Dedicated Endoscopy for Barrett's Oesophagus With Higher Dysplasia Yield May Reduce Seattle Protocol Biopsies: Results From UK Multicentre Study.

DIAGNOSIS: Diagnosis of BE requires intestinal metaplasia in the tubular esophagus (conditional, very-low certainty) AND columnar mucosa of at least 1 cm (conditional, low). Patients with a normal-appearing Z line, or a Z line with <1 cm proximal displacement from the top of the gastric folds and no visible lesion, should NOT undergo routine biopsy. At screening endoscopy with findings consistent with possible BE, obtain at least 8 biopsies, following the Seattle protocol (4-quadrant biopsies every 1-2 cm plus targeted sampling of any visible lesion) for segments longer than 4 cm (conditional, low). The at-least-8-biopsy minimum applies to all screening exams regardless of segment length and is NOT waived for shorter (<=4 cm) segments; when a short segment - typically 1-2 cm, e.g. a single tongue - will not physically support 8 biopsies, obtain at least 4 biopsies per cm of circumferential BE and 1 biopsy per cm of tongues of BE, so that short segments are still adequately sampled and dysplasia or cancer is not missed. Dysplasia of any grade must be confirmed by a SECOND pathologist with expertise in GI pathology (STRONG, low). SURVEILLANCE: Use both high-definition white-light endoscopy AND chromoendoscopy (STRONG, moderate) with a structured biopsy protocol (STRONG, low). Intervals are dictated by degree of dysplasia (conditional, very-low) and by segment length (STRONG, moderate): nondysplastic BE <3 cm - EGD every 5 years; nondysplastic BE >=3 cm - EGD every 3 years. Indefinite for dysplasia (confirmed by a second pathologist), any length - escalate to twice-daily PPI and repeat EGD within 6 months; if still indefinite, EGD annually; if downgraded/upgraded, follow the NDBE or LGD algorithm. Confirmed LGD opting for surveillance - EGD at 6 months, at 12 months from diagnosis, then annually, sampling with 4-quadrant biopsies every 1 cm. MEDICAL: At least once-daily PPI in patients with BE without allergy or other contraindication to PPI use (conditional, VERY-LOW certainty); higher/twice-daily dosing is reserved for those who need it for symptom control, as the incremental antineoplastic benefit of dose escalation is unclear. Suggest AGAINST antireflux surgery as an antineoplastic measure (conditional, low). No recommendation could be made on aspirin plus PPI chemoprevention, on WATS-3D, or on p53 IHC/TissueCypher. ENDOSCOPIC THERAPY: For BE with HGD or intramucosal carcinoma (T1a), EET is recommended over ESOPHAGECTOMY (STRONG, moderate). For confirmed LGD, endoscopic therapy is SUGGESTED to reduce progression to HGD/EAC, with endoscopic surveillance of confirmed LGD explicitly retained as an ACCEPTABLE ALTERNATIVE (conditional, moderate) - this is a shared-decision-making choice, not a mandate. Resect all visible lesions endoscopically BEFORE ablation of the residual segment (conditional, very-low); RFA is the preferred ablative modality; goal is complete eradication of intestinal metaplasia. EET should be performed at high-volume centers (conditional, very-low). T1b (submucosal) cancer: the default is surgical referral for esophagectomy, BUT EET may be considered for sm1 disease (invasion into the upper third of the submucosa, depth <500 micrometers) with low-risk features - well differentiated, <2 cm, no lymphovascular invasion, negative deep margin. Patients with high-risk histology are best treated with esophagectomy unless they are poor surgical candidates, for whom multidisciplinary discussion of alternatives such as ADJUVANT chemoradiation may be appropriate. POST-EET: An endoscopic surveillance program is recommended after successful EET (STRONG, moderate), with intervals set by the BASELINE degree of dysplasia: baseline LGD - 1 year, 3 years, then every 2 years; baseline HGD or T1a - 3, 6, and 12 months, then annually.