Barrett's esophagus: A historical perspective, an update on core practicalities and predictions on future evolutions of management

Application of artificial intelligence in gastrointestinal endoscopy

Endoscopy is an important method for diagnosing gastrointestinal (GI) diseases. In this study, we provide an overview of the advances in artificial intelligence (AI) technology in the field of GI endoscopy over recent years, including esophagus, stomach, large intestine, and capsule endoscopy (small intestine). AI-assisted endoscopy shows high accuracy, sensitivity, and specificity in the detection and diagnosis of GI diseases at all levels. Hence, AI will make a breakthrough in the field of GI endoscopy in the near future. However, AI technology currently has some limitations and is still in the preclinical stages.

Deep Learning in Barrett's Esophagus Diagnosis: Current Status and Future Directions

Barrett's esophagus (BE) represents a pre-malignant condition characterized by abnormal cellular proliferation in the distal esophagus. A timely and accurate diagnosis of BE is imperative to prevent its progression to esophageal adenocarcinoma, a malignancy associated with a significantly reduced survival rate. In this digital age, deep learning (DL) has emerged as a powerful tool for medical image analysis and diagnostic applications, showcasing vast potential across various medical disciplines. In this comprehensive review, we meticulously assess 33 primary studies employing varied DL techniques, predominantly featuring convolutional neural networks (CNNs), for the diagnosis and understanding of BE. Our primary focus revolves around evaluating the current applications of DL in BE diagnosis, encompassing tasks such as image segmentation and classification, as well as their potential impact and implications in real-world clinical settings. While the applications of DL in BE diagnosis exhibit promising results, they are not without challenges, such as dataset issues and the "black box" nature of models. We discuss these challenges in the concluding section. Essentially, while DL holds tremendous potential to revolutionize BE diagnosis, addressing these challenges is paramount to harnessing its full capacity and ensuring its widespread application in clinical practice.

Artificial Intelligence in Endoscopy

Artificial intelligence (AI) is rapidly developing in various medical fields, and there is an increase in research performed in the field of gastrointestinal (GI) endoscopy. In particular, the advent of convolutional neural network, which is a class of deep learning method, has the potential to revolutionize the field of GI endoscopy, including esophagogastroduodenoscopy (EGD), capsule endoscopy (CE), and colonoscopy. A total of 149 original articles pertaining to AI (27 articles in esophagus, 30 articles in stomach, 29 articles in CE, and 63 articles in colon) were identified in this review. The main focuses of AI in EGD are cancer detection, identifying the depth of cancer invasion, prediction of pathological diagnosis, and prediction of Helicobacter pylori infection. In the field of CE, automated detection of bleeding sites, ulcers, tumors, and various small bowel diseases is being investigated. AI in colonoscopy has advanced with several patient-based prospective studies being conducted on the automated detection and classification of colon polyps. Furthermore, research on inflammatory bowel disease has also been recently reported. Most studies of AI in the field of GI endoscopy are still in the preclinical stages because of the retrospective design using still images. Video-based prospective studies are needed to advance the field. However, AI will continue to develop and be used in daily clinical practice in the near future. In this review, we have highlighted the published literature along with providing current status and insights into the future of AI in GI endoscopy.

Correlation between gastroesophageal flap valve abnormality and novel parameters in patients with gastroesophageal reflux disease symptoms by the lyon consensus

Gastroesophageal flap valve (GEFV) grading is a simple and reproducible parameter. There is limited information about the association between GEFV abnormality and novel parameters in patients with gastroesophageal reflux disease(GERD) symptoms by the Lyon Consensus. To investigate the value of GEFV grading in GERD, the clinical data of 320 patients with GERD symptoms who underwent endoscopy, 24-h multichannel intraluminal impedance-pH (MII-pH) monitoring, and high-resolution manometry (HRM) were retrospectively analyzed. The percentage of acid exposure time (AET%)(4.2 [1.5–7.4] vs. 1.3 [0.3–4.2], P < 0.001) and the proportion of abnormal esophagogastric junction (EGJ) morphology (71 [87.7%] vs. 172 [72.0%], P = 0.011) were significantly higher, while the mean nocturnal baseline impedance (MNBI) (2068.3 [1658.4–2432.4] vs. 2228.5 [1794.8–2705.3]Ω, P = 0.012) and post-reflux swallow-induced peristaltic wave index (PSPWI) (19.7 [13.9–29.0] vs. 33.3 [25.0–44.0]%, P < 0.001) were significantly lower in the abnormal GEFV group compared with the normal GEFV group. AET% and EGJ morphology showed positive correlations with GEFV grade, while PSPWI and MNBI showed negative correlations. Patients with an abnormal GEFV had a significantly greater risk of conclusive evidence of GERD compared to those with a normal GEFV (OR 3.035, 95% CI 1.758–5.240, P < 0.001). Further, when identifying patients with conclusive evidence of GERD, abnormal GEFV had a specificity of 80.4% (95% CI 75.3–85.5%). GEFV grading might be regarded as supportive evidence for GERD diagnosis.

