Increased detection of Barrett's esophagus-associated neoplasia using wide-area trans-epithelial sampling: a multicenter, prospective, randomized trial

Adjunctive Use of Wide-Area Transepithelial Sampling-3D in Patients With Symptomatic Gastroesophageal Reflux Increases Detection of Barrett's Esophagus and Dysplasia

INTRODUCTION

Patients with gastroesophageal reflux (GERD) symptoms undergoing screening upper endoscopy for Barrett's esophagus (BE) frequently demonstrate columnar-lined epithelium, with forceps biopsies (FBs) failing to yield intestinal metaplasia (IM). Repeat endoscopy is then often necessary to confirm a BE diagnosis. The aim of this study was to assess the yield of IM leading to a diagnosis of BE by the addition of wide-area transepithelial sampling (WATS-3D) to FB in the screening of patients with GERD.

METHODS

We performed a prospective registry study of patients with GERD undergoing screening upper endoscopy. Patients had both WATS-3D and FB. Patients were classified by their Z line appearance: regular, irregular (<1 cm columnar-lined epithelium), possible short-segment BE (1 to <3 cm), and possible long-segment BE (≥3 cm). Demographics, IM yield, and dysplasia yield were calculated. Adjunctive yield was defined as cases identified by WATS-3D not detected by FB, divided by cases detected by FB. Clinicians were asked if WATS-3D results affected patient management.

RESULTS

Of 23,933 patients, 6,829 (28.5%) met endoscopic criteria for BE. Of these, 2,878 (42.1%) had IM identified by either FB or WATS-3D. Among patients fulfilling endoscopic criteria for BE, the adjunctive yield of WATS-3D was 76.5% and absolute yield was 18.1%. One thousand three hundred seventeen patients (19.3%) who fulfilled endoscopic BE criteria had IM detected solely by WATS-3D. Of 240 patients with dysplasia, 107 (44.6%) were found solely by WATS-3D. Among patients with positive WATS-3D but negative FB, the care plan changed in 90.7%.

DISCUSSION

The addition of WATS-3D to FB in patients with GERD being screened for BE resulted in confirmation of BE in an additional one-fifth of patients. Furthermore, dysplasia diagnoses approximately doubled.

The Evolving Role of Artificial Intelligence in Gastrointestinal Histopathology: An Update

Significant advances in artificial intelligence (AI) over the past decade potentially may lead to dramatic effects on clinical practice. Digitized histology represents an area ripe for AI implementation. We describe several current needs within the world of gastrointestinal histopathology, and outline, using currently studied models, how AI potentially can address them. We also highlight pitfalls as AI makes inroads into clinical practice.

Benefit of adjunctive wide-area transepithelial sampling with 3-dimensional computer-assisted analysis plus forceps biopsy based on Barrett's esophagus segment length

BACKGROUND AND AIMS

Wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS-3D) has been shown to increase the diagnostic yield of intestinal metaplasia (IM) and dysplasia within a segment of suspected or known Barrett's esophagus (BE) when used as an adjunct to forceps biopsies. Few data are available regarding how segment length affects WATS-3D yield. The purpose of this study was to evaluate adjunctive WATS-3D use in patients with varying lengths of BE.

METHODS

A total of 8471 patients (52.5% male; mean age, 63 years) enrolled in 2 registry studies were included in this study. All patients were being screened or surveyed for BE with both forceps biopsies and WATS-3D. The adjunctive and absolute yield of WATS-3D was calculated according to the length of the patient's BE segment.

RESULTS

The overall adjunctive and absolute increased diagnostic yields with WATS-3D were 47.6% and 17.5%, respectively, for detection of IM, and 139% and 2.4% for detection of dysplasia. IM and dysplasia detection both increased with the use of WATS-3D regardless of segment length. Increase in IM diagnostic yield was significantly higher in short- versus long-segment cases but higher in long-segment cases for dysplasia detection.

CONCLUSIONS

This study shows that when WATS-3D is added as an adjunct to forceps biopsies, it is effective at increasing the diagnostic yield of both BE and associated dysplasia in patients with both short and long segments of esophageal columnar-lined epithelium.

Wide-area transepithelial sampling with computer-assisted analysis to detect high grade dysplasia and cancer in Barrett's esophagus: a multicenter randomized study

BACKGROUND

Current surveillance for Barrett's esophagus (BE), consisting of four-quadrant random forceps biopsies (FBs), has an inherent risk of sampling error. Wide-area transepithelial sampling (WATS) may increase detection of high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). In this multicenter randomized trial, we aimed to evaluate WATS as a substitute for FB.

METHODS

Patients with known BE and a recent history of dysplasia, without visible lesions, at 17 hospitals were randomized to receive either WATS followed by FB or vice versa. All WATS samples were examined, with computer assistance, by at least two experienced pathologists at the CDx Diagnostics laboratory. Similarly, all FBs were examined by two expert pathologists. The primary end point was concordance/discordance for detection of HGD/EAC between the two techniques.

RESULTS

172 patients were included, of whom 21 had HGD/EAC detected by both modalities, 18 had HGD/EAC detected by WATS but missed by FB, and 12 were detected by FB but missed by WATS. The detection rate of HGD/EAC did not differ between WATS and FB (P = 0.36). Using WATS as an adjunct to FB significantly increased the detection of HGD/EAC vs. FB alone (absolute increase 10 % [95 %CI 6 % to 16 %]). Mean procedural times in minutes for FB alone, WATS alone, and the combination were 6.6 (95 %CI 5.9 to 7.1), 4.9 (95 %CI 4.1 to 5.4), and 11.2 (95 %CI 10.5 to 14.0), respectively.

CONCLUSIONS

Although the combination of WATS and FB increases dysplasia detection in a population of BE patients enriched for dysplasia, we did not find a statistically significant difference between WATS and FB for the detection of HGD/EAC as single modality.

Randomized Clinical Trials of Machine Learning Interventions in Health Care: A Systematic Review

IMPORTANCE

Despite the potential of machine learning to improve multiple aspects of patient care, barriers to clinical adoption remain. Randomized clinical trials (RCTs) are often a prerequisite to large-scale clinical adoption of an intervention, and important questions remain regarding how machine learning interventions are being incorporated into clinical trials in health care.

OBJECTIVE

To systematically examine the design, reporting standards, risk of bias, and inclusivity of RCTs for medical machine learning interventions.

EVIDENCE REVIEW

In this systematic review, the Cochrane Library, Google Scholar, Ovid Embase, Ovid MEDLINE, PubMed, Scopus, and Web of Science Core Collection online databases were searched and citation chasing was done to find relevant articles published from the inception of each database to October 15, 2021. Search terms for machine learning, clinical decision-making, and RCTs were used. Exclusion criteria included implementation of a non-RCT design, absence of original data, and evaluation of nonclinical interventions. Data were extracted from published articles. Trial characteristics, including primary intervention, demographics, adherence to the CONSORT-AI reporting guideline, and Cochrane risk of bias were analyzed.

FINDINGS

Literature search yielded 19 737 articles, of which 41 RCTs involved a median of 294 participants (range, 17-2488 participants). A total of 16 RCTS (39%) were published in 2021, 21 (51%) were conducted at single sites, and 15 (37%) involved endoscopy. No trials adhered to all CONSORT-AI standards. Common reasons for nonadherence were not assessing poor-quality or unavailable input data (38 trials [93%]), not analyzing performance errors (38 [93%]), and not including a statement regarding code or algorithm availability (37 [90%]). Overall risk of bias was high in 7 trials (17%). Of 11 trials (27%) that reported race and ethnicity data, the median proportion of participants from underrepresented minority groups was 21% (range, 0%-51%).

