Complete Remission Of Intestinal Metaplasia Research Articles

Rates of Recurrent Intestinal Metaplasia and Dysplasia After Successful Endoscopic Therapy of Barrett's Neoplasia by Endoscopic Mucosal Resection vs Endoscopic Submucosal Dissection and Ablation: A Large North American Multicenter Cohort.

Endoscopic eradication therapy (EET) combining endoscopic resection (ER) with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) followed by ablation is the standard of care for the treatment of dysplastic Barrett's esophagus (BE). We have previously shown comparable rates of complete remission of intestinal metaplasia (CRIM) with both approaches. However, data comparing recurrence after CRIM are lacking. We compared rates of recurrence after CRIM with both techniques in a multicenter cohort. Patients undergoing EET achieving CRIM at 3 academic institutions were included. Demographic and clinical data were abstracted. Outcomes included rates and predictors of any BE and dysplastic BE recurrence in the 2 groups. Cox-proportional hazards models and inverse probability treatment weighting (IPTW) analysis were used for analysis. A total of 621 patients (514 EMR and 107 ESD) achieving CRIM were included in the recurrence analysis. The incidence of any BE (15.7, 5.7 per 100 patient-years) and dysplastic BE recurrence (7.3, 5.3 per 100 patient-years) were comparable in the EMR and ESD groups, respectively. On multivariable analyses, the chances of BE recurrence were not influenced by ER technique (hazard ratio 0.87; 95% confidence interval 0.51-1.49; P = 0.62), which was also confirmed by IPTW analysis (ESD vs EMR: hazard ratio 0.98; 95% confidence interval 0.56-1.73; P = 0.94). BE length, lesion size, and history of cigarette smoking were independent predictors of BE recurrence. Patients with BE dysplasia/neoplasia achieving CRIM, initially treated with EMR/ablation, had comparable recurrence rates to ESD/ablation. Randomized trials are needed to confirm these outcomes between the 2 ER techniques.

Location and appearance of dysplastic Barrett’s esophagus recurrence after endoscopic eradication therapy: no additional yield from random biopsy sampling neosquamous mucosa

Surveillance after complete remission of intestinal metaplasia (CRIM) is essential. Current recommendations are to sample visible lesions first, followed by random 4-quadrant biopsy sampling of the original Barrett's esophagus (BE) length. To inform post-CRIM surveillance protocols, we aimed to identify the anatomic location, appearance, and histology of BE recurrences. We performed an analysis of 216 patients who achieved CRIM after endoscopic eradication therapy for dysplastic BE at a Barrett's Referral Unit between 2008 and 2021. The anatomic location, recurrence histology, and endoscopic appearance of dysplastic recurrences were evaluated. After a median of 5.5 years (interquartile range, 2.9-7.2) of follow-up after CRIM, 57 patients (26.4%) developed nondysplastic BE (NDBE) recurrence and 18 patients (8.3%) developed dysplastic recurrence. From 8158 routine surveillance biopsy samplings of normal-appearing tubular esophageal neosquamous epithelium, the yield for recurrent NDBE or dysplasia was 0%. One hundred percent of dysplastic tubular esophageal recurrences were visible and in BE islands, whereas 77.8% of gastroesophageal junction dysplastic recurrences were nonvisible. Four distinct endoscopic features suspicious for recurrent advanced dysplasia or neoplasia were identified: buried or subsquamous BE, irregular mucosal pattern, loss of vascular pattern, and nodularity or depression. The yield of routine surveillance biopsy sampling of normal-appearing tubular esophageal neosquamous epithelium was zero. BE islands with indistinct mucosal or loss of vascular pattern, nodularity or depression, and/or signs of buried BE should raise clinician suspicion for advanced dysplasia or neoplasia recurrence. We suggest a new surveillance biopsy sampling protocol with a focus on meticulous inspection, followed by targeted biopsy sampling of visible lesions and random 4-quadrant biopsy sampling of the gastroesophageal junction.

Hybrid argon plasma coagulation in Barrett's esophagus: a systematic review and meta-analysis.

