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1
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Pulvirenti R, Sreeram II, van Wijk MP, IJsselstijn H, Kamphuis LS, Rottier RJ, Wijnen RMH, Spaander MCW, Schnater JM. Prevalence of Gastroesophageal Reflux Disease in Congenital Diaphragmatic Hernia Survivors From Infancy to Adulthood. J Pediatr Surg 2024; 59:161593. [PMID: 39004585 DOI: 10.1016/j.jpedsurg.2024.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 05/23/2024] [Accepted: 06/03/2024] [Indexed: 07/16/2024]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a common comorbidity associated with congenital diaphragmatic hernia (CDH), with reported cases of Barrett's esophagus (BE) and esophageal adenocarcinoma before the age of 25. The prevalence and natural course of GERD in CDH survivors remain uncertain due to variations in diagnostic methods. We aimed to analyse the GERD prevalence from infancy through young adulthood. METHODS We retrospectively analyzed pH-impedance measurements and endoscopic findings in 96 CDH survivors evaluated as routine care using well established clinical protocols. GERD was defined as an abnormal acid exposure time for pH-MII measurements and as presence of reflux esophagitis or BE at upper endoscopy. Clinical data including symptoms at time of follow-up and use of antireflux medication were collected. RESULTS GERD prevalence remained consistently low (≤10%) across all age groups, yet many patients experienced GER symptoms. Histological abnormalities were observed in 80% of adolescents and young adults, including microscopic esophagitis in 50%. BE was diagnosed in 7% before the age of 18, all had GER symptoms. CDH severity, anatomy at the time of CDH correction, alcohol usage, and smoking did not emerge as significant risk factors for GERD. CONCLUSIONS Given the low GERD prevalence in CDH survivors, a symptom-driven approach to diagnosis and follow-up is warranted. We advise long-term follow-up for all adult patients due to the early onset of BE and the limited evidence available. The longitudinal course and impact of GERD on other long-term CDH-related comorbidities should be explored in larger cohorts. LEVEL OF EVIDENCE Not applicable.
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Affiliation(s)
- Rebecca Pulvirenti
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands; Pediatric Surgery Unit, Department of Women's and Children's Health, Padua University Hospital, Padua, Italy
| | - Isabel I Sreeram
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Michiel P van Wijk
- Department of Pediatric Gastroenterology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Lieke S Kamphuis
- Department of Pulmonology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Robbert J Rottier
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - René M H Wijnen
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - J Marco Schnater
- Department of Pediatric Surgery, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands.
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2
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Eusebi LH, Telese A, Castellana C, Engin RM, Norton B, Papaefthymiou A, Zagari RM, Haidry R. Endoscopic Management of Dysplastic Barrett's Oesophagus and Early Oesophageal Adenocarcinoma. Cancers (Basel) 2023; 15:4776. [PMID: 37835470 PMCID: PMC10571849 DOI: 10.3390/cancers15194776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
Barrett's oesophagus is a pathological condition whereby the normal oesophageal squamous mucosa is replaced by specialised, intestinal-type metaplasia, which is strongly linked to chronic gastro-oesophageal reflux. A correct endoscopic and histological diagnosis is pivotal in the management of Barrett's oesophagus to identify patients who are at high risk of progression to neoplasia. The presence and grade of dysplasia and the characteristics of visible lesions within the mucosa of Barrett's oesophagus are both important to guide the most appropriate endoscopic therapy. In this review, we provide an overview on the management of Barrett's oesophagus, with a particular focus on recent advances in the diagnosis and recommendations for endoscopic therapy to reduce the risk of developing oesophageal adenocarcinoma.
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Affiliation(s)
- Leonardo Henry Eusebi
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Andrea Telese
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Division of Surgery and Interventional Science, University College London, London NW1 2BU, UK
| | - Chiara Castellana
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Rengin Melis Engin
- Gastroenterology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy; (C.C.); (R.M.E.)
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
| | - Benjamin Norton
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Department of Gastroenterology, University College London Hospital (UCLH), London NW1 2BU, UK;
- Centre for Obesity Research, Department of Medicine, Rayne Institute, University College London, London NW1 2BU, UK
| | - Apostolis Papaefthymiou
- Department of Gastroenterology, University College London Hospital (UCLH), London NW1 2BU, UK;
| | - Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy;
- Esophagus and Stomach Organic Diseases Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Rehan Haidry
- Digestive Disease and Surgery Institute Cleveland Clinic, London SW1X 7HY, UK; (A.T.); (B.N.)
- Division of Surgery and Interventional Science, University College London, London NW1 2BU, UK
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3
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Stibbe JA, Hoogland P, Achterberg FB, Holman DR, Sojwal RS, Burggraaf J, Vahrmeijer AL, Nagengast WB, Rogalla S. Highlighting the Undetectable - Fluorescence Molecular Imaging in Gastrointestinal Endoscopy. Mol Imaging Biol 2023; 25:18-35. [PMID: 35764908 PMCID: PMC9971088 DOI: 10.1007/s11307-022-01741-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 05/08/2022] [Accepted: 05/10/2022] [Indexed: 11/27/2022]
Abstract
Flexible high-definition white-light endoscopy is the current gold standard in screening for cancer and its precursor lesions in the gastrointestinal tract. However, miss rates are high, especially in populations at high risk for developing gastrointestinal cancer (e.g., inflammatory bowel disease, Lynch syndrome, or Barrett's esophagus) where lesions tend to be flat and subtle. Fluorescence molecular endoscopy (FME) enables intraluminal visualization of (pre)malignant lesions based on specific biomolecular features rather than morphology by using fluorescently labeled molecular probes that bind to specific molecular targets. This strategy has the potential to serve as a valuable tool for the clinician to improve endoscopic lesion detection and real-time clinical decision-making. This narrative review presents an overview of recent advances in FME, focusing on probe development, techniques, and clinical evidence. Future perspectives will also be addressed, such as the use of FME in patient stratification for targeted therapies and potential alliances with artificial intelligence. KEY MESSAGES: • Fluorescence molecular endoscopy is a relatively new technology that enables safe and real-time endoscopic lesion visualization based on specific molecular features rather than on morphology, thereby adding a layer of information to endoscopy, like in PET-CT imaging. • Recently the transition from preclinical to clinical studies has been made, with promising results regarding enhancing detection of flat and subtle lesions in the colon and esophagus. However, clinical evidence needs to be strengthened by larger patient studies with stratified study designs. • In the future fluorescence molecular endoscopy could serve as a valuable tool in clinical workflows to improve detection in high-risk populations like patients with Barrett's esophagus, Lynch syndrome, and inflammatory bowel syndrome, where flat and subtle lesions tend to be malignant up to five times more often. • Fluorescence molecular endoscopy has the potential to assess therapy responsiveness in vivo for targeted therapies, thereby playing a role in personalizing medicine. • To further reduce high miss rates due to human and technical factors, joint application of artificial intelligence and fluorescence molecular endoscopy are likely to generate added value.
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Affiliation(s)
- Judith A Stibbe
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Petra Hoogland
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Friso B Achterberg
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Derek R Holman
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - Raoul S Sojwal
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jacobus Burggraaf
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
- Centre for Human Drug Research, Leiden, The Netherlands
| | - Alexander L Vahrmeijer
- Department of Surgery, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Wouter B Nagengast
- Department of Gastroenterology and Hepatology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
| | - Stephan Rogalla
- Department of Medicine, Division of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA.
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4
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Bahdi F, Katti CC, Mansour N, Gagneja H, Anandasabapathy S, Othman MO. Outcomes of endoscopic submucosal dissection (ESD) plus radiofrequency ablation (RFA) for nodular Barrett's esophagus. Scand J Gastroenterol 2023; 58:123-132. [PMID: 35968576 DOI: 10.1080/00365521.2022.2111226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Although Endoscopic Submucosal Dissection (ESD) was proven superior to Endoscopic Mucosal Resection (EMR) in achieving higher complete remission rates for neoplastic Barrett's Esophagus (BE), its safety with Radiofrequency Ablation (RFA) remains unstudied. We share our experience with ESD + RFA for nodular BE eradication. METHODS A retrospective study of all patients ≥18-years with nodular BE who underwent ESD + RFA between September 2015 and December 2020 at our tertiary center. Patients with advanced adenocarcinoma requiring esophagectomy were excluded. Primary outcomes included adverse events (AE) rates and complete eradication rates for adenocarcinoma (CE-EAC), dysplasia (CE-D), and intestinal metaplasia (CE-IM). Secondary outcomes included local recurrence rates following eradication. RESULTS Eighteen patients were included with a total of 22 ESDs performed and a median of 2 RFA sessions-per-patient [IQR: 1.25, 3]. Sixteen patients were males and/or white (88.9%) with a median BMI of 29.75 kg/m2 [IQR: 26.9, 31.5]. Fourteen patients had long-segment BE (77.7%) while 16 had hiatal hernias (88.9%). Median resection size was 12.1 cm2 [IQR: 5.6, 20.2]. AEs included one intraprocedural micro-perforation (4.5%) and 4 strictures (22.2%), only one of which developed post-RFA. All AEs were successfully treated endoscopically. Over a median of 42.5 months [IQR: 28, 59.25], CE-EAC was achieved in 13 patients (100%), CE-D in 15 patients (100%), and CE-IM in 14 patients (77.8%). Following eradication, 2 patients had recurrent dysplasia (2/15, 13.3%) and one had recurrent intestinal metaplasia (1/14, 7.1%). CONCLUSION In high-risk patients with long-segment neoplastic BE requiring extensive endoscopic resection, ESD + RFA offers excellent complete eradication rates with rare additional adverse events by RFA. Standard endoscopic surveillance following eradication remains important.
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Affiliation(s)
- Firas Bahdi
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Chafik Clement Katti
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA
| | - Nabil Mansour
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA.,Baylor St Luke's Medical Center, Houston, TX, USA
| | | | - Sharmila Anandasabapathy
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA.,Baylor St Luke's Medical Center, Houston, TX, USA
| | - Mohamed O Othman
- Department of Medicine, Section of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, TX, USA.,Baylor St Luke's Medical Center, Houston, TX, USA
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5
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Wenzel AA, Kagalwalla AF, Wechsler JB. Pre-endoscopy Symptoms and Age, But Not Esophageal Biopsy Number Are Associated With Post-endoscopy Adverse Events. J Pediatr Gastroenterol Nutr 2022; 75:656-660. [PMID: 36305884 PMCID: PMC9627599 DOI: 10.1097/mpg.0000000000003594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Esophagogastroduodenoscopy (EGD) is a frequently utilized investigative tool in the management of gastrointestinal conditions in children. Biopsies obtained during EGD may pose risk for post-operative adverse events (AEs), and further understanding of risk is imperative to provide informed consent to families and safe patient care. In particular, the impact of biopsy number and location on the development of AEs has not been studied in pediatric patients. We prospectively assessed for AEs by telephone survey 3-7 days after 209 EGDs performed on patients ages 1-21 years over a 1-year period. Demographic, endoscopic, and histologic data were collected. The most common symptoms reported were throat pain (61%), chest pain (26%), and dysphagia (26%). Binary regression models identified age and pre-operative symptoms as factors that influenced the likelihood of post-operative morbidity. Multiple biopsies from 3 different locations of the esophagus did not impact the risk of post-operative AEs.
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Affiliation(s)
- Amanda A Wenzel
- From the Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Amir F Kagalwalla
- From the Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
- the Division of Pediatric Gastroenterology John H Stroger Hospital of Cook County, Chicago, IL
| | - Joshua B Wechsler
- From the Division of Gastroenterology, Hepatology and Nutrition, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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6
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Uno K, Koike T, Hatta W, Saito M, Tanabe M, Masamune A. Development of Advanced Imaging and Molecular Imaging for Barrett's Neoplasia. Diagnostics (Basel) 2022; 12:2437. [PMID: 36292126 PMCID: PMC9600913 DOI: 10.3390/diagnostics12102437] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 10/04/2022] [Indexed: 11/17/2022] Open
Abstract
Barrett esophagus (BE) is a precursor to a life-threatening esophageal adenocarcinoma (EAC). Surveillance endoscopy with random biopsies is recommended for early intervention against EAC, but its adherence in the clinical setting is poor. Dysplastic lesions with flat architecture and patchy distribution in BE are hardly detected by high-resolution endoscopy, and the surveillance protocol entails issues of time and labor and suboptimal interobserver agreement for diagnosing dysplasia. Therefore, the development of advanced imaging technologies is necessary for Barrett's surveillance. Recently, non-endoscopic or endoscopic technologies, such as cytosponge, endocytoscopy, confocal laser endomicroscopy, autofluorescence imaging, and optical coherence tomography/volumetric laser endomicroscopy, were developed, but most of them are not clinically available due to the limited view field, expense of the equipment, and significant time for the learning curve. Another strategy is focused on the development of molecular biomarkers, which are also not ready to use. However, a combination of advanced imaging techniques together with specific biomarkers is expected to identify morphological abnormalities and biological disorders at an early stage in the surveillance. Here, we review recent developments in advanced imaging and molecular imaging for Barrett's neoplasia. Further developments in multiple biomarker panels specific for Barrett's HGD/EAC include wide-field imaging systems for targeting 'red flags', a high-resolution imaging system for optical biopsy, and a computer-aided diagnosis system with artificial intelligence, all of which enable a real-time and accurate diagnosis of dysplastic BE in Barrett's surveillance and provide information for precision medicine.
