Susan E. Moist

Clinical Outcomes Following Recurrence of Intestinal Metaplasia After Successful Treatment of Barrett’s Esophagus With Radiofrequency Ablation

Objectives:Radiofrequency ablation (RFA) is an effective treatment for Barrett’s esophagus (BE). However, recurrence of BE after initially successful RFA is common, and outcomes following recurrence not well described. We report the outcomes associated with recurrence following initially successful RFA.Methods:We performed a retrospective cohort study of 306 patients treated with RFA for dysplastic BE. Complete eradication of intestinal metaplasia (CE-IM) was defined as complete histological and endoscopic remission of IM. Recurrence was defined as any presence of IM or dysplasia in the tubular esophagus or dysplasia in the gastric cardia subsequent to CE-IM. We examined rates and risk factors for recurrence, dysplastic recurrence, and invasive adenocarcinoma after CE-IM. We also describe the clinical course of patients following recurrence.Results:Of the 306 eligible patients undergoing RFA, 218 achieved CE-IM and also had subsequent surveillance endoscopy. Of these, 52 (24%) experienced recurrence of IM or Barrett’s-associated neoplasia over 540.6 person-years (incidence rate 9.6%/year). Thirty (58%) of these achieved second CE-IM; 4 (1.8% of total, 7.7% of recurrences) ultimately progressed to invasive adenocarcinoma (incidence rate 0.65%/year). Longer Prague M was a strong risk factor for invasive adenocarcinoma (rate ratio of 1.34/cm). Most dysplastic recurrences were in the cardia, and the majority were not visible but detected on random biopsies.Conclusions:Most patients with recurrent BE after initially successful RFA achieve second CE-IM; however, 1.8% progressed to invasive adenocarcinoma. Longer Prague M was predictive of invasive adenocarcinoma. Four-quadrant random biopsy of the cardia is advisable during surveillance endoscopy after CE-IM.

Safety and Acceptability of a Nonendoscopic Esophageal Sampling Device – Cytosponge: A Systematic Review of Multicenter Data

Background & Aims: Diagnosis and surveillance of Barretts esophagus (BE) and eosinophilic esophagitis (EoE) have become emerging public health issues. Cytosponge is a novel, minimally invasive esophageal cell collection device. We aimed to assess the data on safety and acceptability of this device. Methods: We performed a patient‐level review of 5 prospective trials assessing Cytosponge performance in patients with reflux disease, BE and EoE in primary and secondary care. Acceptability of Cytosponge and subsequent endoscopy were recorded with visual analogue scale (VAS), wherein 0 and 10 denoted lowest and highest acceptability. Median VAS scores were compared using a Mann‐Whitney test. The number of attempts, failures in swallowing the device and occurrence of adverse events were analyzed. Risk factors for failure in swallowing were analyzed using a multivariate regression model. Results: In total, 2672 Cytosponge procedures were performed, in 2418 individuals from 2008 through 2017. There were 2 adverse events related to the device: a minor pharyngeal bleed and a case of detachment (<1:2000). The median acceptability score for the Cytosponge was 6.0 (interquartile range [IQR], 5.0–8.0), which was higher than the score for endoscopy without sedation (median 5.0; IQR, 3.0–7.0; P < .001) and lower than the score for endoscopy with sedation (median 8.0; IQR, 5.0–9.0; P < .001). Nearly all patients (91.1%) successfully swallowed the Cytosponge, most on the first attempt (90.1%). Failure to swallow the device was more likely to occur in secondary care (odds ratio, 5.13; 95% CI, 1.48–17.79; P < .01). Conclusions: The Cytosponge test is a safe procedure with good acceptability ratings in a variety of health care settings.

106 Random Biopsies in Endoscopically Normal Esophagus Improve Yield of Recurrent Intestinal Metaplasia After Successful Radiofrequency Ablation

