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Laparoscopic transgastric esophageal mucosal resection: a treatment option for patients with high-grade dysplasia in Barrett's esophagus
The American Journal of Surgery (2016) 211, 534-536
Midwest Surgical Association
Laparoscopic transgastric esophageal mucosal resection: a treatment option for patients with high-grade dysplasia in Barrett’s esophagus Constantine T. Frantzides, M.D.a,*, Shaun C. Daly, M.D.b, Alexander T. Frantzides, M.D.a, Thomas Manelis, M.D.a, Algis Marcinkevicius, M.D.a, Minh B. Luu, M.D.b a
Chicago Institute of Minimally Invasive Surgery, 4905 Old Orchard Center, Suite 409, Skokie, IL 60077, USA; bDepartment of Surgery, Rush University Medical Center, Chicago, IL, USA
KEYWORDS: Mucosal resection; Endoscopic resection; High-grade dysplasia; Barrett’s esophagus
Abstract BACKGROUND: We present long-term follow-up data on patients with esophageal high-grade dysplasia and/or carcinoma in situ who were treated with laparoscopic transgastric esophageal mucosal resection (LTEMR). METHODS: Patient demographics, operative outcomes, and follow-up results were tabulated. RESULTS: LTEMR was performed in 11 patients (9 male, 2 female). The median age was 54 (44 to 75) years. The 30-day morbidity or mortality was zero. The median follow-up was 5.2 (2 to 12) years. Upper endoscopy was performed at 3, 6, and 12 month, and yearly thereafter. All patients regenerated squamous epithelium at 6 months. One patient developed a recurrence of Barrett’s epithelium 2 years after resection. No recurrences of high-grade dysplasia or carcinoma were observed in any of the patients. Two patients developed an esophageal stricture; both were treated successfully with endoscopic balloon dilation and have suffered no further sequelae. CONCLUSIONS: LTEMR is safe and effective alternative method to treat patients with Barrett’s esophagus with high-grade dysplasia. Ó 2016 Elsevier Inc. All rights reserved.
The risk of developing adenocarcinoma in a patient with Barrett’s esophagus (BE) is estimated to be .3% a year and this risk increases 10-fold with the presence of high-grade dysplasia (HGD).1–3 Surveillance and several treatment options exist for patients with BE with HGD but optimal management is unclear. None of these techniques have
The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-847-676-2200; fax: 11-847-6761813. E-mail address: [email protected] Manuscript received July 18, 2015; revised manuscript December 22, 2015 0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.12.008
established itself as superior to the others in both efficacy and risk profile. Endoscopic surveillance has the lowest risk of complications but confers no therapeutic benefit to reduce progression to cancer. In contrast, esophagectomy is the definitive surgical management but carries the highest morbidity. Various mucosal ablative treatments have been developed to balance the benefit of risk reduction of cancer progression against the risk of treatment complications. These treatment options include argon plasma coagulation, multipolar electrocoagulation, photodynamic therapy, radiofrequency ablation and endoscopic mucosal resection (EMR). We previously described the technique of laparoscopic transgastric esophageal mucosal resection (LTEMR)
C.T. Frantzides et al.
Laparoscopic transgastric mucosal resection
for the treatment of HGD in BE.4,5 We report follow-up data on our first 11 patients treated with LTEMR.
Methods LTEMR consists of circumferential and caudal esophageal mucosal resection. In addition, primary cruroplasty is performed for concurrent hiatal hernias. A 5 -cm gastrotomy is made 4 cm distal to the gastroesophageal junction. A mixture of epinephrine (1:100,000) and normal saline is injected at the Zline and carried cephalad to the extent of the abnormal mucosa. The abnormal mucosa is removed with a combination of Endo Shears and hook electrocautery in 4 quadrants. A lighted bougie is used for retraction of the esophagus. The anterior quadrant is excised 1st, followed by the 2 lateral quadrants and finally the posterior quadrant. The specimen is then removed and oriented for pathology. The anterior gastrotomy is approximated with interrupted sutures and closed with a linear endostapler. A short floppy Nissen fundoplication is constructed to complete the operation.4–6 Patient demographics and follow-up data were collected and categorized.
