Long-term results of the mucosal ablation of Barrett's esophagus: efficacy and recurrence

DIAGNOSIS, TREATMENT AND FOLLOW-UP OF BARRETT'S ESOPHAGUS: A SYSTEMATIC REVIEW

BACKGROUND

Barrett's esophagus (BE) is a premalignant condition that raises controversy among general practitioners and specialists, especially regarding its diagnosis, treatment, and follow-up protocols.

OBJECTIVE

This systematic review aims to present the particularities and to clarify controversies related to the diagnosis, treatment and surveillance of BE.

METHODS

A systematic review was conducted on PubMed, Cochrane, and SciELO based on articles published in the last 10 years. PRISMA guidelines were followed and the search was made using MeSH and non-MeSH terms "Barrett" and "diagnosis or treatment or therapy or surveillance". We searched for complete randomized controlled clinical trials or Phase IV studies, carried out with individuals over 18 years old.

RESULTS

A total of 42 randomized controlled trials were selected after applying all inclusion and exclusion criteria. A growing trend of alternative and safer techniques to traditional upper gastrointestinal endoscopy were identified, which could improve the detection of BE and patient acceptance. The use of chromoendoscopy-guided biopsy protocols significantly reduced the number of biopsies required to maintain similar BE detection rates. Furthermore, the value of BE chemoprophylaxis with esomeprazole and acetylsalicylic acid was relevant, as well as the establishment of protocols for the follow-up and endoscopic surveillance of patients with BE based predominantly on the presence and degree of dysplasia, as well as on the length of the follow-up affected by BE.

CONCLUSION

Although further studies regarding the diagnosis, treatment and follow-up of BE are warranted, in light of the best evidence presented in the last decade, there is a trend towards electronic chromoendoscopy-guided biopsies for the diagnosis of BE, while treatment should encompass endoscopic techniques such as radiofrequency ablation. Risks of ablative endoscopic methods should be weighted against those of resective surgery. It is also important to consider lifetime endoscopic follow-up for both short and long term BE patients, with consideration to limitations imposed by a range of comorbidities. Unfortunately, there are no randomized controlled trials that have evaluated which is the best recommendation for BE follow-up and endoscopic surveillance (>1 cm) protocols, however, based on current International Guidelines, it is recommended esophagogastroduodenoscopy (EGD) every 5 years in BE without dysplasia with 1 up to 3 cm of extension; every 3 years in BE without dysplasia with >3 up to 10 cm of extension, every 6 to 12 months in BE with low grade dysplasia and, finally, EGD every 3 months after ablative endoscopic therapy in cases of BE with high grade dysplasia.

Surveillance of neo-squamous epithelium after ablation of Barrett's esophagus: is it better to use jumbo over standard biopsy forceps?

BACKGROUND AND AIMS

As obtaining adequate tissue on biopsy is critical for the detection of residual and recurrent intestinal metaplasia/dysplasia in Barrett's esophagus (BE) patients undergone Barrett's endoscopic eradication therapy (BET), we decided to compare the adequacy of biopsy specimens using jumbo versus standard biopsy forceps.

METHODS

This is a two-center study of patients' post-radiofrequency ablation of dysplastic BE. After BET, jumbo (Boston Scientific©, Radial Jaw 4, opening diameter 2.8 mm) or standard (Boston Scientific©, Radial Jaw 4, opening diameter 2.2 mm) biopsy forceps were utilized to obtain surveillance biopsies from the neo-squamous epithelium. Presence of lamina propria and proportion of squamous epithelium with partial or full thickness lamina propria was recorded by two experienced gastrointestinal pathologists who were blinded. Squamous epithelial biopsies that contained at least two-thirds of lamina propria were considered 'adequate'.

RESULTS

In a total of 211 biopsies from 55 BE patients, 145 biopsies (29 patients, 18 males, mean age 61 years, interquartile range [IQR] 33-83) were obtained using jumbo forceps and 66 biopsies (26 patients, all males, mean age 65 years, IQR 56-76) using standard forceps biopsies. Comparing jumbo versus standard forceps, the proportion of specimens with any subepithelial lamina propria was 51.7% versus 53%, P = 0.860 and the presence of adequate subepithelial lamina propria was 17.9% versus 9.1%, P = 0.096 respectively.

CONCLUSIONS

Use of jumbo forceps does not appear to have added advantage over standard forceps to obtain adequate biopsy specimens from the neo-squamous mucosa post-ablation.

Point-Counterpoint: Screening and Surveillance for Barrett's Esophagus, Is It Worthwhile?

The exponential rise in incidence of esophageal adenocarcinoma (EAC), paired with persistently poor survival, continues to drive efforts to improve and optimize screening and surveillance practices. While advancements in endoscopic therapy have generated a shift in management and significantly improved the outcomes of patients with early-stage EAC, the majority of prevalent EAC continues to be diagnosed at advanced stages, remaining ineligible for curative therapy. Barrett's esophagus (BE) screening, when applied to high-yield target populations, using minimally or noninvasive accurate tests, followed by endoscopic surveillance to detect prevalent or incident dysplasia/EAC (which can then be treated successfully) is the cornerstone of the current BE management paradigm. While supported by some empiric evidence and attractive, this approach faces a number of challenges, which are also balanced by numerous recent advances in these areas. In this manuscript, we review the rationale, supportive evidence, current challenges, and recent progress in BE screening and surveillance.

Barrett's esophagus: best practices for treatment and post-treatment surveillance

Barrett's esophagus (BE) is a premalignant condition that increases the risk of esophageal adenocarcinoma (EAC). Significantly more common in the Western world, risk factors include increased age, male sex, white race, gastro-esophageal reflux disease (GERD), central obesity, and cigarette smoking. The rates of progression to cancer depend on the grade of Barrett's dysplasia. Screening for BE is recommended in patients with GERD and additional risk factors. Endoscopic surveillance of patients with BE likely improves overall outcomes. Advanced endoscopic imaging can help increase the efficiency of current endoscopic surveillance. Endoscopic therapy is safe and effective for the treatment of dysplastic BE and intramucosal EAC, but ongoing surveillance following treatment is necessary. This review will cover screening, surveillance, advanced imaging, chemoprevention, endoscopic treatment, and post-treatment surveillance of BE.

Genomics, Endoscopy, and Control of Gastroesophageal Cancers: A Perspective

In The Cancer Genome Atlas the goals were to define how to treat advanced cancers with targeted therapy. However, the challenges facing cancer interception for early detection and prevention include length bias in which current screening and surveillance approaches frequently miss rapidly progressing cancers that then present at advanced stages in the clinic with symptoms (underdiagnosis). In contrast, many early detection strategies detect benign conditions that may never progress to cancer during a lifetime, and the patient dies of unrelated causes (overdiagnosis). This challenge to cancer interception is believed to be due to the speed at which the neoplasm evolves, called length bias sampling; rapidly progressing cancers are missed by current early detection strategies. In contrast, slowly or non-progressing cancers or their precursors are selectively detected. This has led to the concept of cancer interception, which can be defined as active interception of a biological process that drives cancer development before the patient presents in the clinic with an advanced, symptomatic cancer. The solutions needed to advance strategies for cancer interception require assessing the rate at which the cancer evolves over time and space. This is an essential challenge that needs to be addressed by robust study designs including normal and non-progressing controls when known to be appropriate.