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Tu1146 Persistent and Multifocal Low Grade Dysplasia (LGD) and Topographic Location of LGD Are Not Associated With Progression to High Grade Dysplasia (HGD) or Esophageal Adenocarcinoma (EAC) in Patients With Long Segment Barrett's (Lsb)
Abstracts
Tu1146 Persistent and Multifocal Low Grade Dysplasia (LGD) and Topographic Location of LGD Are Not Associated With Progression to High Grade Dysplasia (HGD) or Esophageal Adenocarcinoma (EAC) in Patients With Long Segment Barrett’s (Lsb) Allon Kahn*, Jonathan K. Callaway, Mohanad Al-Qaisi, David E. Fleischer, George E. Burdick, Rahul Pannala, Dora Lam-Himlin, Marcelo F. Vela, Francisco C. Ramirez Mayo Clinic, Scottsdale, AZ Background: Persistence of LGD (2 consecutive endoscopies with LGD) and multifocality have been suggested as predictive risk factors for progression to HGD or EAC in Barrett’s esophagus. There is also reported evidence of an increased prevalence of LGD in the proximal segment of Barrett’s esophagus. Aims: To compare the persistence, multifocality and topographic presence of LGD between progressors and non progressors with long segment Barrett’s esophagus. Methods: A retrospective review of our Barrett’s esophagus endoscopic data base from 1991 to 2015 was performed. Patients with LGD and no prior or concomitant higher grade of dysplasia were reviewed. Only those with LSB 3 cm were included in the analysis to more accurately address the multifocality of LGD. Persistent LGD was defined as patients having 2 consecutive endoscopies with LGD and multifocality was defined as the presence of more than 1 set of biopsies with LGD taken at least 2 cm apart. The topographic presence of dysplasia was assessed for each individual patient depending on their average length of BE (before any treatment, RFA effect). The total area of BE was divided into proximal, middle, and distal segments. Continuous data were compared using the Student’s t test whereas proportional data were compared using the Fisher’s exact test. A p value < 0.05 was considered statistically significant. Results: A total of 177 patients with LSB and LGD were analyzed; of these 42 (23.7%) progressed to HGD/EAC. The follow up period was similar in both the progressors and non-progressors (82.660.9 vs 78.560 months). There was a trend towards a higher rate of persistent LGD in those that progressed when compared to those who did not (55.2% vs 34.8%; pZ0.055). Multifocality was similar in both groups (75% for progressors vs. 60% for non-progressors; pZn.s.). The mean BE length was significantly higher in progressors (7.83.7 cm vs 6.53.0 cm). The topographical distribution of LGD stratified by dysplasia is presented in Table 1. There were significantly more patients with involvement of the middle and distal segments alone in progressors (25%) than non-progressors (5.5%) (p<0.05). There were significantly more patients with middle segment involvement alone in the group that progressed (25% vs. 0%) (p<0.05). Conclusions: In this large cohort of patients with LSB and LGD, only the length of BE segment differed significantly between progressors and non-progressors. The distribution of LGD in the Barrett’s segment was generally similar at each level, although interestingly those with involvement of the middle and distal segments alone were more likely to progress. Table 1. Topographical distribution of dysplasia Segment affected with LGD Proximal alone Middle alone Distal alone Proximal and middle alone Middle and distal alone Proximal and distal alone Proximal, middle, and distal Any proximal Any distal Any middle
Progressors, N (%) 6 0 2 4 8 11 1 22 11 23
(18.8%) (0%) (6.3%) (12.5%) (25%) (38.4%) (3.1%) (68.8%) (34.4%) (68.8%)
Non-Progressors, N (%) 20 16 14 18 6 28 1 67 49 68
(18.2%) (14.5%) (12.7%) (16.4%) (5.5%) (25.5%) (0.9%) (60.9%) (44.5%) (61.8%)
