Seattle Biopsy Protocol Research Articles

Significant Reduction in the Diagnosis of Barrett's Esophagus and Related Dysplasia During the COVID-19 Pandemic.

The coronavirus disease 19 (COVID-19) pandemic disrupted endoscopy practices, creating unprecedented decreases in cancer screening and surveillance services. We aimed to assess the impact of the pandemic on the proportion of patients diagnosed with Barrett's esophagus (BE) and BE-related dysplasia and adherence to established quality indicators. Data from all esophagogastroduodenoscopies in the GI Quality Improvement Consortium, a national repository of matched endoscopy and pathology data, were analyzed from January 2018 to December 2022. Four cohorts were created based on procedure date and COVID-19 data: pre-pandemic (January 2018 to February 2020), pandemic-phase I (March 2020 to July 2020), pandemic-phase II (August 2020 to May 2021), and pandemic-phase III (June 2021 to December 2022). Observed and expected number of BE and BE-related dysplasia cases per month and adherence to the Seattle biopsy protocol and recommended surveillance intervals for nondysplastic BE (NDBE) were evaluated. Among 2,446,857 esophagogastroduodenoscopies performed during the study period, 104,124 (4.3%) had pathology-confirmed BE. The histologic distribution was 87.4% NDBE, 1.8% low-grade dysplasia, 2.4% indefinite for dysplasia, and 1.4% high-grade dysplasia. The number of monthly BE (-47.9% pandemic-phase I, -21.5% pandemic-phase II, and -19.0% pandemic-phase III) and BE-related dysplasia (high-grade dysplasia: 41.2%, -27.7%, and -19.0%; low-grade dysplasia: 49.1%, -35.3%, and -26.5%; any dysplasia: 46.7%, -32.3%, and -27.9%) diagnoses were significantly reduced during the pandemic phases compared with pre-pandemic data. Adherence rates to the Seattle protocol and recommended surveillance intervals for NDBE did not decline during the pandemic. There was a significant decline in the number of BE and BE-related dysplasia diagnoses during the COVID-19 pandemic, with an approximately 50% reduction in the number of cases of dysplasia diagnosed in the early pandemic. The absence of a compensatory increase in diagnoses in the pandemic-phase II and III periods may result in deleterious downstream effects on esophageal adenocarcinoma morbidity and mortality.

Quality indicators in Barrett's endoscopy: Best is yet to come.

There is growing interest in establishing quality indicators (QIs) for endoscopic screening and surveillance in Barrett's esophagus (BE). QIs are objective, measurable, and evidence-based metrics that are applicable in a health-care setting to monitor a process and identify key performance indicators (KPIs) to achieve defined goals. In the Barrett's endoscopy setting, QIs can offer a standardized approach to monitor and maintain high-quality endoscopy for BE screening and surveillance that will allow measuring performance of an endoscopist as an individual, a group, or a facility. Since BE is an endoscopically identifiable premalignant condition with histological corroboration, adherence to QIs is paramount for the early and accurate detection of dysplasia and neoplasia. It is the holy grail for BE screening and surveillance. Although several suggested QIs for Barrett's endoscopy exist, issues remain in determining the most appropriate ones. These issues include inconsistent use of terminology, unclear definitions, and a scarcity of studies linking these QIs with relevant patient outcomes, making it difficult for clinicians to understand the concept and clinical importance. Hence, there is an urgent need to determine what should constitute appropriate QIs for Barrett's endoscopy, clearly define items used in the QIs, and identify ways to measure these KPIs. Ultimately, well-defined and validated QIs will contribute to clinically effective, safe, timely, and patient-focused care. In this review, we summarize recent literature and discuss four proposed QIs: (i) neoplasia detection rate; (ii) postendoscopy Barrett's neoplasia; (iii) Barrett's inspection time; and (iv) adherence to the Seattle biopsy protocol.

