RESUMEN
BACKGROUND AND AIMS: Performing a high-quality colonoscopy is critical for optimizing the adenoma detection rate (ADR). Colonoscopy withdrawal time (a surrogate measure) of ≥6 minutes is recommended; however, a threshold of a high-quality withdrawal and its impact on ADR are not known. METHODS: We examined withdrawal time (excluding polyp resection and bowel cleaning time) of subjects undergoing screening and/or surveillance colonoscopy in a prospective, multicenter, randomized controlled trial. We examined the relationship of withdrawal time in 1-minute increments on ADR and reported odds ratio (OR) with 95% confidence intervals. Linear regression analysis was performed to assess the maximal inspection time threshold that impacts the ADR. RESULTS: A total of 1142 subjects (age, 62.3 ± 8.9 years; 80.5% men) underwent screening (45.9%) or surveillance (53.6%) colonoscopy. The screening group had a median withdrawal time of 9.0 minutes (interquartile range [IQR], 3.3) with an ADR of 49.6%, whereas the surveillance group had a median withdrawal time of 9.3 minutes (IQR, 4.3) with an ADR of 63.9%. ADR correspondingly increased for a withdrawal time of 6 minutes to 13 minutes, beyond which ADR did not increase (50.4% vs 76.6%, P < .01). For every 1-minute increase in withdrawal time, there was 6% higher odds of detecting an additional subject with an adenoma (OR, 1.06; 95% confidence interval, 1.02-1.10; P = .004). CONCLUSIONS: Results from this multicenter, randomized controlled trial underscore the importance of a high-quality examination and efforts required to achieve this with an incremental yield in ADR based on withdrawal time. (Clinical trial registration number: NCT03952611.).
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Adenoma , Pólipos del Colon , Neoplasias Colorrectales , Masculino , Humanos , Persona de Mediana Edad , Anciano , Femenino , Estudios Prospectivos , Neoplasias Colorrectales/diagnóstico , Factores de Tiempo , Adenoma/diagnóstico , Colonoscopía/métodos , Detección Precoz del Cáncer , Pólipos del Colon/diagnósticoRESUMEN
BACKGROUND AND AIMS: Mucosal exposure devices including distal attachments such as the cuff and cap have shown variable results in improving adenoma detection rate (ADR) compared with high-definition white light colonoscopy (HDWLE). METHODS: We performed a prospective, multicenter randomized controlled trial in patients undergoing screening or surveillance colonoscopy comparing HDWLE to 2 different types of distal attachments: cuff (CF) (Endocuff Vision) or cap (CP) (Reveal). The primary outcome was ADR. Secondary outcomes included adenomas per colonoscopy, advanced adenoma and sessile serrated lesion detection rate, right-sided ADR, withdrawal time, and adverse events. Continuous variables were compared using Student's t test and categorical variables were compared using chi-square or Fisher's exact test using statistical software Stata version16. A P value <.05 was considered significant. RESULTS: A total of 1203 subjects were randomized to either HDWLE (n = 384; mean 62 years of age; 81.3% males), CF (n = 379; mean 62.7 years of age; 79.9% males) or CP (n = 379; mean age 62.1 years of age; 80.5% males). No significant differences were found among 3 groups for ADR (57.3%, 59.1%, and 55.7%; P = .6), adenomas per colonoscopy (1.4 ± 1.9, 1.6 ± 2.4, and 1.4 ± 2; P = .3), advanced adenoma (7.6%, 9.2%, and 8.2%; P = .7), sessile serrated lesion (6.8%, 6.3%, and 5.5%; P = .8), or right ADR (48.2%, 49.3%, and 46.2%; P = .7). The number of polyps per colonoscopy were significantly higher in the CF group compared with HDWLE and CP group (2.7 ± 3.4, 2.3 ± 2.5, and 2.2 ± 2.3; P = .013). In a multivariable model, after adjusting for age, sex, body mass index, withdrawal time, and Boston Bowel Preparation Scale score, there was no impact of device type on the primary outcome of ADR (P = .77). In screening patients, CF resulted in more neoplasms per colonoscopy (CF: 1.7 ± 2.6, HDWLE: 1.3 ± 1.7, and CP: 1.2 ± 1.8; P = .047) with a shorter withdrawal time. CONCLUSIONS: Results from this multicenter randomized controlled trial do not show any significant benefit of using either distal attachment devices (CF or CP) over HDWLE, at least in high-detector endoscopists. The Endocuff may have an advantage in the screening population. (ClinicalTrials.gov, Number: NCT03952611).
