Systematic four-quadrant biopsy detects Barrett's dysplasia in more patients than nonsystematic biopsy

Measuring and improving quality in esophageal care and swallowing disorders

Evaluating clinical care through quality-related metrics is increasingly common. There are now numerous quality statements and indicators related to the medical management of benign and pre-malignant esophageal diseases. Expert consensus leveraging evidence-based recommendations from published society guidelines has been the most frequently used basis for developing esophageal quality statements. While surgical care of patients with esophageal malignancies, including squamous cell carcinoma, has also been developed, those related to benign esophageal disease now include domains of diagnosis, treatment, and monitoring for gastroesophageal reflux disease, eosinophilic esophagitis (EoE), achalasia, and Barrett's esophagus (BE). Several recent studies evaluating adherence to quality metrics affirm substantial variation in practice patterns with opportunities for improvement in care across esophageal diseases. In particular, patient education regarding treatment options in achalasia, frequency of esophageal biopsies among patients with dysphagia to evaluate for EoE, and endoscopic evaluation within a BE segment are areas identified to have need for improvement. As the management of esophageal diseases becomes more complex and interdisciplinary, adherence to quality metrics may be a source of standardization and improvement in delivery and ultimately patient outcomes. Indeed, the development of national quality databases has resulted in a significant growth in the use of these metrics for quality improvement activities and may form the basis for future inclusion in quality reporting and payment programs.

Quality indicators in Barrett's endoscopy: Best is yet to come

There is growing interest in establishing quality indicators (QIs) for endoscopic screening and surveillance in Barrett's esophagus (BE). QIs are objective, measurable, and evidence-based metrics that are applicable in a health-care setting to monitor a process and identify key performance indicators (KPIs) to achieve defined goals. In the Barrett's endoscopy setting, QIs can offer a standardized approach to monitor and maintain high-quality endoscopy for BE screening and surveillance that will allow measuring performance of an endoscopist as an individual, a group, or a facility. Since BE is an endoscopically identifiable premalignant condition with histological corroboration, adherence to QIs is paramount for the early and accurate detection of dysplasia and neoplasia. It is the holy grail for BE screening and surveillance. Although several suggested QIs for Barrett's endoscopy exist, issues remain in determining the most appropriate ones. These issues include inconsistent use of terminology, unclear definitions, and a scarcity of studies linking these QIs with relevant patient outcomes, making it difficult for clinicians to understand the concept and clinical importance. Hence, there is an urgent need to determine what should constitute appropriate QIs for Barrett's endoscopy, clearly define items used in the QIs, and identify ways to measure these KPIs. Ultimately, well-defined and validated QIs will contribute to clinically effective, safe, timely, and patient-focused care. In this review, we summarize recent literature and discuss four proposed QIs: (i) neoplasia detection rate; (ii) postendoscopy Barrett's neoplasia; (iii) Barrett's inspection time; and (iv) adherence to the Seattle biopsy protocol.

Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2:  ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3:  ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4:  ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5:  ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6:  ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7:  ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8:  ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9:  ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B:  ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C:  ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D:  ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E:  ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11:  After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.

Adherence to guideline recommendations for Barrett's esophagus (BE) surveillance endoscopies: Effects of dedicated BE endoscopy lists

Background and study aims For non-dysplastic Barrett's Esophagus (BE) patients, guidelines recommend endoscopic surveillance every 3 to 5 years with four-quadrant random biopsies every 2 cm of BE length. Adherence to these guidelines is low in clinical practice. Pooling BE surveillance endoscopies on dedicated endoscopy lists performed by dedicated endoscopists could possibly enhance guideline adherence, detection of visible lesions, and dysplasia detection rates (DDRs). Patients and methods Data were used from the ACID-study (Netherlands Trial Registry NL8214), a prospective trial of BE surveillance in the Netherlands. BE patients with known or previously treated dysplasia were excluded. Guideline adherence, detection of visible lesions, and DDRs were compared for patients on dedicated and general endoscopy lists. Results A total of 1,244 patients were included, 318 on dedicated lists and 926 on general lists. Endoscopies on dedicated lists showed significantly higher adherence to the random biopsy protocol (85% vs. 66%, P <0.01) and recommended surveillance intervals (60% vs. 47%, P <0.01) compared to general lists. Detection of visible lesions (8.8% vs. 8.1%, P =0.79) and DDRs were not significantly different (6.9% and 6.6%, P =0.94). None (0.0%) of the patients scheduled on dedicated lists and 10 (1.1%) on general lists were diagnosed with esophageal adenocarcinoma ( P =0.07). In multivariable analysis, dedicated lists were significantly associated with biopsy protocol adherence and adherence to surveillance interval recommendations with odds ratios of 4.45 (95% confidence interval [CI] 2.07-9.57) and 1.64 (95% CI 1.03-2.61), respectively. Conclusions Dedicated endoscopy lists are associated with better adherence to the random biopsy protocol and surveillance interval recommendations.

Surveillance in Barrett's Esophagus: Challenges, Progress, and Possibilities

Endoscopic surveillance of Barrett's esophagus, aiming to detect prevalent dysplasia and adenocarcinoma, followed by effective endoscopic treatment, is an integral part of the esophageal adenocarcinoma prevention paradigm. However, several limitations, such as the subtle appearance of dysplasia, sampling error (inherent in current surveillance protocols), and noncompliance with surveillance recommendations, lead to missed dysplasia and neoplasia, reducing the effectiveness of surveillance as currently practiced. Careful endoscopic assessment with high-resolution white-light endoscopy, dye-based or electronic chromoendoscopy, and comprehensive sampling of the BE mucosa, remains the cornerstone of endoscopic surveillance. Emerging innovations in this area span the gamut of more efficient sampling methods, advanced imaging tools, artificial intelligence, and molecular marker-powered approaches as adjuncts, to identify prevalent and predict incident dysplasia or adenocarcinoma. Development and implementation of validated quality indicators will allow additional advancement of this critical field. These approaches will hopefully enable efficient and effective cancer prevention and treatment.

