Cory Richardson, MD1, Paul Colavita, MD2, Christy Dunst, MD3, John Bagnato, MD4, Peter Billing, MD5, Kurt Birkenhagen, MD6, Francis Buckley, MD7, William Buitrago, MD8, Joseph Burnette, MD4, Phil Leggett, MD8, Howard McCollister, MD9, Kurt Stewart, MD5, Thomas Wang, MD8, Alvin Zfass, MD10, Paul Severson, MD9. 1Northwest Institute for Digestive Surgery, 2Carolinas Medical Center, 3The Oregon Clinic, 4Coliseum Northside Hospital, 5Puget Sound Surgical Center, 6Bingham Memorial Hospital, 7Scott & White Healthcare, 8Houston Northwest Medical Center, 9Minnesota Institute for Minimally Invasive Surgery, 10Virginia Commonwealth University
Introduction: Endoscopic evaluation with high-definition white-light endoscopy and random 4 quadrant biopsy (Seattle protocol) is the current standard of care for the detection of Barrett’s Esophagus (BE). Recently, enhanced imaging technologies have become available with the aim to provide real-time diagnosis of Intestinal Metaplasia (IM) and dysplasia, reducing the need for tissue biopsy. Probe-based Confocal Laser Endomicroscopy (pCLE) provides dynamic microscopic views of gastrointestinal mucosa, rapidly capturing numerous digital images that become optical biopsies. This study examines the role of pCLE in BE screening and surveillance as compared to the Seattle protocol.
Methods: Adults undergoing BE screening or surveillance endoscopy were eligible for enrollment unless they had a contraindication to fluorescein or a history of esophageal ablation for BE. Endoscopy technique was standardized across centers and included routine white light and narrow band imaging evaluation, landmark identification, and recording of visible columnar lined esophagus according to the Prague classification. Optical biopsy using pCLE was interpreted in real time and immediately after the procedure. Endoscopists performing pCLE were novice users with a mean experience of 6.6 months (range 0-18 months) and no formal training in surgical pathology. Routine esophageal biopsies were then taken per Seattle Protocol (four quadrant biopsies starting at the squamocolumnar junction and proceeding in 1 cm segments to the gastroesophageal junction). Recorded pCLE images were reviewed by a single blinded expert with more than 7 years of experience in optical biopsy interpretation.
Results: Of the 172 patients, 94 had visible columnar lined esophagus. Mean length was 1.83cm (range 1-10cm). IM was identified by pCLE in 99 patients (57.6%) and dysplasia in 7 (4%). Tissue biopsy yielded IM in 47 (27%), dysplasia in 2 and indeterminate in 3. Blinded expert pCLE review of negative tissue biopsies identified IM in 52 of 55 patients. There were 6 patients with IM on tissue biopsy that were missed by novice pCLE. Five of these were detected by blinded expert review.
Conclusion: Optical biopsy using pCLE technology allows for the real time evaluation of entire segments of columnar lined esophagus. Consequently, pCLE is considerably more sensitive in the detection of Barrett’s Esophagus than the Seattle Protocol, which leaves a majority of epithelium unexamined. This effect is seen even in novice users and increases with experience. Overall, pCLE provides a promising advance in Barrett’s detection which will likely result in superior identification of individuals at risk for esophageal adenocarcinoma.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 85074
Program Number: S071
Presentation Session: Flexible Endoscopy Session
Presentation Type: Podium
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