Esophagogastroduodenoscopy Reports Research Articles

Assessing the benefits of repeated esophagogastroduodenoscopy at a specialized center before gastric and esophageal cancer surgery.

The surgical treatment of gastric and esophageal cancer in Denmark is centralized in four specialized esophagogastric cancer (EGC) centers. Patients are referred after an esophagogastroduodenoscopy (EGD) at a secondary healthcare facility. The EGD is repeated at the specialized EGC center before determining a surgical treatment strategy. This multicenter retrospective study aimed to investigate the quality of EGDs performed at a secondary healthcare facility and evaluate the clinical value of repeated EGD at a specialized center when determining the surgical treatment strategy. Patients from three of the four centers, who underwent esophagectomy or gastrectomy with curative intent from 1 June 2016 to 1 May 2021, were included. EGD reports from the referral facilities and EGC centers were compared based on a predefined checklist. Furthermore, endoscopist experience, the time between examinations, and histology were registered. Finally, it was assessed whether the specialized EGD led to any substantial changes in surgical treatment. Baseline characteristics and differences in EGD reports were described and McNemar's chi-square test was performed. A logistic regression analysis was conducted to identify risk factors for a change in surgical strategy. The study included 953 patients who underwent both an initial EGD and EGD at referral to a specialized center. In 644 cases (68%), the information from the initial EGD was considered insufficient concerning preoperative tumor information. In 113 (12%) cases, the findings in the specialized EGD would lead to a significant alteration in the surgical strategy compared with the primary EGD. The findings suggest that repeated EGD at a specialized center is of clinical value and helps ensure proper surgical treatment for patients undergoing curative surgery for gastroesophageal cancer.

Effect of a deep learning-based automatic upper gastrointestinal endoscopic reporting system: a randomized crossover study.

Esophagogastroduodenoscopy (EGD) is essential for gastrointestinal disorders, and reports are pivotal to facilitating post-procedure diagnosis and treatment. Manual report generation lacks sufficient quality and is labor intensive. We first reported and validated an artificial intelligence-based endoscopy automatic reporting system (AI-EARS). The AI-EARS was designed for automatic report generation, including real-time image capturing, diagnosis and textual description. It was developed using multicenter datasets from eight hospitals in China, including 252111 images for training, 62706 images and 950 videos for testing.Twelve endoscopists and 44 endoscopy procedures were consecutively enrolled to evaluate the effect of AI-EARS in a multi-reader multi-case (MRMC) crossover study. The precision and completeness of the reports were compared between endoscopists using AI-EARS and conventional reporting systems. In video validation, AI-EARS achieved completeness of 98.59% and 99.69% for esophageal and gastric abnormality records, accuracies of 87.99% and 88.85% for esophageal and gastric lesion location records, and 73.14% and 85.24% for diagnosis.Compared to the conventional reporting systems, AI-EARS achieved greater completeness (79.03% vs. 51.86%, p<0.001), accuracy (64.47% vs. 42.81%, p<0.001) of the textual description, and completeness of the photo-documents of landmarks (92.23% vs. 73.69%, p<0.001). The mean reporting time for an individual lesion was significantly reduced (80.13±16.12 vs. 46.47±11.68 seconds, P<0.001) after AI-EARS assistance. AI-EARS showed its efficacy in improving the accuracy and completeness of the EGD reports. It might facilitate the generation of complete endoscopy reports and post-endoscopy patient management. (ClinicalTrails.gov, number NCT05479253).

Unique Epidemiologic Features of Esophageal Squamous Dysplasia: A Retrospective Single Institution Study

