Barrett's Esophagus Surveillance Research Articles

Acetic acid chromoendoscopy in Barrett's esophagus surveillance is superior to the standardized random biopsy protocol: results from a large cohort study (with video)

Currently, various advanced endoscopic techniques are available with varying success rates. These technologies are manufacturer dependent, which has financial implications in the current era of austerity. Acetic acid is a commonly available dye that has been used in the detection of neoplasia within Barrett's esophagus. It has been shown to be effective in detecting neoplasia in high-risk subgroups, but its efficacy in a low-prevalence surveillance population remains unproven. This study aimed to investigate the effectiveness of acetic acid chromoendoscopy in a Barrett's esophagus surveillance population. We aimed to compare the neoplasia yield of acetic acid chromoendoscopy (AAC) with the neoplasia yield from standardized random biopsy (SBP) protocol-guided biopsies in the routine surveillance of patients with Barrett's esophagus. Retrospective cohort study. Tertiary referral hospital in the United Kingdom. Patients 18 years of age and older with a diagnosis of Barrett's esophagus undergoing surveillance gastroscopy. AAC versus standardized random biopsy protocol (SBP) for Barrett's esophagus surveillance. Neoplasia detection in 2 groups. The overall neoplasia detection rates for all grades of neoplasia were 13 of 655 (2%) in the SBP-guided biopsy cohort and 41 of 327 (12.5%) in the AAC cohort (P= .0001). On per-patient analysis, a 6.5-fold gain in neoplasia detection was seen in the AAC cohort compared with the SBP cohort (0.13 vs 0.02, P= .000). In the SBP cohort, a total of 13 of 655 (2%) neoplasias were detected, of which 3 of 655 patients (0.5%) had low-grade dysplasia, 7 of 655 (1%) had high-grade dysplasia, and 3 of 655 (0.5%) were found to have superficial cancer (T1a/T1b). In the AAC cohort, a total of 41 of 327 neoplasias (12.5%) were found, of which 9 of 327 patients (2.7%) had low-grade dysplasia, 18 of 327 (5.5%) had high-grade dysplasia, and 14 of 327 (4.2%) were found to have superficial cancer. The number of biopsies required to detect 1 neoplasia was 15 times lower in the AAC cohort (40 biopsies) than in the SBP cohort (604 biopsies). On per-biopsy analysis, a 14.7-fold increase in neoplasia detection was seen in the AAC cohort per biopsy compared with the SBP cohort (0.025 vs 0.0017; P= .000). Not a randomized, controlled study. Our study demonstrates that acetic acid detects more neoplasias than conventional protocol-guided mapping biopsies and requires 15 times fewer biopsies per neoplasia detected.

Barrett Esophagus: When to Endoscope

Increasing interest in identifying an effective strategy for decreasing the burden of esophageal adenocarcinoma (EAC) has been fuelled by the rising EAC rates worldwide, the morbidity associated with esophagectomy, and the development of endoscopic methods for curing early-stage EAC. In the face of this enthusiasm, however, we should be cautious about continuing our current evidence-free approach to screening and one with unclear benefits and unclear costs to the community. The literature is increasingly recognizing that the value of traditional endoscopy for screening and surveillance of Barrett esophagus may be more limited than initially believed. A better understanding of the risk factors for Barrett esophagus and progression to dysplasia and a more individualized risk calculation will be useful in defining populations to consider for Barrett screening. The development of novel, nonendoscopic screening techniques and of less expensive endoscopic techniques holds promise for a cost-effective screening and surveillance method to curtail the increasing rates of EAC.

Barrett's oesophagus: Evidence from the current meta-analyses.