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Adenoma , Pólipos del Colon , Neoplasias Colorrectales , Anciano , Anciano de 80 o más Años , Colonoscopía , Detección Precoz del Cáncer , Femenino , Humanos , Masculino , Tamizaje Masivo , Persona de Mediana Edad , Estudios ProspectivosRESUMEN
BACKGROUND AND AIMS: We examined the accuracy of narrow-band imaging (NBI) findings in nonerosive reflux disease (NERD) patients compared with control subjects and the impact of proton pump inhibitor (PPI) therapy on these mucosal changes in a multicenter, double-blind, randomized controlled trial. METHODS: NERD patients (typical symptoms using a validated GERD questionnaire, absence of erosive esophagitis, and abnormal 48-hour pH study) and control subjects underwent high-definition white-light endoscopy followed by NBI and biopsy sampling of the distal esophagus. Then, NERD patients were randomized to esomeprazole 40 mg/day or placebo for 8 weeks, followed by repeat endoscopy. The presence of distal esophageal mucosal changes on NBI were recorded at baseline and after treatment: intrapapillary capillary loops (IPCLs; number, dilation, and tortuosity), microerosions, increased vascularity, columnar islands, and ridge/villous pattern (RVP) above the squamocolumnar junction. RESULTS: Of 122 screened, 21 NERD and 21 control subjects were identified (mean age, 49.5 ± 14.6 years; 62% men; and 85% white). The combination of IPCL tortuosity, RVP, and microerosions (62% vs 19%, P < .05) had a high specificity (86%) and moderate sensitivity (60%) for NERD with an area under the curve of .74. In 10 NERD patients treated with PPIs, resolution of microerosions was most significant (P = .047) compared with placebo (n = 11). RVP resolved in all NERD patients after therapy (P = .02) and correlated with acid exposure time (P = .004). Papillary length (P = .02) and basal cell thickness (P = .02) significantly correlated with a combination of IPCL tortuosity, RVP, and microerosions. CONCLUSIONS: In this randomized controlled trial, RVP on NBI demonstrated a high specificity, correlated with acid exposure time, and improved with PPI therapy, suggesting that it could be used as a surrogate marker for diagnosis of NERD. (Clinical trial registration number: NCT02081404.).
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Reflujo Gastroesofágico , Adulto , Femenino , Reflujo Gastroesofágico/diagnóstico por imagen , Reflujo Gastroesofágico/tratamiento farmacológico , Humanos , Masculino , Persona de Mediana Edad , Imagen de Banda Estrecha , Estudios Prospectivos , Inhibidores de la Bomba de Protones/uso terapéuticoRESUMEN
BACKGROUND AND AIM: Previous two generations of esophageal capsule did not show adequate detection rates for Barrett's esophagus (BE). We assessed the diagnostic accuracy of a novel third generation capsule with an improved frame rate of 35 frames per second for the detection of BE in a pilot study. METHODS: This was a blinded prospective pilot study conducted at a tertiary medical center. Patients with known BE (at least C0M > 1) who presented for endoscopic surveillance (May to October 2017) were included. All patients underwent novel esophageal capsule (PillCam™ UGI; Medtronic) ingestion using the simplified ingestion protocol followed by standard high-definition upper endoscopy (esophagogastroduodenoscopy [EGD]). Capsule endoscopy findings were interpreted by examiners blinded to endoscopy results and compared with endoscopic findings (gold standard). Following completion of both tests, a subjective questionnaire was provided to all patients regarding their experience. RESULTS: Twenty patients (95%males, mean age 66.3 [±7.9] years) with BE undergoing surveillance EGD were eligible. The mean BE length was 3.5 (±2.7) cm. Novel esophageal capsule detected BE in 75% patients when images were compared with endoscopy. Novel capsule detected BE in 82% patients when the BE length was ≥2 cm. The mean esophageal transit time was 0.59 s. On a subjective questionnaire, all 20 patients reported novel capsule as being more convenient compared with EGD. CONCLUSIONS: In this pilot, single-center study, novel esophageal capsule was shown to be not ready for population screening of BE. Studies integrating artificial intelligence into improved quality novel esophageal capsule should be performed for BE screening.