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Affiliation(s)
- Kaname Uno
- Division of Gastroenterology, Tohoku University Hospital, Sendai 981-8574, Japan
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7
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Wolfson P, Ho KMA, Wilson A, McBain H, Hogan A, Lipman G, Dunn J, Haidry R, Novelli M, Olivo A, Lovat LB. Endoscopic eradication therapy for Barrett's esophagus-related neoplasia: a final 10-year report from the UK National HALO Radiofrequency Ablation Registry. Gastrointest Endosc 2022; 96:223-233. [PMID: 35189088 DOI: 10.1016/j.gie.2022.02.016] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/09/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Long-term durability data for effectiveness of radiofrequency ablation (RFA) to prevent esophageal adenocarcinoma in patients with dysplastic Barrett's esophagus (BE) are lacking. METHODS We prospectively collected data from 2535 patients with BE (mean length, 5.2 cm; range, 1-20) and neoplasia (20% low-grade dysplasia, 54% high-grade dysplasia, 26% intramucosal carcinoma) who underwent RFA therapy across 28 UK hospitals. We assessed rates of invasive cancer and performed detailed analyses of 1175 patients to assess clearance rates of dysplasia (CR-D) and intestinal metaplasia (CR-IM) within 2 years of starting RFA therapy. We assessed relapses and rates of return to CR-D (CR-D2) and CR-IM (CR-IM2) after further therapy. CR-D and CR-IM were confirmed by an absence of dysplasia and intestinal metaplasia on biopsy samples taken at 2 consecutive endoscopies. RESULTS Ten years after starting treatment, the Kaplan-Meier (KM) cancer rate was 4.1% with a crude incidence rate of .52 per 100 patient-years. CR-D and CR-IM after 2 years of therapy were 88% and 62.6%, respectively. KM relapse rates were 5.9% from CR-D and 18.7% from CR-IM at 8 years, with most occurring in the first 2 years. Both were successfully retreated with rates of CR-D2 of 63.4% and CR-IM2 of 70.0% 2 years after retreatment. EMR before RFA increased the likelihood of rescue EMR from 17.2% to 41.7% but did not affect the rate of CR-D, whereas rescue EMR after RFA commenced reduced CR-D from 91.4% to 79.7% (χ2P < .001). CONCLUSIONS RFA treatment is effective and durable to prevent esophageal adenocarcinoma. Most treatment relapses occur early and can be successfully retreated.
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Affiliation(s)
- Paul Wolfson
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Kai Man Alexander Ho
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK; Gastrointestinal Services, University College London Hospital, London, UK
| | - Ash Wilson
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Hazel McBain
- Gastrointestinal Services, University College London Hospital, London, UK
| | - Aine Hogan
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Gideon Lipman
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Jason Dunn
- Division of Surgery and Interventional Sciences, University College London, London, UK
| | - Rehan Haidry
- Division of Surgery and Interventional Sciences, University College London, London, UK; Gastrointestinal Services, University College London Hospital, London, UK
| | - Marco Novelli
- Research Department of Pathology, Cancer Institute, University College London Hospital, London, UK
| | - Alessandro Olivo
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK
| | - Laurence B Lovat
- Wellcome/EPSRC Centre for Interventional & Surgical Sciences, University College London, London, UK; Division of Surgery and Interventional Sciences, University College London, London, UK; Gastrointestinal Services, University College London Hospital, London, UK
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8
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Paiji C, Sedarat A. Endoscopic Management of Esophageal Cancer. Cancers (Basel) 2022; 14:cancers14153583. [PMID: 35892840 PMCID: PMC9329770 DOI: 10.3390/cancers14153583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 07/18/2022] [Accepted: 07/20/2022] [Indexed: 02/04/2023] Open
Abstract
Advances in technology and improved understanding of the pathobiology of esophageal cancer have allowed endoscopy to serve a growing role in the management of this disease. Precursor lesions can be detected using enhanced diagnostic modalities and eradicated with ablation therapy. Furthermore, evolution in endoscopic resection has provided larger specimens for improved diagnostic accuracy and offer potential for cure of early esophageal cancer. In patients with advanced esophageal cancer, endoluminal therapy can improve symptom burden and provide therapeutic options for complications such as leaks, perforations, and fistulas. The purpose of this review article is to highlight the role of endoscopy in the diagnosis, treatment, and palliation of esophageal cancer.
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9
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Ten Kate CA, van Hal AFRL, Erler NS, Doukas M, Nikkessen S, Vlot J, IJsselstijn H, Wijnhoven BPL, Wijnen RMH, Spaander MCW. Recommendations for endoscopic surveillance after esophageal atresia repair in adults. Dis Esophagus 2022; 35:6509009. [PMID: 35034110 DOI: 10.1093/dote/doab095] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/13/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Endoscopic surveillance of adults with esophageal atresia is advocated, but the optimal surveillance strategy remains uncertain. This study aimed to provide recommendations on appropriate starting age and intervals of endoscopic surveillance in adults with esophageal atresia. METHODS Participants underwent standardized upper endoscopies with biopsies. Surveillance intervals of 3-5 years were applied, depending on age and histopathological results. Patient's age and time to development of (pre)malignant lesions were calculated. RESULTS A total of 271 patients with esophageal atresia (55% male; median age at baseline endoscopy 26.7 (range 15.6-68.5) years; colon interposition n = 17) were included. Barrett's esophagus was found in 19 (7%) patients (median age 32.3 (17.8-56.0) years at diagnosis). Youngest patient with a clinically relevant Barrett's esophagus was 20.9 years. Follow-up endoscopies were performed in 108 patients (40%; median follow-up time 4.6 years). During surveillance, four patients developed Barrett's esophagus but no dysplasia or cancer was found. One 45-year-old woman with a colon interposition developed an adenoma with high-grade dysplasia which was radically removed. Two new cases of esophageal carcinoma were diagnosed in patients (55 and 66 years old) who were not under surveillance. One of them had been curatively treated for esophageal carcinoma 13 years ago. CONCLUSIONS This study shows that endoscopic screening of patients with esophageal atresia, including those with a colon interposition, can be started at 20 years of age. Up to the age of 40 years a surveillance interval of 10 years appeared to be safe. Endoscopic surveillance may also be warranted for patients after curative esophageal cancer treatment.
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Affiliation(s)
- Chantal A Ten Kate
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Anne-Fleur R L van Hal
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Nicole S Erler
- Department of Biostatistics, Erasmus University Medical Center, Rotterdam, the Netherlands.,Department of Epidemiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Michail Doukas
- Department of Pathology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Suzan Nikkessen
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - John Vlot
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Hanneke IJsselstijn
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Bas P L Wijnhoven
- Department of Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - René M H Wijnen
- Department of Pediatric Surgery and Intensive Care, Erasmus MC Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Manon C W Spaander
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, the Netherlands
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10
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Maione F, Chini A, Maione R, Manigrasso M, Marello A, Cassese G, Gennarelli N, Milone M, De Palma GD. Endoscopic Diagnosis and Management of Barrett's Esophagus with Low-Grade Dysplasia. Diagnostics (Basel) 2022; 12:1295. [PMID: 35626450 PMCID: PMC9141542 DOI: 10.3390/diagnostics12051295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 02/05/2023] Open
Abstract
Barrett's Esophagus is a common condition associated with chronic gastroesophageal reflux disease. It is well known that it has an association with a higher incidence of esophageal adenocarcinoma, but this neoplastic transformation is first preceded by the onset of low and high-grade dysplasia. The evaluation of low grade dysplastic esophageal mucosa is still controversial; although endoscopic surveillance is preferred, several minimally invasive endoscopic therapeutic approaches are available. Endoscopic mucosal resection and radiofrequency ablation are the most used endoscopic treatments for the eradication of low-grade dysplasia, respectively, for nodular and flat dysplasia. Novel endoscopic treatments are cryotherapy ablation and argon plasma coagulation, that have good rates of eradication with less complications and post-procedural pain.
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Affiliation(s)
- Francesco Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Alessia Chini
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Rosa Maione
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Michele Manigrasso
- Department of Advanced Biomedical Sciences, University of Naples “Federico II”, 80131 Naples, Italy;
| | - Alessandra Marello
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Gianluca Cassese
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Nicola Gennarelli
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Marco Milone
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
| | - Giovanni Domenico De Palma
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80131 Naples, Italy; (A.C.); (A.M.); (G.C.); (N.G.); (M.M.); (G.D.D.P.)
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11
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Genere JR, Visrodia K, Zakko L, Hoefnagel SJM, Wang KK. Spray cryotherapy versus continued radiofrequency ablation in persistent Barrett's esophagus. Dis Esophagus 2022; 35:6512102. [PMID: 35059707 DOI: 10.1093/dote/doab084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 11/09/2021] [Indexed: 12/11/2022]
Abstract
Radiofrequency ablation (RFA) is the first-line treatment for flat Barrett's esophagus (BE) with dysplasia, however its role for persistent Barrett's esophagus (PBE) is unclear. PBE requires additional RFA sessions or application of cryotherapy to improve therapeutic response. We performed a retrospective cohort study evaluating cases of PBE treated by endoscopic eradication programs, with and without spray cryotherapy, and evaluated their safety and efficacy. We retrospectively identified patients with PBE, defined as ≤50% BE reduction or unchanged dysplasia after at least two RFA sessions. PBE was treated either by continued RFA (RFA Group) or converting to spray cryotherapy (CRYO Group), both followed by surveillance period. The rate of adverse events (AE), complete response of intestinal metaplasia (CRIM) and complete response of dysplasia (CRD) were recorded. A total of 46 patients, 23 per group, underwent 622 endoscopic therapies. Circumferential BE length was longer in the CRYO Group, but other baseline characteristics were similar, including maximal BE length. Esophageal strictures accounted for 14/16 total AE, 71% of which were RFA related, compared with 14% related to spray cryotherapy (P = 0.02). Overall CRIM/CRD rates in CRYO (83%) and RFA (96%) groups were not statistically different (P = 0.16), however cases in the CRYO Group required more treatment encounters (Median 19 vs. 12, P ≤ 0.01). Multimodal endotherapy is effective for eradicating PBE. Treatment programs incorporating spray cryotherapy are associated with less esophageal strictures but may require more treatment sessions to achieve eradication.
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Affiliation(s)
- Juan Reyes Genere
- Department of Medicine, Division of Gastroenterology, Washington University School of Medicine, Saint Louis, MO, USA
| | - Kavel Visrodia
- Department of Medicine, Division of Digestive and Liver Diseases, Columbia University Medical Center, New York, NY, USA
| | - Liam Zakko
- Connecticut Gastroenterology, Bristol, CT, USA
| | - Sanne J M Hoefnagel
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Kenneth K Wang
- Department of Medicine, Division of Gastroenterology and Hepatology, Mayo Clinic Rochester, Rochester, MN, USA
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12
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Zellenrath PA, Roumans CA, Spaander MC. Today’s Mistakes and Tomorrow’s Wisdom… In Barrett’s Surveillance. Visc Med 2022; 38:168-172. [DOI: 10.1159/000522376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/25/2022] [Indexed: 11/19/2022] Open
Abstract
<b><i>Background:</i></b> Barrett’s esophagus (BE) is the only known precursor lesion of esophageal adenocarcinoma, a malignancy with increasing incidence and poor survival rates. To reduce mortality, regular endoscopic surveillance of BE patients is recommended to detect neoplasia in an (endoscopically) curable stage. In this review, we aim to provide an overview of current BE surveillance strategies, its pitfalls, and potential future directions to optimize BE surveillance. <b><i>Summary:</i></b> Several societal guidelines provide surveillance strategies. However, when practicing those endoscopies multiple drawbacks are encountered. Important challenges are time-consuming biopsy protocols with low adherence rates, biopsy sampling error, interobserver variability in endoscopic detection of lesions, and interobserver variability in diagnosis of dysplasia. Furthermore, the overall efficacy and cost-effectiveness of surveillance are questioned. Using novel techniques, such as artificial intelligence and personalized surveillance intervals, can help to overcome these obstacles. <b><i>Key Messages:</i></b> Currently, there is room for improvement in BE surveillance. Better risk-stratification is expected to reduce both patient and healthcare burdens. Personalized and dynamic surveillance intervals accompanied by novel techniques in detection and histopathological assessment of dysplasia may be tools for a change in the right direction.
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13
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Ratcliffe E, Britton J, Hamdy S, McLaughlin J, Ang Y. Developing patient-orientated Barrett's oesophagus services: the role of dedicated services. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000829. [PMID: 35193888 PMCID: PMC8867250 DOI: 10.1136/bmjgast-2021-000829] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 01/09/2022] [Indexed: 11/03/2022] Open
Abstract
Introduction Barrett’s oesophagus (BO) is common and is a precursor to oesophageal adenocarcinoma with a 0.33% per annum risk of progression. Surveillance and follow-up services for BO have been shown to be lacking, with studies showing inadequate adherence to guidelines and patients reporting a need for greater disease-specific knowledge. This review explores the emerging role of dedicated services for patients with BO. Methods A literature search of PubMed, MEDLINE, Embase, Emcare, HMIC, BNI, CiNAHL, AMED and PsycINFO in regard to dedicated BO care pathways was undertaken. Results Prospective multicentre and randomised trials were lacking. Published cohort data are encouraging with improvements in guideline adherence with dedicated services, with one published study showing significant improvements in dysplasia detection rates. Accuracy of allocation to surveillance endoscopy has been shown to hold cost savings, and a study of a dedicated clinic showed increased discharges from unnecessary surveillance. Training modalities for BO surveillance and dysplasia detection exist, which could be used to educate a BO workforce. Qualitative and quantitative studies have shown patients report high levels of cancer worry and poor disease-specific knowledge, but few studies have explored follow-up care models despite being a patient and clinician priority for research. Conclusions Cost–benefit analysis for dedicated services, considering both financial and environmental impacts, and more robust clinical data must be obtained to support this model of care in the wider health service. Greater understanding is needed of the root causes for poor guideline adherence, and disease-specific models of care should be designed around clinical and patient-reported outcomes to address the unmet needs of patients with BO.
