Complete Eradication Of Intestinal Metaplasia Research Articles

Cryotherapy versus radiofrequency ablation in the treatment of dysplastic Barrett's esophagus with or without early esophageal neoplasia: a systematic review and meta-analysis.

Radiofrequency ablation (RFA) is the first-line therapy for dysplastic Barrett's esophagus (BE). Therefore, cryotherapy has emerged as an alternative treatment option. This study aimed to compare the efficacies of these two techniques based on the rates of complete eradication of intestinal metaplasia (CE-IM) and dysplasia (CE-D). Adverse events and recurrence have also been reported. An electronic search was conducted using the Medline (PubMed), Embase, LILACS, and Google Scholar databases until December 2022. Studies were included comparing cryotherapy and RFA for treating dysplastic BE with or without early esophageal neoplasia. This study was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three retrospective cohort studies involving 627 patients were included. Of these, 399 patients underwent RFA, and 228 were treated with cryotherapy. There was no difference in CE-IM (risk difference [RD], -0.03; 95% confidence interval [CI], -0.25 to 0.19; p=0.78; I2=86%) as well as in CE-D (RD, -0.03; 95% CI, -0.15 to 0.09; p=0.64; I2=70%) between the groups. The absolute number of adverse events was low, and there was no difference in the recurrence rate. Cryotherapy and RFA were equally effective in treating dysplastic BE, with or without early esophageal neoplasia.

Multi-focal dysplasia is associated with high recurrence rates after successful ablation of dysplastic Barrett's esophagus

Background & AimsBarrett's esophagus (BE) might recur after complete eradication of intestinal metaplasia (CEIM). We investigated factors associated with recurrence of BE after successful Radiofrequency ablation (RFA). MethodsA longitudinal study of BE patients with dysplasia treated with RFA from 2014 to 2021 in two large referral centers. Recurrence was identified in histologic specimens. Factors associated with post-RFA recurrence were analyzed using Cox regression analysis. ResultsA total of 728 patients with BE were identified, 118 had underwent RFA, and 113 had sufficient follow up time. Mean age was 63.7 (±11.7) years, 73.5% were males, 59.3% had long segment of BE, and 30.1% had multifocal dysplasia. During 340.8 patient-years of follow-up, 15 patients (13.3%) had recurrence of BE, which represent an incidence rate of 4.41% per patient-year. Incidence rate of recurrence with dysplasia was 1.17% per patient-year. Multifocal dysplasia, number of RFA sessions, and endoscopic resection before RFA were associated with risk of recurrence in univariate analysis. However, in cox regression analysis only multifocal dysplasia (HR 10.99; 95% CI 2.83–22.62, p = 0.001) was associated with post-RFA recurrence. ConclusionTotal recurrence rates after CEIM are low, and multifocal dysplasia before the ablative therapy is significantly associated with BE recurrence after CEIM. Patients with multifocal dysplasia should be monitored rigorously after successful ablation.

Long-term outcomes following successful endoscopic treatment of T1 esophageal adenocarcinoma: a multicenter cohort study

Endoscopic eradication therapy (EET) is guideline endorsed for management of early-stage (T1) esophageal adenocarcinoma (EAC). Patients with baseline high grade dysplasia (HGD) and EAC are at highest risk of recurrence following successful EET, but limited data exist on long-term (> 5 year) recurrence outcomes. We aimed to assess the incidence and predictors of long-term recurrence in a multicenter cohort of T1EAC patients treated with EET. Patients with T1 EAC achieving successful endoscopic cancer eradication with a minimum of 5-years clinical follow-up were included. The primary outcome was neoplastic recurrence, defined as dysplasia or EAC, and was characterized as early (<2 years), intermediate (2-5 years), or late (>5 years). Predictors of recurrence were assessed by time to event analysis. 84 T1 EAC patients (75 T1a, 9 T1b) with a median 9.1 years (range 5.1-18.3 years) of follow-up were included. The overall incidence of neoplastic recurrence was 2.0/100 patient years of follow up. 7 recurrences (3 dysplasia, 4 EAC) occurred after 5 years of EAC remission. 88% of recurrences were treated successfully endoscopically. EAC recurrence-related mortality occurred in 3 patients at a median of 5.2 years from EAC remission. Complete eradication of intestinal metaplasia (CE-IM) was independently associated with reduced recurrence (HR 0.13). Following successful EET of T1 EAC, neoplastic recurrence occurred after 5 years in 8.3% of cases. Careful long-term surveillance should be continued in this patient population. CE-IM should be the therapeutic endpoint for EET.

