Diagnosis and management of Barrett esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

MR1 : ESGE recommends the following standards for Barrett esophagus (BE) surveillance:- a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy- photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions- use of the Prague and (for visible lesions) Paris classification- collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2: ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3: ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4: ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5: ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6: ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7: ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8: ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9: ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 A: ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. B: ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. C: ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. D: ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. E: ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11: After successful EET, ESGE recommends the following surveillance intervals:- For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.- For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.

Side-Viewing Duodenoscope versus Forward-Viewing Gastroscope for Endoscopic Retrograde Cholangiopancreatography in Billroth II Gastrectomy Patients.

Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) in patients with Billroth II gastrectomy is still a challenging procedure. The optimal approach, namely the type of endoscope and sphincter management, has yet to be defined. Aim: To compare the efficacy and safety of forward-viewing gastroscope and the side-viewing duodenoscope in ERCP of patients with Billroth II gastrectomy. Methods: We conducted a retrospective, single-center cohort study of consecutive patients with Billroth II gastrectomy submitted to ERCP in an expert center for ERCP between 2005 and 2021. The outcomes assessed were: papilla identification, deep biliary cannulation, and adverse events (AEs). Multivariate analysis was performed to evaluate potential associations and predictors of the main outcomes. Results: We included 83 patients with a median age of 73 (IQR 65-81) years. ERCP was performed using side-viewing duodenoscope in 52 and forward-viewing gastroscope in 31 patients. Patients' characteristics were similar in the two groups. The global rate of papilla identification was 66% (n = 55). The rate of deep cannulation was 58% considering all patients and 87% in the subgroup of patients in which the papilla major was identified. Cannulation was performed with standard methods in 65% of cases and with needle-knife fistulotomy in 35%. AEs occurred in 4 patients. There was no difference between duodenoscope and gastroscope in papilla identification (64% [95% CI: 51-77] vs. 71% [55-87]). Although not statistically significant, duodenoscope had a lower deep cannulation rate when considering all patients (52% [15-39] vs. 68% [7-35]) and a higher AEs rate (8% [1-15] vs. 0% [0-1]). In a multivariate analysis, the use of gastroscope significantly increased the deep cannulation rate (OR = 152.62 [2.5-9,283.6]). Conclusion: This study demonstrates that forward-viewing gastroscope is at least as effective and safe as side-viewing duodenoscope for ERCP in patients with Billroth II gastrectomy. Moreover, our study showed that gastroscope is an independent predictor of successful cannulation.

Introdução: Colangiopancreatografia retrógrada endoscópica (CPRE) em doentes submetidos previamente a gastrectomia com reconstrução Billroth II é ainda um exame desafiante. A melhor abordagem, nomeadamente o tipo de endoscópio e a técnica de canulação biliar, ainda não está definida. Objectivo: Comparar a eficácia e segurança do gastroscópio de visão frontal e do duodenoscópio de visão lateral na CPRE de doentes com gastrectomia com reconstrução Billroth II. Métodos: Conduzimos um estudo de coorte retrospectivo e unicêntrico que incluiu consecutivamente doentes com gastrectomia com reconstrução Billroth II submetidos a CPRE num centro de referência para CPRE entre 2005 e 2021. Os outcomes avaliados foram: identificação da papila, canulação biliar profunda e efeitos adversos (EAs). Regressão logística foi realizada para avaliar possíveis associações e preditores dos outcomes. Resultados: Incluímos 83 doentes com uma idade mediana de 73 (IIQ 65­81) anos. A CPRE foi realizada usando duodenoscópio em 52 doentes e usando o gastroscópio de visão frontal em 31 doentes. As características dos doentes foram semelhantes entre os dois grupos. A taxa global de identificação da papila foi de 66% (n = 55). A taxa de canulação profunda foi de 58% considerando todos os doentes e de 87% considerando apenas o subgrupo de doentes nos quais a papila major foi identificada. A canulação foi realizada usando métodos convencionais em 65% e usando fistulotomia com faca em 35% dos doentes. EAs ocorreram em 4 doentes. Não houve diferenças entre duodenoscópio e gastroscópio relativamente à identificação da papila [64% (95% CI: 51­77) vs 71% (55­87)]. Apesar de estatisticamente não significativo, o uso de duodenoscópio teve uma menor taxa de canulação profunda quando considerados todos os doentes [52% (15­39) vs 68% (7­35)] e uma maior taxa de EAs [8% (1­15) vs 0% (0­1)]. Na regressão logística, o uso de gastroscópio significativamente aumentou a taxa de canulação profunda [OR = 152.62 (2.5­9,283.6)]. Conclusão: Este estudo demonstra que o uso de gastroscópio de visão frontal é pelo menos igualmente eficaz e seguro ao duodenoscópio na CPRE de doentes com gastrectomia com reconstrução Billroth II. Para além disso, o nosso estudo demonstrou que o uso de gastroscópio é um predictor independente para canulação.

