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Endoscopic management of Barrett s esophagus: European ...

Endoscopic management of Barrett s esophagus: EuropeanSociety of gastrointestinal endoscopy (ESGE) Position StatementAuthorsBas Weusten1,2, Raf Bisschops3, Emanuel Coron4,M rioDinis-Ribeiro5, Jean-Marc Dumonceau6, Jos -Miguel Esteban7,CesareHassan8,OliverPech9, Alessandro Repici10,JacquesBergman2,Massimiliano di Pietro11 Institutions1 Department of Gastroenterology and Hepatology, St. AntoniusHospital, Nieuwegein, The Netherlands2 Department of Gastroenterology and Hepatology, AcademicMedical Center, Amsterdam, The Netherlands3 Department of Gastroenterology, University Hospital Leuven,Leuven, Belgium4 Institut des Maladies de l Appareil Digestif, CHU and University,Nantes, France5 Department of Gastroenterology, Portuguese OncologyInstitute-Porto, Porto, Portugal6 Gedyt endoscopy Center, Buenos Aires, Argentina7 Department of endoscopy , Hospital Clinico San Carlos, Madrid,Spain8 Department of Gastroenterology, Nuovo Regina MargheritaHospital, Rome, Italy9 Department of Gastroenterology and InterventionalEndoscopy, St.

burden on gastrointestinal (GI) endoscopy facilities and health care resources might therefore be reduced. In developing this Statement, we focused on issues that were directly relevant to endoscopy practice. Hence, other is-sues, such as chemoprevention for progression of BE or the use of biomarkers for prediction of progression in BE, are not

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1 Endoscopic management of Barrett s esophagus: EuropeanSociety of gastrointestinal endoscopy (ESGE) Position StatementAuthorsBas Weusten1,2, Raf Bisschops3, Emanuel Coron4,M rioDinis-Ribeiro5, Jean-Marc Dumonceau6, Jos -Miguel Esteban7,CesareHassan8,OliverPech9, Alessandro Repici10,JacquesBergman2,Massimiliano di Pietro11 Institutions1 Department of Gastroenterology and Hepatology, St. AntoniusHospital, Nieuwegein, The Netherlands2 Department of Gastroenterology and Hepatology, AcademicMedical Center, Amsterdam, The Netherlands3 Department of Gastroenterology, University Hospital Leuven,Leuven, Belgium4 Institut des Maladies de l Appareil Digestif, CHU and University,Nantes, France5 Department of Gastroenterology, Portuguese OncologyInstitute-Porto, Porto, Portugal6 Gedyt endoscopy Center, Buenos Aires, Argentina7 Department of endoscopy , Hospital Clinico San Carlos, Madrid,Spain8 Department of Gastroenterology, Nuovo Regina MargheritaHospital, Rome, Italy9 Department of Gastroenterology and InterventionalEndoscopy, St.

2 John of God Hospital, Regensburg, Germany10 Department of Gastroenterology, Humanitas ResearchHospital, Humanitas University, Milano, Italy11 MRC Cancer Unit, University of Cambridge, Cambridge, UnitedKingdomBibliographyDOI online: 2017 Georg Thieme Verlag KG Stuttgart New YorkISSN 0013-726 XCorresponding authorBas L. A. M. Weusten, MD, PhD, Department of Gastroenterologyand Hepatology, St. Antonius Hospital Nieuwegein, Koekoekslaan 1,3435CM Nieuwegein, The NetherlandsFax: practices for the management of Barrett s esophagus (BE)vary across Europe, as several national European guidelines Position Statement from the European Society of Gastrointesti-nal endoscopy (ESGE) is an attempt to homogenize recommenda-tions and, hence, patient management according to the best scien-tific evidence and other considerations ( health policy). A Work-ing Group developed consensus statements, using the existing na-tional guidelines as a starting point and considering new evidencein the literature.

