Aims:
Guideline recommendations for surveillance of Barrett's esophagus (BE) aim to reduce
heterogeneity and to improve quality of care. We aimed to estimate the clinical consequences
of non-adherence on (1) the endoscopic resectability of esophageal adenocarcinoma
(EAC), (2) mortality due to EAC, and (3) the risk of misdiagnosis of grade of dysplasia.
Methods:
In this multicenter prospective cohort study, data from BE patients were collected
in 13 hospitals. We assessed the proportion of (non-)adherent endoscopies for both
surveillance interval and Seattle protocol (1) in patients with EAC at stage ≤T1a
or >T1a, and (2) in patients with mortality due to EAC. Also, (3) the probability
of misdiagnosis of grade of dysplasia due to non-adherence to the Seattle protocol
was estimated with a multistate Markov model.
Results:
3815 endoscopies were performed in 726 BE patients; in 18 patients EAC was detected.
Adherence to the recommended surveillance interval or the Seattle protocol did not
influence endoscopic resectability of EAC (p = 0.68 & p = 0.34, respectively). Six
patients died due to EAC. Two deceased during surveillance. The surveillance interval
was among these patients, if non-adherent, shorter than recommended; the Seattle protocol
was followed appropriately particularly in their last endoscopies. In the remaining
four patients neoplastic progression was detected at surveillance endoscopies and
they deceased after drop-out due to therapy complications or EAC recurrence. The risk
of misdiagnosis of grade of dysplasia was reduced by 23% if biopsied according to
the Seattle protocol (OR 0.77, 95% CI 0.60 – 0.98).
Conclusions:
The disadvantageous effect of non-adherence to guideline recommendations may be limited
with respect to endoscopic resectability of EAC and mortality. These results are in
line with the lack of evidence underpinning the guideline. Despite the proven effectiveness
of the Seattle protocol, it is time-consuming and error-prone due to non-adherence.
Other strategies should be evaluated to estimate the neoplastic progression risk.
