Limitations of current Barrett's surveillance protocol Current guidelines for surveillance include taking biopsy specimens from endoscopically visible mucosal abnormality followed by random 4-quadrant biopsies every 2 cm throughout the entire length of BE (15). Unfortunately, the effectiveness of this strategy is hampered by numerous factors. Apart from being labor intensive and time consuming for the patient; the accuracy of this protocol is limited by sampling errors. Biopsy specimens from short segments or tongues of columnar mucosa generally reveal intestinal metaplasia in only 40-60% of patients (16). In a study of 570 patients undergoing upper endoscopy, BE was suspected in 146 patients; however, only 60 patients had diagnosis confirmed by biopsy. Short segment BE (SSBE) was more frequently suspected than long segment BE (LSBE) but was correctly diagnosed only 25% of the time compared with 55% for LSBE (17). Similar to the distribution of the metaplastic tissue, the presence of dysplasia or early adenocarcinoma within a Barrett's segment is patchy and focal. Standard endoscopy and random biopsies might fail to detect these lesions. Early neoplastic lesions are not visible to the eye of the endoscopist at standard endoscopy and random biopsies sample only a small proportion of the epithelium at risk. Also, this "hit and miss" nature of biopsy increases the cost of the procedure and limits the reliability of histologic interpretation of dysplasia. The increasing use of endoscopy has led to more and more patients being diagnosed with BE and offered surveillance. Also, the number of patients being followed up, and to whom potentially curative therapy can be offered, have increased. The advent of newer methods of endoscopic treatment of high-grade dysplasia (HGD) and early EAC in the form of ablative therapy and EMR makes it highly desirable to diagnose dysplasia and EAC early in the disease process. This may help in alleviating the morbidity and mortality associated with esophagectomy for EAC. These compelling reasons coupled with the limitations of current surveillance protocols make the development of new approaches aimed at improving efficacy of Barrett's surveillance mandatory.