Impact of Residing in Below Median Household Income Districts on Outcomes in Patients with Advanced Barrett's Esophagus.

Barrett's esophagus (BE) is a premalignant condition to esophageal adenocarcinoma (EAC). Low socioeconomic (SES) status adversely impacts care and outcomes in patients with EAC, but this has not been evaluated in BE. As the treatment of BE is similarly intensive, we aimed to evaluate the effect of SES on achieving complete eradication of intestinal metaplasia (CE-IM), dysplasia (CE-D) and development of invasive EAC. Our study was a retrospective cohort study. Consecutive patients between January 1, 2010, to December 31, 2018, referred for BE-associated high-grade dysplasia or intramucosal adenocarcinoma were included. Pre, intra and post-procedural data were collected. Household income data was collected from the 2016 census based on postal code region. Patients were divided into income groups relative to the 2016 median household income in Ontario. Multivariate regression was performed for outcomes of interest. Four hundred and fifty-nine patients were included. Rate of CE-IM was similar between income groups. Fifty-five per cent (n = 144/264) versus 65% (n = 48/264) in the below and above-income groups achieved CE-D, respectively, P = 0.02. Eighteen per cent (n = 48/264) versus 11% (n = 22/195) were found to have invasive EAC during their treatment course in below and above-income groups, respectively, P = 0.04. Residing in a below-median-income district was associated with developing invasive EAC (Odds Ratio, [OR] 1.84, 95% confidence interval [CI] 1.01 to 3.35) and failure to achieve CE-D (OR 0.64, 95% CI 0.42 to 0.97). Residing in low-income districts is associated with worse outcomes in patients with advanced BE. Further research is needed to guide future initiatives to address the potential impact of SES barriers in the optimal care of BE.

Management of Post Ablative Barrett's Esophagus: a Review of Current Practices and Look at Emerging Technologies.

Endoscopic eradication therapy is an effective and durable treatment for Barrett's esophagus (BE) related neoplasia, but even after achieving successful eradication, these patients remain at risk for recurrence and require ongoing routine examinations. The optimal surveillance protocol including endoscopic technique, sampling strategy, and timing are still being refined. The aim of this review is to discuss current management principles for the post ablation patient and emerging technologies to guide clinical practice. There is increasing evidence to support less frequent surveillance exams in the first year after complete eradication of intestinal metaplasia and a move towards targeted biopsies of visible lesions and sampling high-risk locations such as the gastroesophageal junction. Promising technologies on the horizon that could impact management include novel biomarkers, personalized surveillance intervals, and non-endoscopic approaches. Ongoing high-quality examinations after endoscopic eradication therapy are key to limiting recurrent BE. Surveillance intervals should be based on the pretreatment grade of dysplasia. Future research should focus on technologies and surveillance practices that are most efficient for patients and the healthcare system.

Radio frequency ablation of dysplastic Barrett's esophagus: Outcomes of a single-center registry.

