2/14/18

1

Please download the CDDW™ app to complete the session evaluation and to receive your certificate of attendance.

Evaluation and Certificate of Attendance

CDDW 2018 Small Group Session:

Barrett's Esophagus in 2018Jeff Mosko

University of Toronto

Clarence WongUniversity of Alberta

Financial Interest Disclosures

• Presenter: Jeff Mosko

• Consultant: Abbvie

• Speaker: Boston Scientific, Abbvie, Shire, Vantage Endoscopy, Cook Endoscopy

• Education grant: Pendopharm

Financial Interest Disclosures

• Presenter: Clarence Wong

• Relationships that may introduce potential bias and/or conflict of interest:

• Grants/Research Support: Somagen

• Speakers Bureau/Honoraria: Allergan, Ferring, Takeda, Pendopharm

• Consulting Fees: Medtronic/Covidien, Ferring

• Other: Employee of Alberta Health Services

lMedical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional attitudes in their provision of patient-centered care. Medical Expert is the central physician Role in the CanMEDS framework.)

Communicator (as Communicators, physicians effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter.)

Collaborator (as Collaborators, physicians effectively work within a healthcare team to achieve optimal patient care.)

Manager (as Managers, physicians are integral participants in healthcare organizations, organizing sustainable practices, making decisions about allocating resources, and contributing to the effectiveness of the healthcare system.)

Health Advocate (as Health Advocates, physicians responsibly use their expertise and influence to advance the health and well-being of individual patients, communities, and populations.)

lScholar (as Scholars, physicians demonstrate a lifelong commitment to reflective learning, as well as the creation, dissemination, application and translation of medical knowledge.)

Professional (as Professionals, physicians are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour.)

CanMEDS Roles Covered in this Session: Objectives

• At the end of this session, attendees will have an improved understanding of the approach to diagnosis and management of Barrett's esophagus. We will specifically focus on:

1. Endoscopic imaging techniques, description and proper classification;

2. Indications for ablation;

3. Medical management and other endoscopic therapies.

2/14/18

2

Barrett’s 2018:Endoscopic imaging techniques, description and proper classificationJeffrey MoskoSt. Michael's HospitalUniversity of Torontomoskoj@smh.ca

CDDW (Feb 11, 2018)

Barrett’s Esophagus• Columnar mucosa

extending above GEJ

• Intestinal metaplasia +/- goblet cells on esophageal biopsy

• Requires accurate localization of the GEJ

Spechler NEJM 2014

CDDW (Feb 11, 2018)

Dysplasia Predicts Cancer Risk

• Non-dysplastic BE: 0.1-0.3%/year

• Low-grade dysplasia: 0.5%/year

• High-grade dysplasia:– Focal HGD: 14% by 3 years–Multifocal HGD: 56% by 3 years

1/3 patients referred for HGD have IMC on EMR

Spechler et al. NEJM 2014Singh et al. GIE 2014Buttar et al. Gastro 2001

CDDW (Feb 11, 2018)

Prague Classification

ASGE

• HD gastroscope (+/- cap)• Thorough cleaning• Complete the exam*• Examine upon withdrawal

• Diaphragmatic inlet• Top of folds/GEJ• C• M

• Retroflexion• +/- red flag imaging• Targeted biopsies• 4-quadrant biopsies

CDDW (Feb 11, 2018) CDDW (Feb 11, 2018)

Detection of dysplasia

• Targeted biopsies

– Should contribute 80-90% of dysplasia

– 80% of pts referred for HGD/IMC on “random” bx have visible lesion detected at expert centre

Look more, biopsy less

Swager et al. BPRCG 2015Curvers et al. GUT 2008

2/14/18

3

CDDW (Feb 11, 2018) CDDW (Feb 11, 2018)

Seeing is believing

Boerwinkel et al. Gastro 2014

CDDW (Feb 11, 2018) CDDW (Feb 11, 2018)

Advanced Imaging Techniques

HD-WLE NBI

Indigo carmine Acetic acid

CDDW (Feb 11, 2018) CDDW (Feb 11, 2018)

Detection of dysplasia• Seattle protocol: 4-quadrant bx every 2 cm

– Only samples 5% of surface area– Poor adherence (~50%)

