Clinical significance of recurrent gastroesophageal junction intestinal metaplasia after endoscopic eradication of Barrett’s esophagus

Abstract

Background and Aims: After endoscopic eradication of Barrett's esophagus (BE), recurrence of intestinal metaplasia at the gastroesophageal junction (GEJIM) is common. The clinical significance of this finding is unclear. We assessed whether recurrent GEJIM is associated with increased risk of subsequent dysplasia and whether endoscopic treatment lowers this risk.Methods: A retrospective, multicenter, cohort study was performed of treated BE patients who achieved complete eradication of intestinal metaplasia (IM). Postablation follow-up was performed at standard intervals. Recurrent GEJIM was defined as nondysplastic IM on gastroesophageal junction biopsy specimens without endoscopic evidence of BE. Patients were categorized as "never-GEJIM," "GEJIM-observed," or "GEJIM-treated." Endoscopic treatment for recurrent GEJIM was at the endoscopists' discretion. The primary outcome was dysplasia recurrence. Analyses were performed using log-rank tests and Cox proportional hazards modeling.Results: Six hundred thirty-three patients were analyzed; median follow-up was 47 months (interquartile range, 24-69). Most patients (81%) had high-grade dysplasia or intramucosal adenocarcinoma before treatment. Dysplasia recurrence was 2.2% per year. GEJIM-observed patients had the lowest rate of recurrence (.6%/y) followed by GEJIM-treated (2.2%/y) and never-GEJIM (2.6%/y) (log-rank P Z .07). In multivariate analyses, compared with never-GEJIM, the risk of dysplasia recurrence was significantly lower in GEJIM-observed patients (adjusted hazard ratio, .19; 95% confidence interval, .05-.81) and not different in GEJIM-treated patients (adjusted hazard ratio, .81; 95% confidence interval, .39-1.67). Older age and longer initial BE length were independently associated with recurrence.Conclusions: Recurrent GEJIM after endoscopic eradication of BE was not associated with an increased risk of subsequent dysplasia. Future studies are warranted to determine if observation is appropriate for this finding.

Recurrent intestinal metaplasia in the gastroesophageal junction after endoscopic eradication of Barrett’s: Is ignorance bliss?

“…Surprisingly, patients with recurrent IM in the GEJ who did not receive additional treatment had the lowest dysplasia recurrence rate (0.6% per year). 6 The risk for dysplasia recurrence also appeared significantly lower in GEJIM-observed patients than in patients who had never experienced GEJIM. Because recurrence of HGD or EAC, but not LGD, is clinically the most relevant, Solfisburg et al 6 also published the annual incidence rate for recurrence of HGD/EAC, which was 1.5% per year.…”

“…Solfisburg et al 6 performed a retrospective multicenter cohort study to determine the risk of dysplasia recurrence in relation to recurrent detection of IM in the GEJ after eradication therapy by the use of either endoscopic resection, RFA, or a combination thereof. The authors hypothesized that the risk for dysplasia recurrence would be higher for patients with recurrent IM in the GEJ.…”

“…The authors conclude that recurrent GEJIM is not uncommon and may be associated with a low risk of subsequent dysplasia. 6 The authors give a clear and extensive overview of the association between recurrence of IM in the GEJ after endoscopic eradication therapy and the risk for recurrent dysplasia. Several limitations of the study have already been discussed by the authors and are mainly due to the retrospective design, causing selection and information bias, lack of standardized biopsy sampling…”

“…Solfisburg et al 6 conclude that a finding of IM in the GEJ during follow-up after endoscopic eradication therapy does not increase the risk of recurrence but that additional prospective randomized studies will be important in determining whether observation may be appropriate for patients with recurrent GEJIM. However, given the very low neoplasia recurrence rate after successful endoscopic eradication therapy, the major limitation of sampling error, the large patient population, and long study period this would require to find significantly relevant outcomes, we do not feel this is a very logical next step.…”

“…In our opinion, the conclusion of the current study, along with our own outcomes, leads to the question whether we really want to know whether there is recurrent IM in the GEJ because this has no clinical relevance in the absence of endoscopic abnormalities. 6,9 In our opinion, we should focus on thorough endoscopic inspection and target biopsies of visible abnormalities. As for random biopsies from the GEJ to detect IM, ignorance might be bliss.…”