Effect of biopsy protocol adherence vs non-adherence on dysplasia detection rates in Barrett's esophagus surveillance endoscopies: a systematic review and meta-analysis

Background  Barrett's esophagus (BE) surveillance endoscopies are advised for early diagnosis of esophageal adenocarcinoma (EAC). Current guidelines recommend obtaining four-quadrant random biopsies every 2 centimeters of BE length alongside with targeted biopsies if visible lesions are present. Low adherence rates for this random biopsy protocol are widely reported. The aim of this systematic review and meta-analysis was to assess the effect of adherence versus non-adherence to the four-quadrant biopsy protocol on detection of dysplasia in BE patients. Methods  We searched for studies that reported effects of adherence and non-adherence to the four-quadrant biopsy protocol on dysplasia detection rates in BE patients. Adherence was defined as taking a minimum of 4 quadrant random biopsies per 2 cm of BE segment. Studies with low risk of bias and without applicability concerns were included in a good quality synthesis. Pooled relative risks (RRs) with 95% confidence interval (CI) of dysplasia detection rates were calculated. Results  A total of 1,570 studies were screened and 8 studies were included. Four studies were included in the good quality synthesis. In the pooled good quality analysis, four-quadrant biopsy protocol adherence significantly increased detection of dysplasia compared to non-adherence (RR 1.90, 95 % CI = 1.36-2.64; I2 = 45 %). Pooled RRs for LGD and HGD/EAC were 2.00 (95 % CI = 1.49-2.69; I2 = 0 %) and 2.03 (95 % CI = 0.98-4.24; I2 = 28 %), respectively. Conclusion  This systematic review and meta-analysis demonstrates that four-quadrant biopsy protocol adherence is associated with increased detection of dysplasia in BE patients. Efforts should be made to increase biopsy protocol adherence rates.

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

BACKGROUND AND AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Barrett's esophagus: The pathomorphological and molecular genetic keystones of neoplastic progression

Barrett's esophagus is a widespread chronically progressing disease of heterogeneous nature. A life threatening complication of this condition is neoplastic transformation, which is often overlooked due to lack of standardized approaches in diagnosis, preventative measures and treatment. In this essay, we aim to stratify existing data to show specific associations between neoplastic transformation and the underlying processes which predate cancerous transition. We discuss pathomorphological, genetic, epigenetic, molecular and immunohistochemical methods related to neoplasia detection on the basis of Barrett's esophagus. Our review sheds light on pathways of such neoplastic progression in the distal esophagus, providing valuable insight into progression assessment, preventative targets and treatment modalities. Our results suggest that molecular, genetic and epigenetic alterations in the esophagus arise earlier than cancerous transformation, meaning the discussed targets can help form preventative strategies in at-risk patient groups.

Identification of Barrett's esophagus in endoscopic images using deep learning

BACKGROUND

Development of a deep learning method to identify Barrett's esophagus (BE) scopes in endoscopic images.

METHODS

443 endoscopic images from 187 patients of BE were included in this study. The gastroesophageal junction (GEJ) and squamous-columnar junction (SCJ) of BE were manually annotated in endoscopic images by experts. Fully convolutional neural networks (FCN) were developed to automatically identify the BE scopes in endoscopic images. The networks were trained and evaluated in two separate image sets. The performance of segmentation was evaluated by intersection over union (IOU).

RESULTS

The deep learning method was proved to be satisfying in the automated identification of BE in endoscopic images. The values of the IOU were 0.56 (GEJ) and 0.82 (SCJ), respectively.

CONCLUSIONS

Deep learning algorithm is promising with accuracies of concordance with manual human assessment in segmentation of the BE scope in endoscopic images. This automated recognition method helps clinicians to locate and recognize the scopes of BE in endoscopic examinations.

Gastro-esophageal reflux disease and Barrett's esophagus: an overview with an histologic diagnostic approach

The first part of this overview on non-neoplastic esophagus is focused on gastro-esophageal reflux disease (GERD) and Barrett’s esophagus. In the last 20 years much has changed in histological approach to biopsies of patients with gastro-esophageal reflux disease. In particular, elementary histologic lesions have been well defined and modality of evaluation and grade are detailed, their sensitivity and specificity has been evaluated and their use has been validated by several authors. Also if there is not a clinical indication to perform biopsies in patient with GERD, the diagnosis of microscopic esophagitis, when biopsies are provided, can be performed by following simple rules for evaluation which allow pathologists to make the diagnosis with confidence. On the other hand, biopsies are required for the diagnosis of Barrett’s esophagus. This diagnosis is the synthesis of endoscopic picture (which has to be provided with the proper description on extent and with adequate biopsies number) and histologic pattern. The current guidelines and expert opinions for the correct management of these diagnosis are detailed.

Best Practices in Surveillance for Barrett's Esophagus

Barrett's esophagus is the precursor lesion for esophageal adenocarcinoma. The goals of endoscopic surveillance are to detect dysplasia and early esophageal adenocarcinoma in order to improve patient outcomes. Despite the ongoing debate regarding the efficacy of surveillance, all current gastrointestinal societies recommend surveillance at this time. Optimal surveillance technique includes adequate inspection time, evaluation using high-definition white light and chromoendoscopy, appropriate documentation of the metaplastic segment using the Prague C & M criteria as well as the Paris classification should lesions be found, utilization of the Seattle biopsy protocol, and endoscopic resection of visible lesions.

Advanced Imaging and Sampling in Barrett's Esophagus: Artificial Intelligence to the Rescue?

Because the current Barrett's esophagus (BE) surveillance protocol suffers from sampling error of random biopsies and a high miss-rate of early neoplastic lesions, many new endoscopic imaging and sampling techniques have been developed. None of these techniques, however, have significantly increased the diagnostic yield of BE neoplasia. In fact, these techniques have led to an increase in the amount of visible information, yet endoscopists and pathologists inevitably suffer from variations in intra- and interobserver agreement. Artificial intelligence systems have the potential to overcome these endoscopist-dependent limitations.

The modern management of Barrett's oesophagus and related neoplasia: role of pathology

Modern management of Barrett's oesophagus and related neoplasia essentially focuses upon surveillance to detect early low-risk neoplastic lesions and offering organ-preserving advanced endoscopic therapies, while traditional surgical treatments of oesophagectomy and lymph node clearance with or without chemoradiation are preserved only for high-risk and advanced carcinomas. With this evolution towards figless invasive therapy, the choice of therapy hinges upon the pathological assessment for risk stratifying patients into those with low risk for nodal metastasis who can continue with less invasive endoscopic therapies and others with high risk for nodal metastasis for which surgery or other forms of treatment are indicated. Detection and confirmation of neoplasia in the first instance depends upon endoscopic and pathological assessment. Endoscopic examination and biopsy sampling should be performed according to the recommended protocols, and endoscopic biopsy interpretation should be performed applying standard criteria using appropriate ancillary studies by histopathologists experienced in the pathology of Barrett's disease. Endoscopic resections (ERs) are both diagnostic and curative and should be performed by clinicians who are skilled with advanced endoscopic techniques. Proper preparation and handling of ERs are essential to assess histological parameters that dictate the curative nature of the procedure. Those parameters are adequacy of resection and risk of lymph node metastasis. The risk of lymph node metastasis is determined by depth invasion and presence of poor differentiation and lymphovascular invasion. Those adenocarcinomas with invasion up to muscularis mucosae (pT1a) and those with superficial submucosal invasion (pT1b) up to 500 µ with no poor differentiation and lymphovascular invasion and negative margins may be considered cured by endoscopic resections.