Barrett's esophagus (BE) is associated with an increased risk of esophageal adenocarcinoma. The use of radio frequency ablation (RFA) for complete eradication of BE with confirmed low-grade dysplasia (LGD) or high-grade dysplasia (HGD) has been promising in multicenter trials. Our aim was to evaluate the safety and efficacy outcomes associated with RFA for patients with BE and LGD/HGD in a single-center setting. This was a retrospective single-center study conducted at Department of Surgery and Transplantation, Rigshospitalet, Denmark. Data were collected from all patients who had undergone RFA for LGD or HGD from January 2014 to December 2018. Effectiveness outcomes were based on histology: complete eradication of dysplasia (CE-D), defined as all esophageal biopsies being negative for dysplasia at the last biopsy session, and complete eradication of intestinal metaplasia (CE-IM) defined as esophageal biopsies being without intestinal metaplasia. Safety outcomes were based on the proportion of complications to the RFA treatment. A total of 107 patients were identified during the follow-up period (75% men, median age = 65 years); 83% had LGD and 17% had HGD. The median follow-up was 25 months. After the last RFA treatment, CE-D was achieved in 89%. CE-D and CE-IM were achieved in 60%. Complications occurred in 6.5% of the patients. In patients with BE and confirmed LGD or HGD, RFA was associated with a high rate of CE-D and a low risk of complications. The observed safety and efficacy outcomes were comparable with those previously reported in multicenter trials, showing that the Danish treatment of BE with LGD and HGD is comparable with those of larger European expert centers.

Predictive factors of radiofrequency ablation failure in the treatment of dysplastic Barrett's esophagus

IntroductionRadiofrequency ablation (RFA) has become the recommended endoscopic treatment for flat dysplastic Barrett's esophagus. However, the outcomes of this treatment are variable across European countries. Our aim was to report the results of a French high-volume center, and to investigate factors associated with treatment failure. MethodsWe conducted a single-center retrospective study from a prospectively collected database from 2011 to 2020, including all consecutive patients treated with RFA for flat dysplastic Barrett's esophagus. The primary endpoint was the failure rate of esophageal radiofrequency treatment, defined as either persistence of intestinal metaplasia at the end of treatment, or neoplastic progression during RFA. Results96 patients treated with a median of four RFA sessions for a mean C5M6 Barrett's esophagus were included in the analysis. Complete eradication of intestinal metaplasia and dysplasia were achieved in 59% and 79% of patients, respectively, resulting in a treatment failure rate of 41%. Ten patients experienced neoplastic progression during treatment. We recorded 14% of post-RFA esophageal strictures, all successfully treated by endoscopic dilatation. Univariate analysis identified the length of Barrett's esophagus and the absence of hiatal hernia as predictive factors for treatment failure, however not confirmed in multivariate analysis. ConclusionIn our experience, RFA of flat dysplastic Barrett's esophagus had a 41% treatment failure rate. The length of the Barrett's segment might be associated with treatment failure. Although our results confirm a role for RFA in the management of dysplastic Barrett's esophagus, the treatment failure rate was higher than expected. This suggest that endoscopists, even in high-volume centers, should receive specific training in RFA.

S400 A Cost Utility Model Supports Changes in Post-Treatment Surveillance Associated With the 2022 American College of Gastroenterology Guidelines

