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van Putten M, Johnston BT, Murray LJ, Gavin AT, McManus DT, Bhat S, Turkington RC, Coleman HG. 'Missed' oesophageal adenocarcinoma and high-grade dysplasia in Barrett's oesophagus patients: A large population-based study. United European Gastroenterol J 2017; 6:519-528. [PMID: 29881607 DOI: 10.1177/2050640617737466] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2017] [Accepted: 09/17/2017] [Indexed: 01/10/2023] Open
Abstract
Background A systematic review suggests that 25% of oesophageal adenocarcinomas (OAC) are 'missed' at index endoscopy for Barrett's oesophagus (BO); however, this included few population-based studies and may be an overestimate. Objective The objective of this article is to quantify the 'missed' rates of high-grade dysplasia (HGD) and OAC at index BO endoscopy. Methods Patients from the Northern Ireland BO register diagnosed between 1993 and 2010 (n = 13,159) were linked to the Northern Ireland Cancer Registry to identify patients who developed OAC or HGD. Logistic regression analysis compared characteristics of 'missed' vs 'incident' HGD/OAC, defined as diagnoses within 3-12 months vs >1 year after incident BO, respectively. Results A total of 267 patients were diagnosed with HGD/OAC ≥3 months after BO diagnosis, of whom 34 (12.7%) were potentially 'missed'. The proportion of 'missed' HGD/OAC was 25% among BO patients with low-grade dysplasia (LGD) and 9% among non-dysplastic BO patients. Older age and BO-LGD carried a higher risk of 'missed' HGD/OAC. Non-dysplastic BO patients were more often diagnosed with a 'missed' OAC (rather than HGD; 89%), compared with BO-LGD patients (40%). Conclusions Approximately one in 10 HGD/OAC cases are 'missed' at incident BO diagnosis, which is significant but lower than previous reports. However, 'missed' HGD/OAC cases represent only 0.26% of all BO patients.
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Affiliation(s)
- Margreet van Putten
- Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Eindhoven, the Netherlands
| | - Brian T Johnston
- 2Department of Gastroenterology, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Liam J Murray
- 3Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Anna T Gavin
- 3Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland.,4Northern Ireland Cancer Registry, Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
| | - Damian T McManus
- 5Department of Pathology, Belfast City Hospital, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Shivaram Bhat
- Department of Gastroenterology, Craigavon Area Hospital, Southern Health and Social Care Trust, Belfast, Northern Ireland
| | - Richard C Turkington
- 7Centre for Cancer Research and Cell Biology, Queen's University Belfast, Belfast, Northern Ireland
| | - Helen G Coleman
- 3Centre for Public Health, Queen's University Belfast, Belfast, Northern Ireland
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2
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Bisschops R, Areia M, Coron E, Dobru D, Kaskas B, Kuvaev R, Pech O, Ragunath K, Weusten B, Familiari P, Domagk D, Valori R, Kaminski MF, Spada C, Bretthauer M, Bennett C, Senore C, Dinis-Ribeiro M, Rutter MD. Performance measures for upper gastrointestinal endoscopy: A European Society of Gastrointestinal Endoscopy quality improvement initiative. United European Gastroenterol J 2016; 4:629-656. [PMID: 27733906 DOI: 10.1177/2050640616664843] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 07/22/2016] [Indexed: 12/14/2022] Open
Affiliation(s)
- Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospital Leuven, Leuven, Belgium
| | - Miguel Areia
- Gastroenterology Department, Portuguese Oncology Institute, Coimbra, Portugal; Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, CHU de Nantes, Nantes, France
| | - Daniela Dobru
- Gastroenterology Department, University of Medicine and Pharmacy, Targu Mures, Romania
| | - Bernd Kaskas
- Department of Environmental and Occupational Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roman Kuvaev
- Endoscopy, Yaroslavl Regional Cancer Hospital, Yaroslavl, Russian Federation
| | - Oliver Pech
- Klinik für Gastroenterologie und interventionelle Endoskopie, Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, UK