Endoscopic Eradication Therapy for Barrett's Neoplasia: Where Do We Stand a Decade Later?

PURPOSE OF REVIEW

Barrett's esophagus (BE) is the only known precursor to esophageal adenocarcinoma (EAC), a cancer associated with increasing incidence and poor survival. Early identification and effective treatment of BE-related neoplasia prior to the development of invasive adenocarcinoma are essential to limiting the morbidity and mortality associated with this cancer. In this review, we summarized the recent evidence guiding endoscopic eradication therapies (EET) for neoplastic BE.

RECENT FINDINGS

New sampling technologies and the application of artificial intelligence (AI) systems have potential to revolutionize early neoplasia detection in BE. EET for BE are safe and effective in achieving complete eradication of intestinal metaplasia (CE-IM) and reducing the progression to EAC, a practice endorsed by all GI society guidelines. EET should be considered in patients with high-grade dysplasia (HGD), intramucosal carcinoma (IMC), and select cases with low-grade dysplasia (LGD). The increasing use of endoscopic submucosal dissection (ESD) in the West may allow EET of select cases with submucosal EAC. Post-EET surveillance strategies will continue to evolve as knowledge of specific risk factors and long-term neoplasia recurrence rates improve. In the last decade, major advancements in EET for neoplastic BE have been achieved. These now represent the standard of care in the management of BE-related dysplasia and intramucosal cancer.

Barrett's Registry Collaboration of academic centers in Ireland reveals high progression rate of low-grade dysplasia and low risk from nondysplastic Barrett's esophagus: report of the RIBBON network

Barrett's esophagus (BE) is the main pathological precursor of esophageal adenocarcinoma (EAC). Progression to high-grade dysplasia (HGD) or EAC from nondysplastic BE (NDBE), low-grade dysplasia (LGD) and indefinite for dysplasia (IND) varies widely between population-based studies and specialized centers for many reasons, principally the rigor of the biopsy protocol and the accuracy of pathologic definition. In the Republic of Ireland, a multicenter prospective registry and bioresource (RIBBON) was established in 2011 involving six academic medical centers, and this paper represents the first report from this network. A detailed clinical, endoscopic and pathologic database registered 3,557 patients. BE was defined strictly by both endoscopic evidence of Barrett's epithelium and the presence of specialized intestinal metaplasia (SIM). A prospective web-based database was used to gather information with initial and follow-up data abstracted by a data manager at each site. A total of 2,244 patients, 1,925 with no dysplasia, were included with complete follow-up. The median age at diagnosis was 60.5 with a 2.1:1 male to female ratio and a median follow-up time of 2.7 years (IQR 1.19-4.04), and 6609.25 person years. In this time period, 125 (5.57%) progressed to HGD/EAC, with 74 (3.3%) after 1 year of follow-up and 38 (1.69%) developed EAC, with 20 (0.89%) beyond 1 year. The overall incidence of HGD/EAC was 1.89% per year; 1.16% if the first year is excluded. The risk of progression to EAC alone overall was 0.57% per year, 0.31% excluding the first year, and 0.21% in the 1,925 patients who had SIM alone at diagnosis. Low-grade dysplasia (LGD) progressed to HGD/EAC in 31% of patients, a progression rate of 12.96% per year, 6.71% with the first year excluded. In a national collaboration of academic centers in Ireland, the progression rate for NDBE was similar to recent population studies. Almost one in two who progressed was evident within 1 year. Crucially, LGD diagnosed and confirmed by specialist gastrointestinal pathologists represents truly high-risk disease, highlighting the importance of expertise in diagnosis and management, and providing indirect support for ablative therapies in this context.

Towards screening Barrett's oesophagus: current guidelines, imaging modalities and future developments

Barrett's oesophagus is the only known precursor to oesophageal adenocarcinoma (OAC). Although guidelines on the screening and surveillance exist in Barrett's oesophagus, the current strategies are inadequate. Oesophagogastroduodenoscopy (OGD) is the gold standard method in screening for Barrett's oesophagus. This invasive method is expensive with associated risks negating its use as a current screening tool for Barrett's oesophagus. This review explores current definitions, epidemiology, biomarkers, surveillance, and screening in Barrett's oesophagus. Imaging modalities applicable to this condition are discussed, in addition to future developments. There is an urgent need for an alternative non-invasive method of screening and/or surveillance which could be highly beneficial towards reducing waiting times, alleviating patient fears and reducing future costs in current healthcare services. Vibrational spectroscopy has been shown to be promising in categorising Barrett's oesophagus through to high-grade dysplasia (HGD) and OAC. These techniques need further validation through multicentre trials.

What is the optimal surveillance strategy for non-dysplastic Barrett's esophagus?

PURPOSE OF REVIEW

There is conflicting data on the effectiveness of the currently recommended endoscopic surveillance strategy in non-dysplastic BE patients. We reviewed the literature to evaluate the (cost) effectiveness of the current surveillance strategy. We also reviewed critical strategies and new technologies which could improve dysplasia detection.

RECENT FINDINGS

Adherence to the current EGD surveillance guidelines is suboptimal with high rates of missed dysplasia/EAC. The influence of surveillance on EAC mortality appears modest. Careful cleansing, inspection and sampling of the BE mucosa using high resolution while light and (electronic) chromoendoscopy is critical. Newer sampling techniques coupled with computer aided diagnosis and emerging imaging technologies have shown promise in improving dysplasia detection. Personalized surveillance with risk stratification based on risk factors for progression may be on the horizon.

SUMMARY

Current BE surveillance strategy will likely be further refined and optimized by emerging new technologies in tissue sampling, advanced imaging and risk stratification.

Diagnostic Inaccuracies of Barrett's Oesophagus on Gastroscopy: Are We Performing Unnecessary Surveillance?

