Surveillance Frequency for Non-Dysplastic Barrett's Esophagus
For patients with non-dysplastic Barrett's esophagus, surveillance endoscopy should be performed every 3-5 years for short segments (<3 cm) and every 2-3 years for long segments (≥3 cm). 1, 2
Surveillance Intervals Based on Segment Length
The frequency of surveillance depends primarily on the length of the Barrett's segment, as longer segments carry higher cancer risk:
- Short segment (<3 cm): Perform surveillance endoscopy every 3-5 years 1, 2, 3
- Long segment (≥3 cm): Perform surveillance endoscopy every 2-3 years 1, 2
- Very long segment (≥10 cm): Refer to a Barrett's expert center for surveillance 4
The American Gastroenterological Association specifically recommends 3-5 year intervals for non-dysplastic Barrett's, acknowledging recent data showing the low risk of malignant progression in this population 1, 3. The British Society of Gastroenterology differentiates by length, recommending 3-5 years for segments <3 cm and 2-3 years for segments ≥3 cm 1. The European Society of Gastrointestinal Endoscopy suggests 5-year intervals for segments 1-3 cm and 3-year intervals for segments 3-10 cm 4.
Essential Biopsy Protocol During Surveillance
When performing surveillance endoscopy, adherence to proper biopsy technique is critical for detecting dysplasia:
- Obtain 4-quadrant biopsies every 2 cm throughout the Barrett's segment 1, 2, 4
- Take separate targeted biopsies of any visible mucosal irregularities or lesions first, before random biopsies 1, 2
- Use high-definition white light endoscopy as the standard of care 1, 4
- Document the extent using the Prague classification (circumferential and maximal extent) 2, 4
- Ensure minimum 1-minute inspection time per cm of Barrett's length 4
Studies demonstrate that adherence to recommended biopsy protocols is associated with significantly higher rates of dysplasia and cancer detection 1, 2.
Prerequisites for Surveillance
Surveillance should only be offered to patients who meet specific criteria:
- Patient must be fit enough to undergo endoscopic therapy or esophagectomy if dysplasia or cancer is detected 1, 5
- Patient should be on at least daily proton pump inhibitor therapy 2
- Avoid performing biopsies in the presence of severe erosive esophagitis (Los Angeles grade C or D); optimize acid suppression first and repeat after inflammation resolves 1
When to Consider Stopping Surveillance
Surveillance can be discontinued in certain circumstances:
- When patient reaches 75 years of age at the time of last surveillance endoscopy 4
- When patient's life expectancy is less than 5 years 4
- For patients with irregular Z-line or columnar-lined esophagus <1 cm, no routine biopsies or surveillance are advised 4
Critical Pitfalls to Avoid
Do not perform surveillance more frequently than recommended for non-dysplastic Barrett's, as this increases costs and procedural risks without proven benefit 3. The 3-5 year interval represents a significant change from older recommendations of 2-3 years, reflecting updated understanding of the low annual cancer risk (approximately 0.5% per year) 6, 7.
Do not rely on inadequate biopsy sampling, as this results in significantly lower dysplasia detection rates 2. Many practicing gastroenterologists fail to adhere to the Seattle protocol (4-quadrant biopsies every 2 cm), and adherence appears poorest for patients with extensive Barrett's metaplasia who are at highest risk 1.
Always confirm any dysplasia diagnosis with a second expert gastrointestinal pathologist before altering surveillance intervals, as low-grade dysplasia is frequently overcalled by community pathologists 1, 8, 2.