Patients with Barrett's esophagus are at increased risk of developing esophageal adenocarcinoma. Endoscopic therapies aim to eradicate dysplastic and metaplastic tissues. Hybrid argon plasma coagulation (hybrid-APC) utilizes submucosal fluid injection to create a protective cushion prior to ablation that shields the submucosa from injury. We performed a pooled meta-analysis to evaluate the safety and efficacy of hybrid-APC. We conducted a systematic search of major electronic databases in April 2022. Studies that included patients with dysplastic and non-dysplastic Barrett's esophagus undergoing treatment with hybrid-APC were eligible for inclusion. Outcome measures included complete remission of intestinal metaplasia (CR-IM), stricture formation, serious adverse events, and number of sessions necessary to achieve CR-IM. Overall pooled CR-IM rate for patients undergoing hybrid-APC was 90.8% (95% confidence interval [CI], 0.872-0.939; I2=0%). Pooled stricture rate was 2.0% (95% CI, 0.005-0.042; I2=0%). Overall serious adverse event rate was 2.7% (95% CI, 0.007-0.055; I2=0%). Results of the current meta-analysis suggest that hybrid-APC is associated with high rates of CR-IM and a favorable safety profile. Interpretation of these results is limited by the inclusion of retrospective cohort and case series data. Randomized controlled trials that standardize treatment and outcome evaluation protocols are necessary to understand how this treatment option is comparable to the current standards of care.

Barrett’s Esophagus in Obese Patient Post-Roux-en-Y Gastric Bypass: a Systematic Review

Barrett's esophagus (BE) is a relative contraindication for sleeve gastrectomy, but not for Roux-en-Y gastric bypass (RNY). However, studies assessing the effect of RNY on BE are limited. We aimed to conduct a systematic review and meta-analysis of studies of obese patients who also had BE and underwent RNY. We conducted a systematic review of literature using multiple search engines from inception to January 2021. The primary outcome of interest was the rate of BE resolution post-RNY. This was reported as a proportion with 95% confidence intervals (CI). Publication bias was assessed by funnels plots and the classic fail test. Forest plots were used to report pooled effect estimates. Heterogeneity was assessed using I2 and p-value. The final search included 4389 citations, 16 were reviewed in full text, and 9 were included in the final analysis, including 7 manuscripts and 2 recent meeting abstracts. In the 9 studies, 104 patients had BE and underwent RNY. On random effect modeling, the rate of complete remission of intestinal metaplasia (CRIM) was 50% [95%CI: 40-61%], p = 0.937, I2 = 4.6%, Q = 8.4, p = 0.396. The pooled rate of BE improvement was 52% [95%CI: 37-66%], p = 0.8, I2 = 16.5%, Q = 4.8, p = 0.31. Complete remission of dysplasia (CRD) was also reported in 4 of 6 patients. Despite the limited data, a majority of patient with BE who underwent RNY for weight loss had remission or improvement in BE on follow-up endoscopy. However, a significant minority had no change to BE on follow-up.

State-of-the-art management of dysplastic Barrett's esophagus.

Endoscopic eradication therapy (EET) has become a standard of care for treatment of dysplastic Barrett's esophagus (BE) and early Barrett's neoplasia. EET mainly consists of removal of any visible lesions via endoscopic resection and eradication of all remaining Barrett's mucosa using endoscopic ablation. Endoscopic mucosal resection and endoscopic submucosal dissection are the two available resection techniques. After complete resection of all visible lesions, it is crucial to perform endoscopic ablation to ensure complete eradication of the remaining Barrett's segment. Endoscopic ablation can be done either with thermal techniques, including radiofrequency ablation and argon plasma coagulation, or cryotherapy techniques. The primary end point of EET is achieving complete remission of intestinal metaplasia (CRIM) to decrease the risk of dysplastic recurrence after successful EET. After CRIM is achieved, a standardized endoscopic surveillance protocol needs to be implemented for early detection of BE recurrence.

