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Quality Indicators in Endoscopic Ablation for Barrett’s Esophagus

  • Endoscopy (P Siersema, Section Editor)
  • Published:
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Opinion Statement

Barrett’s esophagus (BE) is a well-established premalignant condition for esophageal adenocarcinoma (EAC); a cancer that is associated with a poor 5-year survival rate. Several strategies have been explored in the context of reducing the burden of EAC. Endoscopic eradication therapy (EET) is considered the standard of care for the management of patients with BE with dysplasia and early neoplasia; a practice that has been endorsed by all gastroenterology societal guidelines. The effectiveness of EET has been demonstrated in multiple studies and contemporary management includes a combination of endoscopic mucosal resection (EMR) of all visible lesions followed by eradication of the remaining BE using ablative techniques of which radiofrequency ablation (RFA) has the best evidence supporting effectiveness and safety. These techniques are being used increasingly at academic tertiary care centers and community practices. In this era of value-based health care, there is increased focus on the establishment, documentation, and reporting of quality indicators; indicators that are important to physicians, patients, and payers. The purpose of this review is to highlight the current status of quality indicators in EET for the management of patients with BE-related neoplasia and discuss the future steps required to ensure that these quality indicators are uniformly incorporated into practice.

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Abbreviations

BE:

Barrett’s esophagus

EAC:

Esophageal adenocarcinoma

EET:

Endoscopic eradication therapy

EMR:

Endoscopic mucosal resection

RFA:

Radiofrequency ablation

LGD:

Low-grade dysplasia

HGD:

High grade dysplasia

GI:

Gastroenterology

AGA:

American Gastroenterological Association

ASGE:

American Society for Gastrointestinal Endoscopy

ACG:

American College of Gastroenterology

RAM:

RAND/University of California, Los Angeles Appropriateness Methodology

HDWLE:

High definition white light endoscopy

CE-IM:

Complete eradication of intestinal metaplasia

CE-N:

Complete eradication of neoplasia

References and Recommented Reading

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Shaheen NJ, Falk GW, Iyer PG, et al. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol. 2016;111:30–50.

    Article  CAS  PubMed  Google Scholar 

  2. American Gastroenterological Association, Spechler SJ, Sharma P, et al. American Gastroenterological Association medical position statement on the management of Barrett’s esophagus. Gastroenterology. 2011;140(3):1084–91.

    Article  Google Scholar 

  3. Hur C, Miller M, Kong CY, et al. Trends in esophageal adenocarcinoma incidence and mortality. Cancer. 2013;119:1149–58.

    Article  PubMed  Google Scholar 

  4. Wani S, Falk GW, Post J, et al. Risk factors for progression of low-grade dysplasia in patients with Barrett’s esophagus. Gastroenterology. 2011;141:1179–86, 1186 e1.

    Article  PubMed  Google Scholar 

  5. Wani S. Population-based estimates of cancer and mortality in Barrett’s esophagus: implications for the future. Clin Gastroenterol Hepatol. 2011;9:723–4.

    Article  PubMed  Google Scholar 

  6. Rastogi A, Puli S, El-Serag HB, et al. Incidence of esophageal adenocarcinoma in patients with Barrett’s esophagus and high-grade dysplasia: a meta-analysis. Gastrointest Endosc. 2008;67:394–8.

    Article  PubMed  Google Scholar 

  7. Hvid-Jensen F, Pedersen L, Drewes AM, et al. Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med. 2011;365:1375–83.

    Article  CAS  PubMed  Google Scholar 

  8. Bhat S, Coleman HG, Yousef F, et al. Risk of malignant progression in Barrett’s esophagus patients: results from a large population-based study. J Natl Cancer Inst. 2011;103:1049–57.

    Article  PubMed  PubMed Central  Google Scholar 

  9. ASGE Standards of Practice Committee., Evans JA, Early JA, et al. The role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc. 2012; 76(6): 1087–94.

  10. •• Phoa KN, van Vilsteren FG, Weusten BL, et al. Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia: a randomized clinical trial. JAMA. 2014;311(12):1209–17. This randomized multicenter trial compares radiofrequency ablation to endoscopic surveillance alone in low grade dysplasia in Barrett’s demonstrating the superiority of the former in eradicating Barrett’s

    Article  CAS  PubMed  Google Scholar 

  11. •• Shaheen NJ, Sharma P, Overholt BF, et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. N Engl J Med. 2009;360(22):2277. This landmark trial demonstrated the efficacy of radiofrequency ablation in treating and eradicating dysplastic Barrett’s Esophagus.

