Mo1293 FACTORS ASSOCIATED WITH LACK OF COMPLETE REMISSION OF INTESTINAL METAPLASIA IN PATIENTS WITH BARRETT’S ESOPHAGUS ASSOCIATED HIGH GRADE DYSPLASIA AND INTRAMUCOSAL CANCER

Abstract

Barrett’s esophagus (BE) is a well-established precursor of esophageal adenocarcinoma (EAC), which is associated with significant morbidity and mortality. Endoscopic therapy is the current preferred treatment modality for BE-associate high-grade dysplasia (HGD) and intramucosal cancer (IMC). However, little is known about the long-term efficacy of endoscopic therapy for the complete remission of intestinal metaplasia (CRIM), and its relationship with patient-oriented outcomes. The primary aim was to identify independent predictors of failure of CRIM in patients with BE associated HGD and IMC. The secondary aim was to compare adverse events associated with endoscopy therapy. Retrospective cohort study from a prospectively collected database of consecutive adult patients with BE and associated HGD and/or IMC that underwent an upper endoscopy between 2008 and 2018 in a tertiary care center in Canada. Patients that were treated with surgery, chemotherapy, radiotherapy or those without at least one year of follow-up were excluded. Patients’ characteristics were compared using chi-squared or Fisher exact tests for proportions. A multivariable logistic regression model was built to identify independent predictors of lack of CRIM. Of 328 patients with BE, 28% were diagnosed with HGD and 72% with IMC during the study period; 77% were male; mean age 65. Median follow up was 34 (range 12-117) months. Treatment for BE consisted of radiofrequency ablation (RFA), endoscopic mucosal resection (EMR) or hot avulsion (HA). The overall rate of CRIM was 63%; 67% for HGD and 61% for IMC. The median time to achieve CRIM was 20 (range 1-82) months. Rates of CRIM were 82% for younger (≤ 65 years) compared to 52% for older (> 65 years) patients, 59% for those with, and 92% for those without, a hiatal hernia (p<0.001), 78% for short-segment BE vs. 39% for long-segment BE (LSBE) (p<0.001). Patients with diabetes mellitus (p=0.0035) or hypertension (p=0.0016) were also less likely to achieve CRIM; sex, body mass index, smoking history, and dyslipidemia were not associated with CRIM. In multivariate analysis, the factors that remain associated with failure to achieve CRIM were older age (OR 2.26; 95% CI:1.22-4.30), hiatal hernia (OR 4.90; 95% CI:1.61-21.40) and LSBE (OR 3.78; 95% CI:2.21-6.58). Overall incidence of adverse events (predominantly strictures requiring dilation) was 42%; 35% for HGD and 46% for IMC, which was more frequent in the CRIM (48%) compared to the non-CRIM groups (35%) (p=0.029). Older patients, those with a hiatal hernia, and LSBE are predictors of failure to achieve CRIM with endoscopic therapy. These patients may need more aggressive treatment in order to achieve CRIM, but potentially at a cost of an increased rate of esophageal strictures.