This consensus recommendation from the AGA illustrates the importance of the proper documentation of major landmarks [4]. Detection and documentation of these landmarks are associated with a high inter- and intra-observer agreement, allowing for reliable reproducibility [4,10]. While endoscopists often photo-document these landmarks, the location of these landmarks, expressed as the distance (cm) from the incisors, should be included in the endoscopy report to standardize the relative location of the columnar-lined epithelium for each patient [5]. A recent study utilizing the Danish Pathology Registry found that in 300 patients with BE, documentation of the gastroesophageal junction and the squamo-columnar junction was performed by only 23% and 26% of endoscopists, respectively [11]. It should be noted that studies have yet to establish improvement in patient outcomes with proper documentation of landmarks.

The Prague C & M criteria allows for the documentation of the circumferential and maximal extent of the visualized BE segment, thereby standardizing the reporting of the length of BE in each patient [10]. The reliability of these criteria has been validated in multiple studies involving experts and trainees, as well as in endoscopists from Western and Asian countries [5]. The importance of documenting the length of BE via the Prague Criteria is particularly significant in EET, where endoscopists must standardize the location and extent of therapy. In terms of adherence, the same study from Denmark mentioned above also found that only 34% of endoscopy reports included the Prague classification [11]. Similarly, in a recent study, Han et al. showed that the overall Prague criteria adherence rate in patients with histologically confirmed BE was only 41.8% at a tertiary academic medical center in the US [12]. Education regarding the Prague criteria may play a significant role in adherence, as demonstrated by Ooi et al. who implemented a teaching program that resulted in a 93% adherence rate compared to a 16% adherence rate (p<0.001) in a group of endoscopists who did not receive the educational intervention [13]. Similar to landmark documentation, however, use of the Prague criteria has not been shown to improve patient outcomes, which represents a potential area for future investigation.

Visible lesions create cause for concern due to their potential to contain neoplasia. The TREAT-BE consortium recommends the use of the Paris classification to uniformly grade visible lesions. Put simply, the Paris classification separates protruded lesions from flat lesions [5]. Non-flat lesions include (1) 0-Ip (pedunculated) and (2) 0-Is (sessile). Flat lesions consist of 0-IIa (superficially elevated), 0-IIb (flat), 0-IIc (superficially depressed), and 0-III (excavated). Lesions with the 0-Is, 0-IIc, and 0-III classification are more likely to carry invasive cancer, whereas 0-IIa and 0-IIb lesions are unlikely to carry invasive cancer. However, there is currently no evidence that demonstrates an improvement in patient outcomes with the use of the Paris classification.

High-definition white light endoscopy (HD-WLE) enables the procurement of a higher-resolution image that can provide a clearer view of the mucosa affected by BE and has become the standard of care in the primary evaluation of patients with BE [1]. While no randomized controlled trial has directly compared HD-WLE with standard-definition white light endoscopy, data from at least four high-quality observational studies comparing random biopsies using HD-WLE with targeted biopsies using narrow band imaging, including that by Sharma et al., indicate that HD-WLE has a higher sensitivity than standard-definition white light endoscopy in finding BE-related neoplasia [6,14].

While this quality indicator received a weak recommendation from the AGA with a low quality of supporting evidence, its importance derives from the need to reduce unnecessary and frequent endoscopy that adds minimal benefit to patients. As Shaheen et al. recently pointed out, a minimalist approach to endoscopy is crucial to increase the yield of clinically relevant information for the patient while decreasing the costs and risks associated with endoscopy [15]. A recent study by Wani et al. utilizing the GI Quality Improvement Consortium (GIQuIC) registry, a national data repository of endoscopy quality measures from the US, found that of the 25,945 patients with NDBE, 26.9% were recommended surveillance at 1–2 years, which is much sooner than the minimum 3-year interval [16]. Similarly, Tavakkoli et al. showed in a single-center study that only 15.9% of patients with NDBE underwent appropriate surveillance, with 37.9% receiving over-surveillance [17]. Notably, they found that the presence of a primary care physician in their practice decreased the risk of over-surveillance, which represents a potential way to improve appropriate surveillance in this patient population. Given that NDBE is associated with a very low risk of progression to EAC, application of this quality indicator may result in substantial cost savings while adding minimal risk [18].

