Four-quadrant Biopsies Research Articles

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.

Adherence to guideline recommendations for Barrett's esophagus (BE) surveillance endoscopies: Effects of dedicated BE endoscopy lists.

Background and study aims For non-dysplastic Barrett's Esophagus (BE) patients, guidelines recommend endoscopic surveillance every 3 to 5 years with four-quadrant random biopsies every 2 cm of BE length. Adherence to these guidelines is low in clinical practice. Pooling BE surveillance endoscopies on dedicated endoscopy lists performed by dedicated endoscopists could possibly enhance guideline adherence, detection of visible lesions, and dysplasia detection rates (DDRs). Patients and methods Data were used from the ACID-study (Netherlands Trial Registry NL8214), a prospective trial of BE surveillance in the Netherlands. BE patients with known or previously treated dysplasia were excluded. Guideline adherence, detection of visible lesions, and DDRs were compared for patients on dedicated and general endoscopy lists. Results A total of 1,244 patients were included, 318 on dedicated lists and 926 on general lists. Endoscopies on dedicated lists showed significantly higher adherence to the random biopsy protocol (85% vs. 66%, P <0.01) and recommended surveillance intervals (60% vs. 47%, P <0.01) compared to general lists. Detection of visible lesions (8.8% vs. 8.1%, P =0.79) and DDRs were not significantly different (6.9% and 6.6%, P =0.94). None (0.0%) of the patients scheduled on dedicated lists and 10 (1.1%) on general lists were diagnosed with esophageal adenocarcinoma ( P =0.07). In multivariable analysis, dedicated lists were significantly associated with biopsy protocol adherence and adherence to surveillance interval recommendations with odds ratios of 4.45 (95% confidence interval [CI] 2.07-9.57) and 1.64 (95% CI 1.03-2.61), respectively. Conclusions Dedicated endoscopy lists are associated with better adherence to the random biopsy protocol and surveillance interval recommendations.

The Value of Four-Quadrant Cervical Biopsy in Women with Different Colposcopic Impressions.

The aim of this study was to compare the diagnostic efficacy of colposcopic-directed biopsy and four-quadrant biopsy in detecting high-grade cervical intra-epithelial neoplasia (CIN). Women attending three women's clinics for routine cervical screening were recruited. Colposcopy was arranged for women with any cytologic abnormalities greater than atypical squamous cells of undetermined significance (ASCUS), two consecutive ASCUS results or positive HPV testing. During colposcopy, a cervical biopsy was taken from the most suspicious area, but more than one biopsy was allowed. Four-quadrant biopsies at 3, 6, 9 and 12 o'clock and an endocervical curettage were also taken in all cases. A total of 1522 colposcopies were performed in 1311 subjects from June 2010 to August 2017, with 118 cases of high-grade CIN diagnosed. Colposcopic-directed biopsy detected 50.8% of the 118 high-grade CIN, while four-quadrant biopsy detected 86.4% (p < 0.0001). Twenty-seven cases (22.9%) of high-grade CIN were diagnosed in women with normal or unsatisfactory colposcopy. Among the 64 cases with low-grade colposcopic impression, four-quadrant biopsy detected significantly more high-grade CIN (53 cases, 82.8%) than colposcopic-directed biopsy (35 cases, 56.3%) (p = 0.0011). Four-quadrant cervical biopsies should be considered for all women with an abnormal smear or positive HPV testing, especially in patients with low-grade/normal/unsatisfactory colposcopy.

Effect of biopsy protocol adherence vs non-adherence on dysplasia detection rates in Barrett's esophagus surveillance endoscopies: a systematic review and meta-analysis.

