Management of Barrett's esophagus in the UK: Overtreated and underbiopsied but improved by the introduction of a national randomized trial
Management of Barrett's esophagus in the UK: Overtreated and underbiopsied but improved by the introduction of a national randomized trial
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DOI：
10.1111/j.1572-0241.2008.01790.x
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发表时间：
2008-05-01
影响因子：
9.8
通讯作者：
Jankowski, Janusz
中科院分区：
文献类型：
--
作者：
Das, Debasish;Ishaq, Savid;Jankowski, Janusz
目的：通过一项大型BE随机对照试验(RCT)和组织取样方案，评估Barrett‘s食道(BE)管理实践与公认的国际指南的差异。设计：向401名资深主治胃肠病医生发出有效的匿名问卷，询问他们目前对BE的管理，特别是组织学采样的细节。在228名受访者中，57人(每个人来自不同的中心)是第一组参加阿司匹林埃索美拉唑(BE)化学预防试验(Aspect)的人，我们评估了这些中心的实践变化。结果：90%的专家没有进行足够的组织学诊断。此外，74%的患者会考虑对BE中常见的高度不典型增生病例进行积极的手术切除，作为他们的第一线选择，尽管相关的围手术期死亡率。92%的人声称他们不遵守指南是因为需要更有力的证据来进行监测和医疗干预。Aspect试验的效果：与以前的做法相比，那些在Aspect试验开始的中心的临床医生对ACG指南的遵守程度有所提高(P<；0.05)。与以前的做法相比，BE患者现在多做了18.8%的活组织检查，如果患者进入Aspect试验，则多做了37.7%的活组织检查(P<；0.01)。结论：这项大型研究表明，实践中的差异很大，而且对指南的遵从性很差。因为最佳的组织学可以说是BE管理的最重要的方面，参加Aspect试验的中心在实践中的改进表明了大型国际随机对照试验的额外价值。
OBJECTIVES: To assess the variation in practice of Barrett's esophagus (BE) management in comparison with accepted international guidelines before and after the introduction of a large BE randomized controlled trial (RCT) with protocols including those of tissue sampling.DESIGN: A validated anonymized questionnaire was sent to 401 senior attending gastroenterologists asking for details of their current management of BE, especially histological sampling. Of the 228 respondents, 57 individuals (each from a different center) were in the first group to enter the ASPirin Esomeprazole (BE) Chemoprevention Trial (AspECT), and we assessed change in practice in these centers.RESULTS: Ninety percent of specialists did not take adequate biopsies for histological diagnosis. Furthermore, 74% would consider aggressive surgical resection for prevalent cases of high-grade dysplasia in BE as their first-line choice despite the associated perioperative mortality. Ninety-two percent claim their lack of adherence to guidelines is because there is a need for stronger evidence for surveillance and medical interventions.Effect of the AspECT trial: Those clinicians in centers where the AspECT trial has started have improved adherence to ACG guidelines compared with their previous practice (P < 0.05). BE patients now get 18.8% more biopsies compared with previous practice, and 37.7% if the patient is entered into the AspECT trial (P < 0.01).CONCLUSIONS: This large study indicates both wide variation in practice and poor compliance with guidelines. Because optimal histology is arguably the most important facet of BE management, the improvement in practice in centers taking part in the AspECT trial indicates an additional value of large international RCTs.