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Multicenter Randomized Controlled Trial of Surveillance Versus Endoscopic Therapy for Barrett’s Esophagus With Low-grade Dysplasia: The SURVENT Trial: Study Rationale, Methodology, Innovation, and Implications

Post-endoscopy Esophageal Neoplasia in Barrett’s Esophagus: Consensus Statements From an International Expert Panel

Post-endoscopy Esophageal Neoplasia in Barrett’s Esophagus: Consensus Statements From an International Expert Panel

Educational intervention to improve quality of care in Barrett’s esophagus: the AQUIRE randomized controlled trial

Despite quality measures in upper endoscopy (EGD) for Barrett's esophagus (BE), considerable variability remains in practice among gastroenterologists. This randomized controlled trial evaluated the role of structured intensive training on the quality of EGD in BE. In this multicenter study, 8 sites (from the GI Quality Consortium) were cluster randomized (1:1) to receive AQUIRE (A Quality Improvement program in cancer care during Endoscopy) training (intervention) or continue local standard practices (control). The primary outcome was compliance with the Seattle biopsy protocol. Secondary outcomes were change in knowledge of BE detection and sampling assessed by questionnaire and dysplasia detection rate (DDR) before and after completion of the 6-month study period. The intervention sites (n= 4) had 31 gastroenterologists and the control sites (n= 4) had 34. There was a significant improvement in the compliance rates with the Seattle biopsy protocol from baseline to the end of the study in the intervention sites (64.8%-73.2%, P= .002) but not in the control sites (69.5%-69.4%, P= .953). The accurate response rate on the questionnaire at the intervention sites increased from 73% at baseline to 88% after AQUIRE training (difference, 14.8%; standard deviation, 18.7; P= .008). DDR did not change significantly from baseline to 6 months in either the control or intervention groups (P= .06). This study confirms the capacity of a structured educational intervention to improve utilization of a standard biopsy protocol and knowledge of standards of care in BE but without significant change in DDR.

Racial Disparities in Adherence to Quality Indicators in Barrett's Esophagus: An Analysis Using the GIQuIC National Benchmarking Registry.

Racial disparities in outcomes in esophageal adenocarcinoma are well established. Using a nationwide registry, we aimed to compare clinical and endoscopic characteristics of blacks and whites with Barrett's esophagus (BE) and adherence to defined quality indicators. We analyzed data from the Gastrointestinal Quality Improvement Consortium Registry between January 2012 and December 2019. Patients who underwent esophagogastroduodenoscopy with an indication of BE screening or surveillance, or an endoscopic finding of BE, were included. Adherence to recommended endoscopic surveillance intervals of 3-5 years for nondysplastic BE and adherence to Seattle biopsy protocol were assessed. Multivariate logistic regression was conducted to assess variables associated with adherence. A total of 100,848 esophagogastroduodenoscopies in 84,789 patients met inclusion criteria (blacks-3,957 and whites-96,891). Blacks were less likely to have histologically confirmed BE (34.3% vs 51.7%, P < 0.01), had shorter BE lengths (1.61 vs 2.35 cm, P < 0.01), and were less likely to have any dysplasia (4.3% vs 7.1%, P < 0.01). Although whites were predominantly male (62.2%), about half of blacks with BE were female (53.0%). Blacks with nondysplastic BE were less likely to be recommended appropriate surveillance intervals (OR 0.78; 95% CI 0.68-0.89). Adherence rates to the Seattle protocol were modestly higher among blacks overall (OR 1.12, 95% CI 1.04-1.20), although significantly lower among blacks with BE segments >6 cm. The use of sex as a risk factor for BE screening may be inappropriate among blacks. Fewer blacks were recommended appropriate surveillance intervals, and blacks with longer segment BE were less likely to undergo Seattle biopsy protocol.