Results LTEMR was performed in 11 patients (9 males, 2 females) with a median age of 54 years old (range: 44 to 75 years). All patients had HGD on preoperative biopsy. The median length of BE was 4.5 cm (range: .5 to 8.0 cm). Two patients with long-segment BE (6.5 cm and 8.0 cm) required postoperative EMR because the proximal extent of abnormal mucosa was unattainable by laparoscopy. The 30day morbidity and mortality was zero. All patients had confirmed HGD on postoperative pathologic examination and 2 patients had a focus of carcinoma in situ. Upper endoscopy was performed at 3, 6, and 12 months, and yearly thereafter. Multiple mucosal biopsies and methylene blue staining was performed at each endoscopy. Surveillance was performed using the common Settle protocol (4 quadrants, every cm). Methylene blue is used to make the edge of Barrett epithelium more distinct and thus easier for eradication; it will also provide a better pattern to identify potential foci of HGD and cancer to biopsy or perform mucosal resection. The median follow-up was 5.2 years (range: 2 to 12 years). All patients had regeneration of squamous epithelium at 6 months. One patient developed a recurrence of intestinal metaplasia 2 years after resection. He is currently being treated with surveillance and a proton-pump inhibitor. No recurrence of HGD or carcinoma was observed in any of the 11 patients. Two patients developed an esophageal stricture; both were successfully treated with endoscopic balloon dilation and have not required further intervention.
Comments HGD of the esophageal mucosa is a premalignant condition with treatment options ranging from close
535
surveillance to definitive treatment with an esophagectomy. Several mucosal ablative techniques and EMR are also used to treat HGD. The available evidence suggests the incidence of cancer after a mucosal ablative intervention is about one-third in comparison to untreated patients; 2 per 100 patient-years vs 6 per 100 patient-years, respectively.7 The complete response rate in EMR and radiofrequency ablation for HGD is approximately 95% and 77% respectively with symptomatic stricture rates approaching 38% for EMR.8,9 Additional complications of EMR include bleeding and perforation. The rationale for treatment of HGD of the esophageal mucosa with LTEMR has 3 components (1) en block resection of the quadrant of abnormal mucosa, (2) repair of coexisting hiatal hernia, and (3) the ability to perform an antireflux procedure. The last 2 components are unique features of LTEMR and should in theory reduce the future risk of esophageal mucosal injury due to pathologic reflux. A benefit of LTEMR is the ability to orient the specimen for pathology. Our resection technique is limited to abnormal mucosa extending 5 cm proximal to the Z-line. This approach is more invasive than the previously mentioned modalities, requiring general anesthesia, port insertion, mediastinal dissection, fundal mobilization, and a gastrotomy. Despite these risks, the 30-day morbidity was zero. In addition, this report is limited by a select referral pattern of patients for LTEMR. There is no comparison to other techniques and may not be representative of the population of all patients with HGD on esophageal biopsy. LTEMR was completed in 11 patients with no recurrences of HGD. Our stricture rate of 18% is comparable to stricture rates of mucosal ablative techniques that have been reported as high as 30%.7,10 Two patients in our study who would have otherwise undergone esophagectomy for carcinoma in situ were spared this morbid procedure by LTEMR as these patients were treated before the current National Comprehensive Cancer Network guidelines were published.
Conclusions Given the minimally invasive approach and ability to safely treat both the dysplasia and the underlying cause of the dysplasia, LTEMR seems to be a reasonable treatment for HGD of the lower 5 cm of the esophagus.
References 1. Bhat S, Coleman HG, Yousef F, et al. Risk of malignant progression in Barrett’s esophagus patients: results from a large population-based study. J Natl Cancer Inst 2011;103:1049–57. 2. Desai TK, Samala N. The incidence of esophageal adenocarcinoma among patients with nondysplastic Barrett’s esophagus has been overestimated. Clin Gastroenterol Hepatol 2011;9:363–4. 3. Hvid-Jensen F, Pedersen L, Funch-Jensen P, et al. Long-term complications to reflux disease in community practice: a 17-year cohort study of 4706 patients. Scand J Gastroenterol 2011;46:1179–86.