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Esófago de Barrett/diagnóstico , Esófago de Barrett/patología , Endoscopía Capsular/métodos , Adulto , Anciano , Endoscopía del Sistema Digestivo , Femenino , Humanos , Masculino , Persona de Mediana Edad , Proyectos Piloto , Estudios Prospectivos , Sensibilidad y Especificidad , Encuestas y Cuestionarios , Adulto JovenRESUMEN
BACKGROUND AND STUDY AIM: Data are limited on the natural history of patients with Barrett's esophagus with a diagnosis of "indefinite for dysplasia" (IND). The aims of this study were to: (i) determine rates of progression to high grade dysplasia (HGD) or esophageal adenocarcinoma, and compare these with rates for low grade dysplasia (LGD); and (ii) determine the proportion of patients whose histological IND diagnosis changed on follow-up endoscopy. PATIENTS AND METHODS: Demographic, endoscopic, and histologic information of patients with diagnoses of IND and LGD and at least 12 months of follow-up were extracted from the database of a multicenter Barrett's esophagus study. Rates and times for progression to HGD and esophageal adenocarcinoma and regression to nondysplastic epithelium were calculated. Proportions of diagnoses upgraded to HGD/esophageal adenocarcinoma or downgraded to nondysplastic epithelium at first follow-up endoscopy were evaluated. RESULTS: Amongst 2264 patients, 83 with a diagnosis of IND (mean age 60 years, 95â% men, 95â% white; mean follow-up 5.6 years) and 79 with diagnosis of LGD were identified. In the IND group, annual incidences of esophageal adenocarcinoma and HGD were 0.21â% and 0.64â%, respectively, representing a combined incidence of 0.8â%. Mean time to progression was 4.72 years. Within the IND group 55â% patients showed regression to nondysplastic epithelium at first follow-up endoscopy and the overall regression rate was 80â%. Corresponding rates in LGD patients were similar. CONCLUSIONS: Lesions diagnosed as IND and LGD show similar biological behavior and can be treated as a single category with respect to surveillance and follow-up.
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Esófago de Barrett/complicaciones , Trastornos de Deglución/diagnóstico , Endoscopía Gastrointestinal/métodos , Esófago/patología , Esófago de Barrett/diagnóstico , Trastornos de Deglución/epidemiología , Trastornos de Deglución/etiología , Progresión de la Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Lesiones Precancerosas , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND & AIMS: Recent population-based studies have shown a low risk of esophageal adenocarcinoma (EAC) in patients with nondysplastic Barrett's esophagus (NDBE). We evaluated whether persistence of NDBE over multiple consecutive surveillance endoscopic examinations could be used in risk stratification of patients with Barrett's esophagus (BE). METHODS: We performed a multicenter outcomes study of a large cohort of patients with BE. Based on the number of consecutive surveillance endoscopies showing NDBE, we identified 5 groups of patients. Patients in group 1 were found to have NDBE at their first esophagogastroduodenoscopy (EGD). Patients in group 2 were found to have NDBE on their first 2 consecutive EGDs. Similarly, patients in groups 3, 4, and 5 were found to have NDBE on 3, 4, and 5 consecutive surveillance EGDs. A logistic regression model was built to determine whether persistence of NDBE independently protected against development of cancer. RESULTS: Of a total of 3515 patients with BE, 1401 patients met the inclusion criteria (93.3% white; 87.5% men; median age, 60 ±17 years). The median follow-up period was 5 ± 3.9 years (7846 patient-years). The annual risk of EAC in groups 1 to 5 was 0.32%, 0.27%, 0.16%, 0.2%, and 0.11%, respectively (P for trend = .03). After adjusting for age, sex, and length of BE, persistence of NDBE, based on multiple surveillance endoscopies, was associated with a gradually lower likelihood of progression to EAC. CONCLUSIONS: Persistence of NDBE over several endoscopic examinations identifies patients who are at low risk for development of EAC. These findings support lengthening surveillance intervals or discontinuing surveillance of patients with persistent NDBE.
