Introduction

For patients with irregular Z-lines (IrrZ), current guidelines disadvise routine biopsies at the columnar-appearing distal esophagus and endoscopic follow-ups based on the rarity of malignant changes but not on the risk of progression to evident Barrett’s esophagus (BE). The rates of BE development in patients with IrrZ vary widely in limited reports from the US and Europe, ranging from 0% to 25.8%. This study aimed to elucidate the rates and factors associated with BE progression in Asian patients with IrrZ.

Aims & Methods

Patients diagnosed with IrrZ, defined as a columnar-lined esophagus less than 1 cm, by endoscopies with biopsies, and received at least one endoscopic follow-up, were included. The primary endoscopists reappraised the endoscopic images and consensually verified the endoscopic characteristics. We referenced the mucosal patterns applied to BE and classified those over IrrZ as gastric metaplasia (GM) patterns, which comprised round, short straight, or circular pits, and intestinal metaplasia (IM) patterns, including ridged, villous, obscured, or irregular pits. Univariate and multivariate analyses were performed to identify the factors associated with progression to BE or emergence of IM.

Results

A total of 156 patients (106 males) with a median age of 53.9 (interquartile range 46.1–61.3) years, receiving 2 (1–2.8) follow-up endoscopies during a period of 43.3 (24.7–54.4) months, were included. IM was detected at baseline in 54 patients. BE, all short-segmented, developed in 15 patients (9.6 %) during follow-up. No significant association was found between age, gender, body-mass index, abdominal girth, history of diabetes mellitus, gastroesophageal reflux disease (GERD), smoking, fasting glucose, HbA1c, use of proton pump inhibitor, maximum length of mucosal tongues, hiatal hernia, gastroesophageal flap valve, reflux esophagitis, and mucosal patterns, and the development of BE in the entire cohort or the subgroup with baseline IM. The first follow-up endoscopy effectively identified patients with BE development. Only 1 of the 85 patients (1.2%) receiving ≥ 2 follow-up endoscopies was diagnosed with BE after their first follow up. In the subgroup without baseline IM, known GERD was significantly associated with subsequent BE, while smoking and IM pattern were linked to IM emerging. The IM pattern was significantly associated with the maximum length of mucosal tongue and presence of reflux esophagitis. It also correlated with baseline IM, except in the subgroup with reflux esophagitis and maximum length 0.5cm–0.9cm.

Conclusion

A small proportion (9.6%) of Asian patients with IrrZ progressed to BE. Following endoscopy once could identify the patients BE developed and reassure patients without BE. In patients without baseline IM, endoscopic follow-up may be spared in the absence of known GERD. IM pattern could predict the emergence of IM, and in most patients, it correlated with the presence of IM.

References

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Disclosure

The authors declared no potential conflict of interest relevant to this article.

Introduction

With the recent rise in the occurrence of esophageal adenocarcinoma (EAC) in Western nations, there is an escalating worry regarding Barrett’s esophagus (BE). In contrast, Asian countries exhibit a lower prevalence of BE compared to their Western counterparts. Given the annual increase in chronic gastroesophageal reflux disease (GERD) cases, there is an expectation of a concurrent rise in the prevalence of BE. Consequently, we are embarking on a multicenter prospective study to assess the current prevalence of BE and pinpoint its risk factors in Taiwan.

Aims & Methods

Aim: to evaluate current prevalence and risk factors of Barrett's esophagus in Taiwan.
Methods: We carried out a prospective multicenter study involving consecutive outpatients who underwent upper gastrointestinal endoscopy for various upper gastrointestinal symptoms. Biopsies were taken from endoscopically suspected esophageal metaplasia (ESEM), clearly visible at least 1 cm above the gastroesophageal junction during endoscopy. The biopsy procedure involved obtaining standardized random samples, with four pieces taken every 2 cm from the four quarters of the esophagus exhibiting the ESEM lesion. BE was defined based on the histological confirmation of specialized intestinal metaplasia in the metaplastic esophageal epithelium.

Results

A total of 8925 subjects were enrolled in this study. The prevalence of BE was 2.6%. A total of 228 subjects with BE were detected among 751 ESEM subjects. Short segment BE (78.1 % , n = 178) was more prevalent than long segment BE (22.9 % , n = 50). The prevalence of GERD symptoms, erosive esophagitis (EE), and hiatal hernia (HH) was 52.5%, 27.3% and 7.85%, respectively. Multivariate analysis disclosed that old age [odds ratio (OR) = 1.59; 95% CI, 1.20-2.11; P <0.01], male gender (OR = 2.27; 95%CI, 1.65-3.11; P < 0.01),alcohol consumption (OR = 1.70, 95%CI, 1.19-2.44; P< 0.01), GERD symptoms (OR = 1.45, 95%CI, 1.10-1.92; P< 0.01), EE (OR = 1.94, 95%CI, 1.47-2.56; P< 0.01) and presence of hiatal hernia (OR = 2.49; 95%CI, 1.78-3.47; P < 0.001) were significant risk factors predicting BE.
Risk factors for Barrett esophagus: multivariable analysis.

