Introduction
Oesophageal adenocarcinoma (EAC) remains a leading cause of cancer-related mortality, with poor survival outcomes. Early identification and treatment of dysplasia in Barrett’s oesophagus (BE) is critical to reducing the risk of post-endoscopy upper gastrointestinal cancers (PEUGIC). While mucosal cleansing and clear visualisation are recognised as essential, existing evidence also demonstrates that certain procedural factors—such as longer inspection times—can significantly improve dysplasia detection rates (DDR) (2). This raises the possibility that other procedural variables may similarly influence detection outcomes. In this audit, we evaluated whether additional technical and patient-related factors affect dysplasia detection, with the aim of optimising surveillance quality and reducing the risk of Post-Endoscopy Upper GI Cancer (PEUGIC).
Aims & Methods
This audit aimed to assess the impact of procedural variables on dysplasia detection during Barrett’s surveillance endoscopy. A retrospective analysis was conducted in Wales, reviewing 192 patient records from June to December 2023. Factors that may influence dysplasia detection were evaluated including sedation type, use of acetic acid for mucosal enhancement, adherence to the Prague grading system, describing lesions using the Paris classification, NBI use and the Seattle biopsy protocol. Additionally, patient comfort was assessed as it may impact procedural quality and compliance. Analysis was carried out using SPSS (IBM, USA). T-tests were used for parametric data, and Mann Whitney U-tests for non-parametric data. Categorical data were analysed using Chi-square or Fisher’s exact tests. Statistical significance was set at p < 0.01.
Results
Improved imaging quality was significantly associated with higher patient comfort (p = 0.001). Higher doses of midazolam were associated with greater detection of visible lesions, while fentanyl showed less of a significant effect. Additional use of acetic acid and aceto-whitening effect significantly enhanced dysplasia detection, with strong alignment to histological findings (p<0.001). NBI further improved lesion identification when used adjunctively. In procedures performed by expert endoscopists, targeted biopsies identified dysplasia at comparable rates to the Seattle protocol, suggesting limited additional value of the latter in experienced hands.
Conclusion
This study underscores the importance of optimising procedural elements—particularly higher doses midazolam (median 5mg), acetic acid application, and ensuring patient comfort—to improve dysplasia detection in Barrett’s surveillance. Although PEUGIC data seems to show better neoplasia detection rates with combined Midazolam and Fentanyl, we did not demonstrate this(1). seattle protocol may still be helpful for dysplasia detection, but it’s use appears less beneficial than regular use of NBI and acetic acid chromoendoscopy.
References
1. Dhar A. Re: “Dedicated service for Barrett’s oesophagus surveillance endoscopy yields higher dysplasia detection and guideline adherence in a non tertiary setting in the UK: a 5-year comparative cohort study” by Ratcliffe et al. Frontline gastroenterology [Internet]. 2023 Mar;15(3):264. Available from: https://pubmed.ncbi.nlm.nih.gov/38665792/
2. 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. Gastrointestinal Endoscopy. 2012 Sep;76(3):531–8
