Systematic review with meta-analysis: the long-term efficacy of Barrett's endoscopic therapy-stringent selection criteria and a proposal for definitions.

Abstract

Barrett's endoscopic therapy (BET) is well established for neoplasia in Barrett's oesophagus using a concept of complete eradication of all Barrett's. However, long-term efficacy is not known. To perform a systematic review and meta-analysis to examine long-term efficacy of BET for Barrett's neoplasia. Electronic databases were searched for studies meeting stringent criteria: (a) subjects with high-grade dysplasia and/or superficial adenocarcinoma who underwent BET (ablation±endoscopic mucosal resection); (b) BET completion by confirmation of complete eradication of neoplasia (CE-N) and intestinal metaplasia (CE-IM) with systematic sampling and (c) clearly defined follow-up (endoscopy and biopsy) protocol of ≥2years thereafter for detection of recurrence. Pooled estimates of CE-N and CE-IM after BET completion and follow-up were analysed. Eight studies met the stringent criteria (n=794, males 89%, age 64.6years). Despite high efficacy of BET at therapy completion (CE-N: 95.9 [91.7-98.7]%; CE-IM: 90.9 [83-96.6]%), this declined (CE-N: 89 [73.4-98.2]%; CE-IM: 77.8 [65.6-88]%) over 3.4years of follow-up. There was considerable heterogeneity. Only two studies reported a post-BET follow-up of >5years (CE-IM 50 [41.5%-58.5]%). Higher person years of follow-up seem to correlate with decrease in BET efficacy. Using stringent criteria for appropriate study selection with sufficient follow-up, a lack of high-quality controlled intervention trials becomes evident for assessment of long-term durable remission rates of BET despite initial high success rates. We plea for a uniform documentation of study details which could be used in future trials.