ID: 3525809 COMPARATIVE OUTCOMES OF ENDOSCOPIC ERADICATION THERAPY FOR DYSPLASTIC BE USING RADIOREQUENCY ABLATION AND CRYOBALLON ABLATION: A MULTICENTER PROPENSITY SCORE MATCHED COHORT STUDY

Endoscopic eradication therapy (EET) for dysplastic BE combines endoscopic resection and ablation to achieve complete remission of dysplasia (CRD) and complete remission of intestinal metaplasia (CRIM). Level 1 evidence supports the use of radiofrequency ablation (RFA) in reducing progression in BE-high grade dysplasia (HGD) and low-grade dysplasia (LGD). Efficacy of ablation using the Cryoballoon ablation (CBA) system has been demonstrated in a multicenter cohort study. Comparative outcome data between these two modalities are lacking. We aimed to assess the comparative effectiveness of these two ablation modalities in a multicenter cohort study.

Impact of bariatric surgery on surveillance and treatment outcomes of Barrett's esophagus: A stage-matched cohort study.

Obesity could increase the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) could alter the natural course of BE. Data on BE progression after RYGB are scarce. To study endoscopic surveillance and endoscopic eradication therapy (EET) outcomes of BE in post-RYGB patients versus controls with obesity. Academic referral centers, a retrospective cohort study. Patients who underwent RYGB with biopsy-proven BE or intramucosal esophageal adenocarcinoma (IM-EAC) with an endoscopic follow-up of at least 12 months were identified from a prospectively maintained database between January 1992 and February 2019 at 3 tertiary care centers. RYGB patients were matched 1-to-2 to patients with obesity (body mass index > 30 kg/m2) by the initial BE stage at diagnosis. Surveillance and EET outcomes were compared. A total of 147 patients were included (49 RYGB and 98 BE stage-matched controls with obesity). For endoscopic surveillance, the rate of disease progression to high-grade dysplasia /IM-EAC was significantly lower in the RYGB patients than controls (2.6% versus 40.2%, respectively; P < .0001), with a comparable median follow-up time (85 months versus 80 months, respectively). This effect persisted in a multivariate analysis, with a hazard ratio of .09 (95% confidence interval, .01-.69). For EET, no difference in the rate of achieving complete remission of intestinal metaplasia was observed between the RYGB and control groups (71.2% versus 81.3%, respectively; P = .44). RYGB appears to be a protective factor for disease progression to neoplastic BE during endoscopic surveillance. However, disease progression was still observed after RYGB, warranting continuing endoscopic surveillance. EET appeared to be equally effective between RYGB patients and controls with obesity.

State of the Art: Management of Barrett’s Esophagus Related Dysplasia and Neoplasia—Which Patient and What Therapy?

Endoscopic eradication therapy (EET) is safe and effective in the management of Barrett’s esophagus (BE) related dysplasia and early adenocarcinoma. EET includes endoscopic resection of the visible lesions followed by ablation to eradicate the residual Barrett’s epithelium. Techniques available for endoscopic resection include cap-based endoscopic mucosal resection and endoscopic submucosal dissection. Ablative therapies such as RFA, cryoablation and APC are used for the eradication of dysplastic BE and to prevent progression to EAC. Complete remission of intestinal metaplasia is the goal of EET. Post-treatment endoscopic surveillance is recommended to detect recurrence of metaplasia/dysplasia, mostly at the gastroesophageal junction.

Comparative Outcomes of Cap Assisted Endoscopic Resection and Endoscopic Submucosal Dissection in Dysplastic Barrett’s Esophagus