Background Barrett's esophagus (BE) surveillance endoscopies are advised for early diagnosis of esophageal adenocarcinoma (EAC). Current guidelines recommend obtaining four-quadrant random biopsies every 2 centimeters of BE length alongside with targeted biopsies if visible lesions are present. Low adherence rates for this random biopsy protocol are widely reported. The aim of this systematic review and meta-analysis was to assess the effect of adherence versus non-adherence to the four-quadrant biopsy protocol on detection of dysplasia in BE patients. Methods We searched for studies that reported effects of adherence and non-adherence to the four-quadrant biopsy protocol on dysplasia detection rates in BE patients. Adherence was defined as taking a minimum of 4 quadrant random biopsies per 2 cm of BE segment. Studies with low risk of bias and without applicability concerns were included in a good quality synthesis. Pooled relative risks (RRs) with 95% confidence interval (CI) of dysplasia detection rates were calculated. Results A total of 1,570 studies were screened and 8 studies were included. Four studies were included in the good quality synthesis. In the pooled good quality analysis, four-quadrant biopsy protocol adherence significantly increased detection of dysplasia compared to non-adherence (RR 1.90, 95 % CI = 1.36-2.64; I2 = 45 %). Pooled RRs for LGD and HGD/EAC were 2.00 (95 % CI = 1.49-2.69; I2 = 0 %) and 2.03 (95 % CI = 0.98-4.24; I2 = 28 %), respectively. Conclusion This systematic review and meta-analysis demonstrates that four-quadrant biopsy protocol adherence is associated with increased detection of dysplasia in BE patients. Efforts should be made to increase biopsy protocol adherence rates.

Management of nondysplastic Barrett's esophagus: When to survey? When to ablate?

Barrett’s esophagus (BE), a precursor for esophageal adenocarcinoma (EAC), is defined as salmon-colored mucosa extending more than 1 cm proximal to the gastroesophageal junction with histological evidence of intestinal metaplasia. The actual risk of EAC in nondysplastic Barrett’s esophagus (NDBE) is low with an annual incidence of 0.3%. The mainstay in the management of NDBE is control of gastroesophageal reflux disease (GERD) along with enrollment in surveillance programs. The current recommendation for surveillance is four-quadrant biopsies every 2 cm (or 1 cm in known or suspected dysplasia) followed by biopsy of mucosal irregularity (nodules, ulcers, or other visible lesions) performed at 3- to 5-year intervals. Challenges to surveillance include missed cancers, suboptimal adherence to surveillance guidelines, and lack of strong evidence for efficacy. There is minimal role for endoscopic eradication therapy in NDBE. The role for enhanced imaging techniques, artificial intelligence, and risk prediction models using clinical data and molecular markers is evolving.

Endoscopic tissue sampling - Part 2: Lower gastrointestinal tract. European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

1: ESGE suggests performing segmental biopsies (at least two from each segment), which should be placed in different specimen containers (ileum, cecum, ascending, transverse, descending, and sigmoid colon, and rectum) in patients with clinical and endoscopic signs of colitis.Weak recommendation, low quality of evidence. 2: ESGE recommends taking two biopsies from the right hemicolon (ascending and transverse colon) and, in a separate container, two biopsies from the left hemicolon (descending and sigmoid colon) when microscopic colitis is suspected.Strong recommendation, low quality of evidence. 3: ESGE recommends pancolonic dye-based chromoendoscopy or virtual chromoendoscopy with targeted biopsies of any visible lesions during surveillance endoscopy in patients with inflammatory bowel disease. Strong recommendation, moderate quality of evidence. 4: ESGE suggests that, in high risk patients with a history of colonic neoplasia, tubular-appearing colon, strictures, ongoing therapy-refractory inflammation, or primary sclerosing cholangitis, chromoendoscopy with targeted biopsies can be combined with four-quadrant non-targeted biopsies every 10 cm along the colon. Weak recommendation, low quality of evidence. 5: ESGE recommends that, if pouch surveillance for dysplasia is performed, visible abnormalities should be biopsied, with at least two biopsies systematically taken from each of the afferent ileal loop, the efferent blind loop, the pouch, and the anorectal cuff.Strong recommendation, low quality of evidence. 6: ESGE recommends that, in patients with known ulcerative colitis and endoscopic signs of inflammation, at least two biopsies be obtained from the worst affected areas for the assessment of activity or the presence of cytomegalovirus; for those with no evident endoscopic signs of inflammation, advanced imaging technologies may be useful in identifying areas for targeted biopsies to assess histologic remission if this would have therapeutic consequences. Strong recommendation, low quality of evidence. 7: ESGE suggests not biopsying endoscopically visible inflammation or normal-appearing mucosa to assess disease activity in known Crohn's disease.Weak recommendation, low quality of evidence. 8: ESGE recommends that adequately assessed colorectal polyps that are judged to be premalignant should be fully excised rather than biopsied.Strong recommendation, low quality of evidence. 9: ESGE recommends that, where endoscopically feasible, potentially malignant colorectal polyps should be excised en bloc rather than being biopsied. If the endoscopist cannot confidently perform en bloc excision at that time, careful representative images (rather than biopsies) should be taken of the potential focus of cancer, and the patient should be rescheduled or referred to an expert center.Strong recommendation, low quality of evidence. 10: ESGE recommends that, in malignant lesions not amenable to endoscopic excision owing to deep invasion, six carefully targeted biopsies should be taken from the potential focus of cancer.Strong recommendation, low quality of evidence.

