Based on the quality of evidence and expert consensus, a panel put together by the American Society for Gastrointestinal Endoscopy (ASGE) released updated guidelines for the clinical questions regarding the screening and surveillance of Barrett’s esophagus. The goal of these guidelines is to impact the progression of Barrett’s esophagus and improve stage-dependent survival in esophageal adenocarcinoma. This report was published in Gastrointestinal Endoscopy.

The panel performed a systematic review of available literature (existing or new) that addressed the role of screening and surveillance in Barrett’s esophagus, including that of advanced imaging technologies in patients undergoing surveillance. Recommendations were rated on strength and the quality or certainty of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.  The final quality of evidences ranges from very low to high. The recommendations, according to the GRADE method, are either “strong” or “conditional”. Additionally, the words “the guideline panel recommends” are used for strong recommendations and “suggests” for conditional recommendation.

Recommendations for surveillance endoscopy

The ASGE suggests routine surveillance endoscopy in patients with nondysplastic Barrett’s esophagus vs no surveillance (conditional recommendation, very low quality of evidence). They further endorsed the previous clinical practice guidelines’ recommendation that surveillance endoscopy be performed every 3 to 5 years in this patient population.

Recommendations for screening endoscopy

Although evidence on the efficacy of screening for Barrett’s esophagus is limited, the ASGE suggests using a screening strategy that identifies at-risk individuals may be beneficial. High-risk individuals are defined as having a family history of esophageal adenocarcinoma or Barrett’s esophagus; moderate-risk individuals are defined as having a history of gastroesophageal reflux disease with at least 1 other risk factor (male gender, age >50 years, obesity, or history of smoking).

Recommendations for advanced imaging technologies

In patients with Barrett’s esophagus undergoing surveillance for dysplasia, the ASGE recommends using virtual chromoendoscopy (or dye-based chromoendoscopy when virtual chromoendoscopy is not available) in addition to white-light endoscopy and biopsy specimens obtained using the Seattle protocol vs with white-light endoscopy with Seattle protocol biopsy sampling alone (strong recommendation, moderate quality of evidence).

Compared with the use of white-light endoscopy with Seattle protocol biopsy sampling, the ASGE recommends against the routine use of confocal laser endomicroscopy for the detection of dysplasia in patients with Barrett’s esophagus because, in practice, confocal laser endomicroscopy is likely to have a lower diagnostic yield (conditional recommendation, low quality of evidence).

Recommendations for endoscopic ultrasound

To differentiate between mucosal and submucosal disease in patients with Barrett’s esophagus with high-grade dysplasia or early esophageal adenocarcinoma, the ASGE recommends against routine use of endoscopic ultrasound (strong recommendation, moderate quality of evidence). The panel suggests that the use of endoscopic ultrasound is unreliable to distinguish between mucosal and submucosal cancers and is further associated with a relatively high false-positive rate.

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Recommendations for WATS-3D

In patients with known or suspected Barrett’s esophagus, the ASGE suggests using wide-area transepithelial sampling (WATS) with computer-assisted 3D analysis (WATS-3D) in addition to white-light endoscopy with Seattle protocol biopsy sampling, in which WATS-3D significantly increased the detection of dysplasia over white-light endoscopy with Seattle protocol biopsy sampling alone (conditional recommendation, low quality of evidence).

Recommendations for volumetric laser endomicroscopy

The ASGE suggests there is insufficient evidence to recommend for or against routine use of volumetric laser endomicroscopy to identify suspected dysplasia in patients with Barrett’s esophagus undergoing surveillance (no recommendation).

Summary and Conclusions

The updated guidelines highlights several knowledge gaps in the field and discusses the best design for future studies to refine and validate existing prediction tools. Using the GRADE framework, the ASGE offers evidence-based clinical practice guidelines on several key topics regarding screening and surveillance of Barrett’s esophagus.

Reference

Qumseya B, Sultan S, Bain P, et al. ASGE guideline on screening and surveillance of Barrett’s esophagus. Gastrointest Endosc. 2019; 90(3):335-359.