G Longcroft-Wheaton

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 Barretts 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.

Acetic Acid Spray Is an Effective Tool for the Endoscopic Detection of Neoplasia in Patients With Barrett's Esophagus

BACKGROUND & AIMS Diagnosis of Barretts neoplasia requires collection of large numbers of random biopsy samples; the process is time consuming and can miss early-stage cancers. We evaluated the role of acetic acid chromoendoscopy in identifying Barretts neoplasia. METHODS Data were collected from patients with Barretts esophagus examined at a tertiary referral center, between July 2005 and November 2008 using Fujinon gastroscopes and EPX 4400 processor (n = 190). All procedures were performed by a single experienced endoscopist. Patients were examined with white light gastroscopy and visible abnormalities were identified. Acetic acid (2.5%) dye spray was used to identify potentially neoplastic areas and biopsy samples were collected from these, followed by quadrantic biopsies at 2 cm intervals of the remaining Barretts mucosa. The chromoendoscopic diagnosis was compared with the ultimate histological diagnosis to evaluate the sensitivity of acetic acid chromoendoscopy. RESULTS Acetic acid chromoendoscopy had a sensitivity of 95.5% and specificity of 80% for the detection of neoplasia. There was a correlation between lesions predicted to be neoplasias by acetic acid and those diagnosed by histological analysis (r = 0.98). There was a significant improvement in the detection of neoplasia using acetic acid compared with white light endoscopy (P = .001). CONCLUSIONS Analysis of this large series showed that acetic acid-assisted evaluation of Barretts esophagus detects neoplasia better than white light endoscopy, with sensitivity and specificity equal to that of histological analysis.

Same-day bowel cleansing regimen is superior to a split-dose Regimen over 2 days for afternoon colonoscopy: results from a large prospective series

Goals and Background: Conventional bowel preparation for afternoon colonoscopy requires an oral agent the day before the procedure. Bowel cleansing given only on the day of the colonoscopy has never been attempted. The aims of this study were to compare the efficacy of bowel cleansing, impact on activities of daily living (ADLs), side effects, and patient preference of a same-day regimen with a 2-day regimen. Study: A single-blinded, prospective cohort study. Patients were block recruited into 2 groups with the endoscopist blinded to the regimen. Group A: 3 sachets of sodium picosulphate given at 12:00 noon and at 05:00 PM the day before and at 8:00 AM on the morning of the procedure. Group B: 2 sachets of sodium picosulphate on the morning of the procedure at 07:00 and 10:00 AM. Patients completed a quality-of-life questionnaire investigating the side effects, impact on ADLs, and regimen preference. The main outcome measures were mucosal cleansing, impact on ADLs, side effects, and patient preference of the regimen. Results: A total of 227 patients underwent screening colonoscopy. There were 95 patients in group A and 132 in group B, all of whom were age and sex matched. Same-day preparation produced better mucosal cleansing (P=0.0046) with fewer side effects (P=0.002). Impact on ADLs was less with the same-day regimen (P<0.0001). Significantly more number of patients preferred the same-day preparation compared with the 2-day regimen (P=0.0147). Conclusions: Same-day bowel preparation is feasible, safe, and more effective than a split-dose regimen. It has fewer adverse events and is preferred by patients.

Flexible spectral imaging color enhancement and indigo carmine in neoplasia diagnosis during colonoscopy: a large prospective UK series

Objectives At present, all colonic polyps are removed and sent for histopathological evaluation, resulting in laboratory and reporting costs. Recent American Society for Gastrointestinal Endoscopy (ASGE) guidelines have set standards for in-vivo diagnosis in place of conventional histopathology, and all future technologies will have to be tested against these standards. Data on flexible spectral imaging color enhancement (FICE) were very limited. This study aims to evaluate the accuracy of FICE and indigo carmine (IC) for in-vivo histology prediction for polyps of less than 10 mm in size and to assess the economic impact of this strategy. Methods In a screening population, polyps of less than 10 mm were assessed using white light (WLI) by FICE, by IC, and the predicted diagnosis was recorded. Polyps were then removed and sent for histological analysis. Accuracy of the predicted rescope interval was calculated using British Society of Gastroenterology and ASGE guidelines. Two models for using in-vivo diagnosis were proposed and savings in terms of histopathology costs calculated. Results A total of 232 polyps of less than 10 mm were examined. FICE improved the accuracy of in-vivo diagnosis of adenoma to 88% compared with 75% with WLI (P<0.0001). IC after FICE improved this further to 94%. Rescope interval could be set correctly using FICE or IC in 97% of cases by British Society of Gastroenterology guidelines or 97% with FICE and 99% with IC using ASGE guidelines. A saving of £678 253 (&OV0556;762767) per annum could be made within the UK national screening population. Conclusion FICE and IC significantly improves the in-vivo diagnosis of colonic polyps over WLI and can lead to significant cost savings.