Guidelines have been published regarding the management of Barrett's oesophagus (columnar-lined oesophagus). These have examined the role of surveillance in an effort to detect dysplasia and early cancer. The guidelines have provided criteria for enrolment into surveillance and some risk stratification with regard to surveillance interval. The research basis for the decisions reached with regard to cancer risk is weak and this manuscript has examined the available data published from meta-analyses up to 25(th) April 2013 (much of which has been published since the guidelines and their most recent updates have been written). There were 9 meta-analyses comparing patients with Barrett's oesophagus to control populations. These have demonstrated that Barrett's oesophagus is more common in males than females, in subjects who have ever smoked, in subjects with obesity, in subjects with prolonged symptoms of gastro-oesophageal reflux disease, in subjects who do not have infection with Helicobacter pylori and in subjects with hiatus hernia. These findings should inform public health measures in reducing the risk of Barrett's oesophagus and subsequent surveillance burden and cancer risk. There were 8 meta-analyses comparing different groups of patients with Barrett's oesophagus with regard to cancer risk. These have demonstrated that there was no statistically significant benefit of antireflux surgery over medical therapy, that endoscopic ablative therapy was effective in reducing cancer risk that there was similar cancer risk in patients with Barrett's oesophagus independent of geographic origin, that the adenocarcinoma incidence in males is twice the rate in females, that the cancer risk in long segment disease showed a trend to be higher than in short segment disease, that there was a trend for higher cancer risk in low-grade dysplasia over non-dysplastic Barrett's oesophagus, that there is a lower risk in patients with Helicobacter pylori infection and that there is a significant protective effect of aspirin and statins. There were no meta-analyses examining the role of intestinal metaplasia. These results demonstrate that guidance regarding surveillance based on the presence of intestinal metaplasia, segment length and the presence of low-grade dysplasia has a weak basis, and further consideration should be given to gender and helicobacter status, ablation of the metaplastic segment as well as the chemoprotective role of aspirin and statins.

Barrett Esophagus and Risk of Esophageal Cancer

Barrett esophagus, a complication of gastroesophageal reflux disease (GERD), predisposes patients to esophageal adenocarcinoma, a tumor that has increased in incidence more than 7-fold over the past several decades. Controversy exists regarding the issues of endoscopic screening and surveillance for Barrett esophagus, treatment for the underlying GERD, and the role of endoscopic eradication therapy. To review current concepts on the pathogenesis, diagnosis, and treatment of Barrett esophagus; to discuss the importance of dysplasia and the role of endoscopic eradication therapy for its treatment; and to review current management guidelines. MEDLINE and the Cochrane Library were searched from 1984 to April 2013. Additional citations were obtained by reviewing references from selected research and review articles. Risk factors for cancer in Barrett esophagus include chronic GERD, hiatal hernia, advanced age, male sex, white race, cigarette smoking, and obesity with an intra-abdominal body fat distribution. The annual risk of esophageal cancer is approximately 0.25% for patients without dysplasia and 6% for patients with high-grade dysplasia. High-quality studies have found no significant differences in cancer incidence for patients with Barrett esophagus whose GERD is treated medically or surgically. Endoscopic eradication therapy with radiofrequency ablation significantly reduces the frequency of progression to cancer for patients with high-grade dysplasia. Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett esophagus. For patients with Barrett esophagus without dysplasia, endoscopic surveillance at intervals of 3 to 5 years is recommended, and GERD is treated much as it is for patients without Barrett esophagus. Endoscopic eradication therapy is the treatment of choice for high-grade dysplasia and is an option for low-grade dysplasia. Endoscopic eradication therapy is not recommended for the general population of patients with nondysplastic Barrett esophagus.

Effect of Barrett's esophagus surveillance on esophageal preservation, tumor stage, and survival with esophageal adenocarcinoma

Surveillance endoscopy has been recommended for patients with Barrett's esophagus; however, recent studies have questioned the importance owing to the new, lower, estimates of the rate of progression of Barrett's esophagus to cancer. The aim of the present study was to compare the tumor stage, survival, and frequency of esophageal preservation in patients who presented with progression of Barrett's esophagus within a surveillance program versus those who presented with prevalent disease. A retrospective chart review was performed of all patients treated for high-grade dysplasia or esophageal adenocarcinoma from 2005 to 2010. The surveillance group included patients who had had at least 1 endoscopy and biopsy confirming intestinal metaplasia (with or without low-grade dysplasia) 6 months or more before the endoscopy showing progression. A total of 224 patients were included in the present study, 36 in the surveillance group and 188 in the prevalence group. The surveillance patients had significantly earlier stage tumors (P<.0001) and were more likely to undergo endoscopic therapy and to keep their esophagus (44% vs 11%, P<.0001) than were patients with prevalent disease. Furthermore, the patients in the surveillance group were less likely to have lymph node metastases and had better overall and disease-free survival. No patient with high-grade dysplasia or an intramucosal tumor died of cancer. Patients within a surveillance program for Barrett's esophagus had better survival and were less likely to have an esophagectomy than those who presented with prevalent disease. Treatment of intramucosal cancer was curative, and improved survival with surveillance was not secondary to lead time bias. Surveillance endoscopy remains important in patients with Barrett's esophagus.

