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He T, Iyer KG, Lai M, House E, Slavin JL, Holt B, Tsoi EH, Desmond P, Taylor ACF. Endoscopic features of low-grade dysplastic Barrett's. Endosc Int Open 2023; 11:E736-E742. [PMID: 37564334 PMCID: PMC10411114 DOI: 10.1055/a-2102-7726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 05/25/2023] [Indexed: 08/12/2023] Open
Abstract
Background and study aims Barrett's esophagus (BE) with low-grade dysplasia (LGD) is considered usually endoscopically invisible and the endoscopic features are not well described. This study aimed to: 1) evaluate the frequency of visible BE-LGD; 2) compare rates of BE-LGD detection in the community versus a Barrett's referral unit (BRU); and 3) evaluate the endoscopic features of BE-LGD. Patients and methods This was a retrospective analysis of a prospectively observed cohort of 497 patients referred to a BRU with dysplastic BE between 2008 and 2022. BE-LGD was defined as confirmation of LGD by expert gastrointestinal pathologist(s). Endoscopy reports, images and histology reports were reviewed to evaluate the frequency of endoscopically identifiable BE-LGD and their endoscopic features. Results A total of 135 patients (27.2%) had confirmed BE-LGD, of whom 15 (11.1%) had visible LGD identified in the community. After BRU assessment, visible LGD was detected in 68 patients (50.4%). Three phenotypes were observed: (A) Non-visible LGD; (B) Elevated (Paris 0-IIa) lesions; and (C) Flat (Paris 0-IIb) lesions with abnormal mucosal and/or vascular patterns with clear demarcation from regular flat BE. The majority (64.7%) of visible LGD was flat lesions with abnormal mucosal and vascular patterns. Endoscopic detection of BE-LGD increased over time (38.7% (2009-2012) vs. 54.3% (2018-2022)). Conclusions In this cohort, 50.4% of true BE-LGD was endoscopically visible, with increased recognition endoscopically over time and a higher rate of visible LGD detected at a BRU when compared with the community. BRU assessment of BE-LGD remains crucial; however, improving endoscopy surveillance quality in the community is equally important.
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Affiliation(s)
- Tony He
- Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
- Faculty of Medicine, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Australia
| | - Kiran Gopinath Iyer
- Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
| | - Mark Lai
- Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
| | - Eloise House
- Pathology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
| | - John L Slavin
- Pathology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
| | - Bronte Holt
- Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
- Faculty of Medicine, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Australia
| | - Edward H Tsoi
- Faculty of Medicine, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Australia
- Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
| | - Paul Desmond
- Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
- Faculty of Medicine, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Australia
| | - Andrew C F Taylor
- Gastroenterology, St Vincent's Hospital Melbourne Pty Ltd, Fitzroy, Australia
- Faculty of Medicine, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Australia
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2
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Vithayathil M, Modolell I, Ortiz-Fernandez-Sordo J, Pappas A, Januszewicz W, O’Donovan M, Bianchi M, White JR, Kaye P, Ragunath K, di Pietro M. The effect of procedural time on dysplasia detection rate during endoscopic surveillance of Barrett's esophagus. Endoscopy 2023; 55:491-498. [PMID: 36657467 PMCID: PMC10212647 DOI: 10.1055/a-2015-8883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Accepted: 11/23/2022] [Indexed: 01/21/2023]
Abstract
BACKGROUND : Endoscopic surveillance of Barrett's esophagus (BE) with Seattle protocol biopsies is time-consuming and inadequately performed in routine practice. There is no recommended procedural time for BE surveillance. We investigated the duration of surveillance procedures with adequate tissue sampling and effect on dysplasia detection rate (DDR). METHODS : We performed post hoc analysis from the standard arm of a crossover randomized controlled trial recruiting patients with BE (≥C2 and/or ≥M3) and no clearly visible dysplastic lesions. After inspection with white-light imaging, targeted biopsies of subtle lesions and Seattle protocol biopsies were performed. Procedure duration and biopsy number were stratified by BE length. The effect of endoscopy-related variables on DDR was assessed by multivariable logistic regression. RESULTS : Of 142 patients recruited, 15 (10.6 %) had high grade dysplasia/intramucosal cancer and 15 (10.6 %) had low grade dysplasia. The median procedural time was 16.5 minutes (interquartile range 14.0-19.0). Endoscopy duration increased by 0.9 minutes for each additional 1 cm of BE length. Seattle protocol biopsies had higher sensitivity for dysplasia than targeted biopsies (86.7 % vs. 60.0 %; P = 0.045). Longer procedural time was associated with increased likelihood of dysplasia detection on quadrantic biopsies (odds ratio [OR] 1.10, 95 %CI 1.00-1.20, P = 0.04), and for patients with BE > 6 cm also on targeted biopsies (OR 1.21, 95 %CI 1.04-1.40; P = 0.01). CONCLUSIONS : In BE patients with no clearly visible dysplastic lesions, longer procedural time was associated with increased likelihood of dysplasia detection. Adequate time slots are required to perform good-quality surveillance and maximize dysplasia detection.
