Chromoendoscopy Fails to Improve Cancer Detection in Barrett's Oesophagus: BMJ
Netherlands: In a randomised trial involving 2,267 patients, acetic acid chromoendoscopy identified more suspicious lesions but did not improve detection of dysplasia or oesophageal cancer during routine surveillance.
Detecting early cancer in patients with Barrett's oesophagus remains an important challenge for gastroenterologists. Although surveillance endoscopy offers an opportunity to identify dysplasia before progression to oesophageal adenocarcinoma, subtle abnormalities can be difficult to recognise. Acetic acid chromoendoscopy has been proposed as a simple, inexpensive method to improve detection. However, a large randomised trial suggests that adding this technique to routine surveillance may not provide the expected diagnostic advantage.
The ACID trial, published on October 21, 2026, in the BMJ, investigated whether acetic acid chromoendoscopy increased the detection of dysplasia and oesophageal adenocarcinoma in patients undergoing Barrett's oesophagus surveillance.
Conducted across 18 community hospitals in the Netherlands, the prospective, open-label, stepped-wedge cluster randomised trial enrolled 2,267 patients. Individuals with known or previously treated dysplasia were excluded.
Hospitals transitioned from conventional surveillance to surveillance incorporating acetic acid chromoendoscopy, with endoscopists receiving training before implementation.
Acetic acid chromoendoscopy involves applying dilute acetic acid to the oesophageal mucosa. Normal Barrett's epithelium temporarily develops a whitish appearance, while neoplastic areas may lose this whitening effect more rapidly, making suspicious lesions easier to recognise.
The researchers wanted to determine whether improved visualisation translated into more confirmed diagnoses.
Among the 2,267 participants, 163 (7.2%) were diagnosed with neoplasia. This included 111 patients (4.9%) with low-grade dysplasia, 30 (1.3%) with high-grade dysplasia and 22 (1.0%) with oesophageal adenocarcinoma.
The principal finding was that acetic acid chromoendoscopy did not significantly improve overall neoplasia detection.
Neoplasia was detected in 7.4% of patients who underwent acetic acid chromoendoscopy, compared with 7.1% of those who underwent surveillance without it. The adjusted odds ratio was 0.97 (95% confidence interval, 0.65–1.44).
Interestingly, the technique did increase the number of lesions considered suspicious during endoscopy.
Suspected lesions were identified in 14.0% of patients receiving acetic acid chromoendoscopy, compared with 6.4% without the technique.
However, this increase in visual abnormalities did not translate into more histologically confirmed neoplasia.
The targeted neoplasia detection rate was 2.1% with acetic acid chromoendoscopy and 1.8% without it, a difference that was not statistically significant.
These findings raise an important clinical distinction: identifying more suspicious areas during endoscopy does not necessarily mean detecting more clinically significant disease.
In both groups, endoscopists obtained targeted biopsies from visible lesions and performed systematic four-quadrant biopsies. This allowed the researchers to evaluate whether acetic acid staining offered additional diagnostic value alongside established surveillance practices.
The results are relevant because Barrett's surveillance can be time-consuming, and additional imaging techniques may increase procedural complexity without necessarily improving outcomes.
However, the findings should not be interpreted as evidence that acetic acid chromoendoscopy has no role in every clinical setting.
The trial was conducted in community hospitals, and its results may not apply equally to expert referral centres evaluating complex or previously identified neoplastic lesions. Furthermore, only 82% of participants allocated to the intervention actually received acetic acid chromoendoscopy.
The confidence interval also leaves some uncertainty about the precise effect, although the study found no evidence of improved detection in routine practice.
Importantly, the trial evaluated diagnostic detection rather than long-term cancer incidence or mortality.
For gastroenterologists, the findings reinforce the importance of meticulous mucosal inspection, careful assessment of visible abnormalities and adherence to systematic biopsy protocols.
Advanced imaging may help characterise selected lesions, but additional visual techniques should not automatically be assumed to improve diagnostic yield or replace established surveillance methods.
The ACID trial demonstrates that a technique capable of revealing more suspicious lesions may still fail to identify more patients with dysplasia or cancer. In routine Barrett's oesophagus surveillance, the priority remains high-quality endoscopic examination supported by appropriate targeted and systematic biopsies, rather than the routine addition of acetic acid staining without demonstrated incremental benefit.
Original Research Reference
Beaufort IN, Boer LS, Milne AN, et al. Acetic acid chromoendoscopy for detection of neoplastic Barrett's oesophagus: stepped wedge cluster randomised controlled trial (ACID-trial). Journal: The BMJ. 2026;395. Publication date: October 21, 2026. DOI: https://doi.org/10.1136/bmj-2026-100872
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