Multiple-Band Imaging Provides Better Value Than White-light Endoscopy in Detection of Dysplasia in Patients With Barrett's Esophagus

Identification of visible lesions during surveillance endoscopy for Barrett's esophagus: a video-based survey study

BACKGROUND AND AIMS

Visible lesion (VL) detection is essential in patients with Barrett's esophagus (BE). We sought to assess the rate of VL detection by academic and community endoscopists using high-definition white-light endoscopy (HD-WLE) and narrow-band imaging (NBI) during surveillance endoscopy.

METHODS

Fifty endoscopists were invited to participate in a prospective video survey study. Participants viewed 25 standardized clips of patients referred for endoscopic therapy. Participants noted identification of anatomic landmarks and VLs using HD-WLE and NBI and reported practice-level data. The criterion standard of VL identification was established by consensus of 5 BE experts. Our primary outcome was the rate of VL identification using HD-WLE and NBI.

RESULTS

Forty-four of 50 participants completed the study (22 academic and 22 community). Compared with the criterion standard, participants did not identify 28% (HD-WLE) and 31% (NBI) of VLs. Community endoscopists had more experience (>5 years in practice: community 85% vs academic 54.5%, P = .041; >5 surveillance endoscopies a month: community 85% vs academic 31.8%, P = .046). Across all participants, VL detection using NBI improved significantly with a minimum of 5 surveillance endoscopies per month (area under the curve = .72; 95% confidence interval, .56-.85; P = .006).

CONCLUSIONS

Despite improved endoscope resolution and availability of virtual chromoendoscopy, the overall rate of VL detection remains low. Identification of VLs using NBI may be volume dependent. Further education and training efforts focused on VL detection during BE surveillance endoscopy are needed.

Kyoto international consensus report on anatomy, pathophysiology and clinical significance of the gastro-oesophageal junction

OBJECTIVE

An international meeting was organised to develop consensus on (1) the landmarks to define the gastro-oesophageal junction (GOJ), (2) the occurrence and pathophysiological significance of the cardiac gland, (3) the definition of the gastro-oesophageal junctional zone (GOJZ) and (4) the causes of inflammation, metaplasia and neoplasia occurring in the GOJZ.

DESIGN

Clinical questions relevant to the afore-mentioned major issues were drafted for which expert panels formulated relevant statements and textural explanations.A Delphi method using an anonymous system was employed to develop the consensus, the level of which was predefined as ≥80% of agreement. Two rounds of voting and amendments were completed before the meeting at which clinical questions and consensus were finalised.

RESULTS

Twenty eight clinical questions and statements were finalised after extensive amendments. Critical consensus was achieved: (1) definition for the GOJ, (2) definition of the GOJZ spanning 1 cm proximal and distal to the GOJ as defined by the end of palisade vessels was accepted based on the anatomical distribution of cardiac type gland, (3) chemical and bacterial (Helicobacter pylori) factors as the primary causes of inflammation, metaplasia and neoplasia occurring in the GOJZ, (4) a new definition of Barrett's oesophagus (BO).

CONCLUSIONS

This international consensus on the new definitions of BO, GOJ and the GOJZ will be instrumental in future studies aiming to resolve many issues on this important anatomic area and hopefully will lead to better classification and management of the diseases surrounding the GOJ.

The Annual Risk of Esophageal Adenocarcinoma Does Not Decrease Over Time in Patients With Barrett's Esophagus

OBJECTIVES

Endoscopic surveillance is recommended for patients with Barrett's esophagus (BE). However, it remains unclear if all BE patients benefit from long-term surveillance. We investigated the risk of esophageal adenocarcinoma (EAC) in BE patients in relation to number of successive endoscopies, years of follow-up, and calendar year.

METHODS

We conducted a retrospective cohort study of male veterans with newly diagnosed BE during 2004-2009 with follow-up until 30 September 2011. EAC was verified using detailed structured electronic medical records reviews. We used Poisson regression to determine incidence rates, rate ratios (RR), and corresponding 95% confidence intervals (CI) for EAC according to number of successive endoscopies, years of follow-up independent of number of follow-up endoscopies, and calendar year of BE diagnosis.

RESULTS

Among 28,561 male patients with BE, 406 developed EAC during 140,499 person-years of follow-up (median 4.9 years). EAC incidence rates increased with each additional endoscopy following a previous negative endoscopy (RR per additional endoscopy, 1.43; 95% CI, 1.25-1.64). Compared to the EAC incidence rate at the 1st follow-up EGD, the EAC incidence rate at the 5th follow-up EGD was ninefold higher (adjusted RR, 8.82; 95% CI, 4.90-15.9). EAC incidence was highest at the first year of follow-up (5.34 per 1,000 person-years); however, EAC rates starting from the second follow-up year increased during successive years of follow up. Compared to the EAC incidence rate in the 2nd year of follow-up, the EAC incidence rate was 1.5-fold higher in EGDs conducted ≥5 years after the index BE date (adjusted RR, 1.49; 95% CI, 1.07-2.10). In contrast, we found no significant change in EAC incidence rates by calendar year.

CONCLUSIONS

Persistence of non-neoplastic BE on multiple consecutive endoscopies was not associated with lower EAC risk. These findings argue against discontinuation of endoscopic surveillance in patients with persistent nondysplastic BE after multiple negative endoscopies.