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Jaspers TJM, Boers TGW, Kusters CHJ, Jong MR, Jukema JB, de Groof AJ, Bergman JJ, de With PHN, van der Sommen F. Robustness evaluation of deep neural networks for endoscopic image analysis: Insights and strategies. Med Image Anal 2024; 94:103157. [PMID: 38574544 DOI: 10.1016/j.media.2024.103157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 03/19/2024] [Accepted: 03/21/2024] [Indexed: 04/06/2024]
Abstract
Computer-aided detection and diagnosis systems (CADe/CADx) in endoscopy are commonly trained using high-quality imagery, which is not representative for the heterogeneous input typically encountered in clinical practice. In endoscopy, the image quality heavily relies on both the skills and experience of the endoscopist and the specifications of the system used for screening. Factors such as poor illumination, motion blur, and specific post-processing settings can significantly alter the quality and general appearance of these images. This so-called domain gap between the data used for developing the system and the data it encounters after deployment, and the impact it has on the performance of deep neural networks (DNNs) supportive endoscopic CAD systems remains largely unexplored. As many of such systems, for e.g. polyp detection, are already being rolled out in clinical practice, this poses severe patient risks in particularly community hospitals, where both the imaging equipment and experience are subject to considerable variation. Therefore, this study aims to evaluate the impact of this domain gap on the clinical performance of CADe/CADx for various endoscopic applications. For this, we leverage two publicly available data sets (KVASIR-SEG and GIANA) and two in-house data sets. We investigate the performance of commonly-used DNN architectures under synthetic, clinically calibrated image degradations and on a prospectively collected dataset including 342 endoscopic images of lower subjective quality. Additionally, we assess the influence of DNN architecture and complexity, data augmentation, and pretraining techniques for improved robustness. The results reveal a considerable decline in performance of 11.6% (±1.5) as compared to the reference, within the clinically calibrated boundaries of image degradations. Nevertheless, employing more advanced DNN architectures and self-supervised in-domain pre-training effectively mitigate this drop to 7.7% (±2.03). Additionally, these enhancements yield the highest performance on the manually collected test set including images with lower subjective quality. By comprehensively assessing the robustness of popular DNN architectures and training strategies across multiple datasets, this study provides valuable insights into their performance and limitations for endoscopic applications. The findings highlight the importance of including robustness evaluation when developing DNNs for endoscopy applications and propose strategies to mitigate performance loss.
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Affiliation(s)
- Tim J M Jaspers
- Department of Electrical Engineering, Video Coding & Architectures, Eindhoven University of Technology, Eindhoven, The Netherlands.
| | - Tim G W Boers
- Department of Electrical Engineering, Video Coding & Architectures, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Carolus H J Kusters
- Department of Electrical Engineering, Video Coding & Architectures, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Martijn R Jong
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jelmer B Jukema
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Albert J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter H N de With
- Department of Electrical Engineering, Video Coding & Architectures, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering, Video Coding & Architectures, Eindhoven University of Technology, Eindhoven, The Netherlands
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Jukema JB, Kusters CHJ, Jong MR, Fockens KN, Boers T, van der Putten JA, Pouw RE, Duits LC, Weusten BAM, Herrero LA, Houben MHMG, Nagengast WB, Westerhof J, Alkhalaf A, Mallant-Hent R, Scholten P, Ragunath K, Seewald S, Elbe P, Silva FB, Barret M, Fernández-Sordo JO, Villarejo GM, Pech O, Beyna T, Montazeri NSM, van der Sommen F, de With PH, de Groof AJ, Bergman JJ. COMPUTER-AIDED DIAGNOSIS IMPROVES CHARACTERIZATION OF BARRETT'S NEOPLASIA BY GENERAL ENDOSCOPISTS. Gastrointest Endosc 2024:S0016-5107(24)00233-5. [PMID: 38636819 DOI: 10.1016/j.gie.2024.04.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/25/2024] [Accepted: 04/08/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND & AIMS Characterization of visible abnormalities in Barrett esophagus (BE) patients can be challenging, especially for unexperienced endoscopists. This results in suboptimal diagnostic accuracy and poor inter-observer agreement. Computer-aided diagnosis (CADx) systems may assist endoscopists. We aimed to develop, validate and benchmark a CADx system for BE neoplasia. METHODS The CADx system received pretraining with ImageNet with consecutive domain-specific pretraining with GastroNet which includes 5 million endoscopic images. It was subsequently trained and internally validated using 1,758 narrow-band imaging (NBI) images of early BE neoplasia (352 patients) and 1,838 NBI images of non-dysplastic BE (173 patients) from 8 international centers. CADx was tested prospectively on corresponding image and video test sets with 30 cases (20 patients) of BE neoplasia and 60 cases (31 patients) of non-dysplastic BE. The test set was benchmarked by 44 general endoscopists in two phases (phase 1: no CADx assistance; phase 2: with CADx assistance). Ten international BE experts provided additional benchmark performance. RESULTS Stand-alone sensitivity and specificity of the CADx system were 100% and 98% for images and 93% and 96% for videos, respectively. CADx outperformed general endoscopists without CADx assistance in terms of sensitivity (p=0.04). Sensitivity and specificity of general endoscopist increased from 84% to 96% and 90 to 98% with CAD assistance (p<0.001), respectively. CADx assistance increased endoscopists' confidence in characterization (p<0.001). CADx performance was similar to Barrett experts. CONCLUSION CADx assistance significantly increased characterization performance of BE neoplasia by general endoscopists to the level of expert endoscopists. The use of this CADx system may thereby improve daily Barrett surveillance.
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Affiliation(s)
- Jelmer B Jukema
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Carolus H J Kusters
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Martijn R Jong
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kiki N Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Tim Boers
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Joost A van der Putten
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lucas C Duits
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - BasL A M Weusten
- Department of Gastroenterology and Hepatology, UMC Utrecht, University of Utrecht, Utrecht, the Netherlands; Department of Gastroenterology and Hepatology, Sint Antonius hospital, Nieuwegein, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius hospital, Nieuwegein, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, HagaZiekenhuis Den Haag, Den Haag, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, UMC Groningen, University of Groningen, Groningen, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, UMC Groningen, University of Groningen, Groningen, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Hospital Zwolle, Zwolle, the Netherlands
| | - Rosalie Mallant-Hent
- Department of Gastroenterology and Hepatology, Flevoziekenhuis Almere, Almere, the Netherlands
| | - Pieter Scholten
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, the Netherlands
| | - Krish Ragunath
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Curtin University, Perth, Australia
| | - Stefan Seewald
- Department of Gastroenterology and Hepatology, Hirslanden Klinik, Zurich, Switzerland
| | - Peter Elbe
- Department of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Francisco Baldaque Silva
- Department of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Center for Advanced Endoscopy Carlos Moreira da Silva, Gastroenterology Department, Pedro Hispano Hospital, ULSM Matosinhos, Portugal
| | - Maximilien Barret
- Department of Gastroenterology and Hepatology, Cochin hospital Paris, Paris, France
| | - Jacobo Ortiz Fernández-Sordo
- Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Guiomar Moral Villarejo
- Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Oliver Pech
- Department of Gastroenterology and Hepatology, St. John of God Hospital, Regensburg, Germany
| | - Torsten Beyna
- Department of Gastroenterology and Hepatology, Evangalisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Nahid S M Montazeri
- Biostatistics Unit, Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, location Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Peter H de With
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - A Jeroen de Groof
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands.
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Fockens KN, Jukema JB, Jong MR, Boers T, van der Putten JA, Kusters CHJ, Pouw RE, Duits LC, Sommen FVD, de With PH, de Groof AJ, Bergman JJ. The use of a real-time computer-aided detection system for visible lesions in the Barrett's esophagus during live endoscopic procedures, a pilot study. Gastrointest Endosc 2024:S0016-5107(24)00228-1. [PMID: 38604297 DOI: 10.1016/j.gie.2024.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 03/07/2024] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND AND AIMS In this pilot study we evaluated performance of a recently developed computer-aided detection (CADe) system for Barrett's neoplasia during live endoscopic procedures. METHODS 15 patients with and 15 without a visible lesion were included in this study. A CAD assisted workflow was employed that included: a slow pullback video recording of the entire Barrett's segment with live CADe assistance, followed by CADe assisted level-based video recordings every 2cm of the Barrett's segment. Outcomes were per patient and per level diagnostic accuracy of the CAD assisted workflow, where the primary outcome was per patient in-vivo CADe sensitivity. RESULTS In the per patient analyses, the CADe system detected all visible lesions (sensitivity 100%). Per patient CADe specificity was 53%. Per-level sensitivity and specificity of the CADe assisted workflow were 100% and 73%, respectively. CONCLUSION In this pilot study, the CADe system detected all potentially neoplastic lesions in Barrett's esophagus comparable to an expert endoscopist. Continued refinement of the system may improve specificity. External validation in larger multicenter studies is planned.
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Affiliation(s)
- Kiki N Fockens
- Department of gastroenterology and hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jelmer B Jukema
- Department of gastroenterology and hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Martijn R Jong
- Department of gastroenterology and hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Tim Boers
- Department of electrical engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Joost A van der Putten
- Department of electrical engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Carolus H J Kusters
- Department of electrical engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Roos E Pouw
- Department of gastroenterology and hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Lucas C Duits
- Department of gastroenterology and hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Fons van der Sommen
- Department of electrical engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Peter H de With
- Department of electrical engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - A Jeroen de Groof
- Department of gastroenterology and hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of gastroenterology and hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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Fockens KN, Jong MR, Jukema JB, Boers TGW, Kusters CHJ, van der Putten JA, Pouw RE, Duits LC, Montazeri NSM, van Munster SN, Weusten BLAM, Alvarez Herrero L, Houben MHMG, Nagengast WB, Westerhof J, Alkhalaf A, Mallant-Hent RC, Scholten P, Ragunath K, Seewald S, Elbe P, Baldaque-Silva F, Barret M, Ortiz Fernández-Sordo J, Villarejo GM, Pech O, Beyna T, van der Sommen F, de With PH, de Groof AJ, Bergman JJ. A deep learning system for detection of early Barrett's neoplasia: a model development and validation study. Lancet Digit Health 2023; 5:e905-e916. [PMID: 38000874 DOI: 10.1016/s2589-7500(23)00199-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Computer-aided detection (CADe) systems could assist endoscopists in detecting early neoplasia in Barrett's oesophagus, which could be difficult to detect in endoscopic images. The aim of this study was to develop, test, and benchmark a CADe system for early neoplasia in Barrett's oesophagus. METHODS The CADe system was first pretrained with ImageNet followed by domain-specific pretraining with GastroNet. We trained the CADe system on a dataset of 14 046 images (2506 patients) of confirmed Barrett's oesophagus neoplasia and non-dysplastic Barrett's oesophagus from 15 centres. Neoplasia was delineated by 14 Barrett's oesophagus experts for all datasets. We tested the performance of the CADe system on two independent test sets. The all-comers test set comprised 327 (73 patients) non-dysplastic Barrett's oesophagus images, 82 (46 patients) neoplastic images, 180 (66 of the same patients) non-dysplastic Barrett's oesophagus videos, and 71 (45 of the same patients) neoplastic videos. The benchmarking test set comprised 100 (50 patients) neoplastic images, 300 (125 patients) non-dysplastic images, 47 (47 of the same patients) neoplastic videos, and 141 (82 of the same patients) non-dysplastic videos, and was enriched with subtle neoplasia cases. The benchmarking test set was evaluated by 112 endoscopists from six countries (first without CADe and, after 6 weeks, with CADe) and by 28 external international Barrett's oesophagus experts. The primary outcome was the sensitivity of Barrett's neoplasia detection by general endoscopists without CADe assistance versus with CADe assistance on the benchmarking test set. We compared sensitivity using a mixed-effects logistic regression model with conditional odds ratios (ORs; likelihood profile 95% CIs). FINDINGS Sensitivity for neoplasia detection among endoscopists increased from 74% to 88% with CADe assistance (OR 2·04; 95% CI 1·73-2·42; p<0·0001 for images and from 67% to 79% [2·35; 1·90-2·94; p<0·0001] for video) without compromising specificity (from 89% to 90% [1·07; 0·96-1·19; p=0·20] for images and from 96% to 94% [0·94; 0·79-1·11; ] for video; p=0·46). In the all-comers test set, CADe detected neoplastic lesions in 95% (88-98) of images and 97% (90-99) of videos. In the benchmarking test set, the CADe system was superior to endoscopists in detecting neoplasia (90% vs 74% [OR 3·75; 95% CI 1·93-8·05; p=0·0002] for images and 91% vs 67% [11·68; 3·85-47·53; p<0·0001] for video) and non-inferior to Barrett's oesophagus experts (90% vs 87% [OR 1·74; 95% CI 0·83-3·65] for images and 91% vs 86% [2·94; 0·99-11·40] for video). INTERPRETATION CADe outperformed endoscopists in detecting Barrett's oesophagus neoplasia and, when used as an assistive tool, it improved their detection rate. CADe detected virtually all neoplasia in a test set of consecutive cases. FUNDING Olympus.
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Affiliation(s)
- K N Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - M R Jong
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - J B Jukema
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - T G W Boers
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - C H J Kusters
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - J A van der Putten
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - N S M Montazeri
- Biostatistics Unit, Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - S N van Munster
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, UMC Utrecht, University of Utrecht, Utrecht, Netherlands; Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - L Alvarez Herrero
- Department of Gastroenterology and Hepatology, St Antonius Hospital, Nieuwegein, Netherlands
| | - M H M G Houben
- Department of Gastroenterology and Hepatology, HagaZiekenhuis Den Haag, Den Haag, Netherlands
| | - W B Nagengast
- Department of Gastroenterology and Hepatology, UMC Groningen, University of Groningen, Groningen, Netherlands
| | - J Westerhof
- Department of Gastroenterology and Hepatology, UMC Groningen, University of Groningen, Groningen, Netherlands
| | - A Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Hospital Zwolle, Zwolle, Netherlands
| | - R C Mallant-Hent
- Department of Gastroenterology and Hepatology, Flevoziekenhuis Almere, Almere, Netherlands
| | - P Scholten
- Department of Gastroenterology and Hepatology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - K Ragunath
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Curtin University, Perth, WA, Australia
| | - S Seewald
- Department of Gastroenterology and Hepatology, Hirslanden Klinik, Zurich, Switzerland
| | - P Elbe
- Department of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Division of Surgery, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - F Baldaque-Silva
- Department of Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden; Center for Advanced Endoscopy Carlos Moreira da Silva, Gastroenterology Department, Pedro Hispano Hospital, Matosinhos, Portugal
| | - M Barret
- Department of Gastroenterology and Hepatology, Cochin Hospital Paris, Paris, France
| | - J Ortiz Fernández-Sordo
- Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - G Moral Villarejo
- Department of Gastroenterology and Hepatology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - O Pech
- Department of Gastroenterology and Hepatology, St John of God Hospital, Regensburg, Germany
| | - T Beyna
- Department of Gastroenterology and Hepatology, Evangalisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - F van der Sommen
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - P H de With
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands
| | - A J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands.
