Pediatric columnar lined esophagus vs Barrett's esophagus: is it the time for a consensus definition

Barrett's oesophagus and oesophageal cancer following oesophageal atresia repair: a systematic review

BACKGROUND

Concern exists that patients born with oesophageal atresia (OA) may be at high risk for Barrett's oesophagus (BO), a known malignant precursor to the development of oesophageal adenocarcinoma. Screening endoscopy has a role in early BO identification but is not universal in this population. This study aimed to determine prevalence of BO after OA repair surgery, to quantify the magnitude of this association and inform the need for screening and surveillance.

METHODS

A systematic review, undertaken according to PRISMA guidelines, was preregistered on PROSPERO (CRD42017081001). PubMed and EMBASE were interrogated using a standardized search strategy on 31 July 2020. Included papers, published in English, reported either: one or more patients with either BO (gastric/intestinal metaplasia) or oesophageal cancer in patients born with OA; or long-term (greater than 2 years) follow-up after OA surgery with or without endoscopic screening or surveillance.

RESULTS

Some 134 studies were identified, including 19 case reports or series and 115 single- or multi-centre cohort studies. There were 13 cases of oesophageal cancer (9 squamous cell carcinoma, 4 adenocarcinoma) with a mean age at diagnosis of 40.5 (range 20-47) years. From 6282 patients under long-term follow-up, 317 patients with BO were reported. Overall prevalence of BO was 5.0 (95 per cent c.i. 4.5 to 5.6) per cent, with a mean age at detection of 13.8 years (range 8 months to 56 years). Prevalence of BO in series reporting endoscopic screening or surveillance was 12.8 (95 per cent c.i. 11.3 to 14.5) per cent.

CONCLUSION

Despite a limited number of cancers, the prevalence of BO in patients born with OA is relatively high. While limited by the quality of available evidence, this review suggests endoscopic screening and surveillance may be warranted, but uncertainties remain over the design and effectiveness of any putative programme.

Trends in gastroesophageal reflux disease in Japanese children and adolescents

BACKGROUND

Although the prevalence of gastroesophageal reflux disease (GERD) has been increasing in Japan, little is known about the prevalence and severity of GERD in pediatric patients. This study compared the prevalence and severity of endoscopically proven GERD in pediatric patients seen at an endoscopy center in Japan over a 15-year period.

METHODS

This was a retrospective chart review of Japanese children aged 5-18 years undergoing esophagogastroduodenoscopy for upper gastrointestinal symptoms or anemia between 2005 and 2019. The prevalence and severity of reflux esophagitis and endoscopic Barrett's esophagus were compared between the periods 2005-2012 and 2013-2019.

RESULTS

A total of 564 patients were evaluated: 315 from 2005 to 2012 (mean ± SD) age 13.8 ± 3.0 (range, 5-18 years; 147 boys; and 249 from 2013 to 2019 (mean ± SD) 14.7 ± 2.8 (range, 5-18) years; 108 boys. Demographics and clinical features were similar between the two groups. The proportion with erosive esophagitis or endoscopic Barrett's esophagus increased significantly between the two periods (9.8% to 18.1% for GERD, P = 0.0045 and 2.5% to 9.6% for Barrett's esophagus, P = 0.0003). The proportion of GERD patients with endoscopic Barrett's esophagus also significantly increased between the two periods (24/45 [53.3%]) vs (8/31 [25.8%]), P = 0.017].

CONCLUSION

The prevalence and severity of endoscopically proven GERDs has significantly increased over the past 15 years at an endoscopy center in Japan. Detailed population-based studies are needed to assess whether this is occurring throughout Japan.

Endoscopic findings of esophagogastric junction in children

Esophagogastric landmarks are recognizable in the same way both in children and in adults, and palisade-shaped vessels can be observed at the distal position of esophageal mucosa, even in infants. Few studies have been done in respect to Barrett's esophagus (BE) in children. Incidence of endoscopically suspected BE among all children undergoing esophagogastroduodenoscopy (EGD) is approximately 0.25-1.4%, but can be up to 9.7% in patients with gastroesophageal reflux disease (GERD). Some data suggest that BE is an acquired disorder and point to the possibility of a congenital component in combination with severe mucosal injury. Recent reports noted that multilayered epithelium (ME), which shows morphological and immunocytochemical characteristics of both squamous and columnar epithelium, is associated with goblet cell metaplasia in adult patients with columnar-lined esophagus. The role of ME in the development of intestinal metaplasia in children is uncertain. Furthermore, detailed mechanisms about how short-segment BE (SSBE) changes to long-segment BE (LSBE) are not yet well understood. Further studies are required to understand the pathological esophagogastric junction (EGJ) and BE in children based on reliable epidemiological data and analysis especially in children who have reflux symptoms. Better understanding of the pediatric EGJ and BE may allow improved diagnosis, monitoring, therapy and, therefore, prognosis of GERD-related disorders in adulthood.

