From the AGA Journals

Endoscopic therapy decreases recurrence of intestinal metaplasia, dysplasia in patients with Barrett’s esophagus



A study of patients with Barrett’s esophagus found that, although intestinal metaplasia and dysplasia in the cardia were common before treatment, they were more frequently present at higher levels and successful endoscopic eradication therapy lessened the risk.

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“The results of this study provide evidence to suggest that, in Barrett’s esophagus patients who have achieved CEIM [complete eradication of intestinal metaplasia], it is sufficient to perform a close examination of the cardia and, in the absence of visible abnormalities, to randomly biopsy only at the level of TGF [top of gastric folds], rather than deeper into the cardia, during surveillance exams,” wrote Swathi Eluri, MD, of the University of North Carolina in Chapel Hill and coauthors. The study was published in Clinical Gastroenterology and Hepatology.

To determine the prevalence of intestinal metaplasia or dysplasia in the cardia of patients with Barrett’s esophagus who successfully underwent endoscopic eradication therapy (EET), along with the incidence of cardia intestinal metaplasia or dysplasia in patients undergoing EET, this single-center study examined two groups: a cross-sectional group of 116 patients who had achieved CEIM, and a longitudinal group of 42 treatment-naive patients who were receiving EET and subsequently achieved CEIM.

Along with clinical biopsies, the cross-sectional group underwent standardized biopsies from four quadrants in four locations: the distal esophagus, 1 cm proximal to top of gastric folds (TGF–1); at TGF; 1 cm into the gastric cardia (TGF+1); and 2 cm into the cardia (TGF+2). The longitudinal group also underwent 16 biopsies in the same areas; after CEIM was achieved, they underwent standard research biopsies of the distal esophagus and cardia at 6- and 18-month follow-ups.

Within the cross-sectional group, 15% of patients (n = 17) had intestinal metaplasia or dysplasia in the cardia after CEIM. Of those 17 patients, 12 had intestinal metaplasia, 2 were indefinite for dysplasia, and 3 had low-grade dysplasia. Of the 12 patients with cardia intestinal metaplasia, 83% had it at the level of TGF; 50% at TGF+1; and 25% at TGF+2.

Within the longitudinal group, 28% of patients (n = 12) had intestinal metaplasia or dysplasia in the cardia before ablation. Of those 12 patients, 9 had dysplastic intestinal metaplasia. Cases of pretreatment dysplasia were all found at the level of TGF, with one case extended to TGF+1. All patients achieved CEIM; at 18 months post CEIM, two patients had intestinal metaplasia and none had dysplasia.

The authors shared their study’s limitations, which included the lack of generalizability of a single-center study and a notable number of dropouts in the longitudinal group. They also acknowledged using multiple ablation modalities, although they added that most patients in both groups underwent radiofrequency ablation, the most commonly used treatment method and one that made “the results of the study more applicable to real-world practice.”

In turn, the authors noted their study’s strengths, which included the collection of data in a standardized manner and the availability of complete ablation history for all patients. Theirs was also the first study to systematically sample the cardia at multiple levels, which allows for “a more granular understanding of the location of initial and incident cardia lesions, which can guide depth of ablation during EET.”

The study was funded by an American Gastroenterological Association Research Scholar Award and CSA Medical. The authors reported no conflicts of interest.

SOURCE: Eluri S et al. Clin Gastroenterol Hepatol. 2019 May 8. doi: 10.1016/j.cgh.2019.04.065.

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