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Davison JM, Goldblum JR, Duits LC, Khoshiwal AM, Bergman JJ, Falk GW, Diehl DL, Khara HS, Smolko C, Arora M, Siegel JJ, Critchley-Thorne RJ, Thota PN. A Tissue Systems Pathology Test Outperforms the Standard-of-Care Variables in Predicting Progression in Patients With Barrett's Esophagus. Clin Transl Gastroenterol 2023; 14:e00631. [PMID: 37622544 PMCID: PMC10684217 DOI: 10.14309/ctg.0000000000000631] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023] Open
Abstract
INTRODUCTION Objective risk stratification is needed for patients with Barrett's esophagus (BE) to enable risk-aligned management to improve health outcomes. This study evaluated the predictive performance of a tissue systems pathology [TSP-9] test (TissueCypher) vs current clinicopathologic variables in a multicenter cohort of patients with BE. METHODS Data from 699 patients with BE from 5 published studies on the TSP-9 test were evaluated. Five hundred nine patients did not progress during surveillance, 40 were diagnosed with high-grade dysplasia/esophageal adenocarcinoma (HGD/EAC) within 12 months, and 150 progressed to HGD/EAC after 12 months. Age, sex, segment length, hiatal hernia, original and expert pathology review diagnoses, and TSP-9 risk classes were collected. The predictive performance of clinicopathologic variables and the TSP-9 test was compared, and the TSP-9 test was evaluated in clinically relevant patient subsets. RESULTS The sensitivity of the TSP-9 test in detecting progressors was 62.3% compared with 28.3% for expert-confirmed low-grade dysplasia (LGD), while the original diagnosis abstracted from medical records did not provide any significant risk stratification. The TSP-9 test identified 57% of progressors with nondysplastic Barrett's esophagus (NDBE) ( P < 0.0001). Patients with NDBE who scored TSP-9 high risk progressed at a similar rate (3.2%/yr) to patients with expert-confirmed LGD (3.7%/yr). The TSP-9 test provided significant risk stratification in clinically low-risk patients (NDBE, female, short-segment BE) and clinically high-risk patients (IND/LGD, male, long-segment BE) ( P < 0.0001 for comparison of high-risk classes vs low-risk classes). DISCUSSION The TSP-9 test predicts risk of progression to HGD/EAC independently of current clinicopathologic variables in patients with BE. The test provides objective risk stratification results that may guide management decisions to improve health outcomes for patients with BE.
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Affiliation(s)
- Jon M. Davison
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Lucas C. Duits
- Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | | | | | - Gary W. Falk
- Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Fockens KN, Jukema JB, Boers T, Jong MR, van der Putten JA, Pouw RE, Weusten BLAM, Alvarez Herrero L, Houben MHMG, Nagengast WB, Westerhof J, Alkhalaf A, Mallant R, Ragunath K, Seewald S, Elbe P, Barret M, Ortiz Fernández-Sordo J, Pech O, Beyna T, van der Sommen F, de With PH, de Groof AJ, Bergman JJ. Towards a robust and compact deep learning system for primary detection of early Barrett's neoplasia: Initial image-based results of training on a multi-center retrospectively collected data set. United European Gastroenterol J 2023; 11:324-336. [PMID: 37095718 PMCID: PMC10165317 DOI: 10.1002/ueg2.12363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 01/09/2023] [Indexed: 04/26/2023] Open
Abstract
INTRODUCTION Endoscopic detection of early neoplasia in Barrett's esophagus is difficult. Computer Aided Detection (CADe) systems may assist in neoplasia detection. The aim of this study was to report the first steps in the development of a CADe system for Barrett's neoplasia and to evaluate its performance when compared with endoscopists. METHODS This CADe system was developed by a consortium, consisting of the Amsterdam University Medical Center, Eindhoven University of Technology, and 15 international hospitals. After pretraining, the system was trained and validated using 1.713 neoplastic (564 patients) and 2.707 non-dysplastic Barrett's esophagus (NDBE; 665 patients) images. Neoplastic lesions were delineated by 14 experts. The performance of the CADe system was tested on three independent test sets. Test set 1 (50 neoplastic and 150 NDBE images) contained subtle neoplastic lesions representing challenging cases and was benchmarked by 52 general endoscopists. Test set 2 (50 neoplastic and 50 NDBE images) contained a heterogeneous case-mix of neoplastic lesions, representing distribution in clinical practice. Test set 3 (50 neoplastic and 150 NDBE images) contained prospectively collected imagery. The main outcome was correct classification of the images in terms of sensitivity. RESULTS The sensitivity of the CADe system on test set 1 was 84%. For general endoscopists, sensitivity was 63%, corresponding to a neoplasia miss-rate of one-third of neoplastic lesions and a potential relative increase in neoplasia detection of 33% for CADe-assisted detection. The sensitivity of the CADe system on test sets 2 and 3 was 100% and 88%, respectively. The specificity of the CADe system varied for the three test sets between 64% and 66%. CONCLUSION This study describes the first steps towards the establishment of an unprecedented data infrastructure for using machine learning to improve the endoscopic detection of Barrett's neoplasia. The CADe system detected neoplasia reliably and outperformed a large group of endoscopists in terms of sensitivity.
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Affiliation(s)
- Kiki N Fockens
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Jelmer B Jukema
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Tim Boers
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Martijn R Jong
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Joost A van der Putten
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, UMC Utrecht, University of Utrecht, Utrecht, the Netherlands
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Lorenza Alvarez Herrero
- Department of Gastroenterology and Hepatology, Sint Antonius Hospital, Nieuwegein, the Netherlands
| | - Martin H M G Houben
- Department of Gastroenterology and Hepatology, Haga Teaching Hospital, Den Haag, the Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University of Groningen, Groningen, the Netherlands
| | - Jessie Westerhof
- Department of Gastroenterology and Hepatology, University of Groningen, Groningen, the Netherlands
| | - Alaa Alkhalaf
- Department of Gastroenterology and Hepatology, Isala Hospital Zwolle, Zwolle, the Netherlands
| | - Rosalie Mallant
- Department of Gastroenterology and Hepatology, Flevoziekenhuis Almere, Almere, the Netherlands
| | - Krish Ragunath
- Department of Gastroenterology and Hepatology, Royal Perth Hospital, Perth, Australia
| | - Stefan Seewald
- Department of Gastroenterology and Hepatology, Hirslanden Klinik, Zurich, Switzerland
| | - Peter Elbe
- Department of Digestive Diseasess, Karolinska University Hospital, Stockholm, Sweden
- Division of Surgery, Department of Clinical Science, Intervention and Technology, CLINTEC, Karolinska Institutet, Stockholm, Sweden
| | - Maximilien Barret
- Department of Gastroenterology and Hepatology, Cochin Hospital Paris, Paris, France
| | | | - Oliver Pech
- Department of Gastroenterology and Hepatology, Krankenhaus Barmherzige Brüder Regensburg, Regensburg, Germany
| | - Torsten Beyna
- Department of Gastroenterology and Hepatology, Evangalische Klinik Düsseldorf, Düsseldorf, Germany
| | - Fons van der Sommen
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Peter H de With
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - A Jeroen de Groof
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam Gastroenterology, Endocrinology and Metabolism, University of Amsterdam, Amsterdam, the Netherlands
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7
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Rosmolen WD, Pouw RE, van Berge Henegouwen MI, Bergman JJ, Sprangers MA, Nieuwkerk PT. Long-term fear of cancer recurrence in patients treated endoscopically for early Barrett's neoplasia. Dis Esophagus 2022; 36:6862939. [PMID: 36461786 PMCID: PMC10150170 DOI: 10.1093/dote/doac083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/16/2022] [Indexed: 12/11/2022]
Abstract
Previous studies on fear of cancer recurrence after endoscopic treatment for early Barrett's neoplasia focused on fear during a relatively short period after the intervention. The aim of this study was to explore whether fear of cancer (recurrence) persists during long-term follow-up in patients treated endoscopically for Barrett's neoplasia compared to patients treated surgically for a more advanced stage of esophageal adenocarcinoma. Participants previously participated in a prospective longitudinal study investigating quality of life and fear of cancer recurrence and were treated endoscopically for early Barrett's neoplasia (high-grade dysplasia-T1sm1N0M0) or surgically for a more advanced esophageal adenocarcinoma (T1N0M0-T3N1M0). For the present study, participants were again invited to complete a set of questionnaires including the fear of cancer recurrence scale (FORS), worry for cancer scale (WOCS), and the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS Anxiety). Thirty-nine patients were eligible in the endoscopy group and 28 in the surgical group. The median time between the baseline measurement (original study) and the long-term follow-up assessment was 4 years (interquartile range 3-5 years). Fear and worry for cancer recurrence and general anxiety diminished over time in both treatment groups. However, at long-term follow-up, endoscopically treated patients had significantly higher levels of worry for cancer and general anxiety than surgically treated patients. Fear of cancer recurrence did not significantly differ between endoscopically and surgically treated patients. We found that worry and fear of cancer recurrence and general anxiety in endoscopically treated patients declined over time, but not as much as in surgically treated patients.
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Affiliation(s)
- Wilda D Rosmolen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark I van Berge Henegouwen
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Mirjam A Sprangers
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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8
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Struyvenberg MR, de Groof AJ, Fonollà R, van der Sommen F, de With PHN, Schoon EJ, Weusten BLAM, Leggett CL, Kahn A, Trindade AJ, Ganguly EK, Konda VJA, Lightdale CJ, Pleskow DK, Sethi A, Smith MS, Wallace MB, Wolfsen HC, Tearney GJ, Meijer SL, Vieth M, Pouw RE, Curvers WL, Bergman JJ. Prospective development and validation of a volumetric laser endomicroscopy computer algorithm for detection of Barrett's neoplasia. Gastrointest Endosc 2021; 93:871-879. [PMID: 32735947 DOI: 10.1016/j.gie.2020.07.052] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 07/21/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Volumetric laser endomicroscopy (VLE) is an advanced imaging modality used to detect Barrett's esophagus (BE) dysplasia. However, real-time interpretation of VLE scans is complex and time-consuming. Computer-aided detection (CAD) may help in the process of VLE image interpretation. Our aim was to train and validate a CAD algorithm for VLE-based detection of BE neoplasia. METHODS The multicenter, VLE PREDICT study, prospectively enrolled 47 patients with BE. In total, 229 nondysplastic BE and 89 neoplastic (high-grade dysplasia/esophageal adenocarcinoma) targets were laser marked under VLE guidance and subsequently underwent a biopsy for histologic diagnosis. Deep convolutional neural networks were used to construct a CAD algorithm for differentiation between nondysplastic and neoplastic BE tissue. The CAD algorithm was trained on a set consisting of the first 22 patients (134 nondysplastic BE and 38 neoplastic targets) and validated on a separate test set from patients 23 to 47 (95 nondysplastic BE and 51 neoplastic targets). The performance of the algorithm was benchmarked against the performance of 10 VLE experts. RESULTS Using the training set to construct the algorithm resulted in an accuracy of 92%, sensitivity of 95%, and specificity of 92%. When performance was assessed on the test set, accuracy, sensitivity, and specificity were 85%, 91%, and 82%, respectively. The algorithm outperformed all 10 VLE experts, who demonstrated an overall accuracy of 77%, sensitivity of 70%, and specificity of 81%. CONCLUSIONS We developed, validated, and benchmarked a VLE CAD algorithm for detection of BE neoplasia using prospectively collected and biopsy-correlated VLE targets. The algorithm detected neoplasia with high accuracy and outperformed 10 VLE experts. (The Netherlands National Trials Registry (NTR) number: NTR 6728.).
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Affiliation(s)
- Maarten R Struyvenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Albert J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Roger Fonollà
- Department of Electrical Engineering, VCA group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering, VCA group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Peter H N de With
- Department of Electrical Engineering, VCA group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Arvind J Trindade
- Division of Gastroenterology and Hepatology, Zucker School of Medicine at Hofstra/Northwell. Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Eric K Ganguly
- Department of Gastroenterology and Hepatology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Vani J A Konda
- Department of Gastroenterology and Hepatology, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Charles J Lightdale
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital, New York, New York, USA
| | - Douglas K Pleskow
- Department of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Amrita Sethi
- Department of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York, USA
| | - Michael S Smith
- Division of Gastroenterology and Hepatology, Mount Sinai West & Mount Sinai St. Luke's Hospitals, New York, New York, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Gary J Tearney
- Department of Pathology, Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sybren L Meijer
- Department of Pathology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Michael Vieth
- Institute of Pathology, Bayreuth Clinic, Bayreuth, Germany
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
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9
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Struyvenberg M, Kahn A, Fleischer D, Swager AF, Bouma B, Ganguly EK, Konda V, Lightdale CJ, Pleskow D, Sethi A, Smith M, Trindade AJ, Wallace MB, Wang K, Wolfsen HC, Tearney GJ, Curvers WL, Leggett CL, Bergman JJ. Expert assessment on volumetric laser endomicroscopy full scans in Barrett's esophagus patients with or without high grade dysplasia or early cancer. Endoscopy 2021; 53:218-225. [PMID: 32515006 DOI: 10.1055/a-1194-0397] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Volumetric laser endomicroscopy (VLE) allows for near-microscopic imaging of the superficial esophageal wall and may improve detection of early neoplasia in Barrett's esophagus (BE). Interpretation of a 6-cm long, circumferential VLE "full scan" may however be challenging for endoscopists. We aimed to evaluate the accuracy of VLE experts in correctly diagnosing VLE full scans of early neoplasia and non-dysplastic BE (NDBE). METHODS 29 VLE full scan videos (15 neoplastic and 14 NDBE) were randomly evaluated by 12 VLE experts using a web-based module. Experts were blinded to the endoscopic BE images and histology. The 15 neoplastic cases contained a subtle endoscopically visible lesion, which on endoscopic resection showed high grade dysplasia or cancer. NDBE cases had no visible lesions and an absence of dysplasia in all biopsies. VLE videos were first scored as "neoplastic" or "NDBE." If neoplastic, assessors located the area most suspicious for neoplasia. Primary outcome was the performance of VLE experts in differentiating between non-dysplastic and neoplastic full scan videos, calculated by accuracy, sensitivity, and specificity. Secondary outcomes included correct location of neoplasia, interobserver agreement, and level of confidence. RESULTS VLE experts correctly labelled 73 % (95 % confidence interval [CI] 67 % - 79 %) of neoplastic VLE videos. In 54 % (range 27 % - 66 %) both neoplastic diagnosis and lesion location were correct. NDBE videos were consistent with endoscopic biopsies in 52 % (95 %CI 46 % - 57 %). Interobserver agreement was fair (kappa 0.28). High level of confidence was associated with a higher rate of correct neoplastic diagnosis (81 %) and lesion location (73 %). CONCLUSIONS Identification of subtle neoplastic lesions in VLE full scans by experts was disappointing. Future studies should focus on improving methodologies for reviewing full scans, development of refined VLE criteria for neoplasia, and computer-aided diagnosis of VLE scans.