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Pietro Familiari
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Dirk Domagk
- Department of Internal Medicine, Joseph's Hospital, Warendorf, Germany
| | - Roland Valori
- Department of Gastroenterology, Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire, UK
| | - Michal F Kaminski
- Department of Health Management and Health Economy and KG Jebsen Centre for Colorectal Cancer, University of Oslo, Oslo, Norway; Department of Gastroenterological Oncology, The Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, and Medical Center for Postgraduate Education, Warsaw, Poland
| | - Cristiano Spada
- Digestive Endoscopy Unit, Agostino Gemelli University Hospital, Rome, Italy
| | - Michael Bretthauer
- Department of Health Management and Health Economy and KG Jebsen Centre for Colorectal Cancer, University of Oslo, Oslo, Norway; Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway
| | - Cathy Bennett
- Centre for Technology Enabled Research, Coventry University, Coventry, UK
| | - Carlo Senore
- CPO Piemonte, AOU Città della Salute e della Scienza, Torino, Italy
| | - Mário Dinis-Ribeiro
- Center for Health Technology and Services Research (CINTESIS), University of Porto, Porto, Portugal; Servicio de Gastroenterologia, Instituto Portugues de Oncologia Francisco Gentil, Porto, Portugal
| | - Matthew D Rutter
- Department of Gastroenterology, University Hospital of North Tees, Stockton-on-Tees, UK; School of Medicine, Durham University, Durham, UK
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Qiao Y, Hyder A, Bae SJ, Zarin W, O'Neill TJ, Marcon NE, Stein L, Thein HH. Surveillance in Patients With Barrett's Esophagus for Early Detection of Esophageal Adenocarcinoma: A Systematic Review and Meta-Analysis. Clin Transl Gastroenterol 2015; 6:e131. [PMID: 26658838 PMCID: PMC4816094 DOI: 10.1038/ctg.2015.58] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Accepted: 11/03/2015] [Indexed: 12/13/2022] Open
Abstract
Objectives: Although endoscopic surveillance of patients with Barrett's esophagus (BE) has been widely implemented for early detection of esophageal adenocarcinoma (EAC), its justification has been debated. This systematic review aimed to evaluate benefits, safety, and cost effectiveness of surveillance for patients with BE. Methods: MEDLINE, EMBASE, EconLit, Scopus, Cochrane, and CINAHL were searched for published human studies that examined screening practices, benefits, safety, and cost effectiveness of surveillance among patients with BE. Reviewers independently reviewed eligible full-text study articles and conducted data extraction and quality assessment, with disagreements resolved by consensus. Random effects meta-analyses were performed to assess the incidence of EAC, EAC/high-grade dysplasia (HGD), and annual stage-specific transition probabilities detected among BE patients under surveillance, and relative risk of mortality among EAC patients detected during surveillance compared with those not under surveillance. Results: A total of 51 studies with 11,028 subjects were eligible; the majority were of high quality based on the Newcastle–Ottawa quality scale. Among BE patients undergoing endoscopic surveillance, pooled EAC incidence per 1,000 person-years of surveillance follow-up was 5.5 (95% confidence interval (CI): 4.2–6.8) and pooled EAC/HGD incidence was 7.7 (95% CI: 5.7–9.7). Pooled relative mortality risk among surveillance-detected EAC patients compared with nonsurveillance-detected EAC patients was 0.386 (95% CI: 0.242–0.617). Pooled annual stage-specific transition probabilities from nondysplastic BE to low-grade dysplasia, high-grade dysplasia, and EAC were 0.019, 0.003, and 0.004, respectively. There was, however, insufficient scientific evidence on safety and cost effectiveness of surveillance for BE patients. Conclusions: Our findings confirmed a low incidence rate of EAC among BE patients undergoing surveillance and a reduction in mortality by 61% among those who received regular surveillance and developed EAC. Because of knowledge gaps, it is important to assess safety of surveillance and health-care resource use and costs to supplement existing evidence and inform a future policy decision for surveillance programs.