Background It is common for patients to enter Barrett's oesophagus (BO) surveillance based on endoscopic appearances before the diagnosis is histologically confirmed. We set out to review this practice by establishing the accuracy of endoscopic diagnoses of BO. Methods All gastroscopy reports in which a diagnosis of BO was recorded were reviewed over one year. These were compared to the histopathological reports to assess diagnostic accuracy. Results BO was diagnosed in 84 procedures. This diagnosis was incorrect according to histology in 42.9% (n=36) of cases. Diagnostic accuracy was higher with gastroenterologists (38.8% incorrect, n=21) compared to surgeons (50% incorrect, n=15). Diagnostic accuracy was higher with consultants (34.9% incorrect, n=22) compared to registrars (66.7% incorrect, n=14). The dose of sedation used had no impact on accuracy. Unnecessary surveillance was booked in 36.1% (n=13) of cases. Conclusion It is insufficient to rely on endoscopic appearances alone to diagnose BO, irrespective of speciality or experience. The diagnosis should only be made after reviewing the histopathology report. This can eliminate unnecessary repeat endoscopy procedures, sparing patients from unjustifiable risk and helping to cut down on long waiting lists in endoscopy departments. The implementation of the Prague classification and Seattle protocol can improve diagnostic accuracy.

Endoscopists systematically undersample patients with long-segment Barrett's esophagus: an analysis of biopsy sampling practices from a quality improvement registry

BACKGROUND AND AIMS

Guidelines recommend systematic biopsy sampling in Barrett's esophagus (BE) to reduce sampling error. Adherence to this biopsy sampling protocol has been suggested as a quality indicator; however, estimates of adherence are not available. Using a national registry, we assessed adherence and identified predictors of adherence to biopsy sampling protocols.

METHODS

We analyzed data from the GI Quality Improvement Consortium Registry that included procedure indication, demographics, endoscopy, and pathology results. Patients with an indication of BE screening/surveillance or an endoscopic finding of BE were included. Adherence to the Seattle protocol was assessed by dividing BE length by number of pathology jars, with a ratio ≤2.0 with rounding down (lenient definition) or rounding up (stringent definition) for odd BE lengths considered adherent. Variables associated with adherence were assessed using generalized estimating equations to control for clustering within individual physicians.

RESULTS

Of 786,712 EGDs assessed, 58,709 (7.5%) EGDs in 53,541 patients met inclusion criteria (mean age, 61.3 years; 60.4% men; 90.2% white; mean BE length, 2.3 cm). When the lenient and stringent definitions for adherence were used, 87.8% and 82.7% of EGDs were adherent, respectively. Increasing BE length was the most significant predictor of nonadherence (odds ratio, .69; 95% confidence interval, .67-.71). Other predictors were increasing age, male gender, increasing American Society of Anesthesiologists class, and practice location. Performance of EGD by nongastroenterologist physicians was associated with nonadherence (odds ratio, .07; 95% confidence interval, .06-.10).

CONCLUSIONS

Nearly 20% of endoscopies performed in BE patients were not adherent to the Seattle protocol. As BE length increases, endoscopists become less compliant with odds of nonadherence increasing by 31% with every 1-cm increase in length.

Screening and Prevention of Barrett's Esophagus

Barrett's esophagus (BO) is a risk factor for esophageal adenocarcinoma. However, screening for BO is difficult since it is not yet clear who should be screened and which screening method is cost-effective. Screening methods could be upper endoscopy at the time of the first screening colonoscopy, transnasal endoscopy, esophageal capsule endoscopy, or cytosponge. In order to prevent the development of BO or its neoplastic progression, there are modifiable risk factors like obesity or smoking that can be influenced. In addition, several drugs like proton pump inhibitors, aspirin, nonsteroidal anti-inflammatory drugs and statins have shown promising effects in mostly observational studies. However, data from prospective randomized trials are scarce in order to draw final conclusions.

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.

Challenges in Endoscopic Therapy of Dysplastic Barrett's Esophagus

PURPOSE OF REVIEW

Barrett's esophagus (BE) is the only known measurable factor associated with esophageal adenocarcinoma. The development of endoscopic eradication therapy (EET) has transformed the way BE is managed. Given the fairly recent development of EET, its role in BE is still evolving.

RECENT FINDINGS

This paper discusses the challenges that endoscopists face at the preprocedural, intraprocedural, and postprocedural stages of BE management. These include challenges in risk stratification, dysplasia detection, ablation methods and dosimetry, choice of resection technique, and management of refractory disease. Despite the advances in EET in BE, there remain challenges that this review focuses on. Future research into these challenges will optimize ablation techniques and strategies in the future.

A Survey of Expert Practice and Attitudes Regarding Advanced Imaging Modalities in Surveillance of Barrett's Esophagus

BACKGROUND

Published guidelines do not address what the minimum incremental diagnostic yield (IDY) for detection of dysplasia/cancer is required over the standard Seattle protocol for an advanced imaging modality (AIM) to be implemented in routine surveillance of Barrett's esophagus (BE) patients. We aimed to report expert practice patterns and attitudes, specifically addressing the minimum IDY in the use of AIMs in BE surveillance.

METHODS

An international group of BE experts completed an anonymous electronic survey of domains relevant to surveillance practice patterns and use of AIMs. The evaluated AIMs were conventional chromoendoscopy (CC), virtual chromoendoscopy (VC), volumetric laser endomicroscopy (VLE), confocal laser endomicroscopy (CLE), and wide-area transepithelial sampling (WATS^3D). Responses were recorded using five-point balanced Likert items and analyzed as continuous variables.

RESULTS

The survey response rate was 84% (61/73)-41 US and 20 non-US. Experts were most comfortable with and routinely use VC and CC, and least comfortable with and rarely use VLE, CLE, and WATS^3D. Experts rated data from randomized controlled trials (1.4 ± 0.9) and guidelines (2.6 ± 1.2) as the two most influential factors for implementing AIMs in clinical practice. The minimum IDY of AIMs over standard biopsies to be considered of clinical benefit was lowest for VC (15%, IQR 10-29%) and highest for VLE (30%, IQR 20-50%). Compared to US experts, non-US experts reported higher use of CC for BE surveillance (p < 0.001).

CONCLUSION

These results should inform benchmarks that need to be met for guidelines to recommend the routine use of AIMs in the surveillance of BE patients.

How Should We Report Endoscopic Results in Patient's with Barrett's Esophagus?

Barrett's esophagus is the only known pre-cancerous lesion for esophageal adenocarcinoma and is diagnosed by high-definition white light endoscopy demonstrating a columnar-lined esophagus along with biopsy evidence of intestinal metaplasia. With accurate performance and reporting of the endoscopic procedure, an evidence-based management strategy can be developed for treatment of Barrett's dysplasia. However, cross-sectional data demonstrate that there is still inconsistency among gastroenterologists in performance and reporting of endoscopic findings in patients with Barrett's esophagus. Here, we present an evidence-based review of how to report endoscopic findings in Barrett's esophagus.

