Post-endoscopy Barrett’s neoplasia after a negative index endoscopy: a systematic review and proposal for definitions and performance measures in endoscopy

• Introduction
• Methods
• Definitions
• Literature search
• Eligibility
• Data extraction and quality assessment
• Outcomes and statistical analysis
• Results
• Study characteristics
• Quality of studies
• Pooled rates of prevalent, interval (PEBN), and incident neoplasia
• Post-endoscopy Barrett’s neoplasia 3-year rate
• Proportion of neoplasia types relative to total Barrett’s neoplasia
• Meta-regression
• Publication bias
• Discussion
• References

Abstract

Background A high rate of neoplasia, both high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) has been reported in Barrett’s esophagus at index endoscopy, but precise rates of post-endoscopy Barrett’s neoplasia (PEBN) are unknown.

Methods A systematic review and meta-analysis was performed examining electronic databases (inception to October 2021) for studies reporting PEBN. Consistent with the definitions of post-colonoscopy colorectal cancer proposed by the World Endoscopy Organization, we defined neoplasia (HGD/EAC) detected at index endoscopy and/or within 6 months of a negative index endoscopy as “prevalent” neoplasia, that detected after 6 months of a negative index endoscopy and prior to next surveillance interval (i. e. 3 years) as PEBN or “interval” neoplasia, and that detected after 36 months from a negative index endoscopy as “incident” neoplasia. The pooled incidence rates and proportions relative to total neoplasia were analyzed.

Results 11 studies (n = 59 795; 61 % men; mean [SD] age 62.3 [3.3] years) met the inclusion criteria. The pooled incidence rates were: prevalent neoplasia 4.5 % (95 %CI 2.2 %–8.9 %) at baseline and an additional 0.3 % (0.1 %–0.7 %) within the first 6 months, PEBN 0.52 % (0.46 %–0.58 %), and incident neoplasia 1.4 % (0.9 %–2.1 %). At 3 years from the index endoscopy, PEBN accounted for 3 % of total Barrett’s neoplasia, while prevalent neoplasia accounted for 97 %.

Conclusion Neoplasia detected at or within 6 months of index endoscopy accounts for most cases of Barrett’s neoplasia (> 90 %). PEBN accounts for ~3 % of cases and can be used for validation in future. This highlights the importance of a high quality index endoscopy in Barrett’s esophagus and the need to establish quality benchmarks to measure endoscopists’ performance.

Introduction

The incidence of esophageal adenocarcinoma (EAC) is rising in the West, and it carries a poor 5-year prognosis. Currently, gastrointestinal societies recommend screening for Barrett’s esophagus (BE), a precursor of EAC, among those with multiple risk factors and, if detected, close surveillance for any dysplasia that could be effectively treated if caught early [1] [2] [3]. Despite advances in screening, early detection, and management, a majority of patients are found to have Barrett’s neoplasia (high grade dysplasia [HGD]/EAC) at the time they are diagnosed with BE [4] [5] [6]. A recent meta-analysis found ~25 % of EACs are diagnosed within 1 year of BE diagnosis after a negative index endoscopy [5]. However, studies published later from large BE cohorts have reported lower rates of missed cancers [7] [8]. Varying definitions of prevalent versus missed neoplasia (e. g. within 6 months [9], 1 year [7], and 2 years [10]) could be contributory factors, along with the incorporation of studies with selective inclusion (vs. exclusion) of data with index neoplasia.

Rates of Barrett’s neoplasia and its progression after a careful index endoscopy have however not been characterized precisely. Currently, there is a deficit in standard reporting and characterization of post-endoscopy Barrett’s neoplasia (PEBN) after an index endoscopy where no HGD/EAC was found (a “negative” endoscopy). The field of Barrett’s endoscopy has been evolving, with an emphasis on high quality examination and advances in methods to detect Barrett’s neoplasia. However, in the absence of validated benchmarks, performance in BE endoscopy is currently not measured in clinical practice. As an effort to improve quality, the definition of PEBN needs to be characterized further.

The definitions of post-colonoscopy colorectal cancer (PCCRC) by the World Endoscopy Organization [11] could serve as a model to examine PEBN rates. A distinction between the pattern and types of neoplasia in BE is crucial for future benchmarking studies to measure performance and to understand patterns of Barrett’s neoplasia progression. In this systematic review and meta-analysis, we therefore examined the rate of PEBN after a negative index endoscopy and characterized Barrett’s neoplasia among the published data using validated definitions of PCCRC by the World Endoscopy Organization.