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Affiliation(s)
- Yao Qiao
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Ayaz Hyder
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sandy J Bae
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Wasifa Zarin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tyler J O'Neill
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Norman E Marcon
- Division of Gastroenterology, Department of Medicine, The Center of Advanced Therapeutic Endoscopy and Endoscopic Oncology, St Michael's Hospital, Toronto, Ontario, Canada.,Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lincoln Stein
- Ontario Institute for Cancer Research, Toronto, Ontario, Canada
| | - Hla-Hla Thein
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Ontario Institute for Cancer Research, Toronto, Ontario, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
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4
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Sheu BS, Chiu CT, Lee YC, Chang CY, Wu DC, Liou JM, Wu MS, Chang WL, Wu CY, Lin JT. Consensus of gastroesophageal reflux disease in Taiwan with endoscopy-based approach covered by National Health Insurance. ADVANCES IN DIGESTIVE MEDICINE 2015. [DOI: 10.1016/j.aidm.2015.05.002] [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] [Indexed: 12/12/2022]
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Whiteman DC, Appleyard M, Bahin FF, Bobryshev YV, Bourke MJ, Brown I, Chung A, Clouston A, Dickins E, Emery J, Eslick GD, Gordon LG, Grimpen F, Hebbard G, Holliday L, Hourigan LF, Kendall BJ, Lee EY, Levert-Mignon A, Lord RV, Lord SJ, Maule D, Moss A, Norton I, Olver I, Pavey D, Raftopoulos S, Rajendra S, Schoeman M, Singh R, Sitas F, Smithers BM, Taylor AC, Thomas ML, Thomson I, To H, von Dincklage J, Vuletich C, Watson DI, Yusoff IF. Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma. J Gastroenterol Hepatol 2015; 30:804-20. [PMID: 25612140 DOI: 10.1111/jgh.12913] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/19/2014] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.
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Affiliation(s)
- David C Whiteman
- QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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6
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Gordon LG, Mayne GC, Hirst NG, Bright T, Whiteman DC, Watson DI. Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett's esophagus. Gastrointest Endosc 2014; 79:242-56.e6. [PMID: 24079411 DOI: 10.1016/j.gie.2013.07.046] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2013] [Accepted: 07/29/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic surveillance for non-dysplastic Barrett's esophagus (BE) is contentious and its cost effectiveness unclear. OBJECTIVE To perform an economic analysis of endoscopic surveillance strategies. DESIGN Cost-utility analysis by using a simulation Markov model to synthesize evidence from large epidemiologic studies and clinical data for surveillance, based on international guidelines, applied in a coordinator-managed surveillance program. SETTING Tertiary care hospital, South Australia. PATIENTS A total of 2040 patient-years of follow-up. INTERVENTION (1) No surveillance, (2) 2-yearly endoscopic surveillance of patients with non-dysplastic BE and 6-monthly surveillance of patients with low-grade dysplasia, (3) a hypothetical strategy of biomarker-modified surveillance. MAIN OUTCOME MEASUREMENTS U.S. cost per quality-adjusted life year (QALY) ratios. RESULTS Compared with no surveillance, surveillance produced an estimated incremental cost per QALY ratio of $60,858. This was reduced to $38,307 when surveillance practice was modified by a hypothetical biomarker-based strategy. Sensitivity analyses indicated that the likelihood that surveillance alone was cost-effective compared with no surveillance was 16.0% and 60.6% if a hypothetical biomarker-based strategy was added to surveillance, at an acceptability threshold of $100,000 per QALY gained. LIMITATIONS Treatment options for BE that overlap those for symptomatic GERD were omitted. CONCLUSION By using best available estimates of the malignant potential of BE, endoscopic surveillance of patients with non-dysplastic BE is unlikely to be cost-effective for the majority of patients and depends heavily on progression rates between dysplasia grades. However, strategies that modify surveillance according to cancer risk might be cost-effective, provided that high-risk individuals can be identified and prioritized for surveillance.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland, Australia; QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | - George C Mayne
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Nicholas G Hirst
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland, Australia
| | - Timothy Bright
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - David C Whiteman
- QIMR Berghofer Medical Research Institute, Herston, Queensland, Australia
| | | | - David I Watson
- Flinders University Department of Surgery, Flinders Medical Centre, Bedford Park, South Australia, Australia
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7
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Picardo SL, O'Brien MP, Feighery R, O'Toole D, Ravi N, O'Farrell NJ, O'Sullivan JN, Reynolds JV. A Barrett's esophagus registry of over 1000 patients from a specialist center highlights greater risk of progression than population-based registries and high risk of low grade dysplasia. Dis Esophagus 2014; 28:121-6. [PMID: 24428806 DOI: 10.1111/dote.12166] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Barrett's esophagus (BE) arising from chronic gastro-oesophageal reflux (GERD) is the main pathologic precursor of esophageal adenocarcinoma (EAC). The risk of progression to high-grade dysplasia (HGD) and EAC is unclear, and recent population studies from Denmark and Northern Ireland suggest that this has been overestimated in the past. No data exist from the Republic of Ireland. A detailed clinical, endoscopic, and pathologic database was established in one center as a proposed pilot for a national registry, and initial and follow-up data were abstracted by a data manager. One thousand ninety-three patients were registered, 60 patients with HGD were excluded, leaving 1033, with a median age of 59 and 2 : 1 male to female ratio, and 3599 person-years of follow-up. The overall incidence of HGD/EAC was 1.33% per year overall, 0.85% if the first year is excluded. Within the first year after index endoscopy, 18 cases of HGD or EAC were identified, and 30 following the first year. Low-grade dysplasia (LGD) on index endoscopy was associated with an incidence of progression of 6.5% per year, and 3.1% when tertiary referrals were excluded. These data provide important demographic and clinical information on the population of Irish patients with BE, with incidence rates of progression higher than recently published population-based registry series, perhaps relating to sampling and pathological assessment. Low-grade dysplasia on initial biopsy is a significant proxy marker of risk of progression.