Tu1094 Physician Satisfaction With Current Barrett's Esophagus Surveillance and Acceptability of FISH-Based Testing: A Survey of Gastroenterologists Across the United States

Tu1094 Physician Satisfaction With Current Barrett's Esophagus Surveillance and Acceptability of FISH-Based Testing: A Survey of Gastroenterologists Across the United States

Confocal endomicroscopy (CEM) improves efficiency of Barrett surveillance

Endoscopists with extensive experience with confocal endomicroscopy (CEM) have demonstrated that this technology is useful for Barrett's esophagus (BE) surveillance. However, data on endoscopists with minimal experience with this technique are limited. For BE surveillance, an endoscopist with minimal experience in CEM-guided biopsy would achieve a similar diagnostic yield with fewer biopsies when compared to the random 4-quadrant biopsy protocol. To compare the diagnostic yields of CEM-guided biopsy technique with the random 4-quadrant biopsy protocol. Randomized controlled trial. Tertiary care center. Patients with BE. Out of 18 patients who underwent routine BE surveillance, 11 and 7 were randomly assigned to group A (CEM-guided) and to group B (random 4-quadrant biopsy), respectively. The pathologists were blinded to all clinical information. Mean length of endoscopic Barrett was similar in both groups, (5.1 vs. 6.3 cm, p=0.51). The diagnostic yields for detecting SIM (63.6% vs. 59.5%, p=0.5), low grade dysplasia (11. 6% vs. 11.2%, p=NS), high grade dysplasia (10.1% vs. 11.5%, p=0.88). Although the total number of individual mucosal biopsy performed were 52% lower in the CEM group (129 vs. 269), the overall diagnostic yield (85.3% vs. 82.2%, p=0.53) was similar in both groups. Small sample size. For BE surveillance, limited data suggested that endoscopists with minimal experience in CEM can effective use this technology for "smart" biopsy to decrease the need for intense tissue sampling but without lowering the diagnostic yield in detecting dysplasia.

Natural history of Barrett's esophagus

The natural history of Barrett's esophagus (BE) is difficult to quantify because, by definition, it should describe the course of the condition if left untreated. Pragmatically, we assume that patients with BE will receive symptomatic treatment with acid suppression, usually a proton pump inhibitor, to treat their heartburn. This paper describes the development of complications of stricture, ulcer, dysplasia and adenocarcinoma from this standpoint. Controversies over the definition of BE and its implications in clinical practice are presented. The presence of intestinal metaplasia and its relevance to cancer risk is discussed, and the need to measure the extent of the Barrett's epithelium (long and short segments) using the Prague guidelines is emphasized. Guidelines and international consensus over the diagnosis and management of BE are being regularly updated. The need for expert consensus is important due to the lack of randomized trials in this area. After searching the literature, we have tried to collate the important studies regarding progression of Barrett's to dysplasia and adenocarcinoma. No therapeutic studies yet reported show a clear reduction in the development of cancer in BE. The effect of pharmacological and surgical intervention on the natural history of Barrett's is a subject of ongoing research, including the Barrett's Oesophagus Surveillance Study and the aspirin and esomeprazole cancer chemoprevention trial with interesting results. The geographical variation and the wide range of outcomes highlight the difficulty of providing an individualized risk profile to patients with BE. Future studies on the interaction of genome wide abnormalities in Barrett's and their interaction with environmental factors may allow individualization of the risk of cancer developing in BE.

Confocal Endomicroscopy of Colorectal Polyps

Confocal laser endomicroscopy (CLE) is one of several novel methods that provide real-time, high-resolution imaging at a micron scale via endoscopes. CLE has the potential to be a disruptive technology in that it can change the current algorithms that depend on biopsy to perform surveillance of high-risk conditions. Furthermore, it allows on-table decision making that has the potential to guide therapy in real time and reduce the need for repeated procedures. CLE and related technologies are often termed “virtual biopsy” as they simulate the images seen in traditional histology. However, the imaging of living tissue allows more than just pragmatic convenience; it also allows imaging of living tissue such as active capillary circulation, cellular death, and vascular and endothelial translocation, thus extending beyond what is capable in traditional biopsy. Immediate potential applications of CLE are to guide biopsy sampling in Barrett's esophagus and inflammatory bowel disease surveillance, evaluation of colorectal polyps, and intraductal imaging of the pancreas and bile duct. Data on these applications is rapidly emerging, and more is needed to clearly demonstrate the optimal applications of CLE. In this paper, we will focus on the role of CLE as applied to colorectal polyps detected during colonoscopy.

