Endosheath ultrathin transnasal endoscopy is a cost-effective method for screening for Barrett's esophagus in patients with GERD symptoms

Unsedated transnasal endoscopy for the detection of Barrett's esophagus: systematic review and meta-analysis

Conventional esophagogastroduodenoscopy (cEGD) is currently the gold standard endoscopic procedure for diagnosis and surveillance of Barrett's esophagus (BE). This procedure is however less suitable for widespread screening because of its invasiveness and costs. An alternative endoscopic procedure is unsedated transnasal endoscopy (uTNE). We performed a systematic review and meta-analysis to evaluate the diagnostic accuracy, patient tolerability, technical success rate, and safety of uTNE compared with cEGD for detecting BE and related neoplasia. PubMed, EMBASE, and Cochrane Library were searched for studies that reported the diagnostic accuracy of uTNE compared with cEGD for detecting BE and related neoplasia. Eight prospective studies were included, in which 623 patients underwent both uTNE and cEGD. Pooled sensitivity and specificity of uTNE for detecting columnar epithelium were 98% (95% CI 83-100%) and 99% (95% CI 82-100%), respectively. Pooled sensitivity and specificity of uTNE for detecting intestinal metaplasia in biopsies were 89% (95% CI 78-95%) and 93% (95% CI 71-98%), respectively. In three of the six studies that reported patient tolerability, a higher patient tolerability of uTNE compared with cEGD was reported. The technical success rate of uTNE ranged from 89% to 100% and no (serious) adverse events were reported. This systematic review and meta-analysis provides evidence that uTNE is an accurate, safe, and well-tolerated procedure for the detection of columnar epithelium and can be considered as screening modality for BE.

Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline

Barrett's esophagus (BE) is a common condition associated with chronic gastroesophageal reflux disease. BE is the only known precursor to esophageal adenocarcinoma, a highly lethal cancer with an increasing incidence over the last 5 decades. These revised guidelines implement Grading of Recommendations, Assessment, Development, and Evaluation methodology to propose recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia. Important changes since the previous iteration of this guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE. We recommend endoscopic eradication therapy for patients with BE and high-grade dysplasia and those with BE and low-grade dysplasia. We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia. We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data.

Diagnostic Ability of High-definition Imaging Using Ultraslim Endoscopes in Early Gastric Cancer

Purpose

It is unclear whether high-definition (HD) imaging improves visibility and diagnostic ability in early gastric cancer (EGC) compared with standard-definition (SD) imaging. We aimed to compare the diagnostic performance and visibility scores of HD and SD ultraslim endoscopes in EGC.

Materials and Methods

We used HD and SD ultraslim endoscopes to obtain 60 images with similar compositions of gastric environments. Of the 60 images, 30 showed EGC (15 images for each modality) and 30 showed no EGC (15 images for each modality). Seventeen endoscopists evaluated the presence and location of the lesions in each image. Diagnostic ability was compared between modalities. The color difference between a lesion and the surrounding mucosa (ΔE) was measured and compared between the modalities.

Results

The ability of HD to detect EGC was significantly higher than that of SD (accuracy: 80.8% vs. 71.6%, P=0.017; sensitivity: 94.9% vs. 76.5%, P<0.001; positive predictive value, 76.2% vs. 55.3%, P<0.001; and negative predictive value (NPV), 94.1% vs. 73.5%, P<0.001). The ability of HD to determine the horizontal extent of EGC was significantly higher than that of SD (accuracy: 71.0% vs. 57.8%, P=0.004; sensitivity: 75.3% vs. 49.0%, P<0.001; NPV, 72.9% vs. 55.9%, P<0.001; and area under the curve: 0.891 vs. 0.631, P=0.038). The mean ΔE was significantly higher for HD than for SD (10.3 vs. 5.9, P=0.011).

Conclusions

The HD ultraslim endoscope showed a higher diagnostic performance in EGC than the SD endoscope because it provided good color contrast.

Comparative Cost Effectiveness of Reflux-Based and Reflux-Independent Strategies for Barrett's Esophagus Screening

INTRODUCTION

Minimally invasive tests for Barrett's esophagus (BE) detection have raised the prospect of broader nonreflux-based testing. Cost-effectiveness studies have largely studied men aged 50 years with chronic gastroesophageal reflux disease (GERD) symptoms. We evaluated the comparative cost effectiveness of BE screening tests in GERD-based and GERD-independent testing scenarios.

