THE DEVELOPMENT OF DYSPLASIA AND ADENOCARCINOMA DURING ENDOSCOPIC SURVEILLANCE OF BARRETTS-ESOPHAGUS

Objective: Periodic endoscopic surveillance is generally recommended f or patients with Barrett's esophagus, The optimal follow-up strategy f or uncomplicated Barrett's esophagus is controversial, in part because of limited data on the rate of neoplastic progression (through the se quence of metaplasia-dysplasia-carcinoma) during endoscopic surveillan ce. This study aims to quantify the development of dysplasia in patien ts with uncomplicated Barrett's esophagus and to explore clinical risk factors associated with the development of dysplastic lesions. Method s: We identified 102 patients with endoscopic evidence of Barrett's es ophagus and the presence of specialized columnar epithelium who had re ceived endoscopic surveillance for adenocarcinoma at our medical cente r between 1970 and 1994, We abstracted endoscopic and histologic data from the medical record. All specimens that showed any degree of atypi a (per report) were reexamined in blinded fashion by a team of study p athologists who indicated the grade of dysplasia. Time to first diagno sis of dysplasia was plotted using Kaplan-Meier survival curves, and r isk factors for development of dysplasia were assessed using Cox regre ssion, Results: During 563 patient-yr of endoscopic follow-up, three p atients developed adenocarcinoma at least 4 yr after initial diagnosis (one developed adenocarcinoma of the cardia, which was incidentally d etected during surveillance for Barrett's esophagus), At some point du ring follow-up, 19 patients developed new onset, low grade dysplasia a nd four developed high grade dysplasia, None of the patients who had r eceived antireflux surgery developed dysplasia, Conclusion: If confirm ed by larger follow-up studies, our results suggest that surveillance endoscopy can be safely deferred for at least 2 yr following an initia l biopsy that is negative or indeterminate for dysplasia, Adoption of this approach would substantially reduce the cost of surveillance for adenocarcinoma, Future trials should explore the role of antireflux su rgery in protecting against neoplastic transformation of Barrett's eso phagus. (C) 1998 by Am. Coll. of Gastroenterology.