dysplastic barrett’s esophagus : who and how to treat? · making treatment decisions based on...
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Dysplastic Barrett’s Esophagus : Who and How To Treat?
Prateek Sharma, MD
Kansas City
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High Grade Dysplasia/Early Cancer (T1a)
Low Grade Dysplasia
Non-Dysplastic Barrett’s
?
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Eradicating Dysplastic Barrett’s
How We Do It?
What Are The Shortcomings?
What Can We Improve?
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Improving Endoscopic Outcomes
Resect the Highest Grade Lesion
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Improving Endoscopic Outcomes
Eradication of the Remaining BE segment after EMR
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Endo Therapy: Systematic review and meta-analysis
Desai M et al. GIE 2017
Strictures 10.2% 33.5%
Focal EMR + RFA Complete EMR Number of patients 774 751 Median BE length 2 – 8 cm 2 – 5.5 cm Median follow up 12 – 61 months 15 – 54.7 months CE-N 93.4% 94.9%
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Eradicating Dysplastic Barrett’s
How We Do It?
What Are The Shortcomings?
What Can We Improve?
![Page 8: Dysplastic Barrett’s Esophagus : Who and How To Treat? · Making Treatment Decisions Based On Progression in BE (PIB) Score • Multicenter outcomes project 6 centers • 2697 patients;](https://reader033.vdocuments.mx/reader033/viewer/2022053108/6079c0ada1f48439d14eba41/html5/thumbnails/8.jpg)
5.6 %
1 % 0.6 %
0
10
Strictures Bleeding Perforation
Qumseya BJ et al. CGH 2016
Complications: Systematic review and meta-analysis
Poo
led
rate
s
• 37 studies, 9200 patients • RFA ± EMR
Overall Rates: 8.8% (95% CI 6.5 – 11.9%)
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7 %
1.3 % 0.8 %
0
10
Krishnamoorthi R et al. GIE 2016
Recurrences: Systematic review and meta-analysis
Pat
ient
s (%
)
Predictors of recurrence • Increasing age • BE length
• 41 studies • 4443 patients treated • 795 cases of recurrence
IM Dysplasia HGD/Cancer Recurrence rates per year
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BE quality indicators
In patients with BE-associated neoplasia, the goal of the endoscopic treatment should be complete eradication of the BE segment in addition to any
dysplastic lesions Agreement: 100%
Grade of Recommendation: Strong Quality of Evidence: Moderate
Sharma P et al. Gastroenterology 2015
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Eradicating Dysplastic Barrett’s
How We Do It?
What Are The Shortcomings?
What Can We Improve?
![Page 12: Dysplastic Barrett’s Esophagus : Who and How To Treat? · Making Treatment Decisions Based On Progression in BE (PIB) Score • Multicenter outcomes project 6 centers • 2697 patients;](https://reader033.vdocuments.mx/reader033/viewer/2022053108/6079c0ada1f48439d14eba41/html5/thumbnails/12.jpg)
Haidry et al. Endoscopy 2015
0%
100%
Low Rates of EMR Despite EMR Improving Outcomes!
% fr
ee o
f dys
plas
ia
Months from successful eradication
previous EMR no EMR
60 48 36 24 12
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Scholvinck et al. Endoscopy 2015
Focal cryoablation for BE • 39 patients, 90% males • Mean age: 66 yrs. • Mean BE length: 5 cm • Focal area treated
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Making Treatment Decisions Based On Progression in BE (PIB) Score
• Multicenter outcomes project 6 centers • 2697 patients; 6 years median follow up • Split sample derivation model • 70% model development; 30% validation
Risk factors Male gender – 9 points Cigarette smoking – 5 points BE length – 1 point/ cm length Confirmed LGD – 11 points
High Risk (>25 points)
Intermediate Risk (17-24 points)
Low Risk (0-16 points)
Annual risk of progression 0.33%
Annual risk of progression 1.34%
Annual risk of progression 2.7 %
Parasa S et al. Gastroenterology 2018
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Conclusions • Neoplasia in Barrett’s may present as very
subtle lesions
• Endoscopic Resection is critical
• Recurrences happen; close follow up is mandatory
• Newer devices appear promising