Tu1147 Declining Trends in the Prevalence of Barrett’s Esophagus Among Patients With Gastroesophageal Reflux Disease (GERD) Vijay Kanakadandi*1,2, Sreekar Vennelaganti2, Prashanth Vennalaganti1,2, Jesica Brown1,2, Sravanthi Parasa1,2, Benjamin Alsop2,1, Mohammad A. Titi1,2, Ajay Bansal1,2, Kevin Kennedy4, Kapil Kohli1,2, Abhiram Duvvuri2, Babak Gachpaz2, Anusha Vittal1,2, Neil Gupta3, Prateek Sharma1,2 1 The University of Kansas Medical Center, Kansas city, MO; 2Kansas City Veteran Affairs Medical Center, Kansas City, MO; 3Loyola University Medical Center, Maywood, IL; 4Saint Lukes Health Systems, Kansas City, MO Background: Barrett’s esophagus (BE), a pre-malignant condition for development of esophageal adenocarcinoma (EAC) is a known complication of GERD. Although the incidence of EAC is increasing, similar trends for BE are not clear. Aim: To evaluate the prevalence of newly diagnosed BE patients over time in a cohort of patients presenting with GERD symptoms. Methods: Consecutive patients presenting to the endoscopy unit at a tertiary referral center for their index upper endoscopy for evaluation of GERD symptoms were enrolled in this prospective cohort
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study. Patients were asked to complete a validated GERD questionnaire that documents the onset of GERD symptoms (heartburn and acid regurgitation) and grades the frequency and severity of symptoms experienced. Demographic information, body mass index, and use of aspirin/nonsteroidal anti-inflammatory drugs, smoking, family history and endoscopic findings: erosive esophagitis (EE), BE, and hiatus hernia (HH) were recorded. Patients who reported symptoms of heartburn, regurgitation, or both along with average duration of symptoms were recorded. The patients with these symptoms were compared using Chi square. Multivariable logistic regression model was used to evaluate independent predictors. Results: A total of 1,180 patients were included in the analysis [mean age 57 years (SD 13), 83% Caucasian, 93% male, and mean BMI 29.8 (SD 5.5)]. Overall 214 (21.1%) patients were diagnosed with BE, with a mean BE length of 2.3 (SD 2.6) cm. The patients presenting for endoscopy were subdivided into three year intervals starting from 1998-2012 and the prevalence of BE was estimated over time (Table 1). There was a significant decrease in the prevalence of BE over time from 24% in 1998-2003 to 12% in 2010-2012. Chi-square test showed significant difference in the prevalence between groups and linear-by-linear association confirmed a linear trend (p value 0.001). During the same time period, a significant increased trend in the prevalence of PPI use from 41.7% (1998-2003) to 75.9 % (2010-2012) was noted (p value <0.001). In a multivariable logistic regression model predicting the presence of newly diagnosed BE, there was still a significant effect of timeframe after adjusting for possible confounding variables (Table 2). Age, and current smoker, were significant predictors of BE (all p0<.05), while NSAID use was a significant negative predictor of BE (pZ0.011). Conclusion: The results of our study indicate that there has been a steady significant decline in the prevalence of BE in GERD patients across the years, with an accompanying significant increase in the use of PPI. No significant trend in the prevalence of smoking, BMI and erosive esophagitis was noted during the same time period. PPI use may impact the prevalence of BE in GERD patients. Table 1. Time trends in patients with GERD BE Prevalence Severity of erosive esophagitis Prevalence of smoking PPI Use BMI (Kg/m2)
98-03 04-06 07-09 10-12
Total
P value
24.3% 31.5% 32.6% 41.7% 29.5
21.1% 31.6% 34.4% 54.1% 29.8
0.001 0.001 0.001 <0.001 0.096
23.4% 25.8% 40.7% 57.0% 29.8
15.2% 36% 34.7% 71.2% 30
12.3% 39.4% 31.3% 75.9% 30.2
Table 2
TimeFrame 2004-2006 vs 1998-2003 TimeFrame 2007-2009 vs 1998-2003 TimeFrame 2010-2012 vs 1998-2003
OR (95% CI)
p-value
.88 (.59, 1.30) .40 (.23, .68) .38 (.20, .72)
.51 .001 .003