Abstract Introduction/Objective Squamous cell carcinoma (SCC) is the most common esophageal primary tumor worldwide. On the contrary, SCC and its precursor lesion, esophageal squamous dysplasia (ESD), are uncommon in western countries and North America, with smoking and heavy alcohol (EtOH) use being the significant risk factors. Given the influence of geography on the prevalence of SCC, we hypothesize that there may be unique risk factors in the Northeastern United States population compared to worldwide factors. Our retrospective study focuses on ESD, the premalignant condition, examining known risk factors at our institution. Methods/Case Report Patients diagnosed/followed with ESD during 2006-19 were identified from pathology database. Among patients who had an initial esophagogastroduodenoscopy (EGD) finding suspicious for SCC and confirmed by histology were excluded. Demographics, social and medical history (hx), EGD reports, and pathology reports were reviewed. We evaluated subgroups of risk factors. Results (if a Case Study enter NA) Study included 37 patients. Mean age at initial EGD biopsy was 66.8 years (range: 42-94 years); 56.8% (21/37) were female. By endoscopy, the most common finding was erythema followed by friability and nodularity. 45.9% had at least one recurrent ESD in subsequent biopsies, and 35.1% were eventually diagnosed with SCC. 83.3% showed high grade ESD on initial biopsy. Smoking [current, former, or never (NS)] and EtOH hx [heavy, light/moderate, or no] showed no significant association (p=0.38). Majority were either former or NS (72.9%); 34.3% were NS. In NS, 91.7% (11/12) were female, 50.0% did not consume EtOH, and 50.0% had concurrent Barrett esophagus. 33.3% later developed SCC. Also in NS, 50% had a personal hx of cancer and reported no family hx of GI/esophageal cancer. Conclusion In our institution, while some data is consistent with population data (i.e. EGD distribution, appearance), our study cohort is mostly women and within it is a unique subgroup lacking classical strong risk factors. This subset of NS is mostly women with no to moderate alcohol intake and lacking a strong family hx of GI/esophageal cancer. Our data emphasizes that not all predisposing factors have been elucidated in ESD. Our findings may offer a unique opportunity to further the understanding of SCC pathogenesis.

Natural Language Processing for Information Extraction of Gastric Diseases and Its Application in Large-Scale Clinical Research.

Background and Aims: The utility of clinical information from esophagogastroduodenoscopy (EGD) reports has been limited because of its unstructured narrative format. We developed a natural language processing (NLP) pipeline that automatically extracts information about gastric diseases from unstructured EGD reports and demonstrated its applicability in clinical research. Methods: An NLP pipeline was developed using 2000 EGD and associated pathology reports that were retrieved from a single healthcare center. The pipeline extracted clinical information, including the presence, location, and size, for 10 gastric diseases from the EGD reports. It was validated with 1000 EGD reports by evaluating sensitivity, positive predictive value (PPV), accuracy, and F1 score. The pipeline was applied to 248,966 EGD reports from 2010–2019 to identify patient demographics and clinical information for 10 gastric diseases. Results: For gastritis information extraction, we achieved an overall sensitivity, PPV, accuracy, and F1 score of 0.966, 0.972, 0.996, and 0.967, respectively. Other gastric diseases, such as ulcers, and neoplastic diseases achieved an overall sensitivity, PPV, accuracy, and F1 score of 0.975, 0.982, 0.999, and 0.978, respectively. The study of EGD data of over 10 years revealed the demographics of patients with gastric diseases by sex and age. In addition, the study identified the extent and locations of gastritis and other gastric diseases, respectively. Conclusions: We demonstrated the feasibility of the NLP pipeline providing an automated extraction of gastric disease information from EGD reports. Incorporating the pipeline can facilitate large-scale clinical research to better understand gastric diseases.

Effectiveness of a surveillance program of upper endoscopy for upper gastrointestinal cancers in Lynch syndrome patients.

Lynch syndrome (LS) is the most common cause of hereditary colorectal cancer and is associated with an increased lifetime risk of gastric and duodenal cancers of 8-16% and 7%, respectively; therefore, we aim to describe an esophagogastroduodenoscopy (EGD) surveillance program for upper gastrointestinal (GI) precursor lesions and cancer in LS patients. Patients who either had positive genetic testing or met clinical criteria for LS who had a surveillance EGD at our institution from 1996 to 2017 were identified. Patients were included if they had at least two EGDs or an upper GI cancer detected on the first surveillance EGD. EGD and pathology reports were extracted manually. Our cohort included 247 patients with a mean age of 47.1years (SD 12.6) at first EGD. Patients had a mean of 3.5 EGDs (range 1-16). Mean duration of follow-up was 5.7years. Average interval between EGDs was 2.3years. Surveillance EGD detected precursor lesions in 8 (3.2%) patients, two (0.8%) gastric cancers and two (0.8%) duodenal cancers. Two interval cancers were diagnosed: a duodenal adenocarcinoma was detected 2years, 8months after prior EGD and a jejunal adenocarcinoma was detected 1year, 9months after prior EGD. Our data suggest that surveillance EGD is a useful tool to help detect precancerous and cancerous upper GI lesions in LS patients. To our knowledge, this is the first study to examine a program of surveillance EGDs in LS patients. More data are needed to determine the appropriate surveillance interval.

