Following on from the winter newsletter i.e. making it informative, I will try to provide a summary on a selected OG matter and in this newsletter, I chose Barrett’s Oesophagus, specifically in relation to the available clinical standards for radiofrequency ablation (RFA), endoscopic mucosal resection (EMR) and submucosal dissection (ESD). This will be my last newsletter to touch on pre- malignant or malignant OG matters as my colleague James Gossage will be the dedicated lead for the OG Cancer and I will limit myself to non-malignant OG diseases. I will list the full recommendations from each guidance/guideline in a chronological order to show case the evolutionary process of our understanding and its translation into recommendations and I make no apology of making it exhaustive as I believe it to be an essential knowledge to every UGI clinician. I will then make few final comments of my own. Barrett’s Epidemiology in the UK And to set the scene, it is useful to look at the UK epidemiology of BO; Barrett’s oesophagus is prevalent in 1.5–2.5% of the adult UK population1 with around 60,000 new cases per year (annual incidence around 0.1%). In around 60% of cases, Barrett’s oesophagus seem to be associated with chronic gastro-oesophageal reflux2 and is found in 15–20% of adults undergoing endoscopic investigation for symptomatic chronic reflux. The condition can develop in the absence of symptoms and only 5–10% of adults with reflux develop Barrett’s oesophagus3. Other factors associated with increased risk of developing Barrett’s oesophagus are Caucasian race, male sex, and older age.1,3 Men with Barrett’s oesophagus have an absolute lifetime risk of developing oesophageal adeno-carcinoma of about 5% compared with 3% for women3 . In studies of Barrett’s oesophaguspatientswithflatHGD undergoingsurveillance, approximately six patients per 100 patient-years develop oesophageal adenocarcinoma. The combined incidence of HGD and oesophageal adenocarcinoma in patients under surveillance is estimated to be higher in the UK (13.0/1,000 patient-years; 95% CI 7.4 to 22.8) than in other European countries (7.3/1,000 patient-years; 95% CI 3.6 to 23 15.0)5 . The rate of progression to cancer among patients with Barrett’s oesophagus in the UK as a whole is approximately 1% per year1 . The average risk of mortality attributable to oesophagealadenocarcinomaamongBarrett’soesophagus patients under surveillance has been estimated at 0.3% per year (incidence 3.0/1,000 patient-years; 95% CI 2.2 to 3.9)4 . Guidance in relation to BO, RFA and EMR There 4 NICE publications, 3 BSG publications and one European guideline; the full recommendations of each one of them is an essential read for any clinician treating BO and is available on the electronic version of this newsletter at AUGIS website: I. NICE Guidance 1. Epithelial radiofrequency ablation for Barrett’s oesophagus Interventional Procedures Guideline (IPG344], Published 26 May 2010 2. Barrett’s oesophagus: ablative therapy Clinical Guideline [CG106] Published 11 August 2010 https://www.nice.org. uk/Guidance/CG106 3. Endoscopic radiofrequency ablation for Barrett’s oesophagus with low-grade dysplasia or no dysplasia, Interventional Procedures Guideline (IPG496] Published 23 July 2014) https://www.nice.org.uk/guidance/ipg496 4. Endoscopic Submucosal Dissection of Oesophageal Dysplasia and Neoplasia, Interventional Procedures Guidance [IPG355] Published date: September 2010. II. Other Published Guidelines/Guidance 1. British Society of Gastroenterology/ Fitzgerald RC, di Pietro M, Ragunath K, et al.: Guidelines on the diagnosis and management of Barrett’s oesophagus Gut. 2014; 63(1): 7–42. https://www.bsg.org.uk/resource/bsg- guidelines-on-the-diagnosis-and-management-of-barrett- s-oesophagus.html AUGIS Summer 2019 Newsletter Professor Ashraf Rasheed Report from the Lead for Non-Malignant OG Disease 12 2. Addendum to the British Society of Gastroenterology: Guidelines on the diagnosis and management of Barrett’s oesophagus (2015) https://www.bsg.org.uk/resource/ bsg-guidelines-on-the-diagnosis- and-management-of- barrett-s-oesophagus.html. 3. Revised British Society of Gastroenterology recommendation on the diagnosis and management of Barrett’s oesophagus with low-grade dysplasia (2017) https://www.bsg.org.uk/resource/bsg-guidelines- on- the-diagnosis-and-management-of-barrett-s-oesophagus. html. NICE Guidance III. European Guideline on Endoscopic Resection/ Dissection in BO Endoscopic submucosal dissection (ESD): European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47:829-854 Summary and Comments: To summarise, RFA is recommended for LGD in BO and in flat HGD. With regards to EMR and ESD, this depends on what you are doing it for; if this for a nodular area in BO, then the cancer standards must apply, so EMR is perfectly acceptable in superficial oesophageal lesions of less than 15 mm maximum diameter when a complete en bloc removal can be achieved. To remove an oesophageal cancerous or a possible cancerous lesion in a piece meal manner is a direct breach of our learnt surgical oncological principles which is what happens when lesions larger 15 mm are removed by EMR. I put it to you, not being able to do ESD or to do it as good as EMR is not a good enough reason to choose EMR, as this the cohort of patients who are set to benefit the most from a sound complete en bloc endoscopic removal of their early cancer without the comorbidities of an oesophagectomy. And in terms of evidence, the frequent quote of “lack of evidence of benefit of ESD” compared to EMR is not an evidence of lack of benefit; furthermore, the western experience is accumulating to support safety of ESD adding to its potential benefits. Alex Chen from McGill University, Montreal, QC, Canada presented their experience at DDW in San Diego last month of their 93 consecutive ESD for oesophageal and gastric neoplasia and the message is very clear, endoscopic submucosal dissection is a viable, effective, and safe option for superficial lesions of the stomach and oesophagus. There is an urgent need to upskill and efforts should be made to identify and address barriers to adoption and dissemination of this technique in the UK. Professor Pradeep Bhandari’s efforts are to be commended for championing this in the UK; furthermore, the current UK guidelines are outdated from ESD view point and the matter needs revisiting to reflect the accumulating Western experience. It is my recommendation that UGI cancer surgeons should acquire such advanced endoscopic skills to enable delivery of the full complement of treatment options to their patients. 2019 Gloucestershire Upper GI Symposium (GUSS) GUSS took place on the 16th and 17th of May; the programme was inclusive of practical topics of interest, the content was informative and the speakers engaged the audience sparking interesting discussion during the generous Q&A sessions. It was an excellent educational activityandIwouldrecommendyoutosavethedateforthe future symposia and I congratulate Mr Shameen Jaunoo for such a successful meeting. All lectures were excellent especially Prof Hugh Barr one titled “Management & Imaging in Barrett’s Oesophagus”. ProfessorBarr(picturedabove)capturedtheaudiencewith his usual down to earth, entertaining but very informative style. He updated the audience of the advances in matters relating to Barrett’s oesophagus during his memorable talk. This was followed by a another excellent lecture by Mr Simon Dwerryhouse, Consultant Upper GI Surgeon who touched on the importance of training in advanced therapeutic endoscopies for UGI surgeons and that such training opportunities are now available in European centres. Mr Nick Maynard, AUGIS President Elect, provided a comprehensive review of management of achalasia and highlighted need for centralisation of such services. AUGIS Summer 2019 Newsletter 13 Report from the Lead for Non-Malignant OG Disease