New ACG's guideline on Barrett's esophagus recommends against use of antireflux surgery as antineoplastic measure
USA: A recent study published in The American Journal of Gastroenterology reports the American College of Gastroenterology (ACG) updated guidance on the diagnosis and management of Barrett's esophagus.
Barrett's esophagus (BE) is a common condition associated with chronic gastroesophageal reflux disease. BE is the only known precursor to esophageal adenocarcinoma, a highly lethal cancer with an increasing incidence over the last 5 decades.
Grading of Recommendations, Assessment, Development, and Evaluation methodology was implemented to propose recommendations for the definition and diagnosis of BE, screening for BE and esophageal adenocarcinoma, surveillance of patients with known BE, and the medical and endoscopic treatment of BE and its associated early neoplasia.
Important changes since the previous iteration of the guideline include a broadening of acceptable screening modalities for BE to include nonendoscopic methods, liberalized intervals for surveillance of short-segment BE, and volume criteria for endoscopic therapy centers for BE.
Key recommendations include:
Diagnosis of BE
- The authors suggest that a diagnosis of BE require the finding of intestinal metaplasia (IM) in the tubular esophagus.
- The authors suggest that columnar mucosa of at least 1 cm in length be necessary for a diagnosis of BE, and that:
- patients with a normal-appearing Z line should not undergo routine endoscopic biopsies.
- in the absence of any visible lesions, patients with a Z line demonstrating <1 cm of proximal displacement from the top of the gastric folds should not undergo routine endoscopic biopsies.
- The authors suggest at least 8 endoscopic biopsies be obtained in screening examinations with endoscopic findings consistent with possible BE, with the Seattle protocol followed for segments of longer than 4 cm.
- The authors recommend that dysplasia of any grade detected on biopsies of BE be confirmed by a second pathologist with expertise in gastrointestinal (GI) pathology.
Screening for BE
- The authors suggest a single screening endoscopy for patients with chronic GERD symptoms and 3 or more additional risk factors for BE, including male sex, age >50 years, White race, tobacco smoking, obesity, and family history of BE or EAC in a first-degree relative.
- The authors suggest that a swallowable, nonendoscopic capsule sponge device combined with a biomarker is an acceptable alternative to endoscopy for screening for BE in those with chronic reflux symptoms and other risk factors.
- The authors suggest against repeat endoscopic screening in patients who have undergone an initial negative screening examination by endoscopy.
Surveillance of BE
- The authors recommend both white light endoscopy and chromoendoscopy in patients undergoing endoscopic surveillance of BE.
- The authors recommend a structured biopsy protocol be applied to minimize detection bias in patients undergoing endoscopic surveillance of BE.
- The authors suggest endoscopic surveillance be performed in patients with BE at intervals dictated by the degree of dysplasia noted on previous biopsies.
Management of BE with LGD (low-grade dysplasia) or HGD (high-grade dysplasia)
- The authors recommend that length of the NDBE segment be considered when assigning surveillance intervals such that longer segments of BE (≥3 cm) are surveyed on a 3-year interval and shorter segments of BE (<3 cm) are surveyed on a 5-year interval.
- The authors could not make a recommendation on the use of wide-area transepithelial sampling with computer-assisted 3-dimensional (WATS-3D) analysis in patients undergoing endoscopic surveillance of BE.
- The authors could not make a recommendation on the use of predictive tools (p53 staining and TissueCypher) in addition to standard histopathology in patients undergoing endoscopic surveillance of BE.
Nonendoscopic treatment of BE
- The authors suggest at least once-a-day PPI (proton pump inhibitor) therapy in patients with BE without allergy or other contraindication to PPI use.
- The authors could not make a recommendation on combination therapy with use of aspirin (ASA) and PPI in patients with BE to reduce the risk of progression to HGD/EAC.
- The authors suggest against the use of antireflux surgery as an antineoplastic measure in patients with BE.
Endoscopic treatment of BE
- The authors recommend EET (endoscopic eradication therapy) compared with esophagectomy in patients with BE with HGD or intramucosal cancer (IMC).
- The authors suggest endoscopic therapy in patients with BE with confirmed LGD to reduce the risk of progression to HGD/EAC, with endoscopic surveillance of confirmed LGD as an acceptable alternative.
- The authors suggest initial ER of any visible lesions before the application of ablative therapy in patients with BE undergoing EET.
- The authors suggest that patients with BE undergoing EET be treated at high-volume centers.
- The authors recommend an endoscopic surveillance program in patients with BE who have completed successful EET.
"We propose structured surveillance intervals for patients with dysplastic BE after successful ablation based on the baseline degree of dysplasia," wrote the authors. "We could not make recommendations regarding chemoprevention or use of biomarkers in routine practice due to insufficient data."
Reference:
Shaheen, Nicholas J. MD, MPH1; Falk, Gary W. MD, MS2; Iyer, Prasad G. MD, MS3; Souza, Rhonda F. MD4; Yadlapati, Rena H. MD, MHS (GRADE Methodologist)5; Sauer, Bryan G. MD, MSc (GRADE Methodologist)6; Wani, Sachin MD7 Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline, The American Journal of Gastroenterology: April 2022 - Volume 117 - Issue 4 - p 559-587 doi: 10.14309/ajg.0000000000001680