Barrett's esophagus: surveillance and reversal

The following on surveillance and reversal of Barrett's esophagus (BE) includes commentaries on criteria for surveillance even when squamous epithelium stains normally with a variety of biomarkers; the long-term follow-up of surgery versus endoscopic ablation of BE; the recommended surveillance intervals in patients without dysplasia; the sampling problems related to anatomic changes following fundoplication; the value of tissue spectroscopy and optical coherence tomography; the cost-effectiveness of biopsy protocols for surveillance; the quality of life of Barrett's patients; and risk stratification and surveillance strategies.

Su1469 Early Esophageal Cancer: Changing Treatment Trends in an Upper GI (Gastrointestinal) Tertiary Referral Centre Over the Past Decade (2000-2010)

Barrett's esophagus surveillance programs have led to increased detection of early malignant lesions (EM) defined as high grade dysplasia (HGD), intramucosal carcinoma (IMC) & submucosal carcinoma (T1). Minimally-invasive therapies with endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA) are gaining momentum and acceptance as alternatives in the management of EM.

Risk of malignant progression in patients with Barrett's oesophagus: a Dutch nationwide cohort study

BackgroundReported incidence rates of oesophageal adenocarcinoma (OAC) in Barrett's oesophagus (BO) vary widely. As the effectiveness of BO surveillance is crucially dependent on this rate, its clarification is essential.MethodsTo estimate...

Cost‐effectiveness of treatment and endoscopic surveillance of precancerous lesions to prevent gastric cancer

Although surveillance for Barrett esophagus and other gastrointestinal precancerous conditions is recommended, no analogous guidelines exist for gastric lesions. The objective of this study was to estimate the clinical benefits and cost-effectiveness of treatment and endoscopic surveillance to prevent gastric cancer. The authors developed a state-transition decision model for a cohort of US men with a recent incidental diagnosis of gastric precancerous lesions (dysplasia, intestinal metaplasia, or atrophy). Strategies included 1) no surveillance or treatment and 2) referral for surveillance and treatment, and varied by surveillance frequency (none, every 10 years, every 5 years, or every year) and treatment modality for dysplastic and cancerous lesions (surgery or endoscopic mucosal resection [EMR]). The term "post-treatment surveillance" was restricted to surveillance of individuals after treatment. Data were based on published literature and databases. Outcomes included lifetime gastric cancer risk, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios. For a cohort of men with dysplasia aged 50 years, the lifetime gastric cancer risk was 5.9%. EMR with annual surveillance reduced the lifetime cancer risk by 90% and cost $39,800 per quality-adjusted life year (QALY). Addition of post-treatment surveillance every 10 years provided little incremental benefit ( approximately 5%) but cost >$1 million per QALY. Results were most sensitive to surgical risks and the proportion of lesions completely removed with EMR. For intestinal metaplasia, surveillance every 10 years reduced lifetime cancer risk by 61% and cost $544,500 per QALY. EMR with surveillance every 1 to 5 years for gastric dysplasia was promising for secondary cancer prevention and had a cost-effectiveness ratio that would be considered attractive in the United States. Endoscopic surveillance of less advanced lesions did not appear to be cost-effective, except possibly for immigrants from high-risk countries.