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Affiliation(s)
- Mathew Vithayathil
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | - Ines Modolell
- Department of Gastroenterology, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Jacobo Ortiz-Fernandez-Sordo
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Apostolos Pappas
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Wladyslaw Januszewicz
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Department of Gastroenterology, Hepatology and Clinical Oncology, Medical Centre for Postgraduate Education, Warsaw, Poland
| | - Maria O’Donovan
- Department of Histopathology, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Michele Bianchi
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - Jonathan R. White
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Philip Kaye
- Department of Histopathology, Nottingham University Hospital NHS Foundation Trust, Nottingham, United Kingdom
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre and NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Nottingham, United Kingdom
| | - Massimiliano di Pietro
- Early Cancer Institute, Department of Oncology, University of Cambridge, Cambridge, United Kingdom
- Department of Gastroenterology, Cambridge University Hospital NHS Foundation Trust, Cambridge, United Kingdom
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3
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Cotton CC, Eluri S, Shaheen NJ. Management of Dysplastic Barrett's Esophagus and Early Esophageal Adenocarcinoma. Gastroenterol Clin North Am 2022; 51:485-500. [PMID: 36153106 PMCID: PMC10173367 DOI: 10.1016/j.gtc.2022.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
While patients with Barrett's esophagus without dysplasia may benefit from endoscopic surveillance, those with low-grade dysplasia may be managed with either endoscopic surveillance or endoscopic eradication. Patients with Barrett's esophagus with high-grade dysplasia and/or intramucosal adenocarcinoma will generally require endoscopic eradication therapy. The management of Barrett's esophagus with dysplasia and early esophageal adenocarcinoma is predominantly endoscopic, with multiple effective methods available for the resection of raised neoplasia and ablation of flat neoplasia. High-dose proton-pump inhibitor therapy is advised during the treatment of Barrett's esophagus with dysplasia and early esophageal adenocarcinoma. After the endoscopic eradication of Barrett's esophagus and associated neoplasia, surveillance is required for the diagnosis and retreatment of recurrence or progression.
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Affiliation(s)
- Cary C Cotton
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4153, Chapel Hill, NC 27599-7080, USA
| | - Swathi Eluri
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4142, Chapel Hill, NC 27599-7080, USA
| | - Nicholas J Shaheen
- Department of Medicine, Division of Gastroenterology and Hepatology, Center for Esophageal Diseases and Swallowing, University of North Carolina at Chapel Hill, CB#7080, 130 Mason Farm Road, Suite 4150, Chapel Hill, NC 27599-7080, USA.
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4
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Zellenrath PA, Roumans CA, Spaander MC. Today’s Mistakes and Tomorrow’s Wisdom… In Barrett’s Surveillance. Visc Med 2022; 38:168-172. [DOI: 10.1159/000522376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/25/2022] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Barrett’s esophagus (BE) is the only known precursor lesion of esophageal adenocarcinoma, a malignancy with increasing incidence and poor survival rates. To reduce mortality, regular endoscopic surveillance of BE patients is recommended to detect neoplasia in an (endoscopically) curable stage. In this review, we aim to provide an overview of current BE surveillance strategies, its pitfalls, and potential future directions to optimize BE surveillance. <b><i>Summary:</i></b> Several societal guidelines provide surveillance strategies. However, when practicing those endoscopies multiple drawbacks are encountered. Important challenges are time-consuming biopsy protocols with low adherence rates, biopsy sampling error, interobserver variability in endoscopic detection of lesions, and interobserver variability in diagnosis of dysplasia. Furthermore, the overall efficacy and cost-effectiveness of surveillance are questioned. Using novel techniques, such as artificial intelligence and personalized surveillance intervals, can help to overcome these obstacles. <b><i>Key Messages:</i></b> Currently, there is room for improvement in BE surveillance. Better risk-stratification is expected to reduce both patient and healthcare burdens. Personalized and dynamic surveillance intervals accompanied by novel techniques in detection and histopathological assessment of dysplasia may be tools for a change in the right direction.
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5
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Ratcliffe E, Britton J, Hamdy S, McLaughlin J, Ang Y. Developing patient-orientated Barrett's oesophagus services: the role of dedicated services. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000829. [PMID: 35193888 PMCID: PMC8867250 DOI: 10.1136/bmjgast-2021-000829] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/09/2022] [Indexed: 11/03/2022] Open
Abstract
Introduction Barrett’s oesophagus (BO) is common and is a precursor to oesophageal adenocarcinoma with a 0.33% per annum risk of progression. Surveillance and follow-up services for BO have been shown to be lacking, with studies showing inadequate adherence to guidelines and patients reporting a need for greater disease-specific knowledge. This review explores the emerging role of dedicated services for patients with BO. Methods A literature search of PubMed, MEDLINE, Embase, Emcare, HMIC, BNI, CiNAHL, AMED and PsycINFO in regard to dedicated BO care pathways was undertaken. Results Prospective multicentre and randomised trials were lacking. Published cohort data are encouraging with improvements in guideline adherence with dedicated services, with one published study showing significant improvements in dysplasia detection rates. Accuracy of allocation to surveillance endoscopy has been shown to hold cost savings, and a study of a dedicated clinic showed increased discharges from unnecessary surveillance. Training modalities for BO surveillance and dysplasia detection exist, which could be used to educate a BO workforce. Qualitative and quantitative studies have shown patients report high levels of cancer worry and poor disease-specific knowledge, but few studies have explored follow-up care models despite being a patient and clinician priority for research. Conclusions Cost–benefit analysis for dedicated services, considering both financial and environmental impacts, and more robust clinical data must be obtained to support this model of care in the wider health service. Greater understanding is needed of the root causes for poor guideline adherence, and disease-specific models of care should be designed around clinical and patient-reported outcomes to address the unmet needs of patients with BO.