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Adenocarcinoma/patología , Esófago de Barrett/patología , Neoplasias Esofágicas/patología , Lesiones Precancerosas/patología , Anciano , Endoscopía del Sistema Digestivo , Femenino , Estudios de Seguimiento , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , RiesgoRESUMEN
BACKGROUND & AIMS: It is not clear whether length of Barrett's esophagus (BE) is a risk factor for high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) in patients with nondysplastic BE. We studied the risk of progression to HGD or EAC in patients with nondysplastic BE, based on segment length. METHODS: We analyzed data from a large cohort of patients participating in the BE Study-a multicenter outcomes project comprising 5 US tertiary care referral centers. Histologic changes were graded as low-grade dysplasia, HGD, or EAC. The study included patients with BE of documented length without dysplasia and at least 1 year of follow-up evaluation (n = 1175; 88% male), and excluded patients who developed HGD or EAC within 1 year of their BE diagnosis. The mean follow-up period was 5.5 y (6463 patient-years). The annual risk of HGD and EAC was plotted in 3-cm increments (≤3 cm, 4-6 cm, 7-9 cm, 10-12 cm, and ≥13 cm). We calculated the association between time to progression and length of BE. RESULTS: The mean BE length was 3.6 cm; 44 patients developed HGD or EAC, with an annual incidence rate of 0.67%/y. Compared with nonprogressors, patients who developed HGD or EAC had longer BE segments (6.1 vs 3.5 cm; P < .001). Logistic regression analysis showed a 28% increase in risk of HGD or EAC for every 1-cm increase in BE length (P = .01). Patients with BE segment lengths of 3 cm or shorter took longer to develop HGD or EAC than those with lengths longer than 4 cm (6 vs 4 y; P = nonsignificant). CONCLUSIONS: In patients with BE without dysplasia, length of BE was associated with progression to HGD or EAC. The results support the development of a risk stratification scheme for these patients based on length of BE segment.
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Adenocarcinoma/epidemiología , Esófago de Barrett/complicaciones , Esófago de Barrett/patología , Neoplasias Esofágicas/epidemiología , Anciano , Femenino , Histocitoquímica , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Medición de Riesgo , Centros de Atención Terciaria , Estados UnidosRESUMEN
BACKGROUND: Endoscopic management of Barrett's esophagus (BE) has evolved over the past decade; however, the practice patterns for managing BE among gastroenterologists remain unclear. OBJECTIVE: To assess practice patterns for management of BE among gastroenterologists working in various practice settings. DESIGN: A random questionnaire-based survey of practicing gastroenterologists in the United States. The questionnaire contained a total of 10 questions pertaining to practice setting, physician demographics, and strategies used for managing BE. SETTING: Survey of gastroenterologists working in various practice settings. INTERVENTION: Questionnaire. MAIN OUTCOME MEASUREMENTS: Practice patterns for endoscopic imaging and management of BE. RESULTS: The response rate was 45% (236/530). The majority (85%) were gastroenterologists in community practice, 72% were aged 41 to 60 years, 80% had >10 years of experience, and 81% had attended postgraduate courses and/or seminars on BE management. A total of 78% did not use the Prague C & M classification, and about a third used advanced endoscopic imaging routinely (37%) or in selected cases (31%). For nondysplastic BE, 86% practiced surveillance, 12% performed ablation, and 3% did no intervention. For BE with low-grade dysplasia, 56% practiced surveillance, 26% performed endoscopic ablation in all low-grade dysplasia cases, and 18% performed endoscopic ablation in only selected patients with low-grade dysplasia. The majority of respondents (58%) referred their patients with high-grade dysplasia to centers with BE expertise, 13% performed endoscopic ablation in all patients with high-grade dysplasia, 25% performed endoscopic ablation in selected cases only, and 3% referred these patients for surgery. The most frequently used endoscopic eradication therapy was radiofrequency ablation (39%) followed by EMR (17%). LIMITATIONS: The sample may be unrepresentative, participation in the study was voluntary, and responses may be skewed toward following the guidelines. CONCLUSION: Results from this survey show that the majority of practicing gastroenterologists in the United States practice surveillance endoscopy in patients with nondysplastic BE and provide endoscopic therapy for those with high-grade dysplasia. The Prague C & M classification and advanced imaging techniques are used by less than a third of gastroenterologists. Practice patterns did not appear to be affected by respondent age or duration of clinical practice.
