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High Proportions of Newly Detected Visible Lesions and Pathology Grade Change Among Patients with Barrett’s Esophagus Referred to Expert Centers

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Abstract

Background and Aims

Endoscopic eradication therapy for Barrett’s esophagus (BE)-related neoplasia is increasingly being performed at tertiary and community centers. While it has been suggested that these patients should be evaluated at expert centers, the impact of this practice has not been evaluated. We aimed to assess the impact of referral of BE-related neoplasia patients to expert centers by assessing the proportion of patients with change in pathological diagnosis and visible lesions detected.

Methods

Multiple databases were searched until December 2021 for studies of patients with BE referred from the community to expert center. The proportions of pathology grade change and newly detected visible lesions at expert centers were pooled using a random-effects model. Subgroup analyses were performed based on baseline histology and other relevant factors.

Results

Twelve studies were included (1630 patients). The pooled proportion of pathology grade change after expert pathologist review was 47% (95% CI 34–59%) overall and 46% (95% CI 31–62%) among patients with baseline low-grade dysplasia. When upper endoscopy was repeated at an expert center, the pooled proportion of pathology grade change was still high 47% (95% 26–69%) overall and 40% (95% CI 34–45%) among patients with baseline LGD. The pooled proportion of newly detected visible lesions was 45% (95% CI 28–63%) and among patients referred with LGD was 27% (95% CI 22–32%).

Conclusion

An alarmingly high proportion of newly detected visible lesions and pathology grade change were found when patients were referred to expert centers supporting the need for centralized care for BE-related neoplasia patients.

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Data availability

Data, analytic methods, and study materials will be made available to the editorial board and reviewers.

Abbreviations

BE:

Barrett’s esophagus

CI:

Confident interval

EET:

Endoscopic eradication therapy

EAC:

Esophageal adenocarcinoma

HGD:

High-grade dysplasia

LGD:

Low-grade dysplasia

NDBE:

Non-dysplastic Barrett’s esophagus

PEEN:

Post-endoscopy esophageal neoplasia

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

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Acknowledgments

We would like to thank Larry Prokop from the Mayo Clinic, Rochester for the literature search.

Funding

None.

Author information

Author notes

  1. Sachin Wani and Tarek Sawas are co-senior authors.

Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

    Christian Davis & Sachin Wani

  2. Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA

    Andrew Fuller

  3. Division of Gastroenterology and Hepatology, Columbia University, New York, NY, USA

    David Katzka

  4. Division of Digestive and Liver Diseases, University of Texas Southwestern, 1801 Inwood Rd Ste 6-102, Dallas, TX, 75235, USA

    Tarek Sawas

Authors
  1. Christian Davis
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Contributions

Study concept and design: TS, DAK, and SW. Acquisition of data: TS, AF, and CD. Statistical analysis: TS. Data interpretation: TS, AF, CD, DAK, and SW. Drafting of the manuscript: TS, AF, CD, DAK, and SW. Critical revision of the manuscript for important intellectual content: TS, DAK, and SW.

Corresponding author

Correspondence to Tarek Sawas.

Ethics declarations

Conflict of interest

Tarek Sawas, Andrew Fuller, and Christian Davis: None. David A. Katzka was consultant for Celgene and Regeneron. Sachin Wani received funding from the National Institutes of Health (NIH)/National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)—U34-DK124174, U01DK129191, was consultant for Exact Sciences and Castle Biosciences, and received research support from Lucid, Ambu, and CDx Diagnostics.

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Appendix 1

Appendix 1

Ovid

Database(s): EBM Reviews—Cochrane Central Register of Controlled Trials November 2021, Embase 1974 to 2021 December 17, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process, In-Data Review & Other Non-Indexed Citations, and Daily 1946 to December 17, 2021.

