Department of Gastroenterology, St Vincent's Hospital Melbourne and the University of Melbourne, Melbourne, Australia.
Department of Anatomical Pathology, St Vincent's Hospital Melbourne and the University of Melbourne, Melbourne, Australia.
Gastrointest Endosc. 2021 Jul;94(1):14-21. doi: 10.1016/j.gie.2020.12.031. Epub 2020 Dec 26.
Buried Barrett's mucosa is defined as intestinal metaplasia that is "buried" under the normal-appearing squamous epithelium. This can occur in Barrett's esophagus with or without previous endoscopic therapy. Dysplasia and neoplasia within buried Barrett's mucosa have also been reported. However, endoscopic features of buried Barrett's mucosa have not been described. At our tertiary referral center for Barrett's esophagus, several endoscopic features have been observed in patients who were found to have buried Barrett's mucosa on histology. These features are squamous epithelium which is (1) darker pink on white-light and darker brown on narrow-band imaging and/or (2) has a slightly raised or nodular appearance. It was also observed that either of these 2 features is frequently seen adjacent to a Barrett's mucosa island. This study aimed to (1) evaluate the diagnostic accuracy of these endoscopic features, and (2) evaluate the frequency of endoscopically identifiable buried Barrett's mucosa in patients with dysplastic Barrett's esophagus, before and after endoscopic eradication therapy.
This was a retrospective analysis of a prospectively observed cohort of all cases of dysplastic Barrett's esophagus referred to St Vincent's Hospital, Melbourne. Endoscopy documentation software and histopathology reports of esophageal biopsy and EMR specimens between March 2013 and March 2019 were searched for terms "buried" or "subsquamous" Barrett's mucosa. Endoscopic reports, images, and histopathology reports of suspected buried Barrett's mucosa were then reviewed to apply the endoscopic features and correlate with the histologic diagnosis.
In a cohort of 506 patients with dysplastic Barrett's esophagus, 33 (7%) patients (73% male, median age at referral 70.5 years) had buried Barrett's mucosa on histology. Twenty-seven (82%) patients had previous treatment for dysplastic Barrett's esophagus; radiofrequency in 2 (6%), EMR in 4 (12%), and both modalities in 21 (64%). Six (18%) had no previous treatment. Histologically confirmed buried Barrett's mucosa was suspected at endoscopy in 26 patients (79%). Endoscopic features were (1) darker pink or darker brown mucosa underneath squamous epithelium (24%), (2) raised areas underneath squamous mucosa (27%), and both features present concurrently (27%). These features were associated with adjacent islands of Barrett's esophagus in 48%. Forty-four cases of buried Barrett's mucosa were suspected endoscopically, and these were sampled by biopsy (50%) and EMR (50%). Buried Barrett's mucosa was confirmed in 26 cases, with a positive predictive value of endoscopic suspicion of 59%. Eighteen cases of endoscopically suspected buried Barrett's mucosa had no buried Barrett's mucosa on histology; inflammation or reflux was identified in 12 (67%) patients. Dysplasia was identified within buried Barrett's mucosa in 12 (36%) patients; 5 intramucosal adenocarcinoma, 1 high-grade dysplasia, and 6 low-grade dysplasia. Endoscopic features of buried Barrett's mucosa were observed in 11 of 12 cases harboring dysplasia or neoplasia, compared with 15 of 21 cases of buried Barrett's mucosa without dysplasia.
In this retrospective analysis of prospectively observed patients with dysplastic Barrett's esophagus, buried Barrett's mucosa was identified in 7%, including treatment-naive patients. The proposed endoscopic features of buried Barrett's mucosa were seen in 79% of patients with histology confirmed disease. These endoscopic features may predict the presence of buried Barrett's mucosa, which may contain dysplasia or neoplasia. An overlap between the endoscopic features of inflammation, reflux, and buried Barrett's mucosa was observed. Future prospective studies are required to develop and validate endoscopic criteria for identifying buried Barrett's mucosa.
