Prague Criteria Research Articles

Prognostic significance of mucosal transformation factors in patients with Barrett’s esophagus

Relevance: PB is a dynamic state, regression and progression of the disease are possible in the same patient against the background of a long period of observation. Materials and methods. The study was conducted on the basis of the MMC BR in Moscow in the period from 2013 to 2023, both retrospectively and prospectively. The diagnosis of BE was established on the basis of the endoscopic picture (according to the Prague criteria) and the data of the morphological study of the biopsy material. As a result of the analysis, 122 patients were selected who were on inpatient and outpatient treatment, as well as dynamic observation. Examination of patients included: clinical data with an assessment of comorbid pathology, endoscopic examination with sampling of biopsy material, morphological, including immunohistochemical studies of biopsy material: determination of mutations in the P53, P63 genes and the nuclear proliferation marker Ki-67. The treatment was carried out in accordance with the clinical recommendations of the Russian Gastroenterological Association based on the developed algorithm and included conservative therapy for BE and identified comorbid pathology, as well as in groups of patients with low-grade dysplasia, endoscopic intraluminal treatment-argon plasma coagulation. Results. Analysis of the results made it possible to conclude that the applied algorithm was highly effective: high scores on the goal achievement scale were achieved in 88% of patients. Moreover, the greatest success was achieved in groups with low-grade dysplasia due to the use of personalized methods of treating patients with BE based on a deep clinical and morphological analysis, including, in addition to generally accepted, gender and age characteristics, assessment of comorbid pathology and the dynamics of P53, P63 and Ki-67 in determining the timing of dynamic follow-up of patients.

Ntestinal Metaplasia in Barrett’s Oesophagus: A Clinicopathological Study

Introduction: The incidence of Oesophageal Adenocarcinoma (EAC) has increased at a faster rate than any other cancer in the developed nations. Despite advances in treatment, five year survival rate for EAC is <15%. Till date, Barrett’s Oesophagus (BE) is the only known precursor of EAC increasing its risk by greater than 30 to 60 fold. Most important risk factor for development of dysplasia and EAC is specialised Intestinal Metaplasia (IM) in BE. Aim: To find the association between clinical, endoscopic and histopathological features and presence of IM in patients with endoscopically suspected BE. Materials and Methods: This was an institution based descriptive study with a cross-sectional design conducted in the Departments of Pathology and Surgery, in a tertiary care centre of North Bengal for four years (2017-2021), among patients attending surgery and medicine Outpatient Department (OPDs) or Inpatient Department (IPDs), suspected on clinical basis and subsequent endoscopic detection of BE utilising Prague criteria. Periodic Acid-Schiff (PAS) and Alcian Blue (pH 2.5) stains were used to detect complete or incomplete IM and results were analysed using appropriate statistical software. Results: Among 120 cases included in the study, 72 (60%) had Short Segment Barrett’s Oesophagus (SSBE) and 48 (40%) Long Segment Barrett’s Oesophagus (LSBE). Hiatal hernia was significantly more frequent in LSBE patients (32 out of 48) compared to patients with SSBE (24 out of 72). The associations of tobacco and alcohol abuse with microscopically proven BE were statistically significant with p-values of 0.005 and 0.004, respectively. The association of IM with the increasing length of Columnar Lined Oesophagus (CLE) was statistically significant (p-value=0.004). Conclusion: Tobacco and alcohol abuse, presence of hiatal hernia (particularly in LSBE patients) were significantly associated with BE. Increasing length of CLE is more commonly associated with IM. Incomplete IM was observed more commonly in LSBE cases whereas complete IM was detected more frequently in cases diagnosed as SSBE by endoscopy

S432 Fifty Percent Increase in Low-Grade Dysplasia Detection Using Probe-Based Confocal Endomicroscopy in a Metropolitan Veteran Cohort Undergoing Short Segment Barrett’s Esophagus Surveillance

Introduction: Seattle protocol (SP) is the standard method to biopsy Barrett’s esophagus. However, SP may miss dysplasia in all types of BE. Few studies have focused on pCLE in the diagnosis of dysplasia in short segment Barrett’s esophagus (SSBE). The primary aim of our study was to determine if pCLE was more effective in diagnosing dysplastic mucosa in patients undergoing surveillance endoscopy in SSBE. Methods: Patients undergoing surveillance endoscopy and diagnosed with SSBE between January 1, 2018 and January 1, 2021 at the VA Loma Linda Healthcare System (VALLHCS) were included. Patients who underwent pCLE were compared to those undergoing SP. Esophagogastroduodenoscopy (EGD) was performed using a high definition diagnostic upper endoscope (Olympus, Center Valley PA). All patients in both pCLE and SP group underwent high-definition white light examination (HD-WLE). All pCLE examinations were performed by two gastroenterologists (C.S.J.and N.S.) using GastroFlex UHD Confocal Miniprobe (Cellvizio, Mauna Kea Technologies). Age, sex, number of EGDs prior to a diagnosis of dysplasia, hiatal hernia length and pCLE findings were assessed. SSBE was defined using Prague criteria, circumference (C) ≤ 2cm and maximal length of Barrett's segment (M) ≤ 3cm. Two pathologists reviewed all biopsies with a diagnosis of dysplasia. Continuous variables were compared using a Fisher’s exact test with p≤0.05 as statistically significant. This study was approved by the institutional review board for VALLHCS. Results: Sixty-seven patients were identified as having SSBE. Sixteen patients underwent pCLE-targeted biopsies while 51 underwent SP. The mean age of the pCLE group was 64 years and 65.9 years for those who underwent SP. There was no difference in age, BMI, smoking status, statin, H2 blocker or PPI use in patients who underwent pCLE-targeted biopsies versus those who underwent SP. Low-grade dysplasia was detected in 17 patients (25.3%). Of these 17 patients, 11 were detected with pCLE, and 6 were detected with SP. The use of pCLE was significantly associated with detection of low-grade dysplasia (11/16, 68.7%) compared to (6/51, 11.7%) with a p-value of < 0.001. Conclusion: In a primarily male metropolitan veteran population, pCLE may be helpful in identifying low grade dysplasia in patients with SSBE. SP biopsy techniques may miss LGD during SSBE surveillance.