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Affiliation(s)
- Elizabeth Ratcliffe
- Gastroenterology, Wrightington Wigan and Leigh NHS Foundation Trust, Leigh, UK .,School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - James Britton
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Shaheen Hamdy
- School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK.,Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - John McLaughlin
- School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK.,Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Yeng Ang
- School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK.,Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
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6
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Tsoi EH, Mahindra P, Cameron G, Williams R, Norris R, Desmond PV, Raftopoulos S, Pavey D, Rattan A, Hourigan LF, Lee R, Bourke MJ, Sidhu N, Singh R, Chan A, Krishnamurthi S, Taylor ACF. Barrett's esophagus with low-grade dysplasia: high rate of upstaging at Barrett's esophagus referral units suggests progression rates may be overestimated. Gastrointest Endosc 2021; 94:902-908. [PMID: 34033852 DOI: 10.1016/j.gie.2021.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 05/15/2021] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The reported progression rate from low-grade dysplasia (LGD) in Barrett's esophagus (BE) to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) ranges from .4% to 13.4% per year. We hypothesize that some reported progression rates may be overestimated because of prevalent HGD or EAC that was not identified during endoscopic assessments performed in the community. Our aim is to determine the proportion of prevalent HGD or EAC detected by BE referral units (BERUs) in patients referred from the community with a recent diagnosis of LGD. METHODS All patients referred from the community to 6 BERUs with a diagnosis of BE with LGD were identified. Patients with an assessment endoscopy performed at BERUs more than 6 months from their referral endoscopy in the community were excluded. Visible lesions and histology outcomes were compared between the community referral endoscopy and the assessment endoscopy performed at BERUs. RESULTS The median time between BERU assessment and referral endoscopy was 79 days (interquartile range, 54-114). Of the 75 patients referred from the community with LGD, BERU assessment identified HGD or EAC in 20 patients (27%). BERU assessment identified more visible lesions than referral endoscopy performed in the community (39 [52%] vs 9 [12%], respectively; P = .029). CONCLUSIONS BERU assessment endoscopy identified more visible lesions than community referral endoscopy and identified HGD or EAC in 27% of patients referred from the community with a recent diagnosis of LGD. Reported progression rates from LGD to HGD or EAC may be overestimated.
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Affiliation(s)
- Edward H Tsoi
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Victoria, Australia; The Faculty of Medicine, University of Melbourne, Victoria, Australia
| | - Puneet Mahindra
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Georgina Cameron
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Richard Williams
- The Faculty of Medicine, University of Melbourne, Victoria, Australia; Department of Pathology, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Richard Norris
- Department of Pathology, St Vincent's Hospital Melbourne, Victoria, Australia
| | - Paul V Desmond
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Victoria, Australia; The Faculty of Medicine, University of Melbourne, Victoria, Australia
| | - Spiro Raftopoulos
- Department of Gastroenterology, Sir Charles Gairdner Hospital, Western Australia, Australia
| | - Darren Pavey
- Department of Gastroenterology, Bankstown Lidcombe Hospital, New South Wales, Australia
| | - Arti Rattan
- Department of Gastroenterology, Bankstown Lidcombe Hospital, New South Wales, Australia
| | - Luke F Hourigan
- Department of Gastroenterology, Princess Alexandra Hospital, Queensland, Australia; Gallipoli Medical Research Institute, School of Medicine, The University of Queensland, Greenslopes Private Hospital, Brisbane, Queensland, Australia
| | - Richard Lee
- Department of Gastroenterology, Princess Alexandra Hospital, Queensland, Australia
| | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, New South Wales, Australia; Western Clinical School, University of Sydney, New South Wales, Australia
| | - Naaz Sidhu
- Department of Gastroenterology, Westmead Hospital, New South Wales, Australia
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, South Australia, Australia
| | - Andrew Chan
- Department of Gastroenterology, Lyell McEwin Hospital, South Australia, Australia
| | | | - Andrew C F Taylor
- Department of Gastroenterology, St Vincent's Hospital Melbourne, Victoria, Australia; The Faculty of Medicine, University of Melbourne, Victoria, Australia
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7
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Falk GW. Low-grade dysplasia in Barrett's esophagus: More than meets the eye? Gastrointest Endosc 2021; 94:909-911. [PMID: 34535285 DOI: 10.1016/j.gie.2021.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Accepted: 07/24/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Gary W Falk
- Division of Gastroenterology, Department of Medicine, Hospital of the University of Pennsylvania, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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8
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Noordzij IC, Van Loon van de Ende MCM, Curvers WL, van Lijnschoten G, Huysentruyt CJ, Schoon EJ. Dysplasia in Random Biopsies from Barrett's Surveillance Is an Important Marker for More Severe Pathology. Dig Dis Sci 2021; 66:1957-1964. [PMID: 32661766 DOI: 10.1007/s10620-020-06463-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/30/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND AND AIM Although endoscopic recognition of dysplasia in Barrett's esophagus is difficult, experience in recognition of early neoplastic lesions is supposed to increase the detection of early neoplastic lesions. The aim of this study was to assess the significance of dysplasia in random biopsies in Barrett's esophagus, in the absence of reported visible lesions as well as the difference in final outcome of pathology. METHODS We retrospectively identified all patients with Barrett's esophagus with suspicion of dysplasia or early adenocarcinoma who were referred to our center between February 2008 and April 2016. We analyzed all endoscopy reports, pathology reports, and referral letters from 19 different hospitals. Patients were divided into two groups, based on the presence or absence of visible lesions reported upon referral. RESULTS In total, 170 patients diagnosed with dysplasia or adenocarcinoma were referred to our tertiary center. Ninety-one of these referred patients were referred with dysplasia or adenocarcinoma in random biopsies, without a reported lesion during endoscopy in the referral center. During endoscopic work-up at our center, a visible lesion was detected in 44 of these 91 patients (48.4%). After endoscopic work-up and treatment, adenocarcinoma was found in an additional 21 patients. Two of these patients were initially referred with low-grade dysplasia, and 19 patients were initially referred with high-grade dysplasia. The final pathology was upstaged in 35.8% of the patients. CONCLUSIONS The presence of any grade of dysplasia in random biopsies during surveillance in referral centers is a marker for more severe final pathology. Training in recognition of early neoplastic lesions in Barrett's esophagus imaging is recommended for endoscopists performing Barrett's surveillance.