Barrett's Surveillance Identifies Patients with Early Esophageal Adenocarcinoma

Background Barrett's surveillance for dysplasia is recommended, but few studies have documented the benefit of endoscopic surveillance for dysplasia or cancer. Objectives Using a retrospective study design, we aim to demonstrate the impact of a Barrett's surveillance program on the stage of esophageal adenocarcinoma and identify factors for progression of metaplasia to cancer. Subjects The Institutional Review Board at Veterans Affairs Connecticut Healthcare approved the study. We report a retrospective review of a prospectively followed Barrett's cohort in a surveillance program and compared their outcome with patients with a new diagnosis of esophageal adenocarcinoma, identified at the same center between 1999 and 2005. Results There were 248 patients with Barrett's esophagus entered into a surveillance program from 1999 to 2005. During the surveillance period of 987 patient-years, 5 (0.5% patient-year) patients developed esophageal adenocarcinoma. During the same period, 46 patients were diagnosed with new-onset esophageal adenocarcinoma outside of our surveillance program. Only 5% of these patients had a history of gastroesophageal reflux disease. There were 248 patients who underwent a mean number of 2.7 ± 1.7 upper endoscopic procedures, with 26 (10%) patients developing dysplasia. Compared with nonsurveillance, more patients had early stage of cancer in the surveillance group ( P <.001). All 5 patients with cancer diagnosed from Barrett's esophagus surveillance endoscopy were alive, compared with 20 of 46 (43%) patients with cancer diagnosed outside of the surveillance program. The length of Barrett's segment >3 cm was found to be associated with development of dysplasia, P = .004 (odds ratio 1.2; 95% confidence interval, 1.07-1.34). Conclusion Patients with Barrett's esophagus undergoing endoscopic surveillance benefit from early-stage cancer diagnosis. Progression to adenocarcinoma is low, but long-segment and high-grade dysplasias have an increased risk of cancer. A significant number of patients with newly diagnosed esophageal adenocarcinoma do not complain of gastroesophageal reflux disease and are therefore not investigated for Barrett's esophagus nor entered into surveillance. Patients and physicians can use this information in making a decision about surveillance.

Editorial: One Small Step for Metaplasia, but One Giant Leap for Biomarkers Is Needed

There are 5 to 6 levels of biomarker validation. Those for Barrett's esophagus are currently at level 3, despite small prospective studies. What is ideally required is a very large prospective assessment of biopsies in large cohorts, such as the ASPirin Esomeprazole Chemoprevention Trial (AspECT) and Barrett's Oesophagus Surveillance Study (BOSS) trials, so that unbiased and random selection of cases can be subjected to rigorous pathology and biomarker assessment (level 4). Only then can the predictive power of the data be exploited in a randomized intervention trial (level 5) whereby a series of biomarkers would trigger therapy. The real trouble is that this spot is currently occupied, satisfactorily according to some researchers, by conventional histological identification of high-grade dysplasia (HGD) as used in a recent randomized study of ablation in Barrett's esophagus (BE).

Outcome of endoscopy surveillance for Barrett's oesophagus

Endoscopic surveillance of individuals with Barrett's oesophagus is undertaken to detect early stage oesophageal malignancy. The impact of a surveillance programme on endoscopy resources and disease detection is uncertain. In 2004, we commenced a structured Barrett's oesophagus surveillance programme. The surveillance protocol specifies surveillance interval and number of oesophageal biopsies required according to previous endoscopy and biopsy findings. The first 3 years of surveillance were reviewed to assess programme adherence, impact on endoscopy resources and the incidence of high-grade dysplasia and adenocarcinoma in patients undergoing surveillance. Four hundred five patients were enrolled in the surveillance programme, and 776 patient years of endoscopy follow-up were analysed. Four-quadrant biopsies every 2 cm throughout the Barrett's oesophagus were performed in 89.8% of endoscopies. A total of 93.7% of patients had surveillance endoscopy performed at the appropriate time interval. Formalizing surveillance was followed by a decrease in the mean time interval for endoscopy surveillance from 16 months to 15 months, although the mode endoscopy surveillance interval lengthened from 1 year to 2 years. The mean number of biopsies per endoscopy increased from 5.9 to 7. In four patients, T1 stage oesophageal adenocarcinoma was identified, and in six patients, high-grade dysplasia was identified (combined incidence of adenocarcinoma/high-grade dysplasia 1 per 77.6 endoscopy years of follow-up). Structured Barrett's surveillance detects malignant progression at an early stage, which provides opportunities for curative surgical or endoscopic intervention. Formalizing surveillance resulted in a high rate of adherence to agreed guidelines and rationalized the use of endoscopy resources without significantly increasing workload.