204 ENDOSCOPIC EVIDENCE OF BILE REFLUX IS A STRONG INDEPENDENT FACTOR ASSOCIATED WITH THE PRESENCE OF BARRETT’S ESOPHAGUS

Abstract Several basic researches have indicated that there is a significant relationship between bile reflux and the pathogenesis of Barrett’s esophagus (BE). However, only few clinical studies have been reported regarding the endoscopic finding of bile reflux and Barrett’s esophagus. Our objective is to evaluate whether the endoscopic evidence of bile reflux is an independent factor associated with the presence of BE. Methods We conducted a retrospective analysis of a prospectively maintained database comprised of consecutive Japanese patients who underwent screening gastroscopy. Endoscopic findings of BE, reflux esophagitis, atrophic gastritis and sliding hernia were recorded. Evaluation of a BE was based on the Prague criteria. Endoscopic evidence of bile reflux was defined as the presence of yellow or green juice observed by white light image or red juice by narrow band image (NBI) in the gastric fundus. Univariate and multivariate analyses were performed to identify factors that differed significantly between patients with or without BE. Results A total of 454 patients were enrolled; 124 (27%) had BE and 126 (28%) had endoscopic evidence of bile reflux. Compared to patients without BE, patients with BE were more likely to be old, male and to have sliding hernia and endoscopic evidence of bile reflux on univariate analysis. On multivariate analysis, endoscopic evidence of bile reflux was a stronger independent factor associated with BE (odds ratio(OR) 11.3, 95% confidence interval(CI) 6.56–19.4) compared to the presence of sliding hernia (OR 3.58, 95%CI 2.14–6.0). Conclusion Endoscopic evidence of bile reflux identified by white light or NBI is a strong independent factor associated with the presence of BE, implying that this finding should be considered as an important parameter to determine the surveillance strategy for gastroesophageal reflux disease patients same as the presence of sliding hernia.

Multinational survey on the preferred approach to management of Barrett's esophagus in the Asia-Pacific region.

BACKGROUNDMajor societies provide differing guidance on management of Barrett’s esophagus (BE), making standardization challenging.AIMTo evaluate the preferred diagnosis and management practices of BE among Asian endoscopists.METHODSEndoscopists from across Asia were invited to participate in an online questionnaire comprising eleven questions regarding diagnosis, surveillance and management of BE.RESULTSFive hundred sixty-nine of 1016 (56.0%) respondents completed the survey, with most respondents from Japan (n = 310, 54.5%) and China (n = 129, 22.7%). Overall, the preferred endoscopic landmark of the esophagogastric junction was squamo-columnar junction (42.0%). Distal palisade vessels was preferred in Japan (59.0% vs 10.0%, P < 0.001) while outside Japan, squamo-columnar junction was preferred (59.5% vs 27.4%, P < 0.001). Only 16.3% of respondents used Prague C and M criteria all the time. It was never used by 46.1% of Japanese, whereas 84.2% outside Japan, endoscopists used it to varying extents (P < 0.001). Most Asian endoscopists (70.8%) would survey long-segment BE without dysplasia every two years. Adherence to Seattle protocol was poor with only 6.3% always performing it. 73.2% of Japanese never did it, compared to 19.3% outside Japan (P < 0.001). The most preferred (74.0%) treatment of non-dysplastic BE was proton pump inhibitor only when the patient was symptomatic or had esophagitis. For BE with low-grade dysplasia, 6-monthly surveillance was preferred in 61.9% within Japan vs 47.9% outside Japan (P < 0.001). CONCLUSIONDiagnosis and management of BE varied within Asia, with stark contrast between Japan and outside Japan. Most Asian endoscopists chose squamo-columnar junction to be the landmark for esophagogastric junction, which is incorrect. Most also did not consistently use Prague criteria, and Seattle protocol. Lack of standardization, education and research are possible reasons.

S2031 Esophageal Polyps Associated With Barrett’s Esophagus: Is This an Adenocarcinoma or Not?