Introduction: Radiofrequency ablation is a safe and effective treatment for neoplastic Barrett’s esophagus (BE), but surveillance after endoscopic eradication has only been studied observationally without any studies of this disease’s natural history. Recent natural history modeling work has allowed qualified estimation of a natural history scenario. We sought to apply our multi-state model of post-ablation natural history to study the cost effectiveness of surveillance after endoscopic eradication of neoplastic BE. Methods: We constructed a microsimulation cost-utility model of endoscopic surveillance after complete eradication of intestinal metaplasia (CEIM) with intervals as recommended by the 2022 American College of Gastroenterology BE guideline. A cohort of participants were modeled after the United States (US) Radiofrequency Ablation cohort in terms of demographics, worst prior histologic grade, and pre-treatment BE segment length. Transition probabilities for the natural history were estimates from published multi-state models. The model was Markov generalized to allow differing rates of progression based on BE characteristics as covariates to the multi-state model and for other-cause mortality to depend on age. There were states for: no recurrence, recurrence with various histologic grades, ablative re-treatment, endoscopic mucosal resection, invasive adenocarcinoma, and death. We considered a willingness-to-pay threshold of 100,000 2017 US dollars ($) per quality-adjusted life year (QALY). Model parameters and their sources are described in the Table. Results: In the base case scenario of the model, surveillance and re-treatment decreased progression to invasive esophageal adenocarcinoma at ten years by 1.2% in LGD and 13.0% in HGD/IMC (Figure). Compared to the natural history scenario, the incremental cost effectiveness ratio for surveillance at ten years was $79,125 for LGD and $10,952 for HGD/IMC. Conclusion: In the base case scenario of this cost-utility model, newly recommended surveillance intervals were highly cost effective for HGD/IMC and approached the margins of cost-effectiveness for LGD in a microsimulation cost-utility model. This supports the new guideline recommendation to decrease the frequency of post-treatment surveillance of HGD/IMC and LGD. While development of the model requires probabilistic sensitivity analysis and calibration, the model has the potential to inform the health economics of clinical processes after CEIM. Table 1. - Microsimulation model parameters in the base case scenario and their sources. Model variable Base case value Reference/details Structural model assumptions Model cycle length 3 months Model time horizon 10 years Model starting year 2017 For other-cause mortality and inflation adjustment Other cause mortality Population 2020 Social Security actuarial cohort life Tables Time for resection 1 cycle Resection for all recurrent HGD or IMC Resection success rate 100% Simplifying assumption Time for ablation 1 cycle Repeated until successful Discounting of costs/utilities 3% Per year Probabilities per cycle from the literature Death from invasive adenocarcinoma 7.63% SEER 5-Year Relative Survival Rates 2012-2018* Complete eradication of intestinal metaplasia after recurrence 57.7% Guthikonda et al., The American Journal of Gastroenterology, 2017 Cancer progression from recurrence 0.1625% Guthikonda et al., The American Journal of Gastroenterology, 2017 Utilities per cycle from the literature Surveillance after CEIM 97% Boger et al., Alimentary Pharmacology and Therapeutics, 2010 Retreatment endoscopy 94% Boger et al., Alimentary Pharmacology and Therapeutics, 2010 Esophageal adenocarcinoma 96% Boger et al., Alimentary Pharmacology and Therapeutics, 2010 Costs per cycle from the literature Surveillance endoscopy $1,019 Inadomi et al., Gastroenterology, 2009† Cost of cancer care $13,532 Inadomi et al., Gastroenterology, 2009† Cost of ablation re-treatment $4,317 Inadomi et al., Gastroenterology, 2009† Assumed half cost of initial treatment Cost of resection re-treatment $934 Filby et al., Journal of Comparative Effectiveness Research, 2017 ** *Assumes cumulative incidence = 1 – e^(-incidence x time).†Assuming 17.7% inflation.**Assumes 133% exchange rate with the British Pound. Figure 1.: Model state occupancy by months after complete eradication of intestinal metaplasia.

