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

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 PFBN 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 similar to 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.