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Esófago de Barrett/cirugía , Esofagoscopía/estadística & datos numéricos , Gastroenterología/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Lesiones Precancerosas/cirugía , Adulto , Esófago de Barrett/diagnóstico , Ablación por Catéter/estadística & datos numéricos , Humanos , Persona de Mediana Edad , Lesiones Precancerosas/diagnóstico , Encuestas y Cuestionarios , Estados Unidos , Espera Vigilante/estadística & datos numéricosRESUMEN
BACKGROUND: There are limited data on the effect of endoscopic mucosal resection (EMR) on changes of histopathologic diagnosis for Barrett's esophagus (BE) patients undergoing endoscopic eradication therapy (EET); especially those without visible lesions. AIM: To compare the frequency of changes of diagnosis by EMR compared with pre-EMR biopsy diagnosis for patients with and without visible lesions. METHODS: In this multicenter outcomes project, patients with Barrett's-related neoplasia undergoing EET at three tertiary-care centers were included. Patients undergoing biopsies followed by EMR within six months were included. The main outcome measures were frequency of overall change of histopathologic diagnosis, change based on pre-EMR biopsy diagnosis, and change based on the presence of visible lesions. RESULTS: One-hundred and thirty-eight BE patients (low-grade dysplasia (LGD) 15 (10.9 %), high-grade dysplasia (HGD) 87 (63 %), esophageal adenocarcinoma (EAC) 36 (26.1 %)) were included; 114 (82.6 %) patients had visible lesions. EMR resulted in a change of diagnosis for 43 (31.1 %) patients (upgrade 14 (10.1 %); downgrade 29 (21 %)). For HGD patients, EMR downstaged dysplasia grade for 17 (19.5 %) cases and upstaged it to EAC for nine (10.3 %) cases. There was a change of diagnosis for 26 (29.9 %) HGD patients, irrespective of the presence or absence of visible lesions (p = 0.76). For EAC patients, EMR downstaged dysplasia grade in 10 (27.8 %) cases. There was a change of diagnosis for 10 (27.8 %) EAC patients, irrespective of the presence or absence of endoscopically visible lesions (p = 0.48). CONCLUSIONS: EMR results in a change of diagnosis for approximately 30 % of BE patients with early neoplasia (with and without visible lesions) referred for EET.