Virtual Biopsy by Electrical Impedance Spectroscopy in Barrett’s Carcinoma

PurposeEarly detection of adenocarcinomas in the esophagus is crucial for achieving curative endoscopic therapy. Targeted biopsies of suspicious lesions, as well as four-quadrant biopsies, represent the current diagnostic standard. However, this procedure is time-consuming, cost-intensive, and examiner-dependent. The aim of this study was to test whether impedance spectroscopy is capable of distinguishing between healthy, premalignant, and malignant lesions. An ex vivo measurement method was developed to examine esophageal lesions using impedance spectroscopy immediately after endoscopic resection.MethodsAfter endoscopic resection of suspicious lesions in the esophagus, impedance measurements were performed on resected cork-covered tissue using a measuring head that was developed, with eight gold electrodes, over 10 different measurement settings and with frequencies from 100 Hz to 1 MHz.ResultsA total of 105 measurements were performed in 60 patients. A dataset of 400 per investigation and a total of more than 42,000 impedance measurements were therefore collected. Electrical impedance spectroscopy (EIS) was able to detect dysplastic esophageal mucosa with a sensitivity of 81% in Barrett’s esophagus.ConclusionIn summary, EIS was able to distinguish different tissue characteristics in the different esophageal tissues. EIS thus holds potential for further development of targeted biopsies during surveillance endoscopy.Trial RegistrationNCT04046601

Costs and cost-effectiveness of cervical cancer screening strategies in women living with HIV in Burkina Faso: The HPV in Africa Research Partnership (HARP) study.

This study estimated the costs and incremental cost per case detected of screening strategies for high-grade cervical intraepithelial neoplasia (CIN2+) in women living with HIV (WLHIV) attending HIV clinics in Burkina Faso. The direct healthcare provider costs of screening tests (visual inspection with acetic acid (VIA), VIA combined visual inspection with Lugol's iodine (VIA/VILI), cytology and a rapid HPV DNA test (careHPV)) and confirmatory tests (colposcopy, directed biopsy and systematic four-quadrant (4Q) biopsy) were collected alongside the HPV in Africa Research Partnership (HARP) study. A model was developed for a hypothetical cohort of 1000 WLHIV using data on CIN2+ prevalence and the sensitivity of the screening tests. Costs are reported in USD (2019). The study enrolled 554 WLHIV with median age 36 years (inter-quartile range, 31-41) and CIN2+ prevalence of 5.8%. The average cost per screening test ranged from US$3.2 for VIA to US$24.8 for cytology. Compared to VIA alone, the incremental cost per CIN2+ case detected was US$48 for VIA/VILI and US$814 for careHPV. Despite higher costs, careHPV was more sensitive for CIN2+ cases detected compared to VIA/VILI (97% and 56%, respectively). The cost of colposcopy was US$6.6 per person while directed biopsy was US$33.0 and 4Q biopsy was US$48.0. Depending on the willingness to pay for the detection of a case of cervical cancer, decision makers in Burkina Faso can consider a variety of cervical cancer screening strategies for WLHIV. While careHPV is more costly, it has the potential to be cost-effective depending on the willingness to pay threshold. Future research should explore the lifetime costs and benefits of cervical cancer screening to enable comparisons with interventions for other diseases.

Histological Remission in Ulcerative Colitis in Deep Remission under Treatment with Adalimumab