Conclusion

The prevalence of BE was identified as 2.6%. Notably, advanced age (>50), male gender, alcohol consumption, symptoms of gastroesophageal reflux disease (GERD), erosive esophagitis, and the presence of hiatal hernia emerged as independently significant risk factors for Barrett's esophagus.

References

1. Sharma P. Barrett Esophagus: A Review. Jama. 2022;328(7):663-71.
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8. Akiyama T, et al. Alcohol consumption is associated with an increased risk of erosive esophagitis and Barrett's epithelium in Japanese men. BMC Gastroenterol. 2008;8:58.
9. Andrici J,et al. Hiatal hernia and the risk of Barrett's esophagus. J Gastroenterol Hepatol. 2013;28(3):415-31.

Introduction

Barrett’s esophagus (BE) is a precursor to esophageal adenocarcinoma, with its prevalence reported to range from 1.9% to 6.8% in Western countries. We aimed to identify cost-effective pathways for BE screening by combining BE detection using multiple tools with subsequent risk-stratified surveillance.

Aims & Methods

A decision-analytic model was developed using a hypothetical cohort of the general population aged 50 years with BE prevalence rates of 1.0-7.0%. In addition to a no screening strategy, 24 potential screening pathways were evaluated combining six detection strategies (combinations of: guideline-based risk stratification, algorithmic risk stratification, swallowable devices like Cytosponge-trefoil factor 3, and endoscopy) and four surveillance strategies varying endoscopy intervals based on the BE length. Cost-effectiveness was assessed from an Australian health system perspective, using incremental cost-effectiveness ratio (ICER) thresholds for the USA (US$100,000/QALY), UK (US$43,228/QALY), and Australia (US$34,554/QALY).

Results

BE screening was cost-effective compared to no screening at BE prevalences of ≥1.0%, ≥2.4%, and ≥4.7% for the USA, UK, and Australian ICER thresholds, respectively. The optimal screening strategy was different between USA/non-USA thresholds; a 3-step detection (algorithmic risk stratification followed by swallowable devices and then endoscopy) with subsequent surveillance (no surveillance for short segment BE [SSBE] <3 cm, 2 yearly for long segment BE [LSBE] ≥3 cm; eradication for low-grade dysplasia [LGD]) for the UK and Australia. In contrast, for the USA, it was a 2-step detection (swallowable devices followed by endoscopy) with surveillance (no surveillance, SSBE ≤2 cm; 2 yearly, LSBE >2 cm; eradication, LGD) especially at ≥2.4% BE prevalence.

Conclusion

BE screening combining BE detection using multiple tools with subsequent risk-stratified surveillance based on segment length might be cost-effective, depending on BE prevalence in the community and ICER thresholds. Further work is needed to determine the actual BE prevalence in target communities.

Introduction

The prevalences of Barrett’s esophagus (BE) are gradually increasing in recent decades in some Asia-Pacific regions, thus an accurate diagnosis of BE is important to determine the surveillance program. However, most endoscopists in Asia did not adhere to the Seattle biopsy protocol, and the optimal numbers of endoscopic biopsies and their yield rates of intestinal metaplasia (IM) and dysplasia had never been elucidated.

Aims & Methods

The aim of this study is to investigate the yield of IM and dysplasia according to the biopsy numbers. We retrospectively reviewed the upper gastrointestinal endoscopic reports from the database of outpatient setting from January 2008 to December 2020 at E-Da hospital in Taiwan. The numbers of biopsy, length of columnar-lined esophagus (CLE) and the corresponding histology were analyzed to assess the yield rates of IM and dysplasia per-biopsy in patients with endoscopic CLE and without visible cancerous lesions.

Results

A total of 120,362 endoscopies were reviewed, and 5,963 (5.0 %) cases in 3,135 patients were diagnosed as endoscopic CLE (Length, mean:1.4±0.97cm; range, 1-10). The time-trend of cases of endoscopic CLE and BE were slightly increasing in recent decades. Among them, 4,675 (78.4%) cases received a total of 8887 biopsies (number, median: 1; range, 1-9). The histology from biopsies revealed that 1,642 (35.1%) cases and 217 (4.6%) cases per-endoscopy yielded the IM and dysplasia, respectively (Table 1). Among the 913 patients with histology-confirmed BE, the mean age was 53.2 (53.2±15.1) years old and short-segment (<3cm) Barrett's esophagus (SSBE) were predominated (91%). Overall, the yields of IM (75% vs. 33%) and dysplasia (17% vs. 3.5%) were both higher in the long-segment than those in short-segment CLE. The yield rates were positively correlated with the numbers of biopsies for both IM and dysplasia in short-segment CLE. Taking one biopsy only revealed a 26% yield of IM and 3.5% yield of dysplasia, respectively. On the contrary, one biopsy could get a 53% yield of IM and 14% yield of dysplasia in long-segment CLE.

Table 1. yields of intestinal metaplasia according to the number of biopsies per-endoscopy

Conclusion

Sampling bias is a major concern in current clinical practice for diagnosis and management of Barrett’s esophagus. The yield rates of IM and dysplasia were suboptimal by taking one biopsy, especially for short-segment CLE. A randomized study is required to determinate the optimal biopsy number for SSBE-predominant Asian populations.