Convolutional Neural Networks for the evaluation of cancer in Barrett's esophagus: Explainable AI to lighten up the black-box

Even though artificial intelligence and machine learning have demonstrated remarkable performances in medical image computing, their level of accountability and transparency must be provided in such evaluations. The reliability related to machine learning predictions must be explained and interpreted, especially if diagnosis support is addressed. For this task, the black-box nature of deep learning techniques must be lightened up to transfer its promising results into clinical practice. Hence, we aim to investigate the use of explainable artificial intelligence techniques to quantitatively highlight discriminative regions during the classification of early-cancerous tissues in Barrett's esophagus-diagnosed patients. Four Convolutional Neural Network models (AlexNet, SqueezeNet, ResNet50, and VGG16) were analyzed using five different interpretation techniques (saliency, guided backpropagation, integrated gradients, input × gradients, and DeepLIFT) to compare their agreement with experts' previous annotations of cancerous tissue. We could show that saliency attributes match best with the manual experts' delineations. Moreover, there is moderate to high correlation between the sensitivity of a model and the human-and-computer agreement. The results also lightened that the higher the model's sensitivity, the stronger the correlation of human and computational segmentation agreement. We observed a relevant relation between computational learning and experts' insights, demonstrating how human knowledge may influence the correct computational learning.

Artificial intelligence in gastrointestinal endoscopy: general overview

Artificial intelligence (AI) is now a trendy subject in clinical medicine and especially in gastrointestinal (GI) endoscopy. AI has the potential to improve the quality of GI endoscopy at all levels. It will compensate for humans' errors and limited capabilities by bringing more accuracy, consistency, and higher speed, making endoscopic procedures more efficient and of higher quality. AI showed great results in diagnostic and therapeutic endoscopy in all parts of the GI tract. More studies are still needed before the introduction of this new technology in our daily practice and clinical guidelines. Furthermore, ethical clearance and new legislations might be needed. In conclusion, the introduction of AI will be a big breakthrough in the field of GI endoscopy in the upcoming years. It has the potential to bring major improvements to GI endoscopy at all levels.

Assisting Barrett's esophagus identification using endoscopic data augmentation based on Generative Adversarial Networks

Barrett's esophagus figured a swift rise in the number of cases in the past years. Although traditional diagnosis methods offered a vital role in early-stage treatment, they are generally time- and resource-consuming. In this context, computer-aided approaches for automatic diagnosis emerged in the literature since early detection is intrinsically related to remission probabilities. However, they still suffer from drawbacks because of the lack of available data for machine learning purposes, thus implying reduced recognition rates. This work introduces Generative Adversarial Networks to generate high-quality endoscopic images, thereby identifying Barrett's esophagus and adenocarcinoma more precisely. Further, Convolution Neural Networks are used for feature extraction and classification purposes. The proposed approach is validated over two datasets of endoscopic images, with the experiments conducted over the full and patch-split images. The application of Deep Convolutional Generative Adversarial Networks for the data augmentation step and LeNet-5 and AlexNet for the classification step allowed us to validate the proposed methodology over an extensive set of datasets (based on original and augmented sets), reaching results of 90% of accuracy for the patch-based approach and 85% for the image-based approach. Both results are based on augmented datasets and are statistically different from the ones obtained in the original datasets of the same kind. Moreover, the impact of data augmentation was evaluated in the context of image description and classification, and the results obtained using synthetic images outperformed the ones over the original datasets, as well as other recent approaches from the literature. Such results suggest promising insights related to the importance of proper data for the accurate classification concerning computer-assisted Barrett's esophagus and adenocarcinoma detection.

Emerging artificial intelligence applications in gastroenterology: A review of the literature

Artificial intelligence (AI) allows machines to provide disruptive value in several industries and applications. Applications of AI techniques, specifically machine learning and more recently deep learning, are arising in gastroenterology. Computer-aided diagnosis for upper gastrointestinal endoscopy has growing attention for automated and accurate identification of dysplasia in Barrett’s esophagus, as well as for the detection of early gastric cancers (GCs), therefore preventing esophageal and gastric malignancies. Besides, convoluted neural network technology can accurately assess Helicobacter pylori (H. pylori) infection during standard endoscopy without the need for biopsies, thus, reducing gastric cancer risk. AI can potentially be applied during colonoscopy to automatically discover colorectal polyps and differentiate between neoplastic and non-neoplastic ones, with the possible ability to improve adenoma detection rate, which changes broadly among endoscopists performing screening colonoscopies. In addition, AI permits to establish the feasibility of curative endoscopic resection of large colonic lesions based on the pit pattern characteristics. The aim of this review is to analyze current evidence from the literature, supporting recent technologies of AI both in upper and lower gastrointestinal diseases, including Barrett's esophagus, GC, H. pylori infection, colonic polyps and colon cancer.

