Barrett esophagus (BE) represents the metaplastic change of the normal esophageal squamous epithelium to intestinalized columnar epithelium, which is a precursor to esophageal adenocarcinoma (EAC)1. The intestinal metaplasia (IM) seen in BE can progress from IM to IM with low grade dysplasia (LGD), to IM with high-grade dysplasia (HGD), to intramucosal cancer (IMC) and subsequently invasive EAC.1,2 The annual risk of progression from BE to EAC depends on the type and presence of dysplasia: nondysplastic: ~0.2-0.5%/year, LGD ~0.7%/year, HGD ~7%/year3.
The 2016 American College of Gastroenterology (ACG) guidelines recommend endoscopic eradication therapy (EET) as the procedure of choice in patients with non-nodular, confirmed LGD and HGD.3 Broadly, EET includes endoscopic mucosal resection (EMR) and radiofrequency ablation (RFA). Successful endoscopic ablative therapy includes complete eradication of IM (CE-IM) in the esophagus.3.
Surveillance recommendations are based on the initial grade of dysplasia. For patients with baseline LGD, endoscopic surveillance is recommended every 6 months in the first year following CE-IM and then annually. Comparatively, those with baseline HGD at baseline are recommended to have endoscopic surveillance every 3 months in the first year, every 6 months in the second year and then annually. These endoscopic surveillance intervals can potentially place a burden on both patients and physicians, especially in the era of high quality and cost-effective care. Therefore, there is always an interest evaluating these intervals in real-world settings to see if any changes to future guidelines are necessary.
Recently, a group led by Wani et al published their findings regarding the long-term durability of CE-IM in patients with BE who received EET.2 This was a prospective study of 807 patients at 4 tertiary care centers with BE who underwent EET and achieved CE-IM. These four centers were members of the Treatment with Resection and Endoscopic Ablation Techniques for Barrett’s Esophagus (TREAT-BE) Consortium. CE-IM was defined as the absence of endoscopically visible BE and IM on esophageal biopsies that included the entire pretreatment BE length and squamo-columnar junction after a single biopsy.
Ninety four percent of patients underwent EET for dysplasia or EAC with 98% treated with EMR and/or RFA. A mean of 2.6 (standard deviation, SD, 1.3) sessions was needed to achieve CE-IM. The mean follow up was 3.3 (SD 2.7) years per patient with the study accumulating a total of 2,317 patient years.
IM recurred in 121/807 (15%) of patients during the 2,317 person-year follow up period. The incidence rate of IM was 5.2 (95% CI, 4.4-6.2) per 100 person-years in the overall cohort with 2.8 (95% CI, 1.9-4.0) per 100 person-years among patients with LGD and 6.7 (95% CI, 5.4-8.2) per 100 person-years among patients with HGD/EAC. Recurrences peaked approximately 1.6 years after patients achieved CE-IM. Recurrence was associated with HGD or intramucosal cancer (adjusted odds ratio (aOR), 4.19), presence of reflux symptoms (aOR, 12.1), presence of hiatal hernia (aOR, 13.8), and number of sessions required to achieve CE-IM (aOR, 1.8).
All recurrences were of the same or lower histological grade and second CE-IM achieved in close to 98% of patients. No patients with recurrent disease progressed to invasive EAC or required surgery.
This study had several limitations. The data used was collected by four tertiary care centers with experienced endoscopists, therefore the findings may not be generalizable to all physicians, patients and/or sites. In addition, there was a lack of standardization of surveillance protocols between sites. Centralized pathology was not used, but expert gastrointestinal pathologists were involved at all sites. Recurrence estimates were provided for up to 5 years, therefore future studies will have to look at longer-term data.
The authors concluded that the rate of recurrence of IM after CE-IM was low and peaked approximately at 1.6 years, which is contrary to a more aggressive surveillance interval recall as currently recommended by the 2016 ACG guidelines.4 It will be interesting to see how this study and others will impact updates to guidelines with respect to surveillance intervals.
1. Shaheen NJ, Richter JE. Barrett’s oesophagus. Lancet. 2009;373(9666):850-61.
2. Wani S, Han S, Kushnir V, et al. Recurrence is rare following complete eradication of intestinal metaplasia in patients with Barrett’s esophagus and peaks at 18 months. Clin Gastroenterol Hepatol [published online January 23, 2020]. doi:10.1016/j.cgh.2020.01.019
3. Shaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. Am J Gastroenterol. 2016;111(1):30-50.
4. Trindade AJ. How Much Post-ablation Surveillance is Too Much For Patients With Barrett’s Esophagus? [pubished online March 18, 2020], Clin Gastroenterol Hepatol. doi:10.1016/j.cgh.2020.03.030