Endoscopic Eradication Therapy 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.

Incidence and Prediction of Unrelated Mortality After Successful Endoscopic Eradication Therapy for Barrett’s Neoplasia

Background & AimsFollow-up (FU) strategies after endoscopic eradication therapy (EET) for Barrett’s neoplasia do not consider the risk of mortality from causes other than esophageal adenocarcinoma (EAC). We aimed to evaluate this risk during long-term FU, and to assess whether the Charlson Comorbidity Index (CCI) can predict mortality. MethodsWe included all patients with successful EET from the nationwide Barrett registry in the Netherlands. Data were merged with National Statistics for accurate mortality data. We evaluated annual mortality rates (AMRs, per 1000 person-years) and standardized mortality ratio for other-cause mortality. Performance of the CCI was evaluated by discrimination and calibration. ResultsWe included 1154 patients with a mean age of 64 years (±9). During median 59 months (p25–p75 37–91; total 6375 person-years), 154 patients (13%) died from other causes than EAC (AMR, 24.1; 95% CI, 20.5–28.2), most commonly non-EAC cancers (n = 58), cardiovascular (n = 31), or pulmonary diseases (n = 26). Four patients died from recurrent EAC (AMR, 0.5; 95% CI, 0.1–1.4). Compared with the general Dutch population, mortality was significantly increased for patients in the lowest 3 age quartiles (ie, age <71 years). Validation of CCI in our population showed good discrimination (Concordance statistic, 0.78; 95% CI, 0.72–0.84) and fair calibration. ConclusionThe other-cause mortality risk after successful EET was more than 40 times higher (48; 95% CI, 15–99) than the risk of EAC-related mortality. Our findings reveal that younger post-EET patients exhibit a significantly reduced life expectancy when compared with the general population. Furthermore, they emphasize the strong predictive ability of CCI for long-term mortality after EET. This straightforward scoring system can inform decisions regarding personalized FU, including appropriate cessation timing. (NL7039)

Revisiting Proton Pump Inhibitors as Chemoprophylaxis Against the Progression of Barrett's Esophagus.

Barrett's esophagus (BE) is associated with chronic gastroesophageal reflux disease and is a known precursor to esophageal adenocarcinoma. While endoscopic surveillance strategies and the role for endoscopic eradication therapy have been well established, there has been much interest in identifying chemopreventive agents to disrupt or halt the metaplasia-dysplasia-carcinoma sequence in patients with BE. No pharmacological agent has held more hope in reducing the risk of neoplastic progression in BE than proton pump inhibitors (PPIs). However, data supporting PPIs for chemoprevention have largely been from observational cohort and case-control studies with mixed results. In this review, we revisit the literature and highlight the role of PPIs in patients with BE as it pertains to chemoprophylaxis against the progression of BE to dysplasia and esophageal adenocarcinoma.

Incidence of Esophageal Adenocarcinoma, Mortality, and Esophagectomy in Barrett's Esophagus Patients Undergoing Endoscopic Eradication Therapy.

Endoscopic eradication therapy (EET) is the preferred treatment for Barrett's esophagus (BE)-related neoplasia patients. However, the impact of EET on critical outcomes, outside of clinical trials and registry data, remains scarcely studied. We aimed to assess real-world practice patterns and clinical outcomes among BE patients undergoing EET. TriNetX is a large research network comprising linked inpatient and outpatient electronic-health record-derived data from over 80,000,000 patients. Patients with a diagnosis of BE from 2015 to 2020 were identified and included if they underwent EET during the study period. The primary outcome was the progression to EAC after index EET. Secondary outcomes included rate of esophagectomy, and all-cause mortality. All outcomes were stratified by baseline histology. The incidence of EAC and all-cause mortality were reported in person-years and adjusted for age and sex. A total of 4114 patients were analyzed. Distribution of baseline histology was as follows: NDBE (11.8%), LGD (21.4%), HGD (26.4%), EAC (20.8%), and unspecified (19.6%). The total incidence of EAC after index EET was 6.01 per 1000 person-years (PY) for the entire cohort with the highest rate in HGD patients (12.9/1000 PY). The incidence of all-cause mortality was 13.23 per 1000 PY with the highest rates in EAC patients (25.1 per 1000 PY). Rates of esophagectomy were < 1% for all grades of dysplasia. The results of this study provide "real-world" data on critical outcomes for BE patients undergoing EET, demonstrating a low risk of incident EAC, all-cause mortality, and need for esophagectomy.

Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2:  ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3:  ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4:  ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5:  ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6:  ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7:  ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8:  ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9:  ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B:  ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C:  ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D:  ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E:  ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11:  After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.

303. THE TISSUE SYSTEMS PATHOLOGY-9 TEST PROVIDES CLINICALLY-IMPACTFUL RISK STRATIFICATION IN PATIENTS WITH BARRETT’S ESOPHAGUS: CLINICAL EXPERIENCE IN A MULTICENTER COHORT

Abstract Background Barrett’s esophagus (BE) is a precursor to esophageal adenocarcinoma (EAC). Society guidelines recommend surveillance of BE by endoscopy with biopsies with the goal of detecting dysplasia and EAC at early, treatable stages. However, current practices have limited ability to predict which patients with BE will progress to EAC. This study evaluated the use of the validated, commercially-available tissue systems pathology test (TissueCypher, TSP-9) to risk-stratify BE patients in a large clinical practice cohort. Methods TSP-9 test results ordered by 475 physicians from June 2016 to January 2023 for 3935 patients with BE with clinicopathologic data were analyzed. The test orders were from private practices and integrated healthcare systems (92.8%) and academic medical centers (7.2%). Submitted diagnoses were non-dysplastic BE (NDBE, n = 3553, 90.3%), indefinite for dysplasia (IND, n = 190, 4.8%), low-grade dysplasia (LGD, n = 112, 2.8%), or other (BE with sub-category not clearly specified, n = 80, 2.0%). The TSP-9 results (risk classes of low-, intermediate- or high-risk and predicted probability of progression to HGD/EAC within 5 years) were evaluated in all patients. Results The TSP-9 test scored 3267 (83.0%), 377 (9.6%), and 291 (7.4%) low-, intermediate- and high-risk, respectively. The TSP-9 test identified risk for progression in NDBE, IND, and LGD subsets, in males and females, and in patients with short- and long-segment BE (Fig. 1). The test scored 15.2% of NDBE patients as intermediate or high-risk. Patients with NDBE who received TSP-9 intermediate- and high-risk scores had predicted 5-year risk of progression to HGD/EAC of 8.1% and 16.2%, respectively, which are higher than progression rates in BE patients with LGD (6.7% in 5 years) for whom guidelines recommend endoscopic eradication therapy. Conclusions TSP-9 risk-stratified for progression independently of clinicopathologic features in a cohort of 3935 BE patients. The majority of BE patients scored low-risk, providing support for surveillance-only management. The test identified 15.2% of NDBE patients as intermediate/high-risk for progression, indicating that the test can enable early detection of patients who will benefit from escalation of care to prevent EAC. The TSP-9 test provides objective results to enable risk-aligned management to improve health outcomes for BE patients.

High Proportions of Newly Detected Visible Lesions and Pathology Grade Change Among Patients with Barrett's Esophagus Referred to Expert Centers.

Endoscopic eradication therapy for Barrett's esophagus (BE)-related neoplasia is increasingly being performed at tertiary and community centers. While it has been suggested that these patients should be evaluated at expert centers, the impact of this practice has not been evaluated. We aimed to assess the impact of referral of BE-related neoplasia patients to expert centers by assessing the proportion of patients with change in pathological diagnosis and visible lesions detected. Multiple databases were searched until December 2021 for studies of patients with BE referred from the community to expert center. The proportions of pathology grade change and newly detected visible lesions at expert centers were pooled using a random-effects model. Subgroup analyses were performed based on baseline histology and other relevant factors. Twelve studies were included (1630 patients). The pooled proportion of pathology grade change after expert pathologist review was 47% (95% CI 34-59%) overall and 46% (95% CI 31-62%) among patients with baseline low-grade dysplasia. When upper endoscopy was repeated at an expert center, the pooled proportion of pathology grade change was still high 47% (95% 26-69%) overall and 40% (95% CI 34-45%) among patients with baseline LGD. The pooled proportion of newly detected visible lesions was 45% (95% CI 28-63%) and among patients referred with LGD was 27% (95% CI 22-32%). An alarmingly high proportion of newly detected visible lesions and pathology grade change were found when patients were referred to expert centers supporting the need for centralized care for BE-related neoplasia patients.