536 4. Frantzides CT, Madan AK, Keshavarian A, et al. Laparoscopic transgastric esophageal mucosal resection for high-grade dysplasia. J Laparoendosc Adv Surg Tech A 2004;14:261–5. 5. Frantzides CT, Carlson MA, Roberts JE, et al. Laparoscopic transgastric esophageal mucosal resection: 4-year minimum follow-up. Am J Surg 2010;200:305–7. 6. Frantzides CT, Welle SN, Roberts JE, et al. Laparoscopic esophageal mucosal resection for high grade dysplasia. In: Frantzides CT, ed. Video Atlas of Advanced Minimally Invasive Surgery. Chicago, IL: Elsevier/Saunders; 2013. p. 55–8. 7. Wani S, Puli SR, Shaheen NJ, et al. Esophageal adenocarcinoma in Barrett’s esophagus after endoscopic ablative therapy: a metaanalysis and systematic review. Am J Gastroenterol 2009;104:502–13. 8. Chadwick G, Groene O, Hanna GB, et al. Systematic review comparing radiofrequency ablation and complete endoscopic resection in treating dysplastic Barrett’s esophagus: a critical assessment of histologic outcomes and adverse events. Gastrointest Endosc 2014;79. 9. Shaheen NJ, Sharma P, Lightdale CJ, et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 2009;360:2277–88. 10. Waxman I, Konda VJ. Mucosal ablation of Barrett esophagus. Natl Rev 2009;6:393–401.
Discussion Discussant Dr. Raymond P. Onders (Cleveland, OH): I have 2 basic questions. With only 11 patients in 12 years, what are your inclusion criteria for laparoscopic mucosal resection? Did you use endoscopic ultrasound to look at this before going to surgery? What percentage of your patients in your institution underwent standard endoscopic mucosal ablation or resection? The 2nd question would be, you make note of 1 patient with recurrence of the Barrett’s esophagus (BE) that you are treating with proton-pump inhibitors. I do a lot of antireflux operations after ablation of Barrett’s and we completely document lack of reflux before we stop proton pump inhibitor (PPI). It’s very important when you’re kind of doing big cases that you are going to make sure that you give the best therapy. Do you routinely check with your kind of floppy looseness and say that you are stopping reflux before you stop PPIs? Dr. Frantzides: We didn’t have any inclusion criteria, per se. Patients were brought in by their practitioners and themselves knowing that the surgeon who performs this technique has been doing it, and that’s the basis for our referral. All patients that were sent to the surgeon, of those, none of them were excluded from this procedure. However, in our experience, and going forward through the 11 patients that we so far have done this operation on, exclusion criteria in the future might be limited to patients with abnormal mucosa 5 centimeters proximal to the gastroesophageal junction, because anything higher than that is extremely hard with the laparoscopic technique. We do not perform endoscopic ultrasound routinely on
The American Journal of Surgery, Vol 211, No 3, March 2016 patients before this procedure. All the patients that were in our study, this is the 1st time that a procedure has been initiated in terms of their BE other than medical treatment. And to your 2nd question about pH monitoring postoperatively, we do a routine barium swallow study postoperatively. And if this is not demonstrated reflux and the patients were and remain asymptomatic, we do not do any routine pH monitoring and are just followed up as described earlier with esophagogastroduodenoscopies at 6-month intervals and yearly thereafter. Dr. Onders: One concern. Once you ablate the mucosa, their sensation for reflux really goes away. And so that’s why we’re very specific in checking for reflux before stopping PPI, where you are doing very aggressive treatment for Barrett’s. Dr. Robert P. Sticca (Grand Forks, ND): So the current standard of care I think would be ablation with a halo procedure, which is certainly a lot less invasive and has a very low complication rate. What advantage or why would you chose this over an ablation for a Barrett’s even with high-grade dysplasia (HGD)? Dr. Frantzides: One of the advantages that we feel with this procedure that I touched on a little bit in the presentation is the fact that you can concurrently repair any hiatal hernias or perform Nissen fundoplication at the time that you are taking care of the HGD, thus treating the underlying cause that initially caused the BE and HGD. Dr. Margo C. Shoup (Warrenville, IL): It’s standard care to do a mucosal resection for HGD. It’s very rarely, if ever, indicated to do an esophagectomy for those patients. And even with the National Comprehensive Cancer Network guidelines, even for the T1-A lesions and the mucosal resection is quite acceptable. However, T1-B, that’s the one time that you have to really consider resection. But the only way to know that ahead of time is, to do an endoscopic ultrasound. So I would challenge you to go back and look at your policies of not doing endoscopic ultrasounds on patients with HGD because so far you’re lucky that none of those have had underlying adenocarcinoma, but someone will. And at that point you are going to havednow be faced with a T1-B esophogeal cancer on somebody who has had a wrap and an a mucosal resection at the time. So I’d like your comments on that and see if anything’s changed over the past number of years that you have been doing this, and if you look at the National Comprehensive Cancer Network guidelines, it really does include endoscopic ultrasound for all esophageal lesions. Dr. Frantzides: We, in our last patients that we performed this operation on, we still have not been performing routine preoperative endoscopic ultrasounds, but I appreciate your comments, and we will take that into consideration.
