Endoscopic screening for Barrett’s esophagus: while we’re in, do we also need to see the stomach and the duodenum?

In this issue of Endoscopy International Open, the Mayo Clinic team of Dr. Iyer Prasad published a comparative quality assessment of the endoscopy videos recorded in their previous published work on Barrett esophagus screening [1] [2]. Their initial work compared the yield of 2 different endoscopic examinations: unsedated transnasal esophagoscopy (uTNE) and sedated esophago-gastro-duodenoscopy (sEGD).

In uTNE, the tube is covered with a single-use plastic sheath that makes sterilization between procedures unnecessary (Endosheath, TNE-5000, Vision Sciences, Orangeburg, NY, USA). The endoscope’s sheath has an outer parallel biopsy channel made from the same material. Due to its short length, it can only examine the esophagus. In sEGD, a standard high-definition 9.8-m endoscope (GIF-180, Olympus America, Center Valley, PA, USA) is used.

Transnasal esophagoscopy (TNE) was used both in hospital (huTNE) and in a community setting through a specially designed mobile research vehicle (muTNE). Esophago-gastro-duodenoscopy (EGD) was used in hospital. The screening population consisted of individuals aged older than 50, with or without gastroesophageal reflux disease (GERD) symptoms.

The conclusion of the first study [1] was that both hospital and mobile van uTNE screening had comparable clinical effectiveness to sEGD (complete examination of the esophagus in 96 % to 100 % of cases, and similar participation rates [40 % to 45 %] and safety profile). Mean recovery time with uTNE was significantly shorter compared to sEGD (15 minutes versus 1 hour). Rates of successful biopsy acquisition were significantly lower in the uTNE groups compared to sEGD due to inability to advance the TNE scope with the biopsy sheath through narrow nasal passages and patient intolerance (80 % versus 100 %), but switching to a smaller sheath allowed subsequent esophageal examination [1] [3]. Esophagitis was diagnosed in 32 % and Barrett esophagus in 8 % of screened individuals [1].

The current study [2] published in Endoscopy International Open expands upon the previous findings and concludes that the overall quality and gastroesophageal junction visualization of uTNE and sEGD are comparable.

To better understand the big picture in which this paper appears, we need to ask ourselves a few questions.

• References

• 1 Crews NR, Gorospe EC, Johnson ML. et al. Comparative quality assessment of esophageal examination with transnasal and sedated endoscopy. Endoscopy International Open 2017; 05: E340-E344
• 2 Sami SS, Dunagan KT, Johnson ML. et al. A randomized comparative effectiveness trial of novel endoscopic techniques and approaches for Barrett's esophagus screening in the community. Am J Gastroenterol 2015; 110: 148-158
• 3 Sami SS, Ragunath K, Iyer PG. Response to Syed et al. Am J Gastroenterol 2015; 110: 937-938
• 4 ASGE guidelines. The role of endoscopy in Barrett’s esophagus and other premalignant conditions of the esophagus. Gastrointestinal Endoscopy: 2012 76. 1087-1094
• 5 Fitzgerald RC, di Pietro M, Ragunath K. et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's esophagus. Gut 2014; 63: 7-42
• 6 Shaheen NJ, Falk GW, Iyer PG. et al. ACG Clinical Guideline: Diagnosis and Management of Barrett's Esophagus. Am J Gastroenterol 2016; 111: 30-50
• 7 Lin OS, Schembre DB, Mergener K. et al. Blinded comparison of esophageal capsule endoscopy versus conventional endoscopy for a diagnosis of Barrett’s esophagus in patients with chronic gastroesophageal reflux. Gastrointest Endosc 2007; 65: 577-583
• 8 Galmiche JP, Sacher-Huvelin S, Coron E. et al. Screening for esophagitis and Barrett’s esophagus with wireless esophageal capsule endoscopy: a multicenter prospective trial in patients with reflux symptoms. Am J Gastroenterol 2008; 103: 538-555
• 9 Ramirez FC, Akins R, Shaukat M. Screening of Barrett’s esophagus with string- capsule endoscopy: a prospective blinded study of 100 consecutive patients using histology as the criterion standard. Gastrointest Endosc 2008; 68: 25-31
• 10 Paterson AL, Lao-Sirieix P, O'Donovan M. et al. Range of pathologies diagnosed using a minimally invasive capsule sponge to evaluate patients with reflux symptoms. Histopathology 2017; 70: 203-210
• 11 Jobe BA, Hunter JG, Chang EY. et al. Office-based unsedated small-caliber endoscopy is equivalent to conventional sedated endoscopy in screening and surveillance for Barrett's esophagus: a randomized and blinded comparison. Am J Gastroenterol 2006; 101: 2693-2703
• 12 Shariff MK, Bird-Lieberman EL, O'Donovan M. et al. Randomized crossover study comparing efficacy of transnasal endoscopy with that of standard endoscopy to detect Barrett's esophagus. Gastrointest Endosc 2012; 75: 954-961
• 13 ASGE status evaluation report. Equipment for pediatric endoscopy. Gastrointestinal Endoscopy; 2012 76. 8-17
• 14 Sami SS, Subramanian V, Ortiz-Fernández-Sordo J. et al. Performance characteristics of unsedated ultrathin video endoscopy in the assessment of the upper GI tract: systematic review and meta-analysis. Gastrointest Endosc 2015; 82: 782-792
• 15 Roman LD, Lukyanchuk R, Sablin OA. et al. Prevalence of H. pylori Infection and Atrophic Gastritis in a Population-based Screening with Serum Biomarker Panel (GastroPanel^®) in St. Petersburg. Anticancer Res 2016; 36: 4129-4138
• 16 Dinis-Ribeiro M, Areia M, de Vries AC. et al. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy 2012; 44: 74-94
• 17 Zagari RM, Eusebi LH, Rabitti S. et al. Prevalence of upper gastrointestinal endoscopic findings in the community: A systematic review of studies in unselected samples of subjects. J Gastroenterol Hepatol 2016; 31: 1527-1538
• 18 Rubenstein JH, Inadomi JM, Scheiman J. et al. Association between Helicobacter pylori and Barrett's esophagus, erosive esophagitis, and gastroesophageal reflux symptoms. Clin Gastroenterol Hepatol 2014; 12: 239-245
• 19 Tahergorabi Z, Khazaei M, Moodi M. et al. From obesity to cancer: a review on proposed mechanisms. Cell Biochem Funct 2016; 34: 533-545