Cost-Effectiveness of Endoscopic Screening Followed by Surveillance for Barrett's Esophagus: A Review

Screening interventions for Barrett's esophagus (BE) are appealing, but there is little supporting evidence. We reviewed health economics studies about BE endoscopic screening followed by, as required, endoscopic surveillance ("screening and surveillance" hereafter) to help inform the design and conduct of future research. Health economics studies about BE screening and surveillance were identified using electronic database searches and personal contact with authors of identified studies. No studies examined general population screening. Five US studies published between 2003 and 2007 examined the cost effectiveness of screening and surveillance (against no intervention) in patients with chronic gastroesophageal reflux disease (GERD). There was no randomized trial evidence to inform model construction. Assumptions about prevalence and transition probabilities between BE histologic subtypes and about surveillance and treatment protocols varied substantially between studies. Parameters such as potential BE diagnosis-related reduction in quality of life or increase in health care use, diagnostic accuracy, and infrastructural costs (for quality assurance) were considered either "optimistically" or not at all. Only 2 studies considered endoscopic treatments. No study considered the recently introduced radiofrequency ablation technique, or the potential for biomarker-based risk stratification of surveillance interval or duration. Current health economics evidence is likely to have provided optimistic cost-effectiveness estimates and is not sufficient to support introduction of endoscopic BE screening programs among GERD patients. The evidence does not adequately incorporate novel (endoscopic) treatments and the potential for (clinical, endoscopic, or biomarker-based) risk stratification of surveillance. Future research should aim to encompass both these factors.

Comparison of Standard, Large Capacity, and Jumbo Forceps for Sampling of Barrettʼs Esophagus: Results of a Randomized Trial

Purpose: For Barrett's esophagus (BE) surveillance, the Seattle protocol recommends the use of jumbo forceps, which require the use of a therapeutic upper endoscope, although ACG guidelines do not specify forceps size for BE surveillance. There are newer forceps, with larger outer diameters than previous standard forceps that can be used with standard-sized endoscopes. It is unclear whether there are differences with regard to quality of sampling using standard forceps, newer large capacity forceps, and jumbo forceps. Methods: From May to October 2008, patients with BE undergoing surveillance endoscopy were randomly assigned to have biopsies taken with 1 of 3 biopsy forceps (Boston Scientific, Natick, MA): Radial Jaw 3 (RJ3; 2.2mm outer diameter (OD)); Radial Jaw 4 Large Capacity (RJ4; 2.4mm OD); and Radial Jaw 4 Jumbo (Jumbo; 2.8mm OD). Random four quadrant biopsies were taken for every 1-2 cm of BE. Specimens were reviewed by two expert GI pathologists, who were blinded to the forceps used. We recorded number of gross pieces, maximum diameter, tissue layers included, specimen orientation, and adequacy. The a priori definition of an adequate biopsy was a well-oriented specimen ≥2mm in diameter with muscularis mucosa present. Results: Sixty-five patients underwent upper endoscopy with surveillance biopsies: 21 (32%) with RJ3, 21 (32%) with RJ4, and 23 (35%) with jumbo. The mean age was 68, and 72% of patients were male. The mean BE length was 1.7 cm, and 54% of patients had received prior treatment for BE. Mean biopsy diameter was 3.12 mm for jumbo, 2.76 mm for RJ4, and 2.69 mm for RJ3 (Jumbo vs. RJ4, p=0.0002; jumbo vs. RJ3, p<0.0001). There was no significant difference in the proportion of pieces ≥2mm across the three groups. However, a significantly higher proportion of biopsies using RJ4 compared to jumbo forceps was well-oriented (44.2% vs. 35.2%, p=0.03), contained muscularis mucosa, (56.7% vs. 44.1%, p=0.004), and were considered adequate (37.8% vs. 25.2%, p=0.002). There were no significant differences between the three forceps with regard to detection of dysplasia (p=0.97) or intestinal metaplasia (p=0.46). There were no complications due to biopsies in any of the subjects. Conclusion: In our randomized trial, jumbo forceps obtained larger biopsies, but large capacity forceps were superior with respect to specimen orientation, depth of biopsy, and overall specimen adequacy for pathological interpretation. We did not find differences in dysplasia detection rates, although our study was not specifically designed to answer this question. Large capacity RJ4 forceps produced optimal biopsies in BE surveillance and did not require the use of a therapeutic endoscope. This research was supported by an industry grant from Boston Scientific.

