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  • Cryotherapy for persistent Barrett’s esophagus after radiofrequency ablation: a systematic review and meta-analysis

    Background and Aims
    A small but significant proportion of patients with Barrett’s esophagus (BE) have persistent dysplasia or intestinal metaplasia (IM) after treatment with radiofrequency ablation (RFA). Cryotherapy is a cold-based ablative modality that is increasingly being used in this setting. We aimed to better understand the efficacy of second-line cryotherapy in patients with BE who have persistent dysplasia or IM after RFA by conducting a systematic review and meta-analysis. Methods
    We performed a systematic literature search of Pubmed, EMBASE, and Web of Science through September 1, 2017. Articles were included for meta-analysis based on the following inclusion criteria: ≥5 patients with BE treated with RFA had persistent dysplasia or IM; they subsequently underwent ≥1 session of cryotherapy with follow-up endoscopy; the proportions of patients achieving complete eradication of dysplasia (CE-D) and/or IM (CE-IM) were reported. The main outcomes were pooled proportions of CE-D and CE-IM by using a random effects model. Results
    Eleven studies making up 148 patients with BE treated with cryotherapy for persistent dysplasia or IM after RFA were included. The pooled proportion of CE-D was 76.0% (95% confidence interval [CI] 57.7-88.0), with substantial heterogeneity (I2 = 62%). The pooled proportion of CE-IM was 45.9% (95% CI, 32.0-60.5) with moderate heterogeneity (I2 = 57%). Multiple preplanned subgroup analyses did not sufficiently explain the heterogeneity. Adverse effects were reported in 6.7% of patients. Conclusion
    Cryotherapy successfully achieved CE-D in three fourths and CE-IM in half of patients with BE who did not respond to initial RFA. Considering its favorable safety profile, cryotherapy may be a viable second-line option for this therapeutically challenging cohort of patients with BE, but higher-quality studies validating this remain warranted.
  • Endoscopic submucosal dissection for early Barrett’s neoplasia: a meta-analysis

    Background and Aims
    The role of endoscopic submucosal dissection (ESD) in Barrett’s esophagus (BE) is not well established. This meta-analysis aimed to evaluate the safety and efficacy of ESD for the management of early BE neoplasia. Methods
    Three online databases were searched. The Cochran Q test and I2 were used to test for heterogeneity. Pooling was conducted using either fixed- or random-effects models depending on heterogeneity across studies. For the main outcomes, potential sources of heterogeneity were evaluated via linear regression analysis. Results
    Eleven studies (501 patients, 524 lesions) were included. Mean lesion size was 27 mm (95% confidence interval [CI], 20.9-33.1). Pooled estimate for en bloc resection was 92.9% (95% CI, 90.3%-95.2%). The pooled R0 (complete) and curative resection rates were 74.5% (95% CI, 66.3%-81.9%) and 64.9% (95% CI, 55.7%-73.6%), respectively. There was no association between R0 or curative resection rates and study setting (Asia vs West), length of BE, lesion characteristics, procedural time, or length of follow-up. The pooled estimates for perforation and bleeding were 1.5% (95% CI, .4%-3.0%) and 1.7% (95% CI, .6%-3.4%), respectively. Esophageal stricture rate was 11.6% (95% CI, .9%-29.6%). Incidence of recurrence after curative resection was .17% (95% CI, 0%-.3%) at a mean follow-up 22.9 months (95% CI, 17.5-28.3). Conclusions
    ESD for early BE neoplasia is associated with a high en bloc resection rate, acceptable safety profile, and low recurrence after curative resection. ESD should be considered as part of the armamentarium for the management of BE neoplasia.
  • Endoscopic submucosal dissection for early Barrett’s esophagus neoplasia

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