Long-term outcomes after endoscopic treatment for Barrett's neoplasia with radiofrequency ablation ± endoscopic resection: results from the national Dutch database in a 10-year period.

OBJECTIVE: Radiofrequency ablation (RFA)±endoscopic resection (ER) is the preferred treatment for early neoplasia in Barrett's oesophagus (BE). We aimed to report short-term and long-term outcomes for all 1384 patients treated in the Netherlands (NL) from 2008 to 2018, with uniform treatment and follow-up (FU) in a centralised setting. DESIGN: Endoscopic therapy for early BE neoplasia in NL is centralised in nine expert centres with specifically trained endoscopists and pathologists that adhere to a joint protocol. Prospectively collected data are registered in a uniform database. Patients with low/high-grade dysplasia or low-risk cancer, were treated by ER of visible lesions followed by trimonthly RFA sessions of any residual BE until complete eradication of BE (CE-BE). Patients with ER alone were not included. RESULTS: After ER (62% of cases; 43% low-risk cancers) and median 1 circumferential and 2 focal RFA (p25-p75 0-1; 1-2) per patient, CE-BE was achieved in 94% (1270/1348). Adverse events occurred in 21% (268/1386), most commonly oesophageal stenosis (15%), all were managed endoscopically. A total of 1154 patients with CE-BE were analysed for long-term outcomes. During median 43 months (22-69) and 4 endoscopies (1-5), 38 patients developed dysplastic recurrence (3%, annual recurrence risk 1%), all were detected as endoscopically visible abnormalities. Random biopsies from a normal appearing cardia showed intestinal metaplasia (IM) in 14% and neoplasia in 0%. A finding of IM in the cardia was reproduced during further FU in only 33%, none progressed to neoplasia. Frequent FU visits in the first year of FU were not associated with recurrence risk. CONCLUSION: In a setting of centralised care, RFA±ER is effective for eradication of Barrett's related neoplasia and has remarkably low rates of dysplastic recurrence. Our data support more lenient FU intervals, with emphasis on careful endoscopic inspection. Random biopsies from neosquamous epithelium and cardia are of questionable value. NETHERLANDS TRIAL REGISTER NUMBER: NL7039.

Effectiveness of topical budesonide in preventing esophageal strictures after endoscopic resection of esophageal cancer.

Background and study aims A disadvantage of endoscopic resection (ER) of early esophageal cancer (EC) is the high stricture rate after resection. A risk factor for stricture development is a mucosal defect after ER of ≥ 75 % of the esophageal circumference. Stricture rates up to 94 % have been reported in these patients. The aim of this study was to investigate the effectiveness of oral treatment with topical budesonide for stricture prevention after ER of early EC. Patients and methods We performed a retrospective analysis of a prospective cohort study of patients who received topical budesonide after ER of EC between March 2015 and April 2020. The primary endpoint was the esophageal stricture rate after ER. Stricture rates of our cohort were compared with stricture rates of control groups in the literature. Results In total, 42 patients were treated with ER and topical budesonide. A total of 18 of 42 patients (44.9 %) developed a stricture. The pooled stricture rate of control groups in the literature was 75.3 % (95 % CI 68.8 %-81.9 %). Control groups consisted of patients with esophageal squamous cell carcinoma with a mucosal defect after ER of ≥ 75 % of the esophageal circumference. Comparable patients of our cohort had a lower stricture rate (47.8 % vs. 75.3 %, P  = 0.007). Conclusions Topical budesonide therapy after ER for EC seems to be a safe and effective method in preventing strictures. The stricture rate after budesonide treatment is lower compared to the stricture rate of patients who did not receive a preventive treatment after ER reported in the literature.

Assessment and Imaging of the Cerebrovascular Glycocalyx.

The glycocalyx is a gel-like layer lining the luminal surface of the endothelium. The glycocalyx exerts an important barrier role because it prevents exposure of plasma components to the endothelial surface. Disruption of the glycocalyx by local inflammation or ischemia results in decreased glycocalyx thickness which is associated with a number of vascular diseases. The cerebrovascular glycocalyx has sparsely been studied, but is of great interest because of its potential role in cerebrovascular disease. In this review, we describe all existing techniques to visualize the glycocalyx and designate techniques that may be suitable for studying the cerebrovascular glycocalyx. A total of seven imaging techniques are discussed thoroughly, including transmission electron microscopy, intravital microscopy, micro-particle image velocimetry, confocal laser scanning microscopy, two-photon laser scanning microscopy, orthogonal polarization spectral imaging and sidestream dark field/oblique imaging. Measurement of serum concentrations of glycocalyx-specific constituents is another method for glycocalyx analysis. Also, we have reviewed the methods of glycocalyx analysis by using these imaging techniques. So far, the cerebrovascular glycocalyx has only been studied in vitro. However, other cerebral microcirculatory properties have been studied in vivo. This suggests that the cerebrovascular glycocalyx can be studied in vivo by using some of the described techniques, when specific software is subjoined to the analysis. In conclusion, we have summarized techniques available for glycocalyx assessment, and explained the significance and technical possibilities regarding cerebrovascular glycocalyx visualization. Cerebrovascular glycocalyx assessment would add valuable information to our understanding of the pathophysiology of cerebrovascular disease. Moreover, as a part of the blood-brain barrier, more knowledge on the cerebrovascular glycocalyx may lead to better understanding of neurodegenerative conditions that are caused by a compromised blood-brain barrier including Alzheimer`s disease, vascular dementia, multiple sclerosis and epilepsy.