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Adenocarcinoma/cirugía , Esófago de Barrett/cirugía , Neoplasias Esofágicas/cirugía , Esofagoscopía , Esófago/cirugía , Lesiones Precancerosas/cirugía , Adenocarcinoma/patología , Anciano , Esófago de Barrett/patología , Biopsia , Neoplasias Esofágicas/patología , Esófago/patología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Membrana Mucosa/patología , Membrana Mucosa/cirugía , Estadificación de Neoplasias , Lesiones Precancerosas/patología , Resultado del TratamientoRESUMEN
OBJECTIVES: Chronic gastroesophageal reflux disease (GERD) is a risk factor for Barrett's esophagus (BE), the most important surrogate marker for the development of esophageal adenocarcinoma (EAC). The need to document the presence of intestinal metaplasia in esophageal biopsies from a columnar lined esophagus (CLE) to diagnose BE is debated. The objective of this study was to prospectively evaluate the prevalence and risk factors of CLE in a large cohort of GERD patients undergoing upper endoscopy. METHODS: Consecutive patients presenting to the endoscopy unit at a tertiary referral center for their index upper endoscopy for evaluation of GERD symptoms were enrolled in this prospective cohort study. Patients were asked to complete a validated GERD questionnaire that documents the onset of GERD symptoms (heartburn and acid regurgitation) and grades the frequency and severity of symptoms experienced over the past year. Demographic information, body mass index, and use of aspirin/nonsteroidal antiinflammatory drugs were recorded. Endoscopic details including length of CLE, presence and size of hiatal hernia were noted. Patients with CLE (cases) were compared with those without CLE (controls) using Fischer's exact test and t-test. All factors that were statistically significant (P<0.05) were then entered into stepwise logistic regression to evaluate for independent predictors of CLE. RESULTS: A total of 1058 patients with GERD symptoms were prospectively enrolled. On index endoscopy, the prevalence of CLE was 23.3%, whereas of CLE with documented intestinal metaplasia was 14.1%. On univariate analysis, male gender, Caucasian race, heartburn duration of >5 years, presence and size of hiatal hernia were significantly associated with the presence of CLE compared with controls (P<0.05). On multivariate analysis, heartburn duration >5 years (odds ratio (OR): 1.50, 95% confidence interval (CI): 1.07-2.09, P=0.01), Caucasian race (OR: 2.40, 95% CI: 1.42-4.03, P=0.001), and hiatal hernia (OR: 2.07, 95% CI: 1.50-2.87, P<0.01) were found to be independent predictors for CLE. CLE length was significantly associated with the presence of intestinal metaplasia (P<0.001). CONCLUSIONS: If BE is defined by the presence of CLE alone on upper endoscopy, up to 25% of GERD patients are diagnosed with this lesion. Enrolling all these patients in surveillance programs would have significant ramifications on health-care resources.
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Esófago de Barrett/epidemiología , Esófago de Barrett/etiología , Esofagoscopía , Reflujo Gastroesofágico/complicaciones , Reflujo Gastroesofágico/epidemiología , Esófago de Barrett/etnología , Esófago de Barrett/patología , Biopsia , Índice de Masa Corporal , Estudios de Casos y Controles , Femenino , Reflujo Gastroesofágico/etnología , Reflujo Gastroesofágico/patología , Hernia Hiatal/complicaciones , Hernia Hiatal/epidemiología , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Prevalencia , Estudios Prospectivos , Factores de Riesgo , Índice de Severidad de la Enfermedad , Factores Sexuales , Encuestas y Cuestionarios , Factores de TiempoRESUMEN
OBJECTIVES: Ambulatory esophageal pH monitoring has limited diagnostic accuracy in patients with gastroesophageal reflux disease (GERD), especially in those with non-erosive reflux disease (NERD). In addition, there is lack of symptom-reflux association in the majority of GERD patients. The aim of this study was to evaluate the impact of measuring acid exposure 1 cm above the gastroesophageal junction (GEJ) on diagnostic accuracy and symptom correlation in GERD patients compared with conventional pH measurements (6 cm above the GEJ) using the wireless pH system. METHODS: GERD patients and controls as defined by two validated questionnaires (Gastroesophageal Reflux Questionnaire and Reflux Disease Questionnaire) were prospectively enrolled. Under direct endoscopic vision, two wireless pH capsules (BRAVO, Given Imaging, Yokneam, Israel) were placed 6 and 1 cm, respectively, above the GEJ. Receiver operator characteristic curves were constructed, and symptom indexes were calculated separately for pH measurements at 6-cm (proximal) and 1-cm (distal) locations. RESULTS: A total of 40 GERD patients (20 erosive esophagitis (EE) and 20 NERD) and 16 controls were analyzed. Sensitivity and specificity of abnormal acid exposure times in GERD were as follows: proximal: 67 and 66%, distal: 60 and 88%; in EE proximal: 75 and 81%, distal: 84 and 92%; and in NERD proximal: 61 and 67%, distal: 58 and 66%, respectively. The proportion of patients with a positive symptom-reflux correlation in GERD was as follows: symptom index (SI): proximal: 35%, distal: 50%; symptom sensitivity index (SSI): proximal: 25%, distal: 5%; and symptom-associated probability (SAP): proximal: 30% and distal: 35%. The higher proportion of patients with a positive SI distally was due to the EE group (EE, proximal: 35% and distal: 65%; NERD, proximal: 35% and distal: 35%). CONCLUSIONS: Compared with the traditional location, measurement of acid reflux 1 cm above the GEJ improved the diagnostic accuracy as well as symptom correlation in EE, but not in NERD patients. Thus, pH monitoring 1 cm above the GEJ for improving the diagnosis of NERD cannot be recommended in clinical practice at this time.
