Endoscopic diagnosis and surveillance of Barrett's esophagus

There are many questions regarding the screening and surveillance for which there are currently no answers. Despite the use of models and extrapolations by some authors to suggest that screening and surveillance for a cancer of such low incidence will never be justified, others argue just as vociferously that given the continued epidemic rise in incidence of this cancer, the uniformly fatal outcome of these cancers if diagnosed after symptoms occur, and the enormous patients remaining at risk for future cancer development, a focused and prudent screening and surveillance strategy for Barrett's-related esophageal adenocarcinoma is justified. The data also show that a single screening examination is probably as effective as almost all subsequent surveillance examinations in detecting advanced neoplasia, and much of the current resource use and energy for screening and surveillance in BE should be directed toward screening. Whether screening should be offered or recommended to only older patients (> 50-55 years), whites, and men is unknown, but it is premature to adopt this strategy until better evidence exist supporting a restricted screening policy. Regarding the optimal surveillance frequency and technique, examinations more frequent than every 3 to 5 years are not justifiable, and until proven otherwise, biopsy specimens should be obtained with the largest forceps that can be used with the endoscopic instrument and "saturation" biopsies from the Barett's obtained. It is unlikely that too many biopsy specimens can be taken. Furthermore, the safety of this approach has been proven. It is quite likely that the inverse is not true; clinicians likely can do much more harm by taking too few biopsy specimens. It is hoped that the current intense interest in Barrett's neoplasia allows clinicians to address these critical issues in the years to come and resolve this clinical conundrum.