533. OUTCOMES OF RADIOFREQUENCY ABLATION TO TREAT BARRETT’S OESOPHAGUS: AN IRISH MULTICENTRE STUDY

Abstract The standard two-step approach of endoscopic mucosal resection (EMR) followed by radiofrequency ablation (RFA) has shown to be both safe and effective in achieving complete eradication of intestinal metaplasia (CEIM). Despite confidence in the regimen, the long-term sustainability of CEIM has not been well-described, nor has the ideal number of RFA sessions and frequency and length of surveillance. This study used the RIBBON database in Ireland to analyse these factors. Analysis was performed on 398 eligible patients who underwent at least one session of RFA to treat BE from 2009 to 2021 in major centres across Ireland. Patients included had a minimum of 12 months follow-up (FU), with a total 1433.76 patient-years of FU analysed. CEIM was defined as histological and endoscopic absence of BE at post-RFA FU. Patient outcomes were categorised according to recurrence status at FU: sustained CEIM, primary recurrence, treatment failure and unknown outcomes. They were also grouped according to the extent of dysplasia using the Vienna Grading System. Of the 398 patients, 78.14% were male, the mean age at diagnosis was 61.55 years, mean length of Barrett’s segment was 5.36cm, and baseline dysplasia was 19.3% intramucosal carcinoma (IMC), 19% high-grade dysplasia (HGD), 23.3% low-grade dysplasia (LGD) and 37.1% non-dysplastic BE (NBDE). Of these patients, 321 (80.65%) achieved CEIM, at similar proportions. Of those, 67 (20.87%) experienced recurrence over 404.97 patient-years of FU. Further recurrence following subsequent treatment was rare (6 cases). The most common type of recurrence was NDBE (95.64%), and dysplastic recurrence was uncommon (4.36%). The mean time to recurrence was 647.21 days. The results of this study showed that CEIM was achieved by RFA in the majority of cases, with dysplastic recurrence occurring at a very low rate, equating to significantly reduced disease progression. There was a significant difference between the mean number of treatments for those who achieved sustained CEIM (4.15) and those who experienced recurrence (3.29). It is clear that some adjustments to the existing treatment and surveillance regimen could result in improvements in outcome.

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Threshold evaluation for optimal number of endoscopic treatment sessions to achieve complete eradication of Barrett's metaplasia.

Endoscopic eradication therapy (EET) is the standard of care for Barrett's esophagus (BE)-associated neoplasia. Previous data suggest the mean number of EET sessions required to achieve complete eradication of intestinal metaplasia (CE-IM) is 3. This study aimed to define the threshold of EET sessions required to achieve CE-IM. The TREAT-BE Consortium is a multicenter outcomes cohort including prospectively enrolled patients with BE undergoing EET. All patients achieving CE-IM were included. Demographic, endoscopic, and histologic data were recorded at treatment onset along with treatment details and surveillance data. Kaplan-Meier analysis was performed to define a threshold of EET sessions, with 95 %CI, required to achieve CE-IM. A secondary analysis examined predictors of incomplete response to EET using multiple logistic regression and recurrence rates. 623 patients (mean age 65.2 [SD 11.6], 79.6 % male, 86.5 % Caucasian) achieved CE-IM in a mean of 2.9 (SD 1.7) EET sessions (median 2) and a median total observation period of 2.7 years (interquartile range 1.4-5.0). After three sessions, 73 % of patients achieved CE-IM (95 %CI 70 %-77 %). Age (odds ratio [OR] 1.25, 95 %CI 1.05-1.50) and length of BE (OR 1.24, 95 %CI 1.17-1.31) were significant predictors of incomplete response. The current study found that a threshold of three EET sessions would achieve CE-IM in the majority of patients. Alternative therapies and further diagnostic testing should be considered for patients who do not have significant response to EET after three sessions.

Rio de Janeiro Global Consensus on Landmarks, Definitions, and Classifications in Barrett’s Esophagus: World Endoscopy Organization Delphi Study