Tu1148 Magnification Endoscopy With i-SCAN Imaging and Acetic Acid Chromoendoscopy in Barrett’s Esophagus Improves Neoplasia Detection Gideon Lipman*2,1, Raf Bisschops5, Jacobo Ortiz Fernández-Sordo4, Rami Sweis1, Jose Miguel Esteban3, Laurence Lovat2,1, Krish Ragunath4, Rehan Haidry2,1 1 Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom; 2Division of Surgery & Interventional Science, University College London, London, United Kingdom; 3Hospital Clínico San Carlos, Madrid, Spain; 4Nottingham Digestive Diseases Biomedical Research Unit, Nottingham, United Kingdom; 5University Hospitals Leuven, KU Leuven, Belgium Introduction: Barrett’s esophagus (BE) is the pre-cursor for oesophageal adenocarcinoma. Endoscopic surveillance is performed in BE patients to detect dysplasia as an early treatment target. Current surveillance relies on random quadrantic biopsies every 1-2cm through the BE with targeted biopsies for areas of suspicion. This strategy samples less than 5% of the BE mucosa. We present a novel endoscopic classification system utilizing magnification chromo-endoscopy with i-Scan (PENTAX HOYA, Japan) image enhancement technology and acetic acid to improve dysplasia recognition in BE. Methods: High definition (HD) video recordings of suspicious lesions were collected from patients with non-dysplastic (ND-BE) and dysplastic (D-BE) BE undergoing endoscopy at a high volume tertiary centre. Lesions were recorded with magnification endoscopy in all i-Scan modes both before and after application of 2% acetic acid (ACA) before sampling with biopsy forceps or endoscopic mucosal resection to confirm the histological diagnosis. Six expert endoscopists scored videos using a previously validated mucosal (M) and vascular (V) classification system. Normal mucosa was defined as regular circular or villous pits (M1) and abnormal mucosa defined as distorted or irregular pits or featureless mucosa (M2). Normal vascular pattern was defined as regular and uniform vessels (V1) and abnormal vascular pattern was defined as irregular, dilated corkscrew
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB553
Tu1146 Persistent and Multifocal Low Grade Dysplasia (LGD) and Topographic Location of LGD Are Not Associated With Progression to High Grade Dysplasia (HGD) or Esophageal Adenocarcinoma (EAC) in Patients With Long Segment Barrett’s (Lsb) Allon Kahn*, Jonathan K. Callaway, Mohanad Al-Qaisi, David E. Fleischer, George E. Burdick, Rahul Pannala, Dora Lam-Himlin, Marcelo F. Vela, Francisco C. Ramirez Mayo Clinic, Scottsdale, AZ Background: Persistence of LGD (2 consecutive endoscopies with LGD) and multifocality have been suggested as predictive risk factors for progression to HGD or EAC in Barrett’s esophagus. There is also reported evidence of an increased prevalence of LGD in the proximal segment of Barrett’s esophagus. Aims: To compare the persistence, multifocality and topographic presence of LGD between progressors and non progressors with long segment Barrett’s esophagus. Methods: A retrospective review of our Barrett’s esophagus endoscopic data base from 1991 to 2015 was performed. Patients with LGD and no prior or concomitant higher grade of dysplasia were reviewed. Only those with LSB 3 cm were included in the analysis to more accurately address the multifocality of LGD. Persistent LGD was defined as patients having 2 consecutive endoscopies with LGD and multifocality was defined as the presence of more than 1 set of biopsies with LGD taken at least 2 cm apart. The topographic presence of dysplasia was assessed for each individual patient depending on their average length of BE (before any treatment, RFA effect). The total area of BE was divided into proximal, middle, and distal segments. Continuous data were compared using the Student’s t test whereas proportional data were compared using the Fisher’s exact test. A p value < 0.05 was considered statistically significant. Results: A total of 177 