Recurrent intestinal metaplasia after radiofrequency ablation for Barrett’s esophagus: endoscopic findings and anatomic location

Abstract

Background Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett’s esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence is common after CEIM and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well described. Objective The objectives of this study are to describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence. Design Retrospective cohort. Setting Single referral center. Patients 198 BE patients with at least 2 surveillance endoscopies after CEIM. Interventions RFA, endoscopic mucosal resection (EMR), surveillance endoscopy. Main outcome measurements The anatomic location and histologic grade of recurrence. Results In a mean 3.0 years of follow-up, 32 (16.2%; 95% CI, 11.0%–22.0%) patients recurred, 5 (2.5%; 95% CI, 0.3%–4.7%) of which progressed beyond their worst pre-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence greater than 1 cm proximal to the GE junction was always accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white-light or narrow-band imaging for recurrence was 59.4% [42.4%, 76.4%] and the specificity was 80.6% [77.2%, 84.0%]. Limitations Single-center study Conclusions Recurrent IM is often not visible to the endoscopist and is most common near the GEJ. Random biopsies >1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.

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

“…Eighty per cent of recurrences in the tubular oesophagus were visible endoscopically,10 and random biopsies >1 cm proximal to the GOJ had no yield for any recurrence 15. Data from the current larger multicentre cohort show that 82% of tubular oesophageal recurrences were visible, and the yield of random biopsies >1 cm proximal to the GOJ was extremely low (1.2% yield for any recurrence and 0.2% for dysplastic recurrence).…”

Risk of recurrence of Barrett’s esophagus after successful endoscopic therapy

“…This included 21 RFA studies that reported 603 cases of IM recurrence in 3186 patients over 5741 patient-years of follow-up. 9,12,14,15,18,21,22,27,29,30,32,39-41,43,47,49,51,53,54 Figure 1 shows the schematic diagram of study selection.…”

“…Among the 41 included studies, the primary endoscopic treatment modality was RFA in 21 studies, 9,12,14,15,18,21,22,27,29,30,32,39-41,43,47,49,51,53,54 APC in 7 studies, 33,34,36,45,46,48,52 EMR in 7 studies, 20,21,31,37,42,44,50 PDT in 2 studies, 7,19 multipolar electrocoagulation in 2 studies, 13,28 laser in 1 study, 35 and cryotherapy in 1 study. 38 Twenty-three studies were from North America, 9,12,14,15,18-20,22,27,30,32,35,37-39,41-44,47,53,54 15 studies were from Europe, 7,13,21,31,33,34,40,45,46,48-52 and 1 study each was from South America, 28 Africa, 36 and the Asia-Pacific. 29 Four studies included NDBE patients only, 13,28,34,52 and 16 studies included only DBE ± early neoplasia patients, 7,19-21,29,31,37,39,40,42,44,49,51,53,54 with the remainder including NDBE and DBE patients.…”

“…Among the RFA studies, 7 studies were deemed high quality, 9,12,18,32,39,49,54 11 studies were deemed medium quality 14,21,22,29,40,41,43,47,51,53 and 3 studies were deemed low quality. 15,27,30 When all endoscopic modalities were included, 9 studies were deemed high quality, 9,12,18,32,37,39,42,49,54 22 studies were deemed medium quality, 7,13,14,19-22,28,29,31,34,35,40,41,43,44,47,50,51,53 and 10 studies were deemed low quality. 15,27,30,33,36,38,45,46,48,52 …”

“…Substantial heterogeneity (I 2 = 93%) was seen in the analysis. On meta-analysis of the 28 studies that reported histology of recurrence, 7,9,12-15,18,22,28-32,34,35,37,39,42-50,54 the pooled incidence of DBE was 1.3% per patient-year (95% CI, .8-1.7) (Fig. 3B) and of HGD/EAC was .8% per patient-year (95% CI, .5-1.1) (Fig.…”