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.

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 four quadrant biopsies of the original Barrett's length. To inform post-CRIM surveillance protocols, we aimed to identify the anatomic location, appearance and histology of Barrett's recurrences. We performed an analysis of 216 patients who achieved CRIM following endoscopic eradication therapy (EET) for dysplastic Barrett's esophagus (BE) at a Barrett's referral unit between 2008 and 2021. The anatomic location, the recurrence histology and endoscopic appearance of dysplastic recurrences were evaluated. After a median (p25-p-75) 5.5 years (2.9-7.2) of follow up post-CRIM, 57 patients (26.4%) developed NDBE recurrence and 18 patients (8.3%) developed dysplastic recurrence. From a total of 8,158 routine surveillance biopsies of normal appearing tubular esophageal neosquamous epithelium, the yield for recurrent NDBE or dysplasia was 0%. 100% of dysplastic tubular esophageal recurrences were visible and in Barrett's islands, whilst 77.8% of GEJ dysplastic recurrences were non-visible. Four distinct endoscopic features suspicious for recurrent advanced dysplasia or neoplasia were identified: (1) Buried or sub-squamous Barrett's, (2) Irregular mucosal pattern, (3) Loss of vascular pattern, (4) Nodularity or depression. The yield of routine surveillance biopsies of normal appearing tubular esophageal neosquamous epithelium was zero. Barrett's islands with indistinct mucosal or loss of vascular pattern, nodularity or depression and/or signs of buried Barrett's should raise clinician suspicion for advanced dysplasia or neoplasia recurrence. We suggest a new surveillance biopsy protocol with a focus on meticulous inspection, followed by targeted biopsies of visible lesions and random four quadrant biopsies of the GEJ.

Should All Patients with Barrett's Esophagus Receive Ablation?

The aim of this paper is to review and assess the appropriateness of eradication of nondysplastic Barrett's esophagus. Dysplasia in Barrett's esophagus is a known predictor for the development of esophageal cancer, and is currently the best marker in aiding the decision making regarding treatment options. Current data supports endoscopic eradication therapy for most patients with dysplastic Barrett's. The controversy, however, lies in the management of nondysplastic Barrett's and when to recommend ablation versus ongoing surveillance. There have been increasing efforts to identify factors that can help predict which patients with nondysplastic Barrett's esophagus are at increased risk for cancer progression, and to quantify that risk. While there is currently varying data and literature supporting this, a more objective risk score is likely to soon become available and accepted, in an effort to differentiate between low and high risk nondysplastic Barrett's, and better aid in decision making regarding surveillance versus endoscopic eradication. This article reviews the current data on Barrett's esophagus and its risk for cancer progression, and it outlines several factors which impact progression that should be considered in the management approach to nondysplastic Barrett's esophagus.

What Is "Cold" and What Is "Hot" in Mucosal Ablation for Barrett's Oesophagus-Related Dysplasia: A Practical Guide.

Over the last two decades, endoscopic eradication therapy has been established as the therapeutic strategy of choice for patients with Barrett's oesophagus-related dysplasia and early oesophageal adenocarcinoma. With a multimodal approach, ablative therapies have been highly effective in achieving remarkable eradication rates of metaplastic epithelium with an acceptable adverse event rate. Among ablative techniques, radiofrequency ablation is currently considered as the first-line option as its efficacy and safety are strongly supported by relevant data. Nevertheless, radiofrequency ablation is costly, and not universally available, or applicable to every situation. Moreover, primary failure and recurrence rates are not negligible. In the last few years, cryotherapy techniques and hybrid argon plasma coagulation have been increasingly assessed as potential novel ablative therapies. Preliminary data have been promising and suggest that they may even have a role as first-line options, alternatively to radiofrequency ablation. The aim of this review is to provide a practical guide for the ablation of Barrett's oesophagus, with emphasis on the different ablative options.