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Affiliation(s)
- Elizabeth Ratcliffe
- Gastroenterology, Wrightington Wigan and Leigh NHS Foundation Trust, Leigh, UK .,School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | - James Britton
- Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Shaheen Hamdy
- School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK.,Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - John McLaughlin
- School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK.,Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Yeng Ang
- School of Medical Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK.,Department of Gastroenterology, Northern Care Alliance NHS Foundation Trust, Salford, UK
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14
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Upper Gastrointestinal Cancer Surveillance in Lynch Syndrome. Cancers (Basel) 2022; 14:cancers14041000. [PMID: 35205747 PMCID: PMC8869779 DOI: 10.3390/cancers14041000] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/31/2022] [Accepted: 02/09/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary Lynch syndrome is the most common cause of hereditary colorectal cancer, but is also associated with increased extracolonic cancer risk, including upper gastrointestinal cancers. While there is agreement regarding the benefit of frequent colonoscopic surveillance in Lynch syndrome, there remains a lack of consensus on the use of upper gastrointestinal cancer surveillance. Here, we review the upper gastrointestinal cancer risks in Lynch syndrome, the varying guideline recommendations in this area, and the published outcomes of upper gastrointestinal cancer surveillance in this high-risk population. Finally, we highlight ongoing controversies in upper gastrointestinal cancer surveillance and opine on how upper gastrointestinal cancer surveillance can be incorporated into a Lynch syndrome risk management program. Upper gastrointestinal cancer surveillance is an increasingly studied area of risk management in Lynch syndrome, and continued research will be vital in determining how to best incorporate this surveillance in these high-risk patients. Abstract Lynch syndrome is a common hereditary cancer predisposition syndrome associated with increased digestive cancer risk including colorectal, gastric, and duodenal cancers. While colorectal cancer surveillance is widely accepted to be an important part of a comprehensive Lynch syndrome risk management plan, the use of upper gastrointestinal cancer surveillance in Lynch syndrome remains more controversial. Currently, upper gastrointestinal cancer surveillance guidelines for Lynch syndrome vary widely, and there is no consensus on who should undergo upper gastrointestinal cancer surveillance, how surveillance should be performed, the age at which to initiate surveillance, or how often individuals with Lynch syndrome should undergo upper gastrointestinal cancer surveillance. Fortunately, research groups around the world have been focusing on upper gastrointestinal cancer surveillance in Lynch syndrome, and recent evidence in this field has demonstrated that upper gastrointestinal cancer surveillance can be performed with identification of precancerous lesions as well as early-stage upper gastrointestinal cancers. In this manuscript, we review the upper gastrointestinal cancer risks in Lynch syndrome, differing guideline recommendations for surveillance, outcomes of upper gastrointestinal cancer surveillance, and controversies in the field, and we provide a framework based on our collective experience with which to incorporate upper gastrointestinal cancer surveillance into a risk management program for individuals with Lynch syndrome.
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15
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Saller J, Jiang K, Xiong Y, Yoder SJ, Neill K, Pimiento JM, Pena L, Corbett FS, Magliocco A, Coppola D. A microRNA Signature Identifies Patients at Risk of Barrett Esophagus Progression to Dysplasia and Cancer. Dig Dis Sci 2022; 67:516-523. [PMID: 33713247 PMCID: PMC9768694 DOI: 10.1007/s10620-021-06863-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 01/20/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Progression of Barrett esophagus (BE) to esophageal adenocarcinoma occurs among a minority of BE patients. To date, BE behavior cannot be predicted on the basis of histologic features. AIMS We compared BE samples that did not develop dysplasia or carcinoma upon follow-up of ≥ 7 years (BE nonprogressed [BEN]) with BE samples that developed carcinoma upon follow-up of 3 to 4 years (BE progressed [BEP]). METHODS The NanoString nCounter miRNA assay was used to profile 24 biopsy samples of BE, including 13 BENs and 11 BEPs. Fifteen samples were randomly selected for miRNA prediction model training; nine were randomly selected for miRNA validation. RESULTS Unpaired t tests with Welch's correction were performed on 800 measured miRNAs to identify the most differentially expressed miRNAs for cases of BEN and BEP. The top 12 miRNAs (P < .003) were selected for principal component analyses: miR-1278, miR-1301, miR-1304-5p, miR-517b-3p, miR-584-5p, miR-599, miR-103a-3p, miR-1197, miR-1256, miR-509-3-5p, miR-544b, miR-802. The 12-miRNA signature was first self-validated on the training dataset, resulting in 7 out of the 7 BEP samples being classified as BEP (100% sensitivity) and 7 out of the 8 BEN samples being classified as BEN (87.5% specificity). Upon validation, 4 out of the 4 BEP samples were classified as BEP (100% sensitivity) and 4 out of the 5 BEN samples were classified as BEN (80% specificity). Twenty-four samples were evaluated, and 22 cases were correctly classified. Overall accuracy was 91.67%. CONCLUSION Using miRNA profiling, we have identified a 12-miRNA signature able to reliably differentiate cases of BEN from BEP.
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Affiliation(s)
- James Saller
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Kun Jiang
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Yin Xiong
- Department of Biostatistics and Bioinformatics, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Sean J. Yoder
- Molecular Genomics Core Facility, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kevin Neill
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Jose M. Pimiento
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Luis Pena
- Department of Gastrointestinal Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - F. Scott Corbett
- Division of Florida Digestive Health Specialists, Gastroenterology Associates of Sarasota, Bradenton, FL, USA
| | - Anthony Magliocco
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612, USA
| | - Domenico Coppola
- Department of Anatomic Pathology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Dr., Tampa, FL 33612, USA,Division of Florida Digestive Health Specialists, Gastroenterology Associates of Sarasota, Bradenton, FL, USA,Department of Tumor Biology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA,Department of Chemical Biology and Molecular Medicine, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
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16
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Schmidt M, Hackett RJ, Baker AM, McDonald SAC, Quante M, Graham TA. Evolutionary dynamics in Barrett oesophagus: implications for surveillance, risk stratification and therapy. Nat Rev Gastroenterol Hepatol 2022; 19:95-111. [PMID: 34728819 DOI: 10.1038/s41575-021-00531-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 12/13/2022]
Abstract
Cancer development is a dynamic evolutionary process characterized by marked intratumoural heterogeneity at the genetic, epigenetic and phenotypic levels. Barrett oesophagus, the pre-malignant condition to oesophageal adenocarcinoma (EAC), is an exemplary system to longitudinally study the evolution of malignancy. Evidence has emerged of Barrett oesophagus lesions pre-programmed for progression to EAC many years before clinical detection, indicating a considerable window for therapeutic intervention. In this Review, we explore the mechanisms underlying clonal expansion and contraction that establish the Barrett oesophagus clonal mosaicism over time and space and discuss intrinsic genotypic and extrinsic environmental drivers that direct the evolutionary trajectory of Barrett oesophagus towards a malignant phenotype. We propose that understanding and exploiting the evolutionary dynamics of Barrett oesophagus will identify novel therapeutic targets, improve prognostic tools and offer the opportunity for personalized surveillance programmes geared to prevent progression to EAC.
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Affiliation(s)
- Melissa Schmidt
- Evolution and Cancer Laboratory, Centre for Genomics and Computational Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Department of Medicine II, Klinikum rechts der Isar, Technical University Munich (TUM), München, Germany
| | - Richard J Hackett
- Clonal Dynamics in Epithelia Group; Centre for Genomics and Computational Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Ann-Marie Baker
- Evolution and Cancer Laboratory, Centre for Genomics and Computational Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stuart A C McDonald
- Clonal Dynamics in Epithelia Group; Centre for Genomics and Computational Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Michael Quante
- Department of Medicine II, Klinikum rechts der Isar, Technical University Munich (TUM), München, Germany
- Department of Medicine II, Universitaetsklinikum Freiburg, Freiburg, Germany
| | - Trevor A Graham
- Evolution and Cancer Laboratory, Centre for Genomics and Computational Biology, Barts Cancer Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK.
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17
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Chang K, Jackson CS, Vega KJ. Barrett's Esophagus: Diagnosis, Management, and Key Updates. Gastroenterol Clin North Am 2021; 50:751-768. [PMID: 34717869 DOI: 10.1016/j.gtc.2021.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Barrett's esophagus (BE) is the precursor lesion for esophageal adenocarcinoma (EAC) development. Unfortunately, BE screening/surveillance has not provided the anticipated EAC reduction benefit. Noninvasive techniques are increasingly available or undergoing testing to screen for BE among those with/without known risk factors, and the use of artificial intelligence platforms to aid endoscopic screening and surveillance will likely become routine, minimizing missed cases or lesions. Management of high-grade dysplasia and intramucosal EAC is clear with endoscopic eradication therapy preferred to surgery. BE with low-grade dysplasia can be managed with removal of visible lesions combined with endoscopic eradication therapy or endoscopic surveillance at present.
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Affiliation(s)
- Karen Chang
- Department of Internal Medicine, University of California, Riverside School of Medicine, 900 University Avenue, Riverside, CA 92521, USA
| | - Christian S Jackson
- Section of Gastroenterology, Loma Linda VA Healthcare System, 11201 Benton Street, 2A-38, Loma Linda, CA 92357, USA
| | - Kenneth J Vega
- Division of Gastroenterology & Hepatology, Augusta University-Medical College of Georgia, 1120 15th Street, AD-2226, Augusta, GA 30912, USA.
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18
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Saito M, Koike T, Ohara Y, Nakagawa K, Kanno T, Jin X, Hatta W, Uno K, Asano N, Imatani A, Masamune A. Linked-color Imaging May Help Improve the Visibility of Superficial Barrett's Esophageal Adenocarcinoma by Increasing the Color Difference. Intern Med 2021; 60:3351-3358. [PMID: 34719622 PMCID: PMC8627822 DOI: 10.2169/internalmedicine.6674-20] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 03/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Linked-color imaging (LCI), a new technology for image-enhanced endoscopy, emphasizes the color of the mucosa, and its practicality in the detection of early gastric and colon cancers has been reported. However, whether or not LCI is useful for the diagnosis of Barrett's adenocarcinoma (BA) has been unclear. In this study, we explored whether or not LCI enhances the color difference between a BA lesion and the surrounding mucosa. Methods Twenty-one lesions from 20 consecutive patients with superficial BA who underwent endoscopic submucosal dissection between November 2014 and September 2017 were retrospectively examined. The color differences (ΔE*) between the inside and outside of the lesion were evaluated retrospectively using white-light imaging (WLI), blue-light imaging (BLI), and LCI objectively, based on a Commission Internationale de l'Eclairage (CIE) lab color system. Furthermore, we compared the morphology, color, and circumferential location of the lesion. Results The median values of the color difference (ΔE*) in WLI and BLI were 9.1 and 5.8, respectively, and no difference was observed. In LCI, the median color difference was 17.6, which was higher than that of WLI and BLI. Regardless of the morphology, color, and circumferential location of BA lesions, the color difference was larger in LCI than in WLI. Conclusion LCI increases the color difference between the BA and the surrounding Barrett's mucosa.
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Affiliation(s)
- Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
- Tohoku University Tohoku Medical-Megabank Organization, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Yuki Ohara
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kenichiro Nakagawa
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Takeshi Kanno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Xiaoyi Jin
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Waku Hatta
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Akira Imatani
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan
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19
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Condon A, Muthusamy VR. The evolution of endoscopic therapy for Barrett's esophagus. Ther Adv Gastrointest Endosc 2021; 14:26317745211051834. [PMID: 34708204 PMCID: PMC8543722 DOI: 10.1177/26317745211051834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 09/21/2021] [Indexed: 12/20/2022] Open
Abstract
Barrett’s esophagus is the condition in which a metaplastic columnar epithelium
replaces the stratified squamous epithelium that normally lines the distal
esophagus. The condition develops as a consequence of chronic gastroesophageal
reflux disease and predisposes the patient to the development of esophageal
adenocarcinoma. The diagnosis and management of Barrett’s esophagus have
undergone dramatic changes over the years and continue to evolve today.
Endoscopic eradication therapy has revolutionized the management of dysplastic
Barrett’s esophagus and early esophageal adenocarcinoma by significantly
reducing the morbidity and mortality associated with the prior gold standard of
therapy, esophagectomy. The purpose of this review is to highlight current
principles in the management and endoscopic treatment of this disease.
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Affiliation(s)
- Ashwinee Condon
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - V Raman Muthusamy
- Vatche & Tamar Manoukian Division of Digestive Diseases, David Geffen School of Medicine, UCLA, 200 UCLA Medical Plaza, Room 330-37, Los Angeles, CA 90095, USA
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20
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Hajelssedig OE, Zorron Cheng Tao Pu L, Thompson JY, Lord A, El Sayed I, Meyer C, Shaukat Ali F, Abdulazeem HM, Kheir AO, Siepmann T, Singh R. Diagnostic accuracy of narrow-band imaging endoscopy with targeted biopsies compared with standard endoscopy with random biopsies in patients with Barrett's esophagus: A systematic review and meta-analysis. J Gastroenterol Hepatol 2021; 36:2659-2671. [PMID: 34121232 DOI: 10.1111/jgh.15577] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 01/09/2021] [Accepted: 06/08/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM Endoscopic surveillance for dysplasia in Barrett's esophagus (BE) with random biopsies is the primary diagnostic tool for monitoring clinical progression into esophageal adenocarcinoma. As an alternative, narrow-band imaging (NBI) endoscopy offers targeted biopsies that can improve dysplasia detection. This study aimed to evaluate NBI-guided targeted biopsies' diagnostic accuracy for detecting dysplasia in patients undergoing endoscopic BE surveillance compared with the widely used Seattle protocol. METHODS Cochrane DTA Register, MEDLINE/PubMed, EMBASE, OpenGrey, and bibliographies of identified papers were searched until 2018. Two independent investigators resolved discrepancies by consensus, study selection, data extraction, and quality assessment. Data on sensitivity, specificity, and predictive values were pooled and analyzed using a random-effects model. RESULTS Of 9528 identified articles, six studies comprising 493 participants were eligible for quantitative synthesis. NBI-targeted biopsy showed high diagnostic accuracy in detection of dysplasia in BE with a sensitivity of 76% (95% confidence interval [CI]: 0.61-0.91), specificity of 99% (95% CI: 0.99-1.00), positive predictive value of 97% (95% CI: 0.96-0.99), and negative predictive value of 84% (95% CI: 0.69-0.99) for detection of all grades of dysplasia. The receiver-operating characteristic curve for NBI model performance was 0.8550 for detecting all dysplasia. CONCLUSION Narrow-band imaging-guided biopsy demonstrated high diagnostic accuracy and might constitute a valid substitute for random biopsies during endoscopic surveillance for dysplasia in BE.