S3142 Adherence to Seattle Biopsy Protocol in Patients With Long Segment Barrett’s Esophagus at Cairns Hospital, Australia

S3142 Adherence to Seattle Biopsy Protocol in Patients With Long Segment Barrett’s Esophagus at Cairns Hospital, Australia

Evaluación del cumplimiento a largo plazo de los indicadores de calidad en la esofagogastroduodenoscopia

IntroductionIn a previous study we demonstrated that a simple training programme improved quality indicators of Oesophagogastroduodenoscopy (OGD) achieving the recommended benchmarks. However, the long-term effect of this intervention is unknown. The aim of this study was to assess the quality of OGDs performed 3 years after of having completed a training programme. Material and methodsA comparative study of 2 cohorts was designed as follows: Group A included OGDs performed in 2016 promptly after a training programme and Group B with OGDs performed from January to March 2019, this group was also divided into 2 subgroups: subgroup B1 of Endoscopists who had participated in the previous training programme and subgroup B2 of Endoscopists who had not. The intra-procedure quality indicators proposed by ASGE-ACG were used. ResultsA total of 1236 OGDs were analysed, 600 from Group A and 636 from Group B (439 subgroup B1 and 197 subgroup B2). The number of complete examinations was lower in Group B (566 [94.3%] vs. 551 [86.6%]; p<0.001). A significant decrease was observed in nearly all quality indicators and they did not reach the recommended benchmarks: retroflexion in the stomach (96% vs. 81%; p<0.001); Seattle biopsy protocol (86% vs. 50%; p=0.03), description of the upper GI bleeding lesion (100% vs. 62%; p<0.01), sufficient intestinal biopsy specimens (at least 4) in suspected coeliac disease (92.5% vs. 18%; p<0.001), photo documentation of the lesion (94% vs. 90%; p<0.05). Regarding the overall assessment of the procedure (including correct performance and adequate photo documentation), a significant decrease was also observed (90.5% vs. 62%; p<0.001). There were no differences between subgroups B1 and B2. ConclusionsThe improvement observed in 2016 after a training programme did not prevail after 3 years. In order to keep the quality of OGDs above the recommended benchmarks, it is necessary to implement continuous training programmes.

Adequacy of EGD Reporting: a Review of 100 Reports from 100 Endoscopists

IntroductionEsophagogastroduodenoscopy (EGD) is commonly performed in patients with gastroesophageal reflux disease (GERD). An EGD report should document pertinent findings such as esophagitis, a columnar-lined esophagus (CLE), the location of the squamo-columnar and gastroesophageal junctions, the size and type of a hiatal hernia and the number and location of any biopsies. The aim of this study was to evaluate how commonly these findings were noted in the EGD reports of patients referred for antireflux surgery. MethodsA retrospective review was performed of patient charts from 2012 to 2015 to identify 100 consecutive EGD reports from different endoscopists in different patients. Each EGD report was reviewed for pertinent findings and the use of a classification system for esophagitis (Savory-Miller or Los Angeles) and for reporting a CLE (Prague). ResultsIn 100 EGD reports, esophagitis was noted in 33 patients, but was graded in only 14 (42%). A CLE was noted in 28 patients, but the length was reported in only 16 (57%) and no report used the Prague classification system. A hiatal hernia was noted in 61 patients, measured in 31 (51%) and the type classified in 26%. A biopsy was taken in 93 patients and the location noted in 86 patients (93%). The number of biopsies was recorded in only 20 patients (22%). In 12 patients the EGD was for Barrett’s surveillance, yet a Seattle biopsy protocol was reported to be used in only 3 patients. ConclusionEndoscopy reports frequently do not include the use of a grading system for esophagitis or the Prague system for CLE. This hampers the assessment of change with therapy or over time. The size of a hiatal hernia was typically reported in a subjective fashion and only infrequently was the type specified. Lack of clarity about the presence of a paraesophageal hernia can impede evaluation of acute symptoms. In patients with Barrett’s esophagus a standard biopsy protocol was infrequently reported to be used. These findings raise concern about the quality of upper endoscopy, both in the performance of the procedure and the documentation of findings. A consistent reporting system is recommended for routine use with upper endoscopy.

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.

