Discussion
cancer, dysplasia, BE-related neoplasia
CANCER, DISEASE, DYSPLASIA
This study demonstrated that the median duration for an adequate BE endoscopic surveillance procedure was 16.5 minutes, no difference between consultant endoscopists and independent trainees who had completed specialist training. In addition, we found evidence that the duration of the endoscopy procedure correlated with DDR.
Despite unanimous agreement among specialist guidelines in recommending endoscopic surveillance for BE, there is still some debate about the absolute impact of this intervention on patient outcomes. Although most retrospective studies found that surveillance correlated with diagnosis of cancer at an earlier stage and a reduction in mortality from EAC, the evidence suggests that the effect is smaller than expected

BE-related neoplasia can be subtle and focal; therefore, a high quality endoscopic procedure is essential for optimization of dysplasia diagnosis and initiation of timely therapeutic interventions. Although intense research is being undertaken to investigate the impact of image-enhanced endoscopy on DDR, there is no definite evidence that image-enhanced endoscopy improves DDR in BE; therefore, current European and British guidelines recommend against routine use of image-enhanced endoscopy in routine practice

Previous data suggest that adherence to the Seattle protocol drops for long segments of BE

Overall, our findings are in agreement with previous evidence from another randomized trial showing a correlation between BE inspection time and DDR
This study has several strengths. It was a prospective study with good correlation between endoscopic and histopathologic findings, and precise recording of the procedural time. Endoscopy duration included full inspection of the upper GI tract, which is recommended in general practice. As we excluded patients with obvious neoplastic lesions, these data are relevant to the general surveillance population, where endoscopists are not expected to encounter visible lesions in the majority of cases. However, there are potential limitations. This study was a post hoc analysis of a trial assessing the utility of autofluorescence imaging, probe-based confocal laser endomicroscopy, and biomarkers of dysplasia detection. The correlation between procedural time and DDR was not a primary outcome of the original clinical trial, and therefore the current study may not be adequately powered for the outcomes analyzed. Further specific prospective studies on an unselected BE cohort may be required to fully determine the optimal procedural time for dysplasia detection. No image-enhanced endoscopy was allowed in the standard arm of the study. All current endoscopy technologies feature button switch electronic chromoendoscopy, which is easy to perform and increasingly used in standard practice. While use of image-enhanced endoscopy could have had a positive impact on DDR, it is not recommended by the European and British guidelines in routine practice, and therefore was not included in the standard arm of the trial. All endoscopists in this study were BE expert endoscopists from two centers only, including trainees who received extensive training in BE-related neoplasia detection. Therefore, the results of this study cannot be directly translated to practices with endoscopists who are less experienced in BE surveillance. However, as the positive effect of procedure duration on DDR was seen predominantly on Seattle protocol biopsies, this effect is likely to be applicable to standard practice and a wider range of operators. Finally, we did not record the esophageal inspection time separately, only the overall duration of the procedure. Therefore, our data do not allow us to derive definite information on the BE inspection time. However, we were able to show that in an adequate procedure, 0.9 minutes were necessary per additional centimeter of BE length and that DDR increased for each 1 minute of procedural time, providing some indication about the average procedural time required based on the extent of the disease.In conclusion, it is important that time allocation for BE surveillance endoscopy is standardized in order to allow endoscopists to perform adequate procedures. The full beneficial impact of surveillance on patient outcome is only achievable if endoscopists are allowed to spend sufficient time inspecting and sampling the diseased mucosa. Future guidelines must consider this important issue and provide clear recommendation on the optimal duration of BE surveillance procedures.