Multinational survey on the preferred approach to management of Barrett’s esophagus in the Asia-Pacific region

Table 1 Demographics of study respondents

Respondent demographics	Study cohort (n = 569)	Percentage (%)
Age, years (median, IQR)	38 (33-46)	-
Gender
Male	443	77.9
Female	126	22.1
Specialty
Physician	514	90.3
Surgeon	55	9.7
Place of practice
Australia	6	1.1
China	129	22.7
Hong Kong	7	1.2
India	24	4.2
Japan	310	54.5
Laos	1	0.2
Malaysia	17	3.0
Myanmar	1	0.2
Philippines	1	0.2
Singapore	28	4.9
Taiwan	11	1.9
Thailand	1	0.2
Vietnam	33	5.8
Type of practice
Private institution	160	28.1
Academic institution	271	47.6
Both	138	24.3
Years of endoscopic practice (median, IQR)	10 (5-18)	-
Percentage of time performing endoscopy
< 20%	120	21.1
20%-40%	189	33.2
40%-60%	150	26.4
60%-80%	72	12.7
> 80%	38	6.7

IQR: Interquartile range.

Table 2 Survey results of respondents within study cohort

Question	Option	Results
Q1. What is your preferred endoscopic landmark of the esophagogastric junction?	Squamo-columnar Junction (Z-line)	42.0%
	Proximal margin of gastric folds	19.5%
	Distal margin of palisade vessels	36.7%
	Diaphragmatic pinch	1.8%
Q2. What is your preferred endoscopic definition of Barrett’s esophagus?	Length of columnar lined epithelium ≥ 2 cm	29.0%
	Length of columnar lined epithelium ≥ 1 cm	22.7%
	Any length of columnar lined epithelium in the esophagus	48.3%
Q3. How often do you use the Prague C and M criteria in your assessment of Barrett’s esophagus?	All the time	16.3%
	> 70% of the time	9.5%
	30%-70% of the time	11.8%
	< 30% of the time	30.1%
	Never	32.3%
Q4. How comfortable are you with endoscopic assessment (white-light with or without advanced imaging technology) in the diagnosis of Barrett’s esophagus?	100% comfortable	13.0%
	> 70% comfortable	45.2%
	30%-70% comfortable	28.8%
	< 30% comfortable	10.5%
	Not at all	2.5%
Q5. What is your preferred histologic definition of Barrett’s esophagus?	Any columnar tissue	37.1%
	Specialized intestinal metaplasia	25.7%
	Gastric metaplasia	17.4%
	No histological confirmation required	19.9%
Q6. In your practice, how regular do you survey your long-segment Barrett’s esophagus without dysplasia?	Every 2 yr	70.8%
	Every 3 yr	13.0%
	Every 5 yr	3.0%
	None at all	13.2%
Q7. How often do you follow the Seattle protocol (i.e. four-quadrant biopsies every 2 cm) in your biopsies of Barrett’s esophagus during surveillance endoscopy?	All the time	6.3%
	> 70% of the time	6.0%
	30%-70% of the time	9.1%
	< 30% of the time	29.9%
	Never	48.7%
Q8. What is your preferred treatment of Barrett’s esophagus without dysplasia?	Lifelong PPI	21.3%
	PPI only when patient has symptoms of gastroesophageal reflux or evidence of esophagitis	74.0%
	Radiofrequency ablation	2.3%
	Anti-reflux procedure (e.g., fundoplication)	2.5%
Q9. For Barrett’s esophagus patients whose biopsies showed indefinite for dysplasia, your preferred approach is:	Confirm with second pathologist and repeat endoscopy after a course of PPI	44.8%
	Surveillance 6-monthly	30.2%
	Surveillance yearly	24.1%
	Surveillance 3-5 yearly	0.9%
Q10. For Barrett’s esophagus patients without a lesion but whose biopsies showed low grade dysplasia, your preferred approach is:	Surveillance 6-monthly	55.5%
	Surveillance yearly	21.3%
	Surveillance 3-5 yearly	1.8%
	Ablative therapy, e.g., radiofrequency, cryotherapy, argon plasma coagulation	9.5%
	Endoscopic mucosal resection	3.9%
	Endoscopic submucosal dissection	8.1%
Q11. For Barrett’s esophagus patients without a lesion but whose biopsies showed high grade dysplasia, your preferred treatment is:	Endoscopic mucosal resection	17.0%
	Endoscopic submucosal dissection	68.2%
	Ablative therapy, e.g., radiofrequency, cryotherapy, argon plasma coagulation	11.2%
	Surgery, e.g., esophagectomy	3.5%

PPI: Proton pump inhibitor.