Tu1140 REGIONAL VARIATIONS AND TRENDS IN QUALITY INDICATOR (QI) PERFORMANCE IN BARRETT’S ESOPHAGUS (BE): RESULTS FROM A POPULATION-BASED STUDY USING A NATIONAL BENCHMARKING REGISTRY

QIs in BE have been defined with the goal of improving patient outcomes. While adherence to the Seattle biopsy protocol (4-quadrant q2 cm) and surveillance intervals in non-dysplastic BE patients (NDBE) of 3-5 yrs are proposed QIs, population-based data addressing regional variations are not available. Using a national benchmarking clinical registry, to evaluate regional variation in adherence to the Seattle biopsy protocol and adherence to recommended surveillance intervals in NDBE and low-grade dysplasia (LGD). We analyzed data from the GI Quality Improvement Consortium (GIQuIC) Registry, a national data repository of endoscopy quality measures. Upper endoscopy data include procedure indication, demographics, endoscopy findings, and pathology results. EGD records from 1/2012-9/2017 were assessed. Patients (pts) with an indication of BE screening or surveillance, or an endoscopic finding of BE, were included. Adherence to Seattle protocol was defined by dividing the BE length by number of pathology jars, with a ratio of ≤2.0 with rounding down (lenient definition) or rounding up (stringent definition) for odd BE lengths considered adherent. Adherence to surveillance for NDBE was calculated as the proportion recommended to undergo EGD between 3-5 yrs (non-adherent if EGD recommended at 3 months–2 yrs from the index EGD) for NDBE and the proportion recommended an EGD at ≤1 year for LGD. Cochran-Armitage test for trend was applied to detect improvement in adherence. 786,712 EGDs were assessed, and 58,709 (7.5%) EGDs in 53,541 pts met inclusion criteria [mean age 61.3 yrs (SD 12.6), 60.4% male, 90.2% Caucasian]. Majority of cases were performed by GIs (92.3%) with propofol (78.7%), and represented 263 practices nationwide and 1457 unique providers. Distribution of cases based on US census region was: Northeast (n=14735, 27.6%), South (n=16376, 30.7%), Midwest (n=10,068, 18.8%) and West (n=12,152, 22.8%). Mean BE length was 2.3 cm (SD 2.3). No significant regional variations were noted in demographics, proportion of pts undergoing biopsies and confirmed BE and BE pts diagnosed with dysplasia (Table 1). There are marked variations in adherence with Seattle protocol by region (Table 2), with the highest rates of adherence noted in the Northeast and the lowest in the Midwest. In time-trend analysis, there was an improvement in adherence rates in the Midwest and a decline in the South. Among NDBE pts, non-adherence rates with the 3-yr surveillance endoscopy threshold ranged from 24-33% with the highest rates in the Northeast (Table 2). Endoscopists in the Northeast are most likely to be compliant with adherence to the Seattle biopsy protocol, but least likely to be compliant with recommended surveillance intervals. Further research to understand the factors influencing non-adherence to guidelines is warranted.Tabled 1Table 1: Regional variations in patient demographics and endoscopy-based variablesVariableNortheastSouthMidwestWestOverallDemographics (patient-based)Mean age, yrs (SD)61.2 (12.6)61.5 (12.4)60.9 (13.0)61.4 (12.5)61.3 (12.6)Males (n,%)8772 (59.5%)9921 (60.6%)6188 (61.4%)7350 (60.4%)32,346 (60.4%)Caucasians (n,%)89.9%89.2%93.1%89.4%90.2%Endoscopy-based variablesGIs*13,198 (95.1%)15,406 (89.8%)9272 (91.7%)11,671 (93.6%)49,654 (92.3%)Propofol sedation6475 (83%)4775 (79.6%)3283 (65.1%)5686 (83%)20,264 (78.7%)Adverse event rate0.01%0.02%0.02%0.03%0.02%Mean BE length, cm, SD2.05 (1.97)2.4 (2.38)2.5 (2.46)2.3 (2.44)2.3 (2.3)Proportion of patients with biopsies (n, %)15,792 (97.3%)16,594 (92.7%)10,007 (90.3%)12,332 (92.9%)54,943 (93.6%)Confirmed BE (n, %)8413 (55%)8745 (54.9%)5709 (57.5%)7012 (56.8%)29,978 (55.8%)Pathology results (n, %)NDBE7311 (92.2%)7561 (91.7%)4782 (88.5%)6202 (92.7%)25,945 (91.5%)IND/LGD499 (6.3%)565 (6.8%)506 (9.3%)376 (5.6%)1951 (6.8%)HGD113 (1.4%)117 (1.4%)111 (2.1%)107 (1.6%)449 (1.6%) Open table in a new tab