The Prevalence of Gastroesophageal Reflux in Patients With Excessive Central Airway Collapse

BACKGROUND

Gastroesophageal reflux (GER) is increasingly recognized as an exacerbating or causal factor in several respiratory diseases. There is a high prevalence of GER in infants with airway malacia. However, such data are lacking in adults.

METHODS

This retrospective study was conducted to determine the relationship between GER and excessive central airway collapse (ECAC). The study included consecutive patients with ECAC referred to the Complex Airway Center at Beth Israel Deaconess Medical Center who underwent esophageal pH testing for GER between July 2014 and June 2018.

RESULTS

Sixty-three of 139 patients with ECAC (45.3%) had documented GER as shown by an abnormal esophageal pH test result. The mean DeMeester score was 32.2, with a symptom association probability of 39.7% of GER-positive patients. Twenty-nine of 63 patients (46%) with GER reported improvement in respiratory symptoms following maximal medical therapy or antireflux surgery without requiring further treatment for ECAC.

CONCLUSIONS

GER is prevalent among patients with ECAC, and aggressive reflux treatment should be considered in these patients prior to considering invasive airway procedures or surgery.

Effectiveness of Nissen fundoplication versus anterior and posterior partial fundoplications for treatment of gastro-esophageal reflux disease: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to determine the relative effectiveness of Nissen fundoplication compared to anterior and posterior partial fundoplication in controlling the symptoms of gastro-esophageal reflux disease and reducing their side effect profile in adults.The specific questions posed by this review are: what is the effectiveness of Nissen fundoplication in comparison to anterior partial fundoplication (90 degree, 120 degree and 180 degree) and posterior 270 degree fundoplication in terms of symptom control of gastro-esophageal reflux disease, and what are the side effects of these surgical interventions?

A survey on Barrett's esophagus analysis using machine learning

This work presents a systematic review concerning recent studies and technologies of machine learning for Barrett's esophagus (BE) diagnosis and treatment. The use of artificial intelligence is a brand new and promising way to evaluate such disease. We compile some works published at some well-established databases, such as Science Direct, IEEEXplore, PubMed, Plos One, Multidisciplinary Digital Publishing Institute (MDPI), Association for Computing Machinery (ACM), Springer, and Hindawi Publishing Corporation. Each selected work has been analyzed to present its objective, methodology, and results. The BE progression to dysplasia or adenocarcinoma shows a complex pattern to be detected during endoscopic surveillance. Therefore, it is valuable to assist its diagnosis and automatic identification using computer analysis. The evaluation of the BE dysplasia can be performed through manual or automated segmentation through machine learning techniques. Finally, in this survey, we reviewed recent studies focused on the automatic detection of the neoplastic region for classification purposes using machine learning methods.

A review of pharmacotherapy for treating gastroesophageal reflux disease (GERD)

INTRODUCTION

Medical therapy of gastroesophageal reflux disease (GERD) is based on the use of proton pump inhibitors (PPIs) as first choice treatment. Despite their effectiveness, about 20-30% of patients report an inadequate response and alternative drugs are required. Areas covered: This review provides an overview of current pharmacotherapy for treating GERD by showing the results of PPIs, reflux inhibitors, antidepressants and mucosa protective medications. Expert opinion: Medical therapy of GERD does not definitely cure the disease, because even PPIs are not able to change the key factors responsible for it. However, they remain the mainstay of medical treatment, allowing us to alleviate symptoms, heal esophagitis and prevent complications in the majority of cases. Nevertheless, many patients do not respond, because acid does not play any pathogenetic role. Prokinetics and reflux inhibitors have the potential to control motor abnormalities, but the results of clinical trials are inconsistent. Antidepressant drugs are effective in specific subgroups of NERD patients with visceral hypersensitivity, but larger, controlled clinical studies are necessary. Protective drugs or medical devices have been recently adopted to reinforce mucosal resistance and preliminary trials have confirmed their efficacy either combined with or as add-on medication to PPIs in refractory patients.

The natural history of gastro-esophageal reflux disease: a comprehensive review

Gastroesophageal reflux disease (GERD) is a common disorder of the upper gastrointestinal tract which is typically characterized by heartburn and acid regurgitation. These symptoms are widespread in the community and range from 2.5% to more than 25%. Economic analyses showed an increase in direct and indirect costs related to the diagnosis, treatment and surveillance of GERD and its complications. The aim of this review is to provide current information regarding the natural history of GERD, taking into account the evolution of its definition and the worldwide gradual change of its epidemiology. Present knowledge shows that there are two main forms of GERD, that is erosive reflux disease (ERD) and non-erosive reflux disease (NERD) and the latter comprises the majority of patients (up to 70%). The major complication of GERD is the development of Barrett esophagus, which is considered as a pre-cancerous lesion. Although data from medical literature on the natural history of this disease are limited and mainly retrospective, they seem to indicate that both NERD and mild esophagitis tend to remain as such with time and the progression from NERD to ERD, from mild to severe ERD and from ERD to Barrett's esophagus may occur in a small proportion of patients, ranging from 0 to 30%, 10 to 22% and 1 to 13% of cases, respectively. It is necessary to stress that these data are strongly influenced by the use of powerful antisecretory drugs (PPIs). Further studies are needed to better elucidate this matter and overcome the present limitations represented by the lack of large prospective longitudinal investigations, absence of homogeneous definitions of the various forms of GERD, influence of different treatments, clear exclusion of patients with functional disorders of the esophagus.