Background and Aims: Histological remission (HR) has been recently demonstrated as the last therapeutic goal in ulcerative colitis (UC), but it is unknown whether and how it may occur. Our aim was to assess the histology during the follow-up of an UC population in deep remission under treatment with adalimumab (ADA).&#x0D; Methods: We performed a retrospective study on 22 UC patients who were in deep remission and followed-up while receiving therapy with ADA. Colonoscopy in those patients was performed every year. Four-quadrant biopsies every 10 cm were obtained during each colonoscopy and assessed by hematoxylin and eosin stain. Histological activity was classified using the Geboes scale.&#x0D; Results: A total of 22 patients were enrolled in the study. The mean follow-up of those patients was 28±7 months, and 2,592 biopsy specimens in total were taken during 108 colonoscopies performed during the follow-up. At the beginning of the follow-up, histological inflammation was found in 15/22 (68.2%) of patients in deep remissio while receiving maintenance ADA therapy, 8/22 (36.4%) of them with Geboes score ≥3.1. At the end of the follow-up, when patients were still in deep remission while receiving maintenance ADA therapy, only 4 patients (18.2%) had at least one biopsy specimen with evidence of any histological inflammation during the follow-up; only two patients (9.1%) had Geboes score ≥3.1.&#x0D; Conclusions: Our study shows for the first time that UC patients in deep remission under ADA may reach HR, but it seems slower than other clinical or endoscopic goals.

Performance of the Swede score to predict cervical intraepithelial neoplasia in women with HIV-1 in Johannesburg, South Africa.

To evaluate the performance of the Swede score to detect cervical intraepithelial neoplasia (CIN) in women with HIV-1 in Johannesburg, South Africa. A cross-sectional study using secondary data analysis from the HPV in Africa Research Partnership (HARP) study that compared the performance of three different screening tests to detect CIN. Colposcopy was performed on any woman who screened positive and findings were recorded using the Swede score. A biopsy of any lesion and a four-quadrant biopsy was taken. The score was evaluated against a histological diagnosis of >CIN1. The sensistivity, specificity, PPV and NPV for each score was calculated. Median age and CD4+ count of the 576 women eligible from the Johannesburg cohort was 34years (IQR, 30-39) and 427cells/mm3 (IQR, 323-579), respectively. Almost two-thirds (64%) were on ART and about 21% had CIN2+ on histology. A Swede score of 5 or greater had the best combination of sensitivity and specificity for CIN2+ with an AUC of 0.72 (95% CI, 0.68-0.76) corresponding to a sensitivity of 72.1 (95% CI, 63.5-79.6) and specificity of 71.8 (95% CI, 67.4-75.9). The Swede score can assist in determining whether women with HIV/AIDS should have treatment at the first colposcopy visit versus those who may be followed up, thereby individualizing treatment.

Diagnosing dysplasia in Barrett’s oesophagus still requires Seattle protocol biopsy in the era of modern video endoscopy: results from a tertiary centre Barrett’s dysplasia database

Objectives: The role of random, four-quadrant biopsy (i.e. systematic biopsy) in Barrett’s oesophagus surveillance has been questioned given its drawbacks and the emergence of high-resolution endoscopy and advanced imaging modalities. Our study aims to assess whether neoplastic pathology is typically diagnosed in routine clinical practice by random, four-quadrant or targeted biopsy whilst using high-resolution endoscopy.Methods: The Nottingham University Hospital Barrett’s oesophagus dysplasia database was retrospectively analysed. Endoscopic and histopathologic data pertaining to the initial endoscopy in which pathology was diagnosed was extracted from the medical records. The most advanced histopathologic abnormality at initial diagnosis and within twelve months were noted. The corresponding endoscopic impression at initial diagnosis was used to group cases per type of biopsy – random, four-quadrant or targeted. Pearson’s χ2 test of independence was used to analyse the relationship between the type of biopsy and diagnosis, indication for endoscopy, endoscopist level and advanced techniques used.Results: Of the 222 patients involved in the study – a higher proportion were diagnosed through random, four-quadrant biopsy (72.97%) than targeted biopsy (27.03%). 90.91% of low-grade dysplasia, 71.43% of high-grade dysplasia and 50% of intramucosal adenocarcinoma cases were diagnosed by random, four-quadrant biopsy. Across all grades of clinicians, patients were typically diagnosed through random, four-quadrant biopsy. However, amongst specialist consultant endoscopists (n = 10) the proportion was equal.Conclusions: Our findings strongly emphasize the importance of random, four-quadrant biopsy in the detection of not only low-grade dysplasia, but also high-grade dysplasia and early invasive carcinoma as part of Barrett’s oesophagus surveillance.

