Argón plasma versus mucosectomía con bandas en el manejo endoscópico del esófago de Barrett con displasia o el carcinoma de esófago in situ / Argon Plasma Ablation versus Band Mucosectomy for Endoscopic Management of Barrett’s Esophagus with dysplasia or Esophageal Carcinoma

RESUMEN

Introducción: se han descrito diferentes técnicas endoscópicas para la ablación del epitelio metaplásico esofágico manteniendo la integridad de la submucosa, bajo una agresiva terapia supresora de ácido con los bloqueadores de bomba. En lo evaluado hasta la fecha existen muy pocos estudios que comparen las diferentes técnicas endoscópicas que reviertan el esófago de Barrett (EB) con displasia y los factores que pueden influir en el pronóstico con estas terapias no se han evaluado consistentemente. Objetivo: este es un estudio piloto que compara la eficacia en la erradicación completa del EB con displasia, entre la resección endoscópica mucosa (EMR) con bandas y la terapia con argón plasma (APC) con bajo voltaje. Los puntos a evaluar son a) la completa ablación del EB; b) el número de sesiones requeridas; c) las complicaciones. Métodos: la APC se realizó con un catéter flexible 10 Fr. El voltaje utilizado fue de 50 W y el flujo varió entre 1 y 2 l/min. En el grupo de EMR con bandas, la mucosa con EB con un equipo de ligadura multibandas. Hasta seis bandas fueron colocadas por sesión. La mucosa con el EB fue removida con un asa de polipectomía con corriente mezclada. Los pacientes fueron seguidos con endoscopia, se obtuvieron biopsias de cuatro cuadrantes en las áreas tratadas o no a los tres, seis y doce meses después de terminar el tratamiento. Todos los pacientes recibían dosis altas de bloqueadores de bomba de protones. Resultados: este es un estudio prospectivo y describe nuestros resultados en un grupo de 62 pacientes con Barrett y displasia, 33 pacientes (22 hombres, 67%) tratados con APC y 29 con EMR (19 hombres, 66%). La ablación completa del EB se dio en 86,2% con EMR y 79% en la terapia con APC. El número de sesiones requeridas para lograr el tratamiento completo fue de 1±1 con EMR y de 2±1 con APC. No se presentaron complicaciones mayores como sangrado digestivo con necesidad de transfusión o perforaciones. La única complicación ...

ABSTRACT

Introduction: Various endoscopic techniques for ablation of metaplastic esophageal epithelia which maintain the integrity of the submucosa have been described. All maintain patients under aggressive acid suppressive therapy with proton pump inhibitors. To date, few studies have compared the different endoscopic techniques for eradicating Barrett’s esophagus (BE) with dysplasia. Similarly the factors that might influence patients’ prognoses after these therapies have not been very consistently evaluated. Objective: This is a pilot study which compares the effectiveness of complete eradication of BE with dysplasia through endoscopic mucosal resection (EMR) with bands and low voltage endoscopic argon plasma coagulation (APC). The three points evaluated are whether complete ablation of BE was achieved, the number of sessions required and whether and what complications occurred. Methods: APC was performed using a flexible 10 French catheter. The voltage used was 50 W and flow timed varied between 1 minute and 2 l/min. In one group BE mucosa was treated with multi-band ligation. Up to six bands were placed per session. The mucosa with BE was removed with a polypectomy loop and a mixed stream of water. Patients were followed up endoscopically and biopsies were obtained from the four quadrants in both treated and untreated areas at three, six and twelve months after treatment ended. All patients received high doses of proton pump inhibitors. Results: This prospective study describes our results in a group of 62 patients with Barrett’s Esophagus and dysplasia. Thirty-three patients (22 men, 67%) were treated with APC and 29 were treated with EMR (19 men, 66%). Complete ablation of BE was achieved in 86.2% of patients treated with EMR and in 79% of those treated with APC. The number of sessions required to achieve complete ablation was 1 ± 1 for EMR and 2 ± 1 for APC. No major complications such as gastrointestinal bleeding requiring transfusion or perforations occurred. The only complications were two cases of esophageal stenosis, one in each group. These were successfully treated with single sessions of dilation. After a mean of 68.7 ± 18.9 months of follow-up in the APC group and 50.2 ± 19.3 months in the EMR group no cases of carcinoma of the esophagus and no deaths due to disease or therapy had occurred. Conclusions: In patients with BE with high or low grade dysplasia, APC and EMR achieve comparably high eradication rates of neoplasia and intestinal metaplasia (79% versus 86%). Both procedures have comparable levels of effectiveness and safety and have low rates of complications. Nevertheless, APC is associated with a greater number of sessions.