patients with LSB and LGD were analyzed; of these 42 (23.7%) progressed to HGD/EAC. The follow up period was similar in both the progressors and non-progressors (82.660.9 vs 78.560 months). There was a trend towards a higher rate of persistent LGD in those that progressed when compared to those who did not (55.2% vs 34.8%; pZ0.055). Multifocality was similar in both groups (75% for progressors vs. 60% for non-progressors; pZn.s.). The mean BE length was significantly higher in progressors (7.83.7 cm vs 6.53.0 cm). The topographical distribution of LGD stratified by dysplasia is presented in Table 1. There were significantly more patients with involvement of the middle and distal segments alone in progressors (25%) than non-progressors (5.5%) (p<0.05). There were significantly more patients with middle segment involvement alone in the group that progressed (25% vs. 0%) (p<0.05). Conclusions: In this large cohort of patients with LSB and LGD, only the length of BE segment differed significantly between progressors and non-progressors. The distribution of LGD in the Barrett’s segment was generally similar at each level, although interestingly those with involvement of the middle and distal segments alone were more likely to progress. Table 1. Topographical distribution of dysplasia Segment affected with LGD Proximal alone Middle alone Distal alone Proximal and middle alone Middle and distal alone Proximal and distal alone Proximal, middle, and distal Any proximal Any distal Any middle
Progressors, N (%) 6 0 2 4 8 11 1 22 11 23
(18.8%) (0%) (6.3%) (12.5%) (25%) (38.4%) (3.1%) (68.8%) (34.4%) (68.8%)
Non-Progressors, N (%) 20 16 14 18 6 28 1 67 49 68
(18.2%) (14.5%) (12.7%) (16.4%) (5.5%) (25.5%) (0.9%) (60.9%) (44.5%) (61.8%)
Tu1147 Declining Trends in the Prevalence of Barrett’s Esophagus Among Patients With Gastroesophageal Reflux Disease (GERD) Vijay Kanakadandi*1,2, Sreekar Vennelaganti2, Prashanth Vennalaganti1,2, Jesica Brown1,2, Sravanthi Parasa1,2, Benjamin Alsop2,1, Mohammad A. Titi1,2, Ajay Bansal1,2, Kevin Kennedy4, Kapil Kohli1,2, Abhiram Duvvuri2, Babak Gachpaz2, Anusha Vittal1,2, Neil Gupta3, Prateek Sharma1,2 1 The University of Kansas Medical Center, Kansas city, MO; 2Kansas City Veteran Affairs Medical Center, Kansas City, MO; 3Loyola University Medical Center, Maywood, IL; 4Saint Lukes Health Systems, Kansas City, MO Background: Barrett’s esophagus (BE), a pre-malignant condition for development of esophageal adenocarcinoma (EAC) is a known complication of GERD. Although the incidence of EAC is increasing, similar trends for BE are not clear. Aim: To evaluate the prevalence of newly diagnosed BE patients over time in a cohort of patients presenting with GERD symptoms. Methods: Consecutive patients presenting to the endoscopy unit at a tertiary referral center for their index upper endoscopy for evaluation of GERD symptoms were enrolled in this prospective cohort
www.giejournal.org
study. Patients were asked to complete a validated GERD questionnaire that documents the onset of GERD symptoms (heartburn and acid regurgitation) and grades the frequency and severity of symptoms experienced. Demographic information, body mass index, and use of aspirin/nonsteroidal anti-inflammatory drugs, smoking, family history and endoscopic findings: erosive esophagitis (EE), BE, and hiatus hernia (HH) were recorded. Patients who reported symptoms of heartburn, regurgitation, or both along with average duration of symptoms were recorded. The patients with these symptoms were compared using Chi square. Multivariable logistic regression model was used to evaluate independent predictors. Results: A total of 1,180 patients were included in the analysis [mean age 57 years (SD 13), 83% Caucasian, 93% male, and mean BMI 29.8 (SD 5.5)]. Overall 214 (21.1%) patients were diagnosed with BE, with a mean BE length of 2.3 (SD 2.6) cm. The patients presenting for endoscopy were subdivided into three year