A163 MICROCOSTING: ASSESSING HEALTH ECONOMICS IN GI

Abstract Background Micro-costing is a method of collecting precise cost measurements and proves effective in determining economic requirements needed to support health interventions. At St. Paul’s GI Clinic, over 12000 procedures are performed yearly, 80% of which are colonoscopies. Specific standards in the form of appropriate documentation are recommended through Global Rating Scale (GRS) and require yearly auditing to ensure appropriate compliance with these standards. These audits require a time commitment of staff to assess charts. The cost of performing these assessments is not known. Aims To determine the cost of annual data collection suggested by GRS for documentation of procedures. Methods A retrospective chart review and data analysis of patients (≥ 19 years old) admitted to St. Paul’s GI Clinic for a colonoscopy and/or esophagogastroduodenoscopy (EGD). Data is extracted from the St. Paul’s medical database from August 1st 2018 – August 1st 2019. Since it is a ‘time-and-motion’ study, a stopwatch is used to time the collection of data from each chart. The mean time per-case is derived and used to conduct an appropriate economic analysis, such as total working hours, per-minute salary calculations and equipment costs. The purpose is to determine a yearly cost and identify what the main cost drivers were (time/labor). Results As per our annual review format suggested by GRS, 260 procedure reports were reviewed, 150 colonoscopies and 110 EGDs (random sampling of 10 per physician for each type of procedure). A spread sheet outlining key data assessment points for mandatory standard reporting points has been used yearly and was used for this study as well. Mean evaluation time (including recording presence or absence of each item on our standard reporting form): 1 minute and 40 seconds to review the report for a colonoscopy and 1 minute and 33 seconds to review the report for an EGD. A total of 2 hours 51 minutes 16 seconds to review all the EGD reports and 4 hours 8 minutes and 46 seconds for the colonoscopy reports. Conclusions It would cost $126 annually to pay a research student, who makes $18/ hour, to collect this quality assurance data required for auditing completeness of physician colonoscopy and EGD procedure documentation according to standards. Funding Agencies None

Improvement of Endoscopic Reports with Implementation of a Dictation Template.

AimsCompleteness of procedure reports is an important quality indicator in endoscopy. A dictation template was developed to ensure key elements were included in colonoscopy and esophagogastroduodenoscopy (EGD) reports. Endoscopy reports were reviewed prior to and following implementation of the dictation templates to determine whether report completeness improved.MethodsKey elements in an endoscopic report were identified from published guidelines and posted at dictation stations. Colonoscopy and EGD reports were reviewed for the nine physicians performing endoscopy at St. Paul’s Hospital prior to and following implementation of dictation templates. Dictation completeness was defined as inclusion of all key elements. Dictation completeness and inclusion of individual key elements at the two time points were compared using the t-test and Chi-square test.ResultsReports for 4648 procedures undertaken by nine endoscopists were reviewed for completeness at each time point (2008 and 2014). Colonoscopy report completeness increased from 65.8% to 83.2% (P < 0.001). Items that improved included documentation of consent, endoscope used, complications, withdrawal time and rectal retroflexion. EGD report completeness increased from 72.7% to 77.3% (P < 0.001) with improvement in documentation of consent and complications. Items consistently underreported for colonoscopy and EGD at both time points included: patient age, comorbidities, current medications and patient comfort.ConclusionThere was an association between the use of a posted dictation template at dictation stations and the improved completeness of endoscopic reports.