3 The Position Statement wishes to contribute to amore cost-effective approach to the care of patients with BE by re-ducing the number of surveillance endoscopies for patients with alow risk of malignant progression and centralizing care in expertcenters for those with high progression STATEMENTSMS1 The diagnosis of BE is made if the distal esophagus is linedwith columnar epithelium with a minimum length of 1cm (tonguesor circular) containing specialized intestinal metaplasia at histopa-thological ESGE recommends varying surveillance intervals for dif-ferent BE lengths. For patients with an irregular Z-line/columnar-lined esophagus of <1cm, no routine biopsies or Endoscopic sur-veillance is advised. For BE 1cm and <3cm, BE surveillance shouldbe repeated every 5 years. For BE 3cm and <10cm, the interval forendoscopic surveillance should be 3 years. Patients with BE with amaximum extent 10cm should be referred to a BE expert centerfor surveillance endoscopies.

4 Patients with limited life expectancyand advanced age should be discharged from Endoscopic diagnosis of any degree of dysplasia (including indefinitefor dysplasia ) in BE requires confirmation by an expert gastrointes-tinal with visible lesions in BE diagnosed as dysplasia orearly cancer should be referred to a BE expert center. All visible ab-normalities, regardless of the degree of dysplasia, should be re-moved by means of Endoscopic resection techniques in order to ob-tain optimal histopathological stagingMS5 All patients with a BE 10 cm, a confirmed diagnosis of lowgrade dysplasia, high grade dysplasia (HGD), or early cancer shouldbe referred to a BE expert center for surveillance and/or expert centers should meet the following criteria: annual caseload of 10 new patients undergoing Endoscopic treatment forHGD or early carcinoma per BE expert endoscopist; Endoscopic andhistological care provided by endoscopists and pathologists whohave followed additional training; at least 30 supervised endoscopicresection and 30 Endoscopic ablation procedures to acquire com-petence in technical skills, management pathways, and complica-tions.

5 Multidisciplinary meetings with gastroenterologists, sur-geons, oncologists, and pathologists to discuss patients with Bar-rett s neoplasia; access to experienced esophageal surgery; and allBE patients registered prospectively in a statementAppendix e1 e4 Online content viewable at: Bas et al. Endoscopic management of .. endoscopy 2017; 49 IntroductionBarrett s esophagus (BE) is a premalignant condition predispos-ing to esophageal adenocarcinoma (EAC). Although the risk ofcancer progression is low (estimated at about per year[1]), in most countries patients with BE are managed withendoscopic surveillance at regular intervals. However, currentpractices for the management of BE and EAC vary across Eur-ope, as several national European guidelines exist. The currentPosition Statement from the European Society of Gastrointesti-nal endoscopy (ESGE) is an attempt to homogenize recommen-dations and, hence, patient management according to the bestscientific evidence as well as other considerations ( healthpolicy).

6 The aim of this document, therefore, is to deliver avery practical guide, in the form of a Position Statement, evenwhen supporting evidence is weak [2].A secondary aim of the current Position Statement is to con-tribute to a more cost-effective approach to the care of patientswith BE, through reduction of the number of surveillance en-doscopies for patients with a low risk of malignant transforma-tion, and centralization of care for those with higher progres-sion rates. This was felt necessary because, although several re-cent reports indicate that the outcome of BE-associated EAC isimproved with Endoscopic surveillance of BE [3,4], the annualincidence of EAC among patients with BE is relatively low. Theburden on gastrointestinal (GI) endoscopy facilities and healthcare resources might therefore be developing this Statement, we focused on issues thatwere directly relevant to endoscopy practice. Hence, other is-sues, such as chemoprevention for progression of BE or theuse of biomarkers for prediction of progression in BE, are notpart of this Position , several national guidelines have been issued in Europefor the management of BE, either in international scientificjournals or as consensus statements distributed locally by na-tional societies.