Management of Barrett's esophagus: Screening to newer treatments

Barrett's esophagus is a premalignant condition of the esophagus in which the squamous epithelium of the lower end of the esophagus is replaced with columnar epithelium. Since the incidence of esophageal adenocarcinoma is on the rise, the major gastroenterology societies have come up with their recommendations for screening and surveillance. Specific factors like obesity, white race, age over 50 years, early age of onset of GERD, smoking and hiatal hernia have been identified as increasing the risk of Barrett's esophagus and adenocarcinoma. The diagnosis requires both endoscopic identification of columnar-lined mucosa and histological confirmation with biopsy. Most medical societies recommend screening people with GERD and other risk factors with endoscopy, but other alternatives employing less invasive methods are currently being studied. Surveillance strategies vary depending on the endoscopic findings and the Seattle biopsy protocol with random 4-quadrant sampling is recommended. Biomarkers have shown promising results, but more studies are needed in the future. White light endoscopy is the standard practice, but other advanced imaging modalities have shown variable results and hence more studies are awaited for further validation. Endoscopic eradication techniques, including both resection and ablation, have shown good but variable results for treating dysplastic lesions confined to the mucosa. Resection procedures to remove visible lesions followed by ablation of the dysplastic mucosa have shown the best results with higher eradication rates and lower recurrence rates. Surgical management is reserved for lesions with sub-mucosal invasion and lymph node spread with increased risk of metastasis.

Management of Barrett's esophagus: From screening to newer treatments.

Barrett's esophagus is a premalignant condition of the esophagus in which the squamous epithelium of the lower end of the esophagus is replaced with columnar epithelium. Since the incidence of esophageal adenocarcinoma is on the rise, the major gastroenterology societies have come up with their recommendations for screening and surveillance. Specific factors like obesity, white race, age over 50 years, early age of onset of GERD, smoking and hiatal hernia have been identified as increasing the risk of Barrett's esophagus and adenocarcinoma. The diagnosis requires both endoscopic identification of columnar-lined mucosa and histological confirmation with biopsy. Most medical societies recommend screening people with GERD and other risk factors with endoscopy, but other alternatives employing less invasive methods are currently being studied. Surveillance strategies vary depending on the endoscopic findings and the Seattle biopsy protocol with random 4-quadrant sampling is recommended. Biomarkers have shown promising results, but more studies are needed in the future. White light endoscopy is the standard practice, but other advanced imaging modalities have shown variable results and hence more studies are awaited for further validation. Endoscopic eradication techniques, including both resection and ablation, have shown good but variable results for treating dysplastic lesions confined to the mucosa. Resection procedures to remove visible lesions followed by ablation of the dysplastic mucosa have shown the best results with higher eradication rates and lower recurrence rates. Surgical management is reserved for lesions with sub-mucosal invasion and lymph node spread with increased risk of metastasis.

Institutional Experience in Diagnostic Usability of Volumetric Laser Endo-Microscopy in Barrettʼs Esophagus