intervals starting from 1998-2012 and the prevalence of BE was estimated over time (Table 1). There was a significant decrease in the prevalence of BE over time from 24% in 1998-2003 to 12% in 2010-2012. Chi-square test showed significant difference in the prevalence between groups and linear-by-linear association confirmed a linear trend (p value 0.001). During the same time period, a significant increased trend in the prevalence of PPI use from 41.7% (1998-2003) to 75.9 % (2010-2012) was noted (p value <0.001). In a multivariable logistic regression model predicting the presence of newly diagnosed BE, there was still a significant effect of timeframe after adjusting for possible confounding variables (Table 2). Age, and current smoker, were significant predictors of BE (all p0<.05), while NSAID use was a significant negative predictor of BE (pZ0.011). Conclusion: The results of our study indicate that there has been a steady significant decline in the prevalence of BE in GERD patients across the years, with an accompanying significant increase in the use of PPI. No significant trend in the prevalence of smoking, BMI and erosive esophagitis was noted during the same time period. PPI use may impact the prevalence of BE in GERD patients. Table 1. Time trends in patients with GERD BE Prevalence Severity of erosive esophagitis Prevalence of smoking PPI Use BMI (Kg/m2)
98-03 04-06 07-09 10-12
Total
P value
24.3% 31.5% 32.6% 41.7% 29.5
21.1% 31.6% 34.4% 54.1% 29.8
0.001 0.001 0.001 <0.001 0.096
23.4% 25.8% 40.7% 57.0% 29.8
15.2% 36% 34.7% 71.2% 30
12.3% 39.4% 31.3% 75.9% 30.2
Table 2
TimeFrame 2004-2006 vs 1998-2003 TimeFrame 2007-2009 vs 1998-2003 TimeFrame 2010-2012 vs 1998-2003
OR (95% CI)
p-value
.88 (.59, 1.30) .40 (.23, .68) .38 (.20, .72)
.51 .001 .003
Tu1148 Magnification Endoscopy With i-SCAN Imaging and Acetic Acid Chromoendoscopy in Barrett’s Esophagus Improves Neoplasia Detection Gideon Lipman*2,1, Raf Bisschops5, Jacobo Ortiz Fernández-Sordo4, Rami Sweis1, Jose Miguel Esteban3, Laurence Lovat2,1, Krish Ragunath4, Rehan Haidry2,1 1 Department of Gastroenterology, University College Hospital NHS Foundation Trust, London, United Kingdom; 2Division of Surgery & Interventional Science, University College London, London, United Kingdom; 3Hospital Clínico San Carlos, Madrid, Spain; 4Nottingham Digestive Diseases Biomedical Research Unit, Nottingham, United Kingdom; 5University Hospitals Leuven, KU Leuven, Belgium Introduction: Barrett’s esophagus (BE) is the pre-cursor for oesophageal adenocarcinoma. Endoscopic surveillance is performed in BE patients to detect dysplasia as an early treatment target. Current surveillance relies on random quadrantic biopsies every 1-2cm through the BE with targeted biopsies for areas of suspicion. This strategy samples less than 5% of the BE mucosa. We present a novel endoscopic classification system utilizing magnification chromo-endoscopy with i-Scan (PENTAX HOYA, Japan) image enhancement technology and acetic acid to improve dysplasia recognition in BE. Methods: High definition (HD) video recordings of suspicious lesions were collected from patients with non-dysplastic (ND-BE) and dysplastic (D-BE) BE undergoing endoscopy at a high volume tertiary centre. Lesions were recorded with magnification endoscopy in all i-Scan modes both before and after application of 2% acetic acid (ACA) before sampling with biopsy forceps or endoscopic mucosal resection to confirm the histological diagnosis. Six expert endoscopists scored videos using a previously validated mucosal (M) and vascular (V) classification system. Normal mucosa was defined as regular circular or villous pits (M1) and abnormal mucosa defined as distorted or irregular pits or featureless mucosa (M2). Normal vascular pattern was defined as regular and uniform vessels (V1) and abnormal vascular pattern was defined as irregular, dilated corkscrew
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB553