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

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. Design: Retrospective cohort study. 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.