Accuracy of endoscopic staging and targeted biopsies for routine gastric intestinal metaplasia and gastric atrophy evaluation study protocol of a prospective, cohort study: the estimate study

Introduction Patients with chronic atrophic gastritis (CAG) and intestinal metaplasia (IM) are at risk of developing gastric adenocarcinoma. Their diagnosis and management currently rely on histopathological guidance after random endoscopic biopsy sampling (Sydney biopsy strategy). This approach has significant flaws such as under-diagnosis, poor reproducibility and poor correlation between endoscopy and histology. This prospective, international multicentre study aims to establish whether endoscopyled risk stratification accurately and reproducibly predicts CAG and IM extent and disease stage. Methods and analysis Patients with CAG and/or IM on standard white light endoscopy (WLE) will be prospectively identified and invited to undergo a second endoscopy performed by an expert endoscopist using enhanced endoscopic imaging techniques with virtual chromoendoscopy. Extent of CAG/IM will be endoscopically staged with enhanced imaging and compared with standard WLE. Histopathological risk stratification through targeted biopsies will be compared with endoscopic disease staging and to random biopsy staging on WLE as a reference. At least 234 patients are required to show a 10% difference in sensitivity and accuracy between enhanced imaging endoscopy-led staging and the current biopsy-led staging protocol of gastric atrophy with a power (beta) of 80% and a 0.05 probability of a type I error (alpha). Ethics and dissemination The study was approved by the respective Institutional Review Boards (Netherlands: MEC2018-078; UK: 19/LO/0089). The findings will be published in peer-reviewed journals and presented at scientific meetings

Recent advances in the detection and management of early gastric cancer and its precursors

Despite declines in incidence, gastric cancer remains a disease with a poor prognosis and limited treatment options due to its often late stage of diagnosis. In contrast, early gastric cancer has a good to excellent prognosis, with 5-year survival rates as high as 92.6% after endoscopic resection. There remains an East-West divide for this disease, with high incidence countries such as Japan seeing earlier diagnoses and reduced mortality, in part thanks to the success of a national screening programme. With missed cancers still prevalent at upper endoscopy in the West, and variable approaches to assessment of the high-risk stomach, the quality of endoscopy we provide must be a focus for improvement, with particular attention paid to the minority of patients at increased cancer risk. High-definition endoscopy with virtual chromoendoscopy is superior to white light endoscopy alone. These enhanced imaging modalities allow the experienced endoscopist to accurately and robustly detect high-risk lesions in the stomach. An endoscopy-led staging strategy would mean biopsies could be targeted to histologically confirm the endoscopic impression of premalignant lesions including atrophic gastritis, gastric intestinal metaplasia, dysplasia and early cancer. This approach to quality improvement will reduce missed diagnoses and, combined with the latest endoscopic resection techniques performed at expert centres, will improve early detection and ultimately patient outcomes. In this review, we outline the latest evidence relating to diagnosis, staging and treatment of early gastric cancer and its precursor lesions

Biopsy sampling in upper gastrointestinal endoscopy - a survey from ten tertiary referral centres across Europe

BACKGROUND: Guidelines give robust recommendations on which biopsies should be taken when there is endoscopic suggestion of gastric inflammation. Adherence to these guidelines often seems arbitrary. This study aimed to give an overview on current practice in tertiary referral centres across Europe. METHODS: Data was collected at ten tertiary referral centres. Demographic data, the indication for each procedure, endoscopic findings and the number and sampling site of biopsies were recorded. Findings were compared between centres and factors influencing the decision to take biopsies explored. RESULTS: Biopsies were taken in 56.6% of 9425 procedures, with significant variation between centres (p&lt;0.001). Gastric biopsies were taken in 43.8% of all procedures. Sampling location varied with the procedure indication (p&lt;0.001) without consistent pattern across the centres. Fewer biopsies were taken in centres which routinely applied the updated Sydney classification for gastritis assessment (46.0%), compared to centres where this was done only upon request (75.3%, p&lt;0.001). This was the same for centres stratifying patients according to the OLGA system (51.8% vs 73.0%, p&lt;0.001). More biopsies were taken in centres following the MAPS guidelines on stomach surveillance (68.1% vs 37.1%, p&lt;0.001). Biopsy sampling was more likely in younger patients in 8 centres (p&lt;0.05), but this was not true for the whole cohort (p=0.537). The percentage of procedures with biopsies correlated directly with additional costs charged in case of biopsies (r=0.709, p=0.022). CONCLUSION: Adherence to guideline recommendations for biopsy sampling at gastroscopy was inconsistent across the participating centres. Our data suggest that instead centre-specific policies are applied.</p