Despite the significant advances made in the diagnosis and treatment of Barrett's esophagus (BE), there is still a need for standardized definitions, appropriate recognition of endoscopic landmarks, and consistent use of classification systems. Current controversies in basic definitions of BE and the relative lack of anatomic knowledge are significant barriers to uniform documentation. We aimed to provide consensus-driven recommendations for uniform reporting and global application. The World Endoscopy Organization Barrett's Esophagus Committee appointed leaders to develop an evidence-based Delphi study. A working group of 6 members identified and formulated 23 statements, and 30 internationally recognized experts from 18 countries participated in 3 rounds of voting. We defined consensus as agreement by ≥80% of experts for each statement and used the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool to assess the quality of evidence and the strength of recommendations. After 3 rounds of voting, experts achieved consensus on 6 endoscopic landmarks (palisade vessels, gastroesophageal junction, squamocolumnar junction, lesion location, extraluminal compressions, and quadrant orientation), 13 definitions (BE, hiatus hernia, squamous islands, columnar islands, Barrett's endoscopic therapy, endoscopic resection, endoscopic ablation, systematic inspection, complete eradication of intestinal metaplasia, complete eradication of dysplasia, residual disease, recurrent disease, and failure of endoscopic therapy), and 4 classification systems (Prague, Los Angeles, Paris, and Barrett's International NBI Group). In round 1, 18 statements (78%) reached consensus, with 12 (67%) receiving strong agreement from more than half of the experts. In round 2, 4 of the remaining statements (80%) reached consensus, with 1 statement receiving strong agreement from 50% of the experts. In the third round, a consensus was reached on the remaining statement. We developed evidence-based, consensus-driven statements on endoscopic landmarks, definitions, and classifications of BE. These recommendations may facilitate global uniform reporting in BE.

Optimized Surveillance Intervals Following Endoscopic Eradication of Dysplastic Barrett’s Esophagus: An International Cohort Study

Recommended surveillance intervals after complete eradication of intestinal metaplasia (CE-IM) after endoscopic eradication therapy (EET) are largely not evidence-based. Using recurrence rates in a multicenter international Barrett's esophagus (BE) CE-IM cohort, we aimed to generate optimal intervals for surveillance. Patients with dysplastic BE undergoing EET and achieving CE-IM from prospectively maintained databases at 5 tertiary-care centers in the United States and the United Kingdom were included. The cumulative incidence of recurrence was estimated, accounting for the unknown date of actual recurrence that lies between the dates of current and previous endoscopy. This cumulative incidence of recurrence subsequently was used to estimate the proportion of patients with undetected recurrence for various surveillance intervals over 5 years. Intervals were selected that minimized recurrences remaining undetected for more than 6 months. Actual patterns of post-CE-IM follow-up evaluation are described. A total of 498 patients (with baseline low-grade dysplasia, 115 patients; high-grade dysplasia [HGD], 288 patients; and intramucosal adenocarcinoma [IMCa], 95 patients) were included. Any recurrence occurred in 27.1% and dysplastic recurrence occurred in 8.4% over a median of 2.6 years of follow-up evaluation. For pre-ablation HGD/IMCa, intervals of 6, 12, 18, and 24 months, and then annually, resulted in no patients with dysplastic recurrence undetected for more than 6 months, comparable with current guideline recommendations despite a 33% reduction in the number of surveillance endoscopies. For pre-ablation low-grade dysplasia, intervals of 1, 2, and 4 years balanced endoscopic burden and undetected recurrence risk. Lengthening post-CE-IM surveillance intervals would reduce the endoscopic burden after CE-IM with comparable rates of recurrent HGD/IMCa. Future guidelines should consider reduced surveillance frequency.

A127 ENDOSCOPIC MUCOSAL RESECTION FOR DYSPLASTIC AND NEOPLASTIC BARRETT’S ESOPHAGUS: FINDINGS FROM A FOREGUT NEOPLASIA MULTIDISCIPLINARY DATABASE