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Affiliation(s)
- S L Picardo
- Department of Surgery, Trinity Center for Health Sciences, St. James's Hospital and Trinity College Dublin, Dublin, Ireland
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8
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Gordon LG, Mayne GC. Cost-effectiveness of Barrett's oesophagus screening and surveillance. Best Pract Res Clin Gastroenterol 2013; 27:893-903. [PMID: 24182609 DOI: 10.1016/j.bpg.2013.08.019] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 07/19/2013] [Accepted: 08/26/2013] [Indexed: 02/08/2023]
Abstract
Endoscopic screening and surveillance of patients with Barrett's oesophagus to detect oesophageal cancer at earlier stages is contentious. As a consequence, their cost-effectiveness is also debatable. Current health economic evidence shows mixed results for demonstrating their value, mainly due to varied assumptions around progression rates to cancer, quality of life and treatment pathways. No randomized controlled trial exists to definitively support the efficacy of surveillance programs and one is unlikely to be undertaken. Contemporary treatment, cost and epidemiological data to contribute to cost-effectiveness analyses are needed. Risk assessment to stratify patients at low- or high-risk of developing cancer should improve cost-effectiveness outcomes as higher gains will be seen for those at higher risk, and medical resource use will be avoided in those at lower risk. Rapidly changing technologies for imaging, biomarker testing and less-invasive endoscopic treatments also promise to lower health system costs and avoid adverse events in patients.
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Affiliation(s)
- Louisa G Gordon
- Centre for Applied Health Economics, Griffith Health Institute, Griffith University, Logan Campus, University Dr, Meadowbrook, Queensland 4131, Australia.
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9
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Eleftheriadis N, Inoue H, Ikeda H, Onimaru M, Yoshida A, Hosoya T, Maselli R, Kudo SE. Endocytoscopic visualization of squamous cell islands within Barrett’s epithelium. World J Gastrointest Endosc 2013; 5:174-9. [PMID: 23596541 PMCID: PMC3627841 DOI: 10.4253/wjge.v5.i4.174] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Revised: 03/11/2013] [Accepted: 03/15/2013] [Indexed: 02/05/2023] Open
Abstract
AIM: To study the endocytoscopic visualization of squamous cell islands within Barrett’s epithelium.
METHODS: Endocytoscopy (ECS) has been studied in the surveillance of Barrett’s esophagus, with controversial results. In initial studies, however, a soft catheter type endocytoscope was used, while only methylene blue dye was used for the staining of Barrett’s mucosa. Integrated type endocytoscopes (GIF-Q260 EC, Olympus Corp, Tokyo, Japan) have been recently developed, with the incorporation of a high-power magnifying endocytoscope into a standard endoscope together with narrow-band imaging (NBI). Moreover, double staining with a mixture of 0.05% crystal violet and 0.1% of methylene blue (CM) during ECS enables higher quality images comparable to conventional hematoxylin eosin histopathological images.
