Search

Background and study aims: The clinical utility of narrow-band imaging (NBI) for Barrett's esophagus is limited by the multiplicity of classification schemes. We evaluated the interobserver agreement and accuracy of a new consensus-driven simplified binary classification of NBI surface patterns. Patients and methods: NBI images from macroscopically normal areas in patients with Barrett's esophagus were retrieved from endoscopy databases and were randomized for review by seven endoscopists (three experts, four nonexperts). A simplified binary classification of NBI mucosal and vascular patterns was used: (1) regular pattern (nondysplastic Barrett's esophagus); (2) irregular pattern (dysplastic Barrett's esophagus). Agreement in relation to surface patterns and predicted histology (dysplasia vs. no dysplasia) was calculated using κ statistics. Results: A total of 252 NBI images from 75 patients with Barrett's esophagus were assessed: 93 showed intestinal metaplasia, 91 low-grade dysplasia, and 68 high-grade dysplasia/esophageal adenocarcinoma. The median score for image quality was 4 (very good). Interobserver agreement for mucosal and vascular patterns and dysplasia prediction was fair: κ = 0.40 (95%CI: 0.37-0.42), 0.36 (95%CI: 0.33-0.38), and 0.39 (95%CI: 0.36-0.41) respectively, with comparable results for experts and nonexperts. Intraobserver agreement was substantially better among experts than among nonexperts, with mucosal κ = 0.63 vs. 0.49, vascular κ = 0.58 vs. 0.43, and predicted histology κ = 0.68 vs. 0.54 (all P < 0.005). Mean sensitivity and specificity of NBI surface patterns for predicting dysplasia were 47% (95%CI: 44%-55%) and 72% (95%CI: 69%-76%) respectively. Conclusions: Using a consensus-driven simplified classification of NBI surface patterns for Barrett's esophagus, the interobserver agreement was fair with suboptimal sensitivity and specificity. Significant improvements in NBI interpretation are needed prior to the routine use of NBI surface patterns for the assessment of Barrett's esophagus. [ABSTRACT FROM AUTHOR]

Background: Pancreatic cancer has a very poor prognosis. Best practices for the use of chemotherapy, enzyme replacement therapy, and biliary drainage have been identified but their implementation in daily clinical practice is often suboptimal. We hypothesized that a nationwide program to enhance implementation of these best practices in pancreatic cancer care would improve survival and quality of life.Methods/design: PACAP-1 is a nationwide multicenter stepped-wedge cluster randomized controlled superiority trial. In a per-center stepwise and randomized manner, best practices in pancreatic cancer care regarding the use of (neo)adjuvant and palliative chemotherapy, pancreatic enzyme replacement therapy, and metal biliary stents are implemented in all 17 Dutch pancreatic centers and their regional referral networks during a 6-week initiation period. Per pancreatic center, one multidisciplinary team functions as reference for the other centers in the network. Key best practices were identified from the literature, 3 years of data from existing nationwide registries within the Dutch Pancreatic Cancer Project (PACAP), and national expert meetings. The best practices follow the Dutch guideline on pancreatic cancer and the current state of the literature, and can be executed within daily clinical practice. The implementation process includes monitoring, return visits, and provider feedback in combination with education and reminders. Patient outcomes and compliance are monitored within the PACAP registries. Primary outcome is 1-year overall survival (for all disease stages). Secondary outcomes include quality of life, 3- and 5-year overall survival, and guideline compliance. An improvement of 10% in 1-year overall survival is considered clinically relevant. A 25-month study duration was chosen, which provides 80% statistical power for a mortality reduction of 10.0% in the 17 pancreatic cancer centers, with a required sample size of 2142 patients, corresponding to a 6.6% mortality reduction and 4769 patients nationwide.Discussion: The PACAP-1 trial is designed to evaluate whether a nationwide program for enhanced implementation of best practices in pancreatic cancer care can improve 1-year overall survival and quality of life.Trial Registration: ClinicalTrials.gov, NCT03513705. Trial opened for accrual on 22th May 2018. [ABSTRACT FROM AUTHOR]

Volumetric laser endomicroscopy (VLE) is a balloon-based technique, which provides a circumferential near-microscopic scan of the esophageal wall layers, and has potential to improve Barrett's neoplasia detection. Interpretation of VLE imagery in Barrett's esophagus (BE) however is time-consuming and complex, due to a large amount of visual information and numerous subtle gray-shaded VLE images. Computer-aided detection (CAD), analyzing multiple neighboring VLE frames, might improve BE neoplasia detection compared to automated single-frame analyses. This study is to evaluate feasibility of automatic data extraction followed by CAD using a multiframe approach for detection of BE neoplasia. Prospectively collected ex-vivo VLE images from 29 BE-patients with and without early neoplasia were retrospectively analyzed. Sixty histopathology-correlated regions of interest (30 nondysplastic vs. 30 neoplastic) were assessed using different CAD systems. Multiple neighboring VLE frames, corresponding to 1.25 millimeter proximal and distal to each region of interest, were evaluated. In total, 3060 VLE frames were analyzed via the CAD multiframe analysis. Multiframe analysis resulted in a significantly higher median AUC (median level = 0.91) compared to single-frame (median level = 0.83) with a median difference of 0.08 (95% CI, 0.06–0.10), P  < 0.001. A maximum AUC of 0.94 was reached when including 22 frames on each side using a multiframe approach. In total, 3060 VLE frames were automatically extracted and analyzed by CAD in 3.9 seconds. Multiframe VLE image analysis shows improved BE neoplasia detection compared to single-frame analysis. CAD with multiframe analysis allows for fast and accurate VLE interpretation, thereby showing feasibility of automatic full scan assessment in a real-time setting during endoscopy. [ABSTRACT FROM AUTHOR]