Prevalence of Barrett's esophagus in a Southern European country: a multicenter study.

BACKGROUND: Identification of Barrett's esophagus (BE) with the treatment of dysplasia is essential to prevent esophageal adenocarcinoma (EAC). Moreover, determination of BE prevalence is important to define subsequent management strategies. However, precise estimates on BE prevalence from several European countries are lacking. We aimed to determine BE prevalence in a Southern European country. METHODS: A cross-sectional, multicenter study from November 2019 to February 2020 was performed defining BE as a columnar extent in the distal esophagus greater than or equal to 1 cm with intestinal metaplasia. RESULTS: A total of 1550 individuals, 51% male with a mean age of 62 (SD = 15) years undergoing upper endoscopy were included. The overall BE prevalence was 1.29% (95% confidence interval: 0.73-1.85); significantly higher in men [2.05% (1.06-3.04)] vs. women [0.53% (0.01-1.04)]. Of the 20 BE patients, eight were newly diagnosed and 12 were under surveillance. The median extent was C3 (min 0; max 16) M4.5 (min 2; max 16). One patient each had EAC (0.06%) and high-grade dysplasia (0.06%) at the time of endoscopy. There was no difference in prevalence between geographical regions, centers, use of sedation or experience of endoscopists. Considering all reports, 93% used standardized terminology, 23% accurate photodocumentation and 69% photodocumented the esophagogastric junction (EGJ). Furthermore, 80% used Prague classification, 55% Seattle protocol, 60% distance to the squamocolumnar junction, 75% to the EGJ and 40% to the hiatal pinch. When considering only reports with EGJ photodocumentation or Prague classification, the prevalence was 1.78% (0.91-2.64) or 1.03% (0.53-1.53). CONCLUSION: We report for the first time BE prevalence in Southern Europe and report a low overall prevalence in an unselected population. Future studies need to determine progression rates and how to improve quality metrics.

Systematic review of the published guidelines on Barrett's esophagus: should we stress the consensus or the differences?

Multiple guidelines on Barrett's esophagus (BE) have being published in order to standardize and improve clinical practice. However, studies have shown poor adherence to them. Our aim was to synthetize, compare, and assess the quality of recommendations from recently published guidelines, stressing similarities and differences. We conducted a search in Pubmed and Scopus. When different guidelines from the same society were identified, the most recent one was considered. We used the GRADE system to assess the quality of evidence. We included 24 guidelines and position/consensus statements from the European Society of Gastrointestinal Endoscopy, British Society of Gastroenterology, American Society for Gastrointestinal Endoscopy, American Gastroenterological Association, American College of Gastroenterology, Australian guidelines, and Asia-Pacific consensus. All guidelines defend that BE should be diagnosed when there is an extension of columnar epithelium into the distal esophagus. However, there is still some controversy regarding length and histology criteria for BE diagnosis. All guidelines recommend expert pathologist review for dysplasia diagnosis. All guidelines recommend surveillance for non-dysplastic BE, and some recommend surveillance for indefinite dysplasia. While the majority of guidelines recommend ablation therapy for low-grade dysplasia without visible lesion, others recommend ablation therapy or endoscopic surveillance. However, controversy exists regarding surveillance intervals and biopsy protocols. All guidelines recommend endoscopic resection followed by ablation therapy for neoplastic visible lesion. Several guidelines use the GRADE system, but the majority of recommendations are based on low and moderate quality of evidence. Although there is considerable consensus among guidelines, there are some discrepancies resulting from low-quality evidence. The lack of high-quality evidence for the majority of recommendations highlights the importance of continued well-conducted research in this field.