Midwest Surgical Association
Laparoscopic transgastric esophageal mucosal resection: a treatment option for patients with high-grade dysplasia in Barrett’s esophagus Constantine T. Frantzides, M.D.a,*, Shaun C. Daly, M.D.b, Alexander T. Frantzides, M.D.a, Thomas Manelis, M.D.a, Algis Marcinkevicius, M.D.a, Minh B. Luu, M.D.b a
Chicago Institute of Minimally Invasive Surgery, 4905 Old Orchard Center, Suite 409, Skokie, IL 60077, USA; bDepartment of Surgery, Rush University Medical Center, Chicago, IL, USA
KEYWORDS: Mucosal resection; Endoscopic resection; High-grade dysplasia; Barrett’s esophagus
Abstract BACKGROUND: We present long-term follow-up data on patients with esophageal high-grade dysplasia and/or carcinoma in situ who were treated with laparoscopic transgastric esophageal mucosal resection (LTEMR). METHODS: Patient demographics, operative outcomes, and follow-up results were tabulated. RESULTS: LTEMR was performed in 11 patients (9 male, 2 female). The median age was 54 (44 to 75) years. The 30-day morbidity or mortality was zero. The median follow-up was 5.2 (2 to 12) years. Upper endoscopy was performed at 3, 6, and 12 month, and yearly thereafter. All patients regenerated squamous epithelium at 6 months. One patient developed a recurrence of Barrett’s epithelium 2 years after resection. No recurrences of high-grade dysplasia or carcinoma were observed in any of the patients. Two patients developed an esophageal stricture; both were treated successfully with endoscopic balloon dilation and have suffered no further sequelae. CONCLUSIONS: LTEMR is safe and effective alternative method to treat patients with Barrett’s esophagus with high-grade dysplasia. Ó 2016 Elsevier Inc. All rights reserved.
The risk of developing adenocarcinoma in a patient with Barrett’s esophagus (BE) is estimated to be .3% a year and this risk increases 10-fold with the presence of high-grade dysplasia (HGD).1–3 Surveillance and several treatment options exist for patients with BE with HGD but optimal management is unclear. None of these techniques have
The authors declare no conflicts of interest. * Corresponding author. Tel.: 11-847-676-2200; fax: 11-847-6761813. E-mail address: [email protected] Manuscript received July 18, 2015; revised manuscript December 22, 2015 0002-9610/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2015.12.008
established itself as superior to the others in both efficacy and risk profile. Endoscopic surveillance has the lowest risk of complications but confers no therapeutic benefit to reduce progression to cancer. In contrast, esophagectomy is the definitive surgical management but carries the highest morbidity. Various mucosal ablative treatments have been developed to balance the benefit of risk reduction of cancer progression against the risk of treatment complications. These treatment options include argon plasma coagulation, multipolar electrocoagulation, photodynamic therapy, radiofrequency ablation and endoscopic mucosal resection (EMR). We previously described the technique of laparoscopic transgastric esophageal mucosal resection (LTEMR)
C.T. Frantzides et al.
Laparoscopic transgastric mucosal resection
for the treatment of HGD in BE.4,5 We report follow-up data on our first 11 patients treated with LTEMR.
Methods LTEMR consists of circumferential and caudal esophageal mucosal resection. In addition, primary cruroplasty is performed for concurrent hiatal hernias. A 5 -cm gastrotomy is made 4 cm distal to the gastroesophageal junction. A mixture of epinephrine (1:100,000) and normal saline is injected at the Zline and carried cephalad to the extent of the abnormal mucosa. The abnormal mucosa is removed with a combination of Endo Shears and hook electrocautery in 4 quadrants. A lighted bougie is used for retraction of the esophagus. The anterior quadrant is excised 1st, followed by the 2 lateral quadrants and finally the posterior quadrant. The specimen is then removed and oriented for pathology. The anterior gastrotomy is approximated with interrupted sutures and closed with a linear endostapler. A short floppy Nissen fundoplication is constructed to complete the operation.4–6 Patient demographics and follow-up data were collected and categorized.