RESULTS: In vivo endocytoscopic visualization of papillary squamous cell islands within glandular Barrett’s epithelium in a patient with long-segment Barrett’s esophagus is reported. Conventional white light endoscopy showed typical long-segment Barrett’s esophagus, with small squamous cell islands within normal Barrett’s mucosa, which were better visualized by NBI endoscopy. ECS after double CM staining showed regular Barrett’s esophagus, while higher magnification (× 480) revealed the orifices of glandular structures better. Furthermore, typical squamous cell papillary protrusion, classified as endocytoscopic atypia classification (ECA) 2 according to ECA, was identified within regular glandular Barrett’s mucosa. Histological examination of biopsies taken from the same area showed squamous epithelium within glandular Barrett’s mucosa, corresponding well to endocytoscopic findings.
CONCLUSION: To our knowledge, this is the first report of in vivo visualization of esophageal papillary squamous cell islands surrounded by glandular Barrett’s epithelium.
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Affiliation(s)
- Nicholas Eleftheriadis
- Nicholas Eleftheriadis, Haruhiro Inoue, Haruo Ikeda, Manabu Onimaru, Akira Yoshida, Toshihisa Hosoya, Roberta Maselli, Shin-ei Kudo, Digestive Disease Center, Showa University, Northern Yokohama Hospital, Tsuzuki-ku, Yokohama 224-8503, Japan
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10
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El-Serag HB, Duan Z, Hinojosa-Lindsey M, Hou J, Shakhatreh M, Naik AD, Chen GJ, Street RL, Kramer JR. Practice patterns of surveillance endoscopy in a Veterans Affairs database of 29,504 patients with Barrett's esophagus. Gastrointest Endosc 2012; 76:743-55. [PMID: 22985642 PMCID: PMC4689298 DOI: 10.1016/j.gie.2012.06.022] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Accepted: 06/19/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Practice guidelines recommend surveillance endoscopy every 2 to 3 years among patients with Barrett's esophagus (BE) to detect early neoplastic lesions. Although surveys report that >95% of gastroenterologists recommend or practice BE surveillance, the extent and patterns of surveillance in clinical practice are unknown. OBJECTIVE To identify the extent and determinants of endoscopic surveillance among BE patients. DESIGN Retrospective cohort study. SETTING A total of 121 Veterans Affairs facilities nationwide. PATIENTS Veteran patients with BE diagnosed from 2003 to 2009, with follow-up through September 30, 2010. INTERVENTION Not an interventional study. MAIN OUTCOME MEASUREMENTS The proportions of patients with BE who received any EGD after the index BE EGD date. In the subgroup of patients with at least 6 years of follow-up, we also calculated proportions for regular (EGD during both 3-year intervals), irregular (EGD in only 1 interval), and no surveillance. We examined differences in demographics and clinical and facility factors among these groups in unadjusted and adjusted analyses. RESULTS We identified 29,504 patients with BE; 97% were men, 83% white, and their mean age was 61.8 years. During a 3.8-year median follow-up period, 45.4% of patients with BE received at least one EGD. Among the subgroup of 4499 patients with BE who had at least 6 years of follow-up, 23.0% had regular surveillance, and 26.7% had irregular surveillance. There was considerable facility-level variation in percentages with surveillance EGD across the 112 facilities and by geographic region of these facilities. Demographic and clinical factors did not explain these variations. Patients with at least one EGD were significantly more likely to be white; to be aged <65 years, with a low level of comorbidity; to have GERD, obesity, dysphagia, or esophageal strictures; to have more outpatient visits; and to be seen in smaller hospitals (<87 beds) than those without any EGD. LIMITATIONS There might be misclassification of BE and surveillance EGD. Lack of pathology data on dysplasia, which dictates surveillance intervals. CONCLUSION Endoscopic surveillance for BE is considerably less commonly practiced in Veterans Affairs facilities than is self-reported by physicians. Although several clinical factors are associated with variations in surveillance, facility-level factors play a large role. The comparative effectiveness of the different practice-based surveillance patterns needs to be examined.
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Affiliation(s)
- Hashem B El-Serag
- The Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Blvd (152), Houston, TX 77030, USA.
