Location and appearance of dysplastic Barrett's recurrence after endoscopic eradication therapy: no additional yield from random biopsies of neosquamous mucosa.

BACKGROUND & AIMS: Surveillance after complete remission of intestinal metaplasia (CRIM) is essential. Current recommendations are to sample visible lesions first, followed by random four quadrant biopsies of the original Barrett's length. To inform post-CRIM surveillance protocols, we aimed to identify the anatomic location, appearance and histology of Barrett's recurrences.

METHODS: We performed an analysis of 216 patients who achieved CRIM following endoscopic eradication therapy (EET) for dysplastic Barrett's esophagus (BE) at a Barrett's referral unit between 2008 and 2021. The anatomic location, the recurrence histology and endoscopic appearance of dysplastic recurrences were evaluated.

RESULTS: After a median (p25-p-75) 5.5 years (2.9-7.2) of follow up post-CRIM, 57 patients (26.4%) developed NDBE recurrence and 18 patients (8.3%) developed dysplastic recurrence. From a total of 8,158 routine surveillance biopsies of normal appearing tubular esophageal neosquamous epithelium, the yield for recurrent NDBE or dysplasia was 0%. 100% of dysplastic tubular esophageal recurrences were visible and in Barrett's islands, whilst 77.8% of GEJ dysplastic recurrences were non-visible. Four distinct endoscopic features suspicious for recurrent advanced dysplasia or neoplasia were identified: (1) Buried or sub-squamous Barrett's, (2) Irregular mucosal pattern, (3) Loss of vascular pattern, (4) Nodularity or depression.

CONCLUSIONS: The yield of routine surveillance biopsies of normal appearing tubular esophageal neosquamous epithelium was zero. Barrett's islands with indistinct mucosal or loss of vascular pattern, nodularity or depression and/or signs of buried Barrett's should raise clinician suspicion for advanced dysplasia or neoplasia recurrence. We suggest a new surveillance biopsy protocol with a focus on meticulous inspection, followed by targeted biopsies of visible lesions and random four quadrant biopsies of the GEJ.