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Outcomes of Endoscopic Submucosal Dissection vs Esophagectomy for T1 Esophageal Squamous Cell Carcinoma in a Real-World Cohort

期刊: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY, 2019; 17 (1)

BACKGROUND & AIMS: Esophagectomy is the standard treatment for early-stage esophageal squamous cell carcinoma (EESCC), but patients who undergo this procedure have high morbidity and mortality. Endoscopic submucosal dissection (ESD) is a less-invasive procedure for treatment of EESCC, but is considered risky because this tumor frequently metastasizes to the lymph nodes. We aimed to directly compare outcomes of patients with EESCC treated with ESD vs esophagectomy. METHODS: We performed a retrospective cohort study of patients with T1a-m2/m3, or T1b EESCCs who underwent ESD (n = 322) or esophagectomy (n = 274) from October 1, 2011 through September 31, 2016 at Zhongshan Hospital in Shanghai, China. The primary outcome was all-cause mortality at the end of follow up (minimum of 6 months). Secondary outcomes included operation time, hospital stay, cost, perioperative mortalities/severe non-fatal adverse events, requirement for adjuvant therapies, and disease-specific mortality and cancer recurrence or metastasis at the end of the follow up period. RESULTS: Patients who underwent ESD were older (mean 63.5 years vs 62.3 years for patients receiving esophagectomy; P = .006) and a greater proportion was male (80.1% vs 70.4%; P = .006) and had a T1a tumor (74.5% vs 27%; P = .001). A lower proportion of patients who underwent ESD had perioperative mortality (0.3% vs 1.5% of patients receiving esophagectomy; P = .186) and non-fatal severe adverse events (15.2% vs 27.7%; P = .001)-specifically lower proportions of esophageal fistula (0.3% of patients receiving ESD vs 16.4% for patients receiving esophagectomy; P = .001) and pulmonary complications (0.3% vs 3.6%; P = .004). After a median follow-up time of 21 months (range, 6-73 months), there were no significant differences between treatments in all-cause mortality (7.4% for ESD vs 10.9%; P = .209) or rate of cancer recurrence or metastasis (9.1% for ESD vs 8.9%; P = .948). Disease-specific mortality was lower among patients who received ESD (3.4%) vs patients who patients who received esophagectomy (7.4%) (P = .049). In Cox regression analysis, depth of tumor invasion was the only factor associated with all-cause mortality (T1a-m3 or deeper vs T1a-m2: hazard ration, 3.54; P = .04). CONCLUSION: In a retrospective study of patients with T1am2/m3 or T1b EESCCs treated with ESD (n = 322) or esophagectomy (n = 274), we found lower proportions of patients receiving ESD to have perioperative adverse events or disease specific mortality after a median follow up time of 21 months. We found no difference in overall survival or cancer recurrence or metastasis in patients with T1a or T1b ESCCs treated with ESD vs esophagectomy.

IF:7.96

Underuse of Surgery Accounts for Racial Disparities in Esophageal Cancer Survival Times: A Matched Cohort Study

期刊: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY, 2019; 17 (4)

BACKGROUND & AIMS: There are racial disparities in survival times of patients with esophageal cancer. We examined the sequential effects of characteristics, diagnosis, and treatment-related factors on the disparity in survival times of black vs white patients with esophageal cancer. METHODS: We identified 1900 black and 15,523 non-Hispanic white (NHW) patients, 65 years or older, diagnosed with esophageal squamous cell carcinoma or esophageal adenocarcinoma from 1994 through 2011 in the Surveillance Epidemiology and End Results (SEER)-Medicare database. Patients were followed up until death or December 31, 2012. Three sets of 1900 NHW patients were matched sequentially to the same set of 1900 black patients, based on demographics (age, sex, year of diagnosis, and SEER site), presentation (demographics plus cancer stage, grade, and comorbidity), and treatment (presentation variables plus surgery, chemotherapy, or radiation therapy). RESULTS: The absolute difference in 5-year survival between black patients (13.3%) and NHW patients (18.4%) was 5.1% (95% CI, 2.3%-7.7%; P = .001) in the demographics match. After we matched for presentation, the difference in 5-year survival was reduced to 2.3% (95% CI, 0.3%4.8%), but remained statistically significant (P = .04). Additional matching of patients on treatment-related factors eliminated the racial difference in 5-year survival (P = .59). Among patients matched for disease presentation, only 10.8% of black patients underwent surgery, compared with 22.8% of NHW patients (P < .001). Histology, tumor location, socioeconomic status, chemotherapy, and radiation therapy each were associated with the receipt of surgery. None of these factors, however, could explain the racial difference in the receipt of surgery. CONCLUSIONS: In the SEER-Medicare database, underuse of surgical treatment can account for the disparities in survival times between black and NHW patients with esophageal cancer.

