Inflammatory myofibroblastic tumor of the liver in an elderly woman following a second liver biopsy: a case report.

Inflammatory myofibroblastic tumor (IMT) is a rare benign lesion of unknown etiology reported in numerous anatomic sites. Hepatic IMT is rare. It is composed of a dominant spindle cell proliferation with a variable inflammatory component that has unique histological appearance. The tumor is more common in women, who often present with fever of unknown origin or other vague, nonspecific symptoms. A 74-year-old female presented with fever of unknown origin. Abdominal CT-Scan showed focal mass effect with luminal narrowing at the distal sigmoid colon, highly suggestive of a sigmoid neoplasm as well as numerous hypodense lesions scattered throughout the liver, likely representing metastatic disease. Liver biopsy revealed an IMT. Patient was treated conservatively and remained without symptoms. It is extremely difficult to differentiate an IMT from neoplastic disease. Most cases require complete resection to obtain an accurate diagnosis. This entity should be considered in the differential diagnosis in patients with hepatic lesions to avoid unnecessary surgical procedures.

Endoscopic ablation of Barrett's esophagus: a multicenter study with 2.5-year follow-up.

BACKGROUND: For patients with Barrett's esophagus (BE), life-long surveillance endoscopy is recommended because of an elevated risk for developing dysplasia and esophageal adenocarcinoma. Various endoscopic therapies have been used to eradicate BE. Recently circumferential radiofrequency ablation has been used with encouraging short-term results. OBJECTIVE: To provide longer follow-up and to assess the long-term safety and efficacy of step-wise circumferential ablation with the addition of focal ablation for BE. DESIGN: Prospective, multicenter clinical trial (NCT00489268). SETTING: Eight U.S. centers, between May 2004 and February 2007. PATIENTS: Seventy subjects with 2 to 6 cm of BE and histologic evidence of intestinal metaplasia (IM). INTERVENTIONS: Circumferential ablation was performed at baseline and repeated at 4 months if there was residual IM. Follow-up biopsy specimens were obtained at 1, 3, 6, 12, and 30 months. Specimens were reviewed by a central pathology board. Focal ablation was performed after the 12-month follow-up for histological evidence of IM at the 12-month biopsy (absolute indication) or endoscopic appearance suggestive of columnar-lined esophagus (relative indication). Subjects received esomeprazole for control of esophageal reflux. MAIN OUTCOME MEASUREMENTS: Complete absence of IM per patient from biopsy specimens obtained at 12 and 30 months, defined as complete remission-IM (CR-IM). RESULTS: At 12 months, CR-IM was achieved in 48 of 69 available patients (70% per protocol [PP], 69% intention to treat [ITT]). At 30 months after additional focal ablative therapy, CR-IM was achieved in 60 of 61 available patients (98% PP, 97% ITT). There were no strictures or buried glandular mucosa detected by the standardized biopsy protocol at 12 or 30 months, and there were no serious adverse events. LIMITATIONS: This was an uncontrolled clinical trial with 2.5-year follow-up. CONCLUSION: Stepwise circumferential and focal ablation resulted in complete eradication of IM in 98% of patients at 2.5-year follow-up.

Long-term results of radiofrequency energy delivery for the treatment of GERD: sustained improvements in symptoms, quality of life, and drug use at 4-year follow-up.

BACKGROUND: The Stretta endoscopic antireflux procedure has effectively controlled symptoms of patients with GERD refractory to proton pump inhibitor (PPI) medication up to 1 year. OBJECTIVE: The aim of this study was to evaluate the efficacy of the Stretta procedure for patients with GERD based on symptom control, quality of life (QOL), and medication use. DESIGN: Prospective single-center case series. SETTING: Academic endoscopy referral center. PATIENTS: Adults with GERD symptoms and partial response to daily antisecretory medication. INTERVENTION: We have used the Stretta procedure for patients with GERD diagnosed by endoscopic or pH testing since 2000. Our primary assessment was a validated health-related QOL score for heartburn and regurgitation and GERD symptoms index performed at baseline, 12, 36, and 48 months after treatment. A secondary outcome measure was the dose and the frequency of antisecretory pharmaceutical use. RESULTS: We performed the Stretta procedure in 83 consecutive patients with persistent GERD symptoms. Complete matched data for follow-up evaluations are reported at 12, 36, and 48 months. The mean GERD QOL score was 2.4 (baseline), 4.6 (36 months), and 4.3 (48 months, P < .001). The mean GERD symptom score was 2.7 (baseline), 0.3 (36 months), and 0.6 (48 months P < .001). Daily medication usage was 100% (baseline) and 13.6% (48 months, P < .001). LIMITATIONS: Nonrandomized study design, lack of control arm, and lack of 24-hour pH. CONCLUSIONS: For these GERD patients followed to 4 years, the Stretta procedure was a safe, effective, and durable treatment, with significant and sustained improvements in GERD symptoms, QOL, and PPI elimination.