CONCLUSIONS AND RELEVANCE

This systematic review found that despite the large number of medical machine learning-based algorithms in development, few RCTs for these technologies have been conducted. Among published RCTs, there was high variability in adherence to reporting standards and risk of bias and a lack of participants from underrepresented minority groups. These findings merit attention and should be considered in future RCT design and reporting.

Randomized Controlled Trials of Artificial Intelligence in Clinical Practice: Systematic Review

BACKGROUND

The number of artificial intelligence (AI) studies in medicine has exponentially increased recently. However, there is no clear quantification of the clinical benefits of implementing AI-assisted tools in patient care.

OBJECTIVE

This study aims to systematically review all published randomized controlled trials (RCTs) of AI-assisted tools to characterize their performance in clinical practice.

METHODS

CINAHL, Cochrane Central, Embase, MEDLINE, and PubMed were searched to identify relevant RCTs published up to July 2021 and comparing the performance of AI-assisted tools with conventional clinical management without AI assistance. We evaluated the primary end points of each study to determine their clinical relevance. This systematic review was conducted following the updated PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines.

RESULTS

Among the 11,839 articles retrieved, only 39 (0.33%) RCTs were included. These RCTs were conducted in an approximately equal distribution from North America, Europe, and Asia. AI-assisted tools were implemented in 13 different clinical specialties. Most RCTs were published in the field of gastroenterology, with 15 studies on AI-assisted endoscopy. Most RCTs studied biosignal-based AI-assisted tools, and a minority of RCTs studied AI-assisted tools drawn from clinical data. In 77% (30/39) of the RCTs, AI-assisted interventions outperformed usual clinical care, and clinically relevant outcomes improved with AI-assisted intervention in 70% (21/30) of the studies. Small sample size and single-center design limited the generalizability of these studies.

CONCLUSIONS

There is growing evidence supporting the implementation of AI-assisted tools in daily clinical practice; however, the number of available RCTs is limited and heterogeneous. More RCTs of AI-assisted tools integrated into clinical practice are needed to advance the role of AI in medicine.

TRIAL REGISTRATION

PROSPERO CRD42021286539; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=286539.

Multicenter randomized controlled trial comparing forceps biopsy sampling with wide-area transepithelial sampling brush for detecting intestinal metaplasia and dysplasia during routine upper endoscopy

BACKGROUND AND AIMS

Intestinal metaplasia (IM) in the esophagus is a potentially premalignant mucosal change. The aim of this study was to compare the frequency of IM detection during upper endoscopy by forceps biopsy sampling (FB) versus wide-area transepithelial sampling (WATS) brush.

METHODS

Patients presenting for upper endoscopy for foregut symptoms or surveillance of Barrett's esophagus (BE) at 9 centers in the United States were randomized to either FB or WATS.

RESULTS

Of 1002 patients, FB was done in 505 and WATS in 497. The overall frequency of finding IM was 21% and was similar with FB (19.6%) and WATS (22.7%, P = .2). Low-grade dysplasia was found in 8 patients. No patient had high-grade dysplasia. There was no difference in detection of dysplasia between FB and WATS. In patients with no history of IM, WATS found significantly more IM compared with FB when a columnar-lined esophagus (CLE) was present (32.4% with WATS vs 15.2% with FB, P = .004). In 184 patients with known BE, FB and WATS found IM with similar frequency (38.5% FB vs 41.9% WATS, P = .6) with no difference in short- or long-segment BE.

CONCLUSIONS

Overall, FB and WATS detected a similar frequency of IM and dysplasia. WATS was twice as likely as FB to find IM in patients without a history of BE who had CLE on endoscopy. In patients with known BE, WATS and FB showed IM and dysplasia with similar frequency. These findings suggest that WATS can be used instead of FB with similar or improved efficacy at detecting IM and dysplasia. (Clinical trial registration number: NCT03859557.).

Surveillance of Barrett's esophagus using wide-area transepithelial sampling: systematic review and meta-analysis

Background and study aims  Wide-area transepithelial sampling (WATS) is an emerging technique that may increase dysplasia detection in Barrett's esophagus (BE). We conducted a systematic review and meta-analysis of patients who underwent surveillance for BE assessing the additional yield of WATS to forceps biopsy (FB). Methods  We searched Pubmed, Embase, Web of science, and the Cochrane library, ending in January 2021. The primary outcomes of interest were the relative and absolute increase in dysplasia detection when adding WATS to FB. Heterogeneity was assessed using I ² and Q statistic. Publication bias was assessed using funnel plots and classic fail-safe test. Results  A total of seven studies were included totaling 2,816 patients. FB identified 158 dysplasia cases, whereas WATS resulted in an additional 114 cases. The pooled risk ratio (RR) of all dysplasia detection was 1.7 (1.43-2.03), P  < 0.001, I ²  = 0. For high-grade dysplasia (HGD), the pooled RR was 1.88 (1.28-2.77), P  = 0.001, I ²  = 33 %. The yield of WATS was dependent on the prevalence of dysplasia in the study population. Among studies with high rates of dysplasia, the absolute increase in dysplasia detection (risk difference, RD) was 13 % (8 %-18 %, P  < 0.0001, number needed to treat [NNT] = 8). The pooled RD in HGD was 9 % (2 %-16 %), P  < 0.001, NNT = 11. For studies with a low prevalence of dysplasia, RD for all dysplasia was 2 % (1 %-3 %), P  = 0.001, NNT = 50. For HGD, the RD was 0.6 % (0.2 %-1.3 %), P  = 0.019, NNT = 166. Conclusions  In populations with a high prevalence of dysplasia, adding WATS to FB results in a significant increase in dysplasia detection.

Artificial Intelligence in the Management of Barrett’s Esophagus and Early Esophageal Adenocarcinoma

Simple Summary

Esophageal adenocarcinoma is increasing in incidence and is the most common subtype of esophageal cancer in Western societies. AI systems are currently under development and validation in many fields of gas-troenterology.

Abstract

Esophageal adenocarcinoma is increasing in incidence and is the most common subtype of esophageal cancer in Western societies. The stepwise progression of Barrett´s metaplasia to high-grade dysplasia and invasive adenocarcinoma provides an opportunity for screening and surveillance. There are important unresolved issues, which include (i) refining the definition of the screening population in order to avoid unnecessary invasive diagnostics, (ii) a more precise prediction of the (very heterogeneous) individual progression risk from metaplasia to invasive cancer in order to better tailor surveillance recommendations, (iii) improvement of the quality of endoscopy in order to reduce the high miss rate for early neoplastic lesions, and (iv) support for the diagnosis of tumor infiltration depth in order to guide treatment decisions. Artificial intelligence (AI) systems might be useful as a support to better solve the above-mentioned issues.

Progression of Barrett's esophagus, crypt dysplasia, and low-grade dysplasia diagnosed by wide-area transepithelial sampling with 3-dimensional computer-assisted analysis: a retrospective analysis

BACKGROUND AND AIMS

Wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS3D) is used as an adjunct to forceps biopsy sampling in Barrett's esophagus (BE). BE-associated crypt dysplasia (CD), which can be detected by WATS3D, involves crypts but not surface epithelium. The risk of neoplastic progression of CD has never been evaluated. The prognosis of WATS3D-diagnosed nondysplastic BE (NDBE) and low-grade dysplasia (LGD) is also unknown. We assessed the risk of progression of WATS3D-reported NDBE, CD, and LGD with high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC).