Results LTEMR was performed in 11 patients (9 males, 2 females) with a median age of 54 years old (range: 44 to 75 years). All patients had HGD on preoperative biopsy. The median length of BE was 4.5 cm (range: .5 to 8.0 cm). Two patients with long-segment BE (6.5 cm and 8.0 cm) required postoperative EMR because the proximal extent of abnormal mucosa was unattainable by laparoscopy. The 30day morbidity and mortality was zero. All patients had confirmed HGD on postoperative pathologic examination and 2 patients had a focus of carcinoma in situ. Upper endoscopy was performed at 3, 6, and 12 months, and yearly thereafter. Multiple mucosal biopsies and methylene blue staining was performed at each endoscopy. Surveillance was performed using the common Settle protocol (4 quadrants, every cm). Methylene blue is used to make the edge of Barrett epithelium more distinct and thus easier for eradication; it will also provide a better pattern to identify potential foci of HGD and cancer to biopsy or perform mucosal resection. The median follow-up was 5.2 years (range: 2 to 12 years). All patients had regeneration of squamous epithelium at 6 months. One patient developed a recurrence of intestinal metaplasia 2 years after resection. He is currently being treated with surveillance and a proton-pump inhibitor. No recurrence of HGD or carcinoma was observed in any of the 11 patients. Two patients developed an esophageal stricture; both were successfully treated with endoscopic balloon dilation and have not required further intervention.
Comments HGD of the esophageal mucosa is a premalignant condition with treatment options ranging from close
535
surveillance to definitive treatment with an esophagectomy. Several mucosal ablative techniques and EMR are also used to treat HGD. The available evidence suggests the incidence of cancer after a mucosal ablative intervention is about one-third in comparison to untreated patients; 2 per 100 patient-years vs 6 per 100 patient-years, respectively.7 The complete response rate in EMR and radiofrequency ablation for HGD is approximately 95% and 77% respectively with symptomatic stricture rates approaching 38% for EMR.8,9 Additional complications of EMR include bleeding and perforation. The rationale for treatment of HGD of the esophageal mucosa with LTEMR has 3 components (1) en block resection of the quadrant of abnormal mucosa, (2) repair of coexisting hiatal hernia, and (3) the ability to perform an antireflux procedure. The last 2 components are unique features of LTEMR and should in theory reduce the future risk of esophageal mucosal injury due to pathologic reflux. A benefit of LTEMR is the ability to orient the specimen for pathology. Our resection technique is limited to abnormal mucosa extending 5 cm proximal to the Z-line. This approach is more invasive than the previously mentioned modalities, requiring general anesthesia, port insertion, mediastinal dissection, fundal mobilization, and a gastrotomy. Despite these risks, the 30-day morbidity was zero. In addition, this report is limited by a select referral pattern of patients for LTEMR. There is no comparison to other techniques and may not be representative of the population of all patients with HGD on esophageal biopsy. LTEMR was completed in 11 patients with no recurrences of HGD. Our stricture rate of 18% is comparable to stricture rates of mucosal ablative techniques that have been reported as high as 30%.7,10 Two patients in our study who would have otherwise undergone esophagectomy for carcinoma in situ were spared this morbid procedure by LTEMR as these patients were treated before the current National Comprehensive Cancer Network guidelines were published.
Conclusions Given the minimally invasive approach and ability to safely treat both the dysplasia and the underlying cause of the dysplasia, LTEMR seems to be a reasonable treatment for HGD of the lower 5 cm of the esophagus.
References 1. Bhat S, Coleman HG, Yousef F, et al. Risk of malignant progression in Barrett’s esophagus patients: results from a large population-based study. J Natl Cancer Inst 2011;103:1049–57. 2. Desai TK, Samala N. The incidence of esophageal adenocarcinoma among patients with nondysplastic Barrett’s esophagus has been overestimated. Clin Gastroenterol Hepatol 2011;9:363–4. 3. Hvid-Jensen F, Pedersen L, Funch-Jensen P, et al. Long-term complications to reflux disease in community practice: a 17-year cohort study of 4706 patients. Scand J Gastroenterol 2011;46:1179–86.
536 4. Frantzides CT, Madan AK, Keshavarian A, et al. Laparoscopic transgastric esophageal mucosal resection for high-grade dysplasia. J Laparoendosc Adv Surg Tech A 2004;14:261–5. 5. Frantzides CT, Carlson MA, Roberts JE, et al. Laparoscopic transgastric esophageal mucosal resection: 4-year minimum follow-up. Am J Surg 2010;200:305–7. 6. Frantzides CT, Welle SN, Roberts JE, et al. Laparoscopic esophageal mucosal resection for high grade dysplasia. In: Frantzides CT, ed. Video Atlas of Advanced Minimally Invasive Surgery. Chicago, IL: Elsevier/Saunders; 2013. p. 55–8. 7. Wani S, Puli SR, Shaheen NJ, et al. Esophageal adenocarcinoma in Barrett’s esophagus after endoscopic ablative therapy: a metaanalysis and systematic review. Am J Gastroenterol 2009;104:502–13. 8. Chadwick G, Groene O, Hanna GB, et al. Systematic review comparing radiofrequency ablation and complete endoscopic resection in treating dysplastic Barrett’s esophagus: a critical assessment of histologic outcomes and adverse events. Gastrointest Endosc 2014;79. 9. Shaheen NJ, Sharma P, Lightdale CJ, et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med 2009;360:2277–88. 10. Waxman I, Konda VJ. Mucosal ablation of Barrett esophagus. Natl Rev 2009;6:393–401.
