Critical reappraisal of current surveillance strategies for Barrett's esophagus: analysis of a large German Barrett's database

Endoscopic surveillance is recommended for patients with Barrett's esophagus (BE). Based on a large database, gathered from predominantly community‐based practices in Germany, we aimed to investigate the time‐course of malignant progression and apply these findings to current clinical practice. Data of 1438 patients with BE from a large German BE database were analyzed. Patients with at least one follow‐up endoscopy/biopsy were included. Detection of ‘malignant Barrett’ (either high‐grade intra‐epithelial neoplasia or invasive adenocarcinoma) was considered as study end‐point. Of 1438 patients with BE, 57 patients had low‐grade intra‐epithelial neoplasia (LG‐IN) on initial biopsy and 1381 exhibited non‐neoplastic BE. ‘Malignant Barrett’ was detected in 28 cases (1.9%) during a median follow‐up period of 24 months (1–255), accounting for an incidence of 0.95% per patient year of follow‐up. The frequency of ‘malignant Barrett’ was significantly higher (P < 0.001, χ²‐test) in the LG‐IN group (n = 11, 19.3%) compared with the non‐neoplastic BE group (n = 17, 1.2%). In the non‐neoplastic BE group, ‘malignant Barrett’ was predominantly found during re‐endoscopy within the first year of follow‐up (12 of 17; 70.6%), in contrast to the LG‐IN group, in which ‘malignant Barrett’ was observed predominantly after a time exceeding 12 months (8 of 11, 72.7%; P = 0.05, Fisher's exact test). Initial endoscopic evaluations seem to play the most crucial role in managing BE. After 1 year of follow‐up, endoscopic surveillance should be focused on patients with LG‐IN. In patients with repeatedly proven non‐neoplastic BE, elongation of the follow‐up intervals to the upper limit of current guidelines, that is, 5 years, might be justified.