    Article  CAS  PubMed  Google Scholar 

  12. • Overholt BF, Lightdale CJ, Wang KA, et al. Photodynamic therapy with porfimer sodium for ablation of high-grade dysplasia in Barrett’s esophagus: international, partially blinded, randomized phase III trial. Gastrointest Endosc. 2005;62:488–98. This multicentered randomized trial compares photodynamic therapy to omeprazole alone, demonstrating the effectiveness of photodynamic therapy in treating high-grade dysplasia.

    Article  PubMed  Google Scholar 

  13. Pech O, Behrens A, May A, et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus. Gut. 2008;57:1200–6.

    Article  CAS  PubMed  Google Scholar 

  14. Manner H, Pech O, Heldmann Y, et al. Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion. Clin Gastroenterol Hepatol. 2013;11:630–5.

    Article  PubMed  Google Scholar 

  15. Wani S, Rubenstein JH, Vieth M, et al. Diagnosis and management of low-grade dysplasia in Barrett’s esophagus: expert review from the clinical practice updates Committee of the American Gastroenterological Association. Gastroenterology. 2016;151(5):822–35.

    Article  PubMed  Google Scholar 

  16. Qumseya BJ, Wani S, Desai M, et al. Adverse events after radiofrequency ablation in patients with Barrett’s esophagus: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2016;14:1086–95.

    Article  PubMed  Google Scholar 

  17. Council of the Institute of Medicine. America’s health in transition: protecting and improving quality. Washington, DC: National Academy Press; 1994.

    Google Scholar 

  18. US Department of Health and Human Services. Better, smarter, healthier: in historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value. January 26, 2015. Available from: www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-set-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html.

  19. Petersen BT. Quality assurance for endoscopists. Best Pract Res Clin Gastroenterol. 2011;25:349–60.

    Article  PubMed  Google Scholar 

  20. Chassin MR, Galvin RW. The urgent need to improve health care quality. Institute of Medicine National Roundtable on health care quality. JAMA. 1998;280:1000–5.

    Article  CAS  PubMed  Google Scholar 

  21. Rizk MK, Sawhney MS, Cohen J, et al. Quality indicators common to all GI endoscopic procedures. Gastrointest Endosc. 2015;81(1):3–16.

    Article  PubMed  Google Scholar 

  22. •• Sharma P, Katzka DA, Gupta N. Quality indicators for the management of Barrett’s esophagus, dysplasia, and esophageal adenocarcinoma: international consensus recommendations from the American Gastroenterological Association symposium. Gastroenterology. 2015;149:1599–606. This expert panel position paper represents the consensus statement produced by the American Gastroenterological Association in regards to quality indicators for the management of Barrett’s Esophagus and Esophageal Adenocarcinoma.

    Article  PubMed  PubMed Central  Google Scholar 

  23. •• Wani S, Muthusamy VR, Shaheen NJ, et al. Development of quality indicators for endoscopic eradication therapies in Barrett’s esophagus: the TREAT-BE (treatment with resection and endoscopic ablation techniques for Barrett’s esophagus) consortium. Gastrointest Endosc. 2017; In press. This study presents the findings by the TREAT-BE consortium relating to quality indicators in endoscopic techniques for the management of Barrett’s Esophagus.

  24. Fitch K, Aguilar MD, Burnand B, et al. The RAND/UCLA appropriateness method user’s manual. Santa Monica: RAND; 2001.

    Google Scholar 

  25. McKenna BJ, Appelman HD. Dysplasia of the gut: the diagnosis is harder than it seems. J Clin Gastroenterol. 2002;34:111–6.

    Article  PubMed  Google Scholar 

  26. Curvers WL, ten Kate FJ, Krishnadath KK, et al. Low-grade dysplasia in Barrett’s esophagus: overdiagnosed and underestimated. Am J Gastroenterol. 2010;105:1523–30.

    Article  PubMed  Google Scholar 

  27. Duits LC, Phoa KN, Curvers WL, et al. Barrett’s oesophagus patients with low-grade dysplasia can be accurately risk-stratified after histological review by an expert pathology panel. Gut. 2015;64:700–6.

    Article  PubMed  Google Scholar 

  28. Sangle NA, Taylor SL, Emond MJ, et al. Overdiagnosis of high-grade dysplasia in Barrett’s esophagus: a multicenter, international study. Mod Pathol. 2015;28:758–65.