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Affiliation(s)
- Maarten Struyvenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Allon Kahn
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - David Fleischer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Anne-Fre Swager
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Brett Bouma
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eric K Ganguly
- Department of Gastroenterology and Hepatology, University of Vermont Medical Center, Burlington, Vermont, USA
| | - Vani Konda
- Department of Gastroenterology and Hepatology, Baylor Scott & White Quality Alliance in Dallas, Texas, USA
| | - Charles J Lightdale
- Division of Gastroenterology and Hepatology, New York-Presbyterian Hospital, New York, New York, USA
| | - Douglas Pleskow
- Department of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Amrita Sethi
- Department of Gastroenterology and Hepatology, Columbia University Medical Center, New York, New York, USA
| | - Michael Smith
- Division of Gastroenterology and Hepatology, The Mount Sinai Hospital, New York, New York, USA
| | - Arvind J Trindade
- Division of Gastroenterology and Hepatology, Long Island Jewish Medical Center, New Hyde Park, New York, USA
| | - Michael B Wallace
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Kenneth Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Herbert C Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - G J Tearney
- Department of Pathology, Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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10
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Struyvenberg MR, de Groof AJ, van der Putten J, van der Sommen F, Baldaque-Silva F, Omae M, Pouw R, Bisschops R, Vieth M, Schoon EJ, Curvers WL, de With PH, Bergman JJ. A computer-assisted algorithm for narrow-band imaging-based tissue characterization in Barrett's esophagus. Gastrointest Endosc 2021; 93:89-98. [PMID: 32504696 DOI: 10.1016/j.gie.2020.05.050] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 05/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The endoscopic evaluation of narrow-band imaging (NBI) zoom imagery in Barrett's esophagus (BE) is associated with suboptimal diagnostic accuracy and poor interobserver agreement. Computer-aided diagnosis (CAD) systems may assist endoscopists in the characterization of Barrett's mucosa. Our aim was to demonstrate the feasibility of a deep-learning CAD system for tissue characterization of NBI zoom imagery in BE. METHODS The CAD system was first trained using 494,364 endoscopic images of general endoscopic imagery. Next, 690 neoplastic BE and 557 nondysplastic BE (NDBE) white-light endoscopy overview images were used for refinement training. Subsequently, a third dataset of 112 neoplastic and 71 NDBE NBI zoom images with histologic correlation was used for training and internal validation. Finally, the CAD system was further trained and validated with a fourth, histologically confirmed dataset of 59 neoplastic and 98 NDBE NBI zoom videos. Performance was evaluated using fourfold cross-validation. The primary outcome was the diagnostic performance of the CAD system for classification of neoplasia in NBI zoom videos. RESULTS The CAD system demonstrated accuracy, sensitivity, and specificity for detection of BE neoplasia using NBI zoom images of 84%, 88%, and 78%, respectively. In total, 30,021 individual video frames were analyzed by the CAD system. Accuracy, sensitivity, and specificity of the video-based CAD system were 83% (95% confidence interval [CI], 78%-89%), 85% (95% CI, 76%-94%), and 83% (95% CI, 76%-90%), respectively. The mean assessment speed was 38 frames per second. CONCLUSION We have demonstrated promising diagnostic accuracy of predicting the presence/absence of Barrett's neoplasia on histologically confirmed unaltered NBI zoom videos with fast corresponding assessment time.
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Affiliation(s)
- Maarten R Struyvenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Albert J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Joost van der Putten
- Department of Electrical Engineering, VCA Group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering, VCA Group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Francisco Baldaque-Silva
- Department of Gastroenterology and Hepatology, Karolinska University Hospital, Stockholm, Sweden
| | - Masami Omae
- Department of Gastroenterology and Hepatology, Karolinska University Hospital, Stockholm, Sweden
| | - Roos Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Michael Vieth
- Institute of Pathology, Bayreuth Clinic, Bayreuth, Germany
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - Peter H de With
- Department of Electrical Engineering, VCA Group, Eindhoven University of Technology, Eindhoven, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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11
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Struyvenberg MR, de Groof AJ, Bergman JJ, van der Sommen F, de With PHN, Konda VJA, Curvers WL. Advanced Imaging and Sampling in Barrett's Esophagus: Artificial Intelligence to the Rescue? Gastrointest Endosc Clin N Am 2021; 31:91-103. [PMID: 33213802 DOI: 10.1016/j.giec.2020.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Maarten R Struyvenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Albert J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering, VCA group, Eindhoven University of Technology, Groene Loper 19, 5612 AP Eindhoven, the Netherlands
| | - Peter H N de With
- Department of Electrical Engineering, VCA group, Eindhoven University of Technology, Groene Loper 19, 5612 AP Eindhoven, the Netherlands
| | - Vani J A Konda
- Department of Gastroenterology and Hepatology, Baylor University Medical Center, 3500 Gaston Ave, Dallas, TX 75246, USA
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, the Netherlands.
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12
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Hartstra AV, Schüppel V, Imangaliyev S, Schrantee A, Prodan A, Collard D, Levin E, Dallinga-Thie G, Ackermans MT, Winkelmeijer M, Havik SR, Metwaly A, Lagkouvardos I, Nier A, Bergheim I, Heikenwalder M, Dunkel A, Nederveen AJ, Liebisch G, Mancano G, Claus SP, Benítez-Páez A, la Fleur SE, Bergman JJ, Gerdes V, Sanz Y, Booij J, Kemper E, Groen AK, Serlie MJ, Haller D, Nieuwdorp M. Infusion of donor feces affects the gut-brain axis in humans with metabolic syndrome. Mol Metab 2020; 42:101076. [PMID: 32916306 PMCID: PMC7536740 DOI: 10.1016/j.molmet.2020.101076] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 08/31/2020] [Accepted: 09/04/2020] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVE Increasing evidence indicates that intestinal microbiota play a role in diverse metabolic processes via intestinal butyrate production. Human bariatric surgery data suggest that the gut-brain axis is also involved in this process, but the underlying mechanisms remain unknown. METHODS We compared the effect of fecal microbiota transfer (FMT) from post-Roux-en-Y gastric bypass (RYGB) donors vs oral butyrate supplementation on (123I-FP-CIT-determined) brain dopamine transporter (DAT) and serotonin transporter (SERT) binding as well as stable isotope-determined insulin sensitivity at baseline and after 4 weeks in 24 male and female treatment-naïve metabolic syndrome subjects. Plasma metabolites and fecal microbiota were also determined at these time points. RESULTS We observed an increase in brain DAT after donor FMT compared to oral butyrate that reduced this binding. However, no effect on body weight and insulin sensitivity was demonstrated after post-RYGB donor feces transfer in humans with metabolic syndrome. Increases in fecal levels of Bacteroides uniformis were significantly associated with an increase in DAT, whereas increases in Prevotella spp. showed an inverse association. Changes in the plasma metabolites glycine, betaine, methionine, and lysine (associated with the S-adenosylmethionine cycle) were also associated with altered striatal DAT expression. CONCLUSIONS Although more and larger studies are needed, our data suggest a potential gut microbiota-driven modulation of brain dopamine and serotonin transporters in human subjects with obese metabolic syndrome. These data also suggest the presence of a gut-brain axis in humans that can be modulated. NTR REGISTRATION 4488.
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Affiliation(s)
- Annick V Hartstra
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Valentina Schüppel
- Chair of Nutrition and Immunology, Technical University of Munich, Freising, Germany
| | - Sultan Imangaliyev
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Anouk Schrantee
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Andrei Prodan
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Didier Collard
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Evgeni Levin
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Geesje Dallinga-Thie
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Mariette T Ackermans
- Laboratory of Endocrinology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Maaike Winkelmeijer
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Stefan R Havik
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Amira Metwaly
- Chair of Nutrition and Immunology, Technical University of Munich, Freising, Germany
| | - Ilias Lagkouvardos
- ZIEL-Institute for Food and Health, Technical University of Munich, Freising, Germany
| | - Anika Nier
- Department of Nutritional Sciences, Molecular Nutritional Science, University of Vienna, Austria
| | - Ina Bergheim
- Department of Nutritional Sciences, Molecular Nutritional Science, University of Vienna, Austria
| | - Mathias Heikenwalder
- German Cancer Research Center (DKFZ), Division of Chronic Inflammation and Cancer, Heidelberg, Germany
| | - Andreas Dunkel
- Leibniz-Institute for Food Systems Biology, Technical University of Munich, Freising, Germany
| | - Aart J Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Gerhard Liebisch
- Department of Laboratory Medicine, University of Regensburg, Regensburg, Germany
| | - Giulia Mancano
- Department of Food and Nutritional Sciences, University of Reading, Reading, United Kingdom
| | - Sandrine P Claus
- Department of Food and Nutritional Sciences, University of Reading, Reading, United Kingdom
| | - Alfonso Benítez-Páez
- Institute of Agrochemistry and Food Technology, Spanish National Research Council (IATA-CSIC), Valencia, Spain
| | - Susanne E la Fleur
- Laboratory of Endocrinology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Victor Gerdes
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Yolanda Sanz
- Institute of Agrochemistry and Food Technology, Spanish National Research Council (IATA-CSIC), Valencia, Spain
| | - Jan Booij
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Elles Kemper
- Department of Clinical Pharmacy, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Albert K Groen
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Mireille J Serlie
- Department of Endocrinology and Metabolism, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - Dirk Haller
- Chair of Nutrition and Immunology, Technical University of Munich, Freising, Germany; ZIEL-Institute for Food and Health, Technical University of Munich, Freising, Germany
| | - Max Nieuwdorp
- Department of Internal and Vascular Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands.
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13
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Witjes JJ, Smits LP, Pekmez CT, Prodan A, Meijnikman AS, Troelstra MA, Bouter KEC, Herrema H, Levin E, Holleboom AG, Winkelmeijer M, Beuers UH, van Lienden K, Aron-Wisnewky J, Mannisto V, Bergman JJ, Runge JH, Nederveen AJ, Dragsted LO, Konstanti P, Zoetendal EG, de Vos W, Verheij J, Groen AK, Nieuwdorp M. Donor Fecal Microbiota Transplantation Alters Gut Microbiota and Metabolites in Obese Individuals With Steatohepatitis. Hepatol Commun 2020; 4:1578-1590. [PMID: 33163830 PMCID: PMC7603524 DOI: 10.1002/hep4.1601] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/27/2020] [Accepted: 07/31/2020] [Indexed: 12/11/2022] Open
Abstract
The intestinal microbiota has been linked to the development and prevalence of steatohepatitis in humans. Interestingly, steatohepatitis is significantly lower in individuals taking a plant-based, low-animal-protein diet, which is thought to be mediated by gut microbiota. However, data on causality between these observations in humans is scarce. In this regard, fecal microbiota transplantation (FMT) using healthy donors is safe and is capable of changing microbial composition in human disease. We therefore performed a double-blind randomized controlled proof-of-principle study in which individuals with hepatic steatosis on ultrasound were randomized to two study arms: lean vegan donor (allogenic n = 10) or own (autologous n = 11) FMT. Both were performed three times at 8-week intervals. A liver biopsy was performed at baseline and after 24 weeks in every subject to determine histopathology (Nonalcoholic Steatohepatitis Clinical Research Network) classification and changes in hepatic gene expression based on RNA sequencing. Secondary outcome parameters were changes in intestinal microbiota composition and fasting plasma metabolomics. We observed a trend toward improved necro-inflammatory histology, and found significant changes in expression of hepatic genes involved in inflammation and lipid metabolism following allogenic FMT. Intestinal microbial community structure changed following allogenic FMT, which was associated with changes in plasma metabolites as well as markers of . Conclusion: Allogenic FMT using lean vegan donors in individuals with hepatic steatosis shows an effect on intestinal microbiota composition, which is associated with beneficial changes in plasma metabolites and markers of steatohepatitis.
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Affiliation(s)
- Julia J Witjes
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Loek P Smits
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Ceyda T Pekmez
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Andrei Prodan
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Abraham S Meijnikman
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Marian A Troelstra
- Department of Radiology & Nuclear Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Kristien E C Bouter
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Hilde Herrema
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Evgeni Levin
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Adriaan G Holleboom
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Maaike Winkelmeijer
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Ulrich H Beuers
- Department of Gastroenterology and Hepatology Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Krijn van Lienden
- Department of Radiology & Nuclear Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Judith Aron-Wisnewky
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Ville Mannisto
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Jurgen H Runge
- Department of Radiology & Nuclear Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Aart J Nederveen
- Department of Radiology & Nuclear Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Lars O Dragsted
- Department of Nutrition, Exercise and Sports University of Copenhagen Copenhagen Denmark
| | - Prokopis Konstanti
- Laboratory of Microbiology Wageningen University Wageningen the Netherlands
| | - Erwin G Zoetendal
- Laboratory of Microbiology Wageningen University Wageningen the Netherlands
| | - Willem de Vos
- Laboratory of Microbiology Wageningen University Wageningen the Netherlands.,Faculty of Medicine Human Microbiome Research Program University of Helsinki Finland
| | - Joanne Verheij
- Department of Pathology Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
| | - Albert K Groen
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands.,Department of Laboratory Medicine University of Groningen University Medical Center Groningen the Netherlands
| | - Max Nieuwdorp
- Department of Internal and Vascular Medicine Amsterdam University Medical Centers Location AMC Amsterdam the Netherlands
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14
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Frei NF, Konté K, Duits LC, Klaver E, Ten Kate FJ, Offerhaus GJ, Meijer SL, Visser M, Seldenrijk CA, Schoon EJ, Weusten BLAM, Schenk BE, Mallant-Hent RC, Bergman JJ, Pouw RE. The SpaTemp cohort: 168 nondysplastic Barrett's esophagus surveillance patients with and without progression to early neoplasia to evaluate the distribution of biomarkers over space and time. Dis Esophagus 2020; 34:5907935. [PMID: 32944737 PMCID: PMC9155949 DOI: 10.1093/dote/doaa095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 08/11/2020] [Indexed: 12/11/2022]
Abstract
The ReBus cohort is a matched nested case-control cohort of patients with nondysplastic (ND) Barrett's esophagus (BE) at baseline who progressed (progressors) or did not progress (nonprogressors) to high-grade dysplasia (HGD) or cancer. This cohort is constructed using the most stringent inclusion criteria to optimize explorative studies on biomarkers predicting malignant progression in NDBE. These explorative studies may benefit from expanding the number of cases and by incorporating samples that allow assessment of the biomarker over space (spatial variability) and over time (temporal variability). To (i) update the ReBus cohort by identifying new progressors and (ii) identify progressors and nonprogressors within the updated ReBus cohort containing spatial and temporal information. The ReBus cohort was updated by identifying Barrett's patients referred for endoscopic work-up of neoplasia at 4 tertiary referral centers. Progressors and nonprogressors with a multilevel (spatial) endoscopy and additional prior (temporal) endoscopies were identified to evaluate biomarkers over space and over time. The original ReBus cohort consisted of 165 progressors and 723 nonprogressors. We identified 65 new progressors meeting the same strict selection criteria, resulting in a total number of 230 progressors and 723 matched nonprogressors in the updated ReBus cohort. Within the updated cohort, 61 progressors and 107 nonprogressors (mean age 61 ± 10 years) with a spatial endoscopy (median level 3 [2-4]) were identified. 33/61 progressors and 50/107 nonprogressors had a median of 3 (2-4) additional temporal endoscopies. Our updated ReBus cohort consists of 230 progressors and 723 matched nonprogressors using the most strict selection criteria. In a subgroup of 168 Barrett's patients (the SpaTemp cohort), multiple levels have been sampled at baseline and during follow-up providing a unique platform to study spatial and temporal distribution of biomarkers in BE.
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Affiliation(s)
- N F Frei
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - K Konté
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - E Klaver
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - F J Ten Kate
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - G J Offerhaus
- Department of Pathology, University Medical Center, Utrecht, The Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam UMC, location Academic Medical Center, Amsterdam, The Netherlands
| | - M Visser
- Department of Pathology, Symbiant BV, Zaans Medical Center, Zaandam, The Netherlands
| | - C A Seldenrijk
- Department of Pathology, Pathology-DNA BV, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - B E Schenk
- Department of Gastroenterology and Hepatology, Isala Klinieken, Zwolle, The Netherlands
| | - R C Mallant-Hent
- Department of Gastroenterology, Flevo Hospital, Almere, the Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands
| | - R E Pouw
- Address correspondence to: R. E. Pouw, MD, PhD, Department of Gastroenterology and Hepatology, Amsterdam UMC, location Vrije Universiteit, Amsterdam, The Netherlands.