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Monitorización del pH Esofágico/instrumentación , Unión Esofagogástrica , Reflujo Gastroesofágico/diagnóstico , Esofagoscopía , Humanos , Concentración de Iones de Hidrógeno , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Curva ROC , Sensibilidad y Especificidad , Estadísticas no Paramétricas , Encuestas y CuestionariosRESUMEN
BACKGROUND AND STUDY AIMS: It has been postulated that the endoscopic ablation of Barrett's esophagus can lead to complete eradication of the disease. This study was undertaken to evaluate the efficacy of endoscopic eradication therapy for Barrett's esophagus and the rates of recurrence of intestinal metaplasia. PATIENTS AND METHODS: As part of an initial randomized controlled trial, patients with nondysplastic or low grade dysplastic Barrett's esophagus underwent mucosal ablation. Following ablation, the patients had annual surveillance endoscopies. Recurrence was defined as the presence of intestinal metaplasia after initial complete eradication had been achieved. RESULTS: A total of 28 patients with Barrett's esophagus were followed for a mean of 6.4 years after ablation therapy. At baseline, the majority of the patients had nondysplastic Barrett's esophagus (79â%). Initial complete eradication of intestinal metaplasia was achieved at a mean of 4.1 months. During long-term follow-up, initial recurrence of intestinal metaplasia was seen in 14 of the 28 of patients (50â%) at a mean of 40 months, and further maintenance ablation therapy was applied. At the final follow-up, 36â% of the patients had complete eradication of intestinal metaplasia, 18â% of the patients had intestinal metaplasia, and 21â% had died of unrelated causes; invasive esophageal adenocarcinoma had developed in 1 patient. CONCLUSIONS: The long-term results of this study demonstrate a recurrence rate of 50â% after complete eradication of Barrett's esophagus with endoscopic eradication therapy. In addition, re-recurrence (in 36â%), even after further maintenance endoscopic eradication therapy, and deaths unrelated to the disease (21â%) occurred. Complete remission of Barrett's esophagus appears to be a difficult goal to achieve. These results call into question the role of ablation in patients with low risk Barrett's esophagus.
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BACKGROUND: Cigarette smoking has been associated with an increased risk of oesophageal adenocarcinoma (OAC). However, the impact of smoking and more importantly smoking cessation on Barrett's oesophagus (BO) is unclear. OBJECTIVE: The aim of the study is to evaluate the association between cigarette smoking and presence of BO in a large prospective cohort of patients with gastro-oesophageal reflux disease (GORD). METHODS: Patients presenting to the endoscopy unit for upper endoscopy completed a validated GORD questionnaire and information on demographics (age, gender, and ethnicity), cigarette smoking [status (current/past), amount (pack years) and duration of smoking cessation], clinical data [medication history, body mass index (BMI), and family history] and endoscopic findings [BO and hiatal hernia] were recorded. Cigarette smokers (current and past) and nonsmokers were compared using Fisher's Exact test for categorical variables and Mann-Whitney test for continuous variables. Effects of cigarette smoking and smoking cessation on BO risk was assessed by stepwise logistic regression analysis. RESULTS: A total of 1056 patients were included in the analysis [mean age: 57.2 ± 12.7years, Caucasian 880 (83.3%), male 985 (93.3%), and mean BMI 29.6 (SD: ± 5.6)]. 827 (78.3%) were smokers and 229 (21.6%) were nonsmokers. 474 subjects (44.9%) had a previous history of smoking. Anytime smokers were more likely to have BO (adjusted OR: 3.3; 95 CI: 1.7-6.3; p < 0.01). Higher smoking burden (pack years) was associated with higher risk of BO in this GORD cohort (p for trend < 0.01). Duration of smoking cessation was inversely associated with risk of BO (p for trend: 0.01). CONCLUSION: This study shows that smokers with reflux symptoms have about threefold higher risk of BO compared with nonsmokers, whereas discontinuing smoking is associated with a significant reduced risk. Smoking cessation appears to be a viable option to reduce BO risk in patients with reflux disease.