Balloon-based, circumferential, endoscopic radiofrequency ablation of Barrett's esophagus: 1-year follow-up of 100 patients.

OBJECTIVE: To assess the dose-response, safety, and efficacy of circumferential endoscopic ablation of Barrett's esophagus (BE) by using an endoscopic balloon-based ablation device (HALO360 System). DESIGN: This study was conducted in 2 serial phases (dosimetry phase and effectiveness phase) to evaluate a balloon-based ablation device that delivers a pre-set amount of energy density (J/cm2) to BE tissue. The dosimetry phase evaluated the dose-response and the safety of delivering 6 to 12 J/cm2. The effectiveness phase used 10 J/cm2 (delivered twice [x2]) for all patients, followed by EGD with biopsies at 1, 3, 6, and 12 months. A second ablation procedure was performed if BE was present at 1 or 3 months. Patients received esomeprazole 40 mg twice a day for 1 month after ablation, and 40 mg every day thereafter. Postablation symptoms were quantified by using a 14-day symptom diary (scale, 0-100). A complete response (CR) was defined as all biopsy specimens negative for BE at 12 months. SETTING: Eight U.S. centers, between September 2003 and September 2005. PATIENTS: Patients were 18 to 75 years of age, with a diagnosis of BE (without dysplasia), with histopathology reconfirmation of the diagnosis within 6 months of enrollment. RESULTS: In the dosimetry phase, 32 patients (29 men; mean age, 56.8 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 3. There were no dose-related serious adverse events, and the outcomes at 1 and 3 months permitted the selection of 10 J/cm2 (x2) for the subsequent effectiveness phase of the study. In the effectiveness phase, 70 patients (52 men, 18 women; mean age, 55.7 years) were enrolled. Median symptom scores returned to a score of 0 of 100 by day 4. At 12 months (n = 69; mean, 1.5 sessions), a CR for BE was achieved in 70% of patients. There were no strictures and no buried glandular mucosa in either study phase (4306 biopsy fragments evaluated). CONCLUSIONS: Circumferential ablation of nondysplastic BE by using this balloon-based ablation device can be performed with no subsequent strictures or buried glands and with complete elimination of BE in 70% of patients at 1-year follow-up.

Balloon-based electrode for the ablation of non-dysplastic Barrett's esophagus: ablation of intestinal metaplasia (AIM II Trial).

INTRODUCTION: Barrett's esophagus (BE) is a condition in which an abnormal intestinal-type epithelium called specialized intestinal metaplasia (SIM) replaces the stratified squamous epithelium that normally lines the distal esophagus. This occurs as a consequence of chronic gastroesophageal reflux disease (GERD) which is present in more than 20% of adults. It is present in 1-2% of the United States population with an estimated prevalence as high as 25% in white males older than 50 yrs without GERD. This intestinal metaplasia predisposes patients to esophageal adenocarcinoma, the most rapidly rising tumor incidence over the last 30 years, with an annual incidence of 0.5% in patients with BE and a survival rate less than 10% in 5 years. The objective of the study was to assess the safety and efficacy of circumferential endoscopic ablation of Barrett's esophagus using the HALO360 System. METHODS: Patients with non-dysplastic Barrett's esophagus confirmed within the previous year were treated twice per session with a balloon-based, bipolar radiofrequency ablation device with a pre selected energy of 10 J/ cm2 at 260 W for 10 secs, achieving full thickness ablation of epithelium followed by Omeprazole 40 mg PO BID for 1 month and then, daily. Patients were followed at 1, 3, 6 and 12 months with EGD with biopsy and a 2nd re treatment at 4 month if IM persisted. RESULTS: A total of 21 Hispanic patients underwent treatment with a gender distribution of 9 female and 10 male, at a mean age of 59.6 years old (SD +/- 12.9) and a mean weight of 161 Lbs (SD +/- 26.1). There was a complete response of 66.7%, 61.9%, 76.2%, 76.2% at 1, 3, 6, and 12 month respectively and a biopsy clearance rate (BCR) of 84.6% and 92.3% at 6 and 12 mo with single treatment and of 62.5% and 50.0% at 6 and 12 month in retreated patients. No complications from the procedure such as strictures or ulcers were reported at 1 year after treatment. CONCLUSIONS: In spite of the multiple treatment options for BE, especially among ablation techniques, radiofrequency ablation therapy is achieving promising results with a full thickness ablation of Barrett's epithelium in 76.2% of patients without direct injury to the submucosa, avoiding formation of strictures and minimal side effects from treatment.