埋藏性 Barrett 黏膜是指“埋藏”在正常鳞状上皮下的肠上皮化生。这种情况可发生在有或无先前内镜治疗的 Barrett 食管中。在埋藏性 Barrett 黏膜中也已报道有异型增生和肿瘤。然而，尚未描述埋藏性 Barrett 黏膜的内镜特征。在我们的 Barrett 食管三级转诊中心，在组织学发现埋藏性 Barrett 黏膜的患者中观察到了几种内镜特征。这些特征是（1）白光下颜色较深的粉红色或较窄带成像下颜色较深的棕色的鳞状上皮，和/或（2）有略微凸起或结节状外观的鳞状上皮。还观察到这些 2 个特征中的任何一个特征通常与 Barrett 黏膜岛相邻。本研究旨在（1）评估这些内镜特征的诊断准确性，和（2）评估在接受内镜下消除治疗前后，在患有异型增生性 Barrett 食管的患者中，可识别的埋藏性 Barrett 黏膜的频率。
这是对墨尔本圣文森特医院所有异型增生性 Barrett 食管病例进行前瞻性观察的队列的回顾性分析。在 2013 年 3 月至 2019 年 3 月期间，使用内镜文档软件和食管活检及 EMR 标本的组织病理学报告搜索“埋藏”或“黏膜下”Barrett 黏膜等术语。然后审查疑似埋藏性 Barrett 黏膜的内镜报告、图像和组织病理学报告，以应用内镜特征并与组织学诊断相关联。
在 506 例异型增生性 Barrett 食管患者的队列中，有 33 例（7%）患者（73%为男性，转诊时的中位年龄为 70.5 岁）在组织学上有埋藏性 Barrett 黏膜。27 例（82%）患者以前曾接受过异型增生性 Barrett 食管的治疗；射频治疗 2 例（6%），EMR 治疗 4 例（12%），两种方法联合治疗 21 例（64%）。6 例（18%）患者无先前治疗。26 例（79%）患者在进行内镜检查时怀疑有组织学证实的埋藏性 Barrett 黏膜。内镜特征是（1）鳞状上皮下颜色较深的粉红色或较深的棕色黏膜（24%），（2）鳞状黏膜下凸起的区域（27%），以及同时存在这两种特征（27%）。这些特征与 48%的相邻 Barrett 食管岛相关。44 例疑似埋藏性 Barrett 黏膜的病例行内镜活检（50%）和 EMR（50%）取样。26 例被证实有埋藏性 Barrett 黏膜，内镜怀疑的阳性预测值为 59%。18 例疑似埋藏性 Barrett 黏膜的内镜检查中，有 18 例组织学上未见埋藏性 Barrett 黏膜；在 12 例（67%）患者中发现了炎症或反流。在 12 例（36%）患者的埋藏性 Barrett 黏膜中发现了异型增生；5 例黏膜内腺癌，1 例高级别异型增生，6 例低级别异型增生。在 12 例有异型增生或肿瘤的患者中观察到 11 例有埋藏性 Barrett 黏膜的内镜特征，而在 21 例无异型增生的埋藏性 Barrett 黏膜患者中观察到 15 例。
在对有异型增生性 Barrett 食管的前瞻性观察患者进行的回顾性分析中，发现了 7%的埋藏性 Barrett 黏膜，包括未接受治疗的患者。在组织学证实有疾病的患者中，观察到了 79%的患者有埋藏性 Barrett 黏膜的拟议内镜特征。这些内镜特征可能预测埋藏性 Barrett 黏膜的存在，其中可能包含异型增生或肿瘤。观察到炎症、反流和埋藏性 Barrett 黏膜的内镜特征之间存在重叠。需要进一步开展前瞻性研究以制定和验证识别埋藏性 Barrett 黏膜的内镜标准。
