Impediments to implementation of real-time pathology prediction in Barrett’s esophagus and colorectal polyps

Tools like narrow band imaging (Olympus, Center Valley, Pennsylvania, United States), confocal laser microscopy (Mauna Kea Technologies, Paris, France), and chromoendoscopy (sometimes with magnification) have been used to successfully predict the pathology of diminutive colon polyps [1,2] as well as the presence of dysplasia in Barrett’s esophagus [3–8]. Despite numerous publications demonstrating that these and other tools can successfully predict pathology compared to white light endoscopy, the influence of such image enhancements in the routine clinical management of colorectal polyps and Barrett’s esophagus has been limited. Colorectal polyps, even when diminutive (and with virtually no risk of malignancy), are resected and consistently sent to pathologists. This paradigm is costly and could be replaced by the more cost-effective practice of estimating polyp pathology in real time during colonoscopy, followed by resection of diminutive lesions without submission to the pathologist. This new paradigm for management of diminutive polyps, usually called resect and discard, was estimated to allow over one billion dollars per year in health care savings in the United States [9]. However, despite nearly 100 published trials showing that trained and interested colonoscopists can differentiate conventional adenomas from lesions in the serrated class [1], resect and discard has yet to enter clinical practice. Similarly, endoscopists continue to manage Barrett’s esophagus by examination of lesions in white light, and if no nodules are identified, they perform systematic biopsy at specified intervals, but otherwise without direction. In clinical practice, these biopsies are frequently not obtained in the recommended number [10]. Further, in expert hands, image enhanced inspection and directed biopsy of Barrett’s esophagus has been shown to improve the yield of dysplasia compared to white light biopsies that may be systematic in number and interval, but are not directed [3–8]. Clearly, it is sometimes difficult to implement new paradigms in endoscopic and other medical practices, even though evidence appears to support the paradigms and they pass the test of common sense. In an attempt to salvage the clinical utility of floundering endoscopic technologies, including endoscopic imaging tools, The American Society for Gastrointestinal Endoscopy (ASGE) initiated a process it called Preservation and Incorporation of Valuable endoscopic Innovation (PIVI) [11,12]. The idea of the PIVIs was that experts would first delineate clinical problems where management could potentially be improved by application of a new endoscopic technology. Experts in the PIVI topic would define the most clinically relevant endpoints that should be addressed by investigators performing evaluations of the new technology. The PIVIs also established performance thresholds that should be achieved by the technology. The final step in the PIVI process is accompanied by an implied guarantee from the ASGE that if the performance thresholds are met, ASGE will endorse use of the new technology by appropriately trained and credentialed individuals as an acceptable alternative for the management of the originally defined clinical problem. In this issue of Endoscopy International Open, Appannagari et al. remind us that incorporating new endoscopic management paradigms can be complex [13]. Approximately 20% of gastroenterologists responding to a survey indicated they would be unwilling to incorporate the management paradigm proposed in the ASGE Barrett’s esophagus PIVI into their practice, because of concerns