INTRODUCTION: Barrett’s esophagus (BE) appears usually as a flat salmon-colored lesion. Esophageal adenocarcinomas associated with BE, traditionally appearing as an ulcer or a mass, seem to originate via the BE-dysplasia-carcinoma sequence. There is only a handful of reported cases of polypoid esophageal adenocarcinomas associated with BE. We describe a compelling case of incidental finding of BE with multiple esophageal polyps that turned out to be invasive adenocarcinoma. CASE DESCRIPTION/METHODS: A 60-year-old male with a past medical history of coronary artery disease and atrial fibrillation underwent laparoscopic cholecystectomy for chronic abdominal discomfort. His postoperative course was complicated by biliary leak; hence ERCP was performed and successful biliary stent placement was achieved. Two months later, an upper endoscopy was being performed for biliary stent removal when multiple 4 to 15 mm pedunculated and sessile polyps were identified in the distal esophagus (Figure 1). The upper endoscopy also revealed mucosal changes consistent with long-segment BE, C8-M10 per Prague criteria, a small hiatal hernia and multiple small gastric polyps. All large esophageal polyps were successfully resected with cold snare, after Eleview injection. The exception was a 10 mm polyp that was not liftable. Pathology reading of the resected polyps demonstrated low- and high-grade dysplasia along with intramucosal carcinoma (Figure 2). While the unresectable polyp revealed a moderately to poorly differentiated adenocarcinoma with HER2 positivity on FISH analysis. This was followed by an endoscopic ultrasound, which showed a 2 cm mass with irregular borders infiltrating the submucosa plus peritumoral lymph node involvement (Figure 3). The patient was referred to a multidisciplinary team of GI oncologists as well as a foregut surgeon for further management. DISCUSSION: Polypoid lesions of the esophagus are considered rare. To this date, there is no clear consensus on their management. We did a literature review, and we found 27 reported cases of polypoid dysplasia of the esophagus, 10 of them were having multiple lesions. The table is showing their characteristics and outcome. Through this case, we emphasize the association between these polypoid lesions and the adenocarcinoma of the esophagus. Hence, when esophageal polyps associated with BE are encountered, we are recommending their resection associated to multiple biopsies.Figure 1.: Upper Gastrointestinal endoscopy: Multiple polypoid lesions in the lower third of the esophagus, no signs of bleeding.Figure 2.: Image A, Esophageal Biopsy, High Magnification: Intestinal metaplasia with nuclear enlargement, loss of nuclear polarization, occasional prominent nucleoli, and increased apoptosis, as well as crypt fusion and cribriforming; changes consistent with high-grade dysplasia. Image B: Sheets of infiltrating malignant cells at medium magnification infiltrating the lamina propria.Figure 3.: Upper Endoscopic Ultrasonography: Hypoechoic mass in the lower third of the esophagus, the lesion is non circumferential, the borders are irregular, 5 mm in thickness with submucosal invasion.

Mo1247 RISK OF NEOPLASTIC PROGRESSION IN PATIENTS WITH LONG-SEGMENT BARRETT'S ESOPHAGUS-JAPAN MULTICENTER PROSPECTIVE COHORT STUDY

The incidence of esophageal adenocarcinoma (EAC) in patients with long-segment Barrett’s esophagus (LSBE) in Japan remains to be fully elucidated. To address this issue, a nationwide multicenter prospective cohort study was designed to investigate EAC incidence rate in patients with BE with a length of at least 3 cm and started in 2011. We previously reported interim analysis findings of follow-up results obtained during the first 4-year period (June 2011 through August 2015), which indicated that the annual incidence rate of EAC in LSBE cases in Japan was 1.2% (Matsuhashi N, et al., J Gastroenterol Hepatol 32: 409-414, 2017). Here, we report findings from the second interim analysis of follow-up results obtained from June 2011 through August 2019. This is an ongoing multicenter prospective cohort study led by the National LSBE Research Group of the Japan Gastroenterological Endoscopy Society involving 13 university medical center and 22 regional hospitals throughout Japan. Based on the Prague criteria, the circumferential (C) and maximum (M) length of BE was noted, then affected patients with a length of 3 cm or longer (M ≥3 cm) were prospectively enrolled. Enrolled BE cases are scheduled for annual esophagogastroduodenoscopy (EGD) examinations for progression to dysplasia or EAC over a 10-year period. Patients with EAC diagnosed from endoscopic examination results undergo subsequent treatment, with their prognosis noted. The registry currently includes 337 participants (males 82.8%; mean age 63.4±12.8 years, range 30-103 years), with a mean follow-up period of 45.3 months (1-8 years). Of those, 12 (3.6%) were initially diagnosed with EAC at enrollment and two-thirds (8/12) were found to be in an advanced clinical stage. Among the remaining 325 with nondysplastic BE, 230 underwent at least 1 follow-up EGD examination, which revealed development of EAC in 6 over a total of 869 patient-years for an annual incidence rate of 0.69%. Five of 6 patients with EAC were male, and the follow-up period until EAC detection varied from 2.6 to 7.0 years. Subgroup analysis found 133 with a long circumferential (C ≥3 cm) BE length and 97 with a short (C <3 cm) BE length, with annual EAC incidence rates of 0.81% and 0.53%, respectively. Most of the EAC cases detected in follow-up annual EGD examinations (5/6, 83.3%) were identified as early stage cancer and those patients underwent curative resection. During follow-up periods ranging from 1-8 years (mean 45.1 months), the annual incidence rate of novel EAC in patients with BE with a length of 3 cm or longer according to the Prague M criteria was estimated to be 0.69%, similar to values reported in Western countries. Most of the EAC cases detected during the follow-up period were early cancer, suggesting the importance of annual surveillance endoscopy.