Table 3 Survey results of respondents comparing Japan vs rest of Asia

Question	Option	Japan	Rest of Asia	P value
Q1. What is your preferred endoscopic landmark of the esophagogastric junction?	Squamo-columnar Junction (Z-line)	27.4%	59.5%	< 0.001
	Proximal margin of gastric folds	12.6%	27.8%
	Distal margin of palisade vessels	59.0%	10.0%
	Diaphragmatic pinch	1.0%	2.7%
Q2. What is your preferred endoscopic definition of Barrett’s esophagus?	Length of columnar lined epithelium ≥ 2 cm	23.2%	35.9%	< 0.001
	Length of columnar lined epithelium ≥ 1 cm	12.6%	34.7%
	Any length of columnar lined epithelium in the esophagus	64.2%	29.3%
Q3. How often do you use the Prague C and M criteria in your assessment of Barrett’s esophagus?	All the time	11.3%	22.4%	< 0.001
	> 70% of the time	4.5%	15.4%
	30%-70% of the time	8.7%	15.4%
	< 30% of the time	29.4%	30.9%
	Never	46.1%	15.8%
Q4. How comfortable are you with endoscopic assessment (white-light with or without advanced imaging technology) in the diagnosis of Barrett’s esophagus?	100% comfortable	17.1%	8.1%	< 0.001
	> 70% comfortable	51.6%	37.5%
	30%-70% comfortable	24.2%	34.4%
	< 30% comfortable	6.5%	15.4%
	Not at all	0.6%	4.6%
Q5. What is your preferred histologic definition of Barrett’s esophagus?	Any columnar tissue	35.2%	39.4%	< 0.001
	Specialized intestinal metaplasia	16.8%	36.3%
	Gastric metaplasia	16.1%	18.9%
	No histological confirmation required	31.9%	5.4%
Q6. In your practice, how regular do you survey your long-segment Barrett’s esophagus without dysplasia?	Every 2 yr	82.3%	57.1%	< 0.001
	Every 3 yr	4.8%	22.8%
	Every 5 yr	1.6%	4.6%
	None at all	11.3%	15.4%
Q7. How often do you follow the Seattle protocol (i.e. four-quadrant biopsies every 2 cm) in your biopsies of Barrett’s esophagus during surveillance endoscopy?	All the time	2.6%	10.8%	< 0.001
	> 70% of the time	4.2%	8.1%
	30%-70% of the time	2.3%	17.4%
	< 30% of the time	17.7%	44.4%
	Never	73.2%	19.3%
Q8. What is your preferred treatment of Barrett’s esophagus without dysplasia?	Lifelong PPI	15.8%	27.8%	< 0.001
	PPI only when patient has symptoms of gastroesophageal reflux or evidence of esophagitis	81.9%	64.5%
	Radiofrequency Ablation	1.0%	3.9%
	Anti-reflux procedure (e.g. fundoplication)	1.3%	3.9%
Q9. For Barrett’s esophagus patients whose biopsies showed indefinite for dysplasia, your preferred approach is:	Confirm with second pathologist and repeat endoscopy after a course of PPI	32.6%	59.5%	< 0.001
	Surveillance 6-monthly	37.7%	21.2%
	Surveillance yearly	29.0%	18.1%
	Surveillance 3-5 yearly	0.6%	1.2%
Q10. For Barrett’s esophagus patients without a lesion but whose biopsies showed low grade dysplasia, your preferred approach is:	Surveillance 6-monthly	61.9%	47.9%	< 0.001
	Surveillance yearly	21.9%	20.5%
	Surveillance 3-5 yearly	1.0%	2.7%
	Ablative therapy, e.gv., radiofrequency, cryotherapy, argon plasma coagulation	1.0%	19.7%
	Endoscopic mucosal resection	1.6%	6.6%
	Endoscopic submucosal dissection	12.6%	2.7%
Q11. For Barrett’s esophagus patients without a lesion but whose biopsies showed high grade dysplasia, your preferred treatment is:	Endoscopic mucosal resection	12.6%	22.4%	< 0.001
	Endoscopic submucosal dissection	83.5%	49.8%
	Ablative therapy, e.g., radiofrequency, cryotherapy, argon plasma coagulation	2.6%	21.6%
	Surgery, e.g., esophagectomy	1.3%	6.2%

PPI: Proton pump inhibitor.