Endoscopic resection is an important component of the endoscopic treatment of Barrett's esophagus (BE) with dysplasia and intramucosal adenocarcinoma. Endoscopic resection can be performed by cap-assisted endoscopic mucosal resection (cEMR) or endoscopic submucosal dissection (ESD). We compared the histologic outcomes of ESD vs cEMR, followed by ablation. We queried a prospectively maintained database of all patients undergoing cEMR and ESD followed by ablation at our institution from January 2006 to March 2020 and abstracted relevant demographic and clinical data. Our primary outcomes included the rate of complete remission of dysplasia (CRD): absence of dysplasia on surveillance histology, and complete remission of intestinal metaplasia (CRIM): absence of intestinal metaplasia. Our secondary outcome included complication rates. We included 537 patients in the study: 456 underwent cEMR and 81 underwent ESD. The cumulative probabilities of CRD at 2 years were 75.8% and 85.6% in the cEMR and ESD groups, respectively (P < .01). Independent predictors of CRD were as follows: ESD (hazard ratio [HR], 2.38; P < .01) and shorter BE segment length (HR, 1.11; P < .01). The cumulative probabilities of CRIM at 2 years were 59.3% and 50.6% in the cEMR and ESD groups, respectively (P > .05). The only independent predictor of CRIM was a shorter BE segment (HR, 1.16; P < .01). BE patients with dysplasia or intramucosal adenocarcinoma undergoing ESD reach CRD at higher rates than those treated with cEMR, although CRIM rates at 2 years and complication rates were similar between the 2 groups.

Cryoballoon ablation for treatment of patients with refractory esophageal neoplasia after first line endoscopic eradication therapy.

Background and study aims Cryoablation with the Cryoballoon device is a novel ablative therapy that uses cycles of freezing and thawing to induce cell death. This single-center prospective study evaluated the feasibility of the focal cryoablation device for the treatment of areas of refractory esophageal neoplasia in patients who had undergone first line endoscopic eradication therapy (EET). Complete remission of dysplasia (CR-D) and complete remission of intestinal metaplasia (CR-IM) at first follow-up endoscopy, durability of disease reversal, rates of stenosis and adverse events were studied. Patients and methods Eighteen cases were treated. At baseline, nine patients had low-grade dysplasia (LGD), six had high-grade dysplasia (HGD) and three had intramucosal carcinoma (IMC). Median length of dysplastic Barrett’s esophagus (BE) treated was 3 cm. The median number of ablations per patient was 11. Each selected area of visible dysplasia received 10 seconds of ablation. One session of cryoablation was performed per patient. Biopsies were performed at around 3 months post-ablation. Results CR-D was achieved in 78 % and CR-IM in 39 % of patients. There were no device malfunction or adverse events. Stenosis was noted in 11 % of cases. At a median follow up of 19-months, CR-D was maintained in 72 % of patients and CR-IM in 33 %. Conclusions Cryoablation appears to be a viable rescue strategy in patients with refractory neoplasia. It is well tolerated and successful in obtaining CR-D and CR-IM in patients with treatment-refractory BE. Further trials of dosimetry, efficacy and safety in treatment-naïve patients are underway.

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

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.

Mo1239 COMPARATIVE OUTCOMES OF CAP ASSISTED ENDOSCOPIC RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION IN PATIENTS WITH DYSPLASTIC BARRETT'S ESOPHAGUS AND INTRAMUCOSAL ADENOCARCINOMA