METHODS

We analyzed patients who underwent WATS3D in routine care. Eligible patients had 2 WATS3D ≥12 months apart. Patients were categorized by the initial WATS3D finding as NDBE, CD, or LGD. Patient-years of observation were calculated by multiplying the mean follow-up by the number of patients. Progression, defined as a subsequent finding of HGD/EAC on forceps biopsy sampling, was assessed. The crude progression rate was calculated, and Kaplan-Meier analysis compared progression rates stratified by baseline histology. Bivariate analysis identified progression risk factors.

RESULTS

Of 151,224 WATS3D cases, 43,145 (29%) had BE. Of these, 4545 patients had 2 WATS3D separated by ≥12 months. The mean follow-up was 1.97 years (range, 1.0-6.42). In patients with baseline NDBE, progression was .08% per patient-year (95% confidence interval [CI], .02%-.14%). Progression of baseline CD was significantly higher, at 1.42% per patient-year (95% CI, 0%-3.01%). For baseline LGD, progression was 5.79% per patient-year (95% CI, 1.02%-10.55%). Other risk factors for progression were increasing age and BE segment length.

CONCLUSIONS

NDBE found on WATS3D has a very low risk of progression. CD reported on WATS3D appears to be a neoplastic precursor lesion, with a risk of progression in this study significantly higher than NDBE but lower than LGD. The clinical utility of CD requires further investigation.

Magnitude and Time-Trend Analysis of Postendoscopy Esophageal Adenocarcinoma: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Identification of postendoscopy esophageal adenocarcinoma (PEEC) among Barrett's esophagus (BE) patients presents an opportunity to improve survival of esophageal adenocarcinoma (EAC). We aimed to estimate the proportion of PEEC within the first year after BE diagnosis.

METHODS

Multiple databases (Medline, Embase, Scopus, and Cochrane databases) were searched until September 2020 for original studies with at least 1-year follow-up evaluation that reported EAC and/or high-grade dysplasia (HGD) in the first year after index endoscopy in nondysplastic BE, low-grade dysplasia, or indefinite dysplasia. The proportions of PEEC defined using EAC alone and EAC+HGD were calculated by dividing EAC or EAC+HGD in the first year over the total number of EAC or EAC+HGD, respectively.

RESULTS

We included 52 studies with 145,726 patients and a median follow-up period of 4.8 years. The proportion of PEEC (EAC) was 21% (95% CI, 13-31) and PEEC (EAC+HGD) was 26% (95% CI, 19-34). Among studies with nondysplastic BE only, the PEEC (EAC) proportion was 17% (95% CI, 11-23) and PEEC (EAC+HGD) was 14% (95% CI, 8-19). Among studies with 5 or more years of follow-up evaluation, the PEEC (EAC) proportion was 10% and PEEC (EAC+HGD) was 19%. Meta-regression analysis showed a strong inverse relationship between PEEC and incident EAC (P < .001). The PEEC (EAC) proportion increased from 5% in studies published before 2000 to 30% after 2015. Substantial heterogeneity was observed for most analyses.

CONCLUSIONS

PEEC accounts for a high proportion of HGD/EACs and is proportional to reduction in incident EAC. Using best endoscopic techniques now and performing future research on improving neoplasia detection through implementation of quality measures and educational tools is needed to reduce PEEC.

Barrett's esophagus: The pathomorphological and molecular genetic keystones of neoplastic progression

Barrett's esophagus is a widespread chronically progressing disease of heterogeneous nature. A life threatening complication of this condition is neoplastic transformation, which is often overlooked due to lack of standardized approaches in diagnosis, preventative measures and treatment. In this essay, we aim to stratify existing data to show specific associations between neoplastic transformation and the underlying processes which predate cancerous transition. We discuss pathomorphological, genetic, epigenetic, molecular and immunohistochemical methods related to neoplasia detection on the basis of Barrett's esophagus. Our review sheds light on pathways of such neoplastic progression in the distal esophagus, providing valuable insight into progression assessment, preventative targets and treatment modalities. Our results suggest that molecular, genetic and epigenetic alterations in the esophagus arise earlier than cancerous transformation, meaning the discussed targets can help form preventative strategies in at-risk patient groups.

Utility of ancillary studies in the diagnosis and risk assessment of Barrett's esophagus and dysplasia

Barrett's esophagus (BE) is a major risk factor for the development of esophageal adenocarcinoma (EAC). BE patients undergo periodic endoscopic surveillance with biopsies to detect dysplasia and EAC, but this strategy is imperfect owing to sampling error and inconsistencies in the diagnosis and grading of dysplasia, which may result in an inaccurate diagnosis or risk assessment for progression to EAC. The desire for more accurate diagnosis and better risk stratification has prompted the investigation and development of potential biomarkers that might assist pathologists and clinicians in the management of BE patients, allowing more aggressive endoscopic surveillance and treatment options to be targeted to high-risk individuals, while avoiding frequent surveillance or unnecessary interventions in those at lower risk. It is known that progression of BE to dysplasia and EAC is accompanied by a host of genetic alterations, and that exploration of these markers could be potentially useful to diagnose/grade dysplasia and/or to risk stratify BE patients. Several biomarkers have shown promise in identifying early neoplastic transformation and thus may be useful adjuncts to histologic evaluation. This review provides an overview of some of the currently available biomarkers and assays, including p53 immunostaining, Wide Area Transepithelial Sampling with Three-Dimensional Computer-Assisted Analysis (WATS^3D), TissueCypher, mutational load analysis (BarreGen), fluorescence in situ hybridization, and DNA content abnormalities as detected by DNA flow cytometry.

Wide-area transepithelial sampling for dysplasia detection in Barrett's esophagus: a systematic review and meta-analysis

BACKGROUND AND AIMS

Seattle protocol forceps biopsy sampling (FB) is currently recommended for surveillance in Barrett's esophagus (BE) but limited by sampling error and lack of compliance. Wide-area transepithelial sampling with 3-dimensional analysis (WATS3D; CDx Diagnostics, Suffern, NY, USA) is reported to increase BE dysplasia detection. We assessed the incremental yield and clinical significance of WATS3D for dysplasia detection over FB in a systematic review and meta-analysis.

METHODS

We queried major scientific databases for studies using WATS3D and FB from 2000 to 2020. The primary outcome was the incremental yield of WATS3D-detected dysplasia (defined as a composite of indefinite for dysplasia, low- and high-grade dysplasia [HGD] and esophageal adenocarcinoma [EAC]) over FB. Secondary outcomes were incremental yields of HGD/EAC and rate of reconfirmation of WATS3D dysplasia on subsequent FB.

RESULTS

Meta-analysis of 7 eligible studies demonstrated that FB diagnosed dysplasia in 15.9% of cases, whereas the incremental yield with WATS3D was 7.2% (95% confidence interval, 3.9%-11.5%; I²= 92.1%). Meta-analysis of 6 studies demonstrated that FB diagnosed HGD/EAC in 2.3% of patients, whereas the incremental yield with WATS3D was 2.1% (95% confidence interval, .4%-5.3%; I²= 92.7%). Notably, WATS3D was negative in 62.5% of cases where FB identified dysplasia. Two studies reported reconfirmation of WATS3D dysplasia with FB histology in only 20 patients.

