Probe based confocal laser endomicroscopy: the new standard for the surveillance of Barrett’s esophagus?

Thomas T Wang, MD, William F Buitrago, MD, PhD, Philip Leggett, MD. University of Texas Health Science Center at Houston

Introduction: Probe-based confocal laser endomicroscopy (pCLE) is one of several emerging technologies that offers unique advantages over conventional endoscopy in the surveillance and treatment of Barrett's esophagus. The goal of this study is to validate the use of pCLE in guiding the surveillance and treatment of Barrett's esophagus.

Methods: In our single-institution prospective study, 22 patients who presented with reflux symptoms were selected to undergo endoscopy with pCLE.  Inclusion criteria were adults with reflux symptoms regardless of PPI use, prior diagnosis of Barrett's esophagus, or prior EGD findings.  Exclusion criteria were patients under the age of 18 and patients whose insurance would not reimburse for the procedure.  For each patient, standard white light endoscopy was performed followed by the application of pCLE imaging regardless of endoscopic findings.  pCLE images of the gastroesophageal junction were obtained and recorded.  Afterwards 4 quadrant biopsies were taken at the same level that was imaged.

Images obtained by pCLE were reviewed at the end of each procedure.  The pCLE diagnosis of Barrett’s esophagus was defined as the presence of intestinal metaplasia and goblet cells.  The presence of dysplasia was determined using validated imaging criteria.  

Results: The incidence of Barrett’s esophagus diagnosed using pCLE ( n=9, 41%) was greater than the incidence found by Seattle protocol (n=4, 18%).  The negative predictive value of Seattle protocol using pCLE as the standard for Barrett’s esophagus detection was 53.9%.   

Regarding the diagnosis of dysplasia, the detection rate of dysplasia positivity was higher when using pCLE criteria (n=3, 13.6%) compared to Seattle protocol (n=1, 4.5%).  The discordance was due to the fact that two patients were diagnosed as indeterminate for dysplasia by histologic analysis. 

Conclusions: Results of this study support the existing literature that there is improved detection rates of Barrett’s esophagus using pCLE, which provides a larger area of diagnostic coverage.   Furthermore a secondary benefit found by this study is that by utilizing pCLE to obtain more information regarding mucosal microarchitecture, a diagnosis of dysplasia may be made with greater confidence.

In this study results from our ongoing experience with pCLE technology has led directly to a change in clinical management in 32% of our patients.  Those patients with Barrett’s esophagus missed by traditional 4-quadrant biopsy surveillance will undergo shorter surveillance intervals.  Patients with pathology indeterminate for dysplasia yet positive for dysplasia on pCLE will receive radiofrequency ablation therapy.  

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