Adherence to clinical practice guidelines for Management of epithelial precancerous conditions and lesions in the stomach in Europe

Abstract

Background

The first international guideline for managing preneoplastic conditions of the stomach (MAPS I) was published in 2012, followed by an update (MAPS II) in 2019. As adherence to these guidelines remains uncertain, we evaluated adherence by comparing the management of preneoplastic gastric conditions before and after the introduction of MAPS I and II in selected European centers.

Methods

Patient data were retrieved from nine endoscopy units in seven European countries during three periods: pre-MAPS I (2010/2011), post-MAPS I (2017/2018), and post-MAPS II (2022/2023). Screening and dyspepsia-related endoscopies were included. Data on endoscopies, histopathology, Helicobacter pylori treatment, and surveillance were collected using a standardized form. Adherence to nine MAPS recommendations was assessed, with improvement defined as a ≥10-percentage point increase in guideline-concordant management.

Results

A total of 2426 patients were included. Over the years, most centers (57%) improved in seven of the nine recommendations. Virtual chromoendoscopy use improved in six centers, with four reporting its use in >50% of cases. All centers improved in performing biopsies from the antrum and corpus, five conducted random biopsies in nearly all patients, and four performed these plus a biopsy from the incisura in >90% of cases. Endoscopic scores for patient stratification were rarely used, although five centers improved in histological scoring or intestinal metaplasia subtyping. H. pylori treatment recommendations remained high (71%–100%), and endoscopic surveillance adherence improved in 4/7 centers.

Conclusions

Adherence to MAPS guidelines improved in most centers; however, gaps in virtual chromoendoscopy, targeted biopsies, and endoscopic/histopathological scoring remain, potentially affecting surveillance recommendations. This underscores the need for a more tailored approach to enhance implementation.