Endoscopic eradication therapy (EET) is the standard of care for the treatment of Barrett’s Esophagus (BE) with dysplasia and intramucosal esophageal adenocarcinoma (EAC). Cap assisted endoscopic resection (cEMR) leads to piecemeal resection in larger lesions. Endoscopic submucosal dissection (ESD) allows for the en bloc removal of larger lesions. Both approaches are followed by mucosal ablation to achieve complete eradication of dysplasia and intestinal metaplasia. Limited data is available for the efficacy of these two approaches followed by mucosal ablation. We studied the outcomes of patients treated with these modalities at our institution, focusing on rates of complete remission of intestinal metaplasia (CRIM) and dysplasia (CRD). We queried a prospectively maintained database of all patients at our institution undergoing EMR and ESD for dysplastic/neoplastic BE and abstracted relevant demographic and clinical data. Only patients with at least one endoscopic follow up were included. Our primary outcome was the achievement of CRIM, defined as the absence of intestinal metaplasia on at least one follow up EGD at 2 years. Secondary outcomes included rates of complete remission of dysplasia (CRD), defined as the absence of dysplastic BE on at least one follow up EGD and rates of complications. All pathology was read by expert gastrointestinal pathologists. Time dependent analyses were conducted to compare outcomes in the two groups. A total of 633 patients, of whom 447 that underwent cEMR and 89 that underwent ESD were included. 447 (100%) and 59 (66.3%) in the cEMR group and ESD groups underwent ablation (either radiofrequency ablation or cryotherapy) post endoscopic resection. Demographic and clinical variables are displayed in Table 1. The ESD group had a higher proportion of EAC patients (48.3% vs 20.1%, p<0.05) but proportions of HGD+EAC were similar in both groups. More complications were associated with the EMR group, driven mainly by post-procedural bleeding rates. Rates of CRD were lower in the EMR group at 6 months but were comparable at 12 and 24 months (see table 1 and Figure 1). Rates of CRIM were comparable between the two groups at 12 and 24 months. A multivariate model (adjusting for age, gender, BMI, smoking status, length of BE, presence of hiatal hernia, and initial histology) showed that EMR was associated with a lower likelihood of achieving CRD (HR 0.487, 95% CI: 0.337-0.703, p <0.0001), but not CRIM at 2 years (HR 0.895, 95% CI: 0.537-1.491, p=.67). EMR and ESD both appear to be effective in the treatment of BE related neoplasia. ESD is safe when performed by expert endoscopists. While there is a higher likelihood of achieving CRD earlier in patients with ESD, both resection techniques when combined with endoscopic ablation appear equally efficacious in achieving CRIM at 24 months.Comparison of baseline characteristics and outcomes (CRIM, CRD and complications) in the two groups.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Mo1256 EPITHELIAL GLAND BURDEN DETERMINED BY VOLUMETRIC LASER ENDOMICROSCOPY IS ASSOCIATED WITH COMPLETE REMISSION OF INTESTINAL METAPLASIA FOLLOWING ENDOSCOPIC ERADICATION THERAPY FOR BARRETT’S ESOPHAGUS

Endoscopic eradication of Barrett’s esophagus (BE) aims to achieve complete remission of intestinal metaplasia (CRIM), defined by absence of visible columnar mucosa on high-definition white light (HDWL) endoscopy and negative biopsies for intestinal metaplasia (IM). Given sampling error associated with random biopsies, some experts recommend two consecutive negative endoscopies to establish CRIM. Volumetric laser endomicroscopy (VLE) is an advanced imaging modality capable of comprehensive high-resolution imaging of BE. Epithelial glands are a VLE feature associated with BE. We hypothesize that VLE epithelial gland burden in the gastroesophageal junction (GEJ) is associated with the presence of IM in patients with BE following endoscopic eradication therapy. Patients with BE with absence of visible columnar mucosa on HDWL endoscopy following endoscopic eradication therapy underwent VLE imaging. Random surveillance biopsies were obtained as per standard protocol. VLE scans were analyzed with intelligent real-time image segmentation (IRIS), an artificial intelligence software that superimposes features of interest (signal intensity, mucosal layering, epithelial glands) onto an en-face map of the esophagus. The GEJ on IRIS en-face scans was defined as the transition between squamous epithelium (presence of layering, normal signal intensity) and cardia (lack of layering, increased signal intensity) and demarcated using image processing software ImageJ. We previously showed that the surface area occupied by epithelial glands correlates with manual gland quantification. The GEJ demarcation was transferred to an en-face map of epithelial glands and the surface area (gland burden) was measured 1 cm proximal and 1 cm distal to the GEJ for each VLE scan (Figure 1) The mean gland surface area of VLE scans from patients with IM negative biopsies was compared to those with IM positive biopsies using the Student t-test. This study was funded by the ASGE Endoscopy Research Award. A total of 123 BE patients without visible BE on HDWL endoscopy following endoscopic therapy underwent VLE. Random biopsies were negative for IM in 87 and positive in 36 patients. Highest grade of histology was non-dysplastic BE (N=32), indefinite (N=2), low-grade (N=2). The mean (SD) gland surface area in the GEJ was significantly higher in patients with IM positive biopsies compared to patients with IM negative biopsies [10.1(9.9)mm2 vs. 6.5(5.5)mm2, p=0.02] (Figure 2) Systematic quantification of epithelial gland burden in the GEJ using VLE can predict presence of IM in patients with BE following endoscopic eradication therapy. VLE may have a role in confirming true CRIM and reducing number of required surveillance endoscopies.Mean gland surface area measured in patients with absence of visible columnar mucosa on high-definition white light endoscopy and negative surveillance biopsies for IM (group 0) and positive surveillance biopsies for IM (group 1)View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Barrett’s Epithelial Thickness, Assessed by Volumetric Laser Endomicroscopy, Is Associated With Response to Radiofrequency Ablation