Disclosure

There was no conflict of interest

Introduction

Patients with Barrett’s Esophagus (BE) undergo regular endoscopic surveillance to timely intervene in the development of esophageal adenocarcinoma (EAC). The current European Society of Gastrointestinal Endoscopy (ESGE) guideline recommends stopping BE surveillance at the age of 75 years, based on average life expectancy. However, clinical studies to support this recommendation are lacking.

Aims & Methods

Therefore, this study aims to determine the optimal age to discontinue surveillance by analyzing incidence and mortality rates in a real-life cohort study. We analyzed data from a multicenter, prospective cohort of BE patients in the Netherlands with a segment length of ≥2 cm, all of whom underwent endoscopic surveillance between 2004 and 2023, in accordance with American College of Gastroenterology guidelines. Patients were linked with the Netherlands Cancer Registry (NCR) to optimize data completeness. Vital status and cause of death of patients were verified with their general practitioner and through the Central Statistical Office (CBS). The cumulative incidence of EAC was calculated, and standardized incidence (SIR) and standardized mortality rate (SMR) were analyzed using a Poisson regression model.

Results

A total of 1,378 BE patients (median age at inclusion 62 years; 73% male) were included for analysis. Median follow-up time was 6.3 years, and median age at cessation of surveillance was 75 years. In total, 57 EAC cases were identified at a median age of 69 years, of which 89% under active surveillance. The majority of cancers was diagnosed at an early stage (47% Stage I, 12% stage II, 3.5% stage III). The cumulative incidence after 10 years of follow-up was 4.4.% in the complete cohort, which was lower in the age group >75 (1.7%). The incidence rate per 1,000 person years was highest amongst patients aged 65-69 years. The SIR was 19.2 in the complete cohort, decreasing to 12.1 in patients >75 years. A total of 350 patients died during follow-up, of which 15 (4.3%) due to EAC. Median age at death was 79 years. The most frequent causes of death were cardiovascular disease (25%), and other malignancies (27%). The mortality rate per 10,000 person years was 10 for EAC-related death and 240 for other causes. The risk of other cause mortality was 24 times higher than EAC-related mortality. The overall SMR for EAC-related death was 3.9, decreasing to 2.5 in patients > 75 years of age.

Conclusion

Our findings support the ESGE guideline recommendation to discontinue surveillance in BE patients older than 75 years, as the cumulative incidence, SIR, and SMR all declined notably in this age group. Although the SIR was still high in patients aged 75 and above, patients in this cohort were 24 times more likely to die from other causes than from EAC.

Introduction

A confirmed diagnosis of low-grade dysplasia (LGD) on two endoscopies is currently considered a predictor for neoplastic progression in patients with Barrett’s esophagus (BE), and, therefore, ablation therapy is offered to these patients. However, recent studies show that aberrant expression of the p53 tumor suppressor protein might be a stronger risk factor for neoplastic progression than dysplasia status.

Aims & Methods

The aim of this study was to evaluate the value of p53 expression compared to confirmed LGD in predicting neoplastic progression in BE patients. Data was analyzed from a large prospective cohort study of 1031 BE patients (73% males, median age 61 years) with index diagnosis of non-dysplastic BE (NDBE), indefinite for dysplasia (IND), and LGD. Confirmed LGD was defined as a LGD diagnosis on 2 separate occasions, each LGD diagnosis was confirmed by two pathologists. P53 immunohistochemistry staining was performed on biopsies of 1545 endoscopies from 655 (64%) patients; both overexpression and loss of expression were considered aberrant. Neoplastic progression was defined as high-grade dysplasia (HGD) and/or esophageal adenocarcinoma (EAC). Cox regression analysis was used to determine neoplastic progression risk.

Results

During a median follow-up of 8.4 (IQR 5.3-12.9) years, 68/655 (10%) patients developed HGD/EAC. Neoplastic progression was found in 20/411 (5%) NDBE patients, 25/149 (17%) patients with a single diagnosis of LGD, and 24/95 (24%) patients with confirmed LGD. P53 expression was aberrant in 28/411 (7%) NDBE patients, 50/149 (34%) single LGD patients, and 51/95 (54%) confirmed LGD patients. Aberrant p53 expression was strongly associated with an increased risk of neoplastic progression after adjusting for age, gender, segment length, esophagitis, and grade of dysplasia (HR 13.5, 95% CI 7.1-25.8). In NDBE patients, the absolute neoplastic progression risk increased from 2% with normal p53 expression to 50% with aberrant p53 expression. In patients with a single diagnosis of LGD, the progression risk increased from 6% to 35% when p53 expression was aberrant. Similar risks where found in patients with confirmed LGD, with a neoplastic progression risk of 2% with normal p53 expression and 43% with aberrant p53 expression.

Conclusion

Aberrant p53 expression is a strong predictor for neoplastic progression in BE patients. The predictive value of aberrant p53 expression is independent of the grade of dysplasia. Aberrant P53 expression may be a better parameter than (confirmed) LGD to identify patients who need close surveillance or could benefit from ablation therapy.