Hello, my name is Dr. Vani Konda. In honor of Esophageal Cancer Awareness Month, it is my pleasure to speak on how to perform a high-quality examination in Barrett's esophagus. Many recommendations have been made by numerous guidelines, best practice statements, and reviews. For how to perform a high-quality endoscopic assessment, I remember how to achieve all of these quality metrics with the five L's. They are landmarks, length, look carefully, lesions, and levels. The first L is landmarks. We want to identify and document the diaphragmatic impression, gastroesophageal junction, and squamo-columnar junction. When all three of these are aligned, that is the normal state. When we have the displacement of the gastroesophageal junction from the diaphragmatic impression, that's a hiatal hernia. When we have displacement of the squamo-columnar junction from the gastroesophageal junction, that is Barrett's esophagus. And when we have displacement of the squamo-columnar junction from the gastroesophageal junction and displacement from that, from the diaphragmatic impression, that is a Barrett's esophagus segment in the setting of a hiatal hernia. The diagnosis of Barrett's esophagus requires two components. The endoscopic features as well as the histologic features. The endoscopic features is salmon-colored lining in the tubular esophagus. And when we see this, we want to perform at least eight biopsies to reduce sampling error. On histology, we want to see evidence of specialized intestinal metaplasia with columnar-lined epithelium with the presence of goblet cells. The second L is length. We want to measure the length of the Barrett's segment. We know that longer segments, those that are 3 centimeters or greater, are at higher risk of progression to cancer compared to shorter segments, those that are 1 centimeter or greater and less than 3 centimeters. We can measure length by using a validated classification system called the Prague classification system. We can measure the distance between the top of the gastric folds to the circumferential extent of the Barrett's as well as the maximal extent of the Barrett's and denote that with a C and M classification system. The third L is to look and look carefully. We want to use the best tools that we have. For example, high resolution endoscopy offers greater detail compared to older generation endoscopes. We can also consider the use of a soft distal attachment cap, which offers more stable imaging at the gastroesophageal junction as well as ONFOS inspection. And we can consider the use of enhanced endoscopic imaging such as virtual chromoendoscopy. Techniques such as tip deflection, suction, irrigation, the use of mucolytics if needed are critical to be able to inspect the mucosa closely. Retroflexion is important for careful inspection of the cardiac as well as insufflation and deflation during your examination. In this example, if we looked straight down the lumen, we might miss the lesion of high grade dysplasia. But with careful inspection, we can see discoloration and irregular mucosal pit pattern. And with closer inspection and a stable view from the soft distal attachment cap, we can better characterize this irregular mucosal pit pattern, which was diagnosed as high grade dysplasia. Longer inspection times are associated with higher rates of detection. And we can appreciate that greater than one minute per centimeter may allow for an appropriate Barrett's inspection time to better characterize and detect neoplastic lesions. Narrowband imaging is a virtual chromoendoscopy modality that is widely available. A simplified criteria looking at both mucosal pattern and vascular pattern, we can see here an example of a regular mucosal pattern and a regular vascular pattern. And contrast this to the irregular mucosal pattern and the irregular vascular pattern. The presence of an irregular mucosal pattern and irregular vascular pattern raise concern for neoplasia. But it's important to look carefully in a Barrett segment. In this example, we can see a long segment of Barrett's esophagus that's a C9M10 segment. We can evaluate the area with careful technique, including insufflation and deflation. This allows us to better characterize lesions that may not move with the rest of the esophageal wall. For example, here we can see at 4 o'clock, there is a slightly raised lesion that in an over insufflated esophagus may be flattened out. Here we can look closer with narrowband imaging with near focus and see an irregular distorted mucosal pit pattern. At the proximal end of this segment, we see another lesion, more flat in nature, but appears to be friable. And with narrowband imaging, we can see a distorted mucosal pit pattern. Both of these lesions were diagnosed as intramucosal carcinoma by endoscopic resections. We want to identify, document, and characterize visible lesions. Using a description like the Paris classification allows us to designate that those lesions that are pedunculated or sessile or those that are slightly depressed or excavated are more likely to have submucosal invasive disease than those that are slightly raised or completely flat. The fifth L is levels. We want to biopsy at multiple levels with the Seattle protocol, which is our standard mapping biopsy protocol. First, we want to target biopsies for any visible lesions and then perform random biopsies for occult or subtle disease. We perform random biopsies every 1 to 2 centimeters in four quadrants, specifically every 1 centimeter if there is a history of dysplasia. If erosive esophagitis is present, we would recommend treating with acid suppression for eight weeks and then repeating the endoscopy for the mapping biopsy protocol. In summary, we can use the five L's to remember how to perform a high quality endoscopic assessment of Barrett's esophagus. Landmarks, length, look carefully, lesions, and biopsy at multiple levels. Thank you for your time.

Barrett's esophagus

high-quality examination

Esophageal Cancer Awareness Month

five L's technique

landmarks