Prevalence of gastro-esophageal reflux disease and its risk factors in a community-based population in southern India

Background

The prevalence of gastro-esophageal reflux disease (GERD) varies widely around the world. This study aimed to investigate the prevalence and risk factors of GERD in a general population of southern India.

Methods

An interview-based observational study was carried out in southern India during 2010 and early 2011 using a GERD questionnaire (GerdQ). In total 1072 participants were enrolled using a multi-stage cluster sampling method. Presence of GERD was defined as a score of ≥ 8. Logistic regression models were used to derive odds ratios (ORs) with 95 % confidence intervals (CIs).

Results

The prevalence of GERD was 22.2 % (238/1072) in southern India, and was more common among older subjects and men. Overweight and obese subjects had a dose-dependent increased risk of GERD, compared to those with body mass index less than 25 (multivariate-adjusted OR = 1.4, 95 % CI 1.0–2.0; OR = 2.3, 95 % CI 1.3–4.1, respectively). People residing in urban community were more vulnerable to GERD than those in rural community (multivariate-adjusted OR = 1.8, 95 % CI 1.3–2.5). Similarly, those with a lower educational level appeared to have an increased risk of GERD. Further, those with a habit of pan masala chewing were more likely to develop GERD compared with those abstained from the habit (multivariate-adjusted OR = 2.0, 95 % CI 1.2–3.2).

Conclusions

GERD is highly prevalent in southern India. Increasing age and BMI, an urban environment, lower educational level, and pan masala chewing appear to be risk factors of GERD symptoms for the studied population.

Short-term Intervention to Revert Premalignant Lesions as Strategy to Prevent Gastrointestinal Cancers

"Prevention might be better than treatment in cancer treatment" is brief conclusion drawn from war on cancer through National Cancer Act of 1971 by U.S. President Richard Nixon. However, the clinical practice of chemoprevention is still in its infancy in spite of a wealth of data showing its effectiveness in experimental animals as well as in vitro mechanism research. Recent advances in either high throughput analysis including cancer genomes and tailored medicine or molecular targeted therapeutics, preventive strategies also should be changes as previous preventive strategies including phytoceuticals, life-style modification, and some empirical agents. Furthermore, molecular targeted therapeutics achieved high goal of effectiveness under the concept of therapeutic or preventive "synthetic lethality", of which extended application can be included within the scope of chemoprevention. Here, we will summarize several recent advances in chemopreventive strategy objected to justify optimism that chemoprevention will be an effective approach for the control of human cancer. siTRP (short-term intervention to revert premalignancy) strategy will be introduced for cancers in gastroenterology.

Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review

OBJECTIVE

To update the findings of the 2005 systematic review of population-based studies assessing the epidemiology of gastro-oesophageal reflux disease (GERD).

DESIGN

PubMed and Embase were screened for new references using the original search strings. Studies were required to be population-based, to include ≥ 200 individuals, to have response rates ≥ 50% and recall periods <12 months. GERD was defined as heartburn and/or regurgitation on at least 1 day a week, or according to the Montreal definition, or diagnosed by a clinician. Temporal and geographic trends in disease prevalence were examined using a Poisson regression model.

RESULTS

16 studies of GERD epidemiology published since the original review were found to be suitable for inclusion (15 reporting prevalence and one reporting incidence), and were added to the 13 prevalence and two incidence studies found previously. The range of GERD prevalence estimates was 18.1%-27.8% in North America, 8.8%-25.9% in Europe, 2.5%-7.8% in East Asia, 8.7%-33.1% in the Middle East, 11.6% in Australia and 23.0% in South America. Incidence per 1000 person-years was approximately 5 in the overall UK and US populations, and 0.84 in paediatric patients aged 1-17 years in the UK. Evidence suggests an increase in GERD prevalence since 1995 (p<0.0001), particularly in North America and East Asia.

CONCLUSIONS

GERD is prevalent worldwide, and disease burden may be increasing. Prevalence estimates show considerable geographic variation, but only East Asia shows estimates consistently lower than 10%.

