication treatment of barrett's esophagus and early esophageal adenocarcinoma as we continue to do our best to reduce the morbidity and mortality associated with esophageal cancer. Thank you for your time and attention.

endoscopic eradication therapy

Barrett's esophagus

resection techniques

ablation techniques

pH control