Real-time diagnosis of Barrett's esophagus: a prospective, multicenter study comparing confocal laser endomicroscopy with conventional histology for the identification of intestinal metaplasia in new users

INTRODUCTION

Endoscopic evaluation with high-definition white light endoscopy and random 4-quadrant biopsy (Seattle Protocol) is the current standard of care for the detection of Barrett's esophagus (BE). Recently, enhanced imaging technologies have become available to provide real-time diagnosis of intestinal metaplasia (IM) and dysplasia, reducing the need for tissue biopsy. Probe-based confocal laser endomicroscopy (pCLE) provides dynamic microscopic mucosal views, rapidly capturing digital images that become optical biopsies. This study examined the role of pCLE in BE screening and surveillance as compared to the Seattle Protocol.

METHODS

Patients undergoing BE screening or surveillance endoscopy were enrolled at eight US centers. Optical biopsy using pCLE was interpreted in real time. Endoscopists performing pCLE were new users with a median experience of 8.5 months and no formal training in surgical pathology. Seattle Protocol biopsies were then taken. Recorded pCLE images were reviewed by a blinded expert in optical biopsy interpretation.

RESULTS

Early pCLE users identified significantly more patients with IM than the Seattle Protocol overall (99/172 vs. 46/172, p < 0.0001). Early users of pCLE also identified significantly more patients with IM than the Seattle Protocol in the patients with visible columnar lined esophagus (75 vs. 31, p < 0.0001), but not in the 76 patients without columnar lined esophagus (24 vs. 15, p = 0.067). There was no statistically significant difference between early pCLE users and expert review.

CONCLUSION

Optical biopsy using pCLE technology allows for the real-time evaluation of entire segments of columnar lined esophagus. Consequently, pCLE is considerably more sensitive in the detection of BE than the Seattle Protocol, which leaves a majority of epithelium unexamined. This effect is seen even in new users and increases with experience. Overall, pCLE provides a promising advance in Barrett's detection which will likely result in superior identification of individuals at risk for esophageal adenocarcinoma.

Can Rural Minimally Invasive Surgery Fellowships Provide Operative Experience Similar to Urban Programs?

OBJECTIVE

Operative experience in rural fellowship programs is largely unknown. The 2 of the most rural minimally invasive surgery (MIS)/bariatric fellowships are located in the upper Midwest. We hypothesized that these 2 programs would offer a similar operative experience to other U.S. programs in more urban locations.

DESIGN

The 2011 to 2012 and 2012 to 2013 fellowship case logs from 2 rural Midwest programs were compared with case logs from 23 U.S. MIS/bariatric programs. All rural Midwest fellowship graduates completed a survey describing their fellowship experience and current practice. Statistical analysis included Wilcoxon rank-sum test.

SETTING

Setting included the 2 rural Midwest U.S. MIS/bariatric fellowship programs.

PARTICIPANTS

Graduates from MIS/bariatric fellowship programs participated in the study.

RESULTS

Mean volumes for bariatric, foregut, abdominal wall, small intestine, and hepatobiliary cases for rural Midwest fellows vs. other U.S. programs were 123.8 ± 23.7 vs. 150.2 ± 49.2 (p = 0.20); 44.3 ± 19.4 vs. 66.3 ± 35.5 (p = 0.18); 48.3 ± 28.0 vs. 57.9 ± 27.8 (p = 0.58); 11.3 ± 1.9 vs. 12.0 ± 8.7 (p = 0.58); and 55.0 ± 34.8 vs. 48.1 ± 42.6 (p = 0.63), respectively. Mean endoscopy volume was significantly higher among rural Midwest fellows (451.0 ± 395.2 vs. 99.7 ± 83.4; p = 0.05). All rural Midwest fellows reported an adequate number of cases as operating surgeon during fellowship. A total of 60% of fellows currently practice in a rural area. In all, 87% and 13% reported that their fellowship training was extremely or somewhat beneficial to their current practice, respectively.

CONCLUSIONS

Rural MIS fellowship programs offer a similar operative experience to other U.S. programs. A greater volume of endoscopy cases was observed in rural Midwest fellowships.