Discussion Discussant Dr. Raymond P. Onders (Cleveland, OH): I have 2 basic questions. With only 11 patients in 12 years, what are your inclusion criteria for laparoscopic mucosal resection? Did you use endoscopic ultrasound to look at this before going to surgery? What percentage of your patients in your institution underwent standard endoscopic mucosal ablation or resection? The 2nd question would be, you make note of 1 patient with recurrence of the Barrett’s esophagus (BE) that you are treating with proton-pump inhibitors. I do a lot of antireflux operations after ablation of Barrett’s and we completely document lack of reflux before we stop proton pump inhibitor (PPI). It’s very important when you’re kind of doing big cases that you are going to make sure that you give the best therapy. Do you routinely check with your kind of floppy looseness and say that you are stopping reflux before you stop PPIs? Dr. Frantzides: We didn’t have any inclusion criteria, per se. Patients were brought in by their practitioners and themselves knowing that the surgeon who performs this technique has been doing it, and that’s the basis for our referral. All patients that were sent to the surgeon, of those, none of them were excluded from this procedure. However, in our experience, and going forward through the 11 patients that we so far have done this operation on, exclusion criteria in the future might be limited to patients with abnormal mucosa 5 centimeters proximal to the gastroesophageal junction, because anything higher than that is extremely hard with the laparoscopic technique. We do not perform endoscopic ultrasound routinely on
The American Journal of Surgery, Vol 211, No 3, March 2016 patients before this procedure. All the patients that were in our study, this is the 1st time that a procedure has been initiated in terms of their BE other than medical treatment. And to your 2nd question about pH monitoring postoperatively, we do a routine barium swallow study postoperatively. And if this is not demonstrated reflux and the patients were and remain asymptomatic, we do not do any routine pH monitoring and are just followed up as described earlier with esophagogastroduodenoscopies at 6-month intervals and yearly thereafter. Dr. Onders: One concern. Once you ablate the mucosa, their sensation for reflux really goes away. And so that’s why we’re very specific in checking for reflux before stopping PPI, where you are doing very aggressive treatment for Barrett’s. Dr. Robert P. Sticca (Grand Forks, ND): So the current standard of care I think would be ablation with a halo procedure, which is certainly a lot less invasive and has a very low complication rate. What advantage or why would you chose this over an ablation for a Barrett’s even with high-grade dysplasia (HGD)? Dr. Frantzides: One of the advantages that we feel with this procedure that I touched on a little bit in the presentation is the fact that you can concurrently repair any hiatal hernias or perform Nissen fundoplication at the time that you are taking care of the HGD, thus treating the underlying cause that initially caused the BE and HGD. Dr. Margo C. Shoup (Warrenville, IL): It’s standard care to do a mucosal resection for HGD. It’s very rarely, if ever, indicated to do an esophagectomy for those patients. And even with the National Comprehensive Cancer Network guidelines, even for the T1-A lesions and the mucosal resection is quite acceptable. However, T1-B, that’s the one time that you have to really consider resection. But the only way to know that ahead of time is, to do an endoscopic ultrasound. So I would challenge you to go back and look at your policies of not doing endoscopic ultrasounds on patients with HGD because so far you’re lucky that none of those have had underlying adenocarcinoma, but someone will. And at that point you are going to havednow be faced with a T1-B esophogeal cancer on somebody who has had a wrap and an a mucosal resection at the time. So I’d like your comments on that and see if anything’s changed over the past number of years that you have been doing this, and if you look at the National Comprehensive Cancer Network guidelines, it really does include endoscopic ultrasound for all esophageal lesions. Dr. Frantzides: We, in our last patients that we performed this operation on, we still have not been performing routine preoperative endoscopic ultrasounds, but I appreciate your comments, and we will take that into consideration.