Barrett’s Esophagus Revisited: Epidemiology, Risk Stratification and Cancer Prevention

Cancer of the esophagus (EAC) is a highly aggressive malignancy worldwide, of which the incidence has increased tremendously during the last decades. Barrett’s esophagus (BE) is the only recognized precursor lesion and is associated with the majority, if not all, cases with adenocarcinoma. BE predisposes to the development of EAC, following a multi-step cascade through stages of esophagitis, intestinal metaplasia, low-grade dysplasia (LGD), high-grade dysplasia (HGD), to invasive adenocarcinoma. Endoscopic screening of subjects with chronic gastro-esophageal reflux symptoms has been proposed as a method for detecting BE. Once BE has been diagnosed, surveillance endoscopy is advised at intervals based on the presence or absence and grade of dysplasia, in order to detect early stage cancers suitable for curative treatment, and ultimately to prevent deaths from EAC. Unfortunately, the efficacy of screening and surveillance of BE remains a strongly debated issue, as there are many unresolved epidemiological dilemmas, of which the inability to predict who has BE prior to endoscopy, and the lack of data on the natural history of BE are the major ones. Improved risk stratification could improve the effectiveness of screening and surveillance in BE patients, and achieve the ultimate goal of reducing EAC mortality. The aim of the studies described in this thesis is to reassess the yield of screening for and surveillance of BE in the prevention of EAC, by exploring the natural course of BE, by investigating various risk factors involved in the progression of chronic gastro-esophageal reflux disease to BE and finally to HGD or EAC, and by examining the value of non-invasive techniques in the identification of high risk groups

Barrett's oesophagus: Epidemiology, cancer risk and implications for management

Although endoscopic surveillance of patients with Barrett's oesophagus has been widely implemented, its effectiveness is debateable. The recently reported low annual oesophageal adenocarcinoma risk in population studies, the failure to identify most Barrett's patients at risk of disease progression, the poor adherence to surveillance and biopsy protocols, and the significant risk of misclassification of dysplasia all tend to undermine the effectiveness of current management, in particular, endoscopic surveillance programmes, to prevent or improve the outcomes of patients with oesophageal adenocarcinoma. The ongoing increase in incidence of Barrett's oesophagus and consequent growth of the surveillance population, together with the associated discomfort and costs of endoscopic surveillance, demand improved techniques for accurately determining individual risk of oesophageal adenocarcinoma. More accurate techniques are needed to run efficient surveillance programmes in the coming decades. In this review, we will discuss the current knowledge on the epidemiology of Barrett's oesophagus, and the challenging epidemiological dilemmas that need to be addressed when a

Is Textbook Outcome a valuable composite measure for short-term outcomes of gastrointestinal treatments in the Netherlands using hospital information system data? A retrospective cohort study

OBJECTIVE: To develop a feasible model for monitoring short-term outcome of clinical care trajectories for hospitals in the Netherlands using data obtained from hospital information systems for identifying hospital variation.STUDY DESIGN: Retrospective analysis of collected data from hospital information systems combined with clinical indicator definitions to define and compare short-term outcomes for three gastrointestinal pathways using the concept of Textbook Outcome.SETTING: 62 Dutch hospitals.PARTICIPANTS: 45 848 unique gastrointestinal patients discharged in 2015.MAIN OUTCOME MEASURE: A broad range of clinical outcomes including length of stay, reintervention, readmission and doctor-patient counselling.RESULTS: Patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease (n=4369), colonoscopy for inflammatory bowel disease (IBD; n=19 330) and colonoscopy for colorectal cancer screening (n=22 149) were submitted to five suitable clinical indicators per treatment. The percentage of all patients who met all five criteria was 54%±9% (SD) for ERCP treatment. For IBD this was 47%±7% of the patients, and for colon cancer screening this number was 85%±14%.CONCLUSION: This study shows that reusing data obtained from hospital information systems combined with clinical indicator definitions can be used to express short-term outcomes using the concept of Textbook Outcome without any excess registration. This information can provide meaningful insight into the clinical care trajectory on the level of individual patient care. Furthermore, this concept can be applied to many clinical trajectories within gastroenterology and beyond for monitoring and improving the clinical pathway and outcome for patients

Screening for synchronous esophageal second primary tumors in patients with head and neck cancer

Patients with head and neck squamous cell carcinoma (HNSCC) have an increased risk of developing esophageal second primary tumors (ESPTs). We aimed to determine the incidence, stage, and outcome of synchronous ESPTs in patients with HNSCC in a Western population. We performed a prospective, observational, and cohort study. Patients diagnosed with HNSCC in the oropharynx, hypopharynx, any other sub-location in combination with alcohol abuse, or patients with two synchronous HNSCCs, between February 2019 and February 2020 underwent screening esophagogastroduodenoscopy (EGD). ESPT was defined as presence of esophageal squamous cell carcinoma (ESCC) or high grade dysplasia (HGD). Eighty-five patients were included. A lesion suspected for ESPT was detected in 14 of 85 patients, which was pathologically confirmed in five patients (1 ESCC and 4 HGD). The radiotherapy field was extended to the esophagus in two of five patients, HGD was treated with endoscopic resection in three of five patients. None of the ESPTs were detected on MRI and/or CT-scan prior to EGD. Of the remaining nine patients, three had low grade dysplasia on histology whereas the other six patients had benign lesions. Incidence of synchronous ESPT was 5.9% in our cohort of HNSCC patients. All ESPTs were diagnosed at an early stage and treated with curative intent. We recommend that screening for synchronous ESPTs should be considered in a selected group of patients with HNSCC