Endoscopy 2017; 49(02): 121-129
DOI: 10.1055/s-0042-120179
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Development and validation of a training module on the use of acetic acid for the detection of Barrett’s neoplasia

Fergus J. Q. Chedgy
1   Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
Kesavan Kandiah
1   Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
Hugh Barr
2   Department of Surgery, Gloucestershire Royal Hospital, Gloucester, United Kingdom
John De Caestecker
3   Department of Gastroenterology, Leicester General Hospital, Leicester, United Kingdom
Simon Dwerryhouse
2   Department of Surgery, Gloucestershire Royal Hospital, Gloucester, United Kingdom
Balint Eross
4   Department of Gastroenterology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
Charles Gordon
4   Department of Gastroenterology, Royal Bournemouth Hospital, Bournemouth, United Kingdom
Susi Green
5   Department of Gastroenterology, Royal Sussex County Hospital, Brighton, United Kingdom
Andy Li
6   Department of Gastroenterology, Worthing Hospital, Worthing, United Kingdom
James Brown
7   School of Pharmacy and Biomedical Sciences, University of Portsmouth, Portsmouth, United Kingdom
Gaius Longcroft-Wheaton
1   Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
Pradeep Bhandari
1   Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth, United Kingdom
› Author Affiliations
Further Information

Publication History

submitted 10 May 2016

accepted after revision 16 September 2016

Publication Date:
19 January 2017 (online)


Background and study aims Acetic acid chromoendoscopy (AAC) enhances the ability to correctly identify Barrett’s neoplasia, and is increasingly used by both expert and nonexpert endoscopists. Despite its increasing use, there is no validated training strategy to achieve competence. The aims of our study were to develop a validated training tool in AAC-assisted lesion recognition, to assess endoscopists’ baseline knowledge of AAC-assisted lesion recognition, and to evaluate the efficacy and impact of this training tool.

Methods A validated assessment of 40 images and 20 videos was developed. A total of 13 endoscopists with experience of Barrett’s endoscopy but no formal training in AAC were recruited to the study. Participants underwent: baseline assessment 1, online training, assessment 2, interactive seminar, assessment 3.

Results Baseline assessment demonstrated a sensitivity of 83 % and a negative predictive value (NPV) of 83 %. The online training intervention significantly improved sensitivity to 95 % and NPV to 94 % (P < 0.01). Further improvement was seen after a 1-day interactive seminar including live cases, with sensitivity increasing to 98 % and NPV to 97 %.

Conclusions The data demonstrate the need for training in AAC-assisted lesion recognition as baseline performance, even by Barrett’s experts, was poor. The online training and testing tool for AAC for Barrett’s neoplasia was successfully developed and validated. The training intervention improved performance of endoscopists to meet ASGE PIVI standards. The training tool increases the endoscopist’s degree of confidence in the use of AAC. The training tool also leads to shift in attitudes of endoscopists from Seattle protocol towards AAC-guided biopsy protocol for Barrett’s surveillance.

