Purpose of review
There is conflicting data on the effectiveness of the currently recommended endoscopic surveillance strategy in non-dysplastic Barrett’s esophagus (BE) patients. We reviewed the literature to evaluate the (cost) effectiveness of the current surveillance strategy. We also reviewed critical strategies and new technologies that could improve dysplasia detection.
Adherence to the current EGD surveillance guidelines is suboptimal with high rates of missed dysplasia/esophageal adenocarcinoma (EAC). The influence of surveillance on EAC mortality appears modest. Careful cleansing, inspection, and sampling of the BE mucosa using high-resolution white light (electronic) chromoendoscopy are critical. Newer sampling techniques coupled with computer aided diagnosis and emerging imaging technologies have shown promise in improving dysplasia detection. Personalized surveillance with risk stratification based on risk factors for progression may be on the horizon.
Current BE surveillance strategy will likely be further refined and optimized by emerging new technologies in tissue sampling, advanced imaging, and risk stratification.
This is a preview of subscription content, log in to check access.
Buy single article
Instant access to the full article PDF.
Price includes VAT for USA
Subscribe to journal
Immediate online access to all issues from 2019. Subscription will auto renew annually.
This is the net price. Taxes to be calculated in checkout.
References and Recommended Reading
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
Pennathur A, Gibson MK, Jobe BA, Luketich JD. Oesophageal carcinoma. Lancet. 2013;381:400–12.
Rubenstein JH, Shaheen NJ. Epidemiology, diagnosis, and management of esophageal adenocarcinoma. Gastroenterology. 2015;149:302–17.
Peters Y, Honing J, Kievit W, Kestens C, Pestman W, Nagtegaal ID, et al. Incidence of progression of persistent nondysplastic Barrett’s esophagus to malignancy. Clin Gastroenterol Hepatol. 2019;17:869–77.
Shaheen N, Falk G, Iyer P, Gerson L. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol. 2016;111:30–50.
American Gastroenterological Association Medical Position Statement on the Management of Barrett’s Esophagus. Gastroenterology. 2011;140:1084–91.
Fitzgerald RC, di Pietro M, Ragunath K, Ang Y, Kang J-Y, Watson P, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut. 2014;63:7–42.
Hvid-Jensen F, Pedersen L, Drewes AM, Sørensen HT, Funch-Jensen P. Incidence of adenocarcinoma among patients with Barrett’s esophagus. N Engl J Med. 2011;365:1375–83.
Wani S, Falk G, Hall M, Gaddam S, Wang A, Gupta N, et al. Patients with nondysplastic Barrett’s esophagus have low risks for developing dysplasia or esophageal adenocarcinoma. Clin Gastroenterol Hepatol. 2011;9:220–7.
Desai TK, Krishnan K, Samala N, Singh J, Cluley J, Perla S, et al. The incidence of oesophageal adenocarcinoma in non-dysplastic Barrett’s oesophagus: a meta-analysis. Gut. 2012;61:970–6.
Theron BT, Padmanabhan H, Aladin H, Smith P, Campbell E, Nightingale P, et al. The risk of oesophageal adenocarcinoma in a prospectively recruited Barrett’s oesophagus cohort. United Eur Gastroenterol J. 2016;4:754–61.
El-Serag HB, Naik AD, Duan Z, Shakhatreh M, Helm A, Pathak A, et al. Surveillance endoscopy is associated with improved outcomes of oesophageal adenocarcinoma detected in patients with Barrett’s oesophagus. Gut. 2016;65:1252–60.
Verbeek R, Leenders M, ten Kate F, van Hillegersberg R, Vleggaar F, van Baal J, et al. Surveillance of Barrett’s esophagus and mortality from esophageal adenocarcinoma: a population-based cohort study. Am J Gastroenterol. 2014;109:1215–22.
Corley DA, Mehtani K, Quesenberry C, Zhao W, de Boer J, Weiss NS. Impact of endoscopic surveillance on mortality from Barrett’s esophagus-associated esophageal adenocarcinomas. Gastroenterology. 2013;145:312–9.