Role of lymphovascular invasion and immunohistochemical expression of IMP3 in the risk stratification of superficially invasive pT1 esophageal adenocarcinoma

BACKGROUND

A problem in the management of patients with Barrett's esophagus-related pT1 esophageal adenocarcinoma is to distinguish those who should be treated conservatively (endoscopic mucosal resection and/or radiofrequency ablation) from those who require esophago-gastrectomy. Recently, lymphovascular invasion (LVI) has emerged as one of the best predictors of regional lymph node metastasis (LNM) and recurrence-free survival (RFS) in pT1 EAC. However, LVI may be underestimated, both because of interobserver variability and incomplete sampling. The aim of our study was to correlate the presence of LVI, with the immunohistochemical expression of IMP3 in pT1 EAC and assess their role in further stratifying these lesions into high and low risk groups based on the potential for lymph node metastasis and poor outcome.

DESIGN

Depth of invasion, assessed in five sublevels (m2, m3, sm1, sm2, and sm3), LVI, and expression of IMP3 were studied in 30 patients who underwent esophagogastrectomy for pT1 EAC (2001-2010) at Hartford Hospital, and correlated with LNM and RFS. IMP3 was considered positive when expressed in >50% of the malignant cells with an intensity of stain of 2-3+.

RESULTS

Ten of 18 (55.5%) cases with IMP3 expression demonstrated LVI and 2/10 (20%) showed LNM and died of disease. In contrast, none of the 12 IMP3 negative cases showed LVI (p<0.004; 2-tailed Fisher exact test) or had LNM/DOD.

CONCLUSIONS

In pT1 EAC, (1) based on IMP3 expression, pT1 EAC may be divided into high risk (LVI+/IMP3+) and low risk (LVI-/IMP3-) categories. (2) Absence of IMP3 expression is associated with a significantly reduced risk of LVI (Negative Predictive Value: 100%). (3) Since identifying lymphovascular invasion and other morphological parameters is prone to significant inter-observer variation, IMP3 may be useful as an ancillary marker especially in these pT1 lesions in predicting their clinical behavior, the risk stratification and potentially on the type of treatment.

Radiofrequency ablation in the management of Barrett's esophagus: present role and future perspective

Esophageal adenocarcinoma is the most rapidly increasing gastrointestinal cancer. Barrett's esophagus has been identified as a precancerous condition and major risk factor for esophageal cancer. Radiofrequency ablation has been shown to be a highly efficient in promoting remission of intestinal metaplasia. This technology has seen widespread clinical use since 2005. Radiofrequency ablation is common with all other ablative techniques; the concern that sound oncological principles are not being adhered to, that is, appropriate pathological staging, followed by appropriate definitive therapy. Endoscopic mucosal excision techniques are technically demanding; however, they are more attractive from an oncological perspective. Future research endeavors focusing on facilitation of large population screening, the identification of high risk phenotypes, endoscopic mucosal resection techniques will combat the esophageal adenocarcinoma epidemic.

Cause of death during long-term follow-up for superficial esophageal adenocarcinoma

BACKGROUND

The purpose of this study was to evaluate long-term prognosis and cause of death in patients with superficial esophageal adenocarcinoma (SEAC) after surgery.

PATIENTS AND METHODS

A total of 85 patients without adjuvant or neoadjuvant treatment underwent surgery for SEAC (pT1N0-1, M0) 1984-2011. Medical records and causes of death were reviewed, and 79 specimens (93 %) were reanalyzed for cancer penetration. Survival was calculated according to Kaplan-Meier and comparisons of survival with log-rank test. Multivariate survival was analyzed with Cox proportional hazards model.

RESULTS

Of 85 patients, 36 had transhiatal, 33 transthoracic en bloc, 6 minimally invasive en bloc, 5 vagal sparing esophageal resection and 5 endoscopic mucosal resections; 7 patients (8 %) had lymph node metastasis (LNM). Cancer penetration: 35 pT1a and 44 pT1b. Overall survival was 67 % at 5 years and 50 % at 10 years. Disease-specific survival was 82 % at 5 years and 78 % at 10 years. Recurrence-free survival was 80 % at 5 years. In a Cox multivariate model, poor overall survival was predicted only by LNM. Cumulative mortality during median follow-up of 5 years (0-25 years): 37 of 85 (44 %). Cause of death of these 37: SEAC recurrence for 15 (41 %), postoperative complications for 4 (11 %), another primary malignancy for 5 (14 %), non-cancer-related for 11 (30 %) and for 2 (5 %) cause unknown. Mortality after 5-year follow-up: 11 (30 %); 82 % of these deaths were unrelated to SEAC recurrence.

CONCLUSIONS

With SEAC recurrence as the single most common cause of death, disease-specific 5-year survival was good. Overall and late (> 5-year) survival is affected by diseases related to aging.