    Article  PubMed  Google Scholar 

  29. Schlemper RJ, Riddell RH, Kato Y, et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut. 2000;47:251–5.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Montgomery E, Goldblum JR, Greenson JK, et al. Dysplasia as a predictive marker for invasive carcinoma in Barrett’s esophagus: a follow-up study based on 138 cases from a diagnostic variability study. Hum Pathol. 2001;32:379–88.

    Article  CAS  PubMed  Google Scholar 

  31. Montgomery E, Bronner MP, Goldblum JR, et al. Reproducibility of the diagnosis of dysplasia in Barrett esophagus: a reaffirmation. Hum Pathol. 2001;32:368–780.

    Article  CAS  PubMed  Google Scholar 

  32. Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut. 2014;63:7–42.

    Article  PubMed  Google Scholar 

  33. Schölvinck DW, van der Meulen K, Bergman JJ, Weusten BL. Detection of lesions in dysplastic Barrett’s esophagus by community and expert endoscopists. Endoscopy. 2016.

  34. Wani S, Sharma P. Challenges with endoscopic therapy for Barrett’s esophagus. Gastroenterol Clin N Am. 2015;44:355–72.

    Article  Google Scholar 

  35. Sharma P, Dent J, Armstrong D, et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology. 2006;131:1392–9.

    Article  PubMed  Google Scholar 

  36. Anonymous. Paris workshop on columnar metaplasia in the esophagus and the Esophagogastric junction, Paris, France, December 11-12 2004. Endoscopy. 2005;37:879–920.

    Article  Google Scholar 

  37. Wolfsen HC, Crook JE, Krishna M, et al. Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett’s esophagus. Gastroenterology. 2008;135:24–31.

    Article  PubMed  Google Scholar 

  38. Kara MA, Peters FP, Rosmolen WD, et al. High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett’s esophagus: a prospective randomized crossover study. Endoscopy. 2005;37:929–36.

    Article  CAS  PubMed  Google Scholar 

  39. Curvers W, Baak L, Kiesslich R, et al. Chromoendoscopy and narrow-band imaging compared with high-resolution magnification endoscopy in Barrett’s esophagus. Gastroenterology. 2008;134:670–9.

    Article  PubMed  Google Scholar 

  40. Sami SS, Subramanian V, Butt WM, et al. High definition versus standard definition white light endoscopy for detecting dysplasia in patients with Barrett’s esophagus. Dis Esophagus. 2015;28:742–9.

    Article  CAS  PubMed  Google Scholar 

  41. Larghi A, Lightdale CJ, Memeo L, et al. EUS followed by EMR for staging of high-grade dysplasia and early cancer in Barrett’s esophagus. Gastrointest Endosc. 2005;62:16–23.

    Article  PubMed  Google Scholar 

  42. Peters FP, Brakenhoff KP, Curvers WL, et al. Histologic evaluation of resection specimens obtained at 293 endoscopic resections in Barrett’s esophagus. Gastrointest Endosc. 2008;67:604–9.

    Article  PubMed  Google Scholar 

  43. Moss A, Bourke MJ, Hourigan LF, et al. Endoscopic resection for Barrett’s high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit. Am J Gastroenterol. 2010;105:1276–83.

    Article  PubMed  Google Scholar 

  44. Chennat J, Konda VJ, Ross AS, et al. Complete Barrett’s eradication endoscopic mucosal resection: an effective treatment modality for high-grade dysplasia and intramucosal carcinoma—an American single-center experience. Am J Gastroenterol. 2009;104:2684–92.

    Article  PubMed  Google Scholar 

  45. Wani S, Abrams J, Edmundowicz SA, et al. Endoscopic mucosal resection results in change of histologic diagnosis in Barrett’s esophagus patients with visible and flat neoplasia: a multicenter cohort study. Digestive Diseases & Sciences. 2013;58:1703–9.

    Article  Google Scholar 

  46. Wani S, Mathur SC, Curvers WL, et al. Greater interobserver agreement by endoscopic mucosal resection than biopsy samples in Barrett’s dysplasia. Clinical Gastroenterology & Hepatology. 2010;8:783–8.

    Article  Google Scholar 

  47. Mino-Kenudson M, Hull MJ, Brown I, et al. EMR for Barrett’s esophagus-related superficial neoplasms offers better diagnostic reproducibility than mucosal biopsy. Gastrointest Endosc. 2007;66:660–6. quiz 767, 769

    Article  PubMed  Google Scholar 

  48. Orman ES, Li N, Shaheen NJ. Efficacy and durability of radiofrequency ablation for Barrett’s esophagus: systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2013;11:1245–55.

    Article  PubMed  Google Scholar 

  49. van Vilsteren FG, Pouw RE, Seewald S, et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut. 2011;60:765–73.