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Affiliation(s)
- I C Noordzij
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - M C M Van Loon van de Ende
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - W L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - G van Lijnschoten
- PAMM (Laboratory of Pathology and Medical Microbiology), Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - C J Huysentruyt
- PAMM (Laboratory of Pathology and Medical Microbiology), Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, 5623 EJ, Eindhoven, The Netherlands.
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9
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Optimizing Outcomes with Radiofrequency Ablation of Barrett's Esophagus: Candidates, Efficacy and Durability. Gastrointest Endosc Clin N Am 2021; 31:131-154. [PMID: 33213792 DOI: 10.1016/j.giec.2020.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The treatment of early Barrett's esophagus (BE) has undergone a paradigm shift from surgical subtotal esophagectomy to organ-saving endoluminal treatment. Over the past 15 years, several high-quality studies were conducted to assess safe oncological outcome of endoscopic resection of mucosal adenocarcinoma and high-grade dysplasia. It became clear that add-on ablative therapy with radiofrequency ablation (RFA) significantly reduces recurrence risk of neoplasia after resection. In this review, we highlight the most essential elements to optimize outcomes of RFA of BE, addressing the correct indication and patient selection in combination with the most efficient and safest treatment protocols to obtain long-term durability.
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10
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Mashimo H, Gordon SR, Singh SK. Advanced endoscopic imaging for detecting and guiding therapy of early neoplasias of the esophagus. Ann N Y Acad Sci 2020; 1482:61-76. [PMID: 33184872 DOI: 10.1111/nyas.14523] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 10/08/2020] [Accepted: 10/13/2020] [Indexed: 12/16/2022]
Abstract
Esophageal cancers, largely adenocarcinoma in Western countries and squamous cell cancer in Asia, present a significant burden of disease and remain one of the most lethal of cancers. Key to improving survival is the development and adoption of new imaging modalities to identify early neoplastic lesions, which may be small, multifocal, subsurface, and difficult to detect by standard endoscopy. Such advanced imaging is particularly relevant with the emergence of ablative techniques that often require multiple endoscopic sessions and may be complicated by bleeding, pain, strictures, and recurrences. Assessing the specific location, depth of involvement, and features correlated with neoplastic progression or incomplete treatment may optimize treatments. While not comprehensive of all endoscopic imaging modalities, we review here some of the recent advances in endoscopic luminal imaging, particularly with surface contrast enhancement using virtual chromoendoscopy, highly magnified subsurface imaging with confocal endomicroscopy, optical coherence tomography, elastic scattering spectroscopy, angle-resolved low-coherence interferometry, and light scattering spectroscopy. While there is no single ideal imaging modality, various multimodal instruments are also being investigated. The future of combining computer-aided assessments, molecular markers, and improved imaging technologies to help localize and ablate early neoplastic lesions shed hope for improved disease outcome.
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Affiliation(s)
- Hiroshi Mashimo
- VA Boston Healthcare System, Boston, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | - Stuart R Gordon
- Dartmouth-Hitchcock Medical Center, Dartmouth University, Lebanon, New Hampshire
| | - Satish K Singh
- VA Boston Healthcare System, Boston, Massachusetts.,Boston University School of Medicine, Boston, Massachusetts
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11
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Kahn A, Leggett CL. Artificial intelligence in the age of cognitive endoscopy. Gastrointest Endosc 2020; 91:1251-1252. [PMID: 32439096 DOI: 10.1016/j.gie.2020.03.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 03/05/2020] [Indexed: 02/07/2023]
Affiliation(s)
- Allon Kahn
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Arizona, USA
| | - Cadman L Leggett
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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12
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Sharma P, Shaheen NJ, Katzka D, Bergman JJGHM. AGA Clinical Practice Update on Endoscopic Treatment of Barrett's Esophagus With Dysplasia and/or Early Cancer: Expert Review. Gastroenterology 2020; 158:760-769. [PMID: 31730766 DOI: 10.1053/j.gastro.2019.09.051] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 09/12/2019] [Accepted: 09/16/2019] [Indexed: 12/15/2022]
Abstract
