Validation of the Prague C&M classification of Barrett’s esophagus in clinical practice

 

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Background and study aims: The Prague C&M classification for Barrett’s esophagus has found widespread acceptance but has only been validated by Barrett’s experts scoring video sequences. To date, validation has been lacking for its application in routine practice during real-time endoscopy. The aim of this study was to evaluate agreement between Barrett’s experts and community hospital endoscopists when using this classification to describe Barrett’s esophagus and hiatal hernia length during real-time endoscopy.

Patients and methods: Patients underwent two consecutive endoscopies performed by different endoscopists. The study was performed in two cohorts: one cohort was seen by Barrett’s experts and the other cohort by community hospital endoscopists. Landmarks were recorded according to the Prague classification. Outcomes were interobserver agreement (assessed with intraclass correlation coefficient [ICC]), absolute agreement, and relative agreement.

Results: A total of 187 patients were included, with median extent of C3M5 (IQR C1 – 7 M4 – 9) for Barrett’s esophagus and 3 cm (IQR 2 – 5) for hiatal hernia length. ICC was 0.91 (95 % confidence interval [CI] 0.88 – 0.93) for maximum length, 0.92 (95 %CI 0.90 – 0.94) for circumferential extent, and 0.59 (95 %CI 0.49 – 0.68) for hiatal hernia length. Absolute agreement within ≤ 1 cm was 74 % (95 %CI 68 – 80) for circumference, 68 % (95 %CI 62 – 75) for length, and 63 % (95 %CI 56 – 70) for hiatal hernia length. Relative agreement was 91 % for Barrett’s esophagus and 80 % for hiatal hernia length. Barrett’s experts and community hospital endoscopists showed no differences in agreement. Shorter Barrett’s segments (≤ 5 cm) had lower agreement compared with longer segments (> 5 cm).

Conclusions: Agreement was good for Barrett’s esophagus and reasonable for hiatal hernia length. These findings strengthen the value of the Prague C&M classification to describe Barrett’s esophagus and hiatal hernia length. Although absolute agreement during real-time endoscopy was high, one should anticipate that Barrett’s values may vary by 1 – 2 cm between two endoscopies.

• References

• 1 Wang KK, Sampliner RE. Updated guidelines 2008 for the diagnosis, surveillance and therapy of Barrett’s esophagus. Am J Gastroenterol 2008; 103: 788-797
  CrossrefPubMedGoogle Scholar
• 2 Hameeteman W, Tytgat GN, Houthoff HJ et al. Barrett’s esophagus: development of dysplasia and adenocarcinoma. Gastroenterology 1989; 96: 1249-1256
  CrossrefPubMedGoogle Scholar
• 3 Hirota WK, Zuckerman MJ, Adler DG et al. ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc 2006; 63: 570-580
  CrossrefPubMedGoogle Scholar
• 4 Spechler SJ, Sharma P, Souza RF et al. American Gastroenterological Association technical review on the management of Barrett’s esophagus. Gastroenterology 2011; 140: e18-e52
  PubMedGoogle Scholar
• 5 Iftikhar SY, James PD, Steele RJ et al. Length of Barrett’s oesophagus: an important factor in the development of dysplasia and adenocarcinoma. Gut 1992; 33: 1155-1158
  CrossrefPubMedGoogle Scholar
• 6 Menke-Pluymers MB, Hop WC, Dees J. The Rotterdam Esophageal Tumor Study Group et al. Risk factors for the development of an adenocarcinoma in columnar-lined (Barrett) esophagus. Cancer 1993; 72: 1155-1158
  CrossrefPubMedGoogle Scholar
• 7 Avidan B, Sonnenberg A, Schnell TG et al. Hiatal hernia size, Barrett’s length, and severity of acid reflux are all risk factors for esophageal adenocarcinoma. Am J Gastroenterol 2002; 97: 1930-1936
  CrossrefPubMedGoogle Scholar
• 8 Weston AP, Sharma P, Mathur S et al. Risk stratification of Barrett’s esophagus: updated prospective multivariate analysis. Am J Gastroenterol 2004; 99: 1657-1666
  CrossrefPubMedGoogle Scholar
• 9 Anandasabapathy S, Jhamb J, Davila M et al. Clinical and endoscopic factors predict higher pathologic grades of Barrett dysplasia. Cancer 2007; 109: 668-674
  CrossrefPubMedGoogle Scholar
• 10 Sharma P, Dent J, Armstrong D et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C&M criteria. Gastroenterology 2006; 131: 1392-1399
  CrossrefPubMedGoogle Scholar
• 11 Curvers WL, Herrero LA, Wallace MB et al. Endoscopic tri-modal imaging is more effective than standard endoscopy in identifying early-stage neoplasia in Barrett’s esophagus. Gastroenterology 2010; 139: 1106-1114
  CrossrefPubMedGoogle Scholar
• 12 Curvers WL, Van Vilsteren FG, Baak LC et al. Endoscopic trimodal imaging versus standard video endoscopy for detection of early Barrett’s neoplasia: a multicenter, randomized, crossover study in general practice. Gastrointest Endosc 2010; 73: 195-203
  PubMedGoogle Scholar
• 13 Gardner MJ. Confidence Interval Analysis. London: British Medical Journal 1989;
  PubMedGoogle Scholar
• 14 Bland JM, Altman DG. Statistical methods for assessing agreement between two methods of clinical measurement. Lancet 1986; 1: 307-310
  PubMedGoogle Scholar
• 15 Lee YC, Cook MB, Bhatia S et al. Interobserver reliability in the endoscopic diagnosis and grading of Barrett’s esophagus: an Asian multinational study. Endoscopy 2010; 42: 699-704
  Article in Thieme ConnectPubMedGoogle Scholar
• 16 Bredenoord AJ, Weusten BL, Timmer R et al. Intermittent spatial separation of diaphragm and lower esophageal sphincter favors acidic and weakly acidic reflux. Gastroenterology 2006; 130: 334-340
  CrossrefPubMedGoogle Scholar