Endoscopic follow-up of Barrett's esophagus: protocol and implications

The purpose of endoscopic surveillance in Barrett's esophagus is to detect dysplasia and to diagnose carcinoma in an early, treatable stage. Prospective trials that study the efficacy of a surveillance program in reducing mortality from esophageal adenocarcinoma are lacking. Retrospective studies have shown a significantly better outcome in patients with esophageal cancer that is detected during a surveillance program. Obviously, surveillance is only indicated for those patients fit enough to undergo esophagectomy if high-grade dysplasia (HGD) or malignancy is detected. There is no consensus upon what to do with HGD: some recommend esophagectomy when HGD is diagnosed, because an important proportion of these patients host an adenocarcinoma; others feel that histological proof of malignancy should be established before esophagectomy is proposed. Dysplasia is not a uniform process, causing sampling problems. Using a strict biopsy protocol is helpful to differentiate HGD from carcinoma, but contradictory results about this type of rigorous biopsy protocol have been published. Most groups propose four biopsy specimens, in a circular fashion, from every 2 cm of the Barrett-epithelium, with additional biopsies from any mucosal abnormality. Patients with long-segment Barrett's esophagus need endoscopic surveillance, even if they underwent antireflux surgery. At this moment there are not enough data to support a systematic surveillance of patients with short-segment's Barrett's esophagus. The following endoscopic strategy can be proposed. No dysplasia: surveillance every 2 years. Low-grade dysplasia: surveillance every year; in these cases it is recommended to repeat four-quadrant biopsies at 1 cm interval if numerous biopsies reveal dysplasia to detect foci of HGD/cancer. High-grade dysplasia: repeat immediately four-quadrant biopsies at 1 cm interval; if HGD is confirmed esophagectomy is advised to a patient with acceptable operative risk. Ablation therapy remains experimental.