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Affiliation(s)
- Omer Eljyli Hajelssedig
- Master Program of Clinical Research, Dresden International University, Dresden, Germany
- DRESDEN INTERNATIONAL UNIVERSITAET (Freiberger Str. 37, 01067 Dresden, Germany)
| | | | | | - Anton Lord
- Gut Health Lab, Immunology Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Iman El Sayed
- Department of Biomedical Informatics and Medical Statistics, Medical Research Institute, Alexandria University, Alexandria, Egypt
| | - Chase Meyer
- Department of Internal Medicine, The University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Faisal Shaukat Ali
- Department of Internal Medicine, Saint Joseph Hospital, Chicago, Illinois, USA
| | | | - Ammar O Kheir
- Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, UAE
| | - Timo Siepmann
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Center for Clinical Research and Management Education, Division of Health Care Sciences, Dresden International University, Dresden, Germany
| | - Rajvinder Singh
- Department of Gastroenterology, The Lyell McEwin Hospital, Adelaide, South Australia, Australia
- The University of Adelaide, Adelaide, South Australia, Australia
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21
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Zagari RM, Eusebi LH, Galloro G, Rabitti S, Neri M, Pasquale L, Bazzoli F. Attending Training Courses on Barrett's Esophagus Improves Adherence to Guidelines: A Survey from the Italian Society of Digestive Endoscopy. Dig Dis Sci 2021; 66:2888-2896. [PMID: 32984930 PMCID: PMC8379114 DOI: 10.1007/s10620-020-06615-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little is known on practice patterns of endoscopists for the management of Barrett's esophagus (BE) over the last decade. AIMS Our aim was to assess practice patterns of endoscopists for the diagnosis, surveillance and treatment of BE. METHODS All members of the Italian Society of Digestive Endoscopy (SIED) were invited to participate to a questionnaire-based survey. The questionnaire included questions on demographic and professional characteristics, and on diagnosis and management strategies for BE. RESULTS Of the 883 SIED members, 259 (31.1%) completed the questionnaire. Of these, 73% were males, 42.9% had > 50 years of age and 68.7% practiced in community hospitals. The majority (82.9%) of participants stated to use the Prague classification; however 34.5% did not use the top of gastric folds to identify the gastro-esophageal junction (GEJ); only 51.4% used advanced endoscopy imaging routinely. Almost all respondents practiced endoscopic surveillance for non-dysplastic BE, but 43.7% performed eradication in selected cases and 30% practiced surveillance every 1-2 years. The majority of endoscopists managed low-grade dysplasia with surveillance (79.1%) and high-grade dysplasia with ablation (77.1%). Attending a training course on BE in the previous 5 years was significantly associated with the use of the Prague classification (OR 4.8, 95% CI 1.9-12.1), the top of gastric folds as landmark for the GEJ (OR 2.45, 95% CI 1.27-4.74) and advanced imaging endoscopic techniques (OR 3.33, 95% CI 1.53-7.29). CONCLUSIONS Practice patterns for management of BE among endoscopists are variable. Attending training courses on BE improves adherence to guidelines.
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Affiliation(s)
- Rocco Maurizio Zagari
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy.
| | - Leonardo Henry Eusebi
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy
| | - Giuseppe Galloro
- Surgical Digestive Endoscopy, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
| | - Stefano Rabitti
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy
| | - Matteo Neri
- Department of Medicine and Aging Science, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | - Luigi Pasquale
- Gastroenterology Unit, San Giuseppe Moscati Hospital, Ariano Irpino, Avellino, Italy
| | - Franco Bazzoli
- Department of Medical and Surgical Sciences, University of Bologna, Policlinico S. Orsola-Malpighi, Via Massarenti n. 9, 40138, Bologna, Italy
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22
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Peleg N, Schmilovitz-Weiss H, Shamah S, Schwartz A, Dotan I, Sapoznikov B. Neutrophil to lymphocyte ratio and risk of neoplastic progression in patients with Barrett's esophagus. Endoscopy 2021; 53:774-781. [PMID: 33075822 DOI: 10.1055/a-1292-8747] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patient's with Barrett's esophagus (BE) are at risk of progression to esophageal adenocarcinoma (EAC). Neutrophil to lymphocyte ratio (NLR) was found to be a predictor of poor prognosis in patients with EAC; however, its performance in premalignant esophageal lesions is vague. We aimed to evaluate the utility of NLR as a predictor of histologic progression in patients with BE. METHODS : A prospective cohort of patients with proven BE in a tertiary referral center was retrospectively analyzed. All biopsies were reviewed by an expert gastrointestinal pathologist. The discriminatory capacity of NLR was evaluated by area under the receiver operating characteristic (AUC) curve analysis and Cox regression analysis. RESULTS 324 patients (mean age 62.3 years, 241 [74.4 %] males) were included in the final analysis. Overall, 13 patients demonstrated histologic progression to neoplasia over a mean follow-up of 3.7 years (progression risk 1.0 % per year). The AUC of NLR for progression to high grade dysplasia (HGD) or EAC was 0.88 (95 % confidence interval [CI] 0.83 - 0.96), and baseline NLR was associated with a 3-fold increase of progression to HGD and EAC during follow-up (hazard ratio [HR] 3.2, 95 %CI 1.5 - 5.8; P < 0.001). Notably, in a subgroup analysis of patients with nondysplastic BE (NDBE) at presentation, NLR was also a risk factor for histologic progression (HR 2.4, 95 %CI 1.7 - 3.4; P < 0.001). CONCLUSION NLR predicted histologic progression in patients with BE. Patients with NDBE and NLR above 2.4 can be considered for specific surveillance programs with shorter intervals between sessions.
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Affiliation(s)
- Noam Peleg
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hemda Schmilovitz-Weiss
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Steven Shamah
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ariel Schwartz
- Department of Pathology, Rabin Medical Center, Petah-Tikva, Israel
| | - Iris Dotan
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boris Sapoznikov
- Division of Gastroenterology, Rabin Medical Center, Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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23
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Kawahara D, Murakami Y, Tani S, Nagata Y. A prediction model for degree of differentiation for resectable locally advanced esophageal squamous cell carcinoma based on CT images using radiomics and machine-learning. Br J Radiol 2021; 94:20210525. [PMID: 34235955 DOI: 10.1259/bjr.20210525] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To propose the prediction model for degree of differentiation for locally advanced esophageal cancer patients from the planning CT image by radiomics analysis with machine learning. METHODS Data of 104 patients with esophagus cancer, who underwent chemoradiotherapy followed by surgery at the Hiroshima University hospital from 2003 to 2016 were analyzed. The treatment outcomes of these tumors were known prior to the study. The data were split into 3 sets: 57/16 tumors for the training/validation and 31 tumors for model testing. The degree of differentiation of squamous cell carcinoma was classified into two groups. The first group (Group I) was a poorly differentiated (POR) patients. The second group (Group II) was well and moderately differentiated patients. The radiomics feature was extracted in the tumor and around the tumor regions. A total number of 3480 radiomics features per patient image were extracted from radiotherapy planning CT scan. Models were built with the least absolute shrinkage and selection operator (LASSO) logistic regression and applied to the set of candidate predictors. The radiomics features were used for the input data in the machine learning. To build predictive models with radiomics features, neural network classifiers was used. The precision, accuracy, sensitivity by generating confusion matrices, the area under the curve (AUC) of receiver operating characteristic curve were evaluated. RESULTS By the LASSO analysis of the training data, we found 13 radiomics features from CT images for the classification. The accuracy of the prediction model was highest for using only CT radiomics features. The accuracy, specificity, and sensitivity of the predictive model were 85.4%, 88.6%, 80.0%, and the AUC was 0.92. CONCLUSION The proposed predictive model showed high accuracy for the classification of the degree of the differentiation of esophagus cancer. Because of the good prediction ability of the method, the method may contribute to reducing the pathological examination by biopsy and predicting the local control. ADVANCES IN KNOWLEDGE For esophageal cancer, the differentiation of degree is the import indexes reflecting the aggressiveness. The current study proposed the prediction model for the differentiation of degree with radiomics analysis.
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Affiliation(s)
- Daisuke Kawahara
- Department of Radiation Oncology, Graduate School of Biomedical Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Yuji Murakami
- Department of Radiation Oncology, Graduate School of Biomedical Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shigeyuki Tani
- School of Medicine, Hiroshima University, Hiroshima, Japan
| | - Yasushi Nagata
- Department of Radiation Oncology, Graduate School of Biomedical Health Sciences, Hiroshima University, Hiroshima, Japan.,Hiroshima High-Precision Radiotherapy Cancer Center, Hiroshima, Japan
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24
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Dhaliwal L, Codipilly DC, Gandhi P, Johnson ML, Lansing R, Wang KK, Leggett CL, Katzka DA, Iyer PG. Neoplasia Detection Rate in Barrett's Esophagus and Its Impact on Missed Dysplasia: Results from a Large Population-Based Database. Clin Gastroenterol Hepatol 2021; 19:922-929.e1. [PMID: 32707339 PMCID: PMC7854811 DOI: 10.1016/j.cgh.2020.07.034] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/12/2020] [Accepted: 07/16/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS It is a challenge to detect dysplasia in Barrett's esophagus (BE) and esophageal adenocarcinomas (EACs) are missed in 25%-33% of cases. The neoplasia detection rate (NDR), defined as the rate of high-grade dysplasia (HGD) or EAC detection during initial surveillance endoscopy, has been proposed as a quality metric for endoscopic evaluation of patients with BE. However, current estimates are from referral center cohorts, which might overestimate NDR. Effects on rates of missed dysplasia are also unknown. We analyzed data from a large cohort of patients with BE to estimate the NDR and factors associated with it, and assess the effects of the NDR on the rate of missed dysplasia. METHODS We analyzed data from 1066 patients in the Rochester Epidemiology Project-linked medical record system, a population-based cohort of patients with BE (confirmed by review of the endoscopic and histologic reports) from 11 southeastern Minnesota counties from 1991 through 2019. Biopsies reported to contain dysplasia were confirmed by expert gastrointestinal pathologists. The NDR was calculated as the rate of HGD or EAC detected by histologic analyses of biopsies collected during the first surveillance endoscopy. Patients without HGD or EAC at their initial endoscopy (n = 391) underwent repeat endoscopy within 12 months; HGD or EAC detected at the repeat endoscopy were considered to be missed on index endoscopy. Factors associated with NDR and missed dysplasia were identified using univariate and multivariate logistic regression models. RESULTS The NDR was 4.9% (95% CI, 3.8-6.4); 3.1% of patients had HGD, 1.8% had EAC, and 10.6% had low-grade dysplasia. Factors associated with higher rates of detection of neoplasia included older age, male sex, smoking, increasing length of BE, and surveillance endoscopies by gastroenterologists. This NDR was associated with a substantially lower rate of missed dysplasia (13%). CONCLUSIONS In an analysis of 1066 patients with BE in a population-based cohort, we found a lower NDR and lower rate of missed dysplasia than previously reported. NDR may have value as a quality metric in BE surveillance if validated in other cohorts.
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Affiliation(s)
- Lovekirat Dhaliwal
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - D Chamil Codipilly
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Parth Gandhi
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Michele L Johnson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Ramona Lansing
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kenneth K Wang
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Cadman L Leggett
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - David A Katzka
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota.
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25
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Kew GS, Soh AYS, Lee YY, Gotoda T, Li YQ, Zhang Y, Chan YH, Siah KTH, Tong D, Law SYK, Ruszkiewicz A, Tseng PH, Lee YC, Chang CY, Quach DT, Kusano C, Bhatia S, Wu JCY, Singh R, Sharma P, Ho KY. Multinational survey on the preferred approach to management of Barrett's esophagus in the Asia-Pacific region. World J Gastrointest Oncol 2021; 13:279-294. [PMID: 33889279 PMCID: PMC8040063 DOI: 10.4251/wjgo.v13.i4.279] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 12/31/2020] [Accepted: 03/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Major societies provide differing guidance on management of Barrett's esophagus (BE), making standardization challenging. AIM To evaluate the preferred diagnosis and management practices of BE among Asian endoscopists. METHODS Endoscopists from across Asia were invited to participate in an online questionnaire comprising eleven questions regarding diagnosis, surveillance and management of BE. RESULTS Five 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). CONCLUSION Diagnosis 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.