METHODS

Markov modeling was performed in 3 scenarios in 50 years old individuals: (i) White men with chronic GERD (GERD-based); (ii) GERD-independent (all races, men and women), BE prevalence 1.6%; and (iii) GERD-independent, BE prevalence 5%. The simulation compared multiple screening strategies with no screening: sedated endoscopy (sEGD), transnasal endoscopy, swallowable esophageal cell collection devices with biomarkers, and exhaled volatile organic compounds. A hypothetical cohort of 500,000 individuals followed for 40 years using a willingness to pay threshold of $100,000 per quality-adjusted life year (QALY) was simulated. Incremental cost-effectiveness ratios (ICERs) comparing each strategy with no screening and comparing screening strategies with each other were calculated.

RESULTS

In both GERD-independent scenarios, most non-sEGD BE screening tests were cost effective. Swallowable esophageal cell collection devices with biomarkers were cost effective (<$35,000/QALY) and were the optimal screening tests in all scenarios. Exhaled volatile organic compounds had the highest ICERs in all scenarios. ICERs were low (<$25,000/QALY) for all tests in the GERD-based scenario, and all non-sEGD tests dominated no screening. ICERs were sensitive to BE prevalence and test costs.

DISCUSSION

Minimally invasive nonendoscopic tests may make GERD-independent BE screening cost effective. Participation rates for these strategies need to be studied.

Dietary Management of Eosinophilic Esophagitis: Man Versus Food or Food Versus Man?

An alternative to pharmacologic management of eosinophilic esophagitis, elimination of food antigens for diet therapy is an effective first-line treatment strategy to induce and maintain symptomatic, histologic, and endoscopic disease remission. The 3 dietary strategies for eosinophilic esophagitis include elemental diet, empiric elimination diet, and targeted elimination diet. We review the studies supporting various diet therapy strategies, practical considerations and challenges for applying an elimination diet, and novel testing to identify triggers and optimize food reintroduction.

Progress in Screening for Barrett's Esophagus: Beyond Standard Upper Endoscopy

The rapid increase in the incidence of esophageal adenocarcinoma in Western populations over the past 4 decades and its associated poor prognosis, unless detected early has generated great interest in screening for the precursor lesion Barrett's esophagus (BE). Recently, there have been significant developments in imaging-based modalities and esophageal cell-sampling devices coupled with biomarker assays. In this review, the authors discuss the rationale for screening for BE and the factors to consider for targeting the at-risk population. They also explore future avenues for research in this area.

Cost-Effectiveness of Screening, Surveillance, and Endoscopic Eradication Therapies for Managing the Burden of Esophageal Adenocarcinoma

The authors conducted a review of the literature of cost-effectiveness analyses regarding management of Barrett's esophagus, including screening, surveillance, and treatment strategies. Because of the presence of multiple systematic reviews on this topic, they chose to focus on more recent economic analyses, with an emphasis on comparative modeling because these analyses have been demonstrated to achieve greater validity and impact when there are multiple competing strategies that are clinically reasonable to pursue. The authors identified areas of consensus across studies regarding management strategies and also areas that require additional empirical data.

Endoscopic Screening for Barrett's Esophagus and Esophageal Adenocarcinoma: Rationale, Candidates, and Challenges

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer with increasing incidence and poor survival. Risk of EAC in patients with BE is higher compared with the general population. Endoscopic screening for BE is performed to identify patients earlier in the metaplasia-dysplasia-carcinoma sequence from BE to EAC to enable eradication therapy. BE screening should be considered in individuals with multiple risk factors for BE and EAC. Challenges to BE screening include the absence of a cost-effective, widely applicable minimally invasive screening tool, gastroesophageal reflux disease centric screening recommendations, and limitations of current endoscopic surveillance practice.

High Cost for Low Yield: A Systematic Review and Meta-Analysis to Assess Cost of Routine Preoperative Esophagogastroduodenoscopy Before Bariatric Surgery

Routine esophagogastroduodenoscopy (EGD) is an area of continued controversy in the preoperative evaluation for bariatric surgery; more information is needed regarding its impact on surgical management and associated costs. This systematic review and meta-analysis reports rates of abnormalities detected on preoperative EGD that changed operative management or delayed bariatric surgery. Sensitivity analysis examined the impact of controversial findings of hiatal hernia, Helicobacter pylori, gastritis, peptic ulcer disease. Data were used to calculate the cost per surgical alteration made due to abnormalities detected by routine EGD, compactly termed "cost-of-routine-EGD." Thirty-one retrospective observational studies were included. Meta-analysis found 3.9% of EGDs resulted in a change in operative management; this proportion decreased to 0.3% after sensitivity analysis, as detection of hiatal hernia comprised 85.7% of findings that changed operative management. Half of the 7.5% of cases that resulted in surgical delay involved endoscopic detection of H. pylori. Gastric pathology was detected in a significantly greater proportion of symptomatic patients (65.0%) than in asymptomatic patients (34.1%; P<0.001). Cost-of-routine-EGD to identify an abnormality that changed operative management was $601,060, after excluding controversial findings. The cost-of-routine-EGD to identify any abnormality that led to a change in type of bariatric operation was $281,230 and $766,352 when controversial findings were included versus excluded, respectively. Cost-of-routine-EGD to identify a malignancy was $2,554,506. Cost-of-routine-EGD is high relative to the low proportion of abnormalities that alter bariatric surgery. Our results highlight the need to develop alternative strategies to preoperative screening, in order to improve access and decrease cost associated with bariatric surgery.