IF:7.96

Long-term Outcomes of Autologous Peripheral Blood Stem Cell Transplantation in Patients With Cirrhosis

期刊: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY, 2019; 17 (6)

BACKGROUND & AIMS: Peripheral blood stem cells (PBSCs) mobilized with colony-stimulating factor can promote liver regeneration and increase liver function in patients with liver diseases. However, the long-term effects of stem cell treatments on survival and risk of hepatocellular carcinoma (HCC) in patients with cirrhosis have not been determined. We investigated the long-term effects of autologous stem cell transplantation and risk of HCC in patients with cirrhosis. METHODS: We performed a retrospective analysis of 2 cohorts of patients with decompensated cirrhosis who received transplantations of autologous PBSCs (n = 282) or standard medical treatment (SMT, n = 286) in China from January 1, 2006, through December 31, 2016. Patients were followed up until death or liver transplantation. Mortality data were obtained by case records and confirmed by telephone calls. Survival time was calculated and HCC was confirmed by computed tomography or ultrasound. We used propensity score matching to adjust the differences between the 2 groups. Survival and incidence of HCC were analyzed and Cox proportional hazard regression was used to determine the prognostic factors. RESULTS: After propensity score matching, time of survival was significantly higher in the PBSC group than the SMT group (P = .001). The adjusted rate of 5-year survival was 71.2% in the PBSC group and 52.1% in the SMT group. The overall incidence of HCC did not differ significantly between the PBSC and SMT groups (21.1% vs 20.4%; P = .999). Significant improvement of liver functions was observed at 1 year, 2 years, 3 years, and 5 years after PBSC transplantation compared with the SMT group. CONCLUSIONS: In a long-term analysis of patients with decompensated cirrhosis, autologous transplants of PBSCs significantly improved long-term survival compared with a control group. PBSC transplant did not appear to increase the risk of HCC.

IF:7.96

Cortico-anorectal, Spino-anorectal, and Cortico-spinal Nerve Conduction and Locus of Neuronal Injury in Patients With Fecal Incontinence

期刊: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY, 2019; 17 (6)

BACKGROUND & AIMS: The neuropathophysiology of fecal incontinence (FI) is incompletely understood. We examined the efferent brain-anorectal and spino-anorectal motor-evoked potentials (MEP) to characterize the locus of neuronal injury in patients with FI. METHODS: We performed bilateral transcranial, translumbar, and transsacral magnetic stimulations in 27 patients with FI (19 female) and 31 healthy individuals (controls, 20 female) from 2015 through 2017. MEPs were recorded simultaneously from the rectum and anus using 4 ring electrodes. The difference in MEP latencies between the transcranial (TMS) and translumbar transsacral magnetic stimulations was calculated as cortico-spinal conduction time. MEP data were compared between patients with FI and controls. Patients filled out questionnaires that assessed the severity and effects of FI. RESULTS: The MEP latencies with TMS were significantly longer in patients with FI than controls at most sites, and on both sides (P < .05). Almost all translumbar and transsacral MEP latencies were significantly prolonged in patients with FI vs controls (P < .01). The cortico-spinal conduction time were similar, on both sides, between patients with FI and controls. Ninety-three percent of patients had 1 or more abnormal translumbar and transsacral latencies, but neuropathy was patchy and variable, and not associated with sex or anal sphincter function or defects. CONCLUSIONS: Patients with FI have significant neuropathy that affects the cortico-anorectal and spino-anorectal efferent pathways. The primary loci are the lumbo-rectal, lumbo-anal, sacro-rectal, and sacro-anal nerves; the cortico-spinal segment appears intact. Peripheral spino-anal and spino-rectal neuropathy might therefore contribute to the pathogenesis of FI.

