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Jung et al. [17] found a significant influence of neoadjuvant treatment, intraluminal technique, and increased CRP at diagnosis on therapy failure in 119 patients. They identified 116 patients treated with EVT and found use of the intracavitary technique at first endoscopy, more complications, and higher CRP and WBC count at diagnosis significantly influenced EVT failure. EVT procedures EVT procedures were performed with the patients under deep propofol sedation or general anesthesia. Among the successful EVT treatments, a median of six (IQR 3-11) EVT-related endoscopies were performed during a mean (SD) of 33 (24) days of treatment ( B Table 2 s b ). [Extracted from the article]

Previous studies on fear of cancer recurrence after endoscopic treatment for early Barrett's neoplasia focused on fear during a relatively short period after the intervention. The aim of this study was to explore whether fear of cancer (recurrence) persists during long-term follow-up in patients treated endoscopically for Barrett's neoplasia compared to patients treated surgically for a more advanced stage of esophageal adenocarcinoma. Participants previously participated in a prospective longitudinal study investigating quality of life and fear of cancer recurrence and were treated endoscopically for early Barrett's neoplasia (high-grade dysplasia—T1sm1N0M0) or surgically for a more advanced esophageal adenocarcinoma (T1N0M0–T3N1M0). For the present study, participants were again invited to complete a set of questionnaires including the fear of cancer recurrence scale (FORS), worry for cancer scale (WOCS), and the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS Anxiety). Thirty-nine patients were eligible in the endoscopy group and 28 in the surgical group. The median time between the baseline measurement (original study) and the long-term follow-up assessment was 4 years (interquartile range 3–5 years). Fear and worry for cancer recurrence and general anxiety diminished over time in both treatment groups. However, at long-term follow-up, endoscopically treated patients had significantly higher levels of worry for cancer and general anxiety than surgically treated patients. Fear of cancer recurrence did not significantly differ between endoscopically and surgically treated patients. We found that worry and fear of cancer recurrence and general anxiety in endoscopically treated patients declined over time, but not as much as in surgically treated patients. [ABSTRACT FROM AUTHOR]

1: ESGE suggests performing segmental biopsies (at least two from each segment), which should be placed in different specimen containers (ileum, cecum, ascending, transverse, descending, and sigmoid colon, and rectum) in patients with clinical and endoscopic signs of colitis.Weak recommendation, low quality of evidence. 2: ESGE recommends taking two biopsies from the right hemicolon (ascending and transverse colon) and, in a separate container, two biopsies from the left hemicolon (descending and sigmoid colon) when microscopic colitis is suspected.Strong recommendation, low quality of evidence. 3: ESGE recommends pancolonic dye-based chromoendoscopy or virtual chromoendoscopy with targeted biopsies of any visible lesions during surveillance endoscopy in patients with inflammatory bowel disease. Strong recommendation, moderate quality of evidence. 4: ESGE suggests that, in high risk patients with a history of colonic neoplasia, tubular-appearing colon, strictures, ongoing therapy-refractory inflammation, or primary sclerosing cholangitis, chromoendoscopy with targeted biopsies can be combined with four-quadrant non-targeted biopsies every 10 cm along the colon. Weak recommendation, low quality of evidence. 5: ESGE recommends that, if pouch surveillance for dysplasia is performed, visible abnormalities should be biopsied, with at least two biopsies systematically taken from each of the afferent ileal loop, the efferent blind loop, the pouch, and the anorectal cuff.Strong recommendation, low quality of evidence. 6: ESGE recommends that, in patients with known ulcerative colitis and endoscopic signs of inflammation, at least two biopsies be obtained from the worst affected areas for the assessment of activity or the presence of cytomegalovirus; for those with no evident endoscopic signs of inflammation, advanced imaging technologies may be useful in identifying areas for targeted biopsies to assess histologic remission if this would have therapeutic consequences. Strong recommendation, low quality of evidence. 7: ESGE suggests not biopsying endoscopically visible inflammation or normal-appearing mucosa to assess disease activity in known Crohn's disease.Weak recommendation, low quality of evidence. 8: ESGE recommends that adequately assessed colorectal polyps that are judged to be premalignant should be fully excised rather than biopsied.Strong recommendation, low quality of evidence. 9: ESGE recommends that, where endoscopically feasible, potentially malignant colorectal polyps should be excised en bloc rather than being biopsied. If the endoscopist cannot confidently perform en bloc excision at that time, careful representative images (rather than biopsies) should be taken of the potential focus of cancer, and the patient should be rescheduled or referred to an expert center.Strong recommendation, low quality of evidence. 10: ESGE recommends that, in malignant lesions not amenable to endoscopic excision owing to deep invasion, six carefully targeted biopsies should be taken from the potential focus of cancer.Strong recommendation, low quality of evidence. [ABSTRACT FROM AUTHOR]

