Recurrence of intestinal metaplasia and early neoplasia after endoscopic eradication therapy for Barrett’s esophagus: a systematic review and meta-analysis

Abstract

Background Conflicting data exist with regard to recurrence rates of intestinal metaplasia (IM) and dysplasia after achieving complete eradication of intestinal metaplasia (CE-IM) in Barrett’s esophagus (BE) patients. Aim (i) To determine the incidence of recurrent IM and dysplasia achieving CE-IM and (ii) to compare recurrence rates between treatment modalities [radiofrequency ablation (RFA) with or without endoscopic mucosal resection (EMR) vs stepwise complete EMR (SRER)]. Methods A systematic search was performed for studies reporting on outcomes and estimates of recurrence rates after achieving CE-IM. Pooled incidence [per 100-patient-years (PY)] and risk ratios with 95 %CI were obtained. Heterogeneity was measured using the I 2 statistic. Subgroup analyses, decided a priori, were performed to explore heterogeneity in results. Results A total of 39 studies were identified (25-RFA, 13-SRER, and 2 combined). The pooled incidence of any recurrence was 7.5 (95 %CI 6.1 – 9.0)/100 PY with a pooled incidence of IM recurrence rate of 4.8 (95 %CI 3.8 – 5.9)/100 PY, and dysplasia recurrence rate of 2.0 (95 %CI 1.5 – 2.5)/100 PY. Compared to the SRER group, the RFA group had significantly higher overall [8.6 (6.7 – 10.5)/100 PY vs. 5.1 (3.1 – 7)/100 PY, P = 0.01] and IM recurrence rates [5.8 (4.3 – 7.3)/100 PY vs. 3.1 (1.7 – 4)/100 PY, P < 0.01] with no difference in recurrence rates of dysplasia. Significant heterogeneity between studies was identified. The majority of recurrences were amenable to repeat endoscopic eradication therapy (EET). Conclusion The results of this study demonstrate that the incidence rates of overall, IM, and dysplasia recurrence rates post-EET are not inconsiderable and reinforce the importance of close surveillance after achieving CE-IM.

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

“…Recurrence of intestinal metaplasia and neoplasia after EET was addressed in 2 recent systematic reviews and meta-analyses. 51,52 These studies demonstrated that >95% of all recurrences were successfully treated with EET, adding credence to use of EET for the management of BE-related neoplasia patients. The panel members also accounted for the multiple endoscopy sessions required to achieve the goal of EET: complete eradication of dysplasia and CE-IM.…”

“…Improvement in prevention of stricture formation post-cEMR is also required before this treatment strategy can be recommended as a primary treatment modality. 51 Question 7: After achieving CE-IM, what is the role of surveillance endoscopy?…”

“…Summary of the Evidence: The primary outcomes for this clinical question were recurrence rates of intestinal metaplasia and neoplasia, progression rates to cancer, and EAC-specific and all-cause mortality between patients enrolled in surveillance programs after achieving CE-IM compared with those who are not. The outcome of recurrence of intestinal metaplasia and neoplasia was addressed using evidence from a recent systematic review and metaanalysis by Fujii-Lau et al 51 This study aimed to determine the incidence of recurrent intestinal metaplasia and dysplasia after achieving CE-IM using treatment modalities that included RFA and EMR. From a total of 3311 identified studies, full texts from 144 studies were reviewed, and 39 studies (25 RFA, 13 stepwise complete EMR, 2 combined) were included in the final analysis.…”

“…A reliable estimate of the risk of recurrence after achieving CE-IM, as highlighted above, is critical in the education of physicians and patients before embarking on EET, determining cost-effectiveness of EET, and establishing surveillance guidelines (duration and frequency of surveillance endoscopy). 51,52 Despite the lack of comparative data assessing the impact of surveillance endoscopy in patients achieving CE-IM, a recommendation of surveillance was provided given the risk of recurrence after achieving CE-IM. The panel members also agreed that patients in whom the goal of EET is to achieve complete eradication of dysplasia (select few patients) should also be enrolled in surveillance programs after achieving this endpoint.…”

“…22 Although the number of endoscopies with negative biopsy specimens required to achieve CE-IM is not standardized (CE-IM defined by 1 or 2 consecutive negative endoscopies), no difference in recurrence rates have been reported based on the definition of CE-IM. 51,53 Available data do not allow for a timeto-event analysis accounting for individual patient data and patients lost to follow-up. 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.…”