Recurrence of Barrett’s Esophagus is Rare Following Endoscopic Eradication Therapy Coupled With Effective Reflux Control

Komanduri, Srinadh; Kahrilas, Peter J.; Krishnan, Kumar; McGorisk, Tim; Bidari, Kiran; Grande, David; Keefer, Laurie; Pandolfino, John E.

doi:10.1038/ajg.2017.13

Cited by 69 publications

(56 citation statements)

References 57 publications

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“…None of the three studies that defined CRIM on two negative endoscopies6–8 evaluated the variation in the incidence of recurrence over time across all grades of dysplasia. In one single-centre study, 20% of patients had NDBE at baseline and no recurrences were reported after 3 years, implying little benefit from surveillance beyond 3 years post-CRIM 6. This is in contrast to data from our study in which we estimated the recurrence rate to remain constant, or at least not decrease by more than 7% for every doubling of follow-up time throughout the study period that extended beyond 3 years.…”

Section: Discussioncontrasting

confidence: 96%

Timeline and location of recurrence following successful ablation in Barrett’s oesophagus: an international multicentre study

Sami

Ravindran

Kahn

et al. 2019

Gut

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ObjectiveSurveillance interval protocols after complete remission of intestinal metaplasia (CRIM) post radiofrequency ablation (RFA) in Barrett’s oesophagus (BE) are currently empiric and not based on substantial evidence. We aimed to assess the timeline, location and patterns of recurrence following CRIM to inform these guidelines.DesignData on patients undergoing RFA for BE were obtained from prospectively maintained databases of five (three USA and two UK) tertiary referral centres. RFA was performed until CRIM was confirmed on two consecutive endoscopies.Results594 patients achieved CRIM as of 1 May 2017. 151 subjects developed recurrent BE over a median (IQR) follow-up of 2.8 (1.4–4.4) years. There was 19% cumulative recurrence risk of any BE within 2 years and an additional 49% risk over the next 8.6 years. There was no evidence of a clinically meaningful change in the recurrence hazard rate of any BE, dysplastic BE or high-grade dysplasia/cancer over the duration of follow-up, with an estimated 2% (95% CI −7% to 12%) change in recurrence rate of any BE in a doubling of follow-up time. 74% of BE recurrences developed at the gastro-oesophageal junction (GOJ) (24.1% were dysplastic) and 26% in the tubular oesophagus. The yield of random biopsies from the tubular oesophagus, in the absence of visible lesions, was 1% (BE) and 0.2% (dysplasia).ConclusionsBE recurrence risk following CRIM remained constant over time, suggesting that lengthening of follow-up intervals, at least in the first 5 years after CRIM, may not be advisable. Sampling the GOJ is critical to detecting recurrence. The requirement for random biopsies of the neosquamous epithelium in the absence of visible lesions may need to be re-evaluated.

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Section: Discussioncontrasting

confidence: 96%

Timeline and location of recurrence following successful ablation in Barrett’s oesophagus: an international multicentre study

Sami

Ravindran

Kahn

et al. 2019

Gut

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“…14,22,41 Most patients achieve CE-IM within 3 ablative therapy sessions. 53,54 Esophagectomy is considered as the treatment of choice for patients with submucosal cancer (T1b sm2-3 disease), poorly differentiated cancer, and cancer associated with lymphatic or vascular infiltration given the high risk of lymph node metastasis (at least 20%). 2,23,55 Long-term survival data in patients undergoing EET using contemporary treatment modalities and identification of stage T1b EAC patients who may be able to undergo EET and achieve comparable outcomes with esophagectomy should be addressed in future studies.…”

Section: Resultsmentioning

confidence: 99%

“…Although the temporality of recurrence after achieving CE-IM cannot be established with the available reports, recent reports suggest that most recurrences are reported within the first 3 years after achieving CE-IM. 53,54 A limited number of studies report on the risk factors associated with recurrence (ongoing reflux and presence of erosive esophagitis, older age, nonwhite race, smoking, obesity, pretreatment BE length, number of EET sessions), and these associations need to be explored and confirmed in future studies. 51,53,54,[64][65][66] Surveillance intervals suggested by current guidelines are largely driven by expert opinion and low quality evidence.…”

Section: Resultsmentioning

confidence: 99%

Endoscopic eradication therapy for patients with Barrett’s esophagus–associated dysplasia and intramucosal cancer