Methods

This systematic review and meta-analysis was performed according to the Cochrane Handbook of Systematic Review and Meta-analysis, as well as Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Meta-analysis of Observational Studies in Epidemiology (MOOSE) [12] [13] [14].

Definitions

The World Endoscopy Organization has defined PCCRC as cancer found after a negative colonoscopy (i. e. no cancer was found) [11]. These established PCCRC definitions help define patterns of colorectal cancer (CRC) after a negative examination done for any indication. We used this model to formulate definitions of Barrett’s neoplasia.

CRCs diagnosed at initial colonoscopy or within 6 months of a negative colonoscopy are defined as “detected” or “prevalent” cases. Cancers diagnosed prior to the prescribed surveillance interval (i. e. 3 years) are defined as “interval” PCCRC. Cancers diagnosed at or after the recommended surveillance interval (i. e. at or after 3 years) are identified as new or “incident” cancers. In line with this, we defined Barrett’s neoplasia detected at index endoscopy or within 6 months of a negative index endoscopy as “prevalent” or “detected” neoplasia. Neoplasia diagnosed within the surveillance interval (i. e. 3 years for BE [i. e. between 7 months and 36 months]) was described as PEBN or “interval” neoplasia, and that detected at or after 36 months from a negative index endoscopy was defined as “incident” or “new” neoplasia.

Finally, consistent with the CRC model where “all cancers” is the sum of detected cases and PCCRC, we characterized “total Barrett’s neoplasia” as the sum of prevalent neoplasia (HGD/EAC detected at index endoscopy or detected within 6 months), PEBN (detected at 7–36 months), and incident neoplasia (detected at or after 3 years) ([Fig. 1]). Therefore, total Barrett’s neoplasia = prevalent neoplasia + PEBN + incident neoplasia.

Literature search

An electronic literature search was performed using PubMed/Medline, Embase, Cochrane, and Google Scholar from the inception of the databases until October 1, 2021. The following search terms with respective MeSH/Emtree terms were used to find articles of relevance: “Barrett’s (O)Esophagus,” “Neoplasia,” “High-grade dysplasia,” “Nondysplastic Barrett’s esophagus,” “Esophageal adenocarcinoma,” “O/esophageal cancer,” “Surveillance,” “Missed lesions,” “Incident cancer,” “Interval neoplasia or cancer,” “post endoscopy neoplasia,” “post endoscopy cancer,” “post endoscopy esophageal cancer.” Boolean terminology with “AND,” “OR,” and “NOT” were used with above terms (Appendix 1 s, see online-only Supplementary material).

Four independent authors (M.D., S.S., V.N., and A.C.) performed the literature search and screened the eligible studies. Final article selection as per the inclusion criteria was performed after data extraction and was verified by two separate authors (M.D. and S.S.). When there was any conflict regarding article selection, this was reviewed with a senior author (P.S.) for a final decision.

Eligibility

Non-intervention studies (prospective, retrospective, or clinical trial) providing information on neoplasia among subjects with index endoscopy (baseline), subjects without any neoplasia (HGD/EAC) at index endoscopy, rates of neoplasia at 6 months, rates of interval neoplasia between 7–36 months, and rates of incident neoplasia after 3 years were eligible.

Studies not reporting information on neoplasia at and/or after index endoscopy, only reporting baseline neoplasia with no follow-up data (i. e. HGD/EAC rates at 6 months or later), and only providing information on low grade dysplasia (LGD) and/or indeterminate (indefinite) for dysplasia at baseline with progression rates were excluded. Case reports, editorials, review articles, abstract presentations only, and articles with a prior publication from the same database (with significant overlap with a recent included study) were excluded. Studies examining adjunct modalities (other than white-light examination and standard four-quadrant biopsy) were excluded. Studies examining endoscopic eradication therapy were also excluded.

Data extraction and quality assessment

Study characteristics (name, year, country, design, and total subjects) and patient characteristics (sex, BE length, hiatal hernia, esophagitis, follow-up duration, patients with neoplasia at baseline and within 6 months, patients with neoplasia between 7–36 months and later of a negative baseline exam, interval and incident neoplasia in those with no dysplasia at baseline, and LGD or indefinite for dysplasia at baseline) were extracted. We also examined the stage of Barrett’s neoplasia at these timeframes in terms of whether they were amenable to endoscopic treatment or not (surgical resection or metastatic disease). When some rates were missing but studies were otherwise eligible or providing the required information, the study authors were contacted for the missing data.