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15
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Pouw RE, Klaver E, Phoa KN, van Vilsteren FG, Weusten BL, Bisschops R, Schoon EJ, Pech O, Manner H, Ragunath K, Fernández-Sordo JO, Fullarton G, Di Pietro M, Januszewicz W, O'Toole D, Bergman JJ. Radiofrequency ablation for low-grade dysplasia in Barrett's esophagus: long-term outcome of a randomized trial. Gastrointest Endosc 2020; 92:569-574. [PMID: 32217112 DOI: 10.1016/j.gie.2020.03.3756] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 03/12/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS A prior randomized study (Surveillance versus Radiofrequency Ablation study [SURF study]) demonstrated that radiofrequency ablation (RFA) of Barrett's esophagus (BE) with confirmed low-grade dysplasia (LGD) significantly reduces the risk of esophageal adenocarcinoma. Our aim was to report the long-term outcomes of this study. METHODS The SURF study randomized BE patients with confirmed LGD to RFA or surveillance. For this retrospective cohort study, all endoscopic and histologic data acquired at the end of the SURF study in May 2013 until December 2017 were collected. The primary outcome was rate of progression to high-grade dysplasia (HGD)/cancer. All 136 patients randomized to RFA (n = 68) or surveillance (n = 68) in the SURF study were included. After closure of the SURF study, 15 surveillance patients underwent RFA based on patient preference and study outcomes. RESULTS With 40 additional months (interquartile range, 12-51), the total median follow-up from randomization to last endoscopy was 73 months (interquartile range, 46-85). HGD/cancer was diagnosed in 1 patient in the RFA group (1.5%) and in 23 in the surveillance group (33.8%) (P = .000), resulting in an absolute risk reduction of 32.4% (95% confidence interval [CI], 22.4%-44.2%) with a number needed to treat of 3.1 (95% CI, 2.3-4.5). Seventy-five of 83 patients (90%; 95% CI, 82.1%-95.0%) treated with RFA for BE reached complete clearance of BE and dysplasia. BE recurred in 7 of 75 patients (9%; 95% CI, 4.6%-18.0%), mostly minute islands or tongues, and LGD in 3 of 75 (4%; 95% CI, 1.4%-11.1%). CONCLUSIONS RFA of BE with confirmed LGD significantly reduces the risk of malignant progression, with sustained clearance of BE in 91% and LGD in 96% of patients, after a median follow-up of 73 months. (Clinical trial registration number: NTR1198.).
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Esther Klaver
- Department of Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - K Nadine Phoa
- Department of Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Bas L Weusten
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology, University Hospital Leuven, Leuven, Belgium
| | - Erik J Schoon
- Department of Gastroenterology, Catharina Hospital, Eindhoven, the Netherlands
| | - Oliver Pech
- Department of Gastroenterology, Helios dr. Horst Schmidt Clinics Wiesbaden, Germany
| | - Hendrik Manner
- Department of Gastroenterology, Frankfurt Hoechst Hospital, Frankfurt, Germany
| | - Krish Ragunath
- Department of Gastroenterology, Queens Medical Center, Nottingham, UK
| | | | - Grant Fullarton
- Department of Surgical Gastroenterology, Glasgow Royal Infirmary, Glasgow, Scotland
| | | | | | - Dermot O'Toole
- Department of Clinical Medicine and Gastroenterology, St James's Hospital, Dublin, Ireland
| | - Jacques J Bergman
- Department of Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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16
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Belghazi K, Marcon N, Teshima C, Wang KK, Milano RV, Mostafavi N, Wallace MB, Kandel P, Mejía Pérez LK, Bourke MJ, Bahin F, Everson MA, Haidry R, Ginsberg GG, Ma GK, Koch AD, Ragunath K, Ortiz-Fernandez-Sordo J, di Pietro M, Seewald S, Weusten BL, Schoon EJ, Bisschops R, Bergman JJ, Pouw RE. Risk factors for serious adverse events associated with multiband mucosectomy in Barrett's esophagus: an international multicenter analysis of 3827 endoscopic resection procedures. Gastrointest Endosc 2020; 92:259-268.e2. [PMID: 32240684 DOI: 10.1016/j.gie.2020.03.3842] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 03/19/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Multiband mucosectomy (MBM) is a widely used technique for the treatment of Barrett's esophagus (BE). However, large multicenter studies enabling a generalizable estimation of the risk of serious adverse events, such as perforation and postprocedural bleeding, are lacking. The aim of this study was to estimate the rate of, and risk factors for, serious adverse events associated with MBM. METHODS In this retrospective analysis, consecutive patients who underwent MBM for treatment of BE in 14 tertiary referral centers in Europe, the United States, Canada, and Australia were included. Primary outcomes were perforation and postprocedural bleeding rate. Potential risk factors were identified by logistic regression. RESULTS Between 2001 and 2016, a total of 3827 MBM procedures were performed in 2447 patients (84% male, mean age 66 years, median BE length C2M4). Perforation occurred in 17 procedures (0.4%; 95% confidence interval [CI], 0.3-0.7), of which 15 could be treated endoscopically or conservatively. Female gender was an independent risk factor for perforation (odds ratio [OR], 2.77; 95% CI, 1.02-7.57; P = .05). Postprocedural bleeding occurred after 35 procedures (0.9%; 95% CI, 0.6-1.3). The number of resections (OR, 1.15; 95% CI, 1.06-1.25; P < .001) was significantly associated with postprocedural bleeding. CONCLUSION The results of this study show that MBM for BE is safe with a low risk of serious adverse events. In addition, most of the adverse events could be managed endoscopically or conservatively. The number of resections was an independent risk factor for postprocedural bleeding.
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Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Norman Marcon
- Department of Gastroenterology, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Christopher Teshima
- Department of Gastroenterology, St. Michaels Hospital, Toronto, Ontario, Canada
| | - Kenneth K Wang
- Department of Gastroenterology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Reza V Milano
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Nahid Mostafavi
- Biostatistical Unit, Department of Gastroenterology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Pujan Kandel
- Department of Gastroenterology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | | | - Michael J Bourke
- Department of Gastroenterology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Farzan Bahin
- Department of Gastroenterology, Westmead Hospital, University of Sydney, Sydney, Australia
| | - Martin A Everson
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Gregory G Ginsberg
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Gene K Ma
- Gastroenterology Division, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, Cancer Institute, Rotterdam, the Netherlands
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre & NIHR Biomedical Research Centre, Nottingham University Hospital, Nottingham, United Kingdom
| | - Jacobo Ortiz-Fernandez-Sordo
- Nottingham Digestive Diseases Centre & NIHR Biomedical Research Centre, Nottingham University Hospital, Nottingham, United Kingdom
| | | | - Stefan Seewald
- Department of Gastroenterology, GastroZentrum Hirslanden Zürich, Switzerland
| | - Bas L Weusten
- Department of Gastroenterology and Hepatology, St. Antonius hospital, Nieuwegein, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, UZ Leuven, KU Leuven, Belgium
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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17
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Affiliation(s)
- Esther A Nieuwenhuis
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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18
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de Groof AJ, Fockens KN, Struyvenberg MR, Pouw RE, Weusten BLAM, Schoon EJ, Mostafavi N, Bisschops R, Curvers WL, Bergman JJ. Blue-light imaging and linked-color imaging improve visualization of Barrett's neoplasia by nonexpert endoscopists. Gastrointest Endosc 2020; 91:1050-1057. [PMID: 31904377 DOI: 10.1016/j.gie.2019.12.037] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/10/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Endoscopic recognition of early Barrett's neoplasia is challenging. Blue-light imaging (BLI) and linked-color imaging (LCI) may assist endoscopists in appreciation of neoplasia. Our aim was to evaluate BLI and LCI for visualization of Barrett's neoplasia in comparison with white-light endoscopy (WLE) alone, when assessed by nonexpert endoscopists. METHODS In this web-based assessment, corresponding WLE, BLI, and LCI images of 30 neoplastic Barrett's lesions were delineated by 3 expert endoscopists to establish ground truth. These images were then scored and delineated by 76 nonexpert endoscopists from 3 countries and with different levels of expertise, in 4 separate assessment phases with a washout period of 2 weeks. Assessments were as follows: assessment 1, WLE only; assessment 2, WLE + BLI; assessment 3, WLE + LCI; assessment 4, WLE + BLI + LCI. The outcomes were (1) appreciation of macroscopic appearance and ability to delineate lesions (visual analog scale [VAS] scores); (2) preferred technique (ordinal scores); and (3) assessors' delineation performance in terms of overlap with expert ground truth. RESULTS Median VAS scores for phases 2 to 4 were significantly higher than in phase 1 (P < .001). Assessors preferred BLI and LCI over WLE for appreciation of macroscopic appearance (P < .001) and delineation (P < .001). Linear mixed-effect models showed that delineation performance increased significantly in phase 4. CONCLUSIONS The use of BLI and LCI has significant additional value for the visualization of Barrett's neoplasia when used by nonexpert endoscopists. Assessors appreciated the addition of BLI and LCI better than the use of WLE alone. Furthermore, this addition led to improved delineation performance, thereby allowing for better acquisition of targeted biopsy samples. (The Netherlands Trial Registry number: NL7541.).
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Affiliation(s)
- Albert J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Kiki N Fockens
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Maarten R Struyvenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Bas L A M Weusten
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Nahid Mostafavi
- Biostatistical Unit, Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands
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19
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Struyvenberg MR, van der Sommen F, Swager AF, de Groof AJ, Rikos A, Schoon EJ, Bergman JJ, de With PHN, Curvers WL. Improved Barrett's neoplasia detection using computer-assisted multiframe analysis of volumetric laser endomicroscopy. Dis Esophagus 2020; 33:5541740. [PMID: 31364700 DOI: 10.1093/dote/doz065] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 06/07/2019] [Accepted: 06/18/2019] [Indexed: 12/11/2022]
Abstract
Volumetric laser endomicroscopy (VLE) is a balloon-based technique, which provides a circumferential near-microscopic scan of the esophageal wall layers, and has potential to improve Barrett's neoplasia detection. Interpretation of VLE imagery in Barrett's esophagus (BE) however is time-consuming and complex, due to a large amount of visual information and numerous subtle gray-shaded VLE images. Computer-aided detection (CAD), analyzing multiple neighboring VLE frames, might improve BE neoplasia detection compared to automated single-frame analyses. This study is to evaluate feasibility of automatic data extraction followed by CAD using a multiframe approach for detection of BE neoplasia. Prospectively collected ex-vivo VLE images from 29 BE-patients with and without early neoplasia were retrospectively analyzed. Sixty histopathology-correlated regions of interest (30 nondysplastic vs. 30 neoplastic) were assessed using different CAD systems. Multiple neighboring VLE frames, corresponding to 1.25 millimeter proximal and distal to each region of interest, were evaluated. In total, 3060 VLE frames were analyzed via the CAD multiframe analysis. Multiframe analysis resulted in a significantly higher median AUC (median level = 0.91) compared to single-frame (median level = 0.83) with a median difference of 0.08 (95% CI, 0.06-0.10), P < 0.001. A maximum AUC of 0.94 was reached when including 22 frames on each side using a multiframe approach. In total, 3060 VLE frames were automatically extracted and analyzed by CAD in 3.9 seconds. Multiframe VLE image analysis shows improved BE neoplasia detection compared to single-frame analysis. CAD with multiframe analysis allows for fast and accurate VLE interpretation, thereby showing feasibility of automatic full scan assessment in a real-time setting during endoscopy.
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Affiliation(s)
- M R Struyvenberg
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - F van der Sommen
- Department of Electrical Engineering, VCA Group, Eindhoven University of Technology
| | - A F Swager
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - A J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - A Rikos
- Department of Electrical Engineering, VCA Group, Eindhoven University of Technology
| | - E J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam
| | - P H N de With
- Department of Electrical Engineering, VCA Group, Eindhoven University of Technology
| | - W L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, the Netherlands
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20
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de Groof AJ, Struyvenberg MR, van der Putten J, van der Sommen F, Fockens KN, Curvers WL, Zinger S, Pouw RE, Coron E, Baldaque-Silva F, Pech O, Weusten B, Meining A, Neuhaus H, Bisschops R, Dent J, Schoon EJ, de With PH, Bergman JJ. Deep-Learning System Detects Neoplasia in Patients With Barrett's Esophagus With Higher Accuracy Than Endoscopists in a Multistep Training and Validation Study With Benchmarking. Gastroenterology 2020; 158:915-929.e4. [PMID: 31759929 DOI: 10.1053/j.gastro.2019.11.030] [Citation(s) in RCA: 174] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/31/2019] [Accepted: 11/18/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS We aimed to develop and validate a deep-learning computer-aided detection (CAD) system, suitable for use in real time in clinical practice, to improve endoscopic detection of early neoplasia in patients with Barrett's esophagus (BE). METHODS We developed a hybrid ResNet-UNet model CAD system using 5 independent endoscopy data sets. We performed pretraining using 494,364 labeled endoscopic images collected from all intestinal segments. Then, we used 1704 unique esophageal high-resolution images of rigorously confirmed early-stage neoplasia in BE and nondysplastic BE, derived from 669 patients. System performance was assessed by using data sets 4 and 5. Data set 5 was also scored by 53 general endoscopists with a wide range of experience from 4 countries to benchmark CAD system performance. Coupled with histopathology findings, scoring of images that contained early-stage neoplasia in data sets 2-5 were delineated in detail for neoplasm position and extent by multiple experts whose evaluations served as the ground truth for segmentation. RESULTS The CAD system classified images as containing neoplasms or nondysplastic BE with 89% accuracy, 90% sensitivity, and 88% specificity (data set 4, 80 patients and images). In data set 5 (80 patients and images) values for the CAD system vs those of the general endoscopists were 88% vs 73% accuracy, 93% vs 72% sensitivity, and 83% vs 74% specificity. The CAD system achieved higher accuracy than any of the individual 53 nonexpert endoscopists, with comparable delineation performance. CAD delineations of the area of neoplasm overlapped with those from the BE experts in all detected neoplasia in data sets 4 and 5. The CAD system identified the optimal site for biopsy of detected neoplasia in 97% and 92% of cases (data sets 4 and 5, respectively). CONCLUSIONS We developed, validated, and benchmarked a deep-learning computer-aided system for primary detection of neoplasia in patients with BE. The system detected neoplasia with high accuracy and near-perfect delineation performance. The Netherlands National Trials Registry, Number: NTR7072.
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Affiliation(s)
- Albert J de Groof
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten R Struyvenberg
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Joost van der Putten
- Department of Electrical Engineering, Video Coding & Architectures group, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering, Video Coding & Architectures group, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Kiki N Fockens
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Sveta Zinger
- Department of Electrical Engineering, Video Coding & Architectures group, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Emmanuel Coron
- Institut des Maladies de l'Appareil Digestif, University Hospital of Nantes place Alexis Ricordeau, Nantes, France
| | - Francisco Baldaque-Silva
- Department of Digestive Diseases, Karolinska University Hospital and Karolinska Institute, Stockholm, Sweden
| | - Oliver Pech
- Gastroenterology and Interventional Endoscopy, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | - Bas Weusten
- Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - Horst Neuhaus
- Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - John Dent
- Department of Medicine, University of Adelaide and Royal Adelaide Hospital, Adelaide, South Australia
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Peter H de With
- Department of Electrical Engineering, Video Coding & Architectures group, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands.