1126 Preoperative Endoscopic Findings in Veterans Undergoing Bariatric Surgery: Prevalence and Predictors of Barrett's Esophagus

INTRODUCTION: The role of preoperative esophagogastroduodenoscopy (EGD) in patients seeking bariatric surgery remains unclear, as recommendations are based on data from a younger, largely female population. We aim to characterize and determine the frequency of EGD findings in a predominantly older, male Veteran population undergoing bariatric surgery. METHODS: This is a single-center retrospective analysis of Veterans who underwent Roux-en-Y gastric bypass or laparoscopic sleeve gastrectomy at a Veterans Affairs hospital between January 2008 and December 2017. All patients received a preoperative EGD. Data abstracted included demographics, comorbidities, preoperative laboratory values and EGD reports. Univariate and multivariate analyses using odds ratio (OR) were compared between those with a normal EGD and Barrett’s esophagus. RESULTS: Of the 260 Veterans included in our cohort, most were male (75%) aged 54.0 ± 9.0 years-old with a BMI of 44.9 ± 7.0 kg/m2 (Table 1). Most Veterans identified themselves as Caucasian (73.5%), followed by African American (9.2%), Hispanic (7.3%), Native American (1.2%), Asian (0.8%) and other (8.1%). The majority had hypertension (78.9%), previously smoked (63.9%), used a proton pump inhibitor (PPI) (53.1%) within 6 months of surgery, had gastroesophageal reflux disease (GERD) (49.2%) and diabetes (47.3%). One third of Veterans had a completely normal preoperative EGD. Common EGD findings included gastritis (35.8%), hiatal hernia (25.8%), esophagitis (20.8%), duodenitis (10.4%), Barrett’s esophagus (7.4%), H. pylori infection (4.6%) and gastric intestinal metaplasia (0.8%). On univariate analysis alone, male gender (OR 0.55, P = 0.041) and those with hypertension (OR 0.50, P = 0.025) were less likely associated with a normal EGD. On both univariate and multivariate analyses, those who recently used a PPI were also less likely to have a normal EGD (OR 0.38, P = 0.001; OR 0.030,P &lt; 0.001, respectively). In contrast, on both univariate and multivariate analysis, increasing age (OR 1.08, P = 0.020; OR 1.08; P = 0.040, respectively), recent PPI use (OR 5.20, P = 0.010; OR 10.1, P = 0.002, respectively) and recent histamine receptor 2 blocker (H2B) use (OR 5.58, P = 0.007; OR 8.87 P = 0.014, respectively), were associated with Barrett’s esophagus (Table 3). CONCLUSION: Preoperative factors can be used to identify patients at risk for gastroesophageal pathology. Our data support preoperative EGD in select populations that include older males with recent PPI or H2B use.

Quality of Endoscopy Reports for Esophageal Cancer Patients: Where Do We Stand?

Backgrounds and AimsAs treatment for esophageal cancer often involves a multidisciplinary approach, the initial endoscopic report is essential for communication between providers. Several guidelines have been established to standardize endoscopic reporting. This study evaluates the compliance of esophagogastroduodenoscopy (EGD) and endoscopic ultrasound (EUS) reporting with the current national guidelines. MethodsCombining the National Comprehensive Cancer Network and Society of Thoracic Surgeons guidelines, 11 quality indicators (QIs) for EGD and 8 for EUS were identified. We evaluated initial EGD and EUS reports from our institution (Memorial Sloan Kettering [MSK]) and outside hospitals (OSHs) and calculated individual and overall quality measure scores. Scores between locations were compared using the Wilcoxon signed-rank test and McNemar’s test for paired data. ResultsIn total, 115 initial EGD reports and 105 EUS reports were reviewed for patients who underwent surgery for esophageal cancer between 2014 and 2016. The median number of QIs reported for the initial EGD was 4 (IQR, 3–6)—only 34% of reports qualified as “good quality” (those with ≥ 6 QIs). None of the reports included all QIs. For patients who underwent EGD at both MSK and an OSH, 32% of reports from OSHs were good quality, compared with 68% from MSK (p < 0.001). Compliance with QIs was better for EUS reports: 71% of OSH reports and 72% of MSK reports were good quality. ConclusionsDetailed information on the initial endoscopic assessment is essential in today’s age of multidisciplinary care. Identification and adoption of QIs for endoscopic reporting is warranted to ensure the provision of appropriate treatment.

Is preoperative gastroscopy necessary before sleeve gastrectomy and Roux-en-Y gastric bypass?

