CC BY-NC-ND 4.0 · Endosc Int Open 2023; 11(03): E221-E229
DOI: 10.1055/a-1967-1589

Effect of biopsy protocol adherence vs non-adherence on dysplasia detection rates in Barrett’s esophagus surveillance endoscopies: a systematic review and meta-analysis

Ilse Beaufort
1   Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
2   Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, the Netherlands
Elisabeth Akkerman
2   Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, the Netherlands
Sanne van Munster
3   Department of Gastroenterology and Hepatology, Amsterdam University Medical Center, Amsterdam, the Netherlands
Bas Weusten
1   Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, the Netherlands
2   Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht University, the Netherlands
› Author Affiliations


Background Barrett’s esophagus (BE) surveillance endoscopies are advised for early diagnosis of esophageal adenocarcinoma (EAC). Current guidelines recommend obtaining four-quadrant random biopsies every 2 centimeters of BE length alongside with targeted biopsies if visible lesions are present. Low adherence rates for this random biopsy protocol are widely reported. The aim of this systematic review and meta-analysis was to assess the effect of adherence versus non-adherence to the four-quadrant biopsy protocol on detection of dysplasia in BE patients.

Methods We searched for studies that reported effects of adherence and non-adherence to the four-quadrant biopsy protocol on dysplasia detection rates in BE patients. Adherence was defined as taking a minimum of 4 quadrant random biopsies per 2 cm of BE segment. Studies with low risk of bias and without applicability concerns were included in a good quality synthesis. Pooled relative risks (RRs) with 95% confidence interval (CI) of dysplasia detection rates were calculated.

Results A total of 1,570 studies were screened and 8 studies were included. Four studies were included in the good quality synthesis. In the pooled good quality analysis, four-quadrant biopsy protocol adherence significantly increased detection of dysplasia compared to non-adherence (RR 1.90, 95 % CI = 1.36–2.64; I2 = 45 %). Pooled RRs for LGD and HGD/EAC were 2.00 (95 % CI = 1.49–2.69; I2 = 0 %) and 2.03 (95 % CI = 0.98–4.24; I2 = 28 %), respectively.

Conclusion This systematic review and meta-analysis demonstrates that four-quadrant biopsy protocol adherence is associated with increased detection of dysplasia in BE patients. Efforts should be made to increase biopsy protocol adherence rates.

Supplementary material

Publication History

Received: 04 July 2022

Accepted after revision: 13 October 2022

Article published online:
08 March 2023

© 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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