Background: Radiofrequency ablation (RFA) treatment for dysplastic Barretts Esophagus (BE) is associated with high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence of intestinal metaplasia (IM) in the esophagus is seen in approximately 25% of patients. The endoscopic findings associated with recurrence of IM are poorly described. Methods: We conducted a retrospective study of patients who underwent RFA for BE at University of North Carolina Hospitals between 2006 and 2013. Patients who achieved CEIM with at least two subsequent surveillance endoscopies were included. Patients were excluded if treated for non-dysplastic BE or invasive esophageal adenocarcinoma. Among patients with histologic evidence of recurrent BE during surveillance, we assessed the endoscopic findings associated with the recurrence. All patients had assessment of the distal esophagus by high-resolution white light and narrow band imaging, and all underwent regular biopsies according to a standard four-quadrant, q1cm procedure, as well as biopsy of endoscopically suspicious lesions. Endoscopic signs recorded included esophageal nodules (Paris classifications 0-Ip, 0-Is, 0-IIa), and areas suspicious for recurrent BE based on mucosal color changes. Statistical analysis was performed using SAS (version 9.3). Results: Of 302 patients, 178 met criteria for inclusion. These patients had 673 biopsy sessions (mean 3.8 sessions/pt). In total, 19 patients had histological recurrence of IM in the tubular esophagus (11%). Of these 19, only 5 (26%) had any endoscopic abnormality suggesting recurrence on endoscopy (table). The remaining 14/19 (74%, 95% confidence interval (CI): 49-91%) were found on routine surveillance biopsies. Of the 17 patients biopsied for a raised lesion or mucosal change suspicious for recurrent IM, only 5 (29%) actually had recurrence; 12 such biopsies were negative for recurrent IM. The median location for recurrent IM in targeted biopsies was 1 cm (Mean 2.5, S.D. 4.3) proximal to the top of the gastric folds; most (75%) specimens indicative of recurrence were from within 2 cm of the top of the gastric folds (figure). The odds ratio for recurrent disease in the setting of endoscopic signs was 17.7 (p < 0.001). Histologic grade was significantly higher for recurrence accompanied by endoscopic signs compared to those found on random biopsy (p = 0.016 for trend). Subsquamous recurrence was not identified in any biopsies regardless of endoscopic signs (95% CI: 0-23%). Conclusion: Histologic recurrence of IM following RFA was most common near the gastroesophageal junction. Subsquamous recurrence was not an important factor in recurrence. Most recurrences were found on routine, non-targeted biopsies, but endoscopic signs of recurrence including nodularity or apparent columnar-lined esophagus are associated with improved biopsy yield. Histology of Apparent and Non-Apparent Recurrence or Progression

Mo1817 Dysplasia in the Gastric Cardia Is Not Uncommon Among Patients Who Are Successful Treated by Radiofrequency Ablation for Dysplastic Barrett's Esophagus -A Prospective Study

Background: Radiofrequency ablation (RFA) is effective and safe for eradicating dysplasia and intestinal metaplasia (IM) in patients with dysplastic Barretts esophagus (BE). However, dysplasia or early cancer has been reported in the gastric cardia of patients who achieved complete eradication of intestinal metaplasia (CEIM). Our aim was to determine the prevalence of dysplasia in the endoscopically normal gastric cardia of patients who achieved CEIM in a tertiary care center. Methods: We performed a prospective cohort study of patients treated with RFA for BE who achieved CEIM at the University of North Carolina between 2012 and 2013. Data including demographics, medical history, worst histology, endoscopy findings, and complications were recorded on standardized case report forms. CEIM was defined as complete endoscopic resolution and at least one esophageal biopsy session after RFA demonstrating no IM. To assess for cardiac dysplasia, standard high resolution and narrow band imaging was performed. Then, a standardized study biopsy protocol, which included 4 quadrant biopsies at the top of the gastric folds, 1 cm into the cardia and 2 cm into the cardia (12 biopsies total) was utilized. The main outcome, the prevalence of dysplasia in the gastric cardia among patients who achieved CEIM, was calculated for the entire cohort and stratified by pre-treatment histology. Parametric and non-parametric tests were used to compare the baseline characteristics of patients who had dysplasia in gastric cardia versus patients without dysplasia. Results: 59 patients who achieved CEIM were prospectively enrolled. Of these patients, 4 (6.8%) demonstrated dysplasia in the gastric cardia. Three of these four patients had endoscopically normal appearing cardia; 1 patient had gastric nodularity. The demographic and BE baseline characteristics of patients who had dysplasia in gastric cardia were not significantly different from patients who did not demonstrate dysplasia (Table). When stratified by worst histology prior to RFA, the prevalence of dysplasia in the gastric cardia among patients who achieved CEIM was 6.3% (1 out of 16) for patients with low-grade dysplasia, 5.7% (2 out of 35) for patients with high-grade dysplasia, and 12.5% (1 out of 8) for patients with intramucosal carcinoma. The prevalence of gastric dysplasia did not differ by worst pre-treatment BE histology (P=0.770). Conclusions: Dysplasia in the endoscopically normal gastric cardia following successful eradication of dysplastic BE is not uncommon, with an overall prevalence of 6.8%.Most cases did not have visible nodularity endoscopically. The prevalence does not differ by worst BE histology prior to RFA treatment. Routine endoscopic surveillance of post-ablation patients achieving complete eradication of intestinal metaplasia should include routine surveillance gastric cardia biopsies. The characteristics of patients with dysplasia in gastric cardia vs. patients without dysplasia in gastric cardia