1: ESGE recommends that, where there is a suspicion of eosinophilic esophagitis, at least six biopsies should be taken, two to four biopsies from the distal esophagus and two to four biopsies from the proximal esophagus, targeting areas with endoscopic mucosal abnormalities. Distal and proximal biopsies should be placed in separate containers.Strong recommendation, low quality of evidence. 2: ESGE recommends obtaining six biopsies, including from the base and edge of the esophageal ulcers, for histologic analysis in patients with suspected viral esophagitis.Strong recommendation, low quality of evidence. 3: ESGE recommends at least six biopsies are taken in cases of suspected advanced esophageal cancer and suspected advanced gastric cancer.Strong recommendation, moderate quality of evidence. 4: ESGE recommends taking only one to two targeted biopsies for lesions in the esophagus or stomach that are potentially amenable to endoscopic resection (Paris classification 0-I, 0-II) in order to confirm the diagnosis and not compromise subsequent endoscopic resection.Strong recommendation, low quality of evidence. 5: ESGE recommends obtaining two biopsies from the antrum and two from the corpus in patients with suspected Helicobacter pylori infection and for gastritis staging.Strong recommendation, low quality of evidence. 6: ESGE recommends biopsies from or, if endoscopically resectable, resection of gastric adenomas.Strong recommendation, moderate quality of evidence. 7: ESGE recommends fine-needle aspiration (FNA) and fine-needle biopsy (FNB) needles equally for sampling of solid pancreatic masses.Strong recommendation, high quality evidence. 8: ESGE suggests performing peroral cholangioscopy (POC) and/or endoscopic ultrasound (EUS)-guided tissue acquisition in indeterminate biliary strictures. For proximal and intrinsic strictures, POC is preferred. For distal and extrinsic strictures, EUS-guided sampling is preferred, with POC where this is not diagnostic.Weak recommendation, low quality evidence. 9: ESGE suggests obtaining possible non-neoplastic biopsies before sampling suspected malignant lesions to prevent intraluminal spread of malignant disease.Weak recommendation, low quality of evidence. 10: ESGE suggests dividing EUS-FNA material into smears (two per pass) and liquid-based cytology (LBC), or the whole of the EUS-FNA material can be processed as LBC, depending on local experience.Weak recommendation, low quality evidence. [ABSTRACT FROM AUTHOR]

Introduction: The Radiofrequency Vapor Ablation (RFVA) System (AquaMedical, Inc., Santa Ana, CA) is a novel ablation system for eradication of Barrett's esophagus, that generates vapor at 100 °C using an RF electrode located in the catheter tip. We performed in-vitro dosimetry studies and the first in-human feasibility study.Methods: The system includes an RFVA generator with syringe pump and a through-the-scope-catheter. The RFVA system was tested in-vitro (lean-beef and porcine study) and ablation depth was compared to focal RFA. Two doses were selected for further in-vivo testing in dysplatic BE patients. Repeat endoscopy with histology was performed after 8 weeks to assess squamous conversion.Results: In porcine, RFVA 3-seconds was comparable to RFA, whereas RFVA 5-seconds produced slightly deeper ablation. We selected a conservative 1-second and 3-seconds for human study. Fifty-three ablations were successfully applied in 15 patients with no adverse events. Follow-up endoscopy showed a median squamous conversion of 55 % (IQR 33 - 74) and 98 % (56 - 99) for 1 and 3-seconds, respectively.Conclusions: In this 3-phase study with lean-beef, porcine and the first in-human application, the RFVA system was feasible for esophageal ablation and successfully and safely converted targeted BE areas into squamous epithelium. [ABSTRACT FROM AUTHOR]