Critical appraisal of guidelines for screening and surveillance of Barrett's esophagus

Esophageal adenocarcinoma (EAC) arising on Barrett esophagus (BE) has become the most frequent type of esophageal malignancy in the Western world. BE is a frequent condition but progression to EAC is rare. Scientific societies publish guidelines in order to improve patients' care. However, there are fields where evidence is lacking or there are many controversies. We aimed to spotlight the most important changes, as well as the points of controversy in the recently published guidelines for BE. For most, a length ≥1 cm of a salmon-pink mucosa extending above the eso-gastric junction is required in order to define BE, accompanied with the presence of intestinal metaplasia (IM) at histology. Screening with endoscopy for the general population is not recommended while there is no proof of the efficacy of screening for targeted high risk populations. New techniques permitting a cytologic examination are under evaluation and may change this strategy. The use of high-resolution endoscopes coupled with a careful inspection of the mucosa are required during surveillance of BE. New studies are necessary in order to clarify the real benefit from the use of advanced techniques, such as virtual chromoendoscopy. Length of non-dysplastic BE plays a role for the interval time determination between endoscopies during surveillance. Indefinite for dysplasia and even more low grade dysplasia (LGD) are debatable issues in the matter of BE. There are compelling data suggesting that a definite LGD, defined as a permanent lesion confirmed by a specialist pathologist in BE, has a more dismal prognosis than previously reported and an ablative intervention may be offered in this case. However, most (75-85%) cases with LGD were downstaged in published studies and it remains unknown if in real life, percentages of downstaging are approaching those of studies or there is an over-treatment of pseudo-LGD. Biomarkers such as p53 immunohistochemistry may aid better identification of patients at higher risk. For high grade dysplasia (HGD) visible lesions should be resected with Endoscopic Mucosal Resection (EMR) while flat lesions ablated, for most, nowadays, with radiofrequency ablation (RFA). Endoscopic submucosal dissection (ESD) has not proved superior compared to EMR in BE. It has to be underlined that most studies leading to the new guidelines for BE are not considered of high quality and new guidelines may emerge in the near future.

Controversies in Endoscopic Eradication Therapy for Barrett's Esophagus

Advances in endoscopic eradication therapy for Barrett's Esophagus-associated neoplasia have resulted in a significant paradigm shift in the diagnosis and management of this complex disease. A robust body of literature critically evaluating outcomes of resection and ablative strategies has allowed gastroenterologists to make quality, evidence-based decisions for their patients. Despite this progress, there are still many unanswered questions and challenges that remain. Ultimately, identification of a cost-effective screening modality, biomarkers for risk stratification, and strides to eliminate post surveillance endoscopy after endoscopic eradication therapy are essential to reach our long-term goal for eradication of esophageal adenocarcinoma.

Management of Barrett's esophagus with low-grade dysplasia

Barrett's esophagus progresses to esophageal adenocarcinoma in a stepwise histological fashion of no dysplasia, low grade dysplasia, high grade dysplasia and cancer. Hence the progression to cancer from various histological stages is different. Progression to cancer from low grade dysplasia is highly variable in the literature due to high inter-observer variability between pathologists in diagnosing it. Studies have shown the utility of having confirmation of low grade dysplasia by expert pathologists or documenting its persistence on two subsequent endoscopies in order to unify the diagnosis. The treatment of low grade dysplasia is variable. In this article we summarize the diagnosis, evaluation and management of low grade dysplasia in Barrett's Esophagus.

Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus: a retrospective analysis

BACKGROUND

 Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE).

METHODS

 This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval.

RESULTS

 In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 - 6.82; P  < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 - 1.12; P  < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 - 0.97; P  < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 - 29 months) than the recommended interval.

CONCLUSION

 Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Quality of endoscopic surveillance of Barrett's esophagus

OBJECTIVES

The aim of this study was to evaluate adherence to Barrett's esophagus (BE) surveillance guidelines in Denmark.

METHODS

The Danish Pathology Registry was used to identify 3692 patients. A total of 300 patients were included by drawing a simple random sample. Description of the BE segment, biopsy protocol, communication with the pathologist and planned follow-up endoscopy, was evaluated.

RESULTS

Thirty-one patients were excluded due to missing reports and 83 patients (28%) due to no endoscopic evidence of BE. Endoscopists suspected BE in 186 patients (62%) and these patients were included. Prague C&M classification was used in 34% of the endoscopy reports. The median number of biopsies was 4 (interquartile range (IQR), 3-6). The BE segment was stratified by lengths of 1-5, 6-10 and 11-15 cm and endoscopists obtained a sufficient number of biopsies in 12, 8 and 0% of cases, respectively. 28% of endoscopists described the exact location of the biopsy site in the pathology requisition. Patients with nondysplastic BE had endoscopic surveillance performed after a median of 24 months (IQR, 6-24).

CONCLUSIONS

Adherence to the Danish guidelines was poor. This may be associated with insufficient quality of BE surveillance. Lack of endoscopic evidence of BE in the Danish Pathology Registry may have underestimated the incidence of adenocarcinoma in BE patients in previous studies.

Quality standards in upper gastrointestinal endoscopy: a position statement of the British Society of Gastroenterology (BSG) and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (AUGIS)

This document represents the first position statement produced by the British Society of Gastroenterology and Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, setting out the minimum expected standards in diagnostic upper gastrointestinal endoscopy. The need for this statement has arisen from the recognition that while technical competence can be rapidly acquired, in practice the performance of a high-quality examination is variable, with an unacceptably high rate of failure to diagnose cancer at endoscopy. The importance of detecting early neoplasia has taken on greater significance in this era of minimally invasive, organ-preserving endoscopic therapy. In this position statement we describe 38 recommendations to improve diagnostic endoscopy quality. Our goal is to emphasise practices that encourage mucosal inspection and lesion recognition, with the aim of optimising the early diagnosis of upper gastrointestinal disease and improving patient outcomes.

Barrett’s oesophagus: Current controversies

Oesophageal adenocarcinoma is rapidly increasing in Western countries. This tumour frequently presents late in its course with metastatic disease and has a very poor prognosis. Barrett’s oesophagus is an acquired condition whereby the native squamous mucosa of the lower oesophagus is replaced by columnar epithelium following prolonged gastro-oesophageal reflux and is the recognised precursor lesion for oesophageal adenocarcinoma. There are multiple national and society guidelines regarding screening, surveillance and management of Barrett’s oesophagus, however all are limited regarding a clear evidence base for a well-demonstrated benefit and cost-effectiveness of surveillance, and robust risk stratification for patients to best use resources. Currently the accepted risk factors upon which surveillance intervals and interventions are based are Barrett’s segment length and histological interpretation of the systematic biopsies. Further patient risk factors including other demographic features, smoking, gender, obesity, ethnicity, patient age, biomarkers and endoscopic adjuncts remain under consideration and are discussed in full. Recent evidence has been published to support earlier endoscopic intervention by means of ablation of the metaplastic Barrett’s segment when the earliest signs of dysplasia are detected. Further work should concentrate on establishing better risk stratification and primary and secondary preventative strategies to reduce the risk of adenocarcinoma of the oesophagus.