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Affiliation(s)
- Guan Sen Kew
- Department of Gastroenterology and Hepatology, University Medicine Cluster, National University Health System, Singapore 119228, Singapore
| | - Alex Yu Sen Soh
- Department of Gastroenterology and Hepatology, National University Hospital, National University Health System, Singapore 119074, Singapore
| | - Yeong Yeh Lee
- School of Medical Sciences, Universiti Sains Malaysia, Penang 11800, Malaysia
| | - Takuji Gotoda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Yan-Qing Li
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yan Zhang
- Department of Gastroenterology, Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
| | - Yiong Huak Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore 119228, Singapore
| | - Kewin Tien Ho Siah
- Department of Gastroenterology and Hepatology, University Medicine Cluster, National University Health System, Singapore 119228, Singapore
| | - Daniel Tong
- Department of Surgery, The University of Hong Kong, Hong Kong Pokfulam, Hong Kong, China
| | - Simon Ying Kit Law
- Department of Surgery, The University of Hong Kong, Hong Kong Pokfulam, Hong Kong, China
| | | | - Ping-Huei Tseng
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Yi-Chia Lee
- Department of Internal Medicine, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Chi-Yang Chang
- Department of Internal Medicine, Fu Jen Catholic University Hospital, Taipei 24352, Taiwan
| | - Duc Trong Quach
- Department of Internal Medicine, University of Medicine and Pharmacy at Hochiminh City, Vietnam, Hochiminh 70000, Viet Nam
| | - Chika Kusano
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo 173-8610, Japan
| | - Shobna Bhatia
- Department of Gastroenterology, Seth GS Medical College and King Edward Memorial Hospital, Mumbai 400012, India
| | - Justin Che-Yuen Wu
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Rajvinder Singh
- Department of Gastroenterology, Lyell McEwin Hospital, University of Adelaide, Adelaide 64128, Australia
| | - Prateek Sharma
- Department of Gastroenterology and Hepatology, Kansas City VA Medical Center, Kansas City, KS 64128, United States
| | - Khek-Yu Ho
- Department of Medicine, National University Hospital, Singapore 119074, Singapore
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26
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Fraser-Miller SJ, Rooney JS, Lau M, Gordon KC, Schultz M. Can Coupling Multiple Complementary Methods Improve the Spectroscopic Based Diagnosis of Gastrointestinal Illnesses? A Proof of Principle Ex Vivo Study Using Celiac Disease as the Model Illness. Anal Chem 2021; 93:6363-6374. [PMID: 33844904 DOI: 10.1021/acs.analchem.0c04963] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Spectroscopic methods are a promising approach for providing a point-of-care diagnostic method for gastrointestinal mucosa associated illnesses. Such a tool is desired to aid immediate decision making and to provide a faster pathway to appropriate treatment. In this pilot study, Raman, near-infrared, low frequency Raman, and autofluoresence spectroscopic methods were explored alone and in combination for the diagnosis of celiac disease. Duodenal biopsies (n = 72) from 24 participants were measured ex vivo using the full suite of studied spectroscopic methods. Exploratory principal component analysis (PCA) highlighted the origin of spectral differences between celiac and normal tissue with celiac biopsies tending to have higher protein relative to lipid signals and lower carotenoid spectral signals than the samples with normal histology. Classification of the samples based on the histology and overall diagnosis was carried out for all combinations of spectroscopic methods. Diagnosis based classification (majority rule of class per participant) yielded sensitivities of 0.31 to 0.77 for individual techniques, which was increased up to 0.85 when coupling multiple techniques together. Likewise, specificities of 0.50 to 0.67 were obtained for individual techniques, which was increased up to 0.78 when coupling multiple techniques together. It was noted that the use of antidepressants contributed to false positives, which is believed to be associated with increased serotonin levels observed in the gut mucosa in both celiac disease and the use of selective serotonin reuptake inhibitors (SSRIs); however, future work with greater numbers is required to confirm this observation. Inclusion of two additional spectroscopic methods could improve the accuracy of diagnosis (0.78) by 7% over Raman alone (0.73). This demonstrates the potential for further exploration and development of a multispectroscopic system for disease diagnosis.
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Affiliation(s)
- Sara J Fraser-Miller
- Dodd-Walls Centre for Photonic and Quantum Technologies, Department of Chemistry, University of Otago, Dunedin 9054, New Zealand
| | - Jeremy S Rooney
- Dodd-Walls Centre for Photonic and Quantum Technologies, Department of Chemistry, University of Otago, Dunedin 9054, New Zealand
| | - Michael Lau
- Southern Community Laboratories, Dunedin 9016, New Zealand
| | - Keith C Gordon
- Dodd-Walls Centre for Photonic and Quantum Technologies, Department of Chemistry, University of Otago, Dunedin 9054, New Zealand
| | - Michael Schultz
- Gastroenterology Research Unit, Department of Medicine, Dunedin School of Medicine, University of Otago, Dunedin 9054, New Zealand.,Mercy Hospital, Dunedin 9010, New Zealand.,Gastroenterology Department, Southern District Health Board, Dunedin 9016, New Zealand
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27
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Endoscopic Resection Without Subsequent Ablation Therapy for Early Barrett's Neoplasia: Endoscopic Findings and Long-Term Mortality. J Gastrointest Surg 2021; 25:67-76. [PMID: 33140322 PMCID: PMC7851009 DOI: 10.1007/s11605-020-04836-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 10/17/2020] [Indexed: 01/31/2023]
Abstract
INTRODUCTION After endoscopic resection (ER) of neoplasia in Barrett's esophagus (BE), it is recommended to ablate the remaining BE to minimize the risk for metachronous disease. However, we report long-term outcomes for a nationwide cohort of all patients who did not undergo ablation of the remaining BE after ER for early BE neoplasia, due to clinical reasons or performance status. METHODS Endoscopic therapy for BE neoplasia in the Netherlands is centralized in 8 expert centers with specifically trained endoscopists and pathologists. Uniformity is ensured by a joint protocol and regular group meetings. We report all patients who underwent ER for a neoplastic lesion between 2008 and 2018, without further ablation therapy. Outcomes include progression during endoscopic FU and all-cause mortality. RESULTS Ninety-four patients were included with mean age 74 (± 10) years. ER was performed for low-grade dysplasia (LGD) (10%), high-grade dysplasia (HGD) (25%), or low-risk esophageal adenocarcinoma (EAC) (65%). No additional ablation was performed for several reasons; in 73 patients (78%), the main argument was expected limited life expectancy. Median C2M5 BE persisted after ER, and during median 21 months (IQR 11-51) with 4 endoscopies per patient, no patient progressed to advanced cancer. Seventeen patients (18%) developed HGD/EAC: all were curatively treated endoscopically. In total, 29/73 patients (40%) with expected limited life expectancy died due to unrelated causes during FU, none of EAC. CONCLUSION In selected patients, ER monotherapy with endoscopic surveillance of the residual BE is a valid alternative to eradication therapy with ablation.
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28
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Role of Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in the Management of Barrett's Related Neoplasia. Gastrointest Endosc Clin N Am 2021; 31:171-182. [PMID: 33213794 DOI: 10.1016/j.giec.2020.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Endoscopic resection has been proven to be safe and highly effective for removing early neoplastic lesions in Barrett esophagus. It enables accurate histopathological assessment and is therefore considered as the cornerstone in the endoscopic work-up for patients with Barrett neoplasia. Various techniques are available to perform endoscopic resection. Multiband mucosectomy is the most commonly used resection technique. However, endoscopic submucosal dissection is gaining ground in the Western world. Endoscopic resection for low-risk submucosal lesions already is fully justified. Future studies have to point out whether endoscopic resection and subsequent follow-up are also justified in selected patients with high-risk submucosal tumors.
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29
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Kumarasinghe MP, Armstrong M, Foo J, Raftopoulos SC. The modern management of Barrett's oesophagus and related neoplasia: role of pathology. Histopathology 2020; 78:18-38. [PMID: 33382493 DOI: 10.1111/his.14285] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 10/14/2020] [Accepted: 10/21/2020] [Indexed: 12/13/2022]
Abstract
Modern management of Barrett's oesophagus and related neoplasia essentially focuses upon surveillance to detect early low-risk neoplastic lesions and offering organ-preserving advanced endoscopic therapies, while traditional surgical treatments of oesophagectomy and lymph node clearance with or without chemoradiation are preserved only for high-risk and advanced carcinomas. With this evolution towards figless invasive therapy, the choice of therapy hinges upon the pathological assessment for risk stratifying patients into those with low risk for nodal metastasis who can continue with less invasive endoscopic therapies and others with high risk for nodal metastasis for which surgery or other forms of treatment are indicated. Detection and confirmation of neoplasia in the first instance depends upon endoscopic and pathological assessment. Endoscopic examination and biopsy sampling should be performed according to the recommended protocols, and endoscopic biopsy interpretation should be performed applying standard criteria using appropriate ancillary studies by histopathologists experienced in the pathology of Barrett's disease. Endoscopic resections (ERs) are both diagnostic and curative and should be performed by clinicians who are skilled with advanced endoscopic techniques. Proper preparation and handling of ERs are essential to assess histological parameters that dictate the curative nature of the procedure. Those parameters are adequacy of resection and risk of lymph node metastasis. The risk of lymph node metastasis is determined by depth invasion and presence of poor differentiation and lymphovascular invasion. Those adenocarcinomas with invasion up to muscularis mucosae (pT1a) and those with superficial submucosal invasion (pT1b) up to 500 µ with no poor differentiation and lymphovascular invasion and negative margins may be considered cured by endoscopic resections.
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Affiliation(s)
- M Priyanthi Kumarasinghe
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Michael Armstrong
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Jonathan Foo
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
| | - Spiro C Raftopoulos
- PathWest and Clinipath Laboratories and Sir Charles Gairdner Hospital, QEII Medical Centre, Perth, 6009, WA, Australia
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30
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Han C, Li P, Guo Z, Guo Y, Sun L, Chen G, Qiu X, Mi W, Zhang C, Berra L. Improving mucosal anesthesia for awake endotracheal intubation with a novel method: a prospective, assessor-blinded, randomized controlled trial. BMC Anesthesiol 2020; 20:301. [PMID: 33317460 PMCID: PMC7734729 DOI: 10.1186/s12871-020-01210-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/22/2020] [Indexed: 11/17/2022] Open
Abstract
Background Topical anesthesia is a crucial step in awake endotracheal intubation for providing favorable intubation conditions. The standard of care technique for awake intubation at our institution, which consists of oropharyngeal tetracaine spray, can result in inadequate mucosal anesthesia. Therefore, we sought to compare the effectiveness of dyclonine hydrochloride mucilage to the standard of care tetracaine in achieving anesthesia of the upper airways for awake endotracheal intubation. Methods This is a randomized, assessor-blinded, prospective study. From Jun. 1st, 2019 to Aug. 1st, 2019, patients scheduled for either endoscopic submucosal dissection or peroral endoscopic myotomy were enrolled and randomly allocated into two groups after obtaining written informed consent: patients allocated to novel awake intubation care (Group N-AIC) received a single administration of oral dyclonine hydrochloride mucilage, whereas patients allocated to standard awake intubation care (Group S-AIC) received three oropharyngeal tetracaine sprays before transcricoid tetracaine injection before awake intubation. Mean arterial pressure (MAP), which was the primary outcome of this study, as well as heart rate (HR) were recorded throughout the procedure and compared between the two groups. Feeling of numbness, nausea, and intubation conditions after topical anesthesia were also assessed. Results Sixty patients were enrolled and completed the study. Baseline MAP and HR were similar between the two groups. However, hemodynamic responses to intubation and gastrointestinal endoscopy, especially MAP, were significantly less elevated in Group N-AIC. The degree of numbness of the oropharyngeal mucosa after topical anesthesia did not differ between the two groups, neither did the feeling of nausea during laryngoscopy. The amount of pharyngeal secretions before intubation was less in Group N-AIC. Total intubation time was significantly shorter in Group N-AIC when compared to Group S-AIC (18.4 ± 2.86 vs. 22.3 ± 6.47, P < 0.05). Extubation bucking was significantly less frequent in Group N-AIC (13.3% vs. 76.7%). Patients received in Group N-AIC had a lower rate of post-extubation sore throat compared to Group S-AIC (6.7% vs. 43.3%). No adverse side effects attributable to either tetracaine or dyclonine were observed in this study. Conclusions In awake endotracheal intubation, novel care using oral dyclonine hydrochloride mucilage can provide more favorable mucosal anesthesia and better intubation conditions compared to standard of care practice using oropharyngeal tetracaine spray. Trial registration ChiCTR1900023151. Date of registration: May 14th, 2019. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-020-01210-8.