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

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

Benefits of the Seattle biopsy protocol in the diagnosis of Barrett's esophagus in a Chinese population.

AIMTo investigate the benefits of the Seattle protocol in the diagnosis of Chinese individuals with Barrett’s esophagus.METHODSSubjects enrolled were patients from one center with endoscopically-suspected esophageal metaplasia. These patients first received narrow-band imaging-targeted biopsy, and later, the Seattle protocol-guided biopsy, within a period from October 2012 to December 2014. Those cases without initial pathologic patterns of intestinal metaplasia (IM) and then appearance or loss of IM tissue were designated as Group A or B, respectively. Those with initial pathologic patterns of IM, which then persisted or were lost were designated as Group C or D, respectively.RESULTSThe number of cases for each group was as follows: A: 20, B: 78, C: 31 and D: 14. The distribution of the Prague criteria M levels of Group A was significantly higher than Group B (P = 0.174). Among these groups, Group C had the highest proportions of hiatus hernia (54.8%), long segment Barrett’s esophagus (29%), and also the highest Prague criteria M levels. The sensitivity of IM detection was 69.2% for the narrow-band imaging-targeted biopsy and 78.5% for the Seattle protocol-guided biopsy. The difference was not significant (P = 0.231). The number of detectable dysplasias increased from one case via the NBI-target biopsy to five cases via the Seattle protocol-guided biopsy, including one case of adenocarcinoma.CONCLUSIONThe Seattle protocol improved the IM detection in our subjects with higher Prague criteria M levels and disclosed more cases with dysplastic tissues.

Factors Associated With Poor Adherence to Quality Indicators in Barrett’s Esophagus

Quality indicators (QIs) in Barrett’s esophagus (BE) have been established with the goals of improving patient outcomes, reducing practice variability, and reducing the cost of health care. Limited data exist describing current practices in the United States regarding these QIs. Our aims are to critically assess adherence to endoscopic QIs in BE and explore patient and endoscopist factors associated with performance. A retrospective review was performed of all upper endoscopies resulting in the histologic diagnosis of BE performed at a single academic medical center over 5 years (June 2012 to June 2017). The following information was documented with regard to each endoscopy: patient demographics, documentation of esophageal landmarks, use of Prague criteria, performance of biopsies using Seattle protocol, and final histologic diagnosis. Endoscopist factors included demographics, number of years in practice, and expertise in the foregut. To explore factors associated with adherence to QIs, each endoscopy was scored from 0 to 2 points: 1 point each for use of the Prague criteria and the Seattle protocol. Mean points were determined for each endoscopist; those above the 50th percentile were considered high performers and those below the 50th percentile were considered low performers. A total of 282 endoscopies performed in 232 patients by a total of 21 endoscopists met inclusion criteria. Attending endoscopists had a mean age of 42.4 (±10.4) years and 89.7% were male, with a mean of 10.6 (±10) years in practice. The majority of cases were screening index endoscopies (n = 170 [60.3%]) and trainee involvement was reported in 18.8% (n = 53) of all cases. Overall performance with regard to key quality indicators is shown in Table 1. The overall rate of documenting BE length using Prague criteria was 41.8% and use of Seattle protocol was 49.3%. Trainee participation was associated with a higher documentation rate of esophageal landmarks (esophagogastric junction [P = .04] and diaphragmatic pinch [P = .01]). Compared to low-performance endoscopists, high-performance endoscopists were younger (37.0 vs 47.4 years; P < .01), had fewer years in practice (4.7 vs 15.5 years; P < .01), specialized in the foregut (68.4% vs 31.6%; P < .01), and had a higher overall performance score (1.4 vs 0.5; P < .001) (Table 2). Trainees also had a significantly higher performance if working with a high-performance endoscopist vs a low-performance endoscopist (59.1% vs 25.8%; P = .02) (Table 2). This study demonstrates a low adherence rate to key endoscopy-related QIs in BE. Younger age, fewer years in practice, and trainee involvement were associated with higher endoscopist performance. Future intervention studies are needed to evaluate the impact of education tools using QI-based performance feedback and its impact on patient-centered outcomes in BE patients.Table 1Comparison of Quality Indicators—Overall and Based on Trainee Involvement by Involvement of TraineeHigh-quality practiceTrainee involved, n (%) (n = 53)Attending only, n (%) (n = 229)Overall, n (%) (n = 282)P valueSquamocolumnar junction distance documented31 (58.5)118 (51.5)149 (52.8).36Esophagogastric junction distance documented32 (60.4)102 (44.5)134 (47.5).04Diaphragmatic pinch distance documented11 (20.8)13 (5.7)24 (8.5).01Hiatal hernia length documented29 (55.2)131 (46.3)135 (48).39Retroflexion documented52 (98.1)228 (99.6)280 (99.3).26BE length documented46 (86.8)198 (86.5)244 (86.5).95Prague criteria documented21 (39.6)97 (42.4)118 (41.8).72Seattle protocol usage25 (47.2)114 (49.8)139 (49.3).73Narrow band imaging use documented19 (35.9)63 (27.5)82 (29.1).23Dysplasia detection rate4 (7.6)18 (7.9)22 (7.8).94NOTE. Analysis conducted using 2-tailed Student t test for continuous and χ2 analysis for categorical variables. Dysplasia detection defined as finding low-grade dysplasia, high-grade dysplasia, or esophageal adenocarcinoma on histology.BE, Barrett’s esophagus. Open table in a new tab Table 2Association Between Endoscopist Variable and PerformanceVariableLow-performance(n = 154)High-performance(n = 128)P valueEndoscopist age, y, mean ± SD47.4 ± 12.137.0 ± 1.8.01Female endoscopist, n (%)19 (12.3)10 (7.8).21Endoscopist years in practice, mean ± SD15.5 ± 11.44.7 ± 1.7.01Endoscopist dysplasia detection rate, n (%)11 (7.1)11 (8.6).65Endoscopist volume of BE endoscopies during study period, mean ± SD14.0 ± 11.812.8 ± 25.2.89Endoscopist foregut specialization, n (%)37 (24)80 (62.5).01Patient age, y, mean ± SD60.3 ± 12.059.4 ± 11.6.50Female patient, n (%)57 (37.0)49 (38.3).83Length of BE, cm, mean ± SD3.2 ± 2.94.5 ± 3.6.01High-performance fellow participating in endoscopy, n (%)14 (25.8)31 (59.1).02Endoscopy performed as a combined upper endoscopy and colonoscopy, n (%)10 (6.5)6 (4.7).51Squamocolumnar junction distance documented, n (%)62 (40.3)87 (68).01Esophagogastric junction documented, n (%)59 (38.3)75 (58.6).01Hiatal hernia length documented, n (%)34 (42.5)38 (54.3).15Prague criteria documented, n (%)26 (16.9)92 (71.9).01Seattle protocol use documented, n (%)49 (31.8)90 (70.3).01Narrow band imaging use documented, n (%)21 (13.6)61 (47.7).01Performance score, mean ± SD0.5 ± 0.61.4 ± 0.7.01NOTE. Analysis conducted using 2-tailed Student t-test for continuous and χ2 analysis for categorical variables. Data presented as mean ± SD or n (%) as appropriate.BE, Barrett’s esophagus. Open table in a new tab

