Centralized care for the management of Barrett’s esophagus: the path forward or just an academic dream?

The incidence of esophageal adenocarcinoma (EAC) has been rising dramatically. Unfortunately the large majority of cases are diagnosed at late stages presenting with signs of dysphagia. Clearly, there are missed opportunities to screen and diagnose high risk patients earlier via endoscopic assessment. However, even among those who have undergone surveillance endoscopy for Barrett’s esophagus (BE), up to 24 % will still go on to develop EAC within 1 year [1]. This raises two questions: What are we doing wrong? How effective is endoscopic surveillance of Barrett’s esophagus at preventing esophageal cancer? In order to be effective, the endoscopist needs to perform a high quality examination and recognize high risk lesions. A high quality examination usually consists of documenting the pertinent landmarks [2] (e. g. location of the z-line and pinch, and the Prague criteria), spending 1 minute per centimeter of BE closely examining the mucosa using high definition endoscopy and electronic chromoendoscopy (e. g. narrow-band imaging), targeting visible lesions, and adhering to systemic biopsy protocols. Is this comprehensive examination better performed among centers of excellence for BE?

“...our patients could be greatly served by consistent and clear recommendations worldwide: that complex Barrett’s esophagus (e. g. long-segment disease or BE with a strong family history of BE or esophageal adenocarcinoma), or BE with confirmed dysplasia, should be evaluated and treated at a BE center of excellence (defined by volume of BE cases performed).”

In this issue of Endoscopy, Nieuwenhuis et al. address this issue [3]. The authors compared the endoscopic examination performed in a BE expert center with that in a community hospital, in patients referred for flat low grade dysplasia (LGD) that had been confirmed by an expert pathologist. The study was conducted in the Netherlands, a country whose guidelines recommend referral of dysplastic BE to expert centers. This was a retrospective study of 248 patients with confirmed LGD on pathology. The rate of prevalent high grade dysplasia or cancer that was missed during the community examination was determined from the repeat endoscopy performed within 3 months of the index examination. Almost one quarter of patients were diagnosed with HGD (13 %) or EAC (10 %) on the repeat examination in the expert center; the majority of these patients had visible lesions. Ablation in these patients without expert evaluation may have led to progression of undetected invasive cancer. The authors conclude that their data support referral of these patients to an expert BE center for re-examination. Overall, the study is well conducted and the data presented support the conclusions drawn, making a real argument for centralized care in BE. The main limitations include the retrospective design, inability to account for adherence to random biopsy protocols, inability to account for differences in technology used (e. g. the possibility of lower resolution gastroscopes used in the community), and how applicable/generalizable this study is outside of the Netherlands.

This study adds to the growing worldwide literature that surveillance endoscopy and therapy in BE referral centers may be of higher quality and have better outcomes compared with treatment in community settings. A similar study from Australia showed 27 % prevalent HGD or EAC in a BE expert center for patients referred for BE with LGD from a community setting [4]. A different Dutch study showed BE expert centers can detect visible neoplastic lesions at a statistically higher rate compared with community centers [5]. Literature from the USA has shown that higher numbers of radiofrequency ablation (RFA) procedures performed correlate to higher rates of complete eradication of intestinal metaplasia [6] [7]. The numbers reported from the USA RFA registry that correlate with the learning curve plateauing is approximately 30 cases for an endoscopist, which is generally the case volume encountered by endoscopists in a BE referral center [6]. In addition, smaller centers had higher rates of recurrent disease. Finally, a meta-analysis of 56 studies reporting on adherence in Barrett’s endoscopy (biopsy protocol, landmark identification, surveillance interval, etc.), showed that university hospitals were more adherent to surveillance guidelines for BE than general hospitals [8].

Where do we stand on the status of centralized care for BE? The European Society of Gastrointestinal Endoscopy and Dutch guidelines recommend centralized care for BE patients with visible lesions or any dysplasia [9] [10]. British guidelines recommend management of dysplasia in multidisciplinary tertiary centers, requiring at least 30 cases of supervised endoscopic resection and ablation before this is performed independently by an endoscopist [11]. US guidelines recommend therapy should be performed in high volume centers that treat at least 10 new cases of dysplastic BE a year [12]. In concert with the key findings of the Nieuwenhuis et al. study, and as an endoscopist specializing in BE in an academic center, it is my humble opinion that our patients could be greatly served by consistent and clear recommendations worldwide: that complex Barrett’s esophagus (e. g. long-segment disease or BE with a strong family history of BE/EAC), or BE with confirmed dysplasia, should be evaluated and treated at a BE center of excellence (defined by volume of BE cases performed).

The components of a BE center of excellence could include the following. 1) A careful examination using high definition endoscopy with (virtual) chromoendoscopy by an expert endoscopist, who has training and experience in the detection of subtle neoplastic lesions; the examination should include endoscopic resection if needed. 2) Examinations performed within a dedicated BE block schedule; this allows for the endoscopist and staff to be in the Barrett’s endoscopy “frame of mind,” which may allow for greater adherence to protocols and guidelines. 3) Access to expert pathology review. 4) Access to the full range of endoscopic therapy, from resection to multiple ablation techniques. 5) Multidisciplinary approach to the medical and surgical management of BE and gastroesophageal reflux. Finally, an unrecognized benefit of BE centers of excellence would be a concentration of BE patients to include in BE trials; this would help to standardize and advance the science and care of BE and EAC. The timely and successful completion of BE trials with inclusion of patients with geographic diversity is not an easy feat. Creation of these centers would help in this endeavor and would be the ultimate academic dream in BE research.

In conclusion, the management of complex or dysplastic BE is intricate. It requires the appropriate time and skill to achieve the outcomes our patients deserve. As the study by Nieuwenhuis et al. shows, care in expert referral centers can lead to the detection of more advanced lesions than previously identified. Thus, creating centers of excellence for high risk BE that allows for centralized care and research can be the path forward and the academic dream to improve patient outcomes.

Publication History

Article published online:
03 June 2022

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