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Affiliation(s)
- Chunji Han
- Anesthesia and Operation Center, The First Medical Center of Chinese PLA General Hospital, 28th Fuxing Rd., Haidian District, Beijing, 100853, P. R. China
| | - Peng Li
- Department of Anesthesia, The Sixth Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Zhenggang Guo
- Department of Anesthesiology, Peking University Shougang Hospital, Beijing, 100144, China
| | - Ying Guo
- Anesthesia and Operation Center, The First Medical Center of Chinese PLA General Hospital, 28th Fuxing Rd., Haidian District, Beijing, 100853, P. R. China
| | - Li Sun
- Anesthesia and Operation Center, The First Medical Center of Chinese PLA General Hospital, 28th Fuxing Rd., Haidian District, Beijing, 100853, P. R. China
| | - Gang Chen
- Anesthesia and Operation Center, The First Medical Center of Chinese PLA General Hospital, 28th Fuxing Rd., Haidian District, Beijing, 100853, P. R. China
| | - Xiaojue Qiu
- Department of Gastroenterology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weidong Mi
- Anesthesia and Operation Center, The First Medical Center of Chinese PLA General Hospital, 28th Fuxing Rd., Haidian District, Beijing, 100853, P. R. China
| | - Changsheng Zhang
- Anesthesia and Operation Center, The First Medical Center of Chinese PLA General Hospital, 28th Fuxing Rd., Haidian District, Beijing, 100853, P. R. China.
| | - Lorenzo Berra
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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31
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Chen T, Lin R, Wang W, Lee C, Tseng C, Hsu W, Tai W, Wang H, Chang C. Validation of simplified classification of magnifying endoscopy for diagnosis of Barrett's dysplasia with blue laser imaging. ADVANCES IN DIGESTIVE MEDICINE 2020. [DOI: 10.1002/aid2.13233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Tzu‐Haw Chen
- Department of Internal Medicine E‐Da Hospital/I‐Shou University Kaohsiung Taiwan
| | - Ro‐Ting Lin
- Department of Occupational Safety and Health China Medical University Taichung Taiwan
| | - Wen‐Lun Wang
- Department of Internal Medicine E‐Da Hospital/I‐Shou University Kaohsiung Taiwan
| | - Ching‐Tai Lee
- Department of Internal Medicine E‐Da Hospital/I‐Shou University Kaohsiung Taiwan
| | - Cheng‐Hao Tseng
- Department of Internal Medicine E‐Da Hospital/I‐Shou University Kaohsiung Taiwan
| | - Wen‐Hung Hsu
- Department of Internal Medicine Kaohsiung Medical University Hospital Kaohsiung Taiwan
| | - Wei‐Chen Tai
- Department of Internal Medicine Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine Kaohsiung Taiwan
| | - Hsiu‐Po Wang
- Department of Internal Medicine National Taiwan University Hospital Taipei Taiwan
| | - Chi‐Yang Chang
- Department of Internal Medicine E‐Da Hospital/I‐Shou University Kaohsiung Taiwan
- School of Medicine Fu Jen Catholic University New Taipei Taiwan
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Mastracci L, Grillo F, Parente P, Unti E, Battista S, Spaggiari P, Campora M, Scaglione G, Fassan M, Fiocca R. Gastro-esophageal reflux disease and Barrett's esophagus: an overview with an histologic diagnostic approach. Pathologica 2020; 112:117-127. [PMID: 33179616 PMCID: PMC7931578 DOI: 10.32074/1591-951x-162] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 06/29/2020] [Indexed: 12/12/2022] Open
Abstract
The first part of this overview on non-neoplastic esophagus is focused on gastro-esophageal reflux disease (GERD) and Barrett's esophagus. In the last 20 years much has changed in histological approach to biopsies of patients with gastro-esophageal reflux disease. In particular, elementary histologic lesions have been well defined and modality of evaluation and grade are detailed, their sensitivity and specificity has been evaluated and their use has been validated by several authors. Also if there is not a clinical indication to perform biopsies in patient with GERD, the diagnosis of microscopic esophagitis, when biopsies are provided, can be performed by following simple rules for evaluation which allow pathologists to make the diagnosis with confidence. On the other hand, biopsies are required for the diagnosis of Barrett's esophagus. This diagnosis is the synthesis of endoscopic picture (which has to be provided with the proper description on extent and with adequate biopsies number) and histologic pattern. The current guidelines and expert opinions for the correct management of these diagnosis are detailed.
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Affiliation(s)
- Luca Mastracci
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy
- Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
| | - Federica Grillo
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy
- Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
| | - Paola Parente
- Unit of Pathology, Fondazione IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, (FG), Italy
| | - Elettra Unti
- UOC Anatomia Patologica, ARNAS Ospedali Civico-Di Cristina-Benfratelli, Palermo, Italy
| | - Serena Battista
- SOC di Anatomia Patologica, Azienda Sanitaria Universitaria Friuli Centrale, Udine, Italy
| | - Paola Spaggiari
- Department of Pathology, Humanitas Clinical and Research Center-IRCCS, Rozzano, Milan, Italy
| | - Michela Campora
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy
| | | | - Matteo Fassan
- Surgical Pathology Unit, Department of Medicine (DIMED), University of Padua, Italy
| | - Roberto Fiocca
- Anatomic Pathology, San Martino IRCCS Hospital, Genova, Italy
- Anatomic Pathology, Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genova, Italy
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33
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Hauge T, Franco-Lie I, Løberg EM, Hauge T, Johnson E. Outcome after endoscopic treatment for dysplasia and superficial esophageal cancer - a cohort study. Scand J Gastroenterol 2020; 55:1132-1138. [PMID: 32748653 DOI: 10.1080/00365521.2020.1800813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Dysplasia and superficial esophageal cancer should initially be treated endoscopically. Little is known about post-procedural health-related quality of life (HRQL). The aim of this study was to present our results with endoscopic treatment and post-procedural HRQL. MATERIALS AND METHODS From June 2014 to December 2018, all patients treated with endoscopic mucosal resection (EMR) and/or radiofrequency ablation (RFA) for low-grade dysplasia (LGD), high-grade dysplasia (HGD), T1a and a minority of patients with T1b at Oslo University Hospital were prospectively included. In June 2019, all patients alive were scored according to the Ogilvie dysphagia score as well as the QLQ-C30 and QLQ-OG25 for assessment of HRQL. RESULTS Eighty-six patients were treated out of whom 22 (26%) had LGD, 44 (51%) HGD, 13 (15%) T1a, and six patients (7%) T1b. Histology revealed adenocarcinoma in 18 (21%) and squamous cell carcinoma in one (1%), respectively. The mean follow-up was 22.9 months. Tumor regression or downstaging was archived in 78% of the patients with LGD, 66% of patients with HGD and in 89% of patients with T1a/b. Five patients (6%) had esophagectomy. There were few and no serious complications. The 90-days mortality was 1%. Fifty-two patients (88%) experienced no dysphagia (Ogilvie score 0). There was no difference in 11 out of the 15 variables in QLQ-C30 when compared to a non-cancerous reference population. CONCLUSIONS Endoscopic treatment is safe and efficient for treatment of dysplasia and superficial esophageal cancer. The two-years post-procedural level of HRQL and dysphagia was satisfactory.
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Affiliation(s)
- Tobias Hauge
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Isabel Franco-Lie
- Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Else Marit Løberg
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Pathology, Oslo University Hospital, Oslo, Norway
| | - Truls Hauge
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway.,Department of Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Egil Johnson
- Department of Pediatric and Gastrointestinal Surgery, Oslo University Hospital, Oslo, Norway.,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Subramaniam S, Kandiah K, Schoon E, Aepli P, Hayee B, Pischel A, Stefanovic M, Alkandari A, Coron E, Omae M, Baldaque-Silva F, Maselli R, Bisschops R, Sharma P, Repici A, Bhandari P. Development and validation of the international Blue Light Imaging for Barrett's Neoplasia Classification. Gastrointest Endosc 2020; 91:310-320. [PMID: 31586576 DOI: 10.1016/j.gie.2019.09.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 09/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Detecting subtle Barrett's neoplasia during surveillance endoscopy can be challenging. Blue-light imaging (BLI) is a novel advanced endoscopic technology with high-intensity contrast imaging that may improve the identification of Barrett's neoplasia. The aim of this study was to develop and validate the first classification to enable characterization of neoplastic and non-neoplastic Barrett's esophagus using BLI. METHODS In phase 1, descriptors pertaining to neoplastic and non-neoplastic Barrett's esophagus were identified to form the classification, named the Blue Light Imaging for Barrett's Neoplasia Classification (BLINC). Phase 2 involved validation of these component criteria by 10 expert endoscopists assessing 50 BLI images. In phase 3, a web-based training module was developed to enable 15 general (nonexpert) endoscopists to use BLINC. They then validated the classification with an image assessment exercise in phase 4, and their pre- and post-training results were compared. RESULTS In phase 1 the descriptors were grouped into color, pit, and vessel pattern categories to form the classification. In phase 2 the sensitivity of neoplasia identification was 96.0% with a very good level of agreement among the experts (κ = .83). In phase 3, 15 general endoscopists completed the training module. In phase 4 their pretraining sensitivity (85.3%) improved significantly to 95.7% post-training with a good level of agreement (κ = .67). CONCLUSIONS We developed and validated a new classification system (BLINC) for the optical diagnosis of Barrett's neoplasia using BLI. Despite the limitations of this image-based study with a high prevalence of neoplasia, we believe it has the potential to improve the optical diagnosis of Barrett's neoplasia given the high degree of sensitivity (96%) noted. It is also a promising tool for training in Barrett's esophagus optical diagnosis using BLI.
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Affiliation(s)
- Sharmila Subramaniam
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Kesavan Kandiah
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
| | - Erik Schoon
- Department of Gastroenterology, Catharina Hospital, Eindhoven, Netherlands
| | - Patrick Aepli
- Department of Gastroenterology & Hepatology, Luzerner Kantonsspital, Luzerne, Switzerland
| | - Bu' Hayee
- Department of Gastroenterology, King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Andreas Pischel
- Department of Gastroenterology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Asma Alkandari
- Department of Gastroenterology & Hepatology, Aljahra Hospital, Kuwait
| | - Emmanuel Coron
- Centre Hospitalier Universitaire & Faculté de Médecine de Nantes, Institut des Maladies de l'Appareil Digestif, France
| | - Masami Omae
- Centre for Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden
| | | | - Roberta Maselli
- Digestive Endoscopy Unit, Humanitas Research Hospital, Milan, Italy
| | - Raf Bisschops
- Department of Gastroenterology & Hepatology, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Prateek Sharma
- Department of Gastroenterology & Hepatology, Kansas University Medical Center, Kansas, USA
| | | | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
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Roux-en-Y Gastric Bypass as a Treatment for Barrett’s Esophagus after Sleeve Gastrectomy. Obes Surg 2019; 30:1273-1279. [PMID: 31808119 DOI: 10.1007/s11695-019-04292-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Abstract
Background
Laparoscopic sleeve gastrectomy (SG) is the most frequently performed bariatric procedure today. While an increasing number of long-term studies report the occurrence of Barrett’s esophagus (BE) after SG, its treatment has not been studied, yet.
Objectives
The aim of this study was to evaluate Roux-en-Y gastric bypass (RYGB) as treatment for BE and reflux after SG.
Setting
University hospital setting, Austria
Methods
This multi-center study includes all patients (n = 10) that were converted to RYGB due to BE after SG in Austria. The mean interval between SG and RYGB was 42.7 months. The follow-up after RYGB in this study was 33.4 months. Gastroscopy, 24 h pH-metry, and manometry were performed and patients were asked to complete the BAROS and GIQLI questionnaires.
Results
Weight and BMI at the time of SG was 120.8 kg and 45.1 kg/m2. Eight patients (80.0%) went into remission of BE after the conversion to RYGB. Two patients had RYGB combined with hiatoplasty. The mean acid exposure time in 24 h decreased from 36.8 to 3.8% and the mean DeMeester score from 110.0 to 16.3. Patients scored 5.1 on average in the BAROS after conversion from SG to RYGB which denotes a very good outcome.
Conclusions
RYGB is an effective therapy for patients with BE and reflux after SG. Its outcomes in the current study were BE remission in the majority of cases as well as a decrease in reflux activity. Further studies with larger cohorts are necessary to confirm these findings.
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Minichromosomal Maintenance Component Complex 5 (MCM5) as a Marker of Barrett's Esophagus-Related Neoplasia: A Feasibility Study. Dig Dis Sci 2019; 64:2815-2822. [PMID: 30982210 DOI: 10.1007/s10620-019-05607-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 03/27/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND The endoscopic detection of esophageal cancer is suboptimal in both patients referred with dyspeptic symptoms and those enrolled in Barrett's surveillance programs. MCM5 expression in cells collected from gastric fluid may be correlated with the presence of dysplasia or adenocarcinoma. Analysis of this biomarker may improve the detection of cancer. METHODS Sixty-one patients were enrolled at a single UK referral center. From each patient, 5-10 ml of gastric fluid was aspirated endoscopically. Patients were categorized according to their histology, normal, non-dysplastic Barrett's (NDBE), high-grade dysplastic Barrett's (HGD), and esophageal adenocarcinoma (EAC). All histology was confirmed by Seattle protocol biopsies or endoscopic mucosal resection. Samples were centrifuged, and the cell pellet was lysed. MCM5 expression levels were quantified using a proprietary immunoassay. The mean MCM5 expression was compared between groups by Kruskal-Wallis test. ROC curves were also used to assess diagnostic utility. RESULTS The mean expression of MCM5 increases as patients progress from a normal esophagus to NDBE, HGD, and EAC (14.4; 49.8; 112.3; and 154.1, respectively). There was a significant difference in the MCM5 expression of patients with a normal esophagus compared to those with EAC (p = 0.04). There was a trend toward higher MCM5 expression in patients with EAC compared to those with NDBE (p = 0.34). MCM5 expression was a fair discriminator (AUC 0.70 [95% CI 0.57-0.83]) between patients without neoplasia (normal and NDBE) and those with early neoplasia (HGD and EAC). CONCLUSION MCM5 expression in gastric fluid samples can differentiate patients with a histologically normal esophagus compared to those with early adenocarcinoma. Larger, powered studies are needed to assess whether it can be used to differentiate those with HGD from NDBE.
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Holmberg D, Ness-Jensen E, Mattsson F, Lagergren J. Adherence to clinical guidelines for Barrett's esophagus. Scand J Gastroenterol 2019; 54:945-952. [PMID: 31314608 DOI: 10.1080/00365521.2019.1641740] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Background and aim: Clinical guidelines recommend endoscopy surveillance at given intervals or endoscopic therapy for Barrett's esophagus with low-grade dysplasia (LGD) and high-grade dysplasia (HGD). Whether these guidelines are followed in clinical practice is unknown and was assessed in this study. Methods: This nationwide Swedish cohort study included patients with Barrett's esophagus with histologically verified LGD or HGD from 50 centers in 2006-2013. These patients were followed up using nationwide registers. Adherence to clinical guidelines was explored. Eight potential risk factors for deviation from guidelines were assessed using multivariable logistic regression, providing adjusted odds ratios (OR) with 95% confidence intervals (95%CI). Results: Among 211 patients with Barrett's esophagus (mean age 67.0 years, standard deviation 9.7 years, 81% male), 71% had LGD and 29% had HGD. During median 3.9 years of follow-up, 84% underwent a follow-up endoscopy, 17% received endoscopic therapy and 8% underwent esophagectomy. The clinical management deviated from guidelines in 60% of all patients (69% in LGD and 39% in HGD), which was mainly due to under-surveillance (86%). Risk factors for deviation from guidelines were LGD compared to HGD (OR 3.4, 95%CI 1.7-6.8), longer Barrett's segment length (OR 2.0, 95%CI 1.0-3.9, comparing ≥3 cm with <3 cm), and treatment at gastroenterology compared to surgery departments (OR 2.3, 95%CI 1.2-4.4). Age, sex, calendar period and university hospital status were not associated with deviation from surveillance guidelines. Conclusions: Adherence to guidelines for dysplastic Barrett's esophagus is poor, particularly for LGD. Efforts to implement clinical guideline recommendations are needed.