Columnar islands in Barrett's esophagus: Do they impact Prague C&M criteria and dysplasia grade?

The standard for classifying Barrett's metaplasia on endoscopy, the Prague C&M criteria, ignores all islands of metaplastic-appearing tissue. The aims of the present study were to measure the prevalence of columnar islands, quantify their impact on metaplasia extent, and determine if they harbor advanced dysplasia. Data from two prospective patient cohorts were retrospectively analyzed. They included adults who underwent upper endoscopy to evaluate for gastroesophageal reflux disease, Barrett's esophagus (BE), dysplasia, or adenocarcinoma between 2003 and 2012 at tertiary care centers in the USA and Germany. The BE pattern, location, and pathology were examined. The extent of BE as defined by the Prague criteria (disregarding the location of islands) was compared with the complete maximal extent of BE (incorporating the location of islands). A total of 555 patients underwent endoscopy (mean age 60.1years, 67.2% male, 91.9% white). Among those patients, 191 (34.4%) showed metaplastic-appearing mucosa in islands. Endoscopically, in 101 (52.9%) cases, islands were proximal to the farthest segment of BE as defined by the Prague M location. Histologically, intestinal metaplasia was confirmed in 60 (58.8%) of the 102 esophagogastroduodenoscopies (EGDs) where islands were biopsied. In 41 (40.2%) cases, the histologically confirmed BE islands extended farther than the maximal segment based on the Prague criteria. Pathology from biopsies of islands either changed the diagnosis or worsened the BE dysplasia grade in 16 (15.7%) of the 102 patients. Columnar islands are commonly seen on EGD. The Prague C&M criteria may underestimate the maximal extent of BE and overlook the area of highest dysplasia grade.

Dedicated Barrett's surveillance sessions managed by trained endoscopists improve dysplasia detection rate.

Background and study aim Barrett's esophagus (BE)-associated dysplasia is an important marker for risk of progression to esophageal adenocarcinoma (EAC) and an indication for endoscopic therapy. However, BE surveillance technique is variable. The aim of this study was to assess the effect of dedicated BE surveillance lists on dysplasia detection rate (DDR). Patients and methods This was a prospective study of patients undergoing BE surveillance at two hospitals - community (UHL) and upper gastrointestinal center (GSTT). Four endoscopists (Group A) were trained in Prague classification, Seattle protocol biopsy technique, and lesion detection prior to performing BE surveillance endoscopies at both sites, with dedicated time slots or lists. The DDR was then compared with historical data from 47 different endoscopists at GSTT and 24 at UHL (Group B) who had undertaken Barrett's surveillance over the preceding 5-year period. Results A total of 729 patients with BE underwent surveillance endoscopy between 2007 and 2012. There was no significant difference in patient age, sex, or length of BE between the two groups. There was a significant difference in detection rate of confirmed indefinite or low grade dysplasia and high grade dysplasia (HGD)/EAC between the two groups: 18 % (26 /142) Group A vs. 8 % (45/587) in Group B (P < 0.001). Documentation of Prague criteria and adherence to the Seattle protocol was significantly higher in Group A. Conclusion This study demonstrated that a group of trained endoscopists undertaking Barrett's surveillance on dedicated lists had significantly higher DDR than a nonspecialist cohort. These findings support the introduction of dedicated Barrett's surveillance lists.