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21
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Haidry RJ, van Baar AC, Galvao Neto MP, Rajagopalan H, Caplan J, Levin PS, Bergman JJ, Rodriguez L, Deviere J, Thompson CC. Duodenal mucosal resurfacing: proof-of-concept, procedural development, and initial implementation in the clinical setting. Gastrointest Endosc 2019; 90:673-681.e2. [PMID: 30935932 DOI: 10.1016/j.gie.2019.03.024] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 03/11/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS We aimed to develop duodenal mucosal resurfacing (DMR), a minimally invasive upper endoscopic hydrothermal ablation procedure, to treat insulin-resistant metabolic diseases. METHODS We completed a sham-controlled, rodent proof-of-concept study and longitudinal safety study in pigs to demonstrate feasibility to test DMR in humans. Subsequently, the DMR procedure was implemented in an open-label first-in-human (FIH) study of safety and efficacy in patients with type 2 diabetes (T2D). RESULTS In rats, duodenal abrasion reduced hyperglycemia by 59 mg/dL on average, compared with no change from baseline in the sham treatment arm (P < .05). In pigs, the balloon catheter successfully and safely delivered hydrothermal ablation to the duodenal mucosa and superficial submucosa. Complete mucosal healing was demonstrated by week 6. In the FIH study, hydrothermal ablation was successfully administered with no evidence of perforation, pancreatitis, or hemorrhage. Duodenal biopsy specimens obtained 3 months postprocedure demonstrated full mucosal regrowth. No inflammation was observed, and there was minimal-to-mild collagen banding deposition observed in a proportion of ablation site biopsy specimens with no evidence of fibrotic scarring. Glycemic and hepatic measures improved through 6 months of follow-up. CONCLUSIONS DMR shows potential as an endoscopic intervention that improves glycemic and hepatic parameters in patients with T2D. Further mechanistic and clinical studies are underway to further explore DMR as a treatment for metabolic disease.
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Affiliation(s)
- Rehan J Haidry
- Department of Gastroenterology, University College Hospital, London, UK
| | - Annieke C van Baar
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Manoel P Galvao Neto
- Department of Surgery, Florida International University, Miami, Florida, USA; Bariatric Endoscopy Service, Endovitta Institute, Sao Paulo, Brazil
| | | | - Jay Caplan
- Fractyl Laboratories, Inc, Lexington, Massachusetts, USA
| | | | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Jacques Deviere
- Department Of Gastroenterology, Erasme University Hospital, Brussels, Belgium
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22
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de Groof J, van der Sommen F, van der Putten J, Struyvenberg MR, Zinger S, Curvers WL, Pech O, Meining A, Neuhaus H, Bisschops R, Schoon EJ, de With PH, Bergman JJ. The Argos project: The development of a computer-aided detection system to improve detection of Barrett's neoplasia on white light endoscopy. United European Gastroenterol J 2019; 7:538-547. [PMID: 31065371 PMCID: PMC6488793 DOI: 10.1177/2050640619837443] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 02/02/2019] [Indexed: 12/12/2022] Open
Abstract
Background Computer-aided detection (CAD) systems might assist endoscopists in the recognition of Barrett's neoplasia. Aim To develop a CAD system using endoscopic images of Barrett's neoplasia. Methods White light endoscopy (WLE) overview images of 40 neoplastic Barrett's lesions and 20 non-dysplastic Barret's oesophagus (NDBO) patients were prospectively collected. Experts delineated all neoplastic images.The overlap area of at least four delineations was labelled as the 'sweet spot'. The area with at least one delineation was labelled as the 'soft spot'. The CAD system was trained on colour and texture features. Positive features were taken from the sweet spot and negative features from NDBO images. Performance was evaluated using leave-one-out cross-validation. Outcome parameters were diagnostic accuracy of the CAD system per image, and localization of the expert soft spot by CAD delineation (localization score) and its indication of preferred biopsy location (red-flag indication score). Results Accuracy, sensitivity and specificity for detection were 92, 95 and 85%, respectively. The system localized and red-flagged the soft spot in 100 and 90%, respectively. Conclusion This uniquely trained and validated CAD system detected and localized early Barrett's neoplasia on WLE images with high accuracy. This is an important step towards real-time automated detection of Barrett's neoplasia.
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Affiliation(s)
- Jeroen de Groof
- Department of Gastroenterology and
Hepatology, University of Amsterdam, Amsterdam, The Netherlands
| | - Fons van der Sommen
- Department of Electrical Engineering,
Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Joost van der Putten
- Department of Electrical Engineering,
Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Maarten R Struyvenberg
- Department of Gastroenterology and
Hepatology, University of Amsterdam, Amsterdam, The Netherlands
| | - Sveta Zinger
- Department of Electrical Engineering,
Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and
Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Oliver Pech
- Gastroenterology and Interventional
Endoscopy, Krankenhaus Barmherzige Brüder, Regensburg, Germany
| | | | - Horst Neuhaus
- Internal Medicine, Evangelisches
Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Raf Bisschops
- Department of Gastroenterology and
Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Erik J Schoon
- Department of Gastroenterology and
Hepatology, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Peter H de With
- Department of Electrical Engineering,
Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and
Hepatology, University of Amsterdam, Amsterdam, The Netherlands
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23
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Zeki SS, Bergman JJ, Dunn JM. Endoscopic management of dysplasia and early oesophageal cancer. Best Pract Res Clin Gastroenterol 2018; 36-37:27-36. [PMID: 30551853 DOI: 10.1016/j.bpg.2018.11.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 11/19/2018] [Indexed: 01/31/2023]
Abstract
In the past decade there have been technological advances in Endoscopic Eradication Therapy (EET) for the management of patients with oesophageal neoplasia and early cancer. Multiple endoscopic techniques now exist for both squamous and Barrett's oesophagus associated neoplasia or early cancer. A fundamental aspect of endotherapy is removal of the target lesion by endoscopic mucosal resection, or endosopic submucosal dissection. Residual tissue is subsequently ablated to remove the risk of recurrence. The most validated technique for Barrett's oesophagus is radiofrequency ablation, but other techniques such as hybrid-APC and cryotherapy also show good results. This chapter will discuss the evolution of EET, and which patients are most likely to benefit. It will also explore the evidence behind the success of different techniques and provide practical advice on how to carry out the endoscopic techniques with a focus on radiofrequency ablation and endoscopic mucosal resection in particular.
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Affiliation(s)
- S S Zeki
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom.
| | - J J Bergman
- Dep. of Gastroenterology, Academic Medical Center, Amsterdam, Netherlands
| | - J M Dunn
- Dept of Gastroenterology, Guy's & St Thomas' Hospitals NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, United Kingdom
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24
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Belghazi K, Schölvinck DW, van Berge Henegouwen MI, Gisbertz SS, Weusten BL, Meijer SL, Bergman JJ, Pouw RE. Results of a two-phased clinical study evaluating a new multiband mucosectomy device for early Barrett's neoplasia: a randomized pre-esophagectomy trial and a pilot therapeutic pilot study. Surg Endosc 2018; 33:2864-2872. [PMID: 30456511 PMCID: PMC6684496 DOI: 10.1007/s00464-018-6582-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Accepted: 11/02/2018] [Indexed: 01/05/2023]
Abstract
Background Multiband mucosectomy (MBM) is the preferred technique for piecemeal resection of early neoplastic lesions in Barrett’s esophagus (BE). The currently most widely used device for MBM is the Duette device. Recently, the Captivator EMR device has come available which might have practical advantages over the Duette device. Methods Phase I was a randomized pre-esophagectomy trial with a non-inferiority design aiming to compare EMR specimens obtained with the Captivator and the Duette device. Primary outcome: max diameter of the EMR specimens, secondary outcomes: min diameter, max thickness of the EMR specimens and resected submucosal stroma. Phase II were clinical pilot cases aiming to evaluate the feasibility of EMR using the Captivator device. Primary outcome was the successful EMR rate and secondary outcomes included procedure time and adverse events. Results Phase I: 24 EMR specimens (12 pairs) were obtained from six patients. The median max diameter of EMR specimens obtained with the Captivator device was 16 mm [IQR 12–21] versus 18 mm [IQR 13–23] for the Duette device. Non-inferiority of the max diameter of the Captivator specimens could not be demonstrated (median difference 1 mm, 95% CI − 3.26 to + 5.26). However, when using paired analysis, no significant difference was found (p 0.573). In addition, no statistically significant differences were found in the min diameter, max thickness of EMR specimens, and max thickness of resected submucosal stroma. Phase II: 5 BE patients with early neoplastic lesions were included. Successful EMR was achieved in 100%. Median procedure time was 33 min (IQR 25–39). One patient developed transient dysphagia, without signs of stenosis on endoscopy. Conclusions EMR of early Barrett’s neoplasia using the Captivator device is comparable to Duette EMR when looking at size of resected specimens. In the first patients, EMR using the Captivator was feasible, resulting in successful resection without acute adverse events.
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Affiliation(s)
- K Belghazi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - D W Schölvinck
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | - S S Gisbertz
- Department of Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - B L Weusten
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - S L Meijer
- Department of Pathology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - R E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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25
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Borggreve AS, Mook S, Verheij M, Mul VEM, Bergman JJ, Bartels-Rutten A, Ter Beek LC, Beets-Tan RGH, Bennink RJ, van Berge Henegouwen MI, Brosens LAA, Defize IL, van Dieren JM, Dijkstra H, van Hillegersberg R, Hulshof MC, van Laarhoven HWM, Lam MGEH, van Lier ALHMW, Muijs CT, Nagengast WB, Nederveen AJ, Noordzij W, Plukker JTM, van Rossum PSN, Ruurda JP, van Sandick JW, Weusten BLAM, Voncken FEM, Yakar D, Meijer GJ. Preoperative image-guided identification of response to neoadjuvant chemoradiotherapy in esophageal cancer (PRIDE): a multicenter observational study. BMC Cancer 2018; 18:1006. [PMID: 30342494 PMCID: PMC6195948 DOI: 10.1186/s12885-018-4892-6] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 10/03/2018] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Nearly one third of patients undergoing neoadjuvant chemoradiotherapy (nCRT) for locally advanced esophageal cancer have a pathologic complete response (pCR) of the primary tumor upon histopathological evaluation of the resection specimen. The primary aim of this study is to develop a model that predicts the probability of pCR to nCRT in esophageal cancer, based on diffusion-weighted magnetic resonance imaging (DW-MRI), dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and 18F-fluorodeoxyglucose positron emission tomography with computed tomography (18F-FDG PET-CT). Accurate response prediction could lead to a patient-tailored approach with omission of surgery in the future in case of predicted pCR or additional neoadjuvant treatment in case of non-pCR. METHODS The PRIDE study is a prospective, single arm, observational multicenter study designed to develop a multimodal prediction model for histopathological response to nCRT for esophageal cancer. A total of 200 patients with locally advanced esophageal cancer - of which at least 130 patients with adenocarcinoma and at least 61 patients with squamous cell carcinoma - scheduled to receive nCRT followed by esophagectomy will be included. The primary modalities to be incorporated in the prediction model are quantitative parameters derived from MRI and 18F-FDG PET-CT scans, which will be acquired at fixed intervals before, during and after nCRT. Secondary modalities include blood samples for analysis of the presence of circulating tumor DNA (ctDNA) at 3 time-points (before, during and after nCRT), and an endoscopy with (random) bite-on-bite biopsies of the primary tumor site and other suspected lesions in the esophagus as well as an endoscopic ultrasonography (EUS) with fine needle aspiration of suspected lymph nodes after finishing nCRT. The main study endpoint is the performance of the model for pCR prediction. Secondary endpoints include progression-free and overall survival. DISCUSSION If the multimodal PRIDE concept provides high predictive performance for pCR, the results of this study will play an important role in accurate identification of esophageal cancer patients with a pCR to nCRT. These patients might benefit from a patient-tailored approach with omission of surgery in the future. Vice versa, patients with non-pCR might benefit from additional neoadjuvant treatment, or ineffective therapy could be stopped. TRIAL REGISTRATION The article reports on a health care intervention on human participants and was prospectively registered on March 22, 2018 under ClinicalTrials.gov Identifier: NCT03474341 .
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Affiliation(s)
- A S Borggreve
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands. .,Department of Surgical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.
| | - S Mook
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M Verheij
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - V E M Mul
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GW, Groningen, The Netherlands
| | - J J Bergman
- Department of Gastroenterology, Amsterdam University Medical Centers, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - A Bartels-Rutten
- Department of Radiology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - L C Ter Beek
- Department of Radiology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - R G H Beets-Tan
- Department of Radiology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - R J Bennink
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M I van Berge Henegouwen
- Department of Surgical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - L A A Brosens
- Department of Pathology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - I L Defize
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands.,Department of Surgical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - J M van Dieren
- Department of Gastroenterology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - H Dijkstra
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GW, Groningen, The Netherlands
| | - R van Hillegersberg
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - M C Hulshof
- Department of Radiation Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - H W M van Laarhoven
- Department of Medical Oncology, Cancer Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - M G E H Lam
- Department of Nuclear Medicine, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - A L H M W van Lier
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - C T Muijs
- Department of Radiation Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GW, Groningen, The Netherlands
| | - W B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GW, Groningen, The Netherlands
| | - A J Nederveen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - W Noordzij
- Department of Nuclear Medicine, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GW, Groningen, The Netherlands
| | - J T M Plukker
- Department of Surgical Oncology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GW, Groningen, The Netherlands
| | - P S N van Rossum
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - J P Ruurda
- Department of Surgical Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - J W van Sandick
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - B L A M Weusten
- Department of Gastroenterology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - F E M Voncken
- Department of Radiation Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - D Yakar
- Department of Radiology, University Medical Center Groningen, University of Groningen, Hanzeplein 1, 9713 GW, Groningen, The Netherlands
| | - G J Meijer
- Department of Radiation Oncology, University Medical Center Utrecht, Utrecht University, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
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26
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Pouw RE, Beyna T, Belghazi K, Koch AD, Schoon EJ, Haidry R, Weusten BL, Bisschops R, Shaheen NJ, Wallace MB, Marcon N, Heise-Ginsburg R, Gotink AW, Wang KK, Leggett CL, Ortiz-Fernández-Sordo J, Ragunath K, DiPietro M, Pech O, Neuhaus H, Bergman JJ. A prospective multicenter study using a new multiband mucosectomy device for endoscopic resection of early neoplasia in Barrett's esophagus. Gastrointest Endosc 2018; 88:647-654. [PMID: 30220300 DOI: 10.1016/j.gie.2018.06.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 06/27/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Early neoplasia in Barrett's esophagus (BE) can be effectively and safely removed by endoscopic resection (ER) using multiband mucosectomy (MBM). This study aimed to document performance of a novel MBM device designed for improved visualization, easier passage of accessories, and better suction power compared with other marketed MBM devices. METHODS This international, single-arm, prospective registry in 14 referral centers (Europe, 10; United States, 3; Canada, 1) included patients with early BE neoplasia scheduled for ER. The primary endpoint was successful ER defined as complete resection of the delineated area in 1 procedure. Secondary outcomes were adverse events and procedure time. RESULTS A total of 332 lesions was included in 291 patients (248 men; mean age, 67 years [standard deviation, 9.6]). ER indication was high-grade dysplasia in 64%, early adenocarcinoma in 19%, lesion with low-grade dysplasia in 11%, and a lesion without definite histology in 6%. Successful ER was reached in 322 of 332 lesions (97%; 95% confidence interval [CI], 94.6%-98.4%). A perforation occurred in 3 of 332 procedures (.9%; 95% CI, .31%-2.62%), all were managed endoscopically, and patients were admitted with intravenous antibiotics during days 2, 3, and 9. Postprocedural bleeding requiring an intervention occurred in 5 of 332 resections (1.5%; 95% CI, .65%-3.48%). Dysphagia requiring dilatation occurred in 11 patients (3.8%; 95% CI, 2.1%-6.6%). Median procedure time was 16 minutes (interquartile range, 12.0-26.0). CONCLUSIONS In expert hands, the novel MBM device proved to be effective for resection of early neoplastic lesions in BE, with successful ER in 97% of procedures. Severe adverse events were rare and were effectively managed endoscopically or conservatively. (Clinical trial registration number: NCT02482701.).
