ObjectiveRadiofrequency ablation (RFA)±endoscopic resection (ER) is the preferred treatment for early neoplasia in Barrett’s oesophagus (BE). We aimed to report short-term and long-term outcomes for all 1384 patients treated in the Netherlands (NL) from 2008 to 2018, with uniform treatment and follow-up (FU) in a centralised setting.DesignEndoscopic therapy for early BE neoplasia in NL is centralised in nine expert centres with specifically trained endoscopists and pathologists that adhere to a joint protocol. Prospectively collected data are registered in a uniform database. Patients with low/high-grade dysplasia or low-risk cancer, were treated by ER of visible lesions followed by trimonthly RFA sessions of any residual BE until complete eradication of BE (CE-BE). Patients with ER alone were not included.ResultsAfter ER (62% of cases; 43% low-risk cancers) and median 1 circumferential and 2 focal RFA (p25-p75 0–1; 1–2) per patient, CE-BE was achieved in 94% (1270/1348). Adverse events occurred in 21% (268/1386), most commonly oesophageal stenosis (15%), all were managed endoscopically. A total of 1154 patients with CE-BE were analysed for long-term outcomes. During median 43 months (22–69) and 4 endoscopies (1–5), 38 patients developed dysplastic recurrence (3%, annual recurrence risk 1%), all were detected as endoscopically visible abnormalities. Random biopsies from a normal appearing cardia showed intestinal metaplasia (IM) in 14% and neoplasia in 0%. A finding of IM in the cardia was reproduced during further FU in only 33%, none progressed to neoplasia. Frequent FU visits in the first year of FU were not associated with recurrence risk.ConclusionIn a setting of centralised care, RFA±ER is effective for eradication of Barrett’s related neoplasia and has remarkably low rates of dysplastic recurrence. Our data support more lenient FU intervals, with emphasis on careful endoscopic inspection. Random biopsies from neosquamous epithelium and cardia are of questionable value.Netherlands trial register numberNL7039.

Objective The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett’s esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed inNL. Design We retrospectively assessed ESD outcomes in NL, where treatment for BE neoplasia is centralized in 9 expert centers with jointly trained endoscopists and pathologists, and treatment/follow-up data collected in a joint database. ESD is restricted for selected cases. Results During median 121 minutes (p25-p75 90-180), 130 complete ESDs were performed with 97% (126/130) removed en-bloc. Pathology was HGD (5%), T1a-EAC (43%) or T1b-EAC (52%; 19%sm1, 33%≥sm2). The combined en-bloc and R0 rate was 87% [95%-CI 77-94%] for HGD/T1a-EAC and 49% [37-62%] for T1b-EAC. Upon R1 resection, 29% had residual cancer, in all cases detected at first follow-up endoscopy, while the remaining 71% had no residual cancer in esophagectomy specimen (n=6) or during median 9 months endoscopic FU (p25-p75 4-22) (n=18). Upon R0 resection, local recurrence rate during median 17 months (8-30) was 0% [0-5%]. Adverse events: 1% perforation [0-4%], 3% post-procedural bleeding [1-7%], 13% strictures [8-20%]. Conclusion In expert hands, ESD is safe and allows for removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter is, however, associated with a positive deep resection margin in half of the patients, yet only one third had actual persisting neoplasia at endoscopic FU. To better stratify R1-patients with an indication for additional surgery, repeat endoscopy after healing of the ESD wound may help in predicting residual cancer.

Background and study aims Optimal management for patients with low-grade dysplasia (LGD) in Barrett’s esophagus (BE) is unclear. According to our national guideline, all patients with LGD with histologic confirmation of the diagnosis by an expert pathologist (i.e. “confirmed LGD”), are referred for a dedicated re-staging endoscopy in an expert center. We aimed to assess the diagnostic value of re-staging endoscopy by an expert endoscopist for patients with confirmed LGD. Methods In this retrospective cohort study, we included all patients with flat BE diagnosed in a community center who had confirmed LGD and were referred to one of the nine Barrett expert centers (BEC) in the Netherlands. Primary outcome was the proportion of patients with prevalent high-grade dysplasia (HGD) or cancer during re-staging in a BEC. Results Of the 248 patients with confirmed LGD, re-staging in the BEC revealed HGD or cancer in 23% (57/248). In 79% (45/57), HGD or cancer in a newly detected visible lesion was diagnosed. Of the remaining patients, re-staging in the BEC showed a second diagnosis of confirmed LGD in 68% (168/248), while the remaining 9% (23/248) had non-dysplastic BE. Conclusion One quarter of patients with apparent flat BE with confirmed LGD diagnosed in a community hospital turns out to have prevalent HGD or cancer after re-staging in an expert center. This endorses the advice to refer patients with confirmed LGD – also in the absence of visible lesions – to an expert center for re-staging endoscopy.

Background and aims Current surveillance for Barrett’s esophagus (BE), consisting of 4-quadrant random forceps biopsy (FB), has an inherent risk of sampling error. Wide-Area Transepithelial Sampling (WATS) may increase detection of high-grade dysplasia (HGD) and adenocarcinoma (EAC). In this multicenter, randomized trial, we aimed to evaluate WATS as a substitute for FB. Methods Patients with known BE and a recent history of dysplasia, without visible lesions, at 17 hospitals were randomized to receive either WATS followed by FB or vice-versa. All WATs samples were examined, with computer assistance, by at least two experienced pathologists at the CDx Laboratory. Similarly, all FBs were examined by two expert pathologists. The primary endpoint was concordance/disconcordance for detection of HGD/EAC between both techniques. Results 172 patients were included. Of these, 21 had HGD/EAC detected with both modalities, 18 other had HGD/EAC detected by WATS, but missed with FB and 12 were detected by FB but missed by WATS. The detection rate of HGD/EAC did not differ between WATS and FB (p=0.36). Utilizing WATS as an adjunct to FB significantly increased detection of HGD/EAC vs FB alone (absolute increase 10% [95%-CI: 6-16%]). Mean procedural times in minutes for FB alone, WATS alone, and the combination were 6.6 (95% CI:5.9-7.1), 4.9 (95% CI:4.1-5.4), and 11.2 (95%-CI:10.5-14.0) respectively.. Conclusions Although the combination of WATS and FB increases dysplasia detection in a population of BE patients enriched for dysplasia, we did not find a statistically significant difference between WATS and FB for detection of HGD/EAC as single modality.