Hidden in Plain Sight: The Value of Ex Vivo Volumetric Laser Endomicroscopy in Confirming Neoplastic Changes Within a Barrettʼs Nodule

Volumetric Laser Endomicroscopy (VLE) utilizes next generation optical coherence tomography to produce high-resolution cross-sectional imaging via a swept source laser. Usage to date has focused on the evaluation of Barrett's esophagus (BE), specifically identification of features consistent with dysplasia and neoplasia. A 66 year old male was referred for evaluation and treatment of BE found by his local gastroenterologist to have developed multi-focal low grade dysplasia between surveillance endoscopies in 2013 and 2016. The patient was scheduled for upper endoscopy with mapping BE biopsies. Key findings included a 3 cm hiatal hernia and a BE segment classified as C2-M3 by Prague criteria. Within this segment was a subcm nodule located 1 cm proximal to the top of the gastric folds (Figure 1). VLE of the distal esophagus revealed diffuse loss of normal wall layer architecture, consistent with BE, along with a focal area of abnormal epithelial glands suspicious for dysplasia located on the opposite wall from the nodule. The region near the nodule contained a topographical surface, but no clear suspicious glands were appreciated. The nodule then was resected using a cap-band-ligator with snare mucosectomy technique. An ex vivo VLE scan was performed on the nodule. Images demonstrated multiple areas of markedly abnormal-appearing epithelial glands with some containing what appeared to be necrotic material. These changes were suspicious for high grade dysplasia (Figure 2).Figure 1Figure 2Figure 3Pathology from the resected specimen showed extensive BE with high grade dysplasia. Comparison of the tissue sample and the ex vivo VLE images confirmed a very similar morphologic appearance in both specimens. This case highlights how the limitations of in vivo VLE when nodularity is present to distort normal esophageal anatomy can be overcome through use of the technology following endoscopic resection. The topographical nature of the nodule prevented optimal tissue contact with the VLE probe, resulting in suboptimal in vivo visualization of the highly irregular glandular structures contained within the nodule. Routine use of this technology following resection, especially when images are compared with pathology specimens, can provide confirmation that the appropriate region of concern has been removed from the esophagus.

Using argon plasma coagulation in the treatment of Barrett’s esophagus

Aim. To improve the treatment results of patients with Barrett’s esophagus by using videoendosurgical technologies and the application of argon plasma coagulation.Methods. Treatment results of 16 patients with Barrett’s esophagus who underwent endoscopic argon plasma coagulation of esophageal epithelium metaplasia foci are presented. Endoscopic studies protocols were based on the Prague criteria - the maximum extent of the flames (M) and the maximum extent of the circular segment of Barrett’s esophagus (C). Long segment Barrett’s esophagus prevailed in the majority of patients. Argon plasma coagulation was performed in FORCED mode (power of 30-32 watts with an argon flow of 2-2.2 L/min). For 1 session coagulation of the affected area of no more than 4 cm2 was performed.Results. In the immediate postoperative period, complications of treatment were not observed. In 12 patients course of treatment with argon plasma coagulation was fully completed, repeated courses were administered depending on the segment length (1 patient required 1 session, 3 patients - 2 sessions, 2 - 3 sessions, 4 patients - 4 sessions, 2 patients - 5 sessions). Manipulation duration was about 5-7 minutes. In these patients, there was complete regression of metaplastic epithelium with its replacement by typical stratified squamous epithelium. 4 patients continue treatment.Conclusion. Surgical treatment is indicated to all patients with Barrett’s esophagus, in the postoperative period - the use of endoscopic argon plasma coagulation, which should be performed in stages with 1-1.5 month intervals with obligatory endoscopic and histological control.

PTU-148 Endoscopic Surveillance in Dysplastic Barrett’s Oesophagus (BO)

Introduction Barrett’s oesophagus is a premalignant condition and patients with BO undergo surveillance to detect early cancerous changes. Our aim is to assess the effectiveness of endoscopic surveillance in detecting progression to High-Grade Dysplasia (HGD) or Oesophageal Adenocarcinoma (OAC). Methods All BO cases coded in our histopathology database as dysplastic BO during the period from 2005 to 2015 were identified. The documented endoscopy reports were matched with histopathology reports. A retrospective database was then constructed including demographics, pathological features, modes and rates of follow-up and pathological progression. Our surveillance practice was also audited against the 2013 BSG guidance. Results A total of 73 cases were identified as dysplastic BO; the cohort consisted of 55 males and 18 females. (Mean age: 70.1 years, range: from 51.4 to 88.4 years). 47/73 (64%) had hiatus hernia. Intestinal metaplasia was reported in 71/73 cases. 14/73 cases (19%) progressed to HGD or OAC. Five patients offered oesophagectomy, while the others had surveillance (3), endoscopic mucosal resection (3) or chemo/radiotherapy (3). 4/14 cases were noted to have either prevalent HGD/OAC (3) or interval OAC (1) and hence excluded from the audit. Five cases did not have any follow up either because of the patient’s noncompliance (2) or the endoscopists’ recommendation (3). 64 (88%) cases had complete data and constituted the cohort for assessment of compliance with BSG guidance. Mean follow up was 4.67 years. The total number of endoscopies performed during this period was 250. 65.2% (163/250) of endoscopies were compliant with BSG follow up protocol. Only 18/130 endoscopies (13.8%) provided both C and M measurements of Prague measurement. Average BO length based on 113 endoscopies was 5.3 cm. The mean expected number of biopsies was 11.0 while the actual number of biopsies taken was 7.3 (66.1%). There was some discordance between the number of biopsies mentioned by endoscopists and the number of biopsies counted by pathologists in 72 available endoscopic and pathological data. Overall compliance with BSG protocol in terms of follow up, Prague criteria and sampling count was 48.4% in total. Conclusion The surveillance program detected progression to HGD or OAC in 10 cases (14.5%). Compliance with BSG protocol in terms of follow up, Prague criteria and sampling count was noted in 48.4%. Further adherence with the BSG guidelines is needed to improve the surveillance program. Disclosure of Interest None Declared