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.

Endoscopic therapy for Barrett’s esophagus: a narrative review of potential complications and their management

: Barrett’s esophagus (BE) is a well-known risk factor for the development of esophageal adenocarcinoma (EAC). This histologic transformation occurs in a stepwise fashion with progression from intestinal metaplasia (IM) to low-grade dysplasia (LGD), high-grade dysplasia (HGD), intramucosal adenocarcinoma (IMCA), and ultimately invasive EAC. Standardized guidelines have been developed for screening, surveillance and treatment of dysplastic/neoplastic BE. Endoscopic eradication therapy (EET) is recommended over esophagectomy for dysplasia and early (mucosal) neoplasia based on its efficacy and favorable risk profile. EET consists of endoscopic resection of any nodular lesions followed by endoscopic ablation of Barrett’s mucosa. Endoscopic resection can be performed by endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). There are several effective modalities available for endoscopic ablation including radiofrequency ablation (RFA), cryoablation, argon plasma coagulation (APC), and/or hybrid-APC. Often times, multimodal endoscopic therapy is utilized with a combination of endoscopic resection and ablation techniques. While generally well tolerated, complications from these therapeutic procedures do occur, including sedation-related events, post-procedure chest pain, luminal perforation, bleeding and esophageal stricture. Complications may occur intraprocedure, immediately post-procedure, or delayed post-procedure. Treatment depends upon the severity of the complication, hemodynamic stability of the patient, and timing of presentation. This review highlights the potential complications associated with BE endotherapy and the management thereof.

Adherence to Quality Indicators for Diagnosis and Surveillance of Barrett's Esophagus: A Comparative Study of Barrett's Experts and Nonexperts

Background and AimsThere is considerable variability in adherence to endoscopic quality indicators (QIs) for Barrett's esophagus (BE). The aims of this study were to (1) assess adherence to published Qis for diagnosis and surveillance of BE, (2) compare adherence between BE experts and nonexperts, and (3) identify factors associated with adherence. MethodsWe identified all patients with BE on esophagogastroduodenoscopy between 2010 and 2018. QIs evaluated included inspection using high-definition white light endoscopy, use of the Prague Classification, identification of endoscopic landmarks, use of the Seattle Protocol, and guideline-adherent recommendations for surveillance or endoscopic eradication therapy. BE experts and nonexperts were compared using logistic mixed-effects models. ResultsA total of 467 patients were identified, with BE experts performing fewer overall esophagogastroduodenoscopies (n = 162, 34.7% vs n = 305, 65.3%). Whereas BE experts were more likely to document Prague Classification (52.5% vs 41.3%; P = 0.017) and landmarks (43.2% vs 22.6%; P = 0.036), there was no significant difference between experts and nonexperts in use of high-definition white light endoscopy (8.6% vs 3.3%; P = 0.123), Seattle Protocol (48.1% vs 40.3%; P = 0.313), or guideline-adherent surveillance or treatment recommendations (71.0% vs 67.5%; P = 0.509). Patient enrollment in a BE surveillance program was the only factor associated with improved QI adherence, specifically adherence to Prague Classification documentation (OR 1.85, 95% CI 1.08-3.14; P = 0.025), Seattle Protocol (1.28, 95% CI 1.16-1.50; P < 0.001), and follow-up recommendations (OR 2.64, 95% CI 1.55-4.48; P < 0.001). ConclusionPatterns of adherence to published QIs for endoscopy in patients with BE are mostly independent of expertise. Further training initiatives are needed to standardize the performance of endoscopic practice in patients with BE.