The Seattle protocol, consisting of systematic 4-quadrant biopsies every 2 cm throughout the length of BE, was recommended by the AGA for performing surveillance [4]. In support of this, Abrams et al. evaluated 2,245 surveillance endoscopies and found that the odds of detecting dysplasia decreased with nonadherence to a systematic biopsy protocol (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.35–0.82), highlighting the clinical importance of standardized tissue sampling [19]. Several studies have examined the adherence by endoscopists to performing the Seattle protocol for surveillance. In a single-center retrospective study examining 397 patients who received an upper endoscopy for BE, Westerveld et al. found adherence to the Seattle protocol to be only 24.1% [20]. Additionally, endoscopists with a longer time in practice had a lower likelihood of performing the Seattle protocol (OR, 0.91; 95% CI, 0.85–0.97, p<0.01). In a prospective study, Ooi et al. incorporated a training program to teach concepts such as the Seattle protocol and found that after the training program, endoscopists had a 77% adherence rate to the Seattle protocol, which was significantly higher than the cohort of endoscopists who did not participate in the training program (10%, p<0.001) [13]. Lastly, a recent study utilizing the GIQuIC registry assessed 58,709 upper endoscopies in the United States and found a Seattle protocol adherence rate of between 73%–77.5% [21]. Surprisingly, there was a strong inverse association between BE length and adherence (p<0.0001), suggesting that patients with the highest risk of dysplasia do not receive proper sampling. Data from this registry also revealed regional variation in adherence rates, with the Northeast region of the US having a 81.4%–84.8% adherence rate compared to the Midwest region of the US, which had an adherence rate from 62.5%–67.8%, which implies variability in practice patterns by geography [22].

This important quality indicator highlights the substantial interobserver variability in the interpretation of dysplasia by pathologists. In a study by Curvers et al., two expert pathologists reviewed the histology of 147 patients diagnosed with LGD at community practices [23]. After review, 85% of the patients were downstaged to either LGD or indefinite for dysplasia. Endoscopic follow-up validated the re-staging as the risk of progression differed significantly between patients with confirmed LGD (13.4% per patient per year) and downgraded patients (0.49% per patient per year). A meta-analysis by Qumseya et al. confirmed these findings, demonstrating a significantly higher cumulative rate of progression from LGD in studies where an expert gastrointestinal pathologist/panel of pathologists confirmed the histological diagnosis of LGD [24]. Therefore, an expert pathologist or group of pathologists should review diagnoses of BE-associated dysplasia to not only provide the best prognostic information, but also to guide treatment and/or surveillance. The TREAT-BE Consortium also advocates for standardization in reporting dysplasia via use of the Vienna classification, as follows: (1) negative for dysplasia, (2) indefinite for dysplasia, (3) LGD, (4) HGD, and (5) invasive neoplasia [5].

This process measure reflects the need for appropriate equipment to detect and treat BE. Although no randomized studies have directly analyzed HD-WLE against standard definition-white light endoscopy, Schölvinck et al. found a significantly lower neoplastic detection rate in community hospitals (60%) than in expert centers (87%, p<0.001), which attests to the importance of having the necessary resources to provide high-quality care [25]. As few studies have examined the level of proficiency needed for ablation and endoscopic mucosal resection (EMR), this indicator cannot address the minimum thresholds for competence in these techniques.

Detailed and thorough informed consent enables patients to understand the risks and benefits of any therapy and gives them the necessary information to make a decision that is consistent with their beliefs and desires. For BE in particular, important aspects include the risk of progression, goals of EET, potential need for repeat endoscopies, post-procedure treatments such as acid suppression, and surveillance intervals after complete eradication of intestinal metaplasia (CE-IM). Future studies should examine the impact of comprehensive informed consent on patient satisfaction.

As supported by both quality indicator documents and several observational studies, endoscopic resection can improve histologic accuracy and offers therapeutic potential in addition to its diagnostic capabilities [4,5]. As Moss et al. demonstrated in their prospective study of 75 patients, endoscopic resection resulted in a change in the grading or staging in 48% of patients, and after a median follow-up period of 31 months, no recurrence occurred at the resection sites in the entire cohort [26]. Comparing EMR to standard biopsy, Wani et al. showed that the interobserver agreement in the diagnosis of dysplasia was significantly greater for EMR specimens (n=251) than for biopsy specimens (n=269) [27]. Furthermore, in a recent meta-analysis by Wani et al. including 14 studies, a random-effects model demonstrated that EMR resulted in a change in the pathologic diagnosis in 39% (95% CI, 34%–45%) of all patients [28].