  • References

  • 1 Bhat S, Coleman HG, Yousef F. et al. Risk of malignant progression in Barrett’s esophagus patients: results from a large population-based study. J Natl Cancer Inst 2011; 103: 1049-1057
  • 2 Office for National Statistics. Cancer survival in England: adults diagnosed in 2010 to 2014, followed up to 2015. 2016; 1–14 [Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/cancersurvivalinenglandadultsdiagnosed/2010and2014andfollowedupto2015#5-year-survival ]
  • 3 de Jonge PJF, van Blankenstein M, Grady WM. et al. Barrett’s oesophagus: epidemiology, cancer risk and implications for management. Gut 2014; 63: 191-202
  • 4 Hvid-Jensen F, Pedersen L. Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med 2011; 365: 1375-1383
  • 5 Yousef F, Cardwell C, Cantwell MM. et al. The incidence of esophageal cancer and high-grade dysplasia in Barrett’s esophagus: a systematic review and meta-analysis. Am J Epidemiol 2008; 168: 237-249
  • 6 Sharma P, Falk GW, Weston AP. et al. Dysplasia and cancer in a large multicenter cohort of patients with Barrett’s esophagus. Clin Gastroenterol Hepatol 2006; 4: 566-572
  • 7 Picardo SL, O’Brien MP, Feighery R. et al. A Barrett’s esophagus registry of over 1000 patients from a specialist center highlights greater risk of progression than population-based registries and high risk of low grade dysplasia. Dis Esophagus 2015; 28: 121-126
  • 8 Singh S, Manickam P, Amin AV. et al. Incidence of esophageal adenocarcinoma in Barrett’s esophagus with low-grade dysplasia: a systematic review and meta-analysis. Gastrointest Endosc 2014; 79: 897-909.e4
  • 9 Konda VJA, Ross AS, Ferguson MK. et al. Is the risk of concomitant invasive esophageal cancer in high-grade dysplasia in Barrett’s esophagus overestimated?. Clin Gastroenterol Hepatol 2008; 6: 159-164
  • 10 Heitmiller RF, Redmond M, Hamilton SR. Barrett’s esophagus with high-grade dysplasia. An indication for prophylactic esophagectomy. Ann Surg 1996; 224: 66-71
  • 11 Fitzgerald RC, di Pietro M, Ragunath K. et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014; 63: 7-42
  • 12 Pech O, Gossner L, Manner H. et al. Prospective evaluation of the macroscopic types and location of early Barrett’s neoplasia in 380 lesions. Endoscopy 2007; 39: 588-593
  • 13 Kariv R, Plesec TP, Goldblum JR. et al. The Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol. Clin Gastroenterol Hepatol 2009; 7: 653-658
  • 14 Peters FP, Curvers WL, Rosmolen WD. et al. Surveillance history of endoscopically treated patients with early Barrett’s neoplasia: nonadherence to the Seattle biopsy protocol leads to sampling error. Dis Esophagus 2008; 21: 475-479
  • 15 Abrams JA, Kapel RC, Lindberg GM. et al. Adherence to biopsy guidelines for Barrett’s esophagus surveillance in the community setting in the United States. Clin Gastroenterol Hepatol 2009; 7: 736-742
  • 16 Ragunath K, Krasner N, Raman VS. et al. A randomized, prospective cross-over trial comparing methylene blue-directed biopsy and conventional random biopsy for detecting intestinal metaplasia and dysplasia in Barrett’s esophagus. Endoscopy 2003; 35: 998-1003
  • 17 Ngamruengphong S, Sharma VK, Das A. Diagnostic yield of methylene blue chromoendoscopy for detecting specialized intestinal metaplasia and dysplasia in Barrett’s esophagus: a meta-analysis. Gastrointest Endosc 2009; 69: 1021-1028
  • 18 Kara MA, Peters FP, Ten Kate FJW. et al. Endoscopic video autofluorescence imaging may improve the detection of early neoplasia in patients with Barrett’s esophagus. Gastrointest Endosc 2005; 61: 679-685
  • 19 Curvers WL, Herrero LA, Wallace MB. et al. Endoscopic tri-modal imaging is more effective than standard endoscopy in identifying early-stage neoplasia in Barrett’s esophagus. Gastroenterology 2010; 139: 1106-1114
  • 20 Curvers WL, Van Vilsteren FG, Baak LC. et al. Endoscopic trimodal imaging versus standard video endoscopy for detection of early Barrett’s neoplasia: a multicenter, randomized, crossover study in general practice. Gastrointest Endosc 2011; 73: 195-203
  • 21 Lambert R, Rey JF, Sankaranarayanan R. Magnification and chromoscopy with the acetic acid test. Endoscopy 2003; 35: 437-445
  • 22 Longcroft-Wheaton G, Brown J, Basford P. et al. Duration of acetowhitening as a novel objective tool for diagnosing high risk neoplasia in Barrett’s esophagus: a prospective cohort trial. Endoscopy 2013; 45: 426-432
  • 23 Longcroft-Wheaton G, Duku M, Mead R. et al. Acetic acid spray is an effective tool for the endoscopic detection of neoplasia in patients with Barrett’s esophagus. Clin Gastroenterol Hepatol 2010; 8: 843-847
  • 24 Pohl J, Pech O, May A. et al. Incidence of macroscopically occult neoplasias in Barrett’s esophagus: are random biopsies dispensable in the era of advanced endoscopic imaging?. Am J Gastroenterol 2010; 105: 2350-2356
  • 25 Bhandari P, Kandaswamy P, Cowlishaw D. et al. Acetic acid-enhanced chromoendoscopy is more cost-effective than protocol-guided biopsies in a high-risk Barrett’s population. Dis Esophagus 2012; 25: 386-392
  • 26 Tholoor S, Bhattacharyya R, Tsagkournis O. et al. Acetic acid chromoendoscopy in Barrett’s esophagus surveillance is superior to the standardized random biopsy protocol: results from a large cohort study (with video). Gastrointest Endosc 2014; 80: 417-424
  • 27 Sharma P, Savides TJ, Canto MI. et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on imaging in Barrett’s Esophagus. Gastrointest Endosc 2012; 76: 252-254
  • 28 Kandiah K, Chedgy FJQ, Longcroft-Wheaton G. et al. Development and validation of a classification system to identify Barrett’s neoplasia using acetic acid chromoendoscopy: the PREDICT classification. Gut 2016; 65 (Suppl. 01) A31
  • 29 Curvers W, Baak L, Kiesslich R. et al. Chromoendoscopy and narrow-band imaging compared with high-resolution magnification endoscopy in Barrett’s esophagus. Gastroenterology 2008; 134: 670-679
  • 30 Thosani N, Abu Dayyeh BK, Sharma P. et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for adopting real-time imaging-assisted endoscopic targeted biopsy during endoscopic surveillance. Gastrointest Endosc 2016; 83: 684-698.e7
  • 31 Phoa KN, van Vilsteren FGI, Weusten BLAM. et al. Radiofrequency ablation vs endoscopic surveillance for patients with Barrett esophagus and low-grade dysplasia. JAMA 2014; 311: 1209