Background and Aim: More insight into the incidence of and factors associated with progression following a first episode of acute pancreatitis (AP) would offer opportunities for improvements in disease management and patient counseling., Methods: A long-term post hoc analysis of a prospective cohort of patients with AP (2008-2015) was performed. Primary endpoints were recurrent acute pancreatitis (RAP), chronic pancreatitis (CP), and pancreatic cancer. Cumulative incidence calculations and risk analyses were performed., Results: Overall, 1184 patients with a median follow-up of 9 years (IQR: 7-11) were included. RAP and CP occurred in 301 patients (25%) and 72 patients (6%), with the highest incidences observed for alcoholic pancreatitis (40% and 22%). Pancreatic cancer was diagnosed in 14 patients (1%). Predictive factors for RAP were alcoholic and idiopathic pancreatitis (OR 2.70, 95% CI 1.51-4.82 and OR 2.06, 95% CI 1.40-3.02), and no pancreatic interventions (OR 1.82, 95% CI 1.10-3.01). Non-biliary etiology (alcohol: OR 5.24, 95% CI 1.94-14.16, idiopathic: OR 4.57, 95% CI 2.05-10.16, and other: OR 2.97, 95% CI 1.11-7.94), RAP (OR 4.93, 95% CI 2.84-8.58), prior pancreatic interventions (OR 3.10, 95% CI 1.20-8.02), smoking (OR 2.33, 95% CI 1.14-4.78), and male sex (OR 2.06, 95% CI 1.05-4.05) were independently associated with CP., Conclusion: Disease progression was observed in a quarter of pancreatitis patients. We identified several risk factors that may be helpful to devise personalized strategies with the intention to reduce the impact of disease progression in patients with AP., (© 2024 The Authors. Journal of Gastroenterology and Hepatology published by Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background and Study Aims: We have recently proposed a classification of mucosal morphology in Barrett's esophagus based on three criteria: regularity of mucosal pattern, regularity of vascular pattern, and presence of abnormal blood vessels. We aimed to evaluate the interobserver agreement with the proposed mucosal morphology classification and to assess the additional value of narrow band imaging (NBI) over high resolution white light endoscopy (HR-WLE)., Patients and Methods: Five international experts in the field of Barrett's imaging and seven community endoscopists with no expertise in this field independently evaluated magnified still images from 50 areas, obtained with HR-WLE and NBI, in Barrett's esophagus patients. Visual analogue scales (VAS) were used for scoring imaging quality. Interobserver agreement for mucosal morphology and yield for identifying early neoplasia were assessed., Results: Imaging qualities of NBI were rated more highly than HR-WLE, when evaluated separately as well as in a side-by-side comparison. The interobserver agreement ranged from 0.40 to 0.56 and did not significantly differ between expert and non-expert endoscopists. The overall yield for correctly identifying images of early neoplasia was 81 % for HR-WLE, 72 % for NBI and 83 % for HR-WLE + NBI, with no significant difference between experts and non-experts., Conclusion: Interobserver agreement for the classification of mucosal morphology was moderate. Although NBI was rated more highly than HR-WLE for imaging quality, this did not result in improved interobserver agreement or increased yield for identifying early neoplasia in Barrett's esophagus. This applied to non-expert as well as expert endoscopists.

Study Aims: The aim of the current study was to evaluate the efficacy and safety of stepwise circumferential and focal ablation using the HALO system for Barrett's esophagus containing flat, high-grade dysplasia (HGD) or residual dysplasia after endoscopic resection for HGD or intramucosal cancer (IMC)., Methods: Visible abnormalities were removed with endoscopic resection prior to ablation. Persistence of dysplasia and absence of IMC were confirmed with biopsy after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation., Results: Twelve patients (nine men; median age 70 years) were treated (median Barrett's length 7 cm). Visible abnormalities were removed by endoscopic resection in seven patients. The worst pathological grade of residual Barrett's esophagus after resection and prior to ablation was low-grade dysplasia (LGD) (n = 1) and HGD (n = 11). Patients underwent a median of one circumferential and two focal ablation sessions. Complete remission of dysplasia was achieved in 12/12 patients (100%). Complete endoscopic and histological removal of Barrett's esophagus was achieved in 12/12 patients (100%). There were no ablation-related stenoses, and no subsquamous Barrett's esophagus was observed in 363 biopsies obtained from post-ablation neo-squamous mucosa. Protocolized cleaning of the ablation zone and electrode in between ablations resulted in superior regression of Barrett's esophagus compared with previous studies. During a median follow-up of 14 months no recurrence of dysplasia or Barrett's esophagus was observed., Conclusions: Stepwise circumferential and focal ablation for Barrett's esophagus with flat HGD or for Barrett's with residual dysplasia after endoscopic resection for HGD/IMC is a safe and effective treatment modality. Its success rate and safety profile compare favorably with alternatives such as esophagectomy, widespread endoscopic resection or photodynamic therapy.

