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Original Article
International development and validation of a classification system for the identification of Barrett’s neoplasia using acetic acid chromoendoscopy: the Portsmouth acetic acid classification (PREDICT)
  1. Kesavan Kandiah1,
  2. Fergus J Q Chedgy1,
  3. Sharmila Subramaniam1,
  4. Gaius Longcroft-Wheaton1,
  5. Paul Bassett2,
  6. Alessandro Repici3,
  7. Prateek Sharma4,
  8. Oliver Pech5,
  9. Pradeep Bhandari1
  1. 1Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
  2. 2Statsconsultancy Limited, Amersham, UK
  3. 3Department of Gastroenterology, Endoscopy Division, Humanitas Research Hospital, Milan, Italy
  4. 4Department of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Kansas, USA
  5. 5Department of Gastroenterology and Interventional Endoscopy, St. John of God Hospital, Regensburg, Germany
  1. Correspondence to Professor Pradeep Bhandari, Department of Gastroenterology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth PO6 3LY, UK; pradeep.bhandari{at}porthosp.nhs.uk

Abstract

Background Barrett’s oesophagus is an established risk factor for developing oesophageal adenocarcinoma. However, Barrett’s neoplasia can be subtle and difficult to identify. Acetic acid chromoendoscopy (AAC) is a simple technique that has been demonstrated to highlight neoplastic areas but lesion recognition with AAC remains a challenge, thereby hampering its widespread use.

Objective To develop and validate a simple classification system to identify Barrett’s neoplasia using AAC.

Design The study was conducted in four phases: phase 1—development of component descriptive criteria; phase 2—development of a classification system; phase 3—validation of the classification system by endoscopists; and phase 4—validation of the classification system by non-endoscopists.

Results Phases 1 and 2 led to the development of a simplified AAC classification system based on two criteria: focal loss of acetowhitening and surface patterns of Barrett’s mucosa. In phase 3, the application of PREDICT (Portsmouth acetic acid classification) by endoscopists improved the sensitivity and negative predictive value (NPV) from 79.3% and 80.2% to 98.1% and 97.4%, respectively (p<0.001). In phase 4, the application of PREDICT by non-endoscopists improved the sensitivity and NPV from 69.6% and 75.5% to 95.9% and 96.0%, respectively (p<0.001).

Conclusion We developed and validated a classification system known as PREDICT for the diagnosis of Barrett’s neoplasia using AAC. The improvement seen in the sensitivity and NPV for detection of Barrett’s neoplasia in phase 3 demonstrates the clinical value of PREDICT and the similar improvement seen among non-endoscopists demonstrates the potential for generalisation of PREDICT once proven in real time.

  • endoscopy
  • Barrett’s oesophagus
  • Barrett’s adenocarcinoma
  • acetic acid chromoendoscopy
  • diagnostic endoscopy
  • endoscopic procedures

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Footnotes

  • Contributors KK: conception and design, development of AAC classification system, acquisition of the endoscopic images, maintaining the image library, designing the tests for validating the criteria, interpretation of the results, drafting the manuscript. FJQC: acquisition of the endoscopic images, designing the tests for validating the criteria. SS: internal validation of the criteria, critical revision of the manuscript for intellectual content. GLW: concept and design, development of AAC classification system, analysis and interpretation of data, critical revision of the manuscript for intellectual content. PBassett: statistical analysis and critical revision of the manuscript for intellectual content. AR and PS: interpretation of the results, critical revision of the manuscript for intellectual content. OP: concept and design, development of AAC classification system, interpretation of the results, critical revision of the manuscript for intellectual content. PBhandari: concept and design, development of AAC classification system, designing the tests for validating the criteria, interpretation of the results, critical revision of the manuscript for intellectual content, study supervision.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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