Harrison et al. AJG 2007Abrams et al. CGH 2009

2/14/18

4

CDDW (Feb 11, 2018)

Red Flag Imaging

Mosko et al. ACG 2014, courtesy of Ninepoint Medical

Barrett’s 2018:Indications for AblationClarence WongEndoscopic Ablation Program, Royal Alexandra HospitalUniversity of AlbertaClarence.wong@ualberta.ca

Rapid rise of esophageal adenocarcinomaSome recent referrals…

I would be most appreciative if you could see this pleasant 68-year-old woman regarding chronic reflux with Barrett esophagus and recent biopsies identifying low-grade dysplasia with focal high-grade dysplasia.

Pre and Post

What is Endoscopic Ablation?

Mechanical Thermal Photochemical

EMR ESD APC RFA PDT

Cryotherapy

2/14/18

5

Surgery?

Ann R Coll Surg Engl 2006; 89: 586–590

“Endoscopic eradication therapy is the procedure of choice for patients with confirmed LGD, and

confirmed HGD…and with T1a EAC” 2015 AJG, Shaheen et al.

BE

Indefinitefor

Dysplasia

Low GradeDysplasia

High GradeDysplasia

Early Esophageal Carcinoma

(IMC)

NonDysplastic

Non dysplastic Barrett’s● Cost vs Benefit

● Does not remove need for follow-up

● Does not change need for medical management

AHS Clinical Practice Guideline GI-011, Esophageal Cancer & Barrett’s, 2014.

Non dysplastic Barrett’s?● ESGE Guideline

Weusten Bas et al. Endoscopic management of Barrett’s. Endoscopy 2017; 49

BE

Low GradeDysplasia

High GradeDysplasia

Early Esophageal Carcinoma

(IMC)

NonDysplastic

Indefinitefor

Dysplasia

2/14/18

6

Indefinite for dysplasia?● AHS ESGE

Weusten Bas et al. Endoscopic management of Barrett’s. Endoscopy 2017;

AHS Clinical Practice Guideline GI-011, Esophageal Cancer & Barrett’s, 2014.

BE

Indefinitefor

Dysplasia

High GradeDysplasia

Early Esophageal Carcinoma

(IMC)

NonDysplastic

Low GradeDysplasia

Low grade dysplasia

● Single diagnosis of LGD insufficient

○30% repeat show no dysplasia

○PPI therapy?

○Careful HDWL review?

○Expert GI pathologist review?

Pohl et al., Gut 2016; 65: 196–201 Weusten Bas et al. Endoscopic management of Barrett’s. Endoscopy 2017;

BE

Indefinitefor

Dysplasia

Early Esophageal Carcinoma

(IMC)

NonDysplastic

Low GradeDysplasia

High GradeDysplasia

High Grade Dysplasia● True flat HGD?

○Only in 20%

ESGE Statement HGD

Weusten Bas et al. Endoscopic management of Barrett’s. Endoscopy 2017;

2/14/18

7

Barrett’s 2018:Medical management and other endoscopic therapies

Chemoprevention● Sparse data

● No RCT

● Biologic plausibility

● Treat asymptomatic Barrett’s?

● Cohort studies: BE patients on PPI reduced neoplastic progression

2015 AJG, Shaheen et al.

Bhat S, et al. J Natl Cancer Inst2011;103:1049–57.Kastelein F, W\et al.. Clin Gastroenterol Hepatol 2013;11:382–8.Nguyen DM, El-Serag HB, et al.. Clin GastroenterolHepatol 2009;7:1299–304.

Medical Therapy During/After Ablation? Medical Therapy During/After Ablation?

Komanduri, Am J Gastro 2017; 112

● 221 patients with dyspasia

● 48 no CE IM in 3 sessions

● After protocol, 94% achieved CE-IM

Komanduri, Am J Gastro 2017; 112

Focal

2/14/18

8

Radiofrequency Ablation

Cryotherapy● Wand systems

● Enclosed systems

Cryotherapy

Summary

• In this session, we have reviewed diagnosis and management of Barrett’s. In particular:

1. Endoscopic imaging techniques, description and proper classification;

2. Indications for ablation;

3. Medical management and other endoscopic therapies.