White Paper AGA: Advanced Imaging in Barrett’s Esophagus

Abstract

Enhanced imaging technologies such as narrow band imaging, flexible spectral imaging color enhancement, i-Scan, confocal laser endomicroscopy, and optical coherence tomography are readily available for use by endoscopists in routine clinical practice. In November 2014, the American Gastroenterological Association's Center for GI Innovation and Technology conducted a 2-day workshop to discuss endoscopic image enhancement technologies, focusing on their role in 2 specific clinical conditions (colon polyps and Barrett's esophagus) and on issues relating to training and implementation of these technologies (white papers). Although the majority of the studies that use enhanced imaging technologies have been positive, these techniques ideally need to be validated in larger cohorts and in community centers. As it stands today, detailed endoscopic examination with high-definition white-light endoscopy and random 4-quadrant biopsy remains the standard of care. However, the workshop panelists agreed that in the hands of endoscopists who have met the preservation and incorporation of valuable endoscopic innovation thresholds (diagnostic accuracy) with enhanced imaging techniques (specific technologies), use of the technique in Barrett's esophagus patients is appropriate.

AGA White Paper: Training and Implementation of Endoscopic Image Enhancement Technologies

“…The first 2 papers covering the data and rationale for application of these technologies in colon polyps and Barrett's esophagus have already been published. 1,2 This white paper outlines a proposed framework for the implementation of endoscopic image-enhancement technologies in routine clinical practice ( Figure 1). Although this outline is not the only way these technologies could be implemented, we believe that this serves as a guide for those wanting to adopt these technologies in their current practice and as a foundation for future forward progress in the field.…”

“…This white paper, along with the 2 accompanying white papers on the use of endoscopic image-enhancement technologies for colon polyp management and Barrett's esophagus, provides additional guidance and addresses potential training and competency assessment issues associated with use of endoscopic image-enhancement technologies. 1,2 As the process moves forward, there will be an ongoing need for support from GI societies to help endoscopists implement these new technologies in practice through the assessment of evidence, creation of guidelines for use, establishing quality indicators, and assisting practitioners with training and implementation.…”

Novel insights into esophageal diagnostic procedures

“…However, CLE is not currently used in routine clinical practice. This may be due to high equipment costs, lack of reimbursement, additional necessary training for image interpretation, and the innate difficulty associated with performing targeted biopsies at the CLE‐visualized site . Further studies should be carried out on cost‐effectiveness, learning curves, and general applicability to determine its clinical efficacy.…”

Are we ready to move toward digital image interpretation in Barrett’s esophagus surveillance?

“…In the past decades, the incidence of esophageal adenocarcinoma has increased despite endoscopic surveillance programs based on random biopsies. The Seattle protocol allows less than 5% of tissue sampling in long-segment disease, 2 and it is commonly thought that an unknown number of lesions (HGD/EAC) in BE are missed during endoscopic procedures because of their subtle and invisible difference from nondysplastic BE, even with the use of high-definition endoscopy. This study, again, highlights the need of an endoscopic technology able to detect precancerous lesions in BE, thus overcoming the limitations of the Seattle biopsy protocol in BE surveillance.…”

“…Consequently, in 2015 the American Society for Gastrointestinal Endoscopy (ASGE) recommended limiting the use of image-enhanced endoscopic techniques to endoscopists who demonstrated the ability to consistently achieve the performance thresholds recommended by ASGE Preservation and Incorporation of Valuable endoscopic Innovations. 2 Volumetric laser endomicroscopy is a secondgeneration OCT that belongs to the realm of real-time high-resolution cross-sectional imaging techniques. This new system overcomes the problem of the small imaging surface of the first-generation OCT. As in all new technologies, high accuracy and interobserver and intraobserver agreement are mandatory, but in a previous study, the sensitivity (83%) and specificity (71%) of VLE with human-eye interpretation were suboptimal.…”