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Endoscopy plays a pivotal role in the early recognition and surveillance of premalignant esophageal diseases. The recent increase in the use of endoscopy for this purpose has spurred the release of new guidelines for its appropriate application (JW Gastroenterol Dec 7 2012), the most recent of which is from the American Society for Gastrointestinal Endoscopy and is summarized below.
For Barrett esophagus (BE) with no dysplasia, consider no endoscopic surveillance. If surveillance is done, conduct endoscopy with 4-quadrant biopsies at 2 cm intervals at a 3- to 5-year interval. A 1-year follow-up after initial diagnosis is not recommended.
For BE with low-grade dysplasia, confirm the diagnosis with an expert pathologist, repeat endoscopy in 6 months to confirm diagnosis and then annually with 4-quadrant biopsies at 1 to 2 cm intervals. Alternatively, consider endoscopic resection or ablation.
For BE with high-grade dysplasia, confirm the diagnosis with an expert pathologist; consider endoscopic surveillance at 3-month intervals with 4-quadrant biopsies at 1 cm intervals; and consider endoscopic resection and radiofrequency ablation (preceded by endoscopic resection in the case of focal nodular or ulcerated changes), endoscopic ultrasound for local staging, and surgical consultation.
For confirmed achalasia, endoscopic surveillance is not recommended.
For history of upper aerodigestive cancer, endoscopic surveillance is not recommended.
For tylosis, begin endoscopic surveillance at age 30 or at onset of disease, and repeat at 1- to 3-year intervals.
For caustic injury, begin surveillance endoscopy 10 to 20 years after the injury at 2- to 3-year intervals.
Evans JA et al. for the ASGE Standards of Practice Committee. The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus. Gastrointest Endosc 2012 Dec; 76:1087.
Comment
This guideline provides recommendations with weighted quality of supporting evidence. Clinicians should note that in this guideline, a repeat endoscopy at 1 year after diagnosis of BE is no longer recommended. I disagree with the recommendation to consider the use of endoscopic ultrasound for staging of high-grade dysplasia in patients with BE. The staging should be done with endoscopic resection of raised or ulcerated lesions. Endoscopic ultrasound is unnecessary if the endoscopic mucosal resection stages the lesion as intramucosal carcinoma or high-grade dysplasia. Endoscopic ultrasound is overutilized in this population.