Table 4 Survey results of respondents comparing academic vs non-academic endoscopists

Question	Option	Academic	Non-academic	P value
Q1. What is your preferred endoscopic landmark of the esophagogastric junction?	Squamo-columnar Junction (Z-line)	37.4%	53.8%	0.005
	Proximal margin of gastric folds	21.0%	15.6%
	Distal margin of palisade vessels	39.9%	28.8%
	Diaphragmatic pinch	1.7%	1.9%
Q2. What is your preferred endoscopic definition of Barrett’s esophagus?	Length of columnar lined epithelium ≥ 2 cm	26.4%	35.6%	0.094
	Length of columnar lined epithelium ≥ 1 cm	23.5%	20.6%
	Any length of columnar lined epithelium in the esophagus	50.1%	43.8%
Q3. How often do you use the Prague C and M criteria in your assessment of Barrett’s esophagus?	All the time	19.3%	8.8%	0.004
	> 70% of the time	11.0%	5.6%
	30%-70% of the time	11.0%	13.8%
	< 30% of the time	28.4%	34.4%
	Never	30.3%	37.5%
Q4. How comfortable are you with endoscopic assessment (white-light with or without advanced imaging technology) in the diagnosis of Barrett’s esophagus?	100% comfortable	13.9%	10.6%	0.043
	> 70% comfortable	46.5%	41.9%
	30%-70% comfortable	28.4%	30.0%
	< 30% comfortable	8.3%	16.3%
	Not at all	2.9%	1.3%
Q5. What is your preferred histologic definition of Barrett’s esophagus?	Any columnar tissue	35.2%	41.9%	0.093
	Specialized intestinal metaplasia	28.4%	18.8%
	Gastric metaplasia	16.4%	20.0%
	No histological confirmation required	20.0%	19.4%
Q6. In your practice, how regular do you survey your long-segment Barrett’s esophagus without dysplasia?	Every 2 yr	69.9%	73.1%	0.001
	Every 3 yr	16.1%	5.0%
	Every 5 yr	2.7%	3.8%
	None at all	11.2%	18.1%
Q7. How often do you follow the Seattle protocol (i.e. four-quadrant biopsies every 2 cm) in your biopsies of Barrett’s esophagus during surveillance endoscopy?	All the time	6.6%	5.6%	0.281
	> 70% of the time	6.6%	4.4%
	30%-70% of the time	9.8%	7.5%
	< 30% of the time	27.4%	36.3%
	Never	49.6%	46.3%
Q8. What is your preferred treatment of Barrett’s esophagus without dysplasia?	Lifelong PPI	23.2%	16.3%	0.091
	PPI only when patient has symptoms of gastroesophageal reflux or evidence of esophagitis	73.1%	76.3%
	Radiofrequency Ablation	1.7%	3.8%
	Anti-reflux procedure (e.g. fundoplication)	2.0%	3.8%
Q9. For Barrett’s esophagus patients whose biopsies showed indefinite for dysplasia, your preferred approach is:	Confirm with second pathologist and repeat endoscopy after a course of PPI	45.2%	43.8%	0.973
	Surveillance 6-monthly	30.1%	30.6%
	Surveillance yearly	23.7%	25.0%
	Surveillance 3-5 yearly	1.0%	0.6%
Q10. For Barrett’s esophagus patients without a lesion but whose biopsies showed low grade dysplasia, your preferred approach is?	Surveillance 6-monthly	56.7%	52.5%	0.956
	Surveillance yearly	20.3%	23.8%
	Surveillance 3-5 yearly	1.7%	1.9%
	Ablative therapy, e.g., radiofrequency, cryotherapy, argon plasma coagulation	9.3%	10.0%
	Endoscopic mucosal resection	3.9%	3.8%
	Endoscopic submucosal dissection	8.1%	8.1%
Q11. For Barrett’s esophagus patients without a lesion but whose biopsies showed high grade dysplasia, your preferred treatment is?	Endoscopic mucosal resection	19.1%	11.9%	0.037
	Endoscopic submucosal dissection	67.2%	70.6%
	Ablative therapy, e.g., radiofrequency, cryotherapy, argon plasma coagulation	11.2%	11.3%
	Surgery, e.g., esophagectomy	2.4%	6.3%

PPI: Proton pump inhibitor.