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Affiliation(s)
- Dag Holmberg
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Eivind Ness-Jensen
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.,Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology , Levanger , Norway.,Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust , Levanger , Norway
| | - Fredrik Mattsson
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden
| | - Jesper Lagergren
- Department of Molecular Medicine and Surgery, Upper Gastrointestinal Surgery, Karolinska Institutet, Karolinska University Hospital , Stockholm , Sweden.,School of Cancer and Pharmaceutical Sciences, King's College London , London , UK
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Improved Progression Prediction in Barrett's Esophagus With Low-grade Dysplasia Using Specific Histologic Criteria. Am J Surg Pathol 2019; 42:918-926. [PMID: 29697438 DOI: 10.1097/pas.0000000000001066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Risk stratification of patients with Barrett's esophagus (BE) is based on diagnosis of low-grade dysplasia (LGD). LGD has a poor interobserver agreement and a limited value for prediction of progression to high-grade dysplasia or esophageal adenocarcinoma. Specific reproducible histologic criteria may improve the predictive value of LGD. Four gastrointestinal pathologists examined 12 histologic criteria associated with LGD in 84 BE patients with LGD (15 progressors and 69 nonprogressors). The criteria with at least a moderate (kappa, 0.4 to 0.6) interobserver agreement were validated in an independent cohort of 98 BE patients with LGD (30 progressors and 68 nonprogressors). Hazard ratios (HR) were calculated by Cox proportional hazard regression analysis using time-dependent covariates correcting for multiple endoscopies during follow-up. Agreement was moderate or good for 4 criteria, that is, loss of maturation, mucin depletion, nuclear enlargement, and increase of mitosis. Combination of the criteria differentiated high-risk and low-risk group amongst patients with LGD diagnosis (P<0.001). When ≥2 criteria were present, a significantly higher progression rate to high-grade dysplasia or esophageal adenocarcinoma was observed (discovery set: HR, 5.47; 95% confidence interval [CI], 1.81-17; P=0.002; validation set: HR, 3.52; 95% CI, 1.56-7.97; P=0.003). Implementation of p53 immunohistochemistry and histologic criteria optimized the prediction of progression (area under the curve, 0.768; 95% CI, 0.656-0.881). We identified and validated a clinically applicable panel of 4 histologic criteria, segregating BE patients with LGD diagnosis into defined prognostic groups. This histologic panel can be used to improve clinical decision making, although additional studies are warranted.
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Wu PC, Chen YH, Wu FZ, Lin KH, Hsu CL, Chen CS, Chen YH, Lin PH, Mar GY, Yu HC. Risk factors for Barrett's esophagus in young adults who underwent upper gastrointestinal endoscopy in a health examination center. Therap Adv Gastroenterol 2019; 12:1756284819853115. [PMID: 31210784 PMCID: PMC6547171 DOI: 10.1177/1756284819853115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 05/03/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Barrett's esophagus (BE) is a premalignant condition with increased incidence worldwide both in old and young individuals. However, the role of certain potential risk factors remains unclear in young adults (< 50 years). We aimed to determine the risk factors of BE in young adults. METHODS A total of 4943 young adults who underwent upper gastrointestinal endoscopy at our health check-up center were enrolled. The diagnosis of BE was based on histological confirmation. We analyzed demographic factors, laboratory data, potential risk factors such as smoking, alcohol consumption, presence of gastroesophageal reflux disease (GERD) symptoms, and metabolic syndrome for the risk of BE by using binary logistic regression analysis. RESULTS The prevalence of BE was 1.8% (88/4943). Male sex, the presence of GERD symptoms, and smoking were three significant risk factors related to BE. Furthermore, participants who had smoked for 10 pack-years or more had increased risk of BE with dose-dependent phenomenon (p trend < 0.001). The proportion of BE in male participants with both GERD symptoms and a smoking history of 10 pack-years or more was as high as 10.3% (16/155). CONCLUSIONS Significant risk factors of BE in young adults are male sex, the presence of GERD symptoms, and smoking. The risk also increases with an increase in cumulative exposure to smoking.
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Affiliation(s)
- Pin-Chieh Wu
- Health Management Center, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Meiho University,
Pingtung, Taiwan, Republic of China
| | - Yan-Hua Chen
- Health Management Center, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Meiho University,
Pingtung, Taiwan, Republic of China
- Department of Internal Medicine, Kaohsiung
Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Fu-Zong Wu
- Department of Radiology, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
- School of Medicine, National Yang Ming
University, Taipei, Taiwan, Republic of China
- Institute of Clinical Medicine, National Yang
Ming University, Taipei, Taiwan, Republic of China
| | - Kung-Hung Lin
- Health Management Center, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Meiho University,
Pingtung, Taiwan, Republic of China Department of Internal Medicine,
Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, Republic of
China
| | - Chiao-Lin Hsu
- Health Management Center, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Meiho University,
Pingtung, Taiwan, Republic of China
| | - Chi-Shen Chen
- Health Management Center, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Yu-Hsun Chen
- Health Management Center, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Po-Hsiang Lin
- Department of Emergency Medicine, Kaohsiung
Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Guang-Yuan Mar
- Health Management Center, Kaohsiung Veterans
General Hospital, Kaohsiung, Taiwan, Republic of China
- Department of Nursing, Meiho University,
Pingtung, Taiwan, Republic of China
- Department of Internal Medicine, Kaohsiung
Veterans General Hospital, Kaohsiung, Taiwan, Republic of China
| | - Hsien-Chung Yu
- Division of Gastroenterology and Hepatology,
Department of Internal Medicine, Kaohsiung Veterans General Hospital, 386,
Ta-Chung 1st Road, Kaohsiung 813, Taiwan, Republic of China
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Peters Y, Al-Kaabi A, Shaheen NJ, Chak A, Blum A, Souza RF, Di Pietro M, Iyer PG, Pech O, Fitzgerald RC, Siersema PD. Barrett oesophagus. Nat Rev Dis Primers 2019; 5:35. [PMID: 31123267 DOI: 10.1038/s41572-019-0086-z] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Barrett oesophagus (BE), the only known histological precursor of oesophageal adenocarcinoma (EAC), is a condition in which the squamous epithelium of the oesophagus is replaced by columnar epithelium as an adaptive response to gastro-oesophageal reflux. EAC has one of the fastest rising incidences of cancers in Western countries and has a dismal prognosis. BE is usually detected during endoscopic examination, and diagnosis is confirmed by the histological presence of intestinal metaplasia. Advances in genomics and transcriptomics have improved our understanding of the pathogenesis and malignant progression of intestinal metaplasia. As the majority of EAC cases are diagnosed in individuals without a known history of BE, screening for BE could potentially decrease disease-related mortality. Owing to the pre-malignant nature of BE, endoscopic surveillance of patients with BE is imperative for early detection and treatment of dysplasia to prevent further progression to invasive EAC. Developments in endoscopic therapy have resulted in a major shift in the treatment of patients with BE who have dysplasia or early EAC, from surgical resection to endoscopic resection and ablation. In addition to symptom control by optimization of lifestyle and pharmacological therapy with proton pump inhibitors, chemopreventive strategies based on NSAIDs and statins are currently being investigated for BE management.
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Affiliation(s)
- Yonne Peters
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Ali Al-Kaabi
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Nicholas J Shaheen
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Amitabh Chak
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, OH, USA
| | - Andrew Blum
- Division of Gastroenterology and Liver Diseases, Case Western Reserve University, Cleveland, OH, USA
| | - Rhonda F Souza
- Department of Medicine and the Center for Esophageal Diseases, Baylor University Medical Center at Dallas and the Center for Esophageal Research, Baylor Scott and White Research Institute, Dallas, TX, USA
| | | | - Prasad G Iyer
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Oliver Pech
- Department of Gastroenterology, St John of God Hospital, Regensburg, Germany
| | | | - Peter D Siersema
- Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, Netherlands.
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Britton J, Chatten K, Riley T, Keld RR, Hamdy S, McLaughlin J, Ang Y. Dedicated service improves the accuracy of Barrett's oesophagus surveillance: a prospective comparative cohort study. Frontline Gastroenterol 2019; 10:128-134. [PMID: 31205652 PMCID: PMC6540283 DOI: 10.1136/flgastro-2018-101019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 07/16/2018] [Accepted: 08/19/2018] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Standards for Barrett's oesophagus (BO) surveillance in the UK are outlined in the British Society of Gastroenterology (BSG) guidelines. This study aimed to assess the quality of current surveillance delivery compared with a dedicated service. DESIGN All patients undergoing BO surveillance between January 2016 and July 2017 at a single National Health Service district general hospital were included. Patients had their endoscopy routed to a dedicated BO endoscopy list or a generic service list. Prospective data were analysed against the BSG guidelines and also compared with each patient's prior surveillance endoscopy. RESULTS 361 patients were scheduled for surveillance of which 217 attended the dedicated list, 78 attended the non-dedicated list and 66 did not have their endoscopy. The dedicated list adhered more closely to the BSG guidelines when compared with the non-dedicated and prior endoscopy, respectively; Prague classification (100% vs 87.3% vs 82.5%, p<0.0001), hiatus hernia delineation (100% vs 64.8% vs 63.3%, p<0.0001), location and number of biopsies recorded (99.5% vs 5.6% vs 6.9%, p<0.0001), Seattle protocol adherence (72% vs 42% vs 50%, p<0.0001) and surveillance interval adherence (dedicated 100% vs prior endoscopy 75%, p<0.0001). Histology results from the dedicated and non-dedicated list cohorts revealed similar rates of intestinal metaplasia (79.8% vs 73.1%, p=0.12) and dysplasia/oesophageal adenocarcinoma (4.3% vs 2.6%, p=0.41). CONCLUSIONS The post-BSG guideline era of BO surveillance remains suboptimal in this UK hospital setting. A dedicated service appears to improve the accuracy and consistency of surveillance care, although the clinical significance of this remains to be determined.
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Affiliation(s)
- James Britton
- Department of Gastroenterology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK,Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Kelly Chatten
- Department of Gastroenterology, Stockport NHS Foundation Trust, Stockport, Stockport, UK
| | - Tom Riley
- Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Richard R Keld
- Department of Gastroenterology, Wrightington, Wigan and Leigh NHS Foundation Trust, Wigan, UK
| | - Shaheen Hamdy
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK,Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
| | - John McLaughlin
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK,Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
| | - Yeng Ang
- Division of Diabetes, Endocrinology and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK,Department of Gastroenterology, Salford Royal NHS Foundation Trust, Salford, UK
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Everson MA, Lovat LB, Graham DG, Bassett P, Magee C, Alzoubaidi D, Fernández-Sordo JO, Sweis R, Banks MR, Wani S, Esteban JM, Ragunath K, Bisschops R, Haidry RJ. Virtual chromoendoscopy by using optical enhancement improves the detection of Barrett's esophagus-associated neoplasia. Gastrointest Endosc 2019; 89:247-256.e4. [PMID: 30291849 DOI: 10.1016/j.gie.2018.09.032] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/24/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS The Seattle protocol for endoscopic Barrett's esophagus (BE) surveillance samples a small portion of the mucosal surface area, risking a potentially high miss rate of early neoplastic lesions. We assessed whether the new iScan Optical Enhancement system (OE) improves the detection of early BE-associated neoplasia compared with high-definition white-light endoscopy (HD-WLE) in both expert and trainee endoscopists to target sampling of suspicious areas. Such a system may both improve early neoplasia detection and reduce the need for random biopsies. METHODS A total of 41 patients undergoing endoscopic BE surveillance from January 2016 to November 2017 were recruited from 3 international referral centers. Matched still images in both HD-WLE (n = 130) and iScan OE (n = 132) were obtained from endoscopic examinations. Two experts, unblinded to the videos and histology, delineated known neoplasia, forming a consensus criterion standard. Seven expert and 7 trainee endoscopists marked 1 position per image where they would expect a target biopsy to identify dysplastic tissue. The same expert panel then reviewed magnification images and, using a previously validated classification system, attempted to classify mucosa as dysplastic or nondysplastic, based on the mucosal and vascular (MV) patterns observed on magnification endoscopy. Diagnostic accuracy, sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV) were calculated. Improvements in dysplasia detection in HD-WLE versus OE and interobserver agreement were assessed by multilevel logistic regression analysis and Krippendorff alpha, respectively. Improvements in diagnostic performance were expressed as an odds ratio between the odds of improvement in OE compared with the odds of improvement in HD-WLE. RESULTS Accuracy of neoplasia detection was significantly higher in all trainees who used OE versus HD-WLE (76% vs 63%) and in 6 experts (84% vs 77%). OE improved sensitivity of dysplasia detection compared with HD-WLE in 6 trainees (81% vs 71%) and 5 experts (77% vs 67%). Specificity improved in 6 trainees who used OE versus HD-WLE (70% vs 55%) and in 5 experts (92% vs 86%). PPV improved in both an expert and trainee cohort, but NPV improved significantly only in trainees. By using the MV classification and OE magnification endoscopy compared with HD-WLE, we demonstrated improvements in accuracy (79.9% vs 66.7%), sensitivity (86.3% vs 83.4%), and specificity (71.2% vs 53.6%) of dysplasia detection. PPV improved (62%-76.6%), as did NPV (67.7%-78.5%). Interobserver agreement also improved by using OE from 0.30 to 0.55. CONCLUSION iScan OE may improve dysplasia detection on endoscopic imaging of BE as well as the accuracy of histology prediction compared with HD-WLE, when OE magnification endoscopy is used in conjunction with a simple classification system by both expert and non-expert endoscopists.