Risk of metastasis in adenocarcinoma of the esophagus: a multicenter retrospective study in a Japanese population

BACKGROUND

Little is known about the specific risks of metastasis in esophageal adenocarcinoma in relation to invasion depth or other pathologic factors.

METHODS

We conducted a multicenter retrospective study in 13 high-volume centers in Japan from January 2000 to October 2014 to elucidate the risk of metastasis of esophageal adenocarcinoma. A total of 458 patients (217 surgically resected and 241 endoscopically resected) with esophageal adenocarcinoma or esophagogastric adenocarcinoma involving the esophagus were included. Metastasis was considered positive if there was histologically confirmed metastasis in the surgical specimen or clinically confirmed metastasis during follow-up. Metastasis was considered negative if no metastasis was identified in resected specimens and during follow-up in patients treated surgically or no metastasis during follow-up for >5 years in patients treated by endoscopic resection.

RESULTS

Metastasis was identified in 72 patients. Multivariate analysis confirmed lymphovascular involvement [odds ratio (OR) 6.20; 95 % confidence interval (CI) 3.12-12.32; p < 0.001], a poorly differentiated component (OR 3.69; 95 % CI 1.92-7.10; p < 0.001), and lesion size >30 mm (OR 3.12; 95 % CI 1.63-5.97; p = 0.001) as independent risk factors for metastasis. No metastasis was detected in patients with mucosal cancer without lymphovascular involvement and a poorly differentiated component (0/186 lesions) or in patients with cancer invading the submucosa (1-500 µm) without lymphovascular involvement, a poorly differentiated component, and ≤30 mm (0/32 lesions).

CONCLUSIONS

Mucosal and submucosal cancers (1-500 µm invasion) without risk factors have a low incidence of metastasis and may thus be good candidates for endoscopic resection.

Diagnosis and Management of Low-Grade Dysplasia in Barrett's Esophagus: Expert Review From the Clinical Practice Updates Committee of the American Gastroenterological Association

The purpose of this clinical practice update expert review is to define the key principles in the diagnosis and management of low-grade dysplasia (LGD) in Barrett's esophagus patients. The best practices outlined in this review are based on relevant publications, including systematic reviews and expert opinion (when applicable). Practice Advice 1: The extent of Barrett's esophagus should be defined using a standardized grading system documenting the circumferential and maximal extent of the columnar lined esophagus (Prague classification) with a clear description of landmarks and visible lesions (nodularity, ulceration) when present. Practice Advice 2: Given the significant interobserver variability among pathologists, the diagnosis of Barrett's esophagus with LGD should be confirmed by an expert gastrointestinal pathologist (defined as a pathologist with a special interest in Barrett's esophagus-related neoplasia who is recognized as an expert in this field by his/her peers). Practice Advice 3: Expert pathologists should report audits of their diagnosed cases of LGD, such as the frequency of LGD diagnosed among surveillance patients and/or the difference in incidence of neoplastic progression among patients diagnosed with LGD vs nondysplastic Barrett's esophagus. Practice Advice 4: Patients in whom the diagnosis of LGD is downgraded to nondysplastic Barrett's esophagus should be managed as nondysplastic Barrett's esophagus. Practice Advice 5: In Barrett's esophagus patients with confirmed LGD (based on expert gastrointestinal pathology review), repeat upper endoscopy using high-definition/high-resolution white-light endoscopy should be performed under maximal acid suppression (twice daily dosing of proton pump inhibitor therapy) in 8-12 weeks. Practice Advice 6: Under ideal circumstances, surveillance biopsies should not be performed in the presence of active inflammation (erosive esophagitis, Los Angeles grade C and D). Pathologists should be informed if biopsies are obtained in the setting of erosive esophagitis and if pathology findings suggest LGD, or if no biopsies are obtained, surveillance biopsies should be repeated after the anti-reflux regimen has been further intensified. Practice Advice 7: Surveillance biopsies should be performed in a four-quadrant fashion every 1-2 cm with target biopsies obtained from visible lesions taken first. Practice Advice 8: Patients with a confirmed histologic diagnosis of LGD should be referred to an endoscopist with expertise in managing Barrett's esophagus-related neoplasia practicing at centers equipped with high-definition endoscopy and capable of performing endoscopic resection and ablation. Practice Advice 9: Endoscopic resection should be performed in Barrett's esophagus patients with LGD with endoscopically visible abnormalities (no matter how subtle) in order to accurately assess the grade of dysplasia. Practice Advice 10: In patients with confirmed Barrett's esophagus with LGD by expert GI pathology review that persists on a second endoscopy, despite intensification of acid-suppressive therapy, risks and benefits of management options of endoscopic eradication therapy (specifically adverse events associated with endoscopic resection and ablation), and ongoing surveillance should be discussed and documented. Practice Advice 11: Endoscopic eradication therapy should be considered in patients with confirmed and persistent LGD with the goal of achieving complete eradication of intestinal metaplasia. Practice Advice 12: Patients with LGD undergoing surveillance rather than endoscopic eradication therapy should undergo surveillance every 6 months times 2, then annually unless there is reversion to nondysplastic Barrett's esophagus. Biopsies should be obtained in 4-quadrants every 1-2 cm and of any visible lesions. Practice Advice 13: In patients with Barrett's esophagus-related LGD undergoing ablative therapy, radiofrequency ablation should be used. Practice Advice 14: Patients completing endoscopic eradication therapy should be enrolled in an endoscopic surveillance program. Patients who have achieved complete eradication of intestinal metaplasia should undergo surveillance every year for 2 years and then every 3 years thereafter to detect recurrent intestinal metaplasia and dysplasia. Patients who have not achieved complete eradication of intestinal metaplasia should undergo surveillance every 6 months for 1 year after the last endoscopy, then annually for 2 years, then every 3 years thereafter. Practice Advice 15: Following endoscopic eradication therapy, the biopsy protocol of obtaining biopsies in 4 quadrants every 2 cm throughout the length of the original Barrett's esophagus segment and any visible columnar mucosa is suggested. Practice Advice 16: Endoscopists performing endoscopic eradication therapy should report audits of their rates of complete eradication of dysplasia and intestinal metaplasia and adverse events in clinical practice.

