Confocal endomicroscopy (CEM) improves efficiency of Barrett surveillance

Abstract

Background: Endoscopists with extensive experience with confocal endomicroscopy (CEM) have demonstrated that this technology is useful for Barrett's esophagus (BE) surveillance. However, data on endoscopists with minimal experience with this technique are limited.

Hypothesis: For BE surveillance, an endoscopist with minimal experience in CEM-guided biopsy would achieve a similar diagnostic yield with fewer biopsies when compared to the random 4-quadrant biopsy protocol.

Objective: To compare the diagnostic yields of CEM-guided biopsy technique with the random 4-quadrant biopsy protocol.

Design: Randomized controlled trial.

Setting: Tertiary care center.

Patients: Patients with BE.

Methods: Out of 18 patients who underwent routine BE surveillance, 11 and 7 were randomly assigned to group A (CEM-guided) and to group B (random 4-quadrant biopsy), respectively. The pathologists were blinded to all clinical information.

Results: Mean length of endoscopic Barrett was similar in both groups, (5.1 vs. 6.3 cm, p=0.51). The diagnostic yields for detecting SIM (63.6% vs. 59.5%, p=0.5), low grade dysplasia (11. 6% vs. 11.2%, p=NS), high grade dysplasia (10.1% vs. 11.5%, p=0.88). Although the total number of individual mucosal biopsy performed were 52% lower in the CEM group (129 vs. 269), the overall diagnostic yield (85.3% vs. 82.2%, p=0.53) was similar in both groups.

Limitations: Small sample size.

Conclusions: For BE surveillance, limited data suggested that endoscopists with minimal experience in CEM can effective use this technology for "smart" biopsy to decrease the need for intense tissue sampling but without lowering the diagnostic yield in detecting dysplasia.

Keywords: Barrett's esophagus; confocal endomicroscopy.

Figure 1

CEM was performed at every 1–2 cm of BE in all 4 quadrants. Presence of BE by CEM in any or more quadrant (for example, in quadrants 2, 3 in B) was sampled by targeted biopsy and these biopsies were used for comparative analysis. The quadrants negative for BE by CEM were sampled by random biopsy (for example, quadrants 1 and 4 in C) at the completion of all CEM-guided biopsy but were excluded from primary analysis.

Figure 2

Randomization process.

Figure 3

A) Normal columnar epithelium without goblet cells; B) BE: goblet cells (black arrows) and narrow lumen (white arrow).

Figure 4

A)HGD: loss of basal border (circle); B)Another example of HGD: disorganized architecture (circle) next to a nondysplastic Barrett's gland (arrows).