These two quality indicators speak to the importance of achieving the treatment goal in line with published rates for the CE-IM and neoplasia, of which CE-IM remains the primary treatment goal. As Pech et al. demonstrated in a longterm follow-up study of 349 patients with HGD or EAC, CE of dysplasia (CE-D) occurred in 96.6% of patients with endoscopic therapy; however, metachronous lesions developed in 21.5% of patients, suggesting that CE-D alone does not facilitate the ideal endpoint for patients [29]. Two major randomized controlled trials by Shaheen et al. and Phoa et al. have set the benchmark for the performance of EET in achieving CE-D and CE-IM [30,31]. In the Ablation of Intestinal Metaplasia dysplasia trial by Shaheen et al. involving patients with LGD and HGD, CE-D and CE-IM was achieved in 90.5% (for LGD) and 77.4% of patients, respectively [30]. Furthermore, patients in the radiofrequency ablation (RFA) group had a lower rate of disease progression (3.6% vs. 16.3%, p=0.03) than did the control group. Similarly, the trial by Phoa et al. randomized patients with LGD to either RFA or surveillance and demonstrated a CE-D rate of 92.6% and CE-IM rate of 88.2% [31]. Ablation also significantly reduced the risk of progression (1.5% vs. 26.5%, p<0.001) in these patients. Overall, RFA has been found to have a CE-D rate of 91% (95% CI, 87%–95%) and a CE-IM rate of 78% (95% CI, 70%–86%) [6]. The timeframe of 18 months was chosen to reflect the median number of sessions required to achieve CE-IM in these trials, but no data currently suggest that this timeline improves outcomes such as progression.

Although CE-IM remains the goal of all endoscopic therapy in patients with dysplastic BE, recurrence remains a serious concern as it can occur in 5%–39.5% of patients after CE-IM [5]. Despite strong agreement on the necessity of surveillance, there is little evidence to guide the establishment of optimal surveillance intervals. Recently, however, Cotton et al. collected data from the United States Radiofrequency Ablation Registry (5,444 patients from 2004–2013) and the United Kingdom National Halo Registry (391 patients from 2007–2015) to build and validate Cox proportional hazard models to predict neoplasia recurrence rates following successful RFA [32]. These models created three risk groups based on the baseline grade of dysplasia categorized into (1) NDBE or indefinite for dysplasia, (2) LGD, and (3) HGD or intramucosal adenocarcinoma. Patients with LGD had a neoplastic recurrence rate of 2.0, leading to a suggested surveillance endoscopy schedule of 1 and 3 years after CE-IM. For patients with HGD or EAC, a neoplasia recurrence rate of 5.5 was found, leading to a recommended surveillance schedule of 0.25, 0.5, and 1 year after CE-IM and annually thereafter.

This statement builds on evidence that improved acid control is associated with improved outcomes after EET such as RFA. In a multicenter study including 278 patients with BE treated with circumferential RFA, van Vilsteren et al. found that an independent predictor for a poor response to treatment included ongoing reflux esophagitis (OR, 37.4; 95% CI, 3.2, 433.2) [33]. Similarly, Komanduri et al. followed 221 consecutive patients treated with RFA [34]. In patients who did not achieve CE-IM within three sessions of RFA, the only predictive factor for incomplete response was a reduction in dose or frequency of proton pump inhibitor during EET. Additionally, among incomplete responders, 93.8% eventually achieved CEIM after acid reduction modifications (primarily fundoplication and alteration in acid suppressive medications) after a mean of 1.1 additional RFA sessions.

The tracking and documentation of adverse events remain a cornerstone in providing high-quality care to patients with BE. A meta-analysis by Qumseya et al. demonstrated an overall 8.8% adverse event rate for RFA in patients with BE [35]. Adverse events included strictures (5.6%), bleeding (1%), and perforation (0.6%). The individual rates of these adverse events for each endoscopist should be relayed to each patient to fully disclose the risks of EET.