Search Strategy:

#

Searches

Results

1

exp Barrett Esophagus/

26,638

2

(((barrett or barretts) and (esophagus or oesophagus or syndrome or epithelium or metaplasia*)) or ((esophag* or oesophag*) adj3 adenocarcinoma*) or ((esophag* or oesophag*) and “low grade dysplasia*”)).ti,ab,kw

40,693

3

1 or 2

45,589

4

exp “Referral and Consultation”/

215,891

5

(downstag* or referral* or referred or upstag*).ti,ab,kw

886,698

6

4 or 5

987,985

7

3 and 6

2388

8

exp Community Health Services/

473,410

9

(BERU* or Community or expert* or “referral center*” or “referral centre*” or “referral unit*”).ti,ab,kw

1,873,457

10

8 or 9

2,222,880

11

7 and 10

837

12

(exp animals/or exp nonhuman/) not exp humans/

11,634,841

13

((alpaca or alpacas or amphibian or amphibians or animal or animals or antelope or armadillo or armadillos or avian or baboon or baboons or beagle or beagles or bee or bees or bird or birds or bison or bovine or buffalo or buffaloes or buffalos or “c elegans” or “Caenorhabditis elegans” or camel or camels or canine or canines or carp or cats or cattle or chick or chicken or chickens or chicks or chimp or chimpanze or chimpanzees or chimps or cow or cows or “D melanogaster” or “dairy calf” or “dairy calves” or deer or dog or dogs or donkey or donkeys or drosophila or “Drosophila melanogaster” or duck or duckling or ducklings or ducks or equid or equids or equine or equines or feline or felines or ferret or ferrets or finch or finches or fish or flatworm or flatworms or fox or foxes or frog or frogs or “fruit flies” or “fruit fly” or “G mellonella” or “Galleria mellonella” or geese or gerbil or gerbils or goat or goats or goose or gorilla or gorillas or hamster or hamsters or hare or hares or heifer or heifers or horse or horses or insect or insects or jellyfish or kangaroo or kangaroos or kitten or kittens or lagomorph or lagomorphs or lamb or lambs or llama or llamas or macaque or macaques or macaw or macaws or marmoset or marmosets or mice or minipig or minipigs or mink or minks or monkey or monkeys or mouse or mule or mules or nematode or nematodes or octopus or octopuses or orangutan or “orang-utan” or orangutans or “orang-utans” or oxen or parrot or parrots or pig or pigeon or pigeons or piglet or piglets or pigs or porcine or primate or primates or quail or rabbit or rabbits or rat or rats or reptile or reptiles or rodent or rodents or ruminant or ruminants or salmon or sheep or shrimp or slug or slugs or swine or tamarin or tamarins or toad or toads or trout or urchin or urchins or vole or voles or waxworm or waxworms or worm or worms or xenopus or “zebra fish” or zebrafish) not (human or humans or patient or patients)).ti,ab,hw,kw

9,966,600

14

11 not (12 or 13)

837

15

(case adj3 report).mp,pt

3,299,164

16

“in vivo”.mp

2,282,152

17

review.pt

5,741,942

18

14 not (15 or 16 or 17)

761

19

limit 18 to (letter or editorial or erratum or note or addresses or autobiography or bibliography or biography or blogs or comment or dictionary or directory or interactive tutorial or interview or lectures or legal cases or legislation or news or newspaper article or overall or patient education handout or periodical index or portraits or published erratum or video-audio media or webcasts) [Limit not valid in CCTR,Embase,Ovid MEDLINE(R),Ovid MEDLINE(R) Daily Update,Ovid MEDLINE(R) PubMed not MEDLINE,Ovid MEDLINE(R) In-Process,Ovid MEDLINE(R) Publisher; records were retained]

7

20

18 not 19

754

21

remove duplicates from 20

557

Scopus

  1. 1.

    TITLE-ABS-KEY(((barrett or barretts) and (esophagus or oesophagus or syndrome or epithelium or metaplasia*)) OR ((esophag* or oesophag*) W/3 adenocarcinoma*) OR ((esophag* or oesophag*) and “low grade dysplasia*”))

  2. 2.