The methodological quality of each included study was assessed by a scale modified from the Newcastle–Ottawa scale for observational cohort studies [15] [16]. The modified scale consisted of nine items, each modified from the original Newcastle–Ottawa scale for this analysis, with 0, 0.5, and 1 point for each, giving a maximum score of 9.

Outcomes and statistical analysis

Pooled (incidence) rates of prevalent neoplasia, PEBN, and incident neoplasia were derived. These rates represent the number of neoplasia events divided by the total number of subjects in the follow-up (incidence rate). For example:

PEBN rate = number of subjects with Barrett’s neoplasia over 7–36 months from a negative index endoscopy divided by the total subjects undergoing surveillance endoscopy over 7–36 months.

We also reported PEBN and incident neoplasia rates as person-years of follow-up.

The relative proportion of PEBN to total Barrett’s neoplasia (ratio) was also calculated using pooled raw data of these events to assess weightage (or proportion contribution) of each type on the total Barrett’s neoplasia. So:

Proportion of PEBN = (PEBN divided by total Barrett’s neoplasia) × 100.

The pooled PEBN 3-year rate (PEBN divided by total Barrett’s neoplasia at 3 years), was also derived similarly to the “PCCRC-3y.” Here, total Barrett’s neoplasia at 3 years includes prevalent neoplasia and PEBN in the given timeframe.

The occurrence of Barrett’s neoplasia among non-intervention studies was considered a common effect across all studies. Effect sizes from individual studies were pooled in a random-effects model using the DerSimonian–Laird method to derive the summary estimates, which were reported as rates with a 95 %CI. Heterogeneity among the outcomes was represented by I ² statistics, where heterogeneity was measured as per the Cochrane Handbook as: not important (0–40 %), moderate (30 %–60 %), substantial (50 %–90 %), and considerable (75 %–100 %) [14]. Variables were reported as frequencies (%) of total for categorial variables, and mean (SD) for continuous variables.

We analyzed the pooled rates and relative proportions of neoplasia as available from the included studies. In addition, for the missing outcomes among the studies, after contacting study authors, we performed Markov chain Monte Carlo (MCMC) multiple imputation to derive missing outcomes data [17]. For missing neoplasia rates at index endoscopy, rates were imputed using a neoplasia detection rate of 7 % from a prior systematic review and meta-analysis [4]. For missing data on neoplasia at 0–6 months, 7–36 months, and after 36 months, the MCMC method was used to derive the proportion event rates with multiple chains to create five imputations. We then performed a separate analysis for the available and imputed outcomes.

Sensitivity analysis was performed for subjects with “no dysplasia at baseline” to examine for any possible confounding by “Pathology (other diagnoses),” other than “only IM or no dysplasia.” In addition, we performed analysis after restricting to prospective studies.

Meta-regression was performed to examine whether specific covariates can impact PEBN rates: neoplasia detected at index endoscopy, low grade (or indefinite) dysplasia at and/or within 6 months from index endoscopy, year of study publication, and years of surveillance. The purpose of including specific covariates was to examine if any of them had a statistically significant impact on PEBN. For example, from a clinical standpoint, LGD detected on index endoscopy could progress to PEBN (and therefore be detected 7–36 months later); early years of study publication could represent practice patterns during that time period that might explain rates of PEBN. Finally, publication bias was assessed using a funnel plot and, if asymmetry was noted, with Egger’s regression.

Multiple imputations were performed using statistical software SAS version 9.3. A P value < 0.05 was considered significant. Comprehensive-Meta-analysis version 3.0 (Biostat, Englewood, New Jersey, USA; 2013) was used to perform meta-analyses including forest plots.

Results

Study characteristics

A total of 9283 records were retrieved from the initial search strategy ([Fig. 2]). After the removal of duplicate titles and title/abstract screening, there were 2647 records. After further review, 76 articles required a detailed review, of which 35 full-text articles were excluded (Table 1 s). After the application of eligibility criteria, 11 studies [8] [9] [18] [19] [20] [21] [22] [23] [24] [25] [26] were included for analysis.