Diagnosis and management of Barrett’s metaplasia: What’s new

Barrett’s esophagus (BE) is a complication of gastroesophageal reflux disease, and a premalignant lesion for esophageal adenocarcinoma (EAC). Observational studies suggest that endoscopic surveillance is associated with the detection of dysplasia and EAC at an early stage along with improved survival, but controversies still remain. The management of patients with BE involves endoscopic surveillance, preventive and clinical measures for cancer, and endoscopic and surgical approaches to treatment. Deciding upon the most appropriate treatment is a challenge. This study presents the results and the effectiveness of these practices.

[Barrett's esophagus. An update]

Barrett's esophagus (BE), a well-known complication of gastroesophageal reflux disease (GERD), constitutes a precancerous condition for adenocarcinoma of the distal esophagus. The so-called Barrett's carcinoma shows increasing incidences in countries of the western hemisphere; new data, however, indicate that the rise in incidence is not quite as dramatic as previously assumed. The definition of BE is currently changing: despite good reasons for a purely endoscopic definition of BE, goblet cells are still mandatory for this diagnosis in Germany and the USA. Dysplastic changes in the epithelium are the most important risk factor for the development of Barrett's adenocarcinoma and recently dysplasia was subclassified into a more frequent adenomatous (intestinal) and a non-adenomatous (gastric-foveolar) types. The gold standard for diagnosing dysplasia is still H&E staining. The histological diagnosis of dysplasia is still encumbered by a significant interobserver variability, especially regarding the differentiation between low grade dysplasia and inflammatory/reactive changes and the discrimination between high grade dysplasia and adenocarcinoma. Current data, however, show much higher interobserver agreement in endoscopic resection specimens than in biopsies. Nevertheless, the histological diagnosis of dysplasia should be corroborated by an external second opinion because of its clinical consequences. In endoscopic resections of early Barrett's adenocarcinoma, the pathological report has to include a risk stratification for the likelihood of lymphogenic metastases.

Consensus statements for management of Barrett's dysplasia and early-stage esophageal adenocarcinoma, based on a Delphi process

BACKGROUND & AIMS

Esophageal adenocarcinoma (EA) is increasingly common among patients with Barrett's esophagus (BE). We aimed to provide consensus recommendations based on the medical literature that clinicians could use to manage patients with BE and low-grade dysplasia, high-grade dysplasia (HGD), or early-stage EA.

METHODS

We performed an international, multidisciplinary, systematic, evidence-based review of different management strategies for patients with BE and dysplasia or early-stage EA. We used a Delphi process to develop consensus statements. The results of literature searches were screened using a unique, interactive, Web-based data-sifting platform; we used 11,904 papers to inform the choice of statements selected. An a priori threshold of 80% agreement was used to establish consensus for each statement.

RESULTS

Eighty-one of the 91 statements achieved consensus despite generally low quality of evidence, including 8 clinical statements: (1) specimens from endoscopic resection are better than biopsies for staging lesions, (2) it is important to carefully map the size of the dysplastic areas, (3) patients that receive ablative or surgical therapy require endoscopic follow-up, (4) high-resolution endoscopy is necessary for accurate diagnosis, (5) endoscopic therapy for HGD is preferred to surveillance, (6) endoscopic therapy for HGD is preferred to surgery, (7) the combination of endoscopic resection and radiofrequency ablation is the most effective therapy, and (8) after endoscopic removal of lesions from patients with HGD, all areas of BE should be ablated.

CONCLUSIONS

We developed a data-sifting platform and used the Delphi process to create evidence-based consensus statements for the management of patients with BE and early-stage EA. This approach identified important clinical features of the diseases and areas for future studies.

Systematic review: patterns of reflux-induced symptoms and esophageal endoscopic findings in large-scale surveys

BACKGROUND & AIMS

This systematic review assesses findings of endoscopic surveys in the general population with regard to gastroesophageal reflux disease (GERD).

METHODS

Systematic searches were conducted in PubMed and EMBASE. Authors were contacted for additional, unpublished data.

RESULTS

Data on 61,281 individuals were included from 3 general population studies (Kalixanda study [Sweden], Loiano-Monghidoro study [Italy], SILC study [China]) and 8 health-check studies (Japan, n = 1; China, n = 1; Taiwan, n = 4; Korea, n = 2). The prevalence of reflux esophagitis was 15.5% (Kalixanda), 11.8% (Loiano-Monghidoro), and 6.4% (SILC); it ranged from 3.4% to 8.5% in health-check studies in Japan, China, and Korea (n = 4), but was higher (mean, 15.6%; range, 9.0%-24.6%; n = 4) in Taiwan. Hiatus hernia prevalence was 23.9% (Kalixanda), 43.0% (Loiano-Monghidoro), and 0.7% (SILC), and 0.8%-19.5% in health-check studies (n = 7). For endoscopically suspected esophageal metaplasia (ESEM), the prevalence was 10.3% (Kalixanda), 3.6% (Loiano-Monghidoro), and 1.8% (SILC), and 0.0%-3.4% in health-check studies (n = 4). The prevalence of reflux esophagitis among individuals without symptom-defined GERD was 12.1% (Kalixanda), 8.6% (Loiano-Monghidoro), 6.1% (SILC), and 1.6%-22.8% (health-check studies; n = 6). For individuals without symptom-defined GERD, the prevalence of ESEM was 9.4% (Kalixanda), 2.8% (Loiano-Monghidoro), and 1.8% (SILC).

