AGA Clinical Practice Guideline on Surveillance of Barrett's Esophagus

Barrett's esophagus (BE) is the only identifiable precursor to esophageal adenocarcinoma (EAC). Endoscopic surveillance has been proposed for early detection of BE-related neoplasia and reducing EAC mortality. This clinical practice guideline aims to inform clinicians and patients by providing evidence-based practice recommendations for surveillance in patients with BE.

The Grading of Recommendations Assessment, Development and Evaluation framework was used to assess evidence and make recommendations. The panel prioritized clinical questions and outcomes according to their importance for clinicians and patients, conducted an evidence review, and used the Evidence-to-Decision Framework to develop recommendations regarding the role of endoscopic surveillance in patients with BE. The clinical domains addressed included: (1) overall role of endoscopic surveillance, (2) surveillance in patients with columnar-lined esophagus <1 cm, (3) optimal imaging modalities, (4) adjunctive sampling techniques, (5) the utility of biomarkers in risk-stratification, (6) chemopreventive strategies, and (7) antireflux procedures in the prevention of progression in patients with BE. Clinical recommendations were based on the balance between the desirable and undesirable effects, patient values, costs, and health equity considerations.

The panel agreed on 8 recommendations. Based on the available evidence, the panel provided a conditional recommendation in favor of surveillance for patients with nondysplastic BE. In patients with columnar-lined esophagus <1 cm, a conditional recommendation was made against endoscopic surveillance. The panel made a strong recommendation in favor of a combination of high-definition white light endoscopy and chromoendoscopy compared with white light endoscopy alone. The panel made no recommendation on the use of enhanced sampling techniques, such as wide-area transepithelial sampling to enhance neoplasia detection and biomarkers such as p53 and TissueCypher to predict progression in BE. The panel provided a conditional recommendation for the use of daily proton pump inhibitor therapy compared with no therapy and compared with antireflux surgery to prevent progression in BE.

This document provides a comprehensive outline on the role of surveillance in patients with BE. Key implementation statements included in this document stress the importance of a high-quality endoscopy examination, sampling using a structured biopsy protocol, and confirming the diagnosis of BE-related neoplasia by an expert pathologist. This document also provides guidance on surveillance intervals and management of patients with BE-related low-grade dysplasia and indefinite for dysplasia. Providers should engage in shared decision making based on patient preferences. Limitations and gaps in the evidence are highlighted to guide future research opportunities.

This guideline is endorsed by the Canadian Association of Gastroenterology.