The global prevalence of Barrett's esophagus: A systematic review of the published literature.

BACKGROUND: Determining the prevalence of Barrett's esophagus is important for defining screening strategies. We aimed to synthesize the available data, determine Barrett's esophagus prevalence, and assess variability. METHODS: Three databases were searched. Subgroup, sensitivity, and meta-regression analyses were conducted and pooled prevalence was computed. RESULTS: Of 3510 studies, 103 were included. In the general population, we estimated a prevalence for endoscopic suspicion of Barrett's esophagus of (a) any length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.85-1.07), (b) ≥1 cm of length with histologic confirmation of intestinal metaplasia as 0.96% (95% confidence interval: 0.75-1.18) and (c) for any length with histologic confirmation of columnar metaplasia as 3.89% (95% confidence interval: 2.25-5.54) . By excluding studies with high-risk of bias, the prevalence decreased to: (a) 0.70% (95% confidence interval: 0.61-0.79) and (b) 0.82% (95% confidence interval: 0.63-1.01). In gastroesophageal reflux disease patients, we estimated the prevalence with afore-mentioned criteria to be: (a) 7.21% (95% confidence interval: 5.61-8.81) (b) 6.72% (95% confidence interval: 3.61-9.83) and (c) 7.80% (95% confidence interval: 4.26-11.34). The Barrett's esophagus prevalence was significantly influenced by time period, region, Barrett's esophagus definition, Seattle protocol, and study design. There was a significant gradient East-West and North-South. There were minimal to no data available for several countries. Moreover, there was significant heterogeneity between studies. CONCLUSION: There is a need to reassess the true prevalence of Barrett's esophagus using the current guidelines in most regions. Having knowledge about the precise Barrett's esophagus prevalence, diverse attitudes from educational to screening programs could be taken.

Cancer-risk by family history and mismatch-repair mutation in Lynch syndrome.

Introduction: Surveillance of Lynch syndrome (LS) is recommended to reduce cancer-risk. There is an increased awareness that cancer-risk may vary with mismatch-repair mutation and family history. However, gene-specific and family-specific surveillance are not recommended. Therefore, we aimed to estimate the cumulative incidence of lesions and to assess the cancer-risk by family history and mismatch-repair mutation (MMR).Methods: Single-centre retrospective cohort of all individuals (n = 241) in a specialized institution was conducted.Results: Forty-eight percent of individuals inherited MSH2 mutations, 32% MLH1, 15% MSH6 and 5% PMS2. The calculated cumulative incidence for any cancer increased with age. By age 70, the cumulative incidence for low-risk, high-risk adenomas and CRC was estimated at 66.6%, 57.7% and 25.7%, respectively. By age 70, the cumulative incidence of endometrial cancer (EC), gastric cancer and urinary tract cancer was estimated at 17.3%, 3.3% and 12.6%, respectively. MLH1 and MSH2 mutation carriers had lower mean age of CRC diagnosis than MSH6 and PMS2 [MLH1:44(CI95% 38-50); MSH2:43(CI95% 40-47); MSH6:52(CI95% 45-59); PMS2:46(CI95% 35-57)]. The risk of EC was higher when family history was present (RR = 2.39, CI95%[1.3;4.6]). MSH6 mutation carriers had higher risk of EC comparative to other MMR mutation carriers (RR = 1.9, p = .09). The risk of urinary tract cancer was higher with MSH2 (RR = 8.4, CI95%[2.7;25.9]) and positive family history (RR = 10.8, CI95%[1.4;82.8]).Conclusion: This cohort demonstrates the effectiveness of LS surveillance and suggests possible tailored surveillance strategies by gene mutation and family history.