Characteristics and causes of post-endoscopy Barrett’s neoplasia: Retrospective multicenter study

Abstract Missed high-grade dysplasia (HGD) or adenocarcinoma in Barrett's esophagus (BE) may have serious consequences, although the attributes of post-endoscopy Barrett's neoplasia (PEBN) remain unexplored. We analyzed the characteristics of Barrett’s neoplasia (BN) eluding detection during screening endoscopy. We retrospectively reviewed endoscopic images of BN, including HGD and adenocarcinoma, diagnosed at six centers in Nagano prefecture. Eligible patients had index endoscopic images obtained 7 to 36 months before BN diagnosis. Causes of PEBN were classified as perceptual error, in which BN was missed despite images taken where it was eventually diagnosed, or exposure error, whereby no images were obtained in the area of BN development. Among the 91 patients with BN, 31 were judged as having PEBN. The majority of PEBN cases were attributed to perceptual error (22 patients, 71%). Lesions within long-segment BE (LSBE) were significantly more likely to be overlooked due to exposure error (67% vs. 18%, P = 0.02), whereas lesions at the 0 to 3 o’clock position in short-segment BE (SSBE) tended to be missed due to perceptual error (76% vs. 33%, P = 0.04). Notably, 39% of perceptual error cases were misdiagnosed as esophagitis on index endoscopy. In the nine patients requiring surgery for PEBN, eight cases were attributed to perceptual error. PEBN occurring in LSBE was mostly overlooked because of inadequate observation, whereas PEBN at the 0 to 3 o'clock position in SSBE was frequently misdiagnosed as esophagitis. Bearing these results in mind may improve quality of endoscopic screening and reduce incidence of PEBN.