DESCRIPTION The purpose of this best practice advice article is to describe the role of Barrett's endoscopic therapy (BET) in patients with Barrett's esophagus (BE) with dysplasia and/or early cancer and appropriate follow-up of these patients. METHODS The best practice advice provided in this document is based on evidence and relevant publications reviewed by the committee. BEST PRACTICE ADVICE 1: In BE patients with confirmed low-grade dysplasia, a repeat examination with high-definition white-light endoscopy should be performed within 3-6 months to rule out the presence of a visible lesion, which should prompt endoscopic resection. BEST PRACTICE ADVICE 2: Both BET and continued surveillance are reasonable options for the management of BE patients with confirmed and persistent low-grade dysplasia. BEST PRACTICE ADVICE 3: BET is the preferred treatment for BE patients with high-grade dysplasia (HGD). BEST PRACTICE ADVICE 4: BET should be preferred over esophagectomy for BE patients with intramucosal esophageal adenocarcinoma (T1a). BEST PRACTICE ADVICE 5: BET is a reasonable alternative to esophagectomy in patients with submucosal esophageal adenocarcinoma (T1b) with low-risk features (<500-μm invasion in the submucosa [sm1], good to moderate differentiation, and no lymphatic invasion) especially in those who are poor surgical candidates. BEST PRACTICE ADVICE 6: In all patients undergoing BET, mucosal ablation should be applied to 1) all visible esophageal columnar mucosa; 2) 5-10 mm proximal to the squamocolumnar junction and 3) 5-10 mm distal to the gastroesophageal junction, as demarcated by the top of the gastric folds (ie, gastric cardia) using focal ablation in a circumferential fashion. BEST PRACTICE ADVICE 7: Mucosal ablation therapy should only be performed in the presence of flat BE without signs of inflammation and in the absence of visible abnormalities. BEST PRACTICE ADVICE 8: BET should be performed by experts in high-volume centers that perform a minimum of 10 new cases annually. BEST PRACTICE ADVICE 9: BET should be continued until there is an absence of columnar epithelium in the tubular esophagus on high-definition white-light endoscopy and preferably optical chromoendoscopy. In case of complete endoscopic eradication, the neosquamous mucosa and the gastric cardia are sampled by 4-quadrant biopsies. BEST PRACTICE ADVICE 10: If random biopsies obtained from the neosquamous epithelium demonstrate intestinal metaplasia/dysplasia or subsquamous intestinal metaplasia, a repeat endoscopy should be performed and visible islands or tongues should undergo targeted focal ablation. BEST PRACTICE ADVICE 11: Intestinal metaplasia of the gastric cardia (without residual columnar epithelium in the tubular esophagus) should not warrant additional ablation therapy. BEST PRACTICE ADVICE 12: When consenting patients for BET, the most common complication of therapy to be quoted is post-procedural stricture formation, occurring in about 6% of cases. Bleeding and perforation occur at rates <1%. BEST PRACTICE ADVICE 13: After complete eradication (endoscopic and histologic) of intestinal metaplasia has been achieved with BET, surveillance endoscopy with biopsies should be performed at the following intervals: for baseline diagnosis of HGD/esophageal adenocarcinoma: at 3, 6, and 12 months and annually thereafter; and baseline diagnosis of low-grade dysplasia: at 1 and 3 years. BEST PRACTICE ADVICE 14: Endoscopic surveillance post therapy should be performed with high-definition white-light endoscopy, including careful inspection of the neosquamous mucosal and retroflexed inspection of the gastric cardia. BEST PRACTICE ADVICE 15: The approach to recurrent disease is similar to that of the initial therapy; visible recurrent nodular lesions require endoscopic resection, whereas flat areas of columnar mucosa in the tubular esophagus can be treated with mucosal ablation. BEST PRACTICE ADVICE 16: Patients should be counseled on cancer risk in the absence of BET, as well as after BET, to allow for informed decision-making between the patient and the physician.
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Affiliation(s)
- Prateek Sharma
- University of Kansas School of Medicine Center, Kansas City, Kansas; Veterans Affairs Medical Center, Kansas City, Kansas.
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Triadafilopoulos G, Clarke J, Hawn M. Whole greater than the parts: integrated esophageal centers (IEC) and advanced training in esophageal diseases. Dis Esophagus 2017; 30:1-9. [PMID: 28859396 DOI: 10.1093/dote/dox084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 05/30/2017] [Indexed: 02/06/2023]
Abstract
An integrated esophageal center (IEC) is a multidisciplinary team with expertise, skill, range, and facilities necessary to achieve optimal outcomes in patients with esophageal diseases efficiently and expeditiously. Within IEC, patients presenting with esophageal symptoms undergo a detailed clinical, functional and structural evaluation of their esophagus prior to implementation of tailored medical, endoscopic or surgical therapy. Serving as a core, the IEC clinical practice also supports research and innovation in esophageal diseases as well as public and physician education. Referrals to the unit may be primary, either from primary care or self-initiated, or secondary from other specialty practices, to reassess patients who have previously failed therapies and to manage complex or complicated cases. The fundamental goals of the IEC are to provide value for patients with esophageal diseases, streamlining complex diagnostic investigations and expediting therapies aiming at reducing costs while improving clinical outcomes, and to accelerate knowledge generation through robust interaction and cross-training across disciplines. The organization of the IEC goes beyond traditional academic and clinical silos and involves a director and administrative team coordinating faculty and fellows from both medical and surgical disciplines and supported by other clinical lines, such as radiology, pathology, etc., while it interfaces with physicians, the public, basic, translational and clinical research groups, and related industry partners.