BackgroundConsensus on the necessity of esophagogastroduodenoscopy (EGD) before bariatric surgery is lacking. Recommendations and practices vary by country and unit. Several reports have expressed concerns on gastroesophageal reflux disease (GERD) and its consequences after sleeve gastrectomy (SG) and the risk of leaving a premalignant lesion in the excluded stomach after Roux-en-Y gastric bypass (RYGB). ObjectivesWe explored the number and types of clinically significant findings in preoperative EGDs and how they associate with preexisting GERD-symptoms (SG) and premalignant lesions (RYGB). We also studied how many reoperations were performed due to postoperative GERD in SG-patients. SettingUniversity hospital. MethodsWe investigated preoperative EGD-findings and gastrointestinal symptoms before bariatric surgery in all patients with a primary bariatric operation in our unit between December 2007 and May 2016. ResultsWe performed 1474 operations: 1047 (71.0%) RYGB, 407 (27.6%) SG, and 20 (1.4%) others. One thousand two hundred seventy-five (86.5%) preoperative EGD reports were analyzed: 647 (50.7%) EGDs were completely normal. Altogether, 294 patients (23.0% of total) had a clinically significant finding that was relevant for SG (hiatal hernia, esophagitis, Barrett’s esophagus, esophageal dysplasia), 144 (49.0%) of whom reported gastrointestinal symptoms. Twenty patients (1.6%) had a significant finding relevant for RYGB (peptic ulcer, atrophic gastritis, gastrointestinal stromal tumor), and 6 (30%) reported gastrointestinal symptoms. Thirteen (3.2%) SGs were converted into RYGB due to GERD. ConclusionsPreoperative EGD is indicated before SG but not before RYGB for asymptomatic patients without a risk for gastric pathology.

Gastric superficial neoplasia: high miss rate but slow progression.

Background and aims Gastric superficial neoplasia (GSN) is often overlooked at endoscopy because of difficulty in identifying it. The miss rate of GSN at endoscopy and the impact on clinical outcome of the missed GSN have not been fully elucidated. In this study, we investigated these issues. Methods Among 1462 endoscopically and pathologically diagnosed gastric cancers in our hospital from January 2011 to December 2014, previous records of esophagogastroduodenoscopy (EGD) were available for 198 lesions (index lesions) and were reviewed retrospectively. Among those, 157 lesions, which were diagnosed as GSN on the basis of their EGD findings at initial endoscopy, were analyzed. Progression was defined as advanced cancer in the index lesion. Results Among the 157 GSNs, 118 (75.2 %) had not been recorded in the previous EGD report but were evident upon review of endoscopic photographs for this study. Progression to advanced cancer was observed in only 13 (8.3 %) of the 157 GSNs during a mean interval of 41 months and as long as 96 months, and the rate of progression was similar in missed and not-missed lesions (8.5 % and 7.7 %, respectively). Cumulative incidence rates of progression of missed GSNs to advanced cancer were 0.8 %, 1.7 %, 4.2 %, and 7.6 % at 36, 48, 60, and 72 months after the initial EGD, respectively. Conclusions Our findings illustrate that GSNs are often missed at endoscopy but progress slowly in most cases. Even though the rate of progression to cancer is relatively low, rigorous attempts should be made to reduce the miss rate of GSNs at EGD.

Real-world Helicobacter pylori diagnosis in patients referred for esophagoduodenoscopy: The gap between guidelines and clinical practice.

Histopathology is the most accurate test to detect H. pylori when performed correctly with unknown validity in daily practice clinic settings. We aimed to determine the rate of potentially false-negative H. pylori results that might be due to continued use of proton pump inhibitors (PPIs) in routine endoscopy practice. We also aimed to establish whether gastroenterologists recommend routine cessation of PPIs before esophagogastroduodenoscopy (EGD) and whether they regularly document that biopsies for H. pylori testing have been taken while the patients are on PPI treatment. Detailed information about three known factors (PPIs, antibiotics and prior H. pylori eradication treatment), which may cause histology or rapid urease test (RUT) to be unreliable, had been prospectively collected through interviews using a questionnaire before each test. Gastric biopsies were stained with H&E for histological analysis. A total of 409 individuals at three academic gastroenterology institutions were tested 200 times with histology. Fifty-six per cent (68 of 122) of all negative tests fell in the category of continuing PPI use, which had the potential to make the histology and RUT results unreliable. These data demonstrate a clear and important gap between current guidelines and real-world practice with regards to the diagnosis of H. pylori during EGD. A negative histology or RUT should be considered false negative until potential protocol violations are excluded. Documentation of PPI use during the EGD should be an integral part of the EGD report. The current practice of taking biopsies for H. pylori testing in patients under PPIs should be reevaluated.