There were 59 795 subjects that underwent an index endoscopy and had PEBN or incident neoplasia information reported. There were seven retrospective studies [8] [9] [19] [21] [22] [23] [26] and four prospective cohort studies [18] [20] [24] [25]. The mean (SD) age of the population was 62.3 (3.3) years, with 61 % being men. The baseline BE length [20] [25] [26], use of proton pump inhibitors [21] [23] [25], and coexistent esophagitis [18] [21] [25] were reported by three studies each ([Table 1]). Two of the studies were conducted in the USA [19] [21], eight in Europe [8] [9] [20] [22] [23] [24] [25] [26], and one in Australia [18]. All 11 studies provided information on prevalent neoplasia (at index endoscopy in nine studies [18] [19] [20] [21] [22] [23] [24] [25] [26]; at 0–6 months in seven [8] [9] [18] [19] [23] [24] [26]) ([Table 2]). None of the available studies reported information on the stage of the detected neoplasia or on endoscopically amenable neoplasia.

Quality of studies

Overall, the studies were not reflective of the general population (because BE subjects have risk factors that are not always present in those without BE) but they had adequate power, inclusion of an appropriate definition of BE, prescription of surveillance interval, an adequate timeframe for the outcome to occur (predominantly PEBN and incident neoplasia), and capture of outcome data. Seven studies had a high score ≥ 7, qualifying them as a high quality study (Table 2 s).

Pooled rates of prevalent, interval (PEBN), and incident neoplasia

The pooled rate of Barrett’s neoplasia at index endoscopy was 4.5 % (n = 9; 2.2 %–8.9 %; I ² = 96 %). The pooled rate of neoplasia within 6 months of a negative index endoscopy was 0.3 % (n = 7; 0.1 %–0.7 %; I ² = 75 %; prediction interval 0.04 %–2.45 %). Furthermore, the pooled rate of prevalent neoplasia was 3.9 % where neoplasia rates at index endoscopy and within 6 months were reported in the same study (n = 5; 1.4 %–10.1 %; I ² = 94 %).

The pooled rate of PEBN (interval neoplasia) was 0.52 % (0.46 %–0.58 %; I ² = 0 %) as reported by seven studies with a prediction interval of 0.45 %–0.60 %. Similarly, the pooled rate of incident neoplasia from 10 studies was 1.4 % (0.9 %–2.1 %; I ² = 90 %), with a prediction interval of 0.38 %–5.26 % ([Fig. 3]).

When analysis was restricted to non-dysplastic BE cases found at index endoscopy alone, the rate of PEBN was no different at 0.6 % (n = 4; 0.19 %–1.85 %; I ² = 0) and incident neoplasia was 1.7 % (n = 6; 1.21 %–2.3 %; I ² = 0) (Fig. 1 s). When analysis was restricted to prospective studies alone, the pooled rate of PEBN and incident neoplasia were 0.7 % (n = 2; 0.14 %–3.41 %, I ² = 0) and 2.29 % (n = 4; 1.56 %–3.34 %; I ² = 0), respectively.

The pooled rates of PEBN and incident neoplasia according to the subjects undergoing follow-up (person-years) were 1/1000 person-years of follow-up (n = 6; 0.9–1.2; I ² = 0) and 3/1000 person-years of follow-up (n = 9; 1.7–5.9; I ² = 89 %), respectively.

None of the contacted study authors were able to provide missing data from their publication (“not available” data are indicated in [Table 2]). Therefore, multiple imputations were performed to derive missing outcomes. The pooled rates of neoplasia at index endoscopy, at 6 months, at 7–36 months, and after 36 months using available and imputed data were: 6.3 % (5.0 %–7.9 %; I ² = 94.8 %), 0.2 % (0.1 %–0.5 %; I ² = 64 %), 0.53 % (0.47 %–0.59 %; I ² = 0), and 1.4 % (0.9 %–2.1 %; I ² = 89 %), respectively (Table 3 s).

Post-endoscopy Barrett’s neoplasia 3-year rate

In line with the PCCRC-3y rate according to the World Endoscopy Organization definitions, we examined the rate of PEBN at 3 years (PEBN-3y). The rate of total Barrett’s neoplasia (prevalent + PEBN) within 3 years from index endoscopy was examined in the available studies. There were only four studies with data available on prevalent neoplasia and PEBN (interval neoplasia) in the same study for the pooled analysis [18] [19] [23] [24]. Based on these data, the pooled rate of PEBN-3y showed that only 3 % of total neoplasia in BE was due to PEBN, while the remaining 97 % was prevalent neoplasia.

