Duodenal inspection during gastroscopy; should there be an exemption in this `standard' for barrett's surveillance?

IntroductionCurrent British Society of Gastroenterology (BSG) guidance recommends that Barrett’s surveillance should adhere to a quadrantic 2 cm biopsy protocol, in addition to sampling any visible lesions (Seattle Biopsy Protocol – SBP)1. This, together with photographic evidence of intubation of second part of duodenum (D2), are part of the BSG measurable standards for gastroscopy (OGD)2. In long Barrett’s segments, OGD can be prolonged and uncomfortable for patients, especially as the majority are performed with anaesthetic throat spray and/or light sedation, which may affect endoscopist compliance with SBP. We postulated that if endoscopists could be reassured that D2 intubation and examination did not alter management, then they would spend more time on careful oesophageal inspection and adherence to the SBP. Therefore, we planned our audit to assess: 5. If adherence to SBP was affected by maximal length of Barrett’s a) Occurrence of dysplasia and neoplasia b) If duodenal findings led to a change in managementMethodsAll patients undergoing Barrett’s surveillance at Newcastle upon Tyne (an upper GI cancer referral centre) and South Tyneside Hospitals in North East UK between from 01/04/18 to 31/03/19 were identified. Their current and previous OGD reports were reviewed to determine demographics, Barrett’s length, adherence to SBP, histology and duodenal findings.ResultsA total of 1335 endoscopy reports were reviewed from 390 patients occurring between January 2008 and April 2020. 282 (72%) were males, with an average age of at diagnosis of 61; 64 years old for females. Barrett’s length was not recorded in 81 cases and excluded from the final analysis. Duodenal inspection findings were: Normal - 96.2%; Duodenitis - 3.4%; Duodenal ulcer (clean base) - 0.4%ConclusionsOur audit demonstrates: As Barrett’s length increases, the risk of high grade dysplasia and malignancy increases, but conversely, the degree of adherence to the SBP decreases. Duodenal inspection rarely identified significant pathology, and the management of the Barrett’s oesophagus superseded the management any duodenal findings. We conclude that in the absence of new symptoms suggesting duodenal pathology, Barrett’s surveillance should be considered a distinct examination from a diagnostic OGD. The endoscopist should not need to inspect the duodenum, allowing more time to focus on careful oesophageal inspection and strict adherence to the SBP.ReferencesFitzgerald RC, et al. Gut 2013;0:1–36. Beg S, et al. Gut 2017;0:1–4