CONCLUSIONS

The prevalence of reflux esophagitis is higher in Sweden and Italy than in China, Korea, and Japan, but is within the range reported in Taiwan. Hiatus hernia and ESEM are generally more prevalent in Europe than in Asia. A considerable proportion of individuals without symptom-defined GERD has reflux esophagitis or ESEM.

Endoscopic diagnosis of Barrett’s esophagus

The Prague C and M Criteria have been developed for the objective endoscopic diagnosis of Barrett’s esophagus (BE). BE arises between the squamocolumnar junction and the gastroesophageal junction at the proximal margin of the gastric folds. In this study, we reported that 43.0% of the subjects examined were diagnosed with BE based on the Prague C and M Criteria. Previous criticism by John Dent proposed that our data should be considered invalid because the prevalence of BE reported in our study was extraordinarily high and discordant with previous studies. Dent predicted that the position of the gastroesophageal junction in our study was judged to be lower than the actual position due to the effacement of the proximal ends of the gastric folds because of the routine use of a high degree of air distension during typical Japanese endoscopic examinations. The endoscopic evaluation of the superior gastric folds is certainly influenced by the degree of air distension of the esophagus. However, in our study, the proximal limit of the gastric mucosal folds was prospectively imaged while the oesophagus was minimally insufflated. Then, under a high level of air distension, the distal ends of the palisade-shaped longitudinal vessels were imaged because they are more easily observed when distended. In the majority of patients, the distal ends of the palisade-shaped longitudinal vessels correspond to the proximal limit of the gastric mucosal folds. Our endoscopic evaluation was appropriately performed according to the Prague C and M Criteria. We suspect that the high prevalence of BE in our study may be due to the inclusion of ultrashort-segment BE, which defines BE with an affected mucosal length under 5 mm, in our positive results.

Increased incidence of endoscopic erosive esophagitis in solid organ transplant recipients

Background/Aims

Solid organ transplant recipients frequently report gastrointestinal symptoms, especially heartburn or dyspepsia. However, the prevalence of endoscopic erosive esophagitis (EE) and associated risk factors after transplantation are unknown. The aim of this study was to determine whether there was a high incidence of endoscopic findings of EE in solid organ transplant recipients.

Methods

This retrospective case-control study included 256 of 3,152 solid organ transplant recipients who underwent sequential screening upper endoscopic examinations and an equal number of controls.

Results

Forty-four (17.2%) and 16 (6.2%) cases of EE were detected in the solid organ transplant and control groups, respectively (p<0.001). In the multivariate analysis, transplantation was significantly associated with EE (odds ratio [OR], 6.48; 95% confidence interval, 2.74 to 15.35). Factors such as old age (OR, 1.17), the presence of a hiatal hernia (OR, 5.84), an increased duration of immunosuppression (OR, 1.07), and the maintenance administration of mycophenolate mofetil (OR, 4.13) were independently associated with the occurrence of EE in the solid organ transplant recipients.

Conclusions

A significant increase in the incidence of endoscopically detected EE was observed in solid organ transplant recipients. This increased incidence was associated with the type and duration of the immunosuppressive therapy.

Barrett's esophagus and esophageal cancer: an overview

Although esophageal cancer (EC) is the eighth most common cancer in several European countries, it is one of deadliest worldwide. The most frequent predisposing factor implicated in its development is Barrett's esophagus (BE), an acquired metaplastic transformation of the esophageal lining cells from normal squamous epithelium into specialised or intestinal-like columnar epithelium. The major risk factor for BE is gastroesophageal reflux disease. Although BE is in itself a benign and often asymptomatic disorder, its clinical importance stems from the recognition that it represents the main precursor lesion for the development of esophageal adenocarcinoma (AC), a tumor that is rapidly increasing especially in developed countries and is associated with a low survival rate. This paper provides an overview of the epidemiology and natural history of BE as well as of the possible pathogenetic mechanisms underlying the development of BE and its progressive transition to AC. New diagnostic tests are described, recommendations for screening and surveillance are provided and surgical and ablative procedures to treat dysplastic lesions and early neoplasia are discussed. Claimed chemopreventive agents and biomarkers that in the near future may help identify people with a higher risk of EC are also considered.

Divergent expression of MUC5AC, MUC6, MUC2, CD10, and CDX-2 in dysplasia and intramucosal adenocarcinomas with intestinal and foveolar morphology: is this evidence of distinct gastric and intestinal pathways to carcinogenesis in Barrett Esophagus?