Introduction Current guidelines advise esophagectomy for submucosal esophageal adenocarcinoma (T1b EAC). Data from retrospective studies suggest that endoscopic follow-up (FU) may be a valid alternative in patients without signs of lymph node metastases (LNM) at baseline. Our aim is to evaluate the safety of a watchful waiting strategy with regular endoscopic FU as an alternative in patients treated endoscopically for T1b EAC (NCT03222635). Methods This study, conducted at 19 hospitals in Europe and Australia, aims to include 141 patients with 5-year FU. After endoscopic resection of T1b EAC (R0), patients are re-staged with endoscopic ultrasound (EUS) and CT/PET. Patients (N0M0) undergo strict endoscopic FU with gastroscopy and EUS. CT/PET is repeated after 1 year. The cohort is divided into 'high-risk' (submucosal invasion ≥500um, a/o poorly/undifferentiated tumor (G3–4), a/o lymphovascular invasion (LVI+)) and 'low-risk' (risk features absent). Outcome parameters are 5-year disease specific survival, overall survival, rates of LNM and local recurrence. Results 134 patients (112 men, median age 69) underwent median FU of 22 (IQR 11–35) months: 87 high-risk and 47 low-risk. 6 patients (4% [95%CI 0.2–8.8]) were diagnosed with LNM after median FU of 8 (IQR 5–16) months. 2/6 underwent neoadjuvant chemo(radio)therapy with esophagectomy (ypT0N1M0, ypT0N0M0), 1/6 underwent esophagectomy only (pT0N2M0), 3/6 underwent selective surgical LN resection. 7 patients (5% [95%CI 0.8–9.6] were diagnosed with an intra-luminal tumor recurrence not eligible for endoscopic re-treatment after median FU of 7 (IQR 6–15) months. 2/7 underwent esophagectomy (pT1bN0M0, pTisN0M0), 1/7 had neoadjuvant chemoradiotherapy and esophagectomy (ypT1aN0M0), 3/7 underwent (chemo)radiotherapy only, of which 1 patient eventually died as result of stenosing EAC, 1/7 refused additional treatment. No distant metastases were diagnosed. Five patients died of an EAC-unrelated cause. Five patients discontinued FU due to old age. Two patients were lost to FU. Conclusion The preliminary analysis from our ongoing prospective study suggest that in patients with radically removed high- or low-risk T1b EAC, without LNM at baseline, a strict endoscopic follow-up protocol is feasible and the window for curative therapy remains open for those patients who develop LNM (4%) or a local intra-luminal recurrence (5%) during FU. Most patients demonstrate uneventful FU. [ABSTRACT FROM AUTHOR]

Pouw is a consultant for MicroTech Europe and Medtronic bv., has received speaker fees from Pentax, and is an advisory board member for EsoCap AG. Letter We thank Mandarino et al. for their knowledgeable comments on our study. Specifically, nonanastomotic esophageal perforations are poorly represented in previous studies; for example, Jung et al. only describe 7/90 patients with benign perforations. [Extracted from the article]