    Article  PubMed  Google Scholar 

  50. Gupta M, Iyer PG, Lutzke L, et al. Recurrence of esophageal intestinal metaplasia after endoscopic mucosal resection and radiofrequency ablation of Barrett’s esophagus: results from a US multicenter consortium. Gastroenterology. 2013;145:79–86.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Gondrie JJ, Pouw RE, Sondermeijer CM, et al. Effective treatment of early Barrett’s neoplasia with stepwise circumferential and focal ablation using the HALO system. Endoscopy. 2008;40:370–9.

    Article  CAS  PubMed  Google Scholar 

  52. Pouw RE, Wirths K, Eisendrath P, et al. Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol. 2010;8:23–9.

    Article  PubMed  Google Scholar 

  53. Fleischer DE, Overholt BF, Sharma VK, et al. Endoscopic radiofrequency ablation for Barrett’s esophagus: 5-year outcomes from a prospective multicenter trial. Endoscopy. 2010;42:781–9.

    Article  CAS  PubMed  Google Scholar 

  54. Vaccaro BJ, Gonzalez S, Poneros JM, et al. Detection of intestinal metaplasia after successful eradication of Barrett’s esophagus with radiofrequency ablation. Dig Dis Sci. 2011;56:1996–2000.

    Article  PubMed  PubMed Central  Google Scholar 

  55. Haidry RJ, Banks M, Gupta A, et al. Recurrence after successful radiofrequency ablation for Barrett’s related neoplasia is more likely in males: data from the United Kingdom patient registry. Gut. 2014;63:A113–4.

    Google Scholar 

  56. Cotton CC, Wolf WA, Pasricha S, et al. Recurrent intestinal metaplasia after radiofrequency ablation for Barrett’s esophagus: endoscopic findings and anatomic location. Gastrointest Endosc. 2015;81:1362–9.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Orman ES, Kim HP, Bulsiewicz WJ, et al. Intestinal metaplasia recurs infrequently in patients successfully treated for Barrett’s esophagus with radiofrequency ablation. Am J Gastroenterol. 2013;108:187–95.

    Article  PubMed  Google Scholar 

  58. Prasad GA, Dunagan KT, Tian J, et al. Recurrence of intestinal metaplasia following radiofrequency ablation: rates and predictors. Gastrointest Endosc. 2011;73:AB145–6.

    Google Scholar 

  59. Krishnan K, Pandolfino JE, Kahrilas PJ, et al. Increased risk for persistent intestinal metaplasia in patients with Barrett’s esophagus and uncontrolled reflux exposure before radiofrequency ablation. Gastroenterology. 2012;143:576–81.

    Article  PubMed  PubMed Central  Google Scholar 

  60. Yasuda K, Choi SE, Nishioka NS, et al. Incidence and predictors of adenocarcinoma following endoscopic ablation of Barrett’s esophagus. Digestive Diseases & Sciences. 2014;59:1560–6.

    Article  Google Scholar 

  61. Akiyama J, Marcus SN, Triadafilopoulos G. Effective intra-esophageal acid control is associated with improved radiofrequency ablation outcomes in Barrett’s esophagus. Dig Dis Sci. 2012;57:2625–32.

    Article  CAS  PubMed  Google Scholar 

  62. Leiman DA, Metz DV, Ginsberg GG, et al. A novel electronic medical record-based workflow to measure and report colonoscopy quality measures. Clin Gastroenterol Hepatol. 2016;14(3):333–7.

    Article  PubMed  Google Scholar 

  63. Mehta SJ, Ahmad NA. Aligning quality with the academic mission: a quality improvement and delivery science Program in gastroenterology. Gastroenterology. 2016;150(3):543–6.

    Article  PubMed  Google Scholar 

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Acknowledgements

This work was supported by the University of Colorado, Department of Medicine Outstanding Early Scholars Program (SW).

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 1635 Aurora Court, Rm 2.031, Aurora, CO, 80045, USA

    Samuel Han MD & Sachin Wani MD

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  1. Samuel Han MD
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  2. Sachin Wani MD
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Correspondence to Sachin Wani MD.

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Samuel Han declares no conflict of interest.

Sachin Wani reports grants from University of Colorado, Department of Medicine Outstanding Early Scholars Program and consultancy fees from Boston Scientific and Medtronic.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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Han, S., Wani, S. Quality Indicators in Endoscopic Ablation for Barrett’s Esophagus. Curr Treat Options Gastro 15, 241–255 (2017). https://doi.org/10.1007/s11938-017-0136-0

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