Introduction: Barrett's Esophagus (BE) is a well-known precursor lesion to Esophageal Adenocarcinoma. Random four-quadrant biopsies every 1-2 cm (the Seattle Biopsy Protocol) in addition to aggressive sampling of any mucosal abnormality has been recommended; however, there is controversy about the intense biopsy sampling protocol in detecting the incidental Barrett's dysplasia and cancer. Volumetric laser endomicroscopy (VLE) is a novel second-generation optical coherence tomography imaging procedure that elicits volumetric cross-sectional and longitudinal images over six cm of the esophagus with resolution less than ten microns Methods: A prospective enrollment of patients with known BE at our institution was conducted from September 2014-Febuary 2015. Patients were undergoing surveillance and/or therapeutic endoscopic procedures along with VLE. Patients of age 18 and above with history of BE were included. Based on VLE findings; lesions with high-risk features were identified and targeted biopsies were taken. Seattle protocol biopsies, which is the standard of care, were also taken in four quadrants every 1 cm for surveillance. Biopsies were evaluated by two-blinded pathologists. Results: Fifty-two patients with known BE were included in the analysis. There were no adverse events associated with the use of VLE. Mean age was 66 +/- 10 years with 71% males (n=37). Out of 52 patients, 41(79 %) underwent prior radio frequency ablations and/or endoscopic mucosal resections. Seattle protocol biopsies were performed in all 52 cases and additional targeted biopsies were performed in 46 cases as prompted by findings seen on VLE. Out of 52 cases, 21 were found to have BE on histopathology. VLE scans were abnormal in 19 out of 21 patients giving the sensitivity of 91% and NPV of 75%. One patient with BE had normal HD-WLE but abnormal features were detected on VLE scan. The two patients missed on VLE scanning had small foci of non-dysplastic BE at the gastro-esophageal junction and these were appreciated as small islands on HD-WLE. All the cases of BE were detected with combination HD-WLE and VLE. Conclusion: VLE is a reliable clinical modality which can be used for detection of BE. When used in conjunction with HD-WLE, the diagnostic yield is favorable and can decrease the miss rate of BE. Our study demonstrated excellent sensitivity and NPV. We believe there is a learning curve and further experience will only improve the diagnostic yield.

PTH-037 Adherence To 2013 Bsg Barrett’s Oesophagus Surveillance Guidelines Could Facilitate Safe Discharge Of Patients

IntroductionThe prevalence of Barrett’s oesophagus (BO) is increasing and surveillance of this population is a growing burden for endoscopy units.1 Guidelines exist to facilitate quality surveillance but are poorly adhered...

Improved Detection of Incident Dysplasia by Probe-Based Confocal Laser Endomicroscopy in a Barrett’s Esophagus Surveillance Program

Probe-based confocal laser endomicroscopy (pCLE) is a new technique allowing in vivo detection of neoplastic tissue using a standard endoscope. Our aim was to compare the incident dysplasia detection rate of biopsies obtained by high-definition white light endoscopy (HD-WLE) or by pCLE in a cohort of patients with Barrett's esophagus (BE) participating in a surveillance program. Fifty of 100 patients underwent pCLE in addition to HD-WLE. Four-quadrant biopsy specimens according to the Seattle biopsy protocol were obtained in all patients to ensure standard-of-care. Diagnosis of dysplasia/neoplasia was made by a blinded gastrointestinal pathologist. Incident high-grade dysplasia (HGD) and low-grade dysplasia (LGD) were diagnosed in 3/100 and in 16/100 cases. In the HD-WLE group, areas suspicious for neoplasia were not observed and dysplasia was diagnosed in 5/50 (10%) patients (one with HGD). In the pCLE group, areas suspicious for neoplasia were observed by pCLE in 21/50 (42%) patients; dysplasia was confirmed in 14 cases (28%) (two with HGD). The dysplasia detection rate was significantly higher in the pCLE group than in the HD-WLE group (P = 0.04). The sensitivity, specificity, positive and negative predictive values of pCLE for dysplasia were 100, 83, 67, and 100%, respectively. Incident dysplasia can be more frequently detected by pCLE than by HD-WLE in BE. The higher dysplasia detection rate provided by pCLE could improve the efficacy of BE surveillance programs.