PWE-082 Audit of Barrett’s Oesophagus Surveillance in The London Cancer Alliance – Structured Programmes with Dedicated Lists/Databases Improve Prague Scoring and Appropriate Follow Up Intervals: Abstract PWE-082 Table 1

Introduction The London Cancer Alliance is a group of 17 hospitals in North West and South London serving an estimated catchment area of 5.7 million. We have previously demonstrated that dedicated Barrett’s oesophagus (BE) surveillance lists improve dysplasia detection. LCA guidelines recommend dedicated surveillance lists, Prague reporting, dual pathology reporting of dysplasia and follow up intervals similar to national guidelines. Methods One month ‘snap shot’ audit of patients undergoing BE surveillance in June 2015. Structure of programme at each site was assessed with questionnaire. All patients undergoing endoscopy for BE were audited using endoscopy reporting software tools. New diagnoses or those referred with dysplasia for endotherapy were excluded. The Prague criteria, dysplasia detection rate and dual pathology reporting were assessed. Analysis was by independent t-tests for continuous variables and chi-squared tests for categorical variables. Results Responses were received from 13/17 sites. 6/13 ran dedicated surveillance lists and 5/6 had an active surveillance database. Dual pathology reporting for dysplasia was confirmed in 11/13 sites and BSG/LCA guidance adhered to in 12/13. A total of 137 patients underwent surveillance endoscopy. Results are shown in table 1. There was no difference in the mean number of procedures between sites with dedicated vs. non dedicated lists. Only 4/137 patients were diagnosed with dysplasia, with no significant difference between the 2 groups. Prague classification was significantly higher on dedicated lists (p Conclusion Approximately half the sites in the LCA have dedicated lists and/or active surveillance databases, with statistically significant higher Prague classification rates and appropriate choice of surveillance interval at follow up. These metrics could be adopted at a national level to assess quality of BE surveillance programmes. A larger national audit assessing utility of dedicated lists is warranted. Disclosure of Interest None Declared

Interobserver reproducibility in pathologist interpretation of columnar-lined esophagus.

Confirmation of endoscopically suspected esophageal metaplasia (ESEM) requires histology, but confusion in the histological definition of columnar-lined esophagus (CLE) is a longstanding problem. The aim of this study is to evaluate interpathologist variability in the interpretation of CLE. Thirty pathologists were invited to review three ten-case sets of CLE biopsies. In the first set, the cases were provided with descriptive endoscopy only; in the second and the third sets, ESEM extent using Prague criteria was provided. Moreover, participants were required to refer to a diagnostic chart for evaluation of the third set. Agreement was statistically assessed using Randolph's free-marginal multirater kappa. While substantial agreement in recognizing columnar epithelium (K = 0.76) was recorded, the overall concordance in clinico-pathological diagnosis was low (K = 0.38). The overall concordance rate improved from the first (K = 0.27) to the second (K = 0.40) and third step (K = 0.46). Agreement was substantial when diagnosing Barrett's esophagus (BE) with intestinal metaplasia or inlet patch (K = 0.65 and K = 0.89), respectively, in the third step, while major problems in interpretation of CLE were observed when only cardia/cardia-oxyntic atrophic-type epithelium was present (K = 0.05-0.29). In conclusion, precise endoscopic description and the use of a diagnostic chart increased consistency in CLE interpretation of esophageal biopsies. Agreement was substantial for some diagnostic categories (BE with intestinal metaplasia and inlet patch) with a well-defined clinical profile. Interpretation of cases with cardia/cardia-oxyntic atrophic-type epithelium, with or without ESEM, was least consistent, which reflects lack of clarity of definition and results in variable management of this entity.