Background and Study Aims: Stepwise circumferential and focal ablation of nondysplastic Barrett's esophagus has proven safe and effective. This study assessed the efficacy and safety of ablation for Barrett's esophagus with high-grade dysplasia (HGD), and residual Barrett's esophagus with dysplasia after prior endoscopic resection for visible lesions., Patients and Methods: This was a prospective cohort study. All visible abnormalities were resected prior to ablation. Persistence of dysplasia and absence of invasive cancer was confirmed with biopsies after endoscopic resection. A balloon-based electrode was used for primary circumferential ablation and an endoscope-mounted electrode was used for secondary focal ablation. Eradication of dysplasia and Barrett's esophagus was the main outcome measure., Results: Eleven patients (eight men; median age 60 years) were treated (median Barrett's length 5 cm). Visible abnormalities were removed with endoscopic resection in six patients. The worst pathological grade of residual Barrett's esophagus after endoscopic resection and prior to ablation was LGD (n = 2) and HGD (n = 9). Patients underwent a median of two circumferential and two focal ablation sessions. Complete remission of dysplasia and complete endoscopic and histological removal of Barrett's esophagus was achieved in 11/11 patients (100%). There were no adverse events or strictures, and in none of the 473 biopsies of neo-squamous mucosa was subsquamous Barrett's esophagus ("buried Barrett's") observed. During a median follow-up period of 14 months after the last treatment session and a median number of two follow-up endoscopies, none of the patients showed recurrence of dysplasia or endoscopic signs of recurrent Barrett's mucosa., Conclusions: Stepwise circumferential and focal ablation appears to be a safe and effective treatment for complete removal of Barrett's esophagus containing HGD, and can be safely performed after prior endoscopic resection for endoscopically visible abnormalities.

The prognosis of oesophageal neoplasia is dependent on the stage of the disease at the time of detection. Early lesions have an excellent prognosis in contrast to more advanced stages that usually have a dismal prognosis. Therefore, the early detection of these lesions is of the utmost importance. In recent years, several new techniques have been introduced to improve the endoscopic detection of early lesions. The most important improvement, in general, has been the introduction of high-resolution/high-definition endoscopy into daily clinical practice. The value of superimposing techniques such as chromoendoscopy, narrow band imaging and computed virtual chromoendoscopy onto high-resolution/high-definition endoscopy will have to be proven in randomised cross-over trials comparing these techniques with standard techniques. Important future adjuncts to white-light endoscopy serving as 'red-flag' techniques for the detection of early neoplasia may be broad field functional imaging techniques such as video autofluorescence endoscopy. In addition, real-time histopathology during endoscopy has become possible with endocytoscopy and confocal endomicroscopy. The clinical value of these techniques needs to be ascertained in the coming years.

Objective: To gain more insight into current surveillance and treatment of patients with Barrett's oesophagus with the aim of developing new guidelines., Design: Questionnaire., Method: In 2004, a questionnaire was sent to 337 physician-endoscopists who were all registered with the Netherlands Society of Gastroenterology. The questionnaire inventoried various aspects of surveillance and treatment of patients with Barrett's oesophagus., Results: Of the 289 respondents (86%), 96% carried out surveillance or had it carried out, on at least a proportion of their patients with Barrett's oesophagus. A total of 258 respondents (89%) carried out the surveillance themselves. An endoscopic indication of the presence of Barrett's oesophagus was, for 31% of the respondents, enough reason to carry out surveillance of this condition irrespective of the results of pathological investigations. 75% applied an age limit for surveillance for Barrett's. The median age limit is 75 years (interquartile distance: 70-75) and 46% of the treating professionals limited themselves to patients who, on the basis of age and co-morbidity, may undergo oesophageal resection. The choice of treatment in early neoplasia, surgical or endoscopic, depends not only on the histological diagnosis, but also on the age and the co-morbidities of the patient., Conclusion: Surveillance of Barrett's oesophagus is widespread in the Netherlands, and in general is carried out in accordance with international guidelines. The possibilities of treating patients with high-grade dysplasia or intramucosal carcinoma of the oesophagus endoscopically, and of consulting external advisory bodies are still insufficiently utilized.