Background
The neoplastic progression risk in Barrett’s Esophagus (BE) increases with increasing BE length. Therefore, some guidelines recommend that patients with ultra long-segment BE ≥10cm (ULS-BE) are referred to an expert center, however, recommendations on further management are lacking. This study aimed to evaluate findings of an imaging endoscopy performed at a Barrett Expert Center (BEC), for patients with ULS-BE.

Methods
We included patients with flat, non-dysplastic BE ≥10cm who were referred to one of the eight Dutch BECs between January 2018 and June 2022. Patients diagnosed with visible lesions or dysplasia in the referring hospital, were excluded. Imaging endoscopy in the BEC consisted of careful imaging with adequate sedation by an experienced endoscopist, and histologic sampling according to the Seattle protocol. As routine of care, histology was assessed by an experienced pathologist. Outcomes included the proportion of patients diagnosed with a visible lesion; the proportion of patients diagnosed with dysplasia; and the risk of progression during surveillance.

Results
We included 220 patients with median BE length of C11M12 (IQR 9-12; 10-14) (mean age 63 years (SD 11)). BEC imaging endoscopy, performed median 3 months (IQR 2-10) after the last endoscopy in the referring center, revealed a visible lesion in 8/220 patients (4%), containing cancer (n=3), high-grade dysplasia (HGD, n=3) or low-grade dysplasia (LGD, n=2). Additionally, random biopsies in the absence of visible lesions showed LGD in 31 patients (14%) and HGD in 2 patients (1%). So, upon referral to a BEC, 41 patients (19%) were upstaged from no dysplasia to BE with dysplasia or cancer.

For 155/220 patients, non-dysplastic ULS-BE was confirmed after BEC imaging endoscopy with adequate biopsy sampling. The remaining patients had dysplasia (n=41) or had inadequate histologic sampling (n=24). Patients with confirmed non-dysplastic ULS-BE underwent endoscopic surveillance (n=119) or will be scheduled for surveillance, according to guideline advised intervals (n=36). During median 27 months of surveillance (IQR 23-47) with median 2 endoscopies (IQR 1-2), 8/119 patients progressed to HGD/cancer (7%) and 14/119 to LGD (12%) after median 26 months (IQR 18-37). The progression rate to HGD/cancer was 2.5 per 100 patient years (95% CI 1-5). Progression to HGD/cancer was detected as visible abnormalities (n=7; 2 HGD, 5 cancer) or in random biopsies (n=1: HGD). All patients with progression to HGD/cancer were treated endoscopically.

Conclusion
Endoscopic inspection with adequate pathology sampling by Barrett experienced endoscopists for patients with USL-BE, upstaged the initial diagnosis of NDBE to dysplasia or cancer in 19% of patients, of which 4% was upstaged to HGD/cancer. Expert care may be beneficial for the high-risk population with ULS-BE.

Maartje Houben

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