Adherence to quality indicators of Barrett’s esophagus surveillance: where do we stand?

Barrett’s esophagus (BE) is a precursor for the development of esophageal adenocarcinoma (EAC). Recent data indicate that surveillance endoscopy is associated with improved outcomes of EAC in patients with BE [1]. Various gastrointestinal societies recommend adherence to the use of a validated classification system (Prague C & M) and systematic four-quadrant biopsy protocol (Seattle protocol) in order to standardize BE surveillance and promote high-quality care [2] [3]. Nonetheless, adherence to these standardized practices remains variable.

In a recent issue of Endoscopy, Ooi et al. [4] reported the results of their study on the effect of dedicated BE surveillance education on dysplasia detection rate (DDR). Four endoscopists (Group A) were trained in the Prague classification, Seattle biopsy protocol, and lesion detection prior to performing BE surveillance during dedicated time slots. The DDR was then compared with historical data from 47 different endoscopists (Group B) over the preceding 5-year period. The authors reported a significant difference in the DDR for high grade dysplasia/EAC between the two groups: 18 % (26/142) in Group A vs. 8 % (45/587) in Group B (P < 0.001). Furthermore, adherence to the use of the Prague classification (93 % in group A vs. 16 % in group B; P < 0.001) and Seattle protocol (77 % in group A vs. 10 % in group B; P < 0.001) were also significantly higher for endoscopists following dedicated BE surveillance sessions. Overall, it is not surprising that performance variability was lower when four trained endoscopists were compared with a group of 47 nontrained gastroenterologists. Owing to limitations of the study design, it is difficult to ascertain whether the improved DDR in Group A was affected by other potential confounding factors, including (but not limited to) better endoscopic imaging techniques during this time period. Furthermore, we can presume that the improved DDR and significantly greater adherence to the use of the Prague classification and Seattle protocol in the prospective cohort (Group A) may have been artificially raised by their own awareness of the study and increased time for the surveillance endoscopy (30 minutes vs. 15 minutes in group B).

We agree with Ooi et al. that BE surveillance education may be associated with improved adherence to the use of the Prague classification. In our single-center retrospective analysis of endoscopies in 397 patients with BE (2008 – 2015), endoscopists trained in BE therapy (i. e. endoscopic resection and/or ablation) and those with more than 10 years in practice were approximately 3-fold more likely to use the Prague classification when compared with their less-experienced counterparts [5]. Conversely, increased experience (longer time in practice) was inversely associated with the use of the Seattle protocol. We speculate that the reduction in the use of systematic biopsies by more experienced endoscopists may reflect the evolving landscape in BE, and perhaps the incorporation of advanced endoscopic imaging and targeted biopsy techniques.

In summary, adherence to quality measures for the evaluation and management of BE is low in clinical practice. As proposed by Ooi et al. and other studies, including our own, dedicated training and adequate time allocation will likely improve the quality of BE surveillance and thereby improve clinical outcomes.

• References

• 1 El-Serag HB, Naik AD, Duan Z. et al. Surveillance endoscopy is associated with improved outcomes of oesophageal adenocarcinoma detected in patients with Barrett’s oesophagus. Gut 2016; 65: 1252-1260
• 2 Sharma P, Dent J, Armstron D. et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology 2006; 131: 1392-1399
• 3 Abela J-E, Going J, Mackenzie J. et al. Systematic four-quadrant biopsy detects Barrett’s dysplasia in more patients than nonsystematic biopsy. Am J Gastroenterol 2008; 103: 850-855
• 4 Ooi J, Wilson P, Walker G. et al. Dedicated Barrett’s surveillance sessions managed by trained endoscopists improve dysplasia detection rate. Endoscopy 2017; 49: 524-528
• 5 Westerveld D, Khullar V, Mramba L. et al. Adherence to quality indicators for the diagnosis and management of Barrett’s esophagus: a single-center retrospective analysis. Gastroenterology 2017; 152: S448-S449