Underwater versus conventional endoscopic resection of nondiminutive nonpedunculated colorectal lesions: a prospective randomized controlled trial (with video)

Incomplete resection of colorectal neoplasia decreases the efficacy of colonoscopy. Conventional resection (CR) of polyps, performed in a gas-distended colon, is the current standard, but incomplete resection rates of approximately 2% to 30% for nondiminutive (>5mm), nonpedunculated lesions are reported. Underwater resection (UR) is a novel technique. The aim of this study was to determine the incomplete resection rates of colorectal lesions removed by UR versus CR. In a randomized controlled trial, patients with small (6-9mm) and large (≥10mm) nonpedunculated lesions were assigned to CR (gas-distended lumen) or UR (water-filled, gas-excluded lumen). Small lesions in both arms were removed with a dedicated cold snare. For CR, large lesions were removed with a hot snare after submucosal injection. For UR, large lesions were removed with a hot snare without submucosal injection. Four-quadrant biopsy samples around the resection sites were used to evaluate for incomplete resection. Four hundred sixty-two eligible polyps (248 UR vs 214 CR) from 255 patients were removed. Incomplete resection rates for UR and CR were low and did not differ (2% vs 1.9%, P= .91). UR was performed significantly faster for lesions≥10mm in size (10-19mm, 2.9 minutes vs 5.6 minutes, P< .0001); ≥20 mm, 7.3 minutes vs 9.5 minutes, P = .015). Low incomplete resection rates are achievable with UR and CR. UR is effective and safe with the advantage of faster resection and potential cost savings for removal of larger (≥10mm) lesions by avoiding submucosal injection. As an added approach, UR has potential to improve the cost-effectiveness of colonoscopy by increasing efficiency and reducing cost while maintaining quality. (Clinical trial registration number: NCT02889679.).

The role of performing a routine four-quadrant cervical biopsy in patients with negative colposcopic findings in increasing the identification rate of cervical intraepithelial neoplasms

Aim: In patients with high-risk human papilloma virus (HPV), there is no consensus on the inclusion of cervical biopsy for diagnostic purposes in cases whereas there is no pathological finding in colposcopy. In this study, we aimed to investigate the effect of simultaneous routine cervical biopsy in patients with normal colposcopic findings on the rate of cervical intraepithelial neoplasia diagnosis. Methods: This retrospective study included 119 patients with colposcopy indications who had no cervical pathology between January 2015 and March 2017 and the histopathological results were evaluated. Results: The mean age of the population was 45.75±9.52 years. The histopathological results obtained in our study patients are as follows; 38.7% (n=46) LSIL, 28.7% (n=33) chronic cervicitis, 15, 3 % (n=19) coilositosis, 9.2% (n=11) HSIL, 2.5% (n=5) adenocarcinoma, 1.7% (n=2) carcinoma in situ and 2.1% (n=3) squamous carcinoma. LSIL 33 (27.5%), HSIL and advanced lesion 11 (9.2%) were detected in patients with normal cervical cytology before colposcopy. LSIL 26 (21.7%), HSIL and advanced lesion were found to be 13 (10.8%) in patients with abnormal cervical cytology. There was no significant difference in terms of biopsy pathology results between normal and non-normal cervical cytology results. Conclusions: In patients with HPV positive and normal colposcopic findings, adding simultaneous routine four-quadrant cervical biopsy to the colposcopy might increase the detection rate of cervical intraepithelial lesions.

A standardized method for collection of human placenta samples in the age of functional magnetic resonance imaging.

Current methods for placental tissue collection assess a delivered organ without direct functional correlates; therefore, the four-quadrant biopsy protocol utilized by many researchers may provide reasonable representation of tissue across a large organ, and offer a snapshot for molecular analysis of the placenta. However, the recent impetus to understand the placenta in real time, and the use of functional imaging to comprehend placental biology, warrants a different sampling approach. Here we present a method to standardize placental tissue collection in a format designed to facilitate correlation of in vivo function with ex vivo assessments. Additionally, we draw comparisons to the quadrant biopsy regimen, and highlight a pathological case of placental infarction detected by in utero imaging.

