COMMENTARY

Top 10 Practice Changers in Gastroenterology: 2013

David A. Johnson, MD

Disclosures

December 13, 2013

In This Article

Author's Note:
The year 2013 saw many valuable contributions to the field of gastroenterology. In this highlight review, I have selected what I believe to be the 10 articles of greatest importance for the clinical gastroenterologist. These articles cover a broad range of topics in gastrointestinal medicine and hopefully will provide readers with meaningful clinical guidance for their patients in 2014. I defer the rating of importance to the clinicians applying the science to patient-specific disease states. These articles have already affected the decision-making for my practice.

Impact of Endoscopic Surveillance on Mortality From Barrett's Esophagus-Associated Esophageal Adenocarcinomas

Corley DA, Mehtani K, Quesenberry C, Zhao W, de Boer J, Weiss NS
Gastroenterology. 2013;145:312-319.e1

Abstract 

Endoscopic Surveillance in Barrett Esophagus

Although standard practice routinely recommends endoscopic surveillance in patients with Barrett esophagus (BE), few studies have documented a risk reduction for the development of dysplasia or cancer. In this case-control study, researchers assessed whether endoscopic surveillance was associated with reduced cancer mortality in 8272 healthcare plan members who had been diagnosed with BE. They also studied 38 case patients who died from esophageal adenocarcinoma (EAC) and who were diagnosed with BE at least 6 months before their cancer diagnosis. In the surveillance group, endoscopy within 3 years was not associated with a lower risk for death from EAC (odds ratio [OR], 0.99; 95% confidence interval [Cl], 0.36-2.75). Although BE segment length longer than 3 cm and a history of dysplasia were each associated with increased risk for mortality, adjustment for these factors did not change the main findings.

Viewpoint

Several studies have documented the development of incurable malignancies in some patients despite adherence to endoscopic surveillance programs. A previous report[1] estimated that the annual incidence of EAC would have to be > 1.9% for surveillance of nondysplastic BE at 5-year intervals to be cost-effective. The most recent annual incidence estimates for high-grade dysplasia or EAC are 0.1% to 0.2%. The time has come to question the standard practice of routine endoscopic surveillance -- much less screening -- for patients with nondysplastic BE. A risk-stratification paradigm improvement is clearly needed.

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