Proportion of neoplasia types relative to total Barrett’s neoplasia

Information on all types of Barrett’s neoplasia, including incident neoplasia identified after 3 years, in the same cohort was reported by four studies [18] [19] [23] [24]. We found that 90.7 % of Barrett’s neoplasia was either found at baseline or within 6 months of index endoscopy, with 89.8 % being found at the baseline endoscopy and an additional 0.8 % within 6 months. PEBN and incident neoplasia comprised 2.5 % and 6.8 % of the total cases of Barrett’s neoplasia ([Fig. 4]).

Meta-regression

Neoplasia detected on index endoscopy (P = 0.80), LGD (or indefinite for dysplasia) detected on index endoscopy (P = 0.4), year of publication (P = 0.25), and years of surveillance (P = 0.28) showed statistically non-significant relationships to PEBN in the meta-regression (Fig. 2 s).

Publication bias

The funnel plot (Fig. 3 s) did not show any asymmetry. Egger’s regression did not suggest any evidence of publication bias (P = 0.19).

Discussion

In line with the PCCRC method of the World Endoscopy Organization [11], in a systematic review and meta-analysis, PEBN accounted for ~3 % of Barrett’s neoplasia at 3 years (similar to the PCCRC-3y), while > 90 % of all cases of Barrett’s neoplasia were detected at baseline or within 6 months of the index endoscopy. Our results emphasize the importance of high quality baseline endoscopy in BE as the highest likelihood of finding neoplasia is at baseline, with a low risk of interval neoplasia (PEBN) at 3 years. In addition, these results support the need to establish quality measures for screening endoscopy in BE to improve neoplasia detection before patients enter the surveillance phase. Repeat endoscopy would be justifiable in cases where the examination was inadequate or suboptimal for various reasons (coexistent esophagitis, inadequate samples etc.).

We attempted to examine patterns of Barrett’s neoplasia using the PCCRC definitions and timeframes [11]. While subjects with CRC might present with symptomatic cancer (i. e. obstruction or bleeding) requiring another colonoscopy after a previous negative colonoscopy, most cases of Barrett’s neoplasia, especially early neoplasia, are detected in the absence of symptoms. After a true negative index endoscopy, very rarely was a neoplasia found within 6 months; especially if no dysplasia had been found previously. However, given that BE is a precancerous condition, the rate of progression of any missed lesion is high. We therefore selected the timeframe of the first 6 months for prevalent neoplasia as the majority of cases are either detected on index endoscopy or a follow-up endoscopy within 6 months. Follow-up endoscopies are generally performed within 3–6 months for various reasons (e. g. coexistent esophagitis, unavailability of expert endoscopist, resection of a lesion that was detected on initial endoscopy but was not biopsied, finding of LGD, or resampling).

Because a repeat endoscopy is advised 3 years after a negative index endoscopy and any neoplasia detected prior to the prescribed surveillance is defined as “interval,” a timeframe of 7–36 months was selected for PEBN (interval neoplasia). The purpose of applying “PEBN” terminology for interval neoplasia in BE was two-fold. First, a majority of endoscopies performed within the first 6 months from index endoscopy are for reasons related to the findings on the previous examination rather than for progression (of missed neoplasia); these are truly prevalent (i. e. detected cancers) rather than PEBN. Second, to capture pure interval neoplasia occurring prior to the prescribed surveillance interval in BE (those occurring between 7–36 months), while segregating true incident neoplasia (after 3 years from the index endoscopy), which is likely a “new” BE-related neoplasia rather than progression of missed neoplasia or PEBN. Therefore, a timeframe of any neoplasia after 3 years (the prescribed interval) was selected for incident neoplasia.