CONCLUSIONS

WATS3D increases dysplasia detection; however, the clinical significance of this increased dysplasia detection remains uncertain. Data from endoscopic follow-up to ascertain FB histology in patients with dysplasia based solely on WATS3D are needed to determine the optimal clinical application and significance of WATS3D-only dysplasia.

Role of Wide-Area Transepithelial Sampling With 3D Computer-Assisted Analysis in the Diagnosis and Management of Barrett's Esophagus

Barrett's esophagus (BE) is a premalignant condition in which cancer prevention is performed by endoscopic surveillance combined with Seattle protocol mucosal biopsies. The Seattle protocol has significant limitations, including a high rate of sampling error due to the focality of dysplasia/carcinoma, low endoscopist adherence to the protocol, and a high degree of variability in pathologic interpretation. These factors all contribute to a high incidence of cancers missed within 1 year of surveillance endoscopy. Wide-area transepithelial sampling with computer-assisted three-dimensional analysis (WATS3D) is a relatively new technique that minimizes sampling error by using a brush biopsy device that extensively samples "at risk" mucosa and helps pathologists diagnose dysplasia/neoplasia by generating three-dimensional images of whole crypts using a neural network-based software program. Several large prospective trials (involving both academic and community practices) have shown significantly increased rates of detection of dysplasia and intestinal metaplasia in both screening and surveillance in patients with BE when used as an adjunct to Seattle protocol-based forceps biopsies. The WATS3D diagnostic platform was included in the most recent American Society for Gastrointestinal Endoscopy Barrett's guideline as an adjunct to forceps biopsies (conditional recommendation and low quality of evidence). This review summarizes the scientific and pathologic basis of WATS3D technology, its potential impact on BE surveillance and management, and its limitations and future directions.

Barrett's esophagus with low-grade dysplasia: high rate of upstaging at Barrett's esophagus referral units suggests progression rates may be overestimated

BACKGROUND AND AIMS

The reported progression rate from low-grade dysplasia (LGD) in Barrett's esophagus (BE) to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) ranges from .4% to 13.4% per year. We hypothesize that some reported progression rates may be overestimated because of prevalent HGD or EAC that was not identified during endoscopic assessments performed in the community. Our aim is to determine the proportion of prevalent HGD or EAC detected by BE referral units (BERUs) in patients referred from the community with a recent diagnosis of LGD.

METHODS

All patients referred from the community to 6 BERUs with a diagnosis of BE with LGD were identified. Patients with an assessment endoscopy performed at BERUs more than 6 months from their referral endoscopy in the community were excluded. Visible lesions and histology outcomes were compared between the community referral endoscopy and the assessment endoscopy performed at BERUs.

RESULTS

The median time between BERU assessment and referral endoscopy was 79 days (interquartile range, 54-114). Of the 75 patients referred from the community with LGD, BERU assessment identified HGD or EAC in 20 patients (27%). BERU assessment identified more visible lesions than referral endoscopy performed in the community (39 [52%] vs 9 [12%], respectively; P = .029).

CONCLUSIONS

BERU assessment endoscopy identified more visible lesions than community referral endoscopy and identified HGD or EAC in 27% of patients referred from the community with a recent diagnosis of LGD. Reported progression rates from LGD to HGD or EAC may be overestimated.

Screening for Barrett's Esophagus in Patients with Cirrhosis Using WATS3D

The prevalence of gastroesophageal reflux disease and neoplastic progression in patients with cirrhosis is higher compared to patients without liver disease. The gold standard for screening for Barrett’s esophagus (BE) is esophagogastroduodenoscopy with forceps biopsy using the Seattle protocol. However, many physicians refrain from taking biopsies in cirrhotic patients and rely solely on endoscopic findings to avoid hemorrhagic complications secondary to variceal bleeding or coagulopathy. In this case series, we present seven cirrhotic patients at high risk of bleeding that underwent screening for BE by upper endoscopy using WATS3D with no postprocedural complications.

Recent advances in early esophageal cancer: diagnosis and treatment based on endoscopy

Esophageal cancer (EC) often cannot be discovered in time because of its asymptomatic or symptom-atypical characteristics in early stage. The risk and probability of lymph node metastasis and distant metastasis increase correspondingly as the cancer aggressively invades deeper layers. Treatment regimens may be shifted to surgery and chemoradiotherapy (CRT) from endoscopic eradication therapy (EET) with poor quality of life and prognosis. It is imperative to identify dysplasia and EC early and enable early curative endoscopic treatments. Newer methods have been attempted in the clinical setting to achieve early detection at a more microscopic and precise level. Newer imaging techniques and artificial intelligence (AI) technology have been involved in targeted biopsies and will gradually unveil the visualization of pathology in the future. Early detection and diagnosis are the prerequisite to choose personal and precise treatment regimens. EET has also been undergoing development and improvement to benefit more patients as the first option or the firstly chosen alternative therapy, when compared with esophagectomy. More clinical studies are needed to provide more possibilities for EET.

Endoscopic management of Barrett's esophagus: Western perspective of current status and future prospects

Barrett's esophagus (BE) is a precursor to esophageal adenocarcinoma and current practice is to establish endoscopic surveillance once diagnosed, in order to identify early dysplasia and neoplasia that has the potential to undergo endoscopic eradication therapy (EET). Before embarking upon EET the clinical team has a duty to consider all viable options and come to a plan based on recent evidence. The therapeutic approach varies greatly but largely adheres to the mantra of 'Detect-Resect-Ablate', in which high-quality endoscopy identifies BE associated pathology, associated lesions (if present) undergo safe endoscopic resection and remaining intestinal metaplasia in the esophagus is ablated to prevent recurrence of dysplasia. In this review, current practice, pitfalls, complications, and the future perspectives on practice in this field are discussed. The Western perspective is focused on here, with an outline of the differences in clinical practice with Asian nations and attempts to bridge these differences.

Revising the European Society of Gastrointestinal Endoscopy (ESGE) research priorities: a research progress update

BACKGROUND

One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities.

METHODS

As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined).

RESULTS

The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition.

CONCLUSIONS

Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.

Application of artificial intelligence to endoscopy on common gastrointestinal benign diseases

Artificial intelligence (AI) has been widely involved in every aspect of healthcare in the preclinical stage. In the digestive system, AI has been trained to assist auxiliary examinations including histopathology, endoscopy, ultrasonography, computerized tomography, and magnetic resonance imaging in detection, diagnosis, classification, differentiation, prognosis, and quality control. In the field of endoscopy, the application of AI, such as automatic detection, diagnosis, classification, and invasion depth, in early gastrointestinal (GI) cancers has received wide attention. There is a paucity of studies of AI application on common GI benign diseases based on endoscopy. In the review, we provide an overview of AI applications to endoscopy on common GI benign diseases including in the esophagus, stomach, intestine, and colon. It indicates that AI will gradually become an indispensable part of normal endoscopic detection and diagnosis of common GI benign diseases as clinical data, algorithms, and other related work are constantly repeated and improved.

