Abstract
Introduction Gastric cancer is the third leading cause of cancer-related deaths in the world. Gastric intestinal metaplasia (GIM) and atrophic gastritis (GA) are known precursors to gastric adenocarcinoma. European Society of Gastrointestinal Endoscopy (ESGE) guidelines on the management of precancerous conditions and lesions in the stomach (MAPS) published in 2012
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recommend endoscopic surveillance of GA/GIM. However, endoscopic recognition of GIM and GA is challenging and little is known regarding adherence to surveillance guidelines in Western centers. In addition, in countries with low incidence of gastric adenocarcinoma and its precursor lesions the awareness about recommendations might also be suboptimal. The aim of this study was to evaluate endoscopic recognition and adequacy of surveillance for GIM and GA. Methods We retrospectively analyzed patients diagnosed with GIM or GA in two academic centers between 2012 till 2019 in The Netherlands and UK. Cases were retrieved through systematic search of pathology reports on their index endoscopy with the diagnosis ‘gastric’ and ‘intestinal metaplasia’ or ‘atrophy’. Endoscopy reports were analyzed to determine the endoscopic diagnoses. Adequacy of surveillance was assessed based on ESGE guidelines and defined by whether surveillance had been appropriately initiated after index endoscopy. Recommended criteria for surveillance include: GA/GIM of the proximal stomach, any location of GA/GIM with a positive family history for gastric cancer or persistent Helicobacter pylori infection. Surveillance was also adequate according to the guideline if patients were discharged if pan-gastric sampling showed only GA/GIM of the distal stomach without risk factors or when age was above 75 years in the absence of dysplasia. Results We included 319 patients, with a mean age of 65 years with a median follow-up of 53 months. H.pylori was present in 15% and 4% had a known positive family history for gastric cancer, however in 47% family history was not reported. Endoscopic recognition rates were 61,1% for GA and 17,4% for GIM. Surveillance was adequately carried out in 139 of 319 patients (43,6%) and inadequate in 180 patients (56,4%). During follow-up two patients (0,6%) developed gastric cancer after the detection of GIM, which gives an incidence of 0,14 per 100 patient years. Conclusion Adequate surveillance of GIM and GA according to current guidelines was under 50% in two academic centers in countries with a low incidence of gastric cancer. The rate of endoscopic recognition of pre-cancerous lesions, in particular of GIM, is low. The results of this study suggest that substantial improvement is required in adherence to published guidelines for surveillance and endoscopic training in detection of pre-malignant conditions.
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