189 Treatment of Experimental Colitis Using Adenovirus-Directed Expression of Prohibitin

associated with an increased risk of neoplastic progression. Aim: To compare the prevalence of DNA promoter hypermethylation in esophageal biopsies of BE patients with residual BE (ND or LGD) after endoscopic ablation therapy versus patients who present with BE and ND or LGD at baseline and have never been treated. Methods: Using a prospective large BE cohort of 220 patients followed over the past 6 years, we performed a case-control study comparing two groups of patients: 1) patients with BE and high-grade dysplasia and/or intramucosal adenocarcinoma who were treated with photodynamic therapy and had residual BE [ND or LGD as the highest grade of dysplasia on follow-up upper endoscopies], and 2) patients with a baseline diagnosis of BE (ND or LGD) who had never undergone endoscopic therapy. All patients had undergone endoscopic surveillance with the Seattle biopsy protocol. Esophageal biopsies of BE from residual disease in group 1 and at baseline in group 2 were analyzed using methylation-specific PCR, and the prevalence of p16 and APC promoter methylation was compared. Results: There were 15 patients with residual BE (ND or LGD) after photodynamic therapy and 82 patients who presented with BE and ND or LGD at baseline and had never been treated. Patients with residual BE (ND or LGD) after ablation had a significantly higher prevalence of DNAmethylation compared to patients who presented with BE and ND or LGD at baseline for both p16 (73% vs. 31%; OR [95% CI]=6.1 [1.7521.2]; p<0.01) and APC (80% vs. 50%; OR [95% CI]=4.0 [1.0-15.3]; p=0.04). Conclusions: Since DNA methylation is a strong predictor of subsequent neoplastic progression to highgrade dysplasia or esophageal adenocarcinoma, the high prevalence of DNA methylation seen in patients with residual BE (ND or LGD) after endoscopic ablation suggest that these patients may have a higher risk of neoplastic progression compared to patients who have an initial presentation of BE and ND or LGD at baseline and have never been treated. Therefore, residual BE (ND or LGD) after endoscopic ablation should likely be managed more aggressively than de novo BE with ND or LGD.

Transatlantic Barrettʼs Esophagus: Are We Divided By More Than the ‘O’?

Purpose: In January 2006, the British Society of Gastroenterology (BSG) updated their guidelines on the management of Barrett's Esophagus (BE). The most notable change cited in this publication was that intestinal metaplasia (IM) was no longer required within the columnar lined esophagus (CLE) to make the diagnosis of BE. Significantly, this made the UK definition far more inclusive than American College of Gastroenterology (ACG) definition of BE, throwing the future of transatlantic research in to doubt. Are we in the same ballpark? Methods: A retrospective analysis of all case notes and endoscopic records of patients diagnosed with BE after January 2006, as per the BSG guidelines, from a single UK tertiary referral centre was carried out. Those with a CLE but no IM (BSG diagnosis) were compared to those with CLE and IM (ACG diagnosis) and significant differences in the length of CLE, the number of biopsies taken and the presence of inflammation and hiatus hernia sought. Results: 196 patients were identified, all fulfilling the BSG diagnosis of BE; of those 76 had no detectable IM within the CLE, not diagnostic of BE by ACG criteria. Those patients meeting the ACG and not the BSG definition of BE had approximately 2.5 times more biopsies taken of their CLE (MWU, p=1.7 × 10-5) than those without IM within the CLE. Interestingly, the number of biopsies taken per cm was not significantly different between the two groups (MWU p=0.1838); patients with IM tended to have slightly fewer biopsies per cm (1.1/cm in the IM group vs. 1.2/cm in the non-IM group). The CLE was on average 1cm longer (MWU, p=0.043) in patients with IM within their CLE and they were more likely to have esophagitis (Chi-squared test p=0.016). No association was found between IM and the presence or length of an hiatus hernia, indicating correct anatomical sampling. Interestingly, those with IM were, on average, 7.5 years older than those without IM (p=.003). No gender difference detected between the two groups. Conclusion: Oscar Wilde was wrong, the US and UK are now separated by more than a common language; the former needs IM, the latter does not. From our data, is appears that strict adherence to the Seattle biopsy protocol in the UK would increase the diagnosis of IM. Consecutive CLE biopsies taken at a younger age in the US, however, may not detect IM, resulting in discharge from the BE screening program. In CLE less than 3 cm in length we suggest a minimal of 8 are biopsies taken; size does matter. However, in the absence of a unified diagnosis transatlantic research in BE is in jeopardy.