High-definition vs. standard-definition colonoscopy in the characterization of small colonic polyps: results from a randomized trial.

BACKGROUND AND STUDY AIMS The resolution of endoscopes has increased in recent years. Modern Fujinon colonoscopes have a charge-coupled device (CCD) pixel density of 650,000 pixels compared with the 410,000 pixel CCD in standard-definition scopes. Acquiring high-definition scopes represents a significant capital investment and their clinical value remains uncertain. The aim of the current study was to investigate the impact of high-definition endoscopes on the in vivo histology prediction of colonic polyps. PATIENTS AND METHODS Colonoscopy procedures were performed using Fujinon colonoscopes and EPX-4400 processor. Procedures were randomized to be performed using either a standard-definition EC-530 colonoscope or high-definition EC-530 and EC-590 colonoscopes. Polyps of <10 mm were assessed using both white light imaging (WLI) and flexible spectral imaging color enhancement (FICE), and the predicted diagnosis was recorded. Polyps were removed and sent for histological analysis by a pathologist who was blinded to the endoscopic diagnosis. The predicted diagnosis was compared with the histology to calculate the accuracy, sensitivity, and specificity of in vivo assessment using either standard or high-definition scopes. RESULTS A total of 293 polyps of <10 mm were examined–150 polyps using the standard-definition colonoscope and 143 polyps using high-definition colonoscopes. There was no difference in sensitivity, specificity or accuracy between the two scopes when WLI was used (standard vs. high: accuracy 70% [95% CI 62–77] vs. 73% [95% CI 65–80]; P=0.61). When FICE was used, high-definition colonoscopes showed a sensitivity of 93% compared with 83% for standard-definition colonoscopes (P=0.048); specificity was 81% and 82%, respectively. CONCLUSIONS There was no difference between high- and standard-definition colonoscopes when white light was used, but FICE significantly improved the in vivo diagnosis of small polyps when high-definition scopes were used compared with standard definition.

Risk stratification system for evaluation of complex polyps can predict outcomes of endoscopic mucosal resection.

BACKGROUND: Apart from size, little is known about what makes a colonic polyp difficult to endoscopically remove. OBJECTIVE: The aim of this study was to evaluate polyp complexity by using a novel classification system and to assess how this affects success at endoscopic resection. DESIGN: This prospective cohort study was conducted at a tertiary referral center in the United Kingdom. INTERVENTIONS: Data were collected on patients referred for endoscopic resection of polyps >2 cm in size. Lesions were classified on the basis of size, morphology, site, and ease of access with the use of a novel scoring system (size/morphology/site/access). Endoscopic resection was performed to resect the lesions. Patients were followed up endoscopically to assess clinical outcomes. MAIN OUTCOME MEASURES: The primary outcomes measured were the endoscopic cure and complication rate by size/morphology/site/access grade and the cost savings of endoscopic resection over surgery. RESULTS: Endoscopic resection was performed on 220 patients (135 male) with 220 polyps, mean size of 43 mm (range, 20 mm–150 mm). Thirty-seven percent were classified as size/morphology/site/access 2 or 3; 63% were classified as the most challenging size/morphology/site/access level 4. Complete endoscopic clearance was achieved in 90% of cases with the first endoscopic resection attempt, improving to 96% with further endoscopic resection attempts. There were complications in 18 of 220 (8.1%) of cases. Complications were independent of lesion size and location but were affected by size/morphology/site/access grade (p = 0.018). Probability of clearance at first endoscopic resection attempt was affected by lesion complexity. Size/morphology/site/access 2 and 3 = 97.5 vs SMSA 4 = 87.5% (p = 0.009). Probability of cancer was not affected by size/morphology/site/access grade. For the whole cohort, endoscopic resection represented a cost saving of £726,288 (

Acetic acid-enhanced chromoendoscopy is more cost-effective than protocol-guided biopsies in a high-risk Barrett's population

1,123,858.05) over that of surgery. LIMITATIONS: The main limitation of this study is that it is a single-center, single-endoscopist series. CONCLUSIONS: The size/morphology/site/access scoring system is easy to use and provides valuable information on the lesion complexity and success and complication rates of endoscopic resection. This can be used for service planning, training endoscopists, and providing prognostic information for patients.