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Endoscopic Eradication Therapy in Barrett's Esophagus. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2017; 19:137-142. [PMID: 29269998 DOI: 10.1016/j.tgie.2017.06.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic eradication therapy (EET), the standard of care for treatment of Barrett's esophagus with dysplasia and early neoplasia, consists of a combination of endoscopic resection and ablative modalities. Resection techniques primarily include endoscopic mucosal resection or endoscopic submucosal dissection. Resection of nodular disease is generally followed by one of multiple ablative therapies among which radiofrequency ablation has the best evidence supporting safety and efficacy. These advanced endoscopic procedures require both experience and expertise in the cognitive and procedural aspects of EET. However, very few formal programs exist that teach endoscopists the necessary skills to perform EET in a safe, standardized, and efficacious manner. Case volume at both the endoscopist and center level has been shown to impact clinical outcomes based on limited data. As a result, some recent guidelines endorse case volume as a measure of competency. Quality indicators, which can be used as benchmarks for training and as part of pay for quality initiatives, have recently been derived for EET. However, quality metrics in EET have not been widely accepted, nor are they broadly used currently. While the efficacy of EET for BE is established, there is a need for application of quality metrics to both assure adequate training in these procedures, as well as to assess treatment outcomes. A standardized EET training curriculum during endoscopic training, with competency assessment of both new clinicians and endoscopists in practice has potential to improve care in EET.
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Rizvi QUA, Balachandran A, Koay D, Sharma P, Singh R. Endoscopic Management of Early Esophagogastric Cancer. Surg Oncol Clin N Am 2017; 26:179-191. [PMID: 28279463 DOI: 10.1016/j.soc.2016.10.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Esophagogastric cancer accounts for the second most common cause of cancer-related mortality worldwide. Significant efforts have been made to detect these malignancies at an earlier stage through the implementation of screening programs in high-risk individuals using advanced diagnostic techniques. Endoscopic management techniques, such as endoscopic mucosal resection and endoscopic submucosal dissection, have consistently demonstrated excellent outcomes in the management of these lesions. These techniques are associated with a lower risk of morbidity and mortality when compared with traditional surgical management.
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Affiliation(s)
- Qurat-Ul-Ain Rizvi
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia 5112, Australia
| | - Arrhchanah Balachandran
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia 5112, Australia
| | - Doreen Koay
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia 5112, Australia
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, University of Kansas School of Medicine, VA Medical Center, 4801 Linwood Boulevard, Kansas City, MO 64128, USA
| | - Rajvinder Singh
- Department of Gastroenterology and Hepatology, Lyell McEwin Hospital, Haydown Road, Elizabeth Vale, South Australia 5112, Australia.
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Cameron GR, Desmond PV, Jayasekera CS, Amico F, Williams R, Macrae FA, Taylor ACF. Recurrent intestinal metaplasia at the gastroesophageal junction following endoscopic eradication of dysplastic Barrett's esophagus may not be benign. Endosc Int Open 2016; 4:E849-58. [PMID: 27540572 PMCID: PMC4988840 DOI: 10.1055/s-0042-109608] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 05/23/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND STUDY AIMS Radiofrequency ablation (RFA) combined with endoscopic mucosal resection (EMR) is effective for eradicating dysplastic Barrett's esophagus. The durability of response is reported to be variable. We aimed to determine the effectiveness and durability of RFA with or without EMR for patients with dysplastic Barrett's esophagus. PATIENTS AND METHODS Patients with dysplastic Barrett's esophagus referred to two academic hospitals were assessed with high definition white-light endoscopy, narrow-band imaging, and Seattle protocol biopsies. EMR was performed in visible lesions. RFA was performed at 3-month intervals until complete remission of dysplasia (CR-D) and intestinal metaplasia (CR-IM) was achieved. RESULTS In total, 137 patients received RFA (78 with EMR); 75 with over 12 months follow-up since commencing RFA. Pretreatment histology was intramucosal cancer (IMC) 21 %, high grade dysplasia (HGD) 54 %, low grade dysplasia (LGD) 25 %. CR-D rates were 88 %, 92 %, and 100 % at 1, 2, and 3 years; CR-IM rates were 69 %, 74 %, and 81 %. Kaplan-Meier analysis showed increasing probability of achieving CR-D/CR-IM over time. Of 26 patients maintaining CR-IM for > 12 months, five relapsed with intestinal metaplasia (19 %), and three with dysplasia (12 %). Recurrences occurred in patients with prior HGD/IMC, predominantly at the gastroesophageal junction (GEJ). None relapsed with cancer. Adverse events occurred in 4 % of RFA and 6.5 % of EMR procedures. CONCLUSIONS RFA combined with EMR is effective in achieving CR-D/CR-IM in the majority of patients with dysplastic Barrett's esophagus, with an incremental response over time. While durable in the majority, recurrent intestinal metaplasia and dysplasia, frequently occurring at the GEJ, suggest long-term surveillance is warranted in high risk groups.