Endoscopic Surveillance After Repair of Oesophageal Atresia: Longitudinal Study in 209 Patients

AIM

After repair of oesophageal atresia (OA), the need for endoscopic follow-up (EFU) remains unclear. To end this, we assessed the trends of oesophageal mucosal changes in successive follow-up biopsies.

METHODS

EFU records of 264 patients including histological grades of oesophagitis (from 0 to III), gastric (GM) or intestinal (IM) metaplasia and dysplasia (mild to severe) at 1, 3, 5 10, 15, and >15 years after repair of OA were reviewed.

RESULTS

Included were 209 patients with 616 biopsies. A total of 60 patients had undergone antireflux surgery and 24 had long-gap OA (LG). Median follow-up was 12 (range 1-17) years with 3 (1-6) endoscopies per patient. Highest grade of oesophagitis was Gr 0 (no oesophagitis) in 47%, Gr I in 37%, and Gr II or III in 16%. Metaplasia, GM (n = 31), IM (n = 4), occurred in 17% of patients and reached 15% prevalence by 15 years. Dysplasia and cancer were not found. From 1 to 15 years after repair grade of histological oesophagitis often fluctuated between Gr 0 and Gr I, but further progression was unlikely, hazard ratio = 0.2-3.4 (95% confidence interval 0.0-29), P = 0.06-0.87. LG and antireflux surgery predicted early detection of metaplasia (P < 0.001). Only 9% of patients with metaplasia and 32% with Gr II oesophagitis were symptomatic. A total of 6 (3%) patients had a symptomatic anastomotic stenosis at 1 year.

CONCLUSIONS

EFU revealed frequent oesophagitis and metaplasia, but no dysplasia or cancer. Routine endoscopic surveillance had limited benefit and seems unnecessary during childhood after repair of OA.

Clinical implications of molecular changes in pediatric Barrett's esophagus

Barrett's esophagus (BE) is a preneoplastic condition that predisposes to esophageal adenocarcinoma. Although data on the occurrence of BE in children are limited, recent studies have suggested an increase in the pediatric population. BE is thought to be a complex disease in which individual genetic predisposition interacts with environmental stimuli. Early premalignant clones produce biological and genetic heterogeneity, resulting in stepwise changes in differentiation, proliferation, and apoptosis, allowing disease progression under selective pressure. The value of endoscopic surveillance biopsy for dysplasia and carcinoma in patients with BE is controversial. Thus, the recognition of early and objective alternative risk markers, less susceptible of sampling error, will be of relevance in the management of BE patients. The possibility of performing molecular genetics on paraffin-embedded biopsies will expand our understanding of the natural history of BE and may lead to the use of biomarkers to inform treatment strategies.

Molecular abnormalities in pediatric barrett esophagus: can we test for potential of neoplastic progression?

Barrett esophagus (BE) is a preneoplastic condition that predisposes to esophageal adenocarcinoma and is a consequence of prolonged gastroesophageal reflux disease. The condition is mainly seen in adults and is thought to be a complex disease in which individual genetic predisposition interacts with environmental stimuli. The aim of our study was to investigate whether genetic biomarkers of potential disease progression are the same in the rare situation of pediatric BE, as described in adults. We performed fluorescence in situ hybridization with probes from Abbott Vysis Corporation on 4-micron sections taken from 48 paraffin-embedded sequential biopsies of 10 cases of BE. The 4 probe sets were specific for HER2 at 17q12/17 centromere/4 centromere, p16 at 9p21/9 centromere, TP53 at 17p13/17 centromere/6 centromere, and CCND1 at 11q13/11 centromere. The probe sets were validated on 10 cases of adult Barrett adenocarcinoma. Of the 10 cases, 6 biopsies in 5 cases were informative. Two had gain of HER2 detected in 1 biopsy each (1 also had gain of chromosome 17) and 4 separate cases showed p16 deletion in 1 biopsy of each (1 also had gain of chromosome 9). The genetic markers informative in 50% of our cases were also identified in adult patients with Barrett adenocarcinoma. The importance of this study is that even at the pediatric level, BE can show genetic changes associated with neoplastic progression.