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Affiliation(s)
- Martin A Everson
- Division of Surgery and Interventional Science, University College London, London; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
| | - Laurence B Lovat
- Division of Surgery and Interventional Science, University College London, London; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
| | - David G Graham
- Division of Surgery and Interventional Science, University College London, London; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
| | - Paul Bassett
- StatsCounsultancy Ltd, Amersham, Buckinghamshire
| | - Cormac Magee
- Division of Surgery and Interventional Science, University College London, London; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
| | - Durayd Alzoubaidi
- Division of Surgery and Interventional Science, University College London, London; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
| | - Jacobo O Fernández-Sordo
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals, NHS Trust, Nottingham, England
| | - Rami Sweis
- Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
| | - Matthew R Banks
- Division of Surgery and Interventional Science, University College London, London; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
| | - Sachin Wani
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | | | - Krish Ragunath
- NIHR Nottingham Digestive Diseases Biomedical Research Unit, Nottingham University Hospitals, NHS Trust, Nottingham, England
| | | | - Rehan J Haidry
- Division of Surgery and Interventional Science, University College London, London; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London
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Itskoviz D, Tamary H, Krasnov T, Yacobovich J, Sahar N, Zevit N, Shamir R, Ben-Bassat O, Leibovici Wiseman Y, Dickman R, Ringel Y, Dotan I, Goldberg Y, Morgenstern S, Levi Z. Endoscopic findings and esophageal cancer incidence among Fanconi Anemia patients participating in an endoscopic surveillance program. Dig Liver Dis 2019; 51:242-246. [PMID: 30249500 DOI: 10.1016/j.dld.2018.08.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 08/08/2018] [Accepted: 08/08/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The primary clinical characteristics of Fanconi Anemia (FA) include typical physical features, progressive bone marrow failure, and an increased incidence of neoplasms, including esophageal carcinoma. Currently, there are no data regarding endoscopic findings or the interval time to malignancy in these patients. Data about the contribution of Human Papilloma Virus (HPV) to esophageal carcinoma is conflicting. Our objective is to document the upper gastrointestinal (GI) findings at baseline, document cancer incidence, and evaluate the role of HPV among these cancers. METHODS We reviewed endoscopic and clinical data of FA subjects who participated in active surveillance before cancer diagnosis. Incident esophageal cancers were stained for HPV p16 protein. RESULTS Eight FA patients were included (men 62.5%; median age at first endoscopy 20 years, median endoscopies number: 5.5). At baseline, 8/8 had endoscopic evidence for reflux esophagitis. In 3/8 the reflux esophagitis was mild and in 5/8 it was moderate or severe. During the follow up time (median time 4.5 years 2/8 developed Barrett's esophagus and 2/8 patients had incident esophageal squamous cell carcinoma during follow up, at intervals of eight and eighteen months from the previous upper endoscopy. Both cancers stained negative for HPV P16. CONCLUSIONS FA subjects have both an extremely high risk for esophageal cancer within short intervals and a very high prevalence of reflux esophagitis with various severities. Active surveillance programs in specialized centers including annual upper endoscopies should be considered in these patients.
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Affiliation(s)
- David Itskoviz
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Hannah Tamary
- Pediatrics Hematology Unit, Schneider's Children Medical Center, Petach Tikva, Israel; Genetic Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tanya Krasnov
- Pediatric Hematology Laboratory, Felsenstein Medical Research Center, Beilinson Campus, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Joannae Yacobovich
- Pediatrics Hematology Unit, Schneider's Children Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Nadav Sahar
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Noam Zevit
- Institue of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Raanan Shamir
- Institue of Gastroenterology, Nutrition and Liver Disease, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Offer Ben-Bassat
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yaara Leibovici Wiseman
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Ram Dickman
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yehuda Ringel
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Iris Dotan
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Yael Goldberg
- Genetic Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Sara Morgenstern
- Pathology Department, Rabin Medical Center, Petach Tikva, Israel
| | - Zohar Levi
- Gastroenterology Department, Rabin Medical Center, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.
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44
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Gibson JA, Odze RD. Tissue Sampling, Specimen Handling, and Laboratory Processing. CLINICAL GASTROINTESTINAL ENDOSCOPY 2019:51-68.e6. [DOI: 10.1016/b978-0-323-41509-5.00005-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2025]
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Abstract
In Western countries, the incidence of esophageal adenocarcinoma has increased rapidly in parallel with its premalignant condition, Barrett esophagus (BE). Unlike colonoscopy, endoscopic screening for BE is not currently recommended for all patients; however, surveillance endoscopy is advocated for patients with established BE. Novel imaging and sampling techniques have been developed and investigated for the purpose of improving the detection of Barrett esophagus, dysplasia, and neoplasia. This article discusses several screening and surveillance techniques, including Seattle protocol, chromoendoscopy, electronic chromoendoscopy, wide area transepithelial sampling with 3-dimensional analysis, nonendoscopic sampling devices, and transnasal endoscopy.
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Affiliation(s)
- Yoshihiro Komatsu
- Esophageal and Lung Institute, Allegheny Health Network, Western Pennsylvania Hospital, Suite 158, Mellon Pavilion, 4815 Liberty Avenue, Pittsburgh, PA 15224, USA
| | - Kirsten M Newhams
- Esophageal and Lung Institute, Allegheny Health Network, Western Pennsylvania Hospital, Suite 158, Mellon Pavilion, 4815 Liberty Avenue, Pittsburgh, PA 15224, USA
| | - Blair A Jobe
- Esophageal and Lung Institute, Allegheny Health Network, Western Pennsylvania Hospital, Suite 158, Mellon Pavilion, 4815 Liberty Avenue, Pittsburgh, PA 15224, USA.
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Qureshi AP, Stachler MD, Haque O, Odze RD. Biomarkers for Barrett's esophagus - a contemporary review. Expert Rev Mol Diagn 2018; 18:939-946. [PMID: 30345836 DOI: 10.1080/14737159.2018.1538793] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Esophageal adenocarcinoma (EAC) has a poor 5-year survival rate (10%-18%), and incidence has increased dramatically in the past three decades. Barrett's esophagus (BE) is the precursor lesion to EAC and is the replacement of the normally squamous lined esophagus with columnar cells that develop an intestinal phenotype characterized by the presence of goblet cells. Given the known precursor state, EAC is amenable to screening and surveillance strategies (analogous to colon cancer). However, unlike from colon cancer screening, BE poses challenges that make effective screening difficult. Robust and concerted effort is under way to find biomarkers of BE. Areas covered: This review summarizes current known biomarkers for BE. These include dysplasia, genomic markers, and gene expression alterations that occur early in the dysplasia/carcinoma sequence. Expert commentary: Despite the tremendous breadth of work in studying molecular advances, the ideal biomarker for BE has not yet been discerned. This review comments on innovations in the field of BE research that combine state-of-the-art molecular advances with simple technologies.
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Affiliation(s)
- Alia P Qureshi
- a Beth Israel Deaconess Medical Center, Department of Surgery , Harvard Medical School , Boston , MA
| | - Matthew D Stachler
- b Department of Pathology, Harvard Medical School , Brigham and Women's Hospital , Boston , MA
| | - Omar Haque
- a Beth Israel Deaconess Medical Center, Department of Surgery , Harvard Medical School , Boston , MA
| | - Robert D Odze
- b Department of Pathology, Harvard Medical School , Brigham and Women's Hospital , Boston , MA
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47
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Reply to the Letter to the Editor "Does Sleeve Gastrectomy Cause Barrett's Oesophagus?". Obes Surg 2018; 28:4051-4052. [PMID: 30317489 DOI: 10.1007/s11695-018-3542-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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48
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Offman J, Muldrew B, O’Donovan M, Debiram-Beecham I, Pesola F, Kaimi I, Smith SG, Wilson A, Khan Z, Lao-Sirieix P, Aigret B, Walter FM, Rubin G, Morris S, Jackson C, Sasieni P, Fitzgerald RC, on behalf of the BEST3 Trial team. Barrett's oESophagus trial 3 (BEST3): study protocol for a randomised controlled trial comparing the Cytosponge-TFF3 test with usual care to facilitate the diagnosis of oesophageal pre-cancer in primary care patients with chronic acid reflux. BMC Cancer 2018; 18:784. [PMID: 30075763 PMCID: PMC6091067 DOI: 10.1186/s12885-018-4664-3] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 07/10/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Early detection of oesophageal cancer improves outcomes; however, the optimal strategy for identifying patients at increased risk from the pre-cancerous lesion Barrett's oesophagus (BE) is not clear. The Cytosponge, a novel non-endoscopic sponge device, combined with the biomarker Trefoil Factor 3 (TFF3) has been tested in four clinical studies. It was found to be safe, accurate and acceptable to patients. The aim of the BEST3 trial is to evaluate if the offer of a Cytosponge-TFF3 test in primary care for patients on long term acid suppressants leads to an increase in the number of patients diagnosed with BE. METHODS The BEST3 trial is a pragmatic multi-site cluster-randomised controlled trial set in primary care in England. Approximately 120 practices will be randomised 1:1 to either the intervention arm, invitation to a Cytosponge-TFF3 test, or the control arm usual care. Inclusion criteria are men and women aged 50 or over with records of at least 6 months of prescriptions for acid-suppressants in the last year. Patients in the intervention arm will receive an invitation to have a Cytosponge-TFF3 test in their general practice. Patients with a positive TFF3 test will receive an invitation for an upper gastro-intestinal endoscopy at their local hospital-based endoscopy clinic to test for BE. The primary objective is to compare histologically confirmed BE diagnosis between the intervention and control arms to determine whether the offer of the Cytosponge-TFF3 test in primary care results in an increase in BE diagnosis within 12 months of study entry. DISCUSSION The BEST3 trial is a well-powered pragmatic trial testing the use of the Cytosponge-TFF3 test in the same population that we envisage it being used in clinical practice. The data generated from this trial will enable NICE and other clinical bodies to decide whether this test is suitable for routine clinical use. TRIAL REGISTRATION This trial was prospectively registered with the ISRCTN Registry on 19/01/2017, trial number ISRCTN68382401 .
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Affiliation(s)
- Judith Offman
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Beth Muldrew
- Cancer Prevention Trials Unit, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Maria O’Donovan
- Department of Histopathology, Addenbrooke’s Hospital, Cambridge, UK
| | - Irene Debiram-Beecham
- MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, UK
| | - Francesca Pesola
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
| | - Irene Kaimi
- Cancer Prevention Trials Unit, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Samuel G. Smith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ashley Wilson
- Cancer Prevention Trials Unit, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Zohrah Khan
- Cancer Prevention Trials Unit, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | | | - Benoit Aigret
- Cancer Prevention Trials Unit, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Fiona M. Walter
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Greg Rubin
- Institute of Health and Society, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle University, Newcastle upon Tyne, UK
| | - Steve Morris
- Department of Applied Health Research, University College London, London, UK
| | | | - Peter Sasieni
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
- Cancer Prevention Trials Unit, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
| | - Rebecca C. Fitzgerald
- MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, UK
| | - on behalf of the BEST3 Trial team
- School of Cancer and Pharmaceutical Sciences, Faculty of Life Sciences & Medicine, King’s College London, London, UK
- Cancer Prevention Trials Unit, Centre for Cancer Prevention, Wolfson Institute of Preventive Medicine, Queen Mary University of London, London, UK
- Department of Histopathology, Addenbrooke’s Hospital, Cambridge, UK
- MRC Cancer Unit, Hutchison/MRC Research Centre, University of Cambridge, Cambridge, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Astra Zeneca, Cambridge, UK
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Institute of Health and Society, Sir James Spence Institute, Royal Victoria Infirmary, Newcastle University, Newcastle upon Tyne, UK
- Department of Applied Health Research, University College London, London, UK
- MRC Biostatistic Unit, University of Cambridge, Cambridge, UK
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Abstract
Barrett's esophagus is the only known pre-cancerous lesion for esophageal adenocarcinoma and is diagnosed by high-definition white light endoscopy demonstrating a columnar-lined esophagus along with biopsy evidence of intestinal metaplasia. With accurate performance and reporting of the endoscopic procedure, an evidence-based management strategy can be developed for treatment of Barrett's dysplasia. However, cross-sectional data demonstrate that there is still inconsistency among gastroenterologists in performance and reporting of endoscopic findings in patients with Barrett's esophagus. Here, we present an evidence-based review of how to report endoscopic findings in Barrett's esophagus.
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50
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Everson MA, Ragunath K, Bhandari P, Lovat L, Haidry R. How to Perform a High-Quality Examination in Patients With Barrett's Esophagus. Gastroenterology 2018; 154:1222-1226. [PMID: 29510131 DOI: 10.1053/j.gastro.2018.03.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Martin A Everson
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Krish Ragunath
- Nottingham Digestive Diseases Centre, University of Nottingham and NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Pradeep Bhandari
- Department of Gastroenterology, Queen Alexandra Hospital, Hampshire, UK
| | - Laurence Lovat
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK
| | - Rehan Haidry
- Division of Surgery & Interventional Science, University College London, London, UK; Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, UK.
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