•• Codipilly DC, Chandar AK, Singh S, Wani S, Shaheen NJ, Inadomi JM, et al. The effect of endoscopic surveillance in patients with Barrett’s esophagus: a systematic review and meta-analysis. Gastroenterology. 2018;154:2068–86 It is a thorough meta-analysis on surveillance on EAC- and overall mortality on NDBE patients. This study also showed that adjusting lead- and length-time biases attenuated the mortality benefit conferred by endoscopic surveillance.
Old O, Moayyedi P, Love S, Roberts C, Hapeshi J, Foy C, et al. Barrett’s oesophagus surveillance versus endoscopy at need Study (BOSS): protocol and analysis plan for a multicentre randomized controlled trial. J Med Screen. 2015;22:158–64.
Abrams JA, Kapel RC, Lindberg GM, Saboorian MH, Genta RM, Neugut AI, et al. Adherence to biopsy guidelines for Barrett’s esophagus surveillance in the community setting in the United States. Clin Gastroenterol Hepatol. 2009;7:736–42.
Westerveld D, Khullar V, Mramba L, Ayoub F, Brar T, Agarwal M, et al. Adherence to quality indicators and surveillance guidelines in the management of Barrett’s esophagus: a retrospective analysis. Endosc Int Open. 2018;6:E300–7.
Tavakkoli A, Appelman HD, Beer DG, Madiyal C, Khodadost M, Nofz K, et al. Use of appropriate surveillance for patients with non-dysplastic Barrett’s esophagus. Clin Gastroenterol Hepatol. 2018;16:862–9.
Wani S, Williams JL, Komanduri S, Muthusamy VR, Shaheen NJ. Over-utilization of repeat upper endoscopy in patients with non-dysplastic Barrettʼs esophagus: a quality registry study. Am J Gastroenterol. 2019;114:1256–64.
Abela J-E, Going JJ, Mackenzie JF, McKernan M, O’Mahoney S, Stuart RC. Systematic four-quadrant biopsy detects Barrett’s dysplasia in more patients than nonsystematic biopsy. Am J Gastroenterol. 2008;103:850–5.
van Putten M, Johnston BT, Murray LJ, Gavin AT, McManus DT, Bhat S, et al. ‘Missed’ oesophageal adenocarcinoma and high-grade dysplasia in Barrett’s oesophagus patients: a large population-based study. United Eur Gastroenterol J. 2018;6:519–28.
Visrodia K, Singh S, Krishnamoorthi R, Ahlquist DA, Wang KK, Iyer PG, et al. Magnitude of missed esophageal adenocarcinoma after Barrett’s esophagus diagnosis: a systematic review and meta-analysis. Gastroenterology. 2016;150:599–607.
Inadomi JM, Saxena N. Screening and surveillance for Barrett’s esophagus: is it cost-effective? Dig Dis Sci. 2018;63:2094–104.
Inadomi JM, Sampliner R, Lagergren J, Lieberman D, Fendrick AM, Vakil N. Screening and surveillance for Barrett esophagus in high-risk groups: a cost-utility analysis. Ann Intern Med. 2003;138:176–86.
Kastelein F, van Olphen S, Steyerberg EW, Sikkema M, Spaander MCW, Looman CWN, et al. Surveillance in patients with long-segment Barrett’s oesophagus: a cost-effectiveness analysis. Gut. 2015;64:864–71.
Gordon LG, Mayne GC, Hirst NG, Bright T, Whiteman DC, Watson DI. Cost-effectiveness of endoscopic surveillance of non-dysplastic Barrett’s esophagus. Gastrointest Endosc. 2014;79:242–56.
Cameron AJ, Carpenter HA. Barrett’s esophagus, high-grade dysplasia, and early adenocarcinoma: a pathological study. Am J Gastroenterol. 1997;92:586–91.
Swager A, Curvers WL, Bergman JJ. Diagnosis by endoscopy and advanced imaging. Best Pract Res Clin Gastroenterol. 2015;29:97–111.
Gupta N, Gaddam S, Wani SB, Bansal A, Rastogi A, Sharma P. Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett’s esophagus. Gastrointest Endosc. 2012;76:531–8.
• Bergman JJGHM, de Groof AJ, Pech O, Ragunath K, Armstrong D, Mostafavi N, et al. An interactive web-based educational tool improves detection and delineation of Barrett’s esophagus–related neoplasia. Gastroenterology. 2019;156:1299–308 First web-based education tool to improve dysplasia detection.