Location, size, and distance: criteria for quality in esophagogastroduodenos copy reporting for pre-operative gastric cancer evaluation

There is a lack of existing literature regarding the quality of esophagogastroduodenoscopy (EGD) reporting for gastric cancer evaluation. This study aims to determine criteria for quality endoscopic evaluation of gastric cancer in North America by identifying important features of the EGD report for pre-operative evaluation of gastric cancer and assessing inclusion of these features in existing reports. Semi-structured interviews were conducted with experienced endoscopists from community and academic hospitals affiliated with the University of Toronto to identify essential elements for an EGD report. Then, 225 EGD reports from 2005 to 2008 were evaluated by two trained reviewers for inclusion of recommended EGD report elements and global assessment of report quality and adequacy for surgical planning. Essential elements recommended by interviewed endoscopists include tumor size, location, and distance from gastroesophageal junction (GEJ). Approximately 95 % of all reports documented the location of lesions, <5 % documented distance from the GEJ, and <15 % documented tumor size. Overall report quality was rated as excellent for 4-5 % of reports; 20-42 % of all reports were deemed to be adequate for surgical planning. All surgeons interviewed as part of the endoscopist panel indicated that they would repeat the EGD before consulting with patients regarding surgical planning. For pre-operative evaluation of gastric cancer, tumor size, location, and distance from key anatomical landmarks were proposed as essential elements of a quality EGD report. Most of the reviewed reports did not document these elements. Report quality is perceived to be poor and may lead to repeat endoscopy. Developing a standardized EGD reporting format based on inclusion of individual parameters can improve the quality of gastric cancer management.

What studies are appropriate and necessary for staging gastric adenocarcinoma? Results of an international RAND/UCLA expert panel

The approach for staging gastric adenocarcinoma (GC) has not been well defined, with heterogeneity in the application of staging modalities. Utilizing a RAND/UCLA appropriateness methodology (RAM), a multidisciplinary expert panel of 16 physicians scored 84 GC staging scenarios. Appropriateness was scored from 1 to 9. Median appropriateness scores from 1 to 3 were considered inappropriate, 4-6 uncertain, and 7-9 appropriate. Agreement was reached when 12 or more of 16 panelists scored the scenario similarly. Appropriate scenarios were subsequently scored for necessity. Pretreatment TNM stage determination is necessary. Necessary staging maneuvers include esophagogastroduodenoscopy (EGD); biopsy of the tumor; documentation of tumor size, description, location, distance from gastroesophageal junction (GEJ), and any GEJ, esophageal, or duodenal involvement; if an EGD report is unclear, surgeons should repeat it to confirm tumor location. Pretreatment radiologic assessment should include computed tomography (CT)-abdomen and CT-pelvis, performed with multidetector CT scanners with 5-mm slices. Laparoscopy should be performed before resection of cT3-cT4 lesions or multivisceral resections. Laparoscopy should include inspection of the stomach, diaphragm, liver, and ovaries. Using a RAM, we describe appropriate and necessary staging tests for the pretreatment staging evaluation of GC, as well as how some of these staging maneuvers should be conducted.

What studies are appropriate and necessary for staging gastric cancer? Results of a RAND/UCLA expert panel.