Objective Focal endoscopic resection (ER) followed by radiofrequency ablation (RFA) safely and effectively eradicates Barrett's oesophagus (BO) containing high-grade dysplasia (HGD) and/or early cancer (EC) in smaller studies with limited follow-up. Herein, we report long-term outcomes of combined ER and RFA for BO (HGD and/or EC) from a single-arm multicentre interventional study. Design In 13 European centres, patients with BO=12 cm with HGD and/or EC on 2 separate endoscopies were eligible for inclusion. Visible lesions (<2 cm length; <50% circumference) were removed with ER, followed by serial RFA every 3 months (max 5 sessions). Follow-up endoscopy was scheduled at 6 months after the first negative post-treatment endoscopic control and annually thereafter. Outcomes: complete eradication of neoplasia (CE-neo) and intestinal metaplasia (CE-IM); durability of CE-neo and CE-IM (once achieved) during follow-up. Biopsy and resection specimens underwent centralised pathology review. Results 132 patients with median BO length C3M6 were included. After entry-ER in 119 patients (90%) and a median of 3 RFA (IQR 3-4) treatments, CE-neo was achieved in 121/132 (92%) and CE-IM in 115/132 patients (87%), per intention-to-treat analysis. Per-protocol analysis, CE-neo and CE-IM were achieved in 98% and 93%, respectively. After a median of 27 months following the first negative post-treatment endoscopic control, neoplasia and IM recurred in 4% and 8%, respectively. Mild-to-moderate adverse events occurred in 25 patients (19%); all managed conservatively or endoscopically. Conclusions In patients with early Barrett's neoplasia, intensive multimodality endotherapy consisting of ER combined with RFA is safe and highly effective, and the treatment effect appears to be durable during mid-term follow-up. [ABSTRACT FROM AUTHOR]

Background: Endoscopic resection is the cornerstone of endoscopic management of esophageal early neoplasia. However, endoscopic resection is a complex technique requiring knowledge and expertise. Our aims were to identify the most important learning points in performing endoscopic resection in a training setting and to provide information on how to improve endoscopic resection technique.Methods: Six gastroenterologists at centers with multidisciplinary expertise in upper gastrointestinal oncology participated in a structured endoscopic resection training program, consisting of four training days with lectures and hands-on training on live pigs, further one-to-one hands-on training days, and written feedback (by an expert) on videos of unsupervised endoscopic resection procedures. The first 20 endoscopic resections of each participant were prospectively registered. Ninety learning points were independently identified by participants using a standardized questionnaire and by an expert providing written feedback on 33 unsupervised endoscopic resection videos. Three expert endoscopists selected and ranked the most important learning points in a consensus meeting. Results. The top 10 tips (illustrated by unique videos of three perforations) were: (1) allow time for inspection and use a high-definition endoscope; (2) create a preprocedural plan by placing electrocoagulation markings; (3) know the management of bleeding; (4) optimize the endoscopic view by repeatedly cleaning out stomach and target area; (5) use a therapeutic endoscope during resection; (6) always perform a test suction; (7) keep instruments close to the tip; (8) lift edges in piecemeal endoscopic cap resections; (9) know the management of perforation; (10) pin specimens down.Conclusions: This study summarized the most important learning points for performing endoscopic resection encountered during a structured endoscopic resection training program. [ABSTRACT FROM AUTHOR]

Background: Although endoscopic resection (ER) for early gastric cancers (EGCs) has become popular with the development of endoscopic instruments and skillful endoscopists, the risk of lymph node metastasis (LNM) is still an obstacle in performing ER. In this study, we aimed to identify the risk factors of LNM and validated the expanded criteria, with the goal of suggesting modified criteria for ER in submucosal EGCs. Methods: Of patients who underwent gastrectomy with LN dissection and were diagnosed as EGCs with depth of invasion such as sm1, sm2 or ≤500 μm from 1999 to 2008, 318 EGCs with submucosal invasion ≤500 μm were enrolled through pathologic evaluations. To identify the risk factors of LNM, a multivariate analysis of clinicopathologic factors was performed. By combining the independent risk factors of LNM, the risk of LNM was analyzed. Result: LNM were detected in 35 cases (11.0 %). Tumors >30 mm in size and with lymphatic invasion were identified as an independent risk factor for LNM in EGCs with depth of invasion ≤500 μm. Among 94 cases meeting the expanded criteria, two cases (2.1 %) were found to have LNM. Based on the submucosal invasion <300 μm, there was no LNM in EGCs with a size ≤30 mm and no lymphovascular invasion, regardless of differentiation grade. Conclusion: To exclude the possibility of LNM, applying the modified criteria based on the submucosal invasion <300 μm in performing ER might be worthwhile. [ABSTRACT FROM AUTHOR]

