As many as one in five endoscopies in patients with Barrett’s esophagus are not being done according to accepted protocol, say the authors of a study published online in Gastrointestinal Endoscopy.
The Seattle biopsy protocol, which is recommended in nondysplastic Barrett’s esophagus to pick up esophageal adenocarcinoma, calls for four-quadrant biopsies at 2-cm intervals in patients without dysplasia and 1-cm intervals in patients with prior dysplasia, as well as targeted biopsies of any mucosal abnormalities.
Sachin Wani, MD, from the University of Colorado at Denver, Aurora, and coauthors used registry data to examine procedures and outcomes in 58,709 esophagogastroduodenoscopies in 53,541 patients with an endoscopic finding of, or screening indication for, Barrett’s esophagus.
They assessed protocol adherence by dividing the Barrett’s esophagus length by the number of pathology jars. A ratio of two or less was considered adherent, and the authors also allowed for a lenient rounding down, or stringent rounding up.
Just over half the procedures in the study (51.1%) resulted in a recorded, pathology-confirmed diagnosis of Barrett’s esophagus, and the mean length of Barrett’s esophagus was 2.3 cm.
Overall, 87.8% of endoscopies were adherent according to the lenient criteria, and 82.7% were adherent by the stringent definition.
Patients with longer lengths of Barrett’s esophagus were significantly less likely to be biopsied according to the Seattle biopsy protocol guidelines, with a 31% decrease in odds of adherence with every 1-cm increase in Barrett’s esophagus length. Patients with lengths from 0-4 cm were 76.3%-80.6% adherent to biopsy protocols, but those with lengths greater than 8 cm were only 37.9%-40.6% adherent.
“These results are most concerning because we found that dysplasia detection rates also increase with increasing [Barrett’s esophagus] length,” the authors wrote. “Therefore, per unit length, patients who need it most are being biopsied least.
Older and male patients also were less likely to be biopsied according to the protocol, and an American Society of Anesthesiologists classification of three or above was a predictor of nonadherence.
“These findings may be a reflection of a higher number of comorbidities in these patients with [Barrett’s esophagus] and perceived lack of benefit of surveillance endoscopy,” the authors wrote.
They also noted a geographic effect, such that patients living in the Northeast regions were more likely to be biopsied according to protocol than were those living in Western regions.
The study was funded by the University of Colorado department of medicine. Four authors declared consultancies and research grants from the medical device sector and others.
SOURCE: Wani S et al. Gastrointest Endosc. 2019, June 11.