Clinical variation in surveillance and management of Barrett’s esophagus: A cross-sectional study of gastroenterologists and gastrointestinal surgeons

Appropriate surveillance and treatment of Barrett's esophagus (BE) is vital to prevent disease progression and decrease esophageal adenocarcinoma (EAC)-related mortality. We sought to determine the variation in BE care and identify improvement opportunities. 275 physicians (113 general gastroenterologists, 128 interventional gastroenterologists, 34 gastrointestinal surgeons) cared for 3 simulated patients, one each from 3 BE clinical scenarios: non-dysplastic BE (NDBE), BE indefinite for dysplasia (IND), and BE with low grade dysplasia (LGD), and care scores were measured against societal guidelines. Overall quality-of-care scores ranged from 17% to 85% with mean of 47.9% ± 11.8% for NDBE, 50.8% ± 11.7% for IND, and 52.7% ± 12.2% for LGD. Participants appropriately determined risk of progression 20.3% of the time: 14.4% for NDBE cases, 19.9% for LGD cases, and 26.8% for IND cases (P = .001). Treatment and follow-up care scores averaged 12.9% ± 17.5% overall. For the LGD cases, guideline-recommended twice-daily PPI treatment was ordered only 24.7% of the time. Guideline-based follow-up endoscopic surveillance was done in only 27.7% of NDBE cases and 32.7% of IND cases. For the LGD cases, 45.4% ordered endoscopic eradication therapy while 25.1% chose annual endoscopic surveillance. Finally, participants provided counseling on lifestyle modifications in just 20% of cases. Overall care of patients diagnosed with BE varied widely and showed room for improvement. Specific opportunities for improvement were adherence to guideline recommended surveillance intervals, patient counseling, and treatment selection for LGD. Physicians would potentially benefit from additional BE education, endoscopic advances, and better methods for risk stratification.

Utility of wide-area transepithelial sampling with 3-dimensional computer-assisted analysis as an adjunct to forceps biopsy sampling in the surveillance of patients with Barrett’s esophagus after endoscopic eradication therapy

Utility of wide-area transepithelial sampling with 3-dimensional computer-assisted analysis as an adjunct to forceps biopsy sampling in the surveillance of patients with Barrett’s esophagus after endoscopic eradication therapy

Novel histologic score predicts recurrent intestinal metaplasia after successful endoscopic eradication therapy.

Endoscopic eradication therapy (EET) is an effective treatment for Barrett's esophagus (BE); however, disease recurrence remains problematic requiring surveillance post-treatment. While data regarding predictors of recurrence are limited, uncontrolled reflux may play a significant role. Our aim was to develop a scoring system based on histopathologic reflux in surveillance biopsies following EET to identify patients at high risk for recurrence of BE. Patients were identified from two centers in the treatment with resection and endoscopic ablation techniques for BE consortium. Hematoxylin and eosin-stained slides of surveillance biopsies post-EET were assessed for histologic changes associated with reflux from a cohort of patients who also underwent pH-metry (derivation cohort). We developed a novel scoring system (Recurrent Epithelial Changes from Uncontrolled Reflux [RECUR]) composed of dilated intercellular spaces, epithelial ballooning, basal cell hyperplasia, and parakeratosis, to identify patients with abnormal esophageal acid exposure. This scoring system was then used to grade surveillance biopsies from patients with or without recurrence of BE following EET (validation cohort). Of 41 patients in the derivation cohort, 19.5% had abnormal acid exposure times (AET) while on proton pump inhibitor therapy. The mean (SD) RECUR score for patients with AET <4% was 4.0 (1.6), compared with 5.5 (0.9) for AET ≥4% (P = 0.015). In the validation cohort consisting of 72 patients without recurrence and 64 patients with recurrence following EET, the RECUR score was the only significant predictor of recurrence (odds ratio: 1.36, 95% confidence interval: 1.10-1.69, P = 0.005). Histologic grading of surveillance biopsies using the RECUR scoring system correlates with BE recurrence following EET.