Cassani L, Sumner E, Slaughter JC, Yachimski P. Directional distribution of neoplasia in Barrett’s esophagus is not influenced by distance from the gastroesophageal junction. Gastrointest Endosc. 2013;77:877–82.
Kariyawasam VC, Bourke MJ, Hourigan LF, Lim G, Moss A, Williams SJ, et al. Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in short-segment Barrett’s esophagus. Gastrointest Endosc. 2012;75:938–44.
Cotton CC, Duits LC, Wolf AW, Peery AF, Dellon ES, Bergman JJ, et al. Spatial predisposition of dysplasia in Barrett’s esophagus segments: a pooled analysis of the SURF and AIM dysplasia trials. Am J Gastroenterol. 2015;110:1412–9.
Otaki F, Iyer PG. Point–counterpoint: screening and surveillance for Barrett’s esophagus, is it worthwhile? Dig Dis Sci. 2018;63:2081–93.
Gross SA, Smith MS, Kaul V. Increased detection of Barrett’s esophagus and esophageal dysplasia with adjunctive use of wide-area transepithelial sample with three-dimensional computer-assisted analysis (WATS). United Eur Gastroenterol J. 2018;6:529–35.
• Vennalaganti PR, Kaul V, Wang KK, Falk GW, Shaheen NJ, Infantolino A, et al. Increased detection of Barrett’s esophagus-associated neoplasia using wide-area trans-epithelial sampling: a multicenter, prospective, randomized trial. Gastrointest Endosc. 2018;87:348–55 A RCT demonstrated the improvement on dysplasia detection using WATS.
• Smith MS, Ikonomi E, Bhuta R, Iorio N, Kataria RD, Kaul V, et al. Wide-area transepithelial sampling with computer-assisted 3-dimensional analysis (WATS) markedly improves detection of esophageal dysplasia and Barrett’s esophagus: analysis from a prospective multicenter community-based study. Dis Esophagus. 2019;32(3). https://doi.org/10.1093/dote/doy115 A large scale multi-center study showed WATS resulted in a substantial increase in dysplasia detection rate.
Qumseya B, Sultan S, Bain P, Jamil L, Jacobson B, Anandasabapathy S, et al. ASGE guideline on screening and surveillance of Barrett’s esophagus. Gastrointest Endosc. 2019;90:335–59.
Manfredi MA, Abu Dayyeh BK, Bhat YM, Chauhan SS, Gottlieb KT, Hwang JH, et al. Electronic chromoendoscopy. Gastrointest Endosc. 2015;81:249–61.
Qumseya BJ, Wang H, Badie N, Uzomba RN, Parasa S, White DL, et al. Advanced imaging technologies increase detection of dysplasia and neoplasia in patients with Barrett’s esophagus: a meta-analysis and systematic review. Clin Gastroenterol Hepatol. 2013;11:1562–70.
Wolfsen HC, Crook JE, Krishna M, Achem SR, Devault KR, Bouras EP, et al. Prospective, controlled tandem endoscopy study of narrow band imaging for dysplasia detection in Barrett’s esophagus. Gastroenterology. 2008;135:24–31.
• Swager A-F, Tearney GJ, Leggett CL, van Oijen MGH, Meijer SL, Weusten BL, et al. Identification of volumetric laser endomicroscopy features predictive for early neoplasia in Barrett’s esophagus using high-quality histological correlation. Gastrointest Endosc. 2017;85:918–26 This study identified VLE features that are highly correlate with neoplasia and used these features to develop a scoring system for cancer prediction.
Swager A-F, de Groof AJ, Meijer SL, Weusten BL, Curvers WL, Bergman JJ. Feasibility of laser marking in Barrett’s esophagus with volumetric laser endomicroscopy: first-in-man pilot study. Gastrointest Endosc. 2017;86:464–72.
Wolfsen HC, Sharma P, Wallace MB, Leggett C, Tearney G, Wang KK. Safety and feasibility of volumetric laser endomicroscopy in patients with Barrett’s esophagus (with videos). Gastrointest Endosc. 2015;82:631–40.
