Critical appraisal of guidelines for screening and surveillance of Barrett's esophagus

Abstract

Esophageal adenocarcinoma (EAC) arising on Barrett esophagus (BE) has become the most frequent type of esophageal malignancy in the Western world. BE is a frequent condition but progression to EAC is rare. Scientific societies publish guidelines in order to improve patients' care. However, there are fields where evidence is lacking or there are many controversies. We aimed to spotlight the most important changes, as well as the points of controversy in the recently published guidelines for BE. For most, a length ≥1 cm of a salmon-pink mucosa extending above the eso-gastric junction is required in order to define BE, accompanied with the presence of intestinal metaplasia (IM) at histology. Screening with endoscopy for the general population is not recommended while there is no proof of the efficacy of screening for targeted high risk populations. New techniques permitting a cytologic examination are under evaluation and may change this strategy. The use of high-resolution endoscopes coupled with a careful inspection of the mucosa are required during surveillance of BE. New studies are necessary in order to clarify the real benefit from the use of advanced techniques, such as virtual chromoendoscopy. Length of non-dysplastic BE plays a role for the interval time determination between endoscopies during surveillance. Indefinite for dysplasia and even more low grade dysplasia (LGD) are debatable issues in the matter of BE. There are compelling data suggesting that a definite LGD, defined as a permanent lesion confirmed by a specialist pathologist in BE, has a more dismal prognosis than previously reported and an ablative intervention may be offered in this case. However, most (75-85%) cases with LGD were downstaged in published studies and it remains unknown if in real life, percentages of downstaging are approaching those of studies or there is an over-treatment of pseudo-LGD. Biomarkers such as p53 immunohistochemistry may aid better identification of patients at higher risk. For high grade dysplasia (HGD) visible lesions should be resected with Endoscopic Mucosal Resection (EMR) while flat lesions ablated, for most, nowadays, with radiofrequency ablation (RFA). Endoscopic submucosal dissection (ESD) has not proved superior compared to EMR in BE. It has to be underlined that most studies leading to the new guidelines for BE are not considered of high quality and new guidelines may emerge in the near future.

Keywords: Barrett esophagus (BE); dysplasia; guidelines; surveillance; treatment.