The importance of biopsy sampling practices in the pathologic evaluation of gastrointestinal disorders

PURPOSE OF REVIEW

To summarize the literature regarding appropriate endoscopic sampling and surveillance protocols for common inflammatory diseases of the digestive tract. Gastroenterologists increasingly use endoscopy with mucosal biopsy to detect inflammatory diseases, assess response to therapy, and monitor for progression to dysplasia.

RECENT FINDINGS

Many diseases show a patchy distribution in the digestive tract and there may be poor correlation between the endoscopic appearance and presence of histologic abnormalities. Indeed, a clinician's ability to render a diagnosis is limited by endoscopic mucosal sampling. The appropriate number of tissue samples and required biopsy sites are not established for many gastrointestinal disorders, and adherence to guidelines may not yield a reliable diagnosis in all cases.

SUMMARY

We discuss the evidence supporting current recommendations and emerging endoscopic techniques for the evaluation of eosinophilic esophagitis, Barrett esophagus, chronic gastritis, celiac disease, and inflammatory bowel disease.

A meta-analysis of confocal laser endomicroscopy for the detection of neoplasia in patients with Barrett's esophagus

BACKGROUND AND AIMS

Barrett's esophagus (BE) is considered the most important risk factor for development of esophageal adenocarcinoma. Confocal laser endomicroscopy (CLE) is a recently developed technique used to diagnose neoplasia in BE. This meta-analysis was performed to assess the accuracy of CLE for diagnosis of neoplasia in BE.

METHODS

We searched EMBASE, PubMed, Cochrane Library, and Web of Science to identify relevant studies for all articles published up to June 27, 2015 in English. The quality of included studies was assessed using QUADAS-2. Per-patient and per-lesion pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio with 95% confidence intervals (CIs) were calculated.

RESULTS

In total, 14 studies were included in the final analysis, covering 789 patients with 4047 lesions. Seven studies were included in the per-patient analysis. Pooled sensitivity and specificity were 89% (95% CI: 0.82-0.94) and 83% (95% CI: 0.78-0.86), respectively. Ten studies were included in the per-lesion analysis. Compared with the PP analysis, the corresponding pooled sensitivity declined to 77% (95% CI: 0.73-0.81) and specificity increased to 89% (95% CI: 0.87-0.90). Subgroup analysis showed that probe-based CLE (pCLE) was superior to endoscope-based CLE (eCLE) in pooled specificity [91.4% (95% CI: 89.7-92.9) vs 86.1% (95% CI: 84.3-87.8)] and AUC for the sROC (0.885 vs 0.762).

CONCLUSION

Confocal laser endomicroscopy is a valid method to accurately differentiate neoplasms from non-neoplasms in BE. It can be applied to BE surveillance and early diagnosis of esophageal adenocarcinoma.

Impact of surveillance for Barrett's oesophagus on tumour stage and survival of patients with neoplastic progression

OBJECTIVE

Endoscopic surveillance for Barrett's oesophagus (BO) is under discussion given the overall low incidence of neoplastic progression and lack of evidence that it prevents advanced oesophageal adenocarcinoma (OAC). The aim of this study was to evaluate the impact of endoscopic BO surveillance on tumour stage and survival of patients with neoplastic progression.

DESIGN

783 patients with BO of at least 2 cm were included in a multicentre prospective cohort and followed during surveillance according to the American College of Gastroenterology guidelines. Cases of high-grade dysplasia and OAC were identified during follow-up. OAC staging was performed according to the 7th UICC-AJCC classification. Survival data were collected and crosschecked using death and municipal registries. Data from patients with OAC in the general population were obtained from the Dutch cancer registry. We compared survival of patients with BO with neoplastic progression during surveillance with those of patients without neoplastic progression and patients with OAC in the general population.

RESULTS

53 patients with BO developed high-grade dysplasia or OAC during surveillance. Thirty-five (66%) were classified as stage 0, 14 (26%) as stage 1 and 4 (8%) as stage 2. OAC was diagnosed at an earlier stage during BO surveillance than in the general population (p<0.001). Survival of patients with BO with neoplastic progression was not significantly worse than those of patients without neoplastic progression and similar to survival of patients with stage 0 or stage 1 OAC in the general population.

CONCLUSIONS

OAC is detected at an earlier stage during BO surveillance than in the general population with good survival rates.

Management of Barrett's high-grade dysplasia: initial results from a population-based national audit

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.

ESGE Survey: worldwide practice patterns amongst gastroenterologists regarding the endoscopic management of Barrett's esophagus

BACKGROUND AND STUDY AIMS

Barrett's esophagus is a common condition that is widely encountered in clinical practice. This European Society of Gastrointestinal Endoscopy (ESGE) survey aimed to determine practice patterns amongst European clinicians with regard to the diagnosis and management of Barrett's esophagus.

METHODS

Clinicians attending the ESGE learning area at the United European Gastroenterology Week in 2014 were invited to complete a 10-question survey. This survey was programed on to two Apple iPads. Information was gathered with regard to demographics, practice settings, and diagnosis and management strategies for Barrett's esophagus.

RESULTS

In total, 163 responses were obtained. Over half of respondents (61 %) were based in university hospitals, the majority (78 %) were aged 30 - 50 and half had more than 10 years' experience; 66 % had attended courses on Barrett's esophagus and more than half (60 %) used the Prague C & M classification. Advanced imaging was used by 73 % of clinicians and 72 % of respondents stated that their group practiced ablation therapy. Most (76 %) practiced surveillance for non-dysplastic Barrett's, 6 % offered ablation therapy in some situations, and 18 % offered no intervention. For low grade dysplasia, 56 % practiced surveillance, 19 % ablated some cases and 15 % ablated all cases. In total, 32 % of clinicians referred high grade dysplasia to expert centers, with 20 % referring directly for surgery and 46 % using ablation therapy in certain cases. Endoscopic mucosal resection was the most commonly used ablation technique (44 %).

CONCLUSIONS

There has been reasonable uptake of the Prague C & M classification for describing Barrett's esophagus, and ablation is widely practiced. However, practice patterns for Barrett's esophagus vary widely between clinicians with clear guidance and quality standards required.

ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus

Barrett's esophagus (BE) is among the most common conditions encountered by the gastroenterologist. In this document, the American College of Gastroenterology updates its guidance for the best practices in caring for these patients. These guidelines continue to endorse screening of high-risk patients for BE; however, routine screening is limited to men with reflux symptoms and multiple other risk factors. Acknowledging recent data on the low risk of malignant progression in patients with nondysplastic BE, endoscopic surveillance intervals are attenuated in this population; patients with nondysplastic BE should undergo endoscopic surveillance no more frequently than every 3-5 years. Neither routine use of biomarker panels nor advanced endoscopic imaging techniques (beyond high-definition endoscopy) is recommended at this time. Endoscopic ablative therapy is recommended for patients with BE and high-grade dysplasia, as well as T1a esophageal adenocarcinoma. Based on recent level 1 evidence, endoscopic ablative therapy is also recommended for patients with BE and low-grade dysplasia, although endoscopic surveillance continues to be an acceptable alternative. Given the relatively common recurrence of BE after ablation, we suggest postablation endoscopic surveillance intervals. Although many of the recommendations provided are based on weak evidence or expert opinion, this document provides a pragmatic framework for the care of the patient with BE.

Interobserver reproducibility in pathologist interpretation of columnar-lined esophagus

Confirmation of endoscopically suspected esophageal metaplasia (ESEM) requires histology, but confusion in the histological definition of columnar-lined esophagus (CLE) is a longstanding problem. The aim of this study is to evaluate interpathologist variability in the interpretation of CLE. Thirty pathologists were invited to review three ten-case sets of CLE biopsies. In the first set, the cases were provided with descriptive endoscopy only; in the second and the third sets, ESEM extent using Prague criteria was provided. Moreover, participants were required to refer to a diagnostic chart for evaluation of the third set. Agreement was statistically assessed using Randolph's free-marginal multirater kappa. While substantial agreement in recognizing columnar epithelium (K = 0.76) was recorded, the overall concordance in clinico-pathological diagnosis was low (K = 0.38). The overall concordance rate improved from the first (K = 0.27) to the second (K = 0.40) and third step (K = 0.46). Agreement was substantial when diagnosing Barrett's esophagus (BE) with intestinal metaplasia or inlet patch (K = 0.65 and K = 0.89), respectively, in the third step, while major problems in interpretation of CLE were observed when only cardia/cardia-oxyntic atrophic-type epithelium was present (K = 0.05-0.29). In conclusion, precise endoscopic description and the use of a diagnostic chart increased consistency in CLE interpretation of esophageal biopsies. Agreement was substantial for some diagnostic categories (BE with intestinal metaplasia and inlet patch) with a well-defined clinical profile. Interpretation of cases with cardia/cardia-oxyntic atrophic-type epithelium, with or without ESEM, was least consistent, which reflects lack of clarity of definition and results in variable management of this entity.

Spatial predisposition of dysplasia in Barrett's esophagus segments: a pooled analysis of the SURF and AIM dysplasia trials

OBJECTIVES

Surveillance endoscopy detects dysplasia within Barrett's esophagus (BE) and dictates treatment. Current biopsy regimens recommend uniformly spaced random biopsies. We assessed the distribution of dysplasia in BE to develop evidence-based biopsy regimens.

METHODS

We performed analysis of the distribution of dysplasia within BE using pretreatment biopsy data from two randomized controlled trials (RCTs) of radiofrequency ablation for dysplastic BE: the SURF (Surveillance vs. Radiofrequency Ablation) trial and the AIM Dysplasia (Ablation of Intestinal Metaplasia (AIM) Containing Dysplasia) trial. We used generalized linear models with generalized estimating equations (GEE) to estimate prevalence differences for dysplasia depending on the standardized location of biopsies. We performed Monte Carlo simulation of biopsy regimens to estimate their yield for any dysplasia within segments.

RESULTS

Dysplasia preferentially resides in the proximal-most half of the BE segment that is almost twice as likely to demonstrate dysplasia as the distal-most quartile. In pooled analysis, compared with the distal-most quarter, the prevalence difference in the proximal-most quarter was 22.6%, in the second proximal-most quarter 23.1%, and in the second distal-most quarter 15.3%. The best performing biopsy regimen in simulation studies acquired 8 biopsies in the most proximal cm of BE, 8 biopsies in the second cm, and 2 biopsies in each cm thereafter (q1cm: 8, 8, 2, 2…). A slightly simpler q2cm (every 2 cm) regimen (q2cm: 12, 12, 4…) was nearly as effective.

CONCLUSIONS

The post hoc analysis of two RCTs reveals a substantially increased prevalence of dysplasia proximally in BE segments. Our simulations suggest an altered biopsy regimen could increase sensitivity of biopsies in short-segment BE by >30%.

Red flag imaging in Barrett's esophagus: does it help to find the needle in the haystack?

Esophageal Adenocarcinoma (EAC) has suffered a sharp increase on its incidence for the last decades, and it is associated with a poor prognosis. Barrett's Esophagus (BE) is the most important identifiable risk factor for the progression to esophageal adenocarcinoma. The key to prevent and provide a curative treatment of esophageal adenocarcinoma is the detection and eradication of early neoplasia in patients with esophagus. Endoscopic surveillance is evolving from a blind or random four quadrant biopsies protocol (Seattle protocol) to a more targeted approach. A detailed white light examination with high-resolution endoscopy is the cornerstone for recognition of early neoplastic lesions in BE. Additional imaging modalities may enhance targeting of lesions or provide more information at a focused level. There are emerging data that some of these new modalities can increase the yield of detecting dysplasia, although its routine use has yet to be validated.

Recurrent intestinal metaplasia after radiofrequency ablation for Barrett's esophagus: endoscopic findings and anatomic location

BACKGROUND

Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett's esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence is common after CEIM, and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well-described.

OBJECTIVE

Describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence.

DESIGN

Retrospective cohort.

SETTING

Single referral center.

PATIENTS

A total of 198 patients with BE with at least 2 surveillance endoscopies after CEIM.

INTERVENTIONS

RFA, EMR, surveillance endoscopy.

MAIN OUTCOME MEASUREMENTS

The anatomic location and histologic grade of recurrence.

RESULTS

In a mean 3.0 years of follow-up, 32 (16.2%; 95% confidence interval [CI], 11.0%-22.0%) patients had recurrence of disease, 5 (2.5%; 95% CI, 0.3%-4.7%) of whom progressed beyond their worst before-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence>1 cm proximal to the GEJ always was accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white light or narrow-band imaging for recurrence was 59.4% (42.4%, 76.4%), and the specificity was 80.6% (77.2%, 84.0%).

LIMITATIONS

Single-center study.

CONCLUSION

Recurrent intestinal metaplasia often is not visible to the endoscopist and is most common near the GEJ. Random biopsies>1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.