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Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Torsten Beyna
- Department of Gastroenterology and Hepatology, Evangelisches Krankenhaus, Düsseldorf, Germany
| | - Kamar Belghazi
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Arjun D Koch
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Erik J Schoon
- Department of Gastroenterology and Hepatology, Catharina Hospital Eindhoven, Eindhoven, Netherlands
| | - Rehan Haidry
- Department of Gastroenterology, University College Hospital, London, United Kingdom
| | - Bas L Weusten
- Department of Gastroenterology, St Antonius Hospital, Nieuwegein, Netherlands
| | - Raf Bisschops
- Department of Gastroenterology, UZ Gasthuisberg, Leuven, Belgium
| | - Nicholas J Shaheen
- Department of Gastroenterology, University North Carolina Hospital, Chapel Hill, North Carolina, USA
| | - Michael B Wallace
- Department of Gastroenterology, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Norman Marcon
- Department of Gastroenterology, St Michaels Hospital, Toronto, Ontario, Canada
| | - Rachel Heise-Ginsburg
- Department of Gastroenterology and Hepatology, Evangelisches Krankenhaus, Düsseldorf, Germany
| | - Anniek W Gotink
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Kenneth K Wang
- Department of Gastroenterology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Cadman L Leggett
- Department of Gastroenterology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Jacobo Ortiz-Fernández-Sordo
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Nottingham BRC, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | | | - Oliver Pech
- Department of Gastroenterology, St John of God Hospital, Regensburg, Germany
| | - Horst Neuhaus
- Department of Gastroenterology and Hepatology, Evangelisches Krankenhaus, Düsseldorf, Germany
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
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Seewald S, Ang TL, Pouw RE, Bannwart F, Bergman JJ. Management of Early-Stage Adenocarcinoma of the Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection. Dig Dis Sci 2018; 63:2146-2154. [PMID: 29934725 DOI: 10.1007/s10620-018-5158-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Barrett's esophagus with high-grade dysplasia and early-stage adenocarcinoma is amenable to curative treatment by endoscopic resection. Histopathological correlation has established that mucosal cancer has minimal risk of nodal metastases and that long-term complete remission can be achieved. Although surgery is the gold-standard treatment once there is submucosal involvement, even T1sm1 (submucosal invasion ≤ 500 μm) cases without additional risk factors for nodal metastases might also be cured with endoscopic resection. Endoscopic resection is foremost an initial diagnostic procedure, and once histopathological assessment confirms that curative criteria are met, it will be considered curative. Endoscopic resection may be achieved by endoscopic mucosal resection, which, although easy to perform with relatively low risk, is limited by an inability to achieve en bloc resection for lesions of size more than 1.5 cm. Conversely, the technique of endoscopic submucosal dissection is more technically demanding with higher risk of complications but is able to achieve en bloc resection for lesions larger than 1.5 cm. Endoscopic submucosal dissection would be particularly important in specific situations such as suspected submucosal invasion and lesion size more than 1.5 cm. In other situations, since endoscopic resection would always be combined with radiofrequency ablation to ablate the remaining Barrett's epithelium, piecemeal endoscopic mucosal resection would suffice since any remnant superficial invisible dysplasia would be ablated.
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Affiliation(s)
- Stefan Seewald
- Centre of Gastroenterology, Klinik Hirslanden, Witellikerstrasse 40, 8008, Zurich, Switzerland.
| | - Tiing Leong Ang
- Department of Gastroenterology and Hepatology, Changi General Hospital, Singapore, Singapore
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Belghazi K, Pouw RE, Bergman JJ. In the expanding arena of endoscopic management for Barrett's neoplasia, how should we fit in endoscopic submucosal dissection? Gastrointest Endosc 2018; 87:1394-1395. [PMID: 29759155 DOI: 10.1016/j.gie.2018.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/02/2018] [Indexed: 12/11/2022]
Affiliation(s)
- Kamar Belghazi
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology, Academic Medical Center, Amsterdam, The Netherlands
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29
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Abstract
The incidence of esophageal adenocarcinoma is on the rise. With advances in endoscopic techniques and imaging technology, early neoplastic lesions are being increasingly detected and treated. Managing early esophageal adenocarcinoma with endoscopic techniques is now considered the cornerstone of therapy, offering an alternative to surgery. The available endoscopic techniques can be broadly categorized into resection and ablation techniques that may be combined to increase the effectiveness of therapy. However, endoscopic treatments are highly specialized and patients with early adenocarcinoma should be referred to centers with expertise in advanced endoscopy of the esophagus. We review the proper method for conducting a thorough evaluation of early neoplastic lesions, staging details, the available endoscopic resection and ablation techniques, and the efficacy and safety of different endoscopic treatments.
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Affiliation(s)
- Reza V Milano
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands -
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30
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Bergman JJ, Yachimski PS. Advances in Endoscopic Therapy. Gastroenterology 2018; 154:1859-1860. [PMID: 29653148 DOI: 10.1053/j.gastro.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Abstract
A substantial literature documents inappropriate usage of gastrointestinal endoscopy in a variety of clinical settings. Overusage of endoscopy appears to be common, and 30% or more of procedures performed in some clinical settings have questionable indications. The potential reasons for overuse of endoscopy are multiple, and include cancer phobia, fear of medical malpractice litigation, profit motive, the investigation of "incidentalomas" found on other imaging, and underappreciation of the delayed harms of endoscopy, among other reasons. Clinical guidelines, which should limit overuse of endoscopy, may instead serve to promote it, if authors opt to be "conservative," recommending endoscopy in situations of unclear utility. Several strategies may decrease overuse of endoscopy, including careful attention to risk stratification when choosing patients to screen, adherence to guidelines for surveillance intervals for colonoscopy, the use of quality indicators to identify outliers in endoscopy utilization, and education on appropriate indications and the risks of overuse at the medical student, residency, and fellowship levels.
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Affiliation(s)
- Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, North Carolina.
| | - M Brian Fennerty
- Division of Gastroenterology and Hepatology, Oregon Health and Sciences University, Portland, Oregon
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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32
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van Baar ACG, Prodan A, Wahlgren CD, Poulsen SS, Knop FK, Groen AK, Bergman JJ, Nieuwdorp M, Levin E. Duodenal L cell density correlates with features of metabolic syndrome and plasma metabolites. Endocr Connect 2018; 7:673-680. [PMID: 29669802 PMCID: PMC5952241 DOI: 10.1530/ec-18-0094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 04/18/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Enteroendocrine cells are essential for the regulation of glucose metabolism, but it is unknown whether they are associated with clinical features of metabolic syndrome (MetS) and fasting plasma metabolites. OBJECTIVE We aimed to identify fasting plasma metabolites that associate with duodenal L cell, K cell and delta cell densities in subjects with MetS with ranging levels of insulin resistance. RESEARCH DESIGN AND METHODS In this cross-sectional study, we evaluated L, K and delta cell density in duodenal biopsies from treatment-naïve males with MetS using machine-learning methodology. RESULTS We identified specific clinical biomarkers and plasma metabolites associated with L cell and delta cell density. L cell density was associated with increased plasma metabolite levels including symmetrical dimethylarginine, 3-aminoisobutyric acid, kynurenine and glycine. In turn, these L cell-linked fasting plasma metabolites correlated with clinical features of MetS. CONCLUSIONS Our results indicate a link between duodenal L cells, plasma metabolites and clinical characteristics of MetS. We conclude that duodenal L cells associate with plasma metabolites that have been implicated in human glucose metabolism homeostasis. Disentangling the causal relation between L cells and these metabolites might help to improve the (small intestinal-driven) pathophysiology behind insulin resistance in human obesity.
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Affiliation(s)
- Annieke C G van Baar
- Department of Gastroenterology and HepatologyAcademic Medical Center, Amsterdam, the Netherlands
| | - Andrei Prodan
- Department of Vascular MedicineAcademic Medical Center, Amsterdam, the Netherlands
| | - Camilla D Wahlgren
- Center for Diabetes ResearchGentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Steen S Poulsen
- Department of Biomedical SciencesFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic ResearchFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Filip K Knop
- Center for Diabetes ResearchGentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Novo Nordisk Foundation Center for Basic Metabolic ResearchFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical MedicineFaculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Albert K Groen
- Department of Vascular MedicineAcademic Medical Center, Amsterdam, the Netherlands
- Department of Laboratory MedicineUniversity of Groningen, University Medical Center, Groningen, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and HepatologyAcademic Medical Center, Amsterdam, the Netherlands
| | - Max Nieuwdorp
- Department of Vascular MedicineAcademic Medical Center, Amsterdam, the Netherlands
- Department of Internal MedicineVUMC Free University, Amsterdam, the Netherlands
- Wallenberg LaboratorySahlgrenska Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Evgeni Levin
- Department of Vascular MedicineAcademic Medical Center, Amsterdam, the Netherlands
- Horaizon BVDelft, the Netherlands
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33
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Bourke MJ, Neuhaus H, Bergman JJ. Endoscopic Submucosal Dissection: Indications and Application in Western Endoscopy Practice. Gastroenterology 2018; 154:1887-1900.e5. [PMID: 29486200 DOI: 10.1053/j.gastro.2018.01.068] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/11/2018] [Accepted: 01/11/2018] [Indexed: 12/11/2022]
Abstract
Endoscopic submucosal dissection was developed in Japan, early in this century, to provide a minimally invasive yet curative treatment for the large numbers of patients with early gastric cancer identified by the national screening program. Previously, the majority of these patients were treated surgically at substantial cost and with significant risk of short- and long-term morbidity. En-bloc excision of these early cancers, most with a limited risk of nodal metastasis, allowed complete staging of the tumor, stratification of the subsequent therapeutic approach, and potential cure. This transformative innovation changed the nature of endoscopic treatment for superficial mucosal neoplasia and, ultimately, for the first time allowed endoscopists to assert that the early cancer had been definitively cured. Subsequently, Western endoscopists have increasingly embraced the therapeutic possibilities offered by endoscopic submucosal dissection, but with some justifiable scientific caution. Here we provide an evidence-based critical appraisal of the role of endoscopic submucosal dissection in advanced endoscopic tissue resection.
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Affiliation(s)
- Michael J Bourke
- Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, New South Wales, Australia; Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia.
| | - Horst Neuhaus
- Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany
| | - Jacques J Bergman
- Academic Medical Centre, Department of Gastroenterology and Hepatology, Amsterdam, Netherlands
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Eluri S, Klaver E, Duits LC, Jackson SA, Bergman JJ, Shaheen NJ. Validation of a biomarker panel in Barrett's esophagus to predict progression to esophageal adenocarcinoma. Dis Esophagus 2018; 31:4959873. [PMID: 29635420 PMCID: PMC6215490 DOI: 10.1093/dote/doy026] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
In a prior study, baseline mutational load (ML) predicted progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in Barrett's esophagus (BE) with an area under the curve (AUC) of 0.95. We aimed to validate the test characteristics of this predictive biomarker panel using crude DNA lysates in a larger well-characterized cohort. We performed a nested case-control study of BE patients from three tertiary referral centers in the Netherlands. Cases had baseline nondysplastic BE (NDBE) and developed HGD/EAC ≥ 2 years later. Controls were matched 2:1, had baseline NDBE, and no progression. Polymerase chain reaction (PCR)-based mutational analysis was performed on crude lysates from formalin-fixed, paraffin-embedded tissue. ML was calculated from loss of heterozygosity (LOH) and microsatellite instability (MSI) at 10 genomic loci. Receiver operator characteristic (ROC) curves were created to assess the diagnostic utility of various cutoffs of ML for progression. Of 159 subjects, 58 were progressors and 101 were nonprogressors, there was no difference in mean ML in preprogression tissue in progressors and nonprogressors (ML = 0.73 ± 0.69 vs. ML = 0.74 ± 0.61, P = 0.93). ROC curves showed poor discrimination of ML in predicting progression with AUC of 0.50 at ML ≥ 1. AUC did not vary with different ML cut-points. The utility of the ML to stratify BE patients for risk of progression was not confirmed in this study. The etiology for discrepancies between this and prior studies showing high predictiveness is likely due to the use of crude lysates in this study, but requires further investigation.
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Affiliation(s)
- S Eluri
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina,Address correspondence to: Swathi Eluri, MD, MSCR, Division of Gastroenterology and Hepatology, University of North Carolina, 130 Mason Farm Road CB#7080, Chapel Hill, NC 27599, USA.
| | - E Klaver
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - L C Duits
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - S A Jackson
- Interpace Diagnostics, Pittsburgh, Pennsylvania, USA
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - N J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina
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35
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van der Wel MJ, Duits LC, Pouw RE, Seldenrijk CA, Offerhaus GJA, Visser M, Ten Kate FJ, Biermann K, Brosens LAA, Doukas M, Huysentruyt C, Karrenbeld A, Kats-Ugurlu G, van der Laan JS, van Lijnschoten GI, Moll FCP, Ooms AHAG, van der Valk H, Tijssen JG, Bergman JJ, Meijer SL. Improved diagnostic stratification of digitised Barrett's oesophagus biopsies by p53 immunohistochemical staining. Histopathology 2018; 72:1015-1023. [PMID: 29314176 DOI: 10.1111/his.13462] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/14/2017] [Accepted: 12/29/2017] [Indexed: 12/15/2022]
Abstract
AIMS Interobserver agreement for dysplasia in Barrett's oesophagus (BO) is low, and guidelines advise expert review of dysplastic cases. The aim of this study was to assess the added value of p53 immunohistochemistry (IHC) for the homogeneity within a group of dedicated gastrointestinal (GI) pathologists. METHODS AND RESULTS Sixty-single haematoxylin and eosin (HE) slide referral BO cases [20 low-grade dysplasia (LGD); 20 high-grade dysplasia (HGD); and 20 non-dysplastic BO reference cases] were digitalised and independently assessed twice in random order by 10 dedicated GI pathologists. After a 'wash-out' period, cases were reassessed with the addition of a corresponding p53 IHC slide. Outcomes were: (i) proportion of 'indefinite for dysplasia' (IND) diagnoses; (ii) interobserver agreement; and (iii) diagnostic accuracy as compared with a consensus 'gold standard' diagnosis defined at an earlier stage by five core expert BO pathologists after their assessment of this case set. Addition of p53 IHC decreased the mean proportion of IND diagnoses from 10 of 60 to eight of 60 (P = 0.071). Mean interobserver agreement increased significantly from 0.45 to 0.57 (P = 0.0021). The mean diagnostic accuracy increased significantly from 72% to 82% (P = 0.0072) after p53 IHC addition. CONCLUSION Addition of p53 IHC significantly improves the histological assessment of BO biopsies, even within a group of dedicated GI pathologists. It decreases the proportion of IND diagnoses, and increases interobserver agreement and diagnostic accuracy. This justifies the use of accessory p53 IHC within our upcoming national digital review panel for BO biopsy cases.