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Affiliation(s)
- Georgina R. Cameron
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia,Corresponding author Georgina R. Cameron, MBBS (Hons) BMus (Hons) St Vincent’s Hospital Melbourne – GastroenterologyLevel 4Daly Wing41 Victoria ParadeFitzroyMelbourneVictoria 3065Australia+61-3-92883590
| | - Paul V. Desmond
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Chatura S. Jayasekera
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,The Royal Melbourne Hospital, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Francesco Amico
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Richard Williams
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Finlay A. Macrae
- The Royal Melbourne Hospital, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
| | - Andrew C. F. Taylor
- St Vincent’s Hospital Melbourne, Melbourne, Victoria, Australia,University of Melbourne, Melbourne, Victoria, Australia
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Chadwick G, Groene O, Taylor A, Riley S, Hardwick RH, Crosby T, Greenaway K, Cromwell DA. Management of Barrett's high-grade dysplasia: initial results from a population-based national audit. Gastrointest Endosc 2016; 83:736-42.e1. [PMID: 26283273 DOI: 10.1016/j.gie.2015.08.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 08/04/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Previous studies reported significant variation in the management of patients with Barrett's esophagus. However, these are based on self-reported clinical practice. The aim of this study was to examine the management of high-grade dysplasia in Barrett's esophagus in England by using patient-level data and to compare practice with guidelines. METHODS From April 2012 to March 2013, National Health Service (NHS) trusts in England prospectively collected data on patients newly diagnosed with high-grade dysplasia (HGD) of the esophagus as part of the National Oesophago-Gastric Cancer Audit. Data were collected on patient characteristics, diagnosis and endoscopic findings, treatment planning, and therapy. RESULTS Between April 2012 and March 2013, NHS trusts reported 465 cases of HGD. Diagnosis was confirmed by a second pathologist in 79.4% of cases (270/340), and 86.0% (374/465) had their treatment planned at a multidisciplinary team meeting. A total of 290 patients (62.4%) were managed endoscopically (frequently with endoscopic resection or radiofrequency ablation), whereas 26 patients (5.6%) had esophagectomy. The proportion of patients managed by surveillance varied by age (P < .001), ranging from 19.5% in patients aged <65 years to 63.8% in patients aged ≥85 years. More patients received active treatment if their cases were discussed at a multidisciplinary meeting (73.5% vs 44.3%; P < .001) or managed at higher-volume trusts (87.8% vs 55.4%; P < .001). CONCLUSIONS There was marked variation in the management of HGD across England, with a third of patients receiving no active treatment. Patients discussed at a specialist multidisciplinary meeting or managed in high-volume trusts were more likely to receive active treatment.
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Affiliation(s)
- Georgina Chadwick
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Imperial College, Department of Surgery and Cancer, London, United Kingdom
| | - Oliver Groene
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Angelina Taylor
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom
| | - Stuart Riley
- Department of Gastroenterology, Northern General Hospital, Sheffield, United Kingdom
| | | | - Tom Crosby
- Velindre Cancer Centre, Cardiff, Wales, United Kingdom
| | | | - David A Cromwell
- Clinical Effectiveness Unit, The Royal College of Surgeons of England, London, United Kingdom; Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Parasa S, Sharma P. Measuring quality of endoscopic eradication therapy in Barrett's esophagus. Gastrointest Endosc 2016; 83:743-5. [PMID: 26975281 DOI: 10.1016/j.gie.2015.12.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 12/17/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Sravanthi Parasa
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, University of Kansas School of Medicine, Kansas City, Missouri, USA
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center, University of Kansas School of Medicine, Kansas City, Missouri, USA
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Rayner-Hartley E, Takach O, Galorport C, Enns RA. Diagnosis and Management of Barrett's Esophagus: A Retrospective Study Comparing the Endoscopic Assessment of Early Esophageal Lesions in the Community versus a Specialized Center. Can J Gastroenterol Hepatol 2016; 2016:5749573. [PMID: 27446850 PMCID: PMC4904634 DOI: 10.1155/2016/5749573] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 07/26/2015] [Indexed: 12/20/2022] Open
Abstract
Specialized endoscopic evaluation for patients with Barrett's esophagus (BE) is well supported; however, no studies have shown that centers with expertise provide better quality care for BE with high-grade dysplasia or early adenocarcinoma. In this study, the investigators aimed to evaluate the management and clinical course for patients treated in a community practice versus a specialized BE center. Methods. A retrospective analysis of referrals from the community to our specialized center for evaluation of BE at St Paul's Hospital Division of Gastroenterology between January 2007 and February 2014 was performed. Subjects were patients who were referred for BE and dysplasia and subsequently reevaluated by endoscopy. The pathology and endoscopy reports from the community and our center were reviewed. Inclusion criteria were as follows: being ≥ 19 years old and pathologic diagnosis of BE or dysplasia in the community. Exclusion criteria were as follows: incomplete pathology data or incomplete endoscopy reports from the community physicians. Results. A total of 77 patients were reviewed. The staging of 28.9% of patients referred from the community was changed from the initial pathological diagnosis. 18.4% of these patients were upstaged. Using Fischer's exact test, we showed that, in our specialized center, endoscopic impressions correlated significantly with pathology results (p < 0.0001).
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Affiliation(s)
- Erin Rayner-Hartley
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, Canada
| | - Oliver Takach
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, Canada
| | - Cherry Galorport
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, Canada
| | - Robert A. Enns
- Department of Medicine, Division of Gastroenterology, University of British Columbia, Vancouver, Canada
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Abstract
Barrett's esophagus is the only identifiable premalignant condition for esophageal adenocarcinoma. Endoscopic eradication therapy (EET) has revolutionized the management of Barrett's-related dysplasia and intramucosal cancer. The primary goal of EET is to prevent progression to invasive esophageal adenocarcinoma and ultimately improve survival rates. There are several challenges with EET that can be encountered before, during, or after the procedure that are important to understand to optimize the effectiveness and safety of EET and ultimately improve patient outcomes. This article focuses on the challenges with EET and discusses them under the categories of preprocedural, intraprocedural, and postprocedural challenges.
