Barrett s Esophagus. Improved Imaging. Endoscopic Therapy

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1 Barrett s Esophagus: Dye, Ablate or Resect? Prateek Sharma, MD Kansas City Barrett s Esophagus Accurate Diagnosis of BE Improved Imaging Endoscopic Therapy 1

2 Accurate Diagnosis: Is It Really Barrett s Esophagus! Barrett s Esophagus Columnar lined esophagus Intestinal Metaplasia 2

3 Endoscopic BE: Prague C&M Criteria Based on Circumference f and Maximum extent Patient with 5 cm long Barrett s, distal 2 cm circumferential and proximal 3 cm in form of a tongue Barrett s: C2M5 Sharma P et al, Gastroenterology 2006 Endoscopic BE: Prague C&M Criteria Based on Circumference f and Maximum extent Patient with 5 cm long Barrett s, distal 2 cm circumferential and proximal 3 cm in form of a tongue Barrett s: C2M5 C2 M5 Sharma P et al, Gastroenterology

4 What is Not Barrett s Esophagus: The slightly irregular z line What is Not Barrett s Esophagus: The slightly irregular z line 4

5 What is Not Barrett s Esophagus: The slightly irregular z line What is Not Barrett s Esophagus: The slightly irregular z line 5

6 What is Not Barrett s Esophagus: The slightly irregular z line Kappa=0.2 What is Not Barrett s Esophagus: The slightly irregular z line Kappa=0.2 Intestinal Metaplasia 6

7 What is Not Barrett s Esophagus: The slightly irregular z line Follow up of GEJ metaplasia 162 patients Follow up: Kappa= years No HGD or cancers developed Intestinal Metaplasia Jung KW et al, Am J Gastro 2011 Sh P t l G t 2000 Barrett s Esophagus Accurate Diagnosis of BE Improved Imaging Endoscopic Therapy 7

8 Current Biopsy Technique Advanced Surface Imaging 8

9 Barrett s Lesion NBI In-vivo Imaging 9

10 Technique of Endomicroscopy Field of view: 500x500µm Range: 0-250µm Lateral resolution: <1µm BE: Non-dysplastic 10

11 BE: Cancer What about those buried glands? 11

12 Detection of Buried Tissue After Ablation Detection of Buried Tissue After Ablation 12

13 Detection of Buried Tissue After Ablation Detection of Buried Tissue After Ablation 13

14 3D-OCT: Volumetric Laser Endomicroscopy 5mm Next generation OCT Uses near infra red light High resolution images Optical probe pulls back 6 cm OFDI Cross-sectional views: Squamous vs. BE Squamous Barrett s

15 OFDI Cross-sectional views: Squamous vs. BE Multi center feasibility trial 74 BE patients Squamous VLE successfully performed Real time imaging of mucosa, sub-mucosa No major adverse events Sharma P et al. DDW 2013 Barrett s Look Before Taking Biopsies! 15

16 16

17 Barrett s Inspection Time (BIT) Gupta N et al. GIE 2012 Barrett s Inspection Time (BIT) Longer BIT led to more HGD/EAC detection (p=0.001) despite no difference in BE length (p=0.10) Gupta N et al. GIE

18 Improving Endoscopic Recognition: Barrett s Oesophagus Related Neoplasia (BORN) Project 18

19 Barrett s Esophagus Accurate Diagnosis of BE Improved Imaging Endoscopic Therapy Improving Endoscopic Outcomes Resect the Highest Grade Lesion 19

20 High Grade Dysplasia and Early Cancer Improving Endoscopic Outcomes Eradication of the Remaining BE segment after EMR 20

21 Circumferential Focal Radiofrequency Eradication A Randomized, Multicenter, Sham Controlled Trial of RF Ablation Patients % p< % LGD Eradication (n=64) 128 patients with BE and dysplasia (LGD/HGD) Mean BE length 5 cm; 12 month follow up 90% * 81% * 19% HGD Eradication (n=63) 2% 77% * SHAM RFA IM Eradication (n=127) Shaheen N et al. NEJM

22 Cryoablation Low pressure device using liquid notrogen at -196 C Delivered via multilayered catheter Complete ablation of BE: 9/11 patients (78%) Complete ablation of HGD 90%, early cancer 75% Johnston MH et al, Gastrointest Endosc 2005 Dumot JA et al, Gastrointest Endosc Recurrences After Ablation 72 BE patients Mean length: 7.8 cms 90 89% Mean follow up 3 years Dysplasia Eradication 79% IM Eradication 28% Recurren Dulai et ce al. Gastrointest Endosc

23 Conclusions Clear identification of endoscopic landmarks is the basis for an endoscopic diagnosis A detailed inspection of the Barrett s mucosa using high definition endoscopes reveals neoplastic lesions Targeting high yield areas and avoiding biopsies of non-dysplastic area appears to be a reality Resect plus ablate strategy is very promising; watch out for recurrences post therapy 23

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