Elsevier

Gastrointestinal Endoscopy

Volume 80, Issue 3, September 2014, Pages 417-424
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Acetic acid chromoendoscopy in Barrett's esophagus surveillance is superior to the standardized random biopsy protocol: results from a large cohort study (with video)

https://doi.org/10.1016/j.gie.2014.01.041Get rights and content

Background

Currently, various advanced endoscopic techniques are available with varying success rates. These technologies are manufacturer dependent, which has financial implications in the current era of austerity. Acetic acid is a commonly available dye that has been used in the detection of neoplasia within Barrett's esophagus. It has been shown to be effective in detecting neoplasia in high-risk subgroups, but its efficacy in a low-prevalence surveillance population remains unproven.

Objective

This study aimed to investigate the effectiveness of acetic acid chromoendoscopy in a Barrett's esophagus surveillance population. We aimed to compare the neoplasia yield of acetic acid chromoendoscopy (AAC) with the neoplasia yield from standardized random biopsy (SBP) protocol–guided biopsies in the routine surveillance of patients with Barrett's esophagus.

Setting

Tertiary referral hospital in the United Kingdom.

Patients

Patients 18 years of age and older with a diagnosis of Barrett's esophagus undergoing surveillance gastroscopy.

Interventions

AAC versus standardized random biopsy protocol (SBP) for Barrett's esophagus surveillance.

Main Outcome Measurements

Neoplasia detection in 2 groups.

Results

The overall neoplasia detection rates for all grades of neoplasia were 13 of 655 (2%) in the SBP-guided biopsy cohort and 41 of 327 (12.5%) in the AAC cohort (P = .0001). On per-patient analysis, a 6.5-fold gain in neoplasia detection was seen in the AAC cohort compared with the SBP cohort (0.13 vs 0.02, P = .000). In the SBP cohort, a total of 13 of 655 (2%) neoplasias were detected, of which 3 of 655 patients (0.5%) had low-grade dysplasia, 7 of 655 (1%) had high-grade dysplasia, and 3 of 655 (0.5%) were found to have superficial cancer (T1a/T1b). In the AAC cohort, a total of 41 of 327 neoplasias (12.5%) were found, of which 9 of 327 patients (2.7%) had low-grade dysplasia, 18 of 327 (5.5%) had high-grade dysplasia, and 14 of 327 (4.2%) were found to have superficial cancer. The number of biopsies required to detect 1 neoplasia was 15 times lower in the AAC cohort (40 biopsies) than in the SBP cohort (604 biopsies). On per-biopsy analysis, a 14.7-fold increase in neoplasia detection was seen in the AAC cohort per biopsy compared with the SBP cohort (0.025 vs 0.0017; P = .000).

Limitations

Not a randomized, controlled study.

Conclusions

Our study demonstrates that acetic acid detects more neoplasias than conventional protocol-guided mapping biopsies and requires 15 times fewer biopsies per neoplasia detected.

Section snippets

Objective

This study aimed to investigate the effectiveness of acetic acid chromoendoscopy (AAC) in a Barrett's esophagus surveillance population. We aimed to compare the neoplasia yield of AAC with the neoplasia yield from the standardized random biopsy protocol (SBP) in the routine surveillance of patients with Barrett's esophagus.

Techniques

This was a retrospective cohort study evaluating the differences in the outcomes of 2 different strategies of Barrett's esophagus surveillance: the standardized random biopsy protocol (SBP) and AAC protocol. All patients in the study provided informed signed consent for the procedure. The study was done as a service evaluation of Barrett's esophagus surveillance that our department provides and was approved by our institution (PHT 2639).

Patients were matched for age, Barrett's esophagus length,

Patient demographics

A total of 972 procedures were performed on 627 patients for Barrett's esophagus surveillance between October 2008 and June 2012. The median age of the patients was 66 years (range 22–87 years). Of the patients, 75% were male. The mean length of Barrett's esophagus was 4.4 cm (range 2–21 cm). The median Barrett's esophagus length was 5 cm with an interquartile range of 3 to 8 cm.

SBP cohort

This cohort included 655 of 972 (67%) patients who underwent SBP-guided biopsies. The median age was 66 years (range

Discussion

This is the largest and only series comparing the neoplasia detection rates between AAC- and SBP-guided biopsies in patients undergoing Barrett's esophagus surveillance endoscopy. We demonstrated that AAC significantly increases neoplasia detection rates compared with mapping biopsies by the SBP. The gain in neoplasia detection is seen on both per-patient and per-biopsy analysis. These results are very significant. Two large cohort studies demonstrated the efficacy of acetic acid for the

Conclusions

This is the first study to specifically examine the use of AAC in a surveillance population. It demonstrates that acetic acid detects more neoplasias than conventional protocol-guided mapping biopsies and requires 15 times fewer biopsies to detect neoplasia. We believe that this provides a compelling argument for further evaluation with a randomized, controlled trial.

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DISCLOSURE: All authors disclosed no financial relationships relevant to this publication.

See CME section; p. 503.

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