High rate of neoplasia diagnosis at endoscopic reassessment and incidence of progression in patients with ultra-long Barrett esophagus referred to expert centers.

Surveillance practice is now defined by the AGA 2025 surveillance guideline (Wani et al., Gastroenterology 2025;169:1184-1231; endorsed by the Canadian Association of Gastroenterology). Its 8 GRADE recommendations are: (1) endoscopic surveillance for nondysplastic BE rather than none (conditional, low certainty); (2) NO endoscopic surveillance for columnar-lined esophagus <1 cm, even with intestinal metaplasia, when there is no neoplasia (conditional); (3) high-definition white-light endoscopy PLUS chromoendoscopy over white light alone (STRONG); (4) no recommendation for or against wide-area transepithelial sampling (WATS-3D) as an adjunct to structured biopsy; (5) no recommendation on p53 IHC and (6) no recommendation on TissueCypher as adjuncts to histopathology in NDBE, indefinite for dysplasia (IND), or LGD; (7) daily PPI over no PPI to prevent neoplastic progression (conditional); (8) PPI over antireflux surgery to prevent progression to HGD/EAC (conditional). Implementation statements require a high-quality exam, a structured (Seattle-type) biopsy protocol, confirmation of any BE-related dysplasia by an expert GI pathologist, intervals tailored to segment length and dysplasia grade, and shared decision-making. Surveillance should stop when a patient could not tolerate endoscopic therapy, surgery, or oncologic treatment for EAC, at any age. The AGA 2025 interval table could not be read directly (full text paywalled). Until it is, the intervals below are the ACG 2022 intervals, which remain consistent with AGA's segment-length framing: NDBE <3 cm every 5 years; NDBE >=3 cm every 3 years; IND, after a second-pathologist read, optimize to twice-daily PPI, repeat EGD within 6 months, then annually if IND persists; confirmed LGD on surveillance, EGD at 6 and 12 months, then annually. Diagnosis (IM plus >=1 cm columnar mucosa, no biopsy of a normal or <1 cm irregular Z line, >=8 biopsies), endoscopic eradication therapy (EET over esophagectomy for HGD/T1a (strong); EET suggested for confirmed LGD with surveillance an acceptable alternative; resect visible lesions before RFA; sm1 low-risk T1b may be considered for EET) and post-EET intervals (baseline LGD: 1 year, 3 years, then every 2 years; baseline HGD/T1a: 3, 6, 12 months, then annually) are still governed by ACG 2022. The AGA surveillance guideline does not address them, and AGA has said a separate screening guideline will follow in 2026.