DOZ047.31: Screening and surveillance in adults after esophageal atresia repair: yield of follow-up endoscopies

Abstract Aim of the Study Because of the high prevalence of Barrett's esophagus (BE) and esophageal carcinoma, it is internationally recommended to perform routine endoscopies in adult esophageal atresia (EA) patients. This study aimed to evaluate the yield of follow-up after the first screening endoscopy. Methods Prospective cohort study in a tertiary referral center since November 2011 was considered. All patients with EA ≥ 17 years old were invited to participate in the screenings and surveillance program. All patients underwent upper endoscopies with random biopsies of the distal esophagus at the level of the gastroesophageal junction and standard four-quadrant biopsies in case of BE. From the age of 25 years old chromoendoscopy with Lugol's staining was performed for detection of superficial squamous cell carcinoma. Depending on their age and the histologic results patients were recommended follow-up endoscopy every 3–5 years. Ethical approval had been obtained. Results In February 2019, 190 patients (58% male, 83% type C, median age at time of first endoscopy 25.5) (range: 16.8–68.6 years) participated in the screenings and surveillance program. Forty-six patients underwent at least one follow-up endoscopy after median 4.7 (range: 1.0–5.9) years. Most recent surveillance endoscopy revealed a normal esophagus in 62%, esophagitis in 10%, and columnar-lined esophagus in 26% of the patients. Histology revealed inflammatory changes within normal limits in 49%, esophagitis in 22%, gastric metaplasia in 18%, and intestinal metaplasia without dysplasia in 6%. In 8 patients (6 males, median age: 25.9 (range: 22.5–34.4)) columnar-lined mucosa was a new finding at the second endoscopy, after median 5.0 (range: 3.6–5.9) years. In two of them histology revealed intestinal metaplasia without dysplasia. Conclusions In line with previous studies, we found a 4-times increased prevalence (6.3%) of BE in adults with EA. Follow-up endoscopies detected two new cases of BE. Future studies are needed to identify patients at risk and personalize screening and surveillance regimes.

Increased detection of Barrett's esophagus and esophageal dysplasia with adjunctive use of wide-area transepithelial sample with three-dimensional computer-assisted analysis (WATS).

Barrett's esophagus (BE) and esophageal dysplasia (ED) are frequently missed during screening and surveillance esophagoscopy because of sampling error associated with four-quadrant random forceps biopsy (FB). The aim of this article is to determine if wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS) used adjunctively with FB can increase the detection of BE and ED. In this multicenter prospective trial, patients screened for suspected BE and those with known BE undergoing surveillance were enrolled. Patients at 25 community-based practices underwent WATS adjunctively to targeted FB and random four-quadrant FB. Of 4203 patients, 594 were diagnosed with BE by FB alone, and 493 additional cases were detected by adding WATS, increasing the overall detection of BE by 83% (493/594, 95% CI 74%-93%). Low-grade dysplasia (LGD) was diagnosed in 26 patients by FB alone, and 23 additional cases were detected by adding WATS, increasing the detection of LGD by 88.5% (23/26, 95% CI 48%-160%). Adjunctive use of WATS to FB significantly improves the detection of both BE and ED. Sampling error, an inherent limitation associated with screening and surveillance, can be improved with WATS allowing better informed decisions to be made about the management and subsequent treatment of these patients.

Accuracy of probe-based confocal laser endomicroscopy (pCLE) compared to random biopsies during endoscopic surveillance of Barrett's esophagus.

Background For surveillance of Barrett’s esophagus (BE), the current standard of random 4-quadrant biopsies misses 10 – 50 % of esophageal neoplasms, and does not permit real-time decision-making. Probe-based confocal laser endomicroscopy (pCLE) permits real-time in vivo histologic assessment of esophageal mucosa during upper endoscopy. Prospective studies comparing the accuracy of pCLE to 4-quadrant biopsies in routine clinical practice are lacking. Methods Consecutive patients with BE underwent high definition white light and narrow-band imaging followed by pCLE and targeted biopsy or mucosal resection. Four-quadrant biopsies were obtained during the same session. Baseline variables, real-time pCLE interpretation, and histology results were prospectively recorded. Blinded expert review of pCLE sequences and histology specimens was performed. A sample size of 64 patients was calculated a priori based on 3 % estimated prevalence of high grade dysplasia (HGD) or cancer. Results In total, 66 patients were included in the study. The prevalence of HGD or cancer was 4.55 %. Both real-time and blinded pCLE correctly identified all cases of cancer. For the primary outcome, real-time pCLE was 98 % specific but only 67 % sensitive for HGD/cancer compared to non-blinded pathologist interpretation. For HGD and cancer, inter-observer agreement was substantial between real-time and blinded endomicroscopists (kappa = 0.6). pCLE identified dysplasia in 75 % of cases where both blinded and unblinded pathology interpretation was low grade dysplasia. Conclusions pCLE demonstrates high specificity for detecting dysplasia and cancer, but lower sensitivity may limit its utility in routine BE surveillance. pCLE may have a role in confirming LGD in real-time before eradication therapy.

