Declaration of Bankruptcy for Four-Quadrant Biopsies in Barrett's Esophagus?

See more, biopsy less! This should be the ultimate goal for every endoscopist treating patients with Barrett's esophagus. But how can this goal be achieved? Four-quadrant biopsy protocols were introduced for surveillance and mapping purposes in patients with Barrett's esophagus more than 15 years ago, and they are still the standard of care in most countries. At that time, however, endoscopists still were using fiberoptic endoscopes with poor image quality. It was not possible to detect subtle changes in the mucosal pattern with such instruments, and it was therefore almost impossible to identify early neoplastic lesions.¹ However, 85% of high-grade dysplasias and mucosal Barrett's cancers appear as very discrete changes in the mucosal and vascular pattern (type II lesions in the Paris classification). Only 13% of these early neoplastic lesions appear as nodules (type I).⁴ It is hardly surprising, therefore, that a systematic biopsy protocol was at that time able to identify significantly more neoplastic lesions than targeted biopsies did. Dramatic developments have taken place in endoscope technology since the early 1990s—but despite this, we are still continuing to cling to the 4-quadrant biopsy protocol, which is now senescent and even starting to look rather antiquated, in view of the technical facilities available today.