Radiofrequency ablation (RFA) is the most common treatment for flat Barrett's esophagus (BE), but reasons for varying outcomes are poorly understood. A recently developed contrast-enhancement algorithm allows reliable measurement of Barrett's epithelial thickness (BET) from volumetric laser endomicroscopy (VLE) images and correlation with response to RFA. Using this algorithm, we investigated whether patients with thicker Barrett's mucosa are less likely to respond to RFA. In the future, this algorithm may guide choice of RFA dosing or endoscopic resection. We performed a retrospective analysis on all patients with BE who received a baseline VLE scan between May 2015 and October 2016, followed by RFA and 1 follow-up exam, from 14 institutions participating in the United States VLE registry. We measured BET on equidistant locations by estimating the distance between the esophageal surface and the superficial edge of the deepest lamina propria. The primary outcome variable was the percentage reduction in Prague length; secondary outcome variables were complete remission of intestinal metaplasia (CRIM) and presence of strictures after 12 months. Images from 61 patients were included in our final analysis. Mean BET per patient ranged from 224 μm to 705 μm. A 100 μm thicker mean BET per patient resulted in a 12% lower response to treatment, measured by a reduction of Prague length (P = .03), after adjustment for confounders. We found an association between mean BET and CRIM, but not with stricture formation. Based on measurements on contrast-enhanced VLE images, we found that BET correlates with response to RFA. For clinical implementation, larger studies with a standardized follow-up and development of computer-aided image analysis systems are needed.

382 Esophageal Mucosal Impedance Measurement During Endoscopy: A New Approach to Diagnosis and Confirmation of Complete Remission of Intestinal Metaplasia Following Radiofrequency Ablation in Barrett’s Esophagus

INTRODUCTION: Mucosal impedance (MI), measured with a specialized balloon catheter at the time of upper endoscopy reveals a distinct pattern within the esophagus in patients with eosinophilic esophagitis and GERD. This novel technology may also be able to identify a unique profile in Barrett’s esophagus (BE) and confirm Endoscopic Complete Remission of Intestinal Metaplasia (ECRIM) following Radiofrequency energy ablation (RFA). AIM: Explore utility of MI in identification of BE and confirmation of ECRIM following RFA. METHODS: Patients (pts) with endoscopic and biopsy proven BE, most dysplasia undergoing RFA were prospectively enrolled. All were maintained on BID PPI. EGD noted top of gastric folds, SCJ, Prague criteria, hernia size and presence of nodules. Pts with nodular disease were excluded. RFA was performed per standard protocol and repeated until ECRIM achieved. Measurements were obtained with an MI balloon (Diversatek Healthcare, CO) 10 cm x 5 mm with two axial arrays of 10 sensors, throughout the entire BE segment and 5 cm above at pre-ablation EGD and following achieving ECRIM. At ECRIM endoscopic surveillance biopsies (q 1 cm; 4 quadrant) and WATS brushings were obtained to confirm CRIM. RESULTS: 16 pts 11M/5F, ages 26-71 years, all Caucasian were enrolled. BE length from 1-15 cm. (adenoca 1, LGD 5, HGD 5, indefinite1, Non dysplastic 4. To date, 7 pts have been studied prior to the initial RFA ablation and at ECRIM. 2 pts were studied only at end of RFA with ECRIM. 7 are in active treatment. MI measured within the BE segment ranged from 350-980 ohms pre RFA. (Normal &gt;2500, EoE, GERD &gt;1000). Post RFA MI measurements ranged from 1800- &gt;5000 ohms. 5/7 pts that achieved ECRIM had normalization of the MI pattern visualized (all values &gt;2500). The 2 pts that did not achieve normalization of the MI pattern demonstrated MI values consistent with inflammation in squamous tissue but no values suggestive of BE. Pathology confirmed absence of IM in all 9 pts. CONCLUSION/SUMMARY: 1) BE exhibits MI consistently &lt; 500 ohms and always below 1000 ohms, a unique MI profile not evident in GERD or EoE. 2) In pts who achieved ECRIM and biopsy and WATS proven CRIM following RFA ablation, the neosquamous esophageal mucosa exhibits a MI pattern similar to normal native squamous epithelium. Balloon catheter MI measurements can reliably identify BE epithelium and may be a valuable tool in assessment of post-RFA reversion to neosquamous epithielium and therefore successful BE ablation.