Dysplasia in Barrett esophagus has been recognized to be morphologically heterogenous, featuring adenomatous, foveolar, and hybrid phenotypes. Recent studies have suggested a tumor suppressor role for CDX-2 in the metaplasia-dysplasia-carcinoma sequence. The phenotypic stability and role of CDX-2 in the neoplastic progression of different types of dysplasias have not been evaluated. Thirty-eight endoscopic mucosal resections with dysplasia and/or intramucosal carcinoma (IMC) arising in Barrett esophagus were evaluated for the expression of MUC5AC, MUC6, MUC2, CD10, and CDX-2. The background mucosa was also evaluated. The results were correlated with morphologic classification and clinicopathologic parameters. Of 38 endoscopic mucosal resections, 23 had IMC and dysplasia, 8 had IMC only, and 7 had dysplasia only. Among dysplastic lesions, 73% were foveolar, 17% were adenomatous, and 10% were hybrid. Twenty of 23 cases with dysplasia and adjacent IMC showed an identical immunophenotype of dysplasia and IMC comprising 16 gastric, 3 intestinal, and 1 mixed immunophenotype. Three cases showed discordance of dysplasia and IMC immunophenotype. These findings suggest that most Barrett-related IMC cases are either gastric or intestinal, with phenotypic stability during progression supporting separate gastric and intestinal pathways of carcinogenesis. CDX-2 showed gradual downregulation of expression during progression in adenomatous dysplasia but not in foveolar or hybrid dysplasia, supporting a tumor suppressor role, at least in the intestinal pathway. CDX-2 was also found to be expressed to a greater degree in intestinal metaplasia compared with nonintestinalized columnar metaplasia. Consistent with CDX-2 as a tumor suppressor, this suggests that nonintestinalized columnar metaplasia may be an unstable intermediate state at risk for neoplastic progression.

Endoscopic Imaging in Barrett's Oesophagus: Applications in Routine Clinical Practice and Future Outlook

The practice for endoscopic surveillance of Barrett's oesophagus has evolved from "blind" or random 4 quadrant biopsies (Seattle protocol) to a more "intelligent" targeted biopsy approach. This evolution has been possible due to the rapid advances in endoscopic imaging technology and expertise in the last decade. Previous endoscopes had relatively poor image resolution that often did not allow the subtle mucosal changes associated with dysplastic Barrett's mucosa to be identified. Newer endoscopic imaging techniques available today may allow endoscopists to identify areas of dysplasia or malignancy and target biopsies accordingly. These modalities which include narrow band imaging, chromoendoscopy, autofluorescence imaging, and confocal endomicroscopy as well as a few novel imaging modalities on the horizon will be discussed further.

Autofluorescence endoscopy with "real-time" digital image processing in differential diagnostics of selected benign and malignant lesions in the oesophagus

BACKGROUND

Oesophageal papilloma and Barrett's oesophagus are benign lesions known as risk factors of carcinoma in the oesophagus. Therefore, it is important to diagnose these early changes before neoplastic transformation.

METHOD

Autofluorescence endoscopy is a fast and non-invasive method of imaging of tissues based on the natural fluorescence of endogenous fluorophores. The aim of this study was to prove the diagnostic utility of autofluorescence endoscopy with digital image processing in histological diagnosis of endoscopic findings in the upper digestive tract, primarily in the imaging of oesophageal papilloma.

RESULTS

During the retrospective analysis of about 200 endoscopic procedures in the upper digestive tract, 67 cases of benign, precancerous or cancerous changes were found. White light endoscopy (WLE) image, single-channel (red or green) autofluorescence images, as well as green and red fluorescence intensities in two modal fluorescence image and red-to-green (R/G) ratio (Numerical Colour Value, NCV) were correlated with histopathologic results. The NCV analysis in autofluorescence imaging (AFI) showed increased R/G ratio in cancerous changes in 96% vs. 85% in WLE. Simultaneous analysis with digital image processing allowed us to diagnose suspicious tissue as cancerous in all of cases. Barrett's metaplasia was confirmed in 90% vs. 79% (AFI vs. WLE), and 98% in imaging with digital image processing. In benign lesions, WLE allowed us to exclude tissue as malignant in 85%. Using autofluorescence endoscopy R/G ratio was increased in only 10% of benign changes causing the picture to be interpreted as suspicious, but when both methods were used together, 97.5% were cases excluded as malignancies. Mean R/G ratios were estimated to be 2.5 in cancers, 1.25 in Barrett's metaplasia and 0.75 in benign changes and were statistically significant (p=0.04).

CONCLUSION

Autofluorescence imaging is a sensitive method to diagnose precancerous and cancerous early stages of the diseases located in oesophagus. Especially in two-modal imaging including white light endoscopy, autofluorescence imaging with digital image processing seems to be a useful modality of early diagnostics. Also in observation of papilloma changes, it facilitates differentiation between neoplastic and benign lesions and more accurate estimation of the risk of potential malignancy.