Surveillance in Barrett’s Esophagus: An Audit of Practice

Determine the rates of follow-up, incident rate of cancer during surveillance, and changes in pathologic grade of patients with Barrett's esophagus during surveillance in a gastroenterology practice without a formal surveillance program. Barrett's esophagus is a pre-malignant condition. Surveillance endoscopy (SE) is recommended in order to detect and treat high-grade dysplasia and esophageal adenocarcinoma early and prevent deaths. SE has not been shown to have mortality benefit and several studies have questioned its cost-effectiveness. Most gastroenterology practices do not have a surveillance program for Barrett's esophagus. The few that exist are only in very specialized and funded programs. Little information exists on outcomes in patients with Barrett's esophagus outside of these well-structured surveillance programs. A retrospective analysis of a cohort of patients with Barrett's esophagus diagnosed and surveyed between 1995 and 2005 at a Veterans Affairs medical center. Data were collected on age, body mass index, and race. Patients who missed their SE by 6 months or more and those that missed their SE by twice the recommended intervals or more were identified and analyzed for changes in pathologic grades. A total of 472 patients were diagnosed with Barrett's esophagus or had SE between 1995 and 2005. Three hundred and five patients only had one endoscopy and biopsy. They did not have follow-up surveillance endoscopies and biopsies. Two patients were excluded from the final analysis: one had an esophagectomy after an index diagnosis of high-grade dysplasia, and one had a diagnosis of esophageal adenocarcinoma 2 days after an initial impression of Barrett's esophagus. There were 165 patients with Barrett's metaplasia or dysplasia who had SE more than once and were included in the final analysis. Overall, 53.3% had no change in pathologic grade, 35.2% regressed to a lower pathologic grade, and 11.5% progressed to a higher grade. None (0/165, 0%) progressed to esophageal adenocarcinoma; 3.6% (6/165) progressed to high-grade dysplasia and 11.5% (19/165) regressed to normal mucosa. Forty-four patients missed their SE by 6 months or more. Of these, 50% regressed, 40.9% had no change, and 9.1% progressed. Four patients regressed to normal mucosa, one progressed to high-grade dysplasia and none progressed to esophageal adenocarcinoma. Twenty-three patients missed their SE by twice the recommended intervals or more. Of these, 60.9% regressed, 34.8% did not change, and 4.3% progressed. None progressed to esophageal adenocarcinoma or high-grade dysplasia but three regressed to normal mucosa. After adjusting for age and body mass index, patients with low-grade dysplasia are nearly seven times more likely to miss their endoscopy by twice the recommended intervals or more (OR 6.56, P-value 0.03). Most veteran patients with Barrett's esophagus do not undergo surveillance endoscopies. Veteran patients with Barrett's esophagus undergoing SE rarely progress to high-grade dysplasia or esophageal adenocarcinoma. Veteran patients with Barrett's esophagus who have longer SE up to twice the recommended intervals because they missed their scheduled SE did not have a worse outcome when compared to the general Barrett's esophagus surveillance group. Veteran patients with low-grade dysplasia are most likely to miss their SE by twice the recommended intervals or more, though the reason for this is unknown.

Capsule Endoscopy of the Esophagus

Video capsule endoscopy has acquired wide clinical acceptance since its the US Food and Drug Administration approval in 2001. Recently, the technology of video capsule endoscopy has been adapted to other organs in the gastrointestinal tract, including the esophagus and colon. In this review, we discuss esophageal capsule endoscopy (ECE)-the procedure, its indications, contraindications, safety, and future applications. ECE is a minimally invasive procedure that uses special video capsules with ability to acquire images from 2 cameras with high image storing speed of 14 to 18 frames per second. A special ingestion procedure allows for prolonged esophageal transit time and an optimized view of the gastroesophageal junction. ECE has been shown to have moderately high sensitivity and accuracy in the diagnosis and surveillance of Barrett esophagus in patients with gastroesophageal reflux disease but has not demonstrated superiority to esogastroduodenoscopy in cost-effectiveness models. In patients with portal hypertension, ECE has a sensitivity of 63% to 100% for screening of esophageal varices, but does not seem to be superior to esogastroduodenoscopy in its cost-effectiveness. No serious complications have been reported after ECE although a low rate of esophageal capsule retention (0.7% to 2.2%) has been reported, usually because of unsuspected esophageal strictures. Contraindications to capsule endoscopy include known or suspected gastrointestinal and esophageal obstruction, strictures, or fistulas, intestinal pseudoobstruction, and children under 10 years of age. It is expected that improvements in imaging technology will improve the accuracy of ECE with the development of immunological-based and chemical-based diagnostic capabilities.