Sa1894 Enhanced Characterization of Barrett's Esophagus Islands Through a Revision of the Prague Criteria

Background: Barrett's esophagus (BE) is a premalignant condition that can progress to adenocarcinoma of the esophagus and gastroesophageal junction. The Prague and criteria was established to provide guidelines on the endoscopic characterization of BE through grading of continuous metaplastic extension from the top of the gastric folds. However, we have observed BE patients with metaplastic columnar ‘islands' that would not be classified under the current criteria. The possibility of dysplasia within these islands and the potential for missed lesions during surveillance or through ablative therapy highlights the need for a revision of the Prague criteria. Aim: To identify and characterize Barrett's esophagus patients that develop metaplastic columnar islands and to assess the utility of a descriptive tool used in addition to the Prague criteria Methods: This retrospective review analyzed consecutive patients with BE referred for management of suspected dysplasia. All patients were assessed with endoscopes equipped with high definition white light, and narrow band imaging. All cases were classified using the Prague criteria for BE at a baseline, mapping upper endoscopy with 4 quadrant biopsies taken at 1 cm intervals from the gastroesophageal junction. After the C and M of the Prague scale were recorded, all additional islands of metaplastic columnar mucosa were mapped. An designation was given to the most proximal island measured from the gastroesophageal junction. The Barrett's segment was represented as a CxMxIx where x is the number in cm from the gastroesophageal junction. Biopsied tissue was assessed for dysplasia, which was confirmed by an expert GI pathologist. Patients with and without islands were compared. Results: From June 2012 to October 2014, 73 patients (mean age 66.0, 61male, 12 female) were referred for assessment of potential dysplastic BE. 49 (67%) patients did not have any observed islands (mean age 67.4, range 19-87). 25 (33%) patients (mean age 63.6, range 37-84) had islands of Barrett's tissue; 11 with de novo islands and 14 with islands appearing after endoscopic ablation was administered. In the non-island BE group, the mean and range of and were 3.3 (011) and 4.8 (1-12) respectively. In the BE group with islands, the mean and range of C, and I were 2.5 (0-11), 3.5 (0-10) and 5.2(1-10) respectively. 2 patients in the island BE group had biopsy confirmed intramucosal carcinoma. All patients had regular surveillance with or without ablative therapy. Conclusion: The Prague criteria is well validated for endoscopic description of BE. However, we have observed that many patients assessed for BE have island configurations of Barrett's tissue that fall outside of classic Prague descriptors. The potential risk of missed dysplastic lesions warrants the need for a revision to the Prague Criteria.

121 Detection of Dysplasia Arising in Barrett's Esophagus Is Improved by Trained Endoscopists With a Specialist Interest on Dedicated Lists

Introduction Barrett’s oesophagus (BE) is the pre-malignant lesion to oesophageal adenocarcinoma (OAC). The presence of dysplasia, when diagnosed in surveillance programmes, is an important marker of risk of progression and an indication for endoscopic therapy. We have previously demonstrated that BE surveillance technique is variable and suggest centralised lists with few highly trained endoscopists. The aim of this study was to assess the introduction of dedicated BE surveillance lists on dysplasia detection rate (DDR). Method Prospective study of patients undergoing BE surveillance at two hospitals – district general hospital (DGH), and tertiary referral upper GI centre. A group of 4 endoscopists (group A) were trained in Prague classification, Seattle protocol biopsy technique and lesion detection. They were nominated to undertake BE surveillance, with dedicated time slots or lists. The DDR was then compared with historical data from 47 different endoscopists at GSTT (group B) and 24 at UHL (Group C) who had undertaken Barrett’s surveillance over the 5 year period. Analysis was by independent t-tests for continuous variables and chi-squared tests for categorical variables. Results A total of 729 patients with BE underwent endoscopy, between 2007 and 2012. Results are shown in Table 1. There was no significant difference in patient’s age, sex or length of BE between the three groups. Of these, 21% (30/144) were diagnosed with dysplasia/EAC by group A endoscopists vs. 9% (55/587) in Group B/C (p = 0.0004). There was a significant difference in detection rate of Indefinite or Low grade dysplasia (IND/LGD) and High grade dysplasia (HGD)/EAC between the 2 groups. There was a significant difference in diagnosis of IND in community (25/271) vs. teaching hospital (5/458) (p = 0.0001). Documentation of length of BE by Prague criteria was significantly higher in group A than group B&C. The use of High Resolution Endoscopy was similar between both groups. Conclusion This study demonstrates that a group of endoscopists trained in BE surveillance, have significantly higher dysplasia detection rate (DDR) than a non specialist cohort. These findings support the argument that BE surveillance, either at DGH or tertiary centre, should only be carried out on dedicated lists by trained endoscopists with a specialist interest. Disclosure of interest None Declared.

Sa1074 Increased Number of Risk Factors Predicts Esophageal Injury and Metaplasia: Results From a Large Prospective Population-Based Study

modalities were included in this analysis. Patients who stopped EET and started surveillance prior to CE-IM were excluded. Complete eradication of intestinal metaplasia (CE-IM) was defined as having an endoscopy with no visible columnar lined epithelium in the tubular esophagus and biopsies of the neo-squamous mucosa showing no intestinal metaplasia. Patients were considered to have achieved CE-IM if they had done so with 2cm were less likely to achieve CE-IM compared to those with C extents ≤2cm (64.3% vs. 73.5%, p=0.027). Patients with M extents of > 3cm were less likely to achieve CE-IM compared to those with M extents ≤3cm (61.2% vs. 88.4%, p<0.001). Conclusions: Results of this multi-center effectiveness trial show that pre-treatment Barrett's esophagus extent as measured by the Prague criteria is associated with the rate of achieving CE-IM with endoscopic eradication therapy. This was true for both the C and M extents of disease. This study provides the first validation of the Prague criteria with clinically relevant outcomes in the management of patients with Barrett's esophagus.