Surveillance history of endoscopically treated patients with early Barrett's neoplasia: nonadherence to the Seattle biopsy protocol leads to sampling error

The study's aim was to retrospectively evaluate the surveillance history of Barrett's esophagus (BE) patients with endoscopically treated early neoplasia. All BE patients endoscopically treated for early cancer (EC) or high-grade intraepithelial neoplasia (HGIN) in a lesion or mass between 1998 and 2005 were included. Endoscopy and histology records were reviewed. Ninety-four patients (78 males, mean age 67 years, 24 HGIN, 70 EC) were included. In 36 (38%) patients, HGIN/EC was diagnosed at (or within 6 months after) initial endoscopy. The remaining 58 (62%) patients had a surveillance history (median duration 7 years, mean 6.7 endoscopies). Seventy-nine percent of these had low-grade intraepithelial neoplasia (LGIN) diagnosed at least once during their surveillance period with a median of seven endoscopies and a median number of biopsies that was 50% of what should have been taken according to the Seattle protocol. Patients without any dysplasia during earlier surveillance (n = 12, 21%) had undergone significantly less endoscopies (median four endoscopies, P = 0.02) and had a median biopsy percentage that was 23% of the Seattle protocol (P < 0.001 versus 50% in LGIN). In this selected cohort of patients with early Barrett's neoplasia, 38% of patients were diagnosed at initial endoscopy. Of the patients with a surveillance history, 79% had shown LGIN prior to HGIN/EC diagnosis. Only 21% of patients had a surveillance history without any dysplasia, which in general encompassed endoscopies with an insufficient number of biopsies, suggesting sampling error. This underlines the importance of obtaining an adequate number of biopsies during surveillance endoscopies.

Is EUS Superior to Standard Surveillance After Endoscopic Ablation for Barrett's Dysplasia?

Background: Barrett's esophagus (BE) patients with high-grade dysplasia (HGD) or early carcinoma treated with surgery or photodynamic therapy (PDT) are at risk for disease recurrence in the esophagus or lymph nodes. Although used to select patients for PDT, the role of EUS for surveillance after PDT is unknown. We hypothesize that EUS is better than EGD and/or CT scan for surveillance of BE neoplasia after PDT. Methods: Consecutive patients with BE with HGD or carcinoma in situ treated with PDT using 2mg/kg porfimer sodium at light doses of 150-225 J/cm fiber length without a fiber centering device were followed with EUS, CT scan and EGD with 4 random jumbo biopsies every 1 cm at 3, 6, 9, 12, and then every 6 month intervals. Patients were excluded if they had less than 6 months of follow up and/or <2 EUS procedures. The outcome was detection of recurrent or residual carcinoma by any method. Results: Thirty of 97 patients did not meet inclusion criteria leaving 67 patients in the analysis (56 men and 11 women) with a median follow up of 16 months. Recurrent or residual adenocarcinoma was detected in 4 patients during follow up (17, 24, 30, and 36 months). Pre-PDT diagnosis in all four was HGD. EGD with random biopsies detected 2 patients, a third patient had a nodule seen on EGD with a biopsy revealing adenocarcinoma. EUS with EMR of the nodule confirmed T1 recurrence. In the fourth patient, CT scan revealed perigastric lymphadenopathy and EUS-FNA confirmed adenocarcinoma in the lymph node. There were 2 deaths. One patient with progression of disease died of metastatic adenocarcinoma. The second patient died of unrelated causes. Overall rate of recurrent/persistent ACA after PDT in this series was 4/67 = 6%. EUS surveillance in 67 of these patients did not detect recurrent/persistent carcinoma that was otherwise detected by surveillance endoscopy using Seattle biopsy protocol and contrast enhanced computed tomography. Conclusions: While considered critical for the initial evaluation of patients being considered for endoscopic ablation therapy, EUS appears to have little role in the subsequent surveillance of these patients, unless discreet abnormalities are found on EGD or cross-sectional imaging.