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11
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Katona BW, Falk GW. Barrett's esophagus surveillance: When, how often, does it work? Gastrointest Endosc Clin N Am 2011; 21:9-24. [PMID: 21112494 DOI: 10.1016/j.giec.2010.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Barrett's esophagus is a well-known risk factor for the development of esophageal adenocarcinoma. Current practice guidelines recommend endoscopic surveillance of patients with Barrett's esophagus in an attempt to detect cancer at an early and potentially curable stage. This review addresses the rationale behind surveillance and criteria for inclusion of patients in surveillance programs as well as the appropriate technique and intervals that should be used. This work addresses other key topics in Barrett's esophagus surveillance, including the efficacy of surveillance programs, physician compliance with surveillance guidelines, cost-effectiveness of surveillance programs, and areas for future research.
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Affiliation(s)
- Bryson W Katona
- Department of Internal Medicine, Hospital of the University of Pennsylvania, 3400 Spruce Street, 100 Centrex, Philadelphia, PA 19104, USA
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12
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Abstract
OBJECTIVES Surveillance endoscopy aims to identify progression to high-grade dysplasia (HGD) or oesophageal adenocarcinoma (OA) at an early stage in patients with Barrett's metaplasia (BM). There are variations in surveillance practice, clinical outcomes and economic analyses. The study examined long-term survival and financial impact in patients undergoing annual surveillance of BM. METHODS Patients with BM and considered fit for curative treatment between January 1994 and July 2001 were studied. Surveillance was scheduled as annual endoscopy with quadrantic biopsies every 2 cm. Financial analysis was based on standard National Health Service costs to death or follow-up to 5 years. Comparison was made with patients presenting with OA over the same time period. RESULTS Three hundred and two patients were identified with BM. Minimum follow-up was 5 years with a total follow-up of 654 patient-years. Two patients developed HGD and six OA. Median time between last nondysplastic biopsy and development of OA or HGD was 16 months (range 9-55). Five underwent potentially curative treatment. The remaining patients were unfit (n=1), refused surgery (n=1) or had metastatic disease (n=1). Four of five treated patients survived up to 5 years. The total cost of the surveillance programme including subsequent surgical or palliative treatment was euro240 682, euro30 085 per patient who progressed and for the prevalent cancer group (n=74) euro630 480 or euro8520 per patient. Only two patients in this group survived beyond 5 years. The additional cost of surveillance was euro4493 per life year gained. CONCLUSION A surveillance programme leads to improved 5-year survival. It is cost-effective compared with dealing with unselected patients.
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13
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Gatenby P, Ramus J, Caygill C, Shepherd N, Winslet M, Watson A. Routinely diagnosed low-grade dysplasia in Barrett's oesophagus: a population-based study of natural history. Histopathology 2009; 54:814-9. [PMID: 19635100 DOI: 10.1111/j.1365-2559.2009.03316.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS To examine the natural history of columnar-lined oesophagus with routinely diagnosed low-grade dysplasia and ascertain the risk of oesophageal adenocarcinoma development. METHODS AND RESULTS A multicentre retrospective cohort study of 283 patients with low-grade dysplasia. Follow-up data were obtained from examination of hospital records. One hundred and forty-four patients had biopsies prior to low-grade dysplasia diagnosis and 217 had follow-up biopsies after index low-grade dysplasia diagnosis. In these patients the incidence of high-grade dysplasia and adenocarcinoma combined was 4.6% per annum and of adenocarcinoma alone was 2.7% per annum. At most recent follow-up, 43 (19.8%) had persistent low-grade dysplasia, 37 (17.1%) had changes indefinite for dysplasia and 108 (49.8%) had non-dysplastic columnar-lined oesophagus. When prevalent cases were excluded (those occurring within 1 year of index low-grade dysplasia diagnosis), the annual incidence of high-grade dysplasia and adenocarcinoma combined was 2.2% and of adenocarcinoma alone was 1.4%. The relative risk for adenocarcinoma development in low-grade dysplasia compared with non-dysplastic columnar-lined oesophagus was 2.871 (P = 0.002). CONCLUSIONS Low-grade dysplasia has a threefold increased risk of progression to cancer compared with non-dysplastic epithelium, but in the majority of patients dysplasia is not subsequently detected.
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Affiliation(s)
- Piers Gatenby
- UK National Barrett's Oesophagus Registry, University Department of Surgery, Royal Free and University College Medical School, London, UK.
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