IF:7.96

Efficacy of MaZiRenWan, a Chinese Herbal Medicine, in Patients With Functional Constipation in a Randomized Controlled Trial

期刊: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY, 2019; 17 (7)

BACKGROUND & AIMS: The Chinese herbal medicine, MaZiRenWan (MZRW), has been used for more than 2000 years to treat constipation, but it has not been tested in a randomized controlled trial. We performed a trial to evaluate the efficacy and safety of MZRW, compared with the stimulant laxative senna or placebo, for patients with functional constipation (FC). METHODS: We performed a double-blind, double-dummy, trial of 291 patients with FC based on Rome III criteria, seen at 8 clinics in Hong Kong from June 2013 through August 2015. Patients were observed for 2 weeks and then assigned randomly (1:1:1) to groups given MZRW (7.5 g, twice daily), senna (15 mg daily), or placebo for 8 weeks. Patients were then followed for 8 weeks and evaluated at baseline and weeks 4, 8 (end of treatment), and 16 (end of follow up). Participants recorded information on stool form and frequency, feeling of complete evacuation, and research medication taken. Data on individual bowel symptoms, global symptom improvement, and adverse events were collected. A complete response was defined as an increase >= 1 complete spontaneous bowel movement (CSBM)/ week from baseline (the primary outcome). Secondary outcomes included response during the follow-up period, colonic transit, individual and global symptom assessments, quality of life measured with 36-item short form Chinese version, and adverse events. RESULTS: Although there was no statistically significant difference in proportions of patients with a complete response to MZRW (68%) vs. senna (57.7%) (P = .14) at week 8, there was a statistically significant difference vs. placebo (33.0%) (P < .005). At the 16-week timepoint (after the 8-week follow-up period), 47.4% of patients had a complete response to MZRW, 20.6% had a complete response to senna, and 17.5% had a complete response to placebo (P < .005 for MZRW vs. placebo). The group that received MZRW group also had significant increases in colonic transit and reduced severity of constipation, straining, incomplete evacuation, and global constipation symptoms compared with the groups that received placebo or senna in (P < .05 for all comparisons). CONCLUSIONS: In a randomized controlled trial of 291 patients with FC, we found MZRW to be well-tolerated and effective in increasing CSBM/week. MZRW did not appear to be more effective than senna and might be considered as an alternative to this drug.

IF:7.96

Rectal Indomethacin and Spraying of Duodenal Papilla With Epinephrine Increases Risk of Pancreatitis Following Endoscopic Retrograde Cholangiopancreatography

期刊: CLINICAL GASTROENTEROLOGY AND HEPATOLOGY, 2019; 17 (8)

BACKGROUND & AIMS: Rectal indomethacin and spraying of the duodenal papilla with epinephrine might reduce the incidence of pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). We performed a randomized trial to compare the effects of the combination of indomethacin and epinephrine (IE) vs indomethacin plus saline (IS) in prophylaxis of post-ERCP pancreatitis (PEP). METHODS: We performed a double-blind trial at 10 centers in China, from February 2017 to October 2017, of 1158 patients with native papilla undergoing ERCP. The patients were assigned randomly to groups given IE (n = 576) or IS (n = 582). All patients received a single dose of rectal indomethacin within 30 minutes before ERCP; 20 mL of dilute epinephrine (IE group) or saline (IS group) then was sprayed on the duodenal papilla at the end of ERCP. The primary outcome was the incidence of overall PEP. Data were analyzed on an intention-to-treat principle. RESULTS: The study was terminated at the interim analysis for safety concerns and futility. The groups had similar baseline characteristics. PEP developed in 49 patients in the IE group (8.5%) and in 31 patients in the IS group (5.3%) (relative risk, 1.60, 95% CI, 1.03-2.47; P = .033). There were no significant differences between groups in proportions of patients with postsphincterotomy bleeding (2.1% in the IE group and 1.5% in the IS group) and biliary infection (1.2% in the IE group and 2.2% in the IS group). CONCLUSIONS: In a randomized trial, we found the combination of rectal indomethacin with papillary epinephrine spraying increased the risk of PEP compared with indomethacin alone. Spray epinephrine should not be used with rectal indomethacin for prevention of post-ERCP pancreatitis.

IF:7.96

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