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Affiliation(s)
- Myrtle J van der Wel
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands.,Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Lucas C Duits
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Cornelis A Seldenrijk
- Department of Pathology, Pathology-DNA, St Antonius Hospital, Nieuwegein, The Netherlands
| | - G J A Offerhaus
- Department of Pathology, University Medical Centre, Utrecht, The Netherlands
| | - Mike Visser
- Department of Pathology, Symbiant BV, Alkmaar, The Netherlands
| | - Fiebo J Ten Kate
- Department of Pathology, University Medical Centre, Utrecht, The Netherlands
| | - Katharina Biermann
- Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Michael Doukas
- Department of Pathology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Arend Karrenbeld
- Department of Pathology, Academic Medical Centre, Groningen, The Netherlands
| | - Gursah Kats-Ugurlu
- Department of Pathology, Academic Medical Centre, Groningen, The Netherlands
| | | | | | - Freek C P Moll
- Department of Pathology, Isala Clinics, Zwolle, The Netherlands
| | - Ariadne H A G Ooms
- Department of Pathology, St Fransiscus Vlietland Gasthuis, Pathan BV, Rotterdam, The Netherlands
| | - Hans van der Valk
- Department of Pathology, St Fransiscus Vlietland Gasthuis, Pathan BV, Rotterdam, The Netherlands
| | - Jan G Tijssen
- Department of Cardiology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre, Amsterdam, The Netherlands
| | - Sybren L Meijer
- Department of Pathology, Academic Medical Centre, Amsterdam, The Netherlands
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36
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van Halsema EE, 't Hoen CA, de Koning PS, Rosmolen WD, van Hooft JE, Bergman JJ. Self-dilation for therapy-resistant benign esophageal strictures: towards a systematic approach. Surg Endosc 2018; 32:3200-3207. [PMID: 29349540 PMCID: PMC5988760 DOI: 10.1007/s00464-018-6037-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Accepted: 01/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Patients with therapy-resistant benign esophageal strictures (TRBES) suffer from chronic dysphagia and generally require repeated endoscopic dilations. For selected patients, esophageal self-dilation may improve patient's autonomy and reduce the number of endoscopic dilations. We evaluated the clinical course and outcomes of patients who started esophageal self-dilation at our institution. METHODS This study was a retrospective case series of patients with TRBES who started esophageal self-dilation between 2012 and 2016 at the Academic Medical Center Amsterdam. To learn self-dilation using Savary-Gilliard bougie dilators, patients visited the outpatient clinic on a weekly basis where they were trained by a dedicated nurse. Endoscopic dilation was continued until patients were able to perform self-bougienage adequately. The primary outcome was the number of endoscopic dilation procedures before and after initiation of self-dilation. Secondary outcomes were technical success, final bougie size, dysphagia scores, and adverse events. RESULTS Seventeen patients started with esophageal self-dilation mainly because of therapy-resistant post-surgical (41%) and caustic (35%) strictures. The technical success rate of learning self-bougienage was 94% (16/17). The median number of endoscopic dilation procedures dropped from 17 [interquartile range (IQR) 11-27] procedures during a median period of 9 (IQR 6-36) months to 1.5 (IQR 0-3) procedures after the start of self-dilation (p < 0.001). The median follow-up after initiation of self-dilation was 17.6 (IQR 11.5-33.3) months. The final bougie size achieved with self-bougienage had a median diameter of 14 (IQR 13-15) mm. All patients could tolerate solid foods (Ogilvie dysphagia score ≤ 1), making the clinical success rate 94% (16/17). One patient (6%) developed a single episode of hematemesis related to self-bougienage. CONCLUSIONS In this small case series, esophageal self-dilation was found to be successful 94% of patients when conducted under strict guidance. All patients performing self-bougienage achieved a stable situation where they could tolerate solid foods without the need for endoscopic dilation.
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Affiliation(s)
- Emo E van Halsema
- Department of Gastroenterology & Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Chantal A 't Hoen
- Department of Gastroenterology & Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Patricia S de Koning
- Department of Gastroenterology & Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Wilda D Rosmolen
- Department of Gastroenterology & Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology & Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology & Hepatology, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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37
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Tsai TH, Leggett CL, Trindade AJ, Sethi A, Swager AF, Joshi V, Bergman JJ, Mashimo H, Nishioka NS, Namati E. Optical coherence tomography in gastroenterology: a review and future outlook. J Biomed Opt 2017; 22:1-17. [PMID: 29260538 DOI: 10.1117/1.jbo.22.12.121716] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 12/05/2017] [Indexed: 05/18/2023]
Abstract
Optical coherence tomography (OCT) is an imaging technique optically analogous to ultrasound that can generate depth-resolved images with micrometer-scale resolution. Advances in fiber optics and miniaturized actuation technologies allow OCT imaging of the human body and further expand OCT utilization in applications including but not limited to cardiology and gastroenterology. This review article provides an overview of current OCT development and its clinical utility in the gastrointestinal tract, including disease detection/differentiation and endoscopic therapy guidance, as well as a discussion of its future applications.
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Affiliation(s)
- Tsung-Han Tsai
- NinePoint Medical, Inc., Bedford, Massachusetts, United States
| | - Cadman L Leggett
- Mayo Clinics, Division of Gastroenterology and Hepatology, Rochester, Minnesota, United States
| | - Arvind J Trindade
- North Shore University Hospital and Hofstra Northwell School of Medicine, Division of Gastroenterolo, United States
| | - Amrita Sethi
- Columbia University Medical Center, Department of Gastroenterology, New York City, New York, United States
| | - Anne-Fré Swager
- Spaarne Gasthuis and Free University Medical Center, Amsterdam, The Netherlands
| | - Virendra Joshi
- Ochsner Clinic Foundation, Department of Gastroenterology, New Orleans, Louisiana, United States
| | - Jacques J Bergman
- Academic Medical Center, Department of Gastroenterology and Hepatology, Amsterdam, The Netherlands
| | - Hiroshi Mashimo
- Veterans Affairs Boston Healthcare System and Harvard Medical School, Department of Gastroenterology, United States
| | - Norman S Nishioka
- Massachusetts General Hospital, Gastrointestinal Unit, Boston, Massachusetts, United States
| | - Eman Namati
- NinePoint Medical, Inc., Bedford, Massachusetts, United States
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38
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van der Wel MJ, Duits LC, Seldenrijk CA, Offerhaus GJ, Visser M, Ten Kate FJ, de Boer OJ, Tijssen JG, Bergman JJ, Meijer SL. Digital microscopy as valid alternative to conventional microscopy for histological evaluation of Barrett's esophagus biopsies. Dis Esophagus 2017; 30:1-7. [PMID: 28881901 DOI: 10.1093/dote/dox078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 05/25/2017] [Indexed: 12/11/2022]
Abstract
Management of Barrett's esophagus (BE) relies heavily on histopathological assessment of biopsies, associated with significant intra- and interobserver variability. Guidelines recommend biopsy review by an expert in case of dysplasia. Conventional review of biopsies, however, is impractical and does not allow for teleconferencing or annotations. An expert digital review platform might overcome these limitations. We compared diagnostic agreement of digital and conventional microscopy for diagnosing BE ± dysplasia. Sixty BE biopsy glass slides (non-dysplastic BE (NDBE); n = 25, low-grade dysplasia (LGD); n = 20; high-grade dysplasia (HGD); n = 15) were scanned at ×20 magnification. The slides were assessed four times by five expert BE pathologists, all practicing histopathologists (range: 5-30 years), in 2 alternating rounds of digital and conventional microscopy, each in randomized order and sequence of slides. Intraobserver and pairwise interobserver agreement were calculated, using custom weighted Cohen's kappa, adjusted for the maximum possible kappa scores. Split into three categories (NDBE, IND, LGD+HGD), the mean intraobserver agreement was 0.75 and 0.84 for digital and conventional assessment, respectively (p = 0.35). Mean pairwise interobserver agreement was 0.80 for digital and 0.85 for conventional microscopy (p = 0.17). In 47/60 (78%) of digital microscopy reviews a majority vote of ≥3 pathologists was reached before consensus meeting. After group discussion, a majority vote was achieved in all cases (60/60). Diagnostic agreement of digital microscopy is comparable to that of conventional microscopy. These outcomes justify the use of digital slides in a nationwide, web-based BE revision platform in the Netherlands. This will overcome the practical issues associated with conventional histologic review by multiple pathologists.
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Affiliation(s)
- M J van der Wel
- Departments of Pathology, and Gastroenterology and Hepatology.,Gastroenterology and Hepatology
| | | | - C A Seldenrijk
- Department of Pathology, St. Antonius Hospital, Nieuwegein
| | - G J Offerhaus
- Department of Pathology, University Medical Center, Utrecht
| | - M Visser
- Department of Pathology, Zaans Medical Center, Zaandam, the Netherlands
| | - F J Ten Kate
- Department of Pathology, University Medical Center, Utrecht
| | - O J de Boer
- Departments of Pathology, and Gastroenterology and Hepatology
| | - J G Tijssen
- Cardiology, Academic Medical Center, Amsterdam
| | | | - S L Meijer
- Departments of Pathology, and Gastroenterology and Hepatology
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Swager AF, Faber DJ, de Bruin DM, Weusten BL, Meijer SL, Bergman JJ, Curvers WL, van Leeuwen TG. Quantitative attenuation analysis for identification of early Barrett's neoplasia in volumetric laser endomicroscopy. J Biomed Opt 2017; 22:86001. [PMID: 28777838 DOI: 10.1117/1.jbo.22.8.086001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/17/2017] [Indexed: 06/07/2023]
Abstract
Early neoplasia in Barrett’s esophagus (BE) is difficult to detect. Volumetric laser endomicroscopy (VLE) incorporates optical coherence tomography, providing a circumferential scan of the esophageal wall layers. The attenuation coefficient (μVLE) quantifies decay of detected backscattered light versus depth, and could potentially improve BE neoplasia detection. The aim is to investigate feasibility of μVLE for identification of early BE neoplasia. In vivo and ex vivo VLE scans with histological correlation from BE patients ± neoplasia were used. Quantification by μVLE was performed manually on areas of interest (AoIs) to differentiate neoplasia from nondysplastic (ND)BE. From ex vivo VLE scans from 16 patients (13 with neoplasia), 68 AoIs were analyzed. Median μVLE values (mm−1) were 3.7 [2.1 to 4.4 interquartile range (IQR)] for NDBE and 4.0 (2.5 to 4.9 IQR) for neoplasia, not statistically different (p=0.82). Fourteen in vivo scans were used: nine from neoplastic and five from NDBE patients. Median μVLE values were 1.8 (1.5 to 2.6 IQR) for NDBE and 2.1 (1.9 to 2.6 IQR) for neoplasia, with no statistically significant difference (p=0.37). In conclusion, there was no significant difference in μVLE values in VLE scans from early neoplasia versus NDBE. Future studies with a larger sample size should explore other quantitative methods for detection of neoplasia during BE surveillance.
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Affiliation(s)
- Anne-Fre Swager
- , Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam
| | - Dirk J Faber
- , Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam
| | - Daniel M de Bruin
- , Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam
| | - Bas L Weusten
- , Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam
| | - Sybren L Meijer
- , Department of Pathology, Academic Medical Center, Amsterdam
| | - Jacques J Bergman
- , Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam
| | | | - Ton G van Leeuwen
- , Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam
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Pouw RE, Bergman JJ. Safety Signal for the Simple Double Ablation Regimen When Using the Barrx 360 Express Radiofrequency Ablation Balloon Catheter. Gastroenterology 2017; 153:614. [PMID: 28672122 DOI: 10.1053/j.gastro.2017.05.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 05/30/2017] [Indexed: 12/02/2022]
Affiliation(s)
- Roos E Pouw
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
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Qumseya BJ, Wani S, Gendy S, Harnke B, Bergman JJ, Wolfsen H. Disease Progression in Barrett's Low-Grade Dysplasia With Radiofrequency Ablation Compared With Surveillance: Systematic Review and Meta-Analysis. Am J Gastroenterol 2017; 112:849-865. [PMID: 28374819 DOI: 10.1038/ajg.2017.70] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 01/28/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Barrett's esophagus (BE) is the only identifiable premalignant condition for esophageal adenocarcinoma (EAC). Management of BE with low-grade dysplasia continues to be controversial. We aimed to conduct a systematic review and meta-analysis comparing the risk of progression to high-grade dysplasia or EAC among patients with BE with low-grade dysplasia treated with radiofrequency ablation (RFA) compared with surveillance endoscopy. METHODS Our search included Medline, Embase, and Cochrane Central, was limited to English language articles, and was last searched on 31 December 2015. Studies were reviewed by title and abstract, and then full text by two independent reviewers. Two independent reviewers extracted data. Differences were resolved by consensus. The primary outcome of interest was the relative risk of disease progression among patients with BE with low-grade dysplasia treated with RFAcompared with surveillance. RESULTS Our search resulted in 2,029 citations, 19 studies were included in the final analysis, totaling 2,746 patients. Relative risk of disease progression in RFA compared with surveillance was 0.14% (95% confidence interval: 0.04-0.45), P=0.001. This measure was stable when only all studies were included. Absolute risk reduction was 10.9% and the number needed to treat was 9.2. Results were stable over several quality measures, overtime, and when excluding randomized trials. The cumulative rate of progression to high-grade dysplasia/EAC was lower in RFA compared with surveillance (1.7% vs. 12.6%, P<0.001). CONCLUSIONS Similarly, the incidence rate of progression among patients with surveillance was significantly higher from those treated with RFA (0.022 vs. 0.005, P<0.001). RFA results in a significant reduction risk of disease progression to high-grade dysplasia/EAC among patients with BE with low-grade dysplasia.
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Affiliation(s)
- Bashar J Qumseya
- Division of Gastroenterology and Hepatology, Archbold Medical Group/Florida State University, Thomasville, Georgia, USA
| | - Sachin Wani
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, USA
| | - Sherif Gendy
- Florida A &M University, Tallahassee, Florida, USA
| | - Ben Harnke
- Division of Gastroenterology and Hepatology, University of Colorado, Aurora, Colorado, USA
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Centre Amsterdam, Amsterdam, Netherlands
| | - Herbert Wolfsen
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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Swager A, Boerwinkel DF, de Bruin DM, Weusten BL, Faber DJ, Meijer SL, van Leeuwen TG, Curvers WL, Bergman JJ. Volumetric laser endomicroscopy in Barrett's esophagus: a feasibility study on histological correlation. Dis Esophagus 2016; 29:505-12. [PMID: 25951873 DOI: 10.1111/dote.12371] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Volumetric laser endomicroscopy (VLE) is a novel balloon-based optical coherence tomography (OCT) imaging technique that may improve detection of early neoplasia in Barrett's esophagus (BE). Most OCT studies lack a direct correlation between histology and OCT images. The aim is to investigate the optimal approach for achieving one-to-one correlation of ex-vivo VLE images of endoscopic resection (ER) specimens with histology. BE patients with and without early neoplasia underwent ER after delineating areas with electrocoagulation markers (ECM). After ER, specimens underwent additional ex-vivo marking with several different markers (ink, pin, Gold Probe) followed by ex-vivo VLE scanning. ER specimens were carefully sectioned into tissue blocks guided by the markers. Histology and VLE slides were considered a match if ≥ 2 markers were visible on both modalities and mucosal patterns aside from these markers matched on both histology and VLE. From 16 ER specimens 120 tissue blocks were sectioned of which 23 contained multiple markers. Fourteen histology-VLE matches were identified. ECMs and ink markers proved to be the most effective combination for matching. The last 6/16 ER specimens yielded 9/14 matches, demonstrating a learning curve due to methodological improvements in marker placement and tissue block sectioning. One-to-one correlation of VLE and histology is complex but feasible. The groundwork laid in this study will provide high-quality histology-VLE correlations that will allow further research on VLE features of early neoplasia in BE.
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Affiliation(s)
- A Swager
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - D F Boerwinkel
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - D M de Bruin
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - B L Weusten
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - D J Faber
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - S L Meijer
- Department of Pathology, Academic Medical Center, Amsterdam, The Netherlands
| | - T G van Leeuwen
- Department of Biomedical Engineering and Physics, Academic Medical Center, Amsterdam, The Netherlands
| | - W L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - J J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
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Curvers WL, Bergman JJ. A new paradigm shift in endoscopy: From interpretation to automated image analysis? Gastrointest Endosc 2016; 83:115-6. [PMID: 26706300 DOI: 10.1016/j.gie.2015.08.057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 08/26/2015] [Indexed: 02/08/2023]
Affiliation(s)
- Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
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Abstract
Evaluation of patients with Barrett's esophagus (BE) using dye-based chromoendoscopy, optical chromoendoscopy, autofluorescence imaging, or confocal laser endomicroscopy does not significantly increase the number of patients with a diagnosis of early neoplasia compared with high-definition white light endoscopy (HD-WLE) with random biopsy analysis. These newer imaging techniques are not more effective in standard surveillance of patients with BE because the prevalence of early neoplasia is low and HD-WLE with random biopsy analysis detects most cases of neoplasia. The evaluation and treatment of patients with BE and early stage neoplasia should be centralized in tertiary referral centers, where procedures are performed under optimal conditions, by expert endoscopists. Lesions that require resection are almost always detected by HD-WLE, although advanced imaging techniques can detect additional flat lesions. However, these are of limited clinical significance because they are effectively eradicated by ablation therapy. No endoscopic imaging technique can reliably assess submucosal or lymphangio invasion. Endoscopic resection of early stage neoplasia in patients with BE is important for staging and management. Optical chromoendoscopy can also be used to evaluate lesions before endoscopic resection and in follow-up after successful ablation therapy.