The Utility of Routine Endoscopic Distal Duodenal Biopsy in Patients with Irritable Bowel Syndrome for Celiac Disease Diagnosis; First Study from Nepal

Aim: To investigate the utility of routine endoscopic distal duodenal biopsy in patients with Irritable Bowel Syndrome (IBS) for the diagnosis of Celiac Disease (CD). Method: This study was conducted at the outpatient Department of Gastroenterology at the Institute of Medicine, Tribhuvan University, Kathmandu, Nepal. One hundred patients with IBS selected by Rome III Criteria were prospectively evaluated from April 2015 through March 2016. Esophagogastroduodenoscopy (EGD) was performed on all patients, with four-quadrant distal duodenal biopsies obtained from each patient. The biopsy sections were studied for Marsh-type histology, a histology characteristic of CD. Patients with Marsh-type histology had Immunoglobulin-A anti-tissue transglutaminase (IgA anti tTG) serology ordered, were recommended to start a gluten-free diet (GFD), and were followed up in clinic in 3-6 weeks. The prevalence of CD (defined as Marsh histology grade I-III with serology positive responding to GFD) was calculated in patients with IBS as a whole and among IBS subtypes. Statistical analysis was done using SPSS version 19 software (Chicago, IL, USA). Results: Of the 100 IBS patients evaluated, 50 patients had abnormal duodenal histology. Among these 50 patients, 13 had Marsh-type histology, and the remaining 37 had non-specific duodenitis. Of the 13 patients with Marsh-type histology, 4 were seropositive for CD and 9 were seronegative. The overall prevalence of CD was 4%. All 4 seropositive and 2 out of 9 seronegative patients responded to GFD in 3 to 6 weeks. Conclusion: Routine endoscopic distal duodenal biopsy is useful for the diagnosis of CD in patients with IBS as it could also detect the disease in patients with negative celiac serology.

Adherence to quality indicators and surveillance guidelines in the management of Barrett's esophagus: a retrospective analysis.

Background Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus (BE) promotes high-quality, cost-effective care. The aims of this study were (1) to evaluate adherence to standardized classification (Prague Criteria) and systematic (four-quadrant) biopsy protocol, (2) to identify predictors of practice patterns, and (3) to assess adherence to surveillance guidelines for non-dysplastic BE (NDBE). Methods This was a single-center retrospective study of esophagogastroduodenoscopy (EGD) performed for BE (June 2008 to December 2015). Patient demographics, procedure characteristics, and histology results were obtained from the procedure report-generating database and chart review. Adherence to Prague Criteria and systematic biopsies was based on operative report documentation. Multiple logistic regression analysis was performed to identify predictors of practice patterns. Guideline adherent surveillance EGD was defined as those performed within 6 months of the recommended 3- to 5-year interval. Results In total, 397 patients (66.5 % male; mean age 60.1 ± 12.5 years) had an index EGD during the study period. Adherence to Prague Criteria and systematic biopsies was 27.4 % and 24.1 %, respectively. Endoscopists who performed therapeutic interventions for BE were more likely to use the Prague Criteria (OR: 3.16; 95 %CI: 1.47 – 6.82; P < 0.01) than those who did not. Longer time in practice was positively associated with adherence to Prague Criteria (OR 1.07; 95 %CI: 1.02 – 1.12; P < 0.01) but with a lower likelihood of performing systematic biopsies (OR 0.91; 95 %CI: 0.85 – 0.97; P < 0.01). More than half (55.6 %) of patients with NDBE underwent surveillance EGD sooner (range 1 – 29 months) than the recommended interval. Conclusion Adherence to quality indicators and surveillance guidelines in BE is low. Operator characteristics, including experience with endoscopic therapy for BE and time in practice predicted practice pattern. Future efforts are needed to reduce variability in practice and promote high-value care.

Cervical intraepithelial neoplasia (CIN) in African women living with HIV: role and effect of rigorous histopathological review by a panel of pathologists in the HARP study endpoint determination

AIMSTo analyse the effect of the expert end-point committee (EPC) review on histological endpoint classification of cervical intraepithelial neoplasia (CIN).MethodsA cohort of women living with HIV were recruited in Burkina...