Radiofrequency Ablation in Patients with Barrett's Esophagus- related Neoplasia - Long-Term Outcomes in the Czech National Database.

Radiofrequency ablation (RFA) with/without endoscopic resection (ER) is the standard endoscopic treatment modality for Barrett's esophagus (BE) related neoplasia (BORN). The main aim of this study was to assess the long-term outcomes of RFA in patients with BORN. We retrospectively analyzed the prospectively collected data from the Czech national database. Main outcomes were: complete remission of neoplasia (CR-N), complete remission of intestinal metaplasia (CR-IM), recurrence of both neoplasia and IM, and safety. From a total of 170 patients with BORN treated with RFA, 136 patients were analyzed. They were followed up for a median of 27.5 months. Fifty-six patients (41%) had low-grade intraepithelial neoplasia (LGIN), 46 (34%) had high-grade intraepithelial neoplasia (HGIN) and 34 (25%) had early adenocarcinoma (EAC). RFA was combined with previous ER in 65 patients (48%). CR-IM and CR-N were achieved in 77.9% (95% CI 70.0-84.6%) and 98.5% (95% CI 94.8-99.8%). Among 30 patients without CR-IM, 22 (73%) did not have macroscopic signs of BE. Recurrent neoplasia was detected in 4.5% of patients (6/134) and 15% (16/106) experienced a recurrence of IM at the level of the neo-Z-line. Diagnosis of cancer was an independent risk factor for recurrent IM after RFA (OR 7.0, 95% CI 1.6-30.9, p<0.0005). RFA is highly effective in achieving remission in patients with BORN. A significant proportion of patients did not achieve CR-IM or had a recurrence of IM despite macroscopically absent BE. Recurrence of neoplasia was infrequent but not negligible, thus, patients after successful RFA still require endoscopic surveillance.

Mo1207 OUTCOMES OF RADIOFREQUENCY ABLATION BY HALO 360 EXPRESS AND HALO 360 BALLOON CATHETERS FOR THE TREATMENT OF DYSPLASTIC BARRETT'S ESOPHAGUS : A MULTICENTER COMPARATIVE COHORT STUDY

Radiofrequency ablation (RFA) is the current standard of care for the ablation of BE related dysplasia and can be performed with both circumferential and focal devices. Recently a self sizing circumferential © RFA catheter (Halo 360 Express) eliminating the need for sizing, has been introduced with some concerns regarding dosimetry and safety, particularly in terms of stricture rates. We aimed to compare the safety (as primary outcome) and efficacy (time to and proportion of complete remission of dysplasia (CR-D) and complete remission of intestinal metaplasia(CR-IM) as secondary outcomes) of the Halo 360 Express catheter with that of the older Halo 360 catheter in a multicenter cohort study.

Timeline and location of recurrence following successful ablation in Barrett’s oesophagus: an international multicentre study

ObjectiveSurveillance interval protocols after complete remission of intestinal metaplasia (CRIM) post radiofrequency ablation (RFA) in Barrett’s oesophagus (BE) are currently empiric and not based on substantial evidence. We aimed to...