7 These existing guidelines served as the startingpoint for the current Position Statement in order to take advan-tage of the discussions of the scientific literature performed bythe respective national BE guideline order to retrieve as many national European guidelines aspossible, an inquiry was sent to all national gastrointestinalendoscopy society members of the ESGE. Questions in the sur-vey were:1. Has your national society ever produced their own nationalguidelineonBE?Ifso,whenwasitwrit tenorpublished?2. Is there a particular guideline on BE that your society re-commends endoscopists follow?3. Which currently available guideline on BE do you think ismostly used by endoscopists in your country?4. Are you currently considering writing a national guideline onBE, or are you planning to revise your current guideline?The results of this inquiry are summarized in SupplementaryMaterial the results of this inquiry, four recent national guide-lines were selected based on year of publication and robustnessof methodology: the British Society of Gastroenterology (BSG)guidelines on the diagnosis and management of Barrett sesophagus [5], the German Society of Gastroenterology, Diges-tive and Metabolic Diseases (DGVS) guideline on gastroesopha-geal reflux disease (GERD), which includes recommendationsfor BE [6], the Italian Society ofDigestive endoscopy (SIED) con-sensus meeting on the diagnosis and management of BE (seeSupplementary Material 2), and the Dutch Guideline on BE fun-ded by the Dutch Quality Fund for Medical Specialists (SKMS; ; Supplementary Material 3, in Dutch only).

8 Members of the Working Group on the ESGE Position State-ment on the Endoscopic management of BE were selectedbased on their contribution to the included national guidelines,complemented by recognized experts on BE from other Euro-pean countries. All Working Group members are listed as con-tributing authors on this list of topics to be covered by the current Position State-ment was derived from the existing guidelines, and agreed onduring a teleconference of the Working Group members (seeSupplementary Material 4). Subsequently, all relevant state-ments of the four selected national guidelines were sortedinto a table, according to this list of topics. All Working Groupmembers where then asked to complete three additional col-umns containing the following questions:1. Are all recommendations from the four merging guidelinesin agreement (Yes/No, explain)?2. If Yes, do you personally agree (Yes/No, explain)?3. Are you aware of any new studies relevant for this issue (Yes/No, explain)?

9 ABBREVIATIONSBEB arrett sesophagusBSGB ritish Society of GastroenterologyDGVSD eutsche Gesellschaft f r Gastroenterologie,Verdauungs- und Stoffwechselkrankheiten(German Society of Gastroenterology, Digestiveand Metabolic Diseases)EACesophageal adenocarcinomaEMRendoscopic mucosal resectionESDendoscopic submucosal dissectionESGEE uropean Society of gastrointestinal EndoscopyGERD gastroesophageal reflux diseaseGIgastrointestinalHGDhigh grade dysplasiaIMintestinal metaplasiaLGDlow grade dysplasiaRFAradiofrequency ablationSIEDLaSociet ItalianadiEndoscopiaDigestiva(Italian Society of Digestive endoscopy )SKMSS tichting Kwaliteitsgelden Medisch Specialisten(Dutch Quality Fund for Medical Specialists)Weusten Bas et al. Endoscopic management of .. endoscopy 2017; 49 Position statementIn order to cover the gap between the time period covered bythe literature searches of the selected national guidelines andthe ESGE Position Statement, aMedline search was performedthrough PubMed for the period January 2013 November a consensus meeting, the statements of the existingnational guidelines were discussed.

10 In the case of discrepancybetween recommendations of the national guidelines, newstatements were generated based on a consensus agreementamong the Working Group members, supported by new litera-ture if available. Comments were added to the statements, ifnecessary, in order to: mention or discuss additional evidencearising from new literature; clarify the statement in case of par-tial agreement or disagreement among the four national guide-lines; highlight additional important insights of the workinggroup members; or a combination thereof. The manuscriptwas then sent to the ESGE Governing Board, member societies,and individual members for the current ESGE Position Statement on the endoscopicmanagement of BE was largely formed by merging the four ex-isting national guidelines, the reader is referred to these publi-cations for full lists of statement is followed by information on: Extent of agreement between the four constituent guide-lines Availability of new evidence Whether there is consensus between the Working Groupmembers on the current may be followed by additional Comments, as describedabove in the Methodology section.


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