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BACKGROUND: Esophageal capsule endoscopy (ECE) is a novel technique that offers noninvasive evaluation of esophageal pathology in gastroesophageal reflux disease (GERD) patients. OBJECTIVE: To assess the diagnostic accuracy of ECE for Barrett's esophagus (BE), erosive esophagitis, and hiatal hernia and to assess the safety profile of ECE. METHODS: Patients with GERD symptoms and those undergoing BE surveillance were prospectively enrolled. All patients underwent ECE followed by standard upper endoscopy. ECE findings were interpreted by examiners blinded to endoscopy results. The gold standard was the findings at endoscopy and ECE results were compared with those at endoscopy. RESULTS: One hundred patients were enrolled of which 94 completed the study. At upper endoscopy, BE was suspected in 53 (mean length 3.1 cm) and confirmed in 45 patients. Erosive esophagitis and hiatal hernia were identified in 18 and 70 patients, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ECE for BE in GERD patients were 67%, 87%, 60%, and 90%, respectively. The sensitivity, specificity, PPV, and NPV of ECE for BE patients undergoing surveillance were 79%, 78%, 94%, and 44%, respectively. The sensitivity, specificity, PPV, and NPV for erosive esophagitis were 50%, 90%, 56%, and 88% and for hiatal hernia were 54%, 67%, 83%, and 33%, respectively. CONCLUSIONS: Current diagnostic rates of ECE for BE are not yet accurate enough for application in clinical practice. An improvement in technology and learning curve assessments are required, until then standard upper endoscopy remains the gold standard.
Asunto(s)
Esófago de Barrett/diagnóstico , Endoscopía Capsular , Reflujo Gastroesofágico/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Esofagitis/diagnóstico , Esofagoscopía , Femenino , Hernia Hiatal/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Sensibilidad y Especificidad , Método Simple CiegoRESUMEN
BACKGROUND: A narrow band imaging (NBI) endoscopy system has been developed that allows superficial surface imaging of esophageal tissue in vivo. OBJECTIVE: The objective was to assess the potential of NBI for prediction of histology during screening and surveillance endoscopy in patients with Barrett's esophagus (BE). DESIGN: A prospective cohort study. SETTING: Veterans Affairs Medical Center. PATIENTS: Fifty-one patients with known or suspected BE. METHODS: NBI images were graded according to mucosal pattern (ridge/villous, circular and irregular/distorted) and vascular pattern (normal and abnormal), and correlated with histology in a prospective, blinded manner. MAIN OUTCOME MEASUREMENTS: Biopsy-confirmed intestinal metaplasia (IM) and dysplasia were used as the outcome measures. RESULTS: Of 51 patients (mean BE length 3.5 cm), 28 had IM without dysplasia, 8 had low-grade dysplasia (LGD), 7 had high-grade dysplasia (HGD), and 8 had cardiac-type mucosa. The sensitivity, specificity, and positive predictive value of ridge/villous pattern for diagnosis of IM without HGD were 93.5%, 86.7%, and 94.7%, respectively. The sensitivity, specificity, and positive predictive value of irregular/distorted pattern for HGD were 100%, 98.7%, and 95.3%, respectively. If biopsies were limited to areas with irregular/distorted pattern, no patient with HGD would have been missed. However, NBI was unable to distinguish areas of IM from those with LGD. LIMITATIONS: The open study design without a control group was the main limitation. CONCLUSIONS: NBI is a novel diagnostic tool with a high degree of accuracy for the detection of metaplastic and dysplastic tissue within the BE segment.