Wani¹,

Qumseya²,

Sultan³

et al. 2018

Gastrointestinal Endoscopy

139

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Barrett's esophagus (BE) is defined by the replacement of the normal squamous epithelium of the distal esophagus with metaplastic intestinal-type columnar epithelium. 1-3 BE is an adverse event of chronic GERD and the only identifiable premalignant condition for esophageal adenocarcinoma (EAC), a cancer that continues to increase in incidence. In 2014 there were approximately 18,170 incident cases of esophageal cancer in the United States, nearly 60% of which were EAC. [4][5][6] Although uncommon, EAC is a highly lethal cancer associated with a poor 5year survival rate of 15% to 20% and an overall median survival of <1 year in cases with advanced disease. [5][6][7] It is estimated that BE is present in 1% to 2% of the general adult population. 8,9 The stepwise and hypothesized progression of BE to invasive EAC is believed to occur through the histopathologic stages of intestinal metaplasia to low-grade dysplasia (LGD) to high-grade dysplasia (HGD) to intramucosal EAC and finally to invasive EAC. 3,[10][11][12][13] Endoscopic eradication therapy (EET) has significantly changed the management of patients with BE-related neoplasia and allows a minimally invasive treatment approach that avoids the morbidity and mortality associated with esophagectomy. Contemporary EET, supported by published literature, entails endoscopic mucosal resection (EMR) of visible lesions within the Barrett's segment and ablative techniques that include radiofrequency ablation (RFA) and cryotherapy. Several studies, including randomized controlled trials (RCTs), large observational studies, and population-based studies, have demonstrated the efficacy, effectiveness, and safety of EET to achieve complete eradication of intestinal metaplasia (CE-IM) and neoplasia while maintaining disease remission. [14][15][16][17][18][19][20][21][22] In addition, population-based studies report comparable outcomes between esophagectomy and EET in the management of BE-related HGD and mucosal EAC. 23 Available data suggest that EET is being performed not only at academic and tertiary care centers but also among community practices. 14,18 AIMS/SCOPEThe aim of this document is to offer evidence-based recommendations and clinical guidelines addressing key issues related to EET in the management of BE-related neoplasia. This document addresses the following clinical questions: 1. What is the role of confirmation of diagnosis by an expert GI pathologist or by a panel of pathologists in BE patients with dysplasia or intramucosal EAC referred for EET? 2. Comparing EET with surveillance, what is the optimal management strategy in BE patients with dysplasia (HGD and LGD) and intramucosal EAC? 3. Comparing EET with esophagectomy, what is the optimal management strategy in BE patients with HGD and intramucosal EAC? 4. What is the role of EMR in BE patients with a visible lesion detected during screening or surveillance? 5. What is the role of ablation of the remaining BE segment after EMR of all visible lesions in BE patients referred for EET? 6. Comparing EMR of visibl...

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“…A systematic review and meta‐analysis identified PPI use associated with a 71% risk reduction of EAC and HGD in BE patients, supporting the role of acid reduction to reduce cancer risk . Furthermore, it has been recently proposed that an effective reflux control is associated with a statistical significant reduction in BE recurrence after RFA . Optimizing the PPI dose or receiving fundoplication was correlated with a low rate of BE recurrence after RFA.…”

Section: Treatmentmentioning

confidence: 94%

“…79,80 Furthermore, it has been recently proposed that an effective reflux control is associated with a statistical significant reduction in BE recurrence after RFA. 81 Optimizing the PPI dose or receiving fundoplication was correlated with a low rate of BE recurrence after RFA. Some studies suggest that fundoplication may result in improved control of gastroesophageal reflux (acid, weakly acid, and weakly alkaline) 82 and is associated with fewer recurrences of intestinal metaplasia after RFA in selected patients with a coexisting hiatal hernia of > 3 cm 83 or more severe reflux exposure.…”

Section: Endoscopic Therapy For Bementioning

confidence: 94%

Recent advances in Barrett's esophagus

Inadomi

Alastal

Bonavina

et al. 2018

Annals of the New York Academy of Sciences

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Barrett's esophagus (BE) is the only known precursor of esophageal adenocarcinoma, one of the few cancers with increasing incidence in developed countries. The pathogenesis of BE is unclear with regard to either the cellular origin of this metaplastic epithelium or the manner in which malignant transformation occurs, although recent data indicate a possible junctional origin of stem cells for BE. Treatment of BE may be achieved using endoscopic eradication therapy; however, there is a lack of discriminatory tools to identify individuals at sufficient risk for cancer development in whom intervention is warranted. Reduction in gastroesophageal reflux of gastric contents including acid is mandatory to achieve remission from BE after endoscopic ablation, and can be achieved using medical or nonmedical interventions. Research topics of greatest interest include the mechanism of BE development and transformation to cancer, risk stratification methods to identify individuals who may benefit from ablation of BE, optimization of eradication therapy, and surveillance methods to ensure that remission is maintained after eradication is achieved.

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Recurrence of Barrett’s Esophagus is Rare Following Endoscopic Eradication Therapy Coupled With Effective Reflux Control

Abstract: The current study highlights the importance of reflux control in patients with BE undergoing EET. In this setting, EET has long-term durability with low recurrence rates providing early evidence for extending endoscopic surveillance intervals after EET.

Cited by 69 publications

References 57 publications

Timeline and location of recurrence following successful ablation in Barrett’s oesophagus: an international multicentre study

Timeline and location of recurrence following successful ablation in Barrett’s oesophagus: an international multicentre study

Endoscopic eradication therapy for patients with Barrett’s esophagus–associated dysplasia and intramucosal cancer

Recent advances in Barrett's esophagus

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