Efficacy and safety of radiofrequency ablation of Barrett's esophagus in the absence of reimbursement: a multicenter prospective Belgian registry.

Radiofrequency ablation (RFA), combined with endoscopic resection, can be used as a primary treatment for low grade dysplasia, high grade dysplasia, and early esophageal adenocarcinoma (EAC) in Barrett's esophagus (BE). The aim of the Belgian RFA registry is to capture the real-life outcome of endoscopic therapy for BE with RFA and to assess efficacy and safety outside study protocols, in the absence of reimbursement. Between February 2008 and January 2017, data from 7 different expert centers were prospectively collected in the registry. Efficacy outcomes included complete remission of intestinal metaplasia (CR-IM), complete remission of dysplasia (CR-D), and durability of remission. Safety outcomes included immediate and late adverse events. 684 RFA procedures in 342 different patients were registered. Of these, 295 patients were included in the efficacy analysis, with CR-IM achieved in 88 % and CR-D in 93 %, in per-protocol analysis; corresponding rates in intention-to-treat analysis were 82 % and 87 %, respectively. Sustained remission was seen in 65 % with a median (interquartile range) follow-up of 25 (12 - 47) months. No risk factors for recurrent disease were identified. Immediate complications occurred in 4 % of all procedures and 6 % of all patients, whereas late complications occurred in 9 % of all procedures and in 20 % of all patients. Data from the Belgian registry confirm that RFA in combination with endoscopic resection is an efficient treatment for BE with dysplasia or early EAC. In the absence of reimbursement, more rescue treatments are used, not compromising outcome. Since there is recurrent disease after CR-IM in 35 %, surveillance endoscopy remains necessary.

A Western Experience in the Use of a Novel CryoBalloon Focal Ablation System for the Management of Barrett’s Neoplasia

Introduction: Cryoablation poses an attractive alternative to radiofrequency ablation in patients with Barrett’s esophagus (BE), particularly those with residual intestinal metaplasia after multiple ablation sessions. The use of spray cryoablation, however, is not without challenges, including the need for simultaneous gastrointestinal venting, potential frosting of the endoscope optics, and dysfunction of the spray catheter. The CryoBalloon focal ablation system (CbFAS) was developed to maintain the advantages of cryoablation, but reduce the limitations of the spray system. We reported a U.S experience regarding the feasibility and safety of CbFAS (C2 Therapeutics, Redwood City, California, USA) in treating BE. Methods: A single-center, retrospective study of patients with dysplastic BE or early esophageal adenocarcinoma (EAC) treated with cryoablation using the CryoBalloon between 2016 and 2017. Our primary outcome was rate of technical success. Secondary outcomes included adverse events, complete remission of intestinal metaplasia (CR-IM), and complete remission of dysplasia (CR-D). Results: Forty-two patients were included and treated with 80 cryoablation sessions. The cohort had a mean age of 69.7±10.2 years (IQR: 66- 77) and was male predominant (83.3%). The majority of patients received prior endoscopic treatment (37/42, 88.1%). The mean length of the BE segment was 4±3.4 cm (IQR: 1-5). The majority of patients had high-grade dysplasia and/or intramucosal EAC 83.3%. Cryoablation was successfully performed in 78/80 (97.5%); one failure was due to device malfunction and another one due to the device not deploying due to a safety mechanism in a narrow esophagus. We did not encounter any major adverse events. Nine patients (21.5%) of patients developed mild adverse events including mild to moderate chest pain, mild esophageal strictures, and self-resolving sinus bradycardia. CR-IM and CR-D were achieved in 9.5% and 54.8%, respectively, during a mean follow-up of 7.5±5.7 months (IQR: 3-12). Conclusion: This is a large western experience with use of the CbFAS in treating BE with dysplasia or EAC. CryoBalloon CbFAS ablation was performed with a high rate of technical success and no significant adverse events. The CryoBalloon focal ablation system may be considered as a potential alternative to spray treatment when Cryoablation is indicated.378 Figure 1 No Caption available.