A new clinical practice guideline offers updated recommendations for the diagnosis, surveillance, and management of Barrett’s esophagus (BE). Developed by a multidisciplinary panel under the American Gastroenterological Association (AGA), the guideline reflects current evidence regarding screening approaches, endoscopic surveillance intervals, biopsy protocols, and treatment of dysplasia. The update was prompted by advances in endoscopic imaging and eradication therapies, as well as the growing need for risk-based management strategies to prevent esophageal adenocarcinoma.
Seven clinical domains were addressed when formulating the new guideline: overall role of endoscopic surveillance, surveillance in patients with columnar-lined esophagus under 1 cm, optimal imaging modalities, adjunctive sampling techniques, utility of biomarkers in risk stratification, chemopreventive strategies, and anti-reflux procedures in the prevention of disease progression. Panel members considered desirable versus undesirable effects, patient values, costs, and issues of health-care equity when deciding on their recommendations.
Using the Evidence-to-Decision framework, the panel came to a consensus on eight recommendations regarding the role of endoscopic surveillance in patients with BE. They provided a conditional recommendation supporting surveillance for patients with nondysplastic BE, as well as for the use of daily proton pump inhibitor therapy compared with no therapy and with anti-reflux surgery to prevent disease progression. For patients with columnar-lined esophagus under 1 cm, endoscopic surveillance was not recommended. However, the panel strongly recommended a combination of high-definition white light endoscopy and chromoendoscopy versus white light endoscopy alone. No recommendation was made on the use of enhanced sampling techniques, such as wide area transepithelial sampling.
High-quality endoscopy, sampling using a structured biopsy protocol, and pathologist confirmation of BE-related dysplasia were noted as important elements in BE surveillance. Also, providers should participate in shared decision-making with patients based upon their preferences, noted Sachin Wani, MD, (Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora) and panel colleagues.
“Each recommendation in this guideline is accompanied by implementation considerations or qualifying remarks that should be considered an integral part of the recommendation statement and should not be omitted. Although no single recommendation can encompass every individual circumstance and context, it can be used to address the benefits and harms of treatments and support the processes of shared decision-making based on patients’ values and preferences,” wrote Dr. Wani and colleagues.
They performed a comprehensive search of systematic reviews and meta-analyses addressing BE screening, surveillance, and treatment outcomes from the PubMed, Embase, and Cochrane Library databases. The search was expanded to the MEDLINE database when initial inclusion criteria were not met. Evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation framework (GRADE). Clinical questions and outcomes were prioritized based on their relevance for clinicians and patients. The target population included adults with histologically confirmed BE—characterized by specialized intestinal metaplasia extending at least 1 cm above the gastroesophageal junction—and individuals at increased risk, including those with chronic gastroesophageal reflux disease, obesity, and a family history of esophageal adenocarcinoma.
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Source: Gastroenterology