WATS3D versus forceps biopsy in screening for Barrett's esophagus: experience in community endoscopy centers

Background

Barrett’s esophagus (BE) is a premalignant condition diagnosed using systematic 4-quadrant forceps biopsies (FB) during endoscopy. This method is fraught with errors due to the randomness of sampling and variability among operators. Wide-area transepithelial sampling with 3-dimensional computer-assisted analysis (WATS^3D) is an emerging technique used to collect esophageal samples. The aim of this study was to evaluate WATS^3D as a diagnostic tool for detecting BE in addition to FB, compared to FB alone.

Methods

A retrospective observational cohort study was conducted and included patients who underwent screening for BE with WATS^3D and FB between January 2015 and January 2019 across 3 endoscopy centers in Wichita, Kansas. The FB specimens were reviewed by community pathologists, while the WATS^3D samples were sent to CDX technology labs, NY.

Results

A total of 108 patients were screened for BE using both modalities concurrently. FB and WATS^3D detected 62 (57.4%) and 83 (76%) cases of BE, respectively. The absolute difference of 21 cases (18.6%) of BE was attributed to the addition of WATS^3D. The number needed to test with WATS^3D was 5. We divided the sample into 4 groups to compare the agreement across all groups: (FB–; WATS^3D+), (FB–; WATS^3D–), (FB+; WATS^3D+), and (FB+ and WATS^3D–). Overall agreement by kappa statistic was 0.74.

Conclusion

WATS^3D identified 21 cases of BE missed by FB. Using WATS^3D in addition to FB increased the yield of BE during surveillance endoscopy, with no increase in complications.

Longitudinal and Circumferential Distributions of Dysplasia and Early Neoplasia in Barrett's Esophagus: A Pooled Analysis of Three Prospective Studies

INTRODUCTION

Studies have shown that dysplasia in Barrett's esophagus (BE) has a predilection for the right hemisphere. There is limited information on the longitudinal distribution. The aim was to determine both the longitudinal and circumferential distributions of dysplasia and early neoplasia from 3 prospective studies.

METHODS

This is a pooled analysis from 3 prospective studies of patients with treatment-naive BE. Both circumferential and longitudinal locations (for BE segments greater than 1 cm) of dysplastic and early neoplastic lesions were recorded.

RESULTS

A total of 177 dysplastic and early neoplastic lesions from 91 patients were included in the pooled analysis; of which 59.3% (n = 105) were seen on high-definition white light endoscopy, 29.4% (n = 52) on advanced imaging, and 11.2% (n = 20) with random biopsies. The average Prague score was C3M5. Of 157 lesions within BE segments greater than 1 cm, 49 (34.8%) lesions were in the proximal half, whereas 92 lesions (65.2%) were in the distal half (P < 0.001). The right hemisphere of the esophagus contained 55% (86/157) of the total lesions compared with 45% (71/157) for the left hemisphere (P = 0.02). This was because of the presence of high-grade dysplasia being concentrated in the right hemisphere compared with the left hemisphere (60% vs 40%, P = 0.002).

DISCUSSION

In this pooled analysis of prospective studies, both low-grade dysplasia and high-grade dysplasia are more frequently found in the distal half of the Barrett's segment. This study confirms that the right hemisphere is a hot spot for high-grade dysplasia. Careful attention to these locations is important during surveillance endoscopy.

Best Practices in Surveillance for Barrett's Esophagus

Barrett's esophagus is the precursor lesion for esophageal adenocarcinoma. The goals of endoscopic surveillance are to detect dysplasia and early esophageal adenocarcinoma in order to improve patient outcomes. Despite the ongoing debate regarding the efficacy of surveillance, all current gastrointestinal societies recommend surveillance at this time. Optimal surveillance technique includes adequate inspection time, evaluation using high-definition white light and chromoendoscopy, appropriate documentation of the metaplastic segment using the Prague C & M criteria as well as the Paris classification should lesions be found, utilization of the Seattle biopsy protocol, and endoscopic resection of visible lesions.

Advanced Imaging and Sampling in Barrett's Esophagus: Artificial Intelligence to the Rescue?

Because the current Barrett's esophagus (BE) surveillance protocol suffers from sampling error of random biopsies and a high miss-rate of early neoplastic lesions, many new endoscopic imaging and sampling techniques have been developed. None of these techniques, however, have significantly increased the diagnostic yield of BE neoplasia. In fact, these techniques have led to an increase in the amount of visible information, yet endoscopists and pathologists inevitably suffer from variations in intra- and interobserver agreement. Artificial intelligence systems have the potential to overcome these endoscopist-dependent limitations.

A Practical Approach to Refractory and Recurrent Barrett's Esophagus

Endoscopic eradication therapy (EET) is recommended for patients with Barrett's esophagus (BE)-associated neoplasia and is effective in achieving complete eradication of intestinal metaplasia (CE-IM). However, BE that is refractory to EET, defined as partial or no improvement in dysplasia after less than or equal to 3 ablative sessions, and the development of recurrence post-EET is not uncommon. Identification of refractory BE or recurrent intestinal metaplasia should prompt esophageal physiologic testing and modification of antireflux strategy, as appropriate. In patients who ultimately fail standard EET despite optimization of reflux control, salvage EET with alternate modalities may need to be considered.

Wide Area Transepithelial Sampling with Computer-Assisted Analysis (WATS3D) Is Cost-Effective in Barrett's Esophagus Screening

BACKGROUND

Wide area transepithelial sampling with three-dimensional computer-assisted analysis (WATS^3D) is an adjunct to the standard random 4-quadrant forceps biopsies (FB, "Seattle protocol") that significantly increases the detection of Barrett's esophagus (BE) and associated neoplasia in patients undergoing screening or surveillance.

AIMS

To examine the cost-effectiveness of adding WATS^3D to the Seattle protocol in screening patients for BE.

METHODS

A decision analytic model was used to compare the effectiveness and cost-effectiveness of two alternative BE screening strategies in chronic gastroesophageal reflux disease patients: FB with and without WATS^3D. The reference case was a 60-year-old white male with gastroesophageal reflux disease (GERD). Effectiveness was measured by the number needed to screen to avert one cancer and one cancer-related death, and quality-adjusted life years (QALYs). Cost was measured in 2019 US$, and the incremental cost-effectiveness ratio (ICER) was measured in $/QALY using thresholds for cost-effectiveness of $100,000/QALY and $150,000/QALY. Cost was measured in 2019 US$. Cost and QALYs were discounted at 3% per year.

RESULTS

Between 320 and 337 people would need to be screened with WATS^3D in addition to FB to avert one additional cancer, and 328-367 people to avert one cancer-related death. Screening with WATS^3D costs an additional $1219 and produced an additional 0.017 QALYs, for an ICER of $71,395/QALY. All one-way sensitivity analyses resulted in ICERs under $84,000/QALY.

CONCLUSIONS

Screening for BE in 60-year-old white male GERD patients is more cost-effective when WATS^3D is used adjunctively to the Seattle protocol than with the Seattle protocol alone.