Background and study aim: In our experience, biopsies from small residual islands of nonburied Barrett's mucosa after radiofrequency ablation (RFA) are occasionally reported by pathologists to contain "buried Barrett's" upon histological evaluation, despite the fact that these islands of columnar mucosa were visible endoscopically. The aim of this study was to evaluate the frequency of buried Barrett's in biopsies obtained from small residual Barrett's islands (<5mm) sampled post-RFA, compared with biopsies from normal neosquamous epithelium. Patients and methods: Biopsies obtained from normal-appearing neosquamous epithelium and from small Barrett's islands (<5mm) in 69 consecutive Barrett's patients treated with RFA were evaluated for the presence of buried columnar mucosa. Results: A total of 2515 biopsies were obtained from neosquamous epithelium during follow-up post-RFA. Buried glands were found in 0.1% of biopsies from endoscopically normal neosquamous epithelium. However, when small islands of columnar mucosawere biopsied, buried glands were detected in 21% of biopsies. Conclusion: To avoid accidental sampling of small islands resulting in a false-positive histological diagnosis of buried Barrett's, thorough inspection should be performed before obtaining biopsies during post-RFA follow-up. [ABSTRACT FROM AUTHOR]

BACKGROUND AND AIMS: Endoscopic resection is safe and effective to remove early neoplasia (ie,high-grade intra-epithelial neoplasia/early cancer) in Barrett''s oesophagus. To prevent metachronous lesions during follow-up, the remaining Barrett''s oesophagus can be removed by stepwise radical endoscopic resection (SRER). The aim was to evaluate the combined experience in four tertiary referral centres with SRER to eradicate Barrett''s oesophagus with early neoplasia. METHODS: Design: Retrospective cohort study. Setting: Four tertiary referral centres. Participants: 169 patients (151 males, age 64 years (IQR 57–71), Barrett''s oesophagus 3 cm (IQR 2–5)) with early neoplasia in Barrett''s oesophagus ≤5 cm, without deep submucosal infiltration or lymph node metastases, treated by SRER between January 2000 and September 2006. Intervention: Endoscopic resection every 4–8 weeks, until complete endoscopic and histological eradication of Barrett''s oesophagus and neoplasia. RESULTS: According to intention-to-treat analysis complete eradication of all neoplasia and all intestinal metaplasia by the end of the treatment phase was reached in 97.6% (165/169) and 85.2% (144/169) of patients, respectively. One patient had progression of neoplasia during treatment and died of metastasised adenocarcinoma (0.6%). After median follow-up of 32 months (IQR 19–49), complete eradication of neoplasia and intestinal metaplasia was sustained in 95.3% (161/169) and 80.5% (136/169) of patients, respectively. Acute, severe complications occurred in 1.2% of patients, and 49.7% of patients developed symptomatic stenosis. CONCLUSIONS: SRER of Barrett''s oesophagus ≤5 cm containing early neoplasia appears to be an effective treatment modality with a low rate of recurrent lesions during follow-up. The procedure, however, is technically demanding and is associated with oesophageal stenosis in half of the patients. [ABSTRACT FROM AUTHOR]

OBJECTIVES:Endoscopic radiofrequency ablation (RFA) eradicates intestinal metaplasia and intraepithelial neoplasia associated with Barrett's esophagus (BE), restoring an endoscopically normal neosquamous epithelium (NSE). We evaluated the post-RFA NSE for genetic abnormalities and buried glandular mucosa.METHODS:Eligible patients underwent RFA for BE containing early cancer and/or high-grade intraepithelial neoplasia with subsequent complete histological reversion to normal NSE. At baseline, the BE was sampled by brush cytology and biopsies. At least 2 months after RFA, the NSE was sampled by brush cytology, keyhole biopsies, and endoscopic resection. The untreated squamous epithelium was biopsied as a control. The baseline BE and post-RFA NSE were evaluated for immunohistochemical expression of Ki-67 and p53, and genetic abnormalities (DNA–fluorescent in situ hybridization: chromosome 1 and 9, p16 and p53). In addition, biopsy depth was compared for biopsies from the NSE and untreated squamous epithelium. The presence of buried glandular mucosa in NSE was assessed with primary and keyhole biopsy, and endoscopic resection.RESULTS:All pretreatment specimens from all 22 patients showed abnormalities on immunohistochemical staining and fluorescent in situ hybridization, whereas all post-RFA NSE specimens were normal. All the post-RFA biopsies from the NSE contained full epithelia, whereas 37% contained lamina propria, a finding no different from biopsies from untreated squamous epithelium (36% lamina propria). Deeper keyhole biopsies contained lamina propria in 51%. All endoscopic resection specimens contained submucosa, whereas no biopsy or endoscopic resection specimen contained buried glandular mucosa.CONCLUSIONS:Rigorous evaluation of the post-RFA NSE in patients who, at baseline, had BE containing early cancer high-grade intraepithelial neoplasia, showed neither persistent genetic abnormalities nor buried glandular mucosa.Am J Gastroenterol 2009; 104:1366–1373; doi:10.1038/ajg.2009.88; published online 21 April 2009 [ABSTRACT FROM AUTHOR]