Understanding why patients die after gastrostomy tube insertion: a retrospective analysis of mortality.

To examine the efficacy and potential cost implications of acetic acid (AA) chromoendoscopy in the assessment of Barretts neoplasia. Our prospective database of patients referred between 2005 and 2010 with suspected early neoplasia was reviewed. High-resolution Fujinon gastroscopes and EPX-4400 processor were used. Inspection of Barretts neoplasia was carried out using white light followed by AA. Neoplastic areas were noted, and targeted biopsy was carried out. This was followed by quadrantic biopsies of the remaining Barretts neoplasia. The cost of protocol-guided biopsies was compared with AA-guided biopsy protocols. Two hundred sixty-three procedures on 197 patients were examined. High-risk neoplasia was found during 143 procedures. In 96% of cases it was identified with AA. The cost of histological evaluation by Cleveland protocol would be £139,416.30. The cost by AA-targeted biopsy followed by random biopsies in one pot would be £25,032.50. For AA-targeted biopsies alone the cost would be £9,541.8 but results in a 4% miss rate. AA localizes neoplastic lesions in the majority of patients and could potentially represent a significant cost saving in patients with suspected neoplasia.

Duration of acetowhitening as a novel objective tool for diagnosing high risk neoplasia in Barrett's esophagus: a prospective cohort trial.

OBJECTIVES To understand the causes of mortality of inpatients receiving a percutaneous endoscopic gastrostomy (PEG) tube compared with a survival curve predicted from a model proposed by Levine et al (2007). DESIGN A retrospective study of patients receiving a PEG over an 18-month period. SETTING Royal United Hospital Bath, a district general hospital in the southwest of England. PATIENTS Fifty-five cases, with 44 found eligible for inclusion. INTERVENTIONS A Levine score was calculated for this cohort. A survival curve after PEG was produced and compared with the Kaplan-Meier curve predicted by the Levine model. MAIN OUTCOME MEASURES Mortality over a period of 1 year. RESULTS The mortality at 1, 3, 6, and 12 months was 16%, 20%, 25%, and 28%, respectively. This matched the predicted death rate from the Levine model closely (Pearsons rank correlation coefficient = 0.96). CONCLUSIONS The authors found that the mortality of patients receiving a PEG followed that predicted for a similar cohort of patients without PEGs in the Levine model. This suggests that the deaths observed were due to underlying comorbidities, can provide a baseline for mortality targets for PEG services, and is useful patient information regarding the risks and benefits of the procedure. The findings demonstrate that PEG does no harm and supports the accepted opinion that nutrition support is associated with a better outcome. Furthermore, they show that most deaths occur within the first month of placement and would support arguments for delaying placement until outcome from the underlying condition is more predictable.

Endocuff-assisted vs. standard colonoscopy in the fecal occult blood test-based UK Bowel Cancer Screening Programme (E-cap study): a randomized trial

BACKGROUND AND STUDY AIMS Acetic acid reacts with Barretts mucosa to produce acetowhitening which disappears with time. The clinical significance of this is unknown. We aimed to quantify the acetowhitening time, developing an objective tool for diagnosis of neoplasia in Barretts esophagus. PATIENTS AND METHODS Prospective cohort study in a tertiary referral center, enrolling patients undergoing surveillance of Barretts metaplasia or referred with suspected neoplasia. Acetic acid 2.5 % was applied to the mucosa via a spray catheter. Acetowhitening was observed and time to disappearance recorded. Targeted biopsies of any neoplasia and quadrantic 2-cm biopsies of residual Barretts area were then taken. Histological findings were investigated in relation to duration of acetowhitening. RESULTS 132 patients were examined. A receiver operating characteristic (ROC) curve was produced for identifying high risk neoplasia according to acetowhitening duration. The area under the curve (AUC) was 0.93 (0.89 - 0.97). Using a threshold of 142 seconds yielded a sensitivity for neoplasia of 98 % (95 % confidence interval [95 %CI] 89 % - 100 %) and specificity of 84 % (74 % - 91 %). The ROC curve for mucosal neoplasia (high grade dysplasia or intramucosal carcinoma) versus deep invasive cancer showed an AUC of 0.786 (0.61 - 0.96); a cutoff of 20 seconds yielded a sensitivity and specificity for invasive cancer of 67 % (35 % - 90 %) and 85 % (69 % - 95 %), respectively. CONCLUSION The time to disappearance of acetowhitening can serve as a simple but very sensitive tool for the diagnosis of high risk neoplasia in Barretts esophagus. It can be used to distinguish mucosal neoplasia from deep invasive cancer.