We have compared the published rates of PCCRC to the analyzed PEBN rates (Table 4 s). The rates of prevalent Barrett’s neoplasia are quite comparable with detected CRCs. However, there is a discrepancy among interval neoplasia rates at 3 years (PEBN-3y 2.5 % vs. PCCRC-3y 7.5 %). This difference could be explained by factors specific to PCCRCs (e. g. inadequate inspection or bowel preparation, incomplete resection). Unfortunately, unlike colonoscopy, definitions of a high quality endoscopy (i. e. Boston bowel preparation scale, cecal intubation rate, withdrawal time) are not used in Barrett's endoscopy. This emphasizes the inconsistency around a "true" missed Barrett's neoplasia and the need for better definitions that can be examined in future prospective studies. In addition, with pathologists’ interobserver reliability in making a diagnosis of HGD vs. LGD, sampling error (biopsy vs. endoscopic mucosal resection for a visible lesion), and coexistent inflammation, it is better to avoid the term “missed” for neoplasia detected within the first 6 months of a negative index endoscopy. Furthermore, the reasons why subjects underwent repeat endoscopy within the first 6 months should be reported for the calculation of prevalent neoplasia. As the included studies did not report the indication for repeat endoscopy within 6 months and did not correlate the findings of the initial endoscopy with the neoplasia detected later, we were not able to study this further.

In a prior publication reporting missed and incident EAC [5], the authors reported 25.3 % as missed and 75.7 % as incident among all cancers found after a negative endoscopy. However, the proportion of cancers at 1–3 years and after 3 years of the negative endoscopy were not analyzed. In addition, several prior studies providing information only on EAC (but not on HGD) were not included in the analysis owing to the absence of adequate information on baseline neoplasia (vs. a negative endoscopy). Neoplasia detected at baseline endoscopy [4] has been examined as a quality improvement parameter in BE endoscopy. We propose that, in addition to neoplasia detected at baseline endoscopy, BE inspection time [27] and adherence to biopsy protocol (systematic four-quadrant sampling and targeted sampling if required) should be used as quality metrics. Furthermore, these PEBN definitions can be used in prospective studies to further validate study results for performance measurement.

This analysis has a few limitations. While our focus was on Barrett’s neoplasia after a negative index endoscopy, similarly to PCCRC, unlike for colonoscopy (e. g. adenoma detection rate and withdrawal time), there are no prospectively validated quality metrics in BE endoscopy. Because of the lack of information on patient and/or endoscopy factors (i. e. indication for previous endoscopy, biopsy protocol, use of image-enhanced endoscopy, type of endoscope used, and inspection time), we could not examine their impact on PEBN. Gastrointestinal society guidelines also endorse surveillance in 5 years [2] [28] for low risk groups (i. e. short-segment BE), which could not be evaluated in this analysis to assess whether their risk is different from that of high risk groups. Confirmation of “dysplasia” by a second pathologist is recommended; however, available studies did not consistently report if this was done.

We performed multiple imputations to overcome missing information and showed comparable incidence rates. However, the proportion values were found to be skewed from the use of imputed values for two large studies [8] [9], impacting the calculation. Our purpose of including covariates in a statistical model was to increase the internal validity of the findings by reducing confounding bias. We attempted to examine the relationship of prevalent LGD and index neoplasia on PEBN using meta-regression; however, only a few studies reported this information.

There was considerable heterogeneity (I ²) in the majority of the pooled estimates that cannot be explained by chance alone; however, this does reflect the varying prevalence of neoplasia in different studies and corresponds to prior work [5] [29]. These results signify the need for more consistent reporting and the limited reliability of the obtained numerical results. Finally, despite a comprehensive approach, we had to exclude studies reporting rates of missed cancer within 12 or 24 months if the rates for the first 6 months were not provided, thereby leaving us with a low number of studies to derive precise rates (Table 2 s).

In conclusion, the majority of neoplasia in BE is diagnosed at the initial index examination; neoplasia detected after a negative baseline endoscopy accounts for a low proportion of the overall burden of neoplasia. Efforts must be focused on improving the reporting of these important parameters to enhance the quality of endoscopy in BE. We propose the use of these definitions of PEBN in future large prospectively designed trials to understand the impact of neoplasia detected at baseline, the relationship with post-endoscopy neoplasia, and how to improve the quality of index endoscopy in these subjects. Furthermore, future research should determine whether, as is done for a high quality negative colonoscopy, the surveillance endoscopy in BE patients can be extended beyond the current recommendation of every 3–5 years.

Competing interests

The authors declare that they have no conflict of interest.

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Corresponding author

Publication History

Received: 27 July 2021

Accepted after revision: 03 January 2022

Accepted Manuscript online:
03 January 2022

Article published online:
25 March 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

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• Supplementary Material