Abstract Background Previously, Barrett’s esophagus with high grade dysplasia (HGD) or neoplasia was treated with esophagectomy, which is associated with a high postoperative morbidity and mortality rate. Recent guidelines support the use of endoscopic mucosal resection (EMR) for T1a esophageal adenocarcinoma (EAC) and potentially T1b EAC; however, data on long term outcomes of endoscopic treatment is lacking. We created a combined prospective and retrospective multidisciplinary database to monitor outcomes of patients with Barrett’s esophagus undergoing endoscopic treatment. Aims Our primary aim was to compare outcomes of EMR and esophagectomy in patients presenting with BE and HGD, and/or early EAC. Methods A collaboration of gastroenterologists, general surgeons and thoracic surgeons from the University of Alberta, Edmonton, Alberta, provided input on the development of the database. All patients referred to the Northern Alberta Endoscopic Ablation Program from 2009–2021 who received at least one endoscopic treatment were included. A sub-analysis of all patients with pathologic confirmation of HGD, and/or early EAC was conducted to compare outcomes of EMR and esophagectomy. Results A total of 212 patients have been entered into the database. The most common findings were HGD, low grade dysplasia (LGD), and adenocarcinoma, respectively. All patients (n=48) who had at least LGD reached complete eradication of dysplasia (CE-D) and 95.8% reached complete eradication of intestinal metaplasia (CE-IM). Of those patients that reached CE-D, 8.3% developed recurrence of dysplasia (n=4). In the sub-analysis, 74 patients (76.3%) received endoscopic therapy while 23 patients (23.7%) received endoscopic therapy then ultimately an esophagectomy. There were significantly more T1b lesions in the esophagectomy group compared to the EMR group ( p&amp;lt;0.0001). Of all the patients in the EMR group, only 5.4% (n=4) had treatment related complications. Of patients receiving an esophagectomy, 60.9% (n=14) experienced treatment related complications. The mean length of stay for patients in the EMR group was 1.03 +/- 0.2 days, compared to 16.5 +/- 11.8 days for esophagectomy ( p&amp;lt;0.0001). Conclusions EMR provides definitive and durable treatment for BE lesions classified as T1b or less severe, with fewer complications and a shorter length of hospital stay than esophagectomy. Funding Agencies Alberta Innovates Health Solutions

Durability of Cryoballoon Ablation in Neoplastic Barrett's Esophagus

BACKGROUND AND AIMSEndoscopic ablation can eradicate neoplastic Barrett's esophagus (BE) without visible lesions. Cryoballoon ablation (CBA) is an established but relatively newer ablative technique that can eliminate BE but data on the durability of its treatment effects are lacking. We assessed the durability of CBA treatment for neoplastic BE. METHODSWe performed a single-center cohort study of consecutive BE patients with confirmed low-grade dysplasia, high-grade dysplasia or intramucosal cancer treated with CBA to eradicate all BE. We excluded patients with prior ablative therapy. Visible lesions were removed with endoscopic mucosal resection prior to CBA. Outcomes included complete eradication of dysplasia (CE-D) and complete eradication of intestinal metaplasia (CE-IM) at 1 year, durability at 2 and 3 years after initial ablation, cumulative recurrence rate of dysplasia and IM, and rate of neoplastic progression. RESULTSFifty-nine patients (55.9% with high-grade dysplasia; 20.3% with prior endoscopic mucosal resection) were tracked for a median of 54.3 months. CE-D and CE-IM at 1 year were 94.6% (53/56) and 75% (42/56), respectively. Allowing for retreatment, rates of maintained CE-D and CE-IM for those who have achieved CE-D or CE-IM were 100% (53/53) and 98% (47/48) at 2 years; 100% (45/45) and 98% (40/41), at 3 years, respectively. Cumulative recurrence rate was 1.9% (1/53) for dysplasia and 14.6% (7/48) for IM (not allowing for retreatment). There was no neoplastic progression. CONCLUSIONIn treatment-naïve patients with dysplastic BE, CBA is a durable endoscopic eradication therapy but endoscopic surveillance after eradication is still warranted.

Hybrid APC in Combination With Resection for the Endoscopic Treatment of Neoplastic Barrett's Esophagus: A Prospective, Multicenter Study.

