1. Endoluminal Treatment of Barrett’s and Early Cancer Brant K. Oelschlager, MD University of Washington

2. CENTER FOR VIDEOENDOSCOPIC SURGERY Paradigm Shifts in GI Diseases

3. CENTER FOR VIDEOENDOSCOPIC SURGERY Dilemma’s Associated with HGD/IM Cancer  Diagnostic  Confidence in the diagnosis has an impact on treatment  Malignant risk of the lesion  Is everyone’s risk the same?  Completeness of Resection/Ablation  How confident can we be?  Morbidity and Mortality of Treatment  Moving target and is provider specific  Eradication of Disease  Cancer, Dysplasia, Barrett’s, GERD

4. CENTER FOR VIDEOENDOSCOPIC SURGERY Risk Benefit Choice RISK BENEFIT Surgery 2008 Endo Tx circa 1998 Surgery circa 1998 Endo Tx 2008 FAVORABLE UNFAVORABLE

5. CENTER FOR VIDEOENDOSCOPIC SURGERY What we learned from surveillance?  With more accurate diagnosis  Better imaging  Better biopsies  Better pathologic recognition  The incidence of progression to cancer goes down  Fewer cancers go undetected

6. CENTER FOR VIDEOENDOSCOPIC SURGERY Assuring the Stage

7. CENTER FOR VIDEOENDOSCOPIC SURGERY Prerequisites for Endoscopic Therapy  No Under-staging  Low failure rate  Accurate assessment of failures  Low complication rate  Excellent functional result  A method for dealing with the underlying disease  ? Consistency among practitioners

8. CENTER FOR VIDEOENDOSCOPIC SURGERY Prerequisites for Surgical Therapy  Low complication rate  Reasonable functional result  ? Consistency among practitioners

9. CENTER FOR VIDEOENDOSCOPIC SURGERY Problems with the Literature  Surgical Literature  All patients or those with unfavorable characteristics  Light on Quality of Life  Lack of consistent approach  Endoscopic Literature  Moving target  Lesions with favorable features  Short follow-up  All from the experts and innovators, none from the “community standard”

10. CENTER FOR VIDEOENDOSCOPIC SURGERY Post-Therapy Management  Post-Endoscopic Therapy  Monetary and emotional costs of surveillance  QOL of ongoing GERD  Anti-reflux Surgery  Post-Surgical Therapy  Few effective interventions for gastric emptying and dumping  Do they need surveillance as well  Can’t go back

11. CENTER FOR VIDEOENDOSCOPIC SURGERY Does One Shoe Fit All?  Young vs. Old  Long vs. Short Segment Barrett’s  Unifocal vs. Multifocal Disease  Well differentiated vs. Poorly differentiated  Nodular vs. Flat lesions  Symptomatic vs. Asymptomatic GERD

12. CENTER FOR VIDEOENDOSCOPIC SURGERY Listen Carefully! They Both May Have a Role Correct Treatment probably depends on:  Patient Characteristics  Disease Characteristics  Extent of Disease  Local or treating expertise

13. CENTER FOR VIDEOENDOSCOPIC SURGERY Endoscopic Mucosal Resection (EMR)  Minimally invasive endoscopic alternative to surgical resection for early GI neoplasia  The largest experience has been in gastric and esophageal neoplasms  EMR results comparable to surgery  EMR may be more cost effective  Improved QOL with EMR

14. CENTER FOR VIDEOENDOSCOPIC SURGERY Risk of Lymph Node Metastases  15-25% for submucosal involvement  < 3% for intramucosal carcinoma  < 2cm in diameter, w/o ulcer <1%  Lower risk of metastases than mortality from surgery (0.36% vs. 0.5%)

15. CENTER FOR VIDEOENDOSCOPIC SURGERY Band-Ligation EMR

16. CENTER FOR VIDEOENDOSCOPIC SURGERY EMR: Band Ligation-Snare Technique

17. CENTER FOR VIDEOENDOSCOPIC SURGERY EMR in Early Esophageal Cancer

18. CENTER FOR VIDEOENDOSCOPIC SURGERY Endoscopic Mucosal Resection (EMR)

19. CENTER FOR VIDEOENDOSCOPIC SURGERY Endoscopic Mucosal Resection (EMR)

20. CENTER FOR VIDEOENDOSCOPIC SURGERY Complications and Outcomes of EMR in Barrett’s Esophagus Complication/outcomeIncidence (%) Perforation0.1-5% Bleeding0-33% Stenosis0-30% Resection rate60-95% Recurrence0-31% Surgery after EMR0-15% Conio et al. Am J Gastroenterol 2006;101:653–663

21. CENTER FOR VIDEOENDOSCOPIC SURGERY EMR and Photodynamic Therapy vs Esophagectomy for Management of Early Esophageal Adenocarcinoma EMR + PDT (n = 24) Surgery (n = 64) Complications431 Procedure-related deaths 01 Disease free during follow-up 20/24 (83%) 63/63 (100%) Pacifico et al. Clin Gastroenterol Hepatol 2003; 1:252

22. CENTER FOR VIDEOENDOSCOPIC SURGERY Magnified electrode Controlled ablation depth by: Bipolar balloon based electrodeBipolar balloon based electrode Fixed energy densityFixed energy density Fixed powerFixed power Automated RF deliveryAutomated RF delivery Radiofrequency Energy Ablation

23. CENTER FOR VIDEOENDOSCOPIC SURGERY

28. Multi-Modality Therapy for Early Barrett’s Neoplasia: Endoscopic Resection Followed by Radiofrequency Energy Ablation

29. CENTER FOR VIDEOENDOSCOPIC SURGERY Cryotherapy

30. CENTER FOR VIDEOENDOSCOPIC SURGERY Is there still a role for PDT?

31. CENTER FOR VIDEOENDOSCOPIC SURGERY Submucosal Dissection