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Affiliation(s)
- Anne-Fré Swager
- Department of Gastroenterology and Hepatology, Academic Medical Center, Room B1-245, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Michelangelolaan 2, Eindhoven, 5623 EJ, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Room B1-245, Meibergdreef 9, Amsterdam, 1105 AZ, The Netherlands.
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Swager AF, Boerwinkel DF, de Bruin DM, Faber DJ, van Leeuwen TG, Weusten BL, Meijer SL, Bergman JJ, Curvers WL. Detection of buried Barrett's glands after radiofrequency ablation with volumetric laser endomicroscopy. Gastrointest Endosc 2016; 83:80-8. [PMID: 26124075 DOI: 10.1016/j.gie.2015.05.028] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 05/20/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The prevalence and clinical relevance of buried Barrett's glands (BB) after radiofrequency ablation (RFA) in Barrett's esophagus (BE) are debated. Recent optical coherence tomography studies demonstrated a high prevalence of BBs. Direct histological correlation, however, has been lacking. Volumetric laser endomicroscopy (VLE) is a second-generation optical coherence tomography system capable of scanning a large surface of the esophageal wall layers with low-power microscopy resolution. The aim was to evaluate whether post-RFA subsquamous glandular structures (SGSs), detected with VLE, actually correspond to BBs by pursuing direct histological correlation with VLE images. METHODS In vivo VLE was performed to detect SGSs in patients with endoscopic regression of BE post-RFA. A second in vivo VLE scan was performed to confirm correct delineation of the SGSs. After endoscopic resection, the specimens were imaged ex vivo with VLE. Extensive histological sectioning of SGS areas was performed, and all histology slides were evaluated by an expert BE pathologist. RESULTS Seventeen patients underwent successful in vivo VLE (histological diagnosis before endoscopic treatment: early adenocarcinoma in 8 patients and high-grade dysplasia in 9). In 4 of 17 patients, no SGSs were identified during VLE, and a random resection was performed. In the remaining 13 patients (76%), VLE detected SGS areas, which were all confirmed on a second in vivo VLE scan and subsequently resected. Most SGSs identified by VLE corresponded to normal histological structures (eg, dilated glands and blood vessels). However, 1 area containing BBs was found on histology. No specific VLE features to distinguish between BBs and normal SGSs were identified. CONCLUSIONS VLE is able to detect subsquamous esophageal structures. One area showed BBs beneath endoscopically normal-appearing neosquamous epithelium; however, most post-RFA SGSs identified by VLE correspond to normal histological structures. ( CLINICAL TRIAL REGISTRATION NUMBER NTR4056.).
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Affiliation(s)
- Anne-Fré Swager
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - David F Boerwinkel
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Daniel M de Bruin
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - Dirk J Faber
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - Ton G van Leeuwen
- Department of Pathology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bas L Weusten
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Sybren L Meijer
- Department of Biomedical Engineering, Academic Medical Center, Amsterdam, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Wouter L Curvers
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, the Netherlands
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Cotton CC, Duits LC, Wolf WA, Peery AF, Dellon ES, Bergman JJ, Shaheen NJ. Spatial predisposition of dysplasia in Barrett's esophagus segments: a pooled analysis of the SURF and AIM dysplasia trials. Am J Gastroenterol 2015; 110:1412-9. [PMID: 26346864 PMCID: PMC4785998 DOI: 10.1038/ajg.2015.263] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 06/02/2015] [Indexed: 02/07/2023]
Abstract
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%.
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Affiliation(s)
- Cary C Cotton
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Lucas C Duits
- Division of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - W Asher Wolf
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Anne F Peery
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Evan S. Dellon
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
| | - Jacques J. Bergman
- Division of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, Netherlands
| | - Nicholas J Shaheen
- University of North Carolina at Chapel Hill, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, Chapel Hill, NC, USA
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Eluri S, Brugge WR, Daglilar ES, Jackson SA, Styn MA, Callenberg KM, Welch DC, Barr TM, Duits LC, Bergman JJ, Shaheen NJ. The Presence of Genetic Mutations at Key Loci Predicts Progression to Esophageal Adenocarcinoma in Barrett's Esophagus. Am J Gastroenterol 2015; 110:828-34. [PMID: 26010308 PMCID: PMC4471888 DOI: 10.1038/ajg.2015.152] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2015] [Revised: 03/02/2015] [Accepted: 04/02/2015] [Indexed: 02/07/2023]
Abstract
OBJECTIVES Risk stratification in Barrett's esophagus (BE) is challenging. We evaluated the ability of a panel of genetic markers to predict progression to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC). METHODS In this case-control study, we assessed a measure of genetic instability, the mutational load (ML), in predicting progression to HGD or EAC. Cases had nondysplastic BE or low-grade dysplasia (LGD) at baseline and developed HGD/EAC ≥1 year later. Controls were matched 2:1, had nondysplastic BE or LGD, and no progression at follow-up. Formalin-fixed, paraffin-embedded tissue was microdissected for the epithelium. Loss of heterozygosity (LOH) and microsatellite instability (MSI) were assessed. ML was calculated from derangements in 10 genomic loci. High-clonality LOH mutations were assigned a value of 1, low-clonality mutations were assigned a value of 0.5, and MSI 0.75 at the first loci, and 0.5 for additional loci. These values were summed to the ML. Receiver operator characteristic (ROC) curves were created. RESULTS There were 69 patients (46 controls and 23 cases). Groups were similar in age, follow-up time, baseline histology, and the number of microdissected targets. Mean ML in pre-progression biopsies was higher in cases (2.21) than in controls (0.42; P<0.0001). Sensitivity was 100% at ML ≥0.5 and specificity was 96% at ML ≥1.5. Accuracy was highest at 89.9% for ML ≥1. ROC curves for ML ≥1 demonstrated an area under the curve (AUC) of 0.95. CONCLUSIONS ML in pre-progression BE tissue predicts progression to HGD or EAC. Although further validation is necessary, ML may have utility as a biomarker in endoscopic surveillance of BE.
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Affiliation(s)
- Swathi Eluri
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - William R Brugge
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ebubekir S Daglilar
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sara A Jackson
- Interpace Diagnostics Corporation, Pittsburgh, Pennsylvania, USA
| | - Mindi A Styn
- Interpace Diagnostics Corporation, Pittsburgh, Pennsylvania, USA
| | | | | | - Todd M Barr
- Department of Pathology and Laboratory Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Lucas C Duits
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA,Medicine and Epidemiology, Center for Esophageal Diseases and Swallowing, Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, 130 Mason Farm Road CB# 7080, Chapel Hill, North Carolina 27599, USA. E-mail:
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Gerritsen A, van der Poel MJ, de Rooij T, Molenaar IQ, Bergman JJ, Busch OR, Mathus-Vliegen EM, Besselink MG. Systematic review on bedside electromagnetic-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes. Gastrointest Endosc 2015; 81:836-47.e2. [PMID: 25660947 DOI: 10.1016/j.gie.2014.10.040] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 10/30/2014] [Indexed: 12/30/2022]
Abstract
BACKGROUND Nasoenteral tube feeding is frequently required in hospitalized patients to either prevent or treat malnutrition, but data on the optimal strategy of tube placement are lacking. OBJECTIVE To compare the efficacy and safety of bedside electromagnetic (EM)-guided, endoscopic, and fluoroscopic placement of nasoenteral feeding tubes in adults. DESIGN Systematic review of the literature. PATIENTS Adult hospitalized patients requiring nasoenteral feeding. INTERVENTIONS EM-guided, endoscopic, and/or fluoroscopic nasoenteral feeding tube placement. MAIN OUTCOME MEASUREMENTS Success rate of tube placement and procedure- or tube-related adverse events. RESULTS Of 354 screened articles, 28 studies were included. Data on 4056 patients undergoing EM-guided (n = 2921), endoscopic (n = 730), and/or fluoroscopic (n = 405) nasoenteral feeding tube placement were extracted. Tube placement was successful in 3202 of 3789 (85%) EM-guided procedures compared with 706 of 793 (89%) endoscopic and 413 of 446 (93%) fluoroscopic procedures. Reinsertion rates were similar for EM-guidance (270 of 1279 [21%] patients) and endoscopy (64 of 394 [16%] patients) or fluoroscopy (10 of 38 [26%] patients). The mean (standard deviation) procedure time was shortest with EM-guided placement (13.4 [12.9] minutes), followed by endoscopy and fluoroscopy (14.9 [8.7] and 16.2 [23.6] minutes, respectively). Procedure-related adverse events were infrequent (0.4%, 4%, and 3%, respectively) and included mainly epistaxis. The tube-related adverse event rate was lowest in the EM-guided group (36 of 242 [15%] patients), followed by fluoroscopy (40 of 191 [21%] patients) and endoscopy (115 of 384 [30%] patients) and included mainly dislodgment and blockage of the tube. LIMITATIONS Heterogeneity and limited methodological quality of the included studies. CONCLUSION Bedside EM-guided placement of nasoenteral feeding tubes appears to be as safe and effective as fluoroscopic or endoscopic placement. EM-guided tube placement by nurses may be preferred over more costly procedures performed by endoscopists or radiologists, but randomized studies are lacking.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands; Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Thijs de Rooij
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, the Netherlands
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | | | - Marc G Besselink
- Department of Surgery, Academic Medical Center, Amsterdam, the Netherlands.
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Gerritsen A, de Rooij T, Dijkgraaf MG, Busch OR, Bergman JJ, Ubbink DT, van Duijvendijk P, Erkelens GW, Molenaar IQ, Monkelbaan JF, Rosman C, Tan AC, Kruyt PM, Bac DJ, Mathus-Vliegen EM, Besselink MG. Electromagnetic guided bedside or endoscopic placement of nasoenteral feeding tubes in surgical patients (CORE trial): study protocol for a randomized controlled trial. Trials 2015; 16:119. [PMID: 25872782 PMCID: PMC4390000 DOI: 10.1186/s13063-015-0633-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 03/04/2015] [Indexed: 12/12/2022] Open
Abstract
Background Gastroparesis is common in surgical patients and frequently leads to the need for enteral tube feeding. Nasoenteral feeding tubes are usually placed endoscopically by gastroenterologists, but this procedure is relatively cumbersome for patients and labor-intensive for hospital staff. Electromagnetic (EM) guided bedside placement of nasoenteral feeding tubes by nurses may reduce patient discomfort, workload and costs, but randomized studies are lacking, especially in surgical patients. We hypothesize that EM guided bedside placement of nasoenteral feeding tubes is at least as effective as endoscopic placement in surgical patients, at lower costs. Methods/Design The CORE trial is an investigator-initiated, parallel-group, pragmatic, multicenter randomized controlled non-inferiority trial. A total of 154 patients admitted to gastrointestinal surgical wards in five hospitals, requiring nasoenteral feeding, will be randomly allocated to undergo EM guided or endoscopic nasoenteral feeding tube placement. Primary outcome is reinsertion of the feeding tube, defined as the insertion of an endoscope or tube in the nose/mouth and esophagus for (re)placement of the feeding tube (e.g. after failed initial placement or dislodgement or blockage of the tube). Secondary outcomes include patient-reported outcomes, costs and tube (placement) related complications. Discussion The CORE trial is designed to generate evidence on the effectiveness of EM guided placement of nasoenteral feeding tubes in surgical patients and the impact on costs as compared to endoscopic placement. The trial potentially offers a strong argument for wider implementation of this technique as method of choice for placement of nasoenteral feeding tubes. Trial registration Dutch Trial Register: NTR4420, date registered 5-feb-2014 Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0633-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Arja Gerritsen
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands. .,Department of Surgery, University Medical Center Utrecht, PO Box 85500, , 3508, GA, Utrecht, the Netherlands.
| | - Thijs de Rooij
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Marcel G Dijkgraaf
- Clinical Research Unit, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Olivier R Busch
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Jacques J Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Dirk T Ubbink
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
| | - Peter van Duijvendijk
- Department of Surgery, Gelre Hospital, PO Box 9014, 7300, DS, Apeldoorn, the Netherlands.
| | - G Willemien Erkelens
- Department of Gastroenterology, Gelre Hospital, PO Box 9014, 7300, DS, Apeldoorn, the Netherlands.
| | - I Quintus Molenaar
- Department of Surgery, University Medical Center Utrecht, PO Box 85500, , 3508, GA, Utrecht, the Netherlands.
| | - Jan F Monkelbaan
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, PO Box 85500, 3508, GA, Utrecht, the Netherlands.
| | - Camiel Rosman
- Department of Surgery, Canisius Wilhelmina Hospital, PO Box 9015, 6500, GS, Nijmegen, the Netherlands.
| | - Adriaan C Tan
- Department of Gastroenterology, Canisius Wilhelmina Hospital, PO Box 9015, 6500, GS, Nijmegen, the Netherlands.
| | - Philip M Kruyt
- Department of Surgery, Hospital Gelderse Vallei, PO Box 9025, 6710, HN, Ede, the Netherlands.
| | - Dirk Jan Bac
- Department of Gastroenterology, Hospital Gelderse Vallei, PO Box 9025, 6710, HN, Ede, the Netherlands.
| | - Elisabeth M Mathus-Vliegen
- Department of Gastroenterology and Hepatology, Academic Medical Center, PO Box 22660, 1100, DD, Amsterdam, the Netherlands.
| | - Marc G Besselink
- Department of Surgery, Academic Medical Center, PO Box 22660, , 1100 DD, Amsterdam, the Netherlands.
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Abstract
Evaluation of patients with Barrett's oesophagus (BO) using dye-based chromoendoscopy, optical chromoendoscopy, autofluorescence imaging, or confocal laser endomicroscopy does not significantly increase the number of patients with a diagnosis of early neoplasia compared with high-definition white light endoscopy (HD-WLE) with random biopsy analysis. These newer imaging techniques are not more effective in standard surveillance of patients with BO because the prevalence of early neoplasia is low and HD-WLE with random biopsy analysis detects most cases of neoplasia. The evaluation and treatment of patients with BO and early-stage neoplasia should be centralized in tertiary referral centers, where procedures are performed under optimal conditions, by expert endoscopists. Lesions that require resection are almost always detected by HD-WLE, although advanced imaging techniques can detect additional flat lesions. However, these are of limited clinical significance because they are effectively eradicated by ablation therapy. No endoscopic imaging technique can reliably assess submucosal or lymphangio-invasion. Endoscopic resection of early-stage neoplasia in patients with BO is important for staging and management. Optical chromoendoscopy can also be used to evaluate lesions before endoscopic resection and in follow-up after successful ablation therapy.
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Affiliation(s)
- A Swager
- Dept. of Gastroenterology and Hepatology Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands.
| | - W L Curvers
- Dept. of Gastroenterology and Hepatology Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands.
| | - J J Bergman
- Dept. of Gastroenterology and Hepatology Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, Netherlands.
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