Faculty Bibliography

Introduction: Barrett's esophagus (BE) is a known precursor to esophageal adenocarcinoma. Endoscopic guidelines for BE and esophageal dysplasia (ED), rely on random four-quadrant forceps biopsies (FB) obtained every 1-2 cm in the BE segment, and are subject to sampling error. Wide area transepithelial brush biopsy combined with 3 dimensional computer image analysis of the sample (WATS^3D) previously has been shown to provide incremental value as an adjunct to FB in the detection of both BE and ED. Aims & Methods: A prospective multi-center, community-based trial utilizing WATS^3D testing was conducted during the period 2012-2014. Patents with symptoms of reflux, suspected BE, and known BE undergoing surveillance for ED were enrolled. A specially designed transepithelial WATS^3D biopsy brushes for tissue sampling in addition to forceps biopsies (FB) during the same endoscopy. WATS^3D and FB samples were sent to a central laboratory for analysis. In contrast to the standard 2 micron cut tissue slice, WATS^3D biopsy specimens also include an uncut direct smear of up to 150 microns in thickness to better capture the natural three dimensional appearance of the glandular tissue. Laboratory analysis of this uniquely thick tissue sample is aided by a computer based image processing system that integrates into a single three dimensional image information taken from up to 150 separate one micron focal planes. This information is then automatically reviewed by the systems image processing algorithms and neural networks which select and display to the pathologist the most suspicious cells that are found in every focal plane of the entire WATS^3D specimen. Results: There were 4203 patients enrolled in the study with adequate FB and WATS^3D specimens. The medianage was 59 yr with 43% being males. BE was diagnosed in 594 patients by FB and in 799 patients byWATS^3D. Of these 799 patients, 493 had no BE seen on FB. Thus, the addition WATS^3D tothe standard forceps biopsy protocol increased the detection of BE by 83.0% (493/594; 95%confidence interval 74%493%), This added detection of BE in 12% (493/ 4203) of all patients testedwith WATS^3D results in a number of patients needed to test (NNT) to obtain one additional BEpatient of 8.53. Esophageal dysplasia was diagnosed in 26 patients by FB and in 33 patients byWATS^3D. Of these 33 patients, 23 had no ED on FB. Thus, the addition of WATS^3D to the standardforceps biopsy protocol increased ED detection by 88.5% (23/26; 95% confidenceinterval 48%4160%). This augmented ED detection in 0.5% (23/4203) of all screening patients testedwith WATS^3D, results in an NNT to obtain one additional ED case of 182.7. There were no adverse events which resulted from use of WATS^3D. Conclusion: This multi-center trial demonstrates the benefit of WATS^3D use in daily community-based endoscopic practice. These results underscore previous data demonstrating the adjunctive benefit of adding WATS^3D to FB for augmented detection of both Barrett's metaplasia and dysplasia. (Table Presented)

OBJECTIVES: The histopathological diagnosis of Barrett's esophagus (BE)-associated dysplasia has poor inter-observer agreement. The wide-area transepithelial sampling (WATS) procedure uses a minimally invasive brush biopsy technique for acquiring wide-area sampling of BE tissue followed by computer-assisted analysis. In this study, our aim was to assess inter-observer agreement among pathologists in the diagnosis of Barrett's-associated dysplasia using the WATS computer-assisted analysis technique. METHODS: WATS slides with varying degrees of BE dysplasia were randomly selected and distributed to four pathologists. Each pathologist graded the slides as nondysplastic, low-grade dysplasia (LGD), or high-grade dysplasia/esophageal adenocarcinoma (HGD/EAC) and completed a standardized case report form (CRF) for each slide. RESULTS: In all, 149 BE slides were evaluated in a blinded manner by 4 pathologists. The slides included the following: no dysplasia (n=109), LGD, and HGD/EAC (n=40). The overall mean kappa value for all 3 diagnoses for the 4 observers was calculated at 0.86 (95% confidence interval (CI) 0.75-0.97). The kappa values (95% CI) for HGD/EAC, IND/LGD, and no dysplasia were 0.95 (0.88-0.99), 0.74 (0.61-0.85), and 0.88 (0.81-0.94), respectively. CONCLUSIONS: The diagnosis of BE and associated dysplasia using the WATS technique has very high inter-observer agreement. This appears to be significantly higher as compared with previously published data using standard histopathology.

BACKGROUND AND STUDY AIMS: Although colonoscopy is the "gold standard" for colorectal cancer screening, a significant number of adenomas are still missed during standard colonoscopy, often because they are hidden behind colonic folds and flexures. The aim of this study was to assess the ability of a novel balloon colonoscope (G-EYE endoscope; Smart Medical Systems, Ra'anana, Israel) to increase adenoma detection and reduce the miss rate compared with standard colonoscopy. PATIENTS AND METHODS: This was a multicenter, randomized, prospective, controlled study in patients (age >/= 40 years) undergoing colonoscopy for screening or diagnostic work-up (including surveillance). Patients underwent same-day, back-to-back tandem colonoscopy. Patients in Group A underwent standard colonoscopy followed by balloon colonoscopy, and patients in Group B underwent balloon colonoscopy followed by the standard technique. The adenoma detection and miss rates were compared between the two colonoscopy procedures. RESULTS: A total of 126 patients were enrolled and randomized into Group A (n = 60) or Group B (n = 66). The adenoma miss rate of balloon colonoscopy was significantly lower than that of standard colonoscopy (7.5 % vs. 44.7 %; P = 0.0002). The detection of additional adenomas by balloon colonoscopy was significant (81.0 %; P = 0.0002), in particular, the relative amount of adenomas detected in the ascending colon by balloon colonoscopy was 41 % versus 14 % for standard colonoscopy. CONCLUSIONS: A novel balloon colonoscopy technique detected significantly more adenomas than standard colonoscopy, and missed fewer adenomas. Balloon colonoscopy has the potential to increase the effectiveness of colorectal cancer screening and surveillance colonoscopy.

Portal hypertensive gastropathy (PHG) is a painless condition of gastric mucosal ectasia and impaired mucosal defense, commonly seen in patients with elevated portal pressures. While it is typically asymptomatic and incidentally discovered on upper endoscopy, acute and chronic bleeding may occur. There are no definitive recommendations for treatment of asymptomatic PHG. Non-selective beta-blockers represent the mainstay of therapy for chronic bleeding, while somatostatin and vasopressin and their derivatives may be used in conjunction with supportive measures for acute bleeding. Salvage therapy with transjugular intrahepatic portosystemic shunt or rarely surgical shunt is appropriate when medical management fails. The role of endoscopic therapy for PHG is controversial. Liver transplantation should be considered as a final resort in cases of refractory bleeding due to PHG.