Publikationsverlauf

Eingereicht: 12. März 2025

Angenommen nach Revision: 15. Juni 2025

Accepted Manuscript online:
03. September 2025

Artikel online veröffentlicht:
06. Oktober 2025

• References

• 1 Bray F, Laversanne M, Sung H. et al. Global cancer statistics 2022: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin 2024; 74: 229-263
• 2 Anderson LA, Tavilla A, Brenner H. et al. Survival for oesophageal, stomach and small intestine cancers in Europe 1999–2007: Results from EUROCARE-5. Eur J Cancer 2015; 51: 2144-2157
• 3 Pimentel-Nunes P, Dinis-Ribeiro M. Endoscopic submucosal dissection in the treatment of gastrointestinal superficial lesions: follow the guidelines!. GE Port J Gastroenterol 2015; 22: 184-186
• 4 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854
• 5 Latorre G, Vargas JI, Shah SC. et al. Implementation of the updated Sydney system biopsy protocol improves the diagnostic yield of gastric preneoplastic conditions: Results from a real-world study. Gastroenterol Hepatol 2024; 47: 793-803
• 6 Pimentel-Nunes P, Libânio D, Marcos-Pinto R. et al. Management of epithelial precancerous conditions and lesions in the stomach (MAPS II): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG), European Society of Pathology (ESP), and Sociedade Portuguesa de Endoscopia Digestiva (SPED) guideline update 2019. Endoscopy 2019; 51: 365-388
• 7 Dinis-Ribeiro M, Areia M, de Vries AC. et al. Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endoscopy 2012; 44: 74-94
• 8 Lahner E, Zullo A, Hassan C. et al. Detection of gastric precancerous conditions in daily clinical practice: a nationwide survey. Helicobacter 2014; 19: 417-424
• 9 Zagari RM, Frazzoni L, Fuccio L. et al. Corrigendum: Adherence to European society of gastrointestinal endoscopy quality performance measures for upper and lower gastrointestinal endoscopy: a nationwide survey from the Italian society of digestive endoscopy. Front Med (Lausanne) 2024; 11: 1406746
• 10 Honing J, Keith Tan W, Dieninyte E. et al. Adequacy of endoscopic recognition and surveillance of gastric intestinal metaplasia and atrophic gastritis: A multicentre retrospective study in low incidence countries. PLoS One 2023; 18: e0287587
• 11 Jacob J, Millien V, Berger S. et al. Improving adherence to clinical practice guidelines for managing gastric intestinal metaplasia among gastroenterologists at a US academic institution. J Clin Gastroenterol 2024; 58: 432-439
• 12 Capelle LG, de Vries AC, Haringsma J. et al. The staging of gastritis with the OLGA system by using intestinal metaplasia as an accurate alternative for atrophic gastritis. Gastrointest Endosc 2010; 71: 1150-1158
• 13 Strauss AT, Yeh J, Martinez DA. et al. A patient-centered framework for health systems engineering in gastroenterology: improving inpatient colonoscopy bowel preparation. BMC Gastroenterology 2021; 21: 89
• 14 Kaslow SR, Ma Z, Hani L. et al. Adherence to guidelines at the patient- and hospital-levels is associated with improved overall survival in patients with gastric cancer. J Surg Oncol 2022; 126: 479-489
• 15 Coburn NG, Swallow CJ, Kiss A. et al. Significant regional variation in adequacy of lymph node assessment and survival in gastric cancer. Cancer 2006; 107: 2143-2151
• 16 Kaslow SR, Hani L, Sacks GD. et al. Regional patterns of hospital-level guideline adherence in gastric cancer: an analysis of the national cancer database. Ann Surg Oncol 2023; 30: 300-308
• 17 Pellisé M, López-Cerón M, Rodríguez de Miguel C. et al. Narrow-band imaging as an alternative to chromoendoscopy for the detection of dysplasia in long-standing inflammatory bowel disease: a prospective, randomized, crossover study. Gastrointest Endosc 2011; 74: 840-848
• 18 Kim JW. Usefulness of narrow-band imaging in endoscopic submucosal dissection of the stomach. Clin Endosc 2018; 51: 527-533
• 19 Capelle LG, Haringsma J, de Vries AC. et al. Narrow band imaging for the detection of gastric intestinal metaplasia and dysplasia during surveillance endoscopy. Dig Dis Sci 2010; 55: 3442-3448
• 20 Pimentel-Nunes P, Libânio D, Lage J. et al. A multicenter prospective study of the real-time use of narrow-band imaging in the diagnosis of premalignant gastric conditions and lesions. Endoscopy 2016; 48: 723-730
• 21 Cho JH, Jin SY, Park S. et al. Carbon footprint and cost reduction by endoscopic grading of gastric intestinal metaplasia using narrow-band imaging. J Gastroenterol Hepatol 2024; 39: 942-948
• 22 Delgado-Guillena PG, Borrallo-Cruz JA, Sánchez-Jara CV. et al. Identifying the gastric atrophic border according to Kimura-Takemoto classification by using high-definition endoscopes and a new virtual chromoendoscopy modality. Gastroenterol Hepatol 2023; 46: 557-559
• 23 Esposito G, Pimentel-Nunes P, Angeletti S. et al. Endoscopic grading of gastric intestinal metaplasia (EGGIM): a multicenter validation study. Endoscopy 2019; 51: 515-521
• 24 Bornschein J, Tran-Nguyen T, Fernandez-Esparrach G. et al. Biopsy sampling in upper gastrointestinal endoscopy: a survey from 10 tertiary referral centres across Europe. Dig Dis 2021; 39: 179-189
• 25 Shah SC, Gawron AJ, Mustafa RA. et al. Histologic subtyping of gastric intestinal metaplasia: overview and considerations for clinical practice. Gastroenterology 2020; 158: 745-750
• 26 González CA, Sanz-Anquela JM, Gisbert JP. et al. Utility of subtyping intestinal metaplasia as marker of gastric cancer risk. A review of the evidence. Int J Cancer 2013; 133: 1023-1032
• 27 Wani S, Williams JL, Komanduri S. et al. Time trends in adherence to surveillance intervals and biopsy protocol among patients with Barrett's esophagus. Gastroenterology 2020; 158: 770-772.e2