Clinical utility of wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D) in identifying Barrett's esophagus and associated neoplasia

Sampling error during screening and surveillance endoscopy is a well-recognized problem. Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS3D), used adjunctively to forceps biopsy (FB), has been shown to increase the detection of Barrett's esophagus (BE) and BE-associated neoplasia. We evaluated the clinical utility of WATS3D and its impact on the management of patients with BE and dysplasia. Between 2013 and 2018, 432 consecutive patients who had a WATS3D positive and an accompanying FB negative result were identified. Physicians were contacted to determine if the WATS3D result impacted their decision to enroll patients in surveillance or increase the frequency of surveillance, recommend ablation, and/or initiate or increase the dose of proton pump inhibitors (PPIs). WATS3D directly impacted the management of 97.8% of 317 BE patients; 96.2% were enrolled in surveillance and 60.2% were started on PPIs or their dose was increased. WATS3D impacted the management of 94.9% and 94.1% of the 98 low-grade dysplasia and 17 high-grade dysplasia patients, respectively. As a result of WATS3D, 33.7% of low-grade dysplasia and 70.6% of high-grade dysplasia patients underwent endoscopic therapy. More than 37% of all dysplasia patients were enrolled in a surveillance program, and nearly 30% were scheduled to be surveilled more frequently. PPIs were either initiated, or the dose was increased in more than 54% of all dysplasia patients. We demonstrate that WATS3D has high clinical utility. By prompting physicians to change their clinical management in patients with negative FB results, WATS3D, used adjunctively to FB, directly impacts patient management, and improves patient outcomes.

Narrative review of the role of gastroenterologist in the diagnosis, treatment and palliation in gastric and gastroesophageal cancer

Esophageal cancer (EC) and gastric cancer (GC) carry a high mortality rate. Unfortunately, a majority of patients are asymptomatic and at the time of diagnosis, the disease may invariably be in its advanced stages with limited curative options. Thus, it is imperative to recognize certain risk factors including gastroesophageal reflux disease (GERD), male gender, pre-existing Barrett’s esophagus, smoking history, obesity, Helicobacter pylori infection, atrophic gastritis among others for both EC and GC, intervene on time with screening and surveillance modalities if indicated and optimize treatment plans. With advances in endoscopic techniques, early neoplastic lesions are increasingly managed by gastroenterologists, offering an alternative to surgery. The gold standard for diagnosis of EC and GC is high definition endoscopy with adequate targeted biopsies. Endoscopic ultrasound (EUS) is a key in the staging of early cancers dictating the pathway for treatment options. We also play a key role in palliation cases with the aim to reduce the symptoms like nausea, vomiting and even when possible, restore oral intake and improve nutrition in both advanced GC and EC. This review article discusses the risk factors, diagnostic and endoscopic treatment modalities of early EC and GC and palliation of advanced cancer where gastroenterologists play a key role.

DIAGNOSIS, TREATMENT AND FOLLOW-UP OF BARRETT'S ESOPHAGUS: A SYSTEMATIC REVIEW

BACKGROUND

Barrett's esophagus (BE) is a premalignant condition that raises controversy among general practitioners and specialists, especially regarding its diagnosis, treatment, and follow-up protocols.

OBJECTIVE

This systematic review aims to present the particularities and to clarify controversies related to the diagnosis, treatment and surveillance of BE.

METHODS

A systematic review was conducted on PubMed, Cochrane, and SciELO based on articles published in the last 10 years. PRISMA guidelines were followed and the search was made using MeSH and non-MeSH terms "Barrett" and "diagnosis or treatment or therapy or surveillance". We searched for complete randomized controlled clinical trials or Phase IV studies, carried out with individuals over 18 years old.

RESULTS

A total of 42 randomized controlled trials were selected after applying all inclusion and exclusion criteria. A growing trend of alternative and safer techniques to traditional upper gastrointestinal endoscopy were identified, which could improve the detection of BE and patient acceptance. The use of chromoendoscopy-guided biopsy protocols significantly reduced the number of biopsies required to maintain similar BE detection rates. Furthermore, the value of BE chemoprophylaxis with esomeprazole and acetylsalicylic acid was relevant, as well as the establishment of protocols for the follow-up and endoscopic surveillance of patients with BE based predominantly on the presence and degree of dysplasia, as well as on the length of the follow-up affected by BE.

CONCLUSION

Although further studies regarding the diagnosis, treatment and follow-up of BE are warranted, in light of the best evidence presented in the last decade, there is a trend towards electronic chromoendoscopy-guided biopsies for the diagnosis of BE, while treatment should encompass endoscopic techniques such as radiofrequency ablation. Risks of ablative endoscopic methods should be weighted against those of resective surgery. It is also important to consider lifetime endoscopic follow-up for both short and long term BE patients, with consideration to limitations imposed by a range of comorbidities. Unfortunately, there are no randomized controlled trials that have evaluated which is the best recommendation for BE follow-up and endoscopic surveillance (>1 cm) protocols, however, based on current International Guidelines, it is recommended esophagogastroduodenoscopy (EGD) every 5 years in BE without dysplasia with 1 up to 3 cm of extension; every 3 years in BE without dysplasia with >3 up to 10 cm of extension, every 6 to 12 months in BE with low grade dysplasia and, finally, EGD every 3 months after ablative endoscopic therapy in cases of BE with high grade dysplasia.

Adjunctive Yield of Wide-Area Transepithelial Sampling for Dysplasia Detection After Advanced Imaging and Random Biopsies in Barrett's Esophagus

INTRODUCTION

Little is known about the additive yield of wide-area transepithelial sampling with computer-assisted three-dimensional analysis (WATS-3D) after a thorough examination with advanced imaging. The aim was to evaluate the adjunctive yield of WATS-3D after advanced imaging.

METHODS

This is an observational cohort study from January 2017 to December 2018 for consecutive patients who underwent an examination that consists of high-definition white light endoscopy (HDWLE), narrow-band imaging (NBI), volumetric laser endomicroscopy (VLE), and Seattle protocol (SP) biopsies (collectively termed HDWLE-NBI-VLE-SP examination). Raised lesions were removed by endoscopic resection. Areas suspicious for dysplasia on NBI and VLE were biopsied. This was followed by random biopsies and WATS-3D brush biopsies.

RESULTS

One hundred thirty-eight cases were included in this study. Thirty-five cases (25% of the total) were identified as some degree of dysplasia on the HDWLE-NBI-VLE-SP examination. Adjunctive use of WATS-3D yielded an additional 12 new cases of dysplasia (9 with crypt dysplasia and 3 with low-grade dysplasia [LGD]), for added yield of 34.3% (=12/35, 95% confidence interval 14.6%-62.2%). When restricting the analysis to LGD and higher, 21 dysplastic cases (15% of the total cases) were identified by HDWLE-NBI-VLE-SP, while WATS-3D found 4 additional new cases (3 with LGD and 1 with high-grade dysplasia) for an added yield of 19% (=4/21, 95% confidence interval 0.6%-45.7%).

DISCUSSION

The addition of WATS-3D to an already thorough examination with HDWLE-NBI-VLE-SP may increase the yield of dysplasia detection.

Wide-area transepithelial sampling in adjunct to forceps biopsy increases the absolute detection rates of Barrett's oesophagus and oesophageal dysplasia: a meta-analysis and systematic review

BACKGROUND

Wide-area transepithelial sampling (WATS) is a new technique that uses an abrasive brush to obtain samples from a larger surface area of the oesophagus. Studies have shown promising results that WATS in adjunct to forceps biopsy (FB) increases the detection rate of Barrett's oesophagus (BE) as well as oesophageal dysplasia (ED). We conducted a systematic review and meta-analysis to compare the detection rates of BE and ED between FB and WATS in adjunct to FB.

METHODS

A Literature search was done using electronic databases, including PubMed, Embase, Scopus, Cochrane and CINAHL from inception to 26 April 2020. A meta-analysis comparing detection rates of WATS in adjunct to FB versus FB using the random-effects model was done using RevMan V.5.3.