INTRODUCTION:The current therapy of neoplastic Barrett's esophagus (BE) consists of endoscopic resection plus ablation, with radiofrequency ablation as the best studied technique. This prospective trial assesses a potential alternative, namely hybrid argon plasma ablation.METHODS:Consecutive patients with neoplastic BE undergoing ablation after curative endoscopic resection (89.6%) or primarily were included into this prospective trial in 9 European centers. Up to 5 ablation sessions were allowed for complete eradication of BE (initial complete eradication of intestinal metaplasia [CE-IM]), by definition including BE-associated neoplasia, documented by 1 negative endoscopy with biopsies. The main outcome was the rate of initial CE-IM in intention-to-treat (ITT) and per-protocol (PP) samples at 2 years. The secondary end points were the rate of recurrence-free cases (sustained CE-IM) documented by negative follow-up endoscopies with biopsies and immediate/delayed adverse events.RESULTS:One hundred fifty-four patients (133 men and 21 women, mean age 64 years) received a mean of 1.2 resection and 2.7 ablation sessions (range 1–5). Initial CE-IM was achieved in 87.2% of 148 cases in the PP analysis (ITT 88.4%); initial BE-associated neoplasia was 98.0%. On 2-year follow-up of the 129 successfully treated cases, 70.8% (PP) or 65.9% (ITT) showed sustained CE-IM; recurrences were mostly endoscopy-negative biopsy-proven BE epithelium and neoplasia in 3 cases. Adverse events were seen in 6.1%.DISCUSSION:Eradication and recurrence rates of Barrett's intestinal metaplasia and neoplasia by means of hybrid argon plasma coagulation at 2 years seem to be within expected ranges. Final evidence in comparison to radiofrequency ablation can only be provided by a randomized comparative trial.

Predictors of recurrence of dysplasia or cancer in patients with dysplastic Barrett's esophagus following complete eradication of dysplasia: a single-center retrospective cohort study.

Endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) for Barrett's esophagus (BE)-related high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) are considered effective treatments for eradication of BE. Little is known about the impact of achieving complete eradication of intestinal metaplasia (CE-IM) following the complete eradication of neoplasia (CE-N), specifically if CE-IM reduces the risk of recurrent dysplasia. Retrospective cohort study of consecutive patients with BE and HGD or intramucosal cancer (IMC)-treated endoscopically at a tertiary referral center between 2001 and 2019. Association between CE-IM and recurrent dysplasia after CE-N was evaluated. A total of 433 patients treated with EMR and/or RFA were included. Of these, 381 (88%) achieved CE-N, of which 345 (80%) had adequate follow-up for inclusion in the analysis. A total of 266 (77%) patients achieved CE-IM; with a median follow-up since initial treatment for HGD/IMC of 45.9months (IQR 25.9, 93.1); 20 patients (5.8%) had recurrent dysplasia after achieving CE-N. Kaplan Meier survival curves revealed that time free of recurrence in those who achieved CE-IM was significantly higher (p = 0.002). In the multivariable analysis, CE-IM was associated with a significant lower hazard of recurrence (HR 0.2, 95% CI 0.1, 0.6), whereas the number of endoscopic treatments to achieve CE-N was associated with a significant higher hazard of recurrence (HR 1.1, 95% CI 1.0, 1.2). Achieving CE-IM following CE-N reduces the risk of recurrent dysplasia and should be considered a treatment target among patients with BE undergoing endoscopic therapies for HGD or EAC.

Post-endoscopy Esophageal Neoplasia in Barrett’s Esophagus: Consensus Statements From an International Expert Panel

Post-endoscopy Esophageal Neoplasia in Barrett’s Esophagus: Consensus Statements From an International Expert Panel

Highlights from the literature

Radiofrequency ablation (RFA) is key in the therapy of early neoplasia in Barrett’s oesophagus (BO). However, a small proportion of patients experience neoplastic recurrence (NR) after complete eradication of intestinal...

Endoscopic radiofrequency ablation or surveillance in patients with Barrett’s oesophagus with confirmed low-grade dysplasia: a multicentre randomised trial

ObjectiveDue to an annual progression rate of Barrett’s oesophagus (BO) with low-grade dysplasia (LGD) between 9% and 13% per year endoscopic ablation therapy is preferred to surveillance. Since this recommendation...