Post written by Tony He, MBBS, FRACP, and Andrew C.F. Taylor, MD, FRACP, from the Department of Gastroenterology, St Vincent’s Hospital, and the University of Melbourne, Melbourne, Victoria, Australia.

We aimed to help inform surveillance guidelines in patients who had successful complete eradication of dysplastic Barrett’s esophagus (BE) by identifying the anatomic location, appearance, and histology of BE recurrences.

High-quality surveillance after successful endoscopic eradication therapy for dysplastic BE is essential. Current surveillance guidelines recommend sampling of visible lesions followed by 4-quadrant biopsy sampling every 1 to 2 cm of the original BE segment.

This rigorous biopsy protocol may be an inefficient use of time and lead to unnecessary excess procedural and pathology costs. Data were needed to describe the location and endoscopic appearance of dysplastic recurrences to help guide a more effective and efficient surveillance approach.

After a median of 5.5 years of follow-up, 18 patients (8.3%) developed dysplastic BE recurrence, half at the gastroesophageal junction (GEJ) and half in the tubular esophagus. The majority (78%) of dysplastic GEJ recurrences were nonvisible; hence, routine biopsy sampling below the Z-line was required.

However, the yield of routine surveillance biopsy sampling of normal-appearing neosquamous epithelium in the tubular esophagus was zero in our study. All 9 recurrences in the tubular esophagus were in visible BE islands with features suspicious for dysplasia.

Meticulous inspection of BE islands for irregular or indistinct mucosal pattern, loss of vascular pattern, nodularity, or depression allows for identification of advanced dysplastic or neoplastic recurrences. Features suggesting buried BE, such as darker, elevated squamous mucosa often around BE islands, should be appreciated. We suggest a surveillance biopsy sampling protocol that focuses on detailed esophageal endoscopic examination, followed by sampling of visible lesions only and 4-quadrant biopsy sampling just below the Z-line (GEJ).

There is growing evidence that suggests that current surveillance biopsy sampling protocols should alter their focus to quality endoscopic examination rather than nontargeted extensive biopsy sampling. Additional prospective research is required to better define the key endoscopic features of recurrent dysplasia and subsquamous BE.

It is important to be suspicious of even small and innocuous-looking BE islands that appear after complete remission, as these can harbor dysplasia and can be surrounded by subsquamous BE.

A-C, An 8-mm Paris 0-IIa island with surrounding 12-mm raised area of darker pink squamous mucosa on high-definition white-light imaging and darker brown mucosa on narrow-band imaging consistent with a buried, subsquamous Barrett’s esophagus lesion. D, EMR specimen confirmed subsquamous high-grade dysplasia recurrence.

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