    TITLE-ABS-KEY(downstag* OR referral* OR referred OR upstag*)

  3. 3.

    TITLE-ABS-KEY(BERU* OR Community OR expert* OR “referral center*” OR “referral centre*” OR “referral unit*”)

  4. 4.

    1 and 2 and 3

  5. 5.

    TITLE-ABS-KEY((alpaca OR alpacas OR amphibian OR amphibians OR animal OR animals OR antelope OR armadillo OR armadillos OR avian OR baboon OR baboons OR beagle OR beagles OR bee OR bees OR bird OR birds OR bison OR bovine OR buffalo OR buffaloes OR buffalos OR “c elegans” OR “Caenorhabditis elegans” OR camel OR camels OR canine OR canines OR carp OR cats OR cattle OR chick OR chicken OR chickens OR chicks OR chimp OR chimpanze OR chimpanzees OR chimps OR cow OR cows OR “D melanogaster” OR “dairy calf” OR “dairy calves” OR deer OR dog OR dogs OR donkey OR donkeys OR drosophila OR “Drosophila melanogaster” OR duck OR duckling OR ducklings OR ducks OR equid OR equids OR equine OR equines OR feline OR felines OR ferret OR ferrets OR finch OR finches OR fish OR flatworm OR flatworms OR fox OR foxes OR frog OR frogs OR “fruit flies” OR “fruit fly” OR “G mellonella” OR “Galleria mellonella” OR geese OR gerbil OR gerbils OR goat OR goats OR goose OR gorilla OR gorillas OR hamster OR hamsters OR hare OR hares OR heifer OR heifers OR horse OR horses OR insect OR insects OR jellyfish OR kangaroo OR kangaroos OR kitten OR kittens OR lagomorph OR lagomorphs OR lamb OR lambs OR llama OR llamas OR macaque OR macaques OR macaw OR macaws OR marmoset OR marmosets OR mice OR minipig OR minipigs OR mink OR minks OR monkey OR monkeys OR mouse OR mule OR mules OR nematode OR nematodes OR octopus OR octopuses OR orangutan OR “orang-utan” OR orangutans OR “orang-utans” OR oxen OR parrot OR parrots OR pig OR pigeon OR pigeons OR piglet OR piglets OR pigs OR porcine OR primate OR primates OR quail OR rabbit OR rabbits OR rat OR rats OR reptile OR reptiles OR rodent OR rodents OR ruminant OR ruminants OR salmon OR sheep OR shrimp OR slug OR slugs OR swine OR tamarin OR tamarins OR toad OR toads OR trout OR urchin OR urchins OR vole OR voles OR waxworm OR waxworms OR worm OR worms OR xenopus OR “zebra fish” OR zebrafish) AND NOT (human OR humans or patient or patients))

  6. 6.

    4 and not 5

  7. 7.

    TITLE-ABS-KEY((case W/3 report) OR “in vivo”)

  8. 8.

    6 and not 7

  9. 9.

    DOCTYPE(le) OR DOCTYPE(ed) OR DOCTYPE(bk) OR DOCTYPE(er) OR DOCTYPE(no) OR DOCTYPE(sh)

  10. 10.

    8 and not 9

  11. 11.

    INDEX(embase) OR INDEX(medline) OR PMID(0* OR 1* OR 2* OR 3* OR 4* OR 5* OR 6* OR 7* OR 8* OR 9*)

  12. 12.

    10 and not 11

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Davis, C., Fuller, A., Katzka, D. et al. High Proportions of Newly Detected Visible Lesions and Pathology Grade Change Among Patients with Barrett’s Esophagus Referred to Expert Centers. Dig Dis Sci 68, 3584–3595 (2023). https://doi.org/10.1007/s10620-023-07968-4

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