RESULTS

Pooled data from 20 392 endoscopies across 11 studies showed an absolute increase in detection of 16% (95% CI 0.10% to 0.22%, p<0.00001). A relative increase of 1.62 was seen in detection rates of BE (95% CI 1.28 to 2.05, p<0.0001) when WATS was used with FB with the number needed to test (NNT) of 6.1 patients. For ED, a 2% absolute increase (95% CI 0.01 to 0.03, p=0.001) in additional diagnostic yield from WATS. A relative increase of 2.05 was seen in the detection rate of ED (95% CI 1.42 to 2.98, p=0.0001) yielding an NNT of 50 patients.

CONCLUSION

Our study shows that WATS, as an adjunct to FB, improves both the absolute detection rate and relative detection rate of both BE and ED as compared to FB alone.

What is the optimal surveillance strategy for non-dysplastic Barrett's esophagus?

PURPOSE OF REVIEW

There is conflicting data on the effectiveness of the currently recommended endoscopic surveillance strategy in non-dysplastic BE patients. We reviewed the literature to evaluate the (cost) effectiveness of the current surveillance strategy. We also reviewed critical strategies and new technologies which could improve dysplasia detection.

RECENT FINDINGS

Adherence to the current EGD surveillance guidelines is suboptimal with high rates of missed dysplasia/EAC. The influence of surveillance on EAC mortality appears modest. Careful cleansing, inspection and sampling of the BE mucosa using high resolution while light and (electronic) chromoendoscopy is critical. Newer sampling techniques coupled with computer aided diagnosis and emerging imaging technologies have shown promise in improving dysplasia detection. Personalized surveillance with risk stratification based on risk factors for progression may be on the horizon.

SUMMARY

Current BE surveillance strategy will likely be further refined and optimized by emerging new technologies in tissue sampling, advanced imaging and risk stratification.

Residual disease after neoadjuvant chemoradiotherapy for oesophageal cancer: locations undetected by endoscopic biopsies in the preSANO trial

Background

Active surveillance has been proposed for patients with oesophageal cancer in whom there is a complete clinical response after neoadjuvant chemoradiotherapy (nCRT). However, endoscopic biopsies have limited negative predictive value in detecting residual disease. This study determined the location of residual tumour following surgery to improve surveillance and endoscopic strategies.

Methods

The present study was based on patients who participated in the prospective preSANO trial with adenocarcinoma or squamous cell carcinoma of the oesophagus or oesophagogastric junction treated in four Dutch hospitals between 2013 and 2016. Resection specimens and endoscopic biopsies taken during clinical response evaluations after nCRT were reviewed by two expert gastrointestinal pathologists. The exact location of residual disease in the oesophageal wall was determined in resection specimens. Endoscopic biopsies were assessed for the presence of structures representing the submucosal layer of the oesophageal wall.

Results

In total, 119 eligible patients underwent clinical response evaluations after nCRT followed by standard surgery. Residual tumour was present in endoscopic biopsies from 70 patients, confirmed on histological analysis of the resected organ. Residual tumour was present in the resection specimen from 27 of the other 49 patients, despite endoscopic biopsies being negative. Of these 27 patients, residual tumour was located in the mucosa in 18, and in the submucosa beneath tumour‐free mucosa in eight. One patient had tumour in muscle beneath tumour‐free mucosa and submucosa.

Conclusion

Most residual disease after nCRT missed by endoscopic biopsies was located in the mucosa. Active surveillance could be improved by more sampling and considering submucosal biopsies.

The Impact of Artificial Intelligence in the Endoscopic Assessment of Premalignant and Malignant Esophageal Lesions: Present and Future

In the gastroenterology field, the impact of artificial intelligence was investigated for the purposes of diagnostics, risk stratification of patients, improvement in quality of endoscopic procedures and early detection of neoplastic diseases, implementation of the best treatment strategy, and optimization of patient prognosis. Computer-assisted diagnostic systems to evaluate upper endoscopy images have recently emerged as a supporting tool in endoscopy due to the risks of misdiagnosis related to standard endoscopy and different expertise levels of endoscopists, time-consuming procedures, lack of availability of advanced procedures, increasing workloads, and development of endoscopic mass screening programs. Recent research has tended toward computerized, automatic, and real-time detection of lesions, which are approaches that offer utility in daily practice. Despite promising results, certain studies might overexaggerate the diagnostic accuracy of artificial systems, and several limitations remain to be overcome in the future. Therefore, additional multicenter randomized trials and the development of existent database platforms are needed to certify clinical implementation. This paper presents an overview of the literature and the current knowledge of the usefulness of different types of machine learning systems in the assessment of premalignant and malignant esophageal lesions via conventional and advanced endoscopic procedures. This study makes a presentation of the artificial intelligence terminology and refers also to the most prominent recent research on computer-assisted diagnosis of neoplasia on Barrett's esophagus and early esophageal squamous cell carcinoma, and prediction of invasion depth in esophageal neoplasms. Furthermore, this review highlights the main directions of future doctor-computer collaborations in which machines are expected to improve the quality of medical action and routine clinical workflow, thus reducing the burden on physicians.

Barrett's Esophagus Management in the Elderly: Principles and Best Practice

PURPOSE OF REVIEW

Endoscopic screening and surveillance for Barrett's esophagus (BE) as well as treatment of dysplastic BE is well established. A significant proportion of BE patients are older (geriatric age group, > 65 years age). There is relatively little information or recommendations in the literature with regards to evaluation and management of geriatric BE patients. The purpose of this review is to outline specific caveats and best practice recommendations to help manage the geriatric BE patient.

RECENT FINDINGS

In this review, we have attempted to summarize the latest evidence and guideline-based recommendations for evaluation and treatment of BE and early esophageal neoplasia, with a special focus on the challenges and considerations involved when caring for the geriatric BE patient. Concepts related to sedation, endoscopy, risk-benefit assessment, and other unique issues pertaining to the older BE patient are discussed. Expert recommendations are provided wherever possible. This review highlights the importance of recognizing the unique aspects of evaluating and managing the geriatric BE patient. Practical recommendations are discussed which will help the provider individualize and optimize care for their geriatric BE patient.

Aneuploidy in targeted endoscopic biopsies outperforms other tissue biomarkers in the prediction of histologic progression of Barrett's oesophagus: A multi-centre prospective cohort study

BACKGROUND

The cancer risk in Barrett's oesophagus (BO) is difficult to estimate. Histologic dysplasia has strong predictive power, but can be missed by random biopsies. Other clinical parameters have limited utility for risk stratification. We aimed to assess whether a molecular biomarker panel on targeted biopsies can predict neoplastic progression of BO.

METHODS

203 patients with BO were tested at index endoscopy for 9 biomarkers (p53 and cyclin A expression; aneuploidy and tetraploidy; CDKN2A (p16), RUNX3 and HPP1 hypermethylation; 9p and 17p loss of heterozygosity) on autofluorescence-targeted biopsies and followed-up prospectively. Data comparing progressors to non-progressors were evaluated by univariate and multivariate analyses using survival curves, Cox-proportional hazards and logistic regression models.