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Affiliation(s)
- Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Mail Stop F735, 1635 Aurora Court, Room 2.031, Aurora, CO 80045, USA.
| | - Prateek Sharma
- Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas, 4801 Linwood Boulevard, Kansas City, MO 64128, USA
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Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection for Endoscopic Therapy of Barrett's Esophagus-related Neoplasia. Gastroenterol Clin North Am 2015; 44:317-35. [PMID: 26021197 DOI: 10.1016/j.gtc.2015.02.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A major paradigm shift has occurred in the management of dysplastic Barrett's esophagus (BE) and early esophageal carcinoma. Endoscopic therapy has now emerged as the standard of care for this disease entity. Endoscopic resection techniques like endoscopic mucosal resection and endoscopic submucosal dissection combined with ablation techniques help achieve long-term curative success comparable with surgical outcomes, in this subgroup of patients. This article is an in-depth review of these endoscopic resection techniques, highlighting their role and value in the overall management of BE-related dysplasia and neoplasia.
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Bennett C, Moayyedi P, Corley DA, DeCaestecker J, Falck-Ytter Y, Falk G, Vakil N, Sanders S, Vieth M, Inadomi J, Aldulaimi D, Ho KY, Odze R, Meltzer SJ, Quigley E, Gittens S, Watson P, Zaninotto G, Iyer PG, Alexandre L, Ang Y, Callaghan J, Harrison R, Singh R, Bhandari P, Bisschops R, Geramizadeh B, Kaye P, Krishnadath S, Fennerty MB, Manner H, Nason KS, Pech O, Konda V, Ragunath K, Rahman I, Romero Y, Sampliner R, Siersema PD, Tack J, Tham TCK, Trudgill N, Weinberg DS, Wang J, Wang K, Wong JYY, Attwood S, Malfertheiner P, MacDonald D, Barr H, Ferguson MK, Jankowski J. BOB CAT: A Large-Scale Review and Delphi Consensus for Management of Barrett's Esophagus With No Dysplasia, Indefinite for, or Low-Grade Dysplasia. Am J Gastroenterol 2015; 110:662-82; quiz 683. [PMID: 25869390 PMCID: PMC4436697 DOI: 10.1038/ajg.2015.55] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 02/03/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Barrett's esophagus (BE) is a common premalignant lesion for which surveillance is recommended. This strategy is limited by considerable variations in clinical practice. We conducted an international, multidisciplinary, systematic search and evidence-based review of BE and provided consensus recommendations for clinical use in patients with nondysplastic, indefinite, and low-grade dysplasia (LGD). METHODS We defined the scope, proposed statements, and searched electronic databases, yielding 20,558 publications that were screened, selected online, and formed the evidence base. We used a Delphi consensus process, with an 80% agreement threshold, using GRADE (Grading of Recommendations Assessment, Development and Evaluation) to categorize the quality of evidence and strength of recommendations. RESULTS In total, 80% of respondents agreed with 55 of 127 statements in the final voting rounds. Population endoscopic screening is not recommended and screening should target only very high-risk cases of males aged over 60 years with chronic uncontrolled reflux. A new international definition of BE was agreed upon. For any degree of dysplasia, at least two specialist gastrointestinal (GI) pathologists are required. Risk factors for cancer include male gender, length of BE, and central obesity. Endoscopic resection should be used for visible, nodular areas. Surveillance is not recommended for <5 years of life expectancy. Management strategies for indefinite dysplasia (IND) and LGD were identified, including a de-escalation strategy for lower-risk patients and escalation to intervention with follow-up for higher-risk patients. CONCLUSIONS In this uniquely large consensus process in gastroenterology, we made key clinical recommendations for the escalation/de-escalation of BE in clinical practice. We made strong recommendations for the prioritization of future research.
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Affiliation(s)
- Cathy Bennett
- Centre for Technology Enabled Health Research, Coventry University, Coventry, UK
| | | | | | | | - Yngve Falck-Ytter
- Case Western Reserve University School of Medicine, Case and VA Medical Center Cleveland, Cleveland, Ohio, USA
| | - Gary Falk
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Nimish Vakil
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin, USA
| | | | | | - John Inadomi
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Khek-Yu Ho
- National University Health System, Singapore, Singapore
| | - Robert Odze
- Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | - Eamonn Quigley
- Weill Cornell Medical College and Houston Methodist Hospital, Houston, Texas, USA
| | | | | | | | | | - Leo Alexandre
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Yeng Ang
- University of Manchester, Manchester, UK
| | - James Callaghan
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | | | - Rajvinder Singh
- Lyell McEwin Hospital/University of Adelaide, Adelaide, South Australia, Australia
| | | | | | - Bita Geramizadeh
- Department of Pathology, Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Philip Kaye
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Sheila Krishnadath
- Gastrointestinal Oncology Research Group, AMC, Amsterdam, The Netherlands
| | | | - Hendrik Manner
- Department of Gastroenterology HSK Wiesbaden, Wiesbaden, Germany
| | - Katie S Nason
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Oliver Pech
- Krankenhaus Barmherzige Brueder, Regensburg, Germany
| | - Vani Konda
- University of Chicago, Chicago, Illinois, USA
| | - Krish Ragunath
- Queens Medical Centre, University of Nottingham, Nottingham, UK
| | | | | | | | | | - Jan Tack
- University of Leuven, Leuven, Belgium
| | | | - Nigel Trudgill
- Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | | | - Jean Wang
- Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | - Jennie Y Y Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | | | - David MacDonald
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Hugh Barr
- Gloucestershire Royal Hospital, Gloucester, UK
| | | | - Janusz Jankowski
- University Hospitals Coventry and Warwickshire and University of Warwick, Coventry, UK
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