Clinical Relevance of Random Biopsies From the Esophagogastric Junction After Complete Eradication of Barrett’s Esophagus is Low

Although random histological sampling from the esophagogastric junction (EGJ) after complete eradication of Barrett's esophagus (BE) is recommended, its clinical relevance is questionable. This study aimed to assess the incidence and long-term outcomes of findings from random EGJ biopsies in a nationwide cohort with long-term follow-up. We included all patients with successful endoscopic eradication therapy (EET), defined as complete endoscopic eradication of all visible BE (CE-BE), for early BE neoplasia from the Dutch registry. Patients were treated and followed-up in 9 expert centers according to a joint protocol. Outcomes included the incidence of intestinal metaplasia (IM) at the EGJ (EGJ-IM) and the association between IM and visible (dysplastic) BE recurrence. A total of 1154 patients were included with a median follow-up of 43 months (interquartile range, 22-69 months). At the time of CE-BE, persisting EGJ-IM was found in 7% of patients (78/1154), which was reproduced during further follow-up in 46% of patients (42/78). No significant association existed between persisting EGJ-IM at CE-BE and recurrent non-dysplastic or dysplastic BE (hazard ratio [HR], 1.15; 95% confidence interval [CI], 0.63-2.13 and HR, 0.73; 95% CI, 0.17-3.06, respectively). Among patients with no EGJ-IM at the time of CE-BE (1043/1154; 90%), EGJ-IM recurred in 7% (72/1043) after a median of 21 months (interquartile range, 15-36 months), and was reproduced during further follow-up in 26% of patients (19/72). No association was found between recurrent EGJ-IM and non-dysplastic or dysplastic recurrence (HR, 1.18; 95% CI, 0.67-2.06 and HR, 0.27; 95% CI, 0.04-1.96, respectively). Because EGJ-IM was not associated with a higher risk for recurrent disease, we recommend to consider abandoning random EGJ sampling after successful EET, under the condition that care is provided in expert centers, and the esophagus, including the EGJ, is carefully inspected (Netherlands Trial Register, NL7309).

Utilization trends for endoscopic ablation therapy and esophagectomy in Barrett’s esophagus from 2005 to 2019

Guidelines have shifted to now recommend endoscopic eradication therapy for Barrett’s esophagus (BE) with low and high-grade dysplasia. Previously, esophagectomy was the standard therapy for high-grade dysplasia. However, it is unclear to what degree ablation therapy has affected utilization of esophagectomy. In this retrospective observational cohort study of BE patients without cancer from the Premier Healthcare Database, the prevalence of utilization of endoscopic ablation therapy and of esophagectomy in BE were calculated and temporal trends were evaluated. A total of 938, 333 BE cases were included in the study. There was a significantly increasing trend of ablation over the period 2006 to 2010 (Annual Percentage Change (APC); 95% CI 0.56% [0.51%, 0.61%]), a significantly decreasing trend for the period 2011 to 2015 (APC; 95% CI − 0.15% [− 0.20%, − 0.11%]), and a shallow increasing trend for the period 2016 to 2019 (APC; 95% CI 0.09% [0.06%, 0.11%]). For esophagectomy, there was a significantly decreasing trend for the period 2006 to 2009 (APC; 95% CI − 0.03% [− 0.04%, − 0.02%]; P < 0.001) that corresponded to the uptrend in utilization of endoscopic ablation. There was a stable trend of esophagectomy over the period 2010 to 2019 (APC; 95% CI − 0.0006% [− 0.0002%, 0.0005%]; P = 0.1947). Adoption and increased utilization of endoscopic ablation therapy for BE has coincided with a decrease in esophagectomy, and is the predominate method of therapy for BE with dysplasia.

Transoral Incisionless Fundoplication in Patients With Barrett's Esophagus

During the past several decades, esophageal adenocarcinoma (EAC) has become one of the fastest growing cancers in the Western world, with over a 7-fold increase in incidence.1,2 Barrett's esophagus (BE) is a known precursor of EAC, and the risk of progression from BE to EAC correlates with the degree of dysplasia.3-5 Thus, early detection and treatment of dysplastic BE is paramount for prevention of EAC. The current standard of care for treatment of dysplastic BE is endoscopic eradication therapy (EET) with endoscopic mucosal resection of visible lesions followed by ablative therapy for remaining flat BE.