FINDINGS

127 patients without high-grade dysplasia (HGD) or oesophageal adenocarcinoma (OAC) at index endoscopy were included, of which 42 had evidence of any histologic progression over time. Aneuploidy was the only predictor of progression from non-dysplastic BO (NDBO) to any grade of neoplasia (p = 0.013) and HGD/OAC (p = 0.002). Aberrant p53 expression correlated with risk of short-term progression within 12 months, with an odds ratio of 6.0 (95% CI: 3.1-11.2). A panel comprising aneuploidy and p53 had an area under the receiving operator characteristics curve of 0.68 (95% CI: 0.59-0.77) for prediction of any progression.

INTERPRETATION

Aneuploidy is the only biomarker that predicts neoplastic progression of NDBO. Aberrant p53 expression suggests prevalent dysplasia, which might have been missed by random biopsies, and warrants early follow up.

SAGES TAVAC safety and efficacy analysis confocal laser endomicroscopy

BACKGROUND

Confocal laser endomicroscopy (CLE) is a novel endoscopic adjunct that allows real-time in vivo histological examination of mucosal surfaces. By using intravenous or topical fluorescent agents, CLE highlights certain mucosal elements that facilitate an optical biopsy in real time. CLE technology has been used in different organ systems including the gastrointestinal tract. There has been numerous studies evaluating this technology in gastrointestinal endoscopy, our aim was to evaluate the safety, value, and efficacy of this technology in the gastrointestinal tract.

METHODS

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Technology and Value Assessment Committee (TAVAC) performed a PubMed/Medline database search of clinical studies involving CLE in May of 2018. The literature search used combinations of the keywords: confocal laser endomicroscopy, pCLE, Cellvizio, in vivo microscopy, optical histology, advanced endoscopic imaging, and optical diagnosis. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded. The manufacturer's website was also used to identify key references. The United States Food and Drug Administration (U.S. FDA) Manufacturer And User facility and Device Experience (MAUDE) database was searched for reports regarding the device malfunction or injuries.

RESULTS

The technology offers an excellent safety profile with rare adverse events related to the use of fluorescent agents. It has been shown to increase the detection of dysplastic Barrett's esophagus, gastric intraepithelial neoplasia/early gastric cancer, and dysplasia associated with inflammatory bowel disease when compared to standard screening protocols. It also aids in the differentiation and classification of colorectal polyps, indeterminate biliary strictures, and pancreatic cystic lesions.

CONCLUSIONS

CLE has an excellent safety profile. CLE can increase the diagnostic accuracy in a number of gastrointestinal pathologies.

Radiofrequency Ablation of Barrett's Esophagus: Have We Gone Too Far, or Not Far Enough?

PURPOSE OF REVIEW

Barrett's esophagus (BE) is a premalignant condition of the esophagus associated with an increased risk for esophageal adenocarcinoma (EAC). Radiofrequency ablation (RFA) is a safe and effective first-line treatment for dysplastic BE and early stage EAC. This report reviews clinically relevant evidence published over the last 3 years regarding RFA for BE.

RECENT FINDINGS

Our use of this technology has simultaneously gone too far, in that many patients who may not derive a benefit from these treatments are receiving them, and not far enough, in that many patients who would be eligible for ablative therapy never undergo screening exams to assess them for dysplastic BE, or do not have endoscopic therapy considered part of the treatment of superficial invasive cancer. Research to better identify patients with BE, risk stratify those patients, improve the quality of RFA treatment, and inform surveillance practices has the potential to optimize the benefit of RFA, and minimize the harms, costs, and risks.

SAGES TAVAC safety and efficacy analysis WATS3D (CDx Diagnostics, Suffern, NY)

BACKGROUND

Wide-area transepithelial sampling of the esophagus with computer-assisted three-dimensional analysis (WATS3D, CDx Diagnostics, Suffern, NY) is an adjunctive technique to random biopsies for early detection of Barrett's esophagus. The aim of the SAGES Technology and Value Assessment Committee aims is to evaluate the efficacy, value, and safety of WATS3D.

METHODS

Clinical studies involving WATS3D were identified via a search of the PubMed/Medline databases ( www.ncbi.nlm.nih.gov/pubmed ) conducted in March of 2019 using search terms, such as wide-area transepithelial sampling, three-dimensional (3D) computer-assisted analysis, WATS-3D, Barrett's esophagus and WATS-3D, Barrett's esophagus and wide-area transepithelial sampling with three-dimensional computer-assisted analysis, Barrett's esophagus, and emerging technology. Bibliographies of key references were searched for relevant studies not covered by the PubMed search. Case reports and small case series were excluded.

RESULTS

No significant morbidity or mortality was reported within the literature associated with the WATS^3D technology. WATS^3D increases diagnostic yield by 38-150% for Barrett's Esophagus, by 40-150% for Low Grade Dysplasia; and by 420% for High Grade Dysplasia; when compared to forceps biopsy alone. WATS^3D technique has very high inter-observer agreement for the pathological diagnosis of non-dysplastic and dysplastic Barrett's Esophagus. Increased detection of pre-malignant diseases of the esophagus by the adjunctive use of WATS^3D supports screening and surveillance by the adjunctive use of WATS^3D during upper endoscopy in appropriate patients.

CONCLUSION

Wide-area transepithelial sampling with three-dimensional computer-assisted analysis (WATS^3D, CDx Diagnostics) is a safe and effective adjunct to forcep biopsies in the evaluation of Barrett's Esophagus, Low Grade Dysplasia, and High Grade Dysplasia.

Liquid nitrogen spray cryotherapy-based multimodal endoscopic management of dysplastic Barrett's esophagus and early esophageal neoplasia: retrospective review and long-term follow-up at an academic tertiary care referral center

BACKGROUND

Endoscopic eradication therapy of dysplastic Barrett's esophagus (BE) and early esophageal neoplasia has emerged as an effective treatment option. Data for the role of spray cryotherapy (SCT) in this setting is relatively limited.

OBJECTIVE

To evaluate the safety and long-term outcomes of SCT-based multimodal therapy in the management of dysplastic BE and early esophageal neoplasia.

DESIGN

Single-center, retrospective, cohort study.

SETTING

Academic, tertiary care center between August 2008 and February 2019.

METHODS

A retrospective chart review was conducted of the prospectively maintained endoscopic cryotherapy database at our center. Fifty-seven patients were identified who underwent SCT treatment for dysplastic BE and esophageal or Gastro-esophageal (GE) junction adenocarcinoma during the study period. Primary outcome was complete eradication of intestinal metaplasia (CE-IM); secondary outcome was complete eradication of dysplasia (CE-D).

RESULTS

A total of 171 SCT procedures were performed in 57 patients. The majority of patients were male (89.5%) with long-segment BE (93%; mean segment length 6.2 cm). Complete follow-up data was available for 56 of these 57 patients. 43.9% (25/57) of patients underwent radiofrequency ablation (RFA) during the course of treatment (e.g. after initiating SCT). 33.3% of patients (19/57) were RFA failures prior to SCT. Additionally, 68.4% (39/57) of patients underwent endoscopic resection (EMR) prior to SCT as part of our multimodal approach to treatment of BE dysplasia/neoplasia. Four patients (7%) are currently undergoing active ablation and/or EMR treatment. CE-IM was achieved in 75% (39/52) of patients, and CE-D in 98.1% (51/52). Mean duration of overall follow-up was 4.8 years, with mean CE-IM durability of 2.6 years.

LIMITATIONS

Single-center only, retrospective study design.

CONCLUSION

SCT-based multimodal endoscopic therapy can achieve very high CE-IM (75%) and CE-D (>98%) rates in a high-risk population with esophageal dysplasia and/or neoplasia.