• Smith MS, Cash B, Konda V, Trindade AJ, Gordon S, DeMeester S, et al. Volumetric laser endomicroscopy and its application to Barrett’s esophagus: results from a 1,000 patient registry. Dis Esophagus. 2019;32(9). https://doi.org/10.1093/dote/doz029 This study established the clinical feasibility and potential of VLE in improving dysplasia evaluation.
van der Sommen F, Zinger S, Curvers W, Bisschops R, Pech O, Weusten B, et al. Computer-aided detection of early neoplastic lesions in Barrett’s esophagus. Endoscopy. 2016;48:617–24.
• de Groof AJ, Struyvenberg MR, van der Putten J, van der Sommen F, Fockens KN, Curvers WL, et al. Deep-learning system detects neoplasia in patients with Barrett’s esophagus with higher accuracy than endoscopists in a multistep training and validation study with benchmarking. Gastroenterology. 2020;158:915–29 This study measured the performance of AI in detecting neoplasia and compared it with endoscopists.
• Hashimoto R, Requa J, Tyler D, Ninh A, Tran E, Mai D, et al. Artificial intelligence using convolutional neural networks for real-time detection of early esophageal neoplasia in Barrett’s esophagus (with video). Gastrointest Endosc. 2020. https://doi.org/10.1016/j.gie.2019.12.049 The AI in this study showed excellent performance in accuracy, sensitivity, and specificity.
Trindade AJ, McKinley MJ, Fan C, Leggett CL, Kahn A, Pleskow DK. Endoscopic surveillance of barrett’s esophagus using volumetric laser endomicroscopy with artificial intelligence image enhancement. Gastroenterology. 2019;157:303–5.
Pohl H, Wrobel K, Bojarski C, Voderholzer W, Sonnenberg A, Rösch T, et al. Risk factors in the development of esophageal adenocarcinoma. Am J Gastroenterol. 2013;108:200–7.
Parasa S, Vennalaganti S, Gaddam S, Vennalaganti P, Young P, Gupta N, et al. Development and validation of a model to determine risk of progression of Barrett’s esophagus to neoplasia. Gastroenterology. 2018;154:1282–9.
Holmberg D, Ness-Jensen E, Mattsson F, Lagergren J. Clinical prediction model for tumor progression in Barrett’s esophagus. Surg Endosc. 2019;33:2901–8.
• Krishnamoorthi R, Singh S, Ragunathan K, Visrodia K, Wang KK, Katzka DA, et al. Factors associated with progression of Barrett’s esophagus: A systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2018;16:1046–55 It is a comprehensive meta-analysis on risk factors that are associated with cancer progression in BE.
Gaddam S, Singh M, Balasubramanian G, Thota P, Gupta N, Wani S, et al. Persistence of nondysplastic Barrett’s esophagus identifies patients at lower risk for esophageal adenocarcinoma: results from a large multicenter cohort. Gastroenterology. 2013;145:548–53.
Krishnamoorthi R, Ramos GP, Crews N, Johnson M, Dierkhising R, Shi Q, et al. Persistence of nondysplastic Barrett’s esophagus is not protective against progression to adenocarcinoma. Clin Gastroenterol Hepatol. 2017;15:950–2.
Nguyen T, Thrift AP, Yu X, Duan Z, El-Serag HB. The annual risk of esophageal adenocarcinoma does not decrease over time in patients with Barrett’s esophagus. Am J Gastroenterol. 2017;112:1049–55.
Abdelmessih R, Packey CD, Lawlor G. Endoscopy in the elderly: a cautionary approach, when to stop. Curr Treat Options Gastroenterol. 2016;14:305–14.
Supported in part by NCI R01 grant CA 241064 (to PGI).
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This article is part of the Topical Collection on Esophagus
About this article
Cite this article
Gibbens, Y., Iyer, P.G. What Is the Optimal Surveillance Strategy for Non-dysplastic Barrett’s Esophagus?. Curr Treat Options Gastro (2020). https://doi.org/10.1007/s11938-020-00297-9
- Barrett’s esophagus
- Esophageal adenocarcinoma
- Endoscopic surveillance
- Cancer progression
- Risk stratification
- Artificial intelligence