15 Background: The approach for staging gastric cancer (GC) patients has not been well defined, resulting in widespread heterogeneity in the application of pre-operative staging modalities. Methods: A multi-disciplinary expert panel of 16 physicians from 6 countries scored 84 scenarios using the RAND/UCLA Appropriateness Methodology. Appropriateness was scored from 1 (highly inappropriate) to 9 (highly appropriate). Median appropriateness scores (AS) from 1-3 were considered inappropriate, 4-6 uncertain, and 7-9, appropriate. Agreement was reached when 11 of 16 panelists scored the scenario similarly. If a scenario was agreed to be appropriate, it was given a necessity score (NS) in the same manner. AS and NS are reported if agreed upon. Results: TNM staging should be determined pre-operatively (AS 7.0-9.0; NS 7.0-9.0). Pre-operative radiological assessment should include a computed tomography (CT)−abdomen, CT−pelvis, and should be performed with a multi−detector CT scanner with 5 mm slices (AS 8.0−9.0; NS 7.0−9.0). A CT Chest may be performed (AS 7.5). The utility of a chest radiograph was indeterminate. All patients should have a pre-operative esophagogastroduodenoscopy (EGD). The endoscopist should biopsy the tumor; document its size, description, location, distance from the GE junction, and any GE junction, esophageal or duodenal involvement. If the EGD report is unclear, the surgeon should repeat it to confirm tumor location (AS 7.5-9.0, NS 7.0−9.0). Endoscopic ultrasound is appropriate prior to endoscopic resection, but not surgical resection (AS 9.0). Diagnostic laparoscopy (DL) should be performed prior to resection of cT3,4 lesions, or multi−visceral resections. DL should include visual inspection of the stomach, diaphragm, liver, and ovaries (AS 8.0−9.0, NS 7.0−9.0). Conclusions: The Gastric Cancer Processes of Care expert panel has made recommendations regarding pre−operative staging modalities in an effort to standardize work up. Standardization could lead to more accurate staging and allocation towards optimal stage−specific treatments.

Increasing Prevalence of Barrett's Esophagus with Relatively Low Risk of Neoplasia - Three-Year Prospective Cohort Study from Central European Country

Background and Aim: Barrett's esophagus (BE) is a premalignant condition. Due to unclear reasons the prevalence of BE as well as the risk of BE-related neoplasia are higher in US and Western Europe in comparison to less developed countries. The aim of the study was to assess the prevalence of BE and BE-related neoplasia in unselected patients undergoing esophago-gastro-duodenoscopy (EGD) in single endoscopy unit in Poland. Material and Methods: All consecutive EGD reports from January 2005 to December 2007 were analyzed, including demographic data, EGD indications and endoscopic findings. Montreal classification definitions were used. Overall 6414 EGDs were included (54% females; median age 56 years, IQ range 45 to 68). Results: The diagnosis of endoscopically suspected esophageal metaplasia (ESEM) was made in 452 of 6414 EGDs (7.0%). In 5.3% of patients this was a new diagnosis and in remaining 1.7% EGD was done for BE surveillance. There was a significant increase during the study years in relative ESEM frequencies, both overall (5.5%, 6.4%, and 9.7% in 2005, 2006 and 2007, respectively, p<0.0001) and as a new diagnosis (4.2%, 5.2%, 7.0%, respectively, p<0.0001). ESEM was found more frequently when GERD was an indication for EGD (11% vs. 4% for other indications, p<0.0001) in males vs. females (9% vs. 5%, p<0.0001), in patients >36 years vs. younger (8% vs. 5%, p=0.001), and in patients with hiatal hernia (27% vs. 5%, p<0.0001). The median ESEM length was 10 mm (IQ range 7 to 20), and 19% of ESEM segments were long (30 mm or more). Standardized random biopsies were taken from ESEM in 325 cases. The specialized intestinal metaplasia (SIM) was found in 51.5% of ESEM. The frequency of SIM also increased over study years (42%, 44%, and 65% respectively, p=0.001). SIM was more frequent in patients >41 years vs. younger (56% vs. 26%, p=0.0001) and in patients with length of ESEM >20 mm vs. shorter (67% vs. 47%, p=0.005). However, SIM was significantly less frequent in patients in whom GERD was the indication for EGD vs. other indications (34% vs. 50%, p=0.02). The prevalence of intraepithelial neoplasia (IN) - low-grade or high-grade IN and cancer - was low (5.8% of ESEM) with only three cases of HGD (0.9%) and one cancer (0.3%). IN was more frequent in patients >57 years vs. younger (11% vs. 1%; p<0.0001), with previously diagnosed BE (16% vs. 2%; p<0.0001) and in patients with length of ESEM > 45 mm (20% vs. 4%; p=0.008). Conclusions: The frequency of diagnosis of BE shows increasing tendency, but the prevalence of BE-related neoplasia in Central Europe is low. The risk of IN is highest in elderly patients with previously diagnosed long segment BE.