Acceptability to patients of screening disposable transnasal endoscopy: qualitative interview analysis

OBJECTIVES

Screening in selected high risk populations for Barrett's oesophagus (BO) and oesophageal varices (OVs) has been proposed, but there are obstacles with conventional oesophagogastroduodenoscopy (C-OGD), including patient acceptability. Portable and disposable office-based transnasal endoscopy (TNE) is a feasible and accurate alternative to C-OGD that may have use in primary and secondary care. This article outlines a qualitative analysis of patient experiences of TNE and C-OGD in order to gain an insight into an acceptable delivery of an endoscopic screening service.

DESIGN

Purposeful sampling identified 23 participants who then underwent semi-structured interviews to determine their experiences of both procedures. Thematic analysis was conducted to derive meaning from their lived experiences.

SETTING

A secondary care endoscopy unit, clinic room and interview room.

PARTICIPANTS

Patients referred for BO or OV surveillance and for endoscopy to investigate dyspepsia underwent unsedated TNE using the EG Scan II device followed by C-OGD with or without sedation (patient choice), as part of a clinical trial.

RESULTS

The themes that arose from our analysis were: inclusivity in one's own healthcare, comfort level and convenience, validity of the procedure and application to a screening population and a sense of altruism and reciprocity. Positive aspects of TNE included participant empowerment, reduced discomfort and avoidance of conscious sedation. Participants felt that if TNE screening was of proven efficacy it would be welcomed, though views on use in a community setting were mixed.

CONCLUSIONS

Most patients preferred TNE to unsedated C-OGD and the reasons they gave featured strongly in the emerging themes. Preferences between TNE and sedated C-OGD were more subtle, with equivalent comfort scores but merits and drawbacks of both being discussed. This information identifies opportunities and challenges in establishing an endoscopic screening service. Trial registration number ISRCTNregistry identifier: 70595405; Pre-results.

Novel Screening Tests for Barrett's Esophagus

PURPOSE OF REVIEW

There has been an exponential increase in the incidence of esophageal adenocarcinoma (EAC) over the last half century. Barrett's esophagus (BE) is the only known precursor lesion of EAC. Screening for BE in high-risk populations has been advocated with the aim of identifying BE, followed by endoscopic surveillance to detect dysplasia and early stage cancer, with the intent that treatment can improve outcomes. We aimed to review BE screening methodologies currently recommended and in development.

RECENT FINDINGS

Unsedated transnasal endoscopy allows for visualization of the distal esophagus, with potential for biopsy acquisition, and can be done in the office setting. Non-endoscopic screening methods being developed couple the use of swallowable esophageal cell sampling devices with BE specific biomarkers, as well as trefoil factor 3, methylated DNA markers, and microRNAs. This approach has promising accuracy. Circulating and exhaled volatile organic compounds and the foregut microbiome are also being explored as means of detecting EAC and BE in a non-invasive manner. Non-invasive diagnostic techniques have shown promise in the detection of BE and may be effective methods of screening high-risk patients.

Barrett oesophagus

Barrett oesophagus (BE), the only known histological precursor of oesophageal adenocarcinoma (EAC), is a condition in which the squamous epithelium of the oesophagus is replaced by columnar epithelium as an adaptive response to gastro-oesophageal reflux. EAC has one of the fastest rising incidences of cancers in Western countries and has a dismal prognosis. BE is usually detected during endoscopic examination, and diagnosis is confirmed by the histological presence of intestinal metaplasia. Advances in genomics and transcriptomics have improved our understanding of the pathogenesis and malignant progression of intestinal metaplasia. As the majority of EAC cases are diagnosed in individuals without a known history of BE, screening for BE could potentially decrease disease-related mortality. Owing to the pre-malignant nature of BE, endoscopic surveillance of patients with BE is imperative for early detection and treatment of dysplasia to prevent further progression to invasive EAC. Developments in endoscopic therapy have resulted in a major shift in the treatment of patients with BE who have dysplasia or early EAC, from surgical resection to endoscopic resection and ablation. In addition to symptom control by optimization of lifestyle and pharmacological therapy with proton pump inhibitors, chemopreventive strategies based on NSAIDs and statins are currently being investigated for BE management.