Background: Radiofrequency ablation is safe and effective for complete eradication of nondysplastic Barrett esophagus (BE). The aim was to report the combined results of two published and two ongoing studies on radiofrequency ablation of BE with early neoplasia, as presented at SSAT presidential plenary session DDW 2008.Methods: Enrolled patients had BE < or = 12 cm with early neoplasia. Visible lesions were endoscopically resected. A balloon-based catheter was used for circumferential ablation and an endoscope-based catheter for focal ablation. Ablation was repeated every 2 months until the entire Barrett epithelium was endoscopically and histologically eradicated.Results: Forty-four patients were included (35 men, median age 68 years, median BE 7 cm). Thirty-one patients first underwent endoscopic resection [early cancer (n = 16), high-grade dysplasia (n = 12), low-grade dysplasia (n = 3)]. Worst histology remaining after resection was high-grade (n = 32), low-grade (n = 10), or no (n = 2) dysplasia. After ablation, complete histological eradication of all dysplasia and intestinal metaplasia was achieved in 43 patients (98%). Complications following ablation were mucosal laceration at resection site (n = 3) and transient dysphagia (n = 4). After 21 months of follow-up (interquartile range 10-27), no dysplasia had recurred.Conclusions: Radiofrequency ablation, with or without prior endoscopic resection for visible abnormalities, is effective and safe in eradicating BE and associated neoplasia. [ABSTRACT FROM AUTHOR]

Background This study evaluated the safety and efficacy of salvage endoscopic submucosal dissection (ESD) for Barrett's neoplasia recurrence after radiofrequency ablation (RFA). Methods Data from patients at 16 centers were collected for a multicenter retrospective study. Patients who underwent at least one RFA treatment for Barrett's esophagus and thereafter underwent further esophageal ESD for neoplasia recurrence were included. Results Data from 56 patients who underwent salvage ESD between April 2014 and November 2022 were collected. Immediate complications included one muscular tear (1.8%) treated with stent (Agree classification: grade IIIa). Two transmural perforations (3.6%; treated with clips) and five muscular tears (8.9%; two treated with clips) had no clinical impact and were not considered as adverse events. Seven patients (12.5%) developed strictures (grade IIIa), which were treated with balloon dilation. Histological analysis showed 36 adenocarcinoma, 17 high grade dysplasia, and 3 low grade dysplasia. En bloc and R0 resection rates were 89.3% and 66.1%, respectively. Resections were curative in 33 patients (58.9%), and noncurative in 22 patients (39.3%), including 11 "local risk" (19.6%) and 11 "high risk" (19.6%) resections. At the end of follow-up with a median time of 14 (0–75) months after salvage ESD, and with further endoscopic treatment if necessary (RFA, argon plasma coagulation, endoscopic mucosal resection, ESD), neoplasia remission ratio was 37/53 (69.8%) and the median remission time was 13 (1–75) months. Conclusion In expert hands, salvage ESD was a safe and effective treatment for recurrence of Barrett's neoplasia after RFA treatment. [ABSTRACT FROM AUTHOR]

Background This study evaluated the proportion of patients with residual neoplasia after endoscopic resection (ER) for Barrett's neoplasia with confirmed tumor-positive vertical resection margin (R1v). Methods This retrospective cohort study included patients undergoing ER for Barrett's neoplasia with histologically documented R1v since 