Introduction
Surveillance endoscopy detects dysplasia within Barrett's esophagus (BE) and dictates treatment. Current biopsy regimens recommend uniformly-spaced random biopsies. We assessed the distribution of dysplasia in BE to develop evidence-based biopsy regimens.
Methods
We performed analysis of the distribution of dysplasia within BE, using pre-treatment biopsy data from two randomized controlled trials (RCT) of radiofrequency ablation (RFA) for dysplastic BE: the SURF Trial and the AIM Dysplasia Trial. We used generalized linear models with generalized estimating equations to estimate prevalence differences for dysplasia depending on the standardized location of biopsies. We performed Monte Carlo simulation of biopsy regimens to estimate their yield for any dysplasia within segments.
Results
Dysplasia preferentially resides in the proximal-most half of the BE segment, which is almost twice as likely to demonstrate dysplasia as the distal-most quartile. In pooled analysis, compared to the distal-most quarter, the prevalence difference in the proximal-most quarter was 22.6%, in the second proximal-most quarter 23.1%, and in the second distal-most quarter 15.3%. The best performing biopsy regimen in simulation studies acquired 8 biopsies in the most proximal centimeter of BE, 8 biopsies in the second cm, and 2 biopsies in each cm thereafter q1cm - (8, 8, 2, 2…). A slightly simpler q2cm regimen q2cm - (12, 12, 4…) was nearly as effective.
Conclusion
Post-hoc analysis of two RCTs reveals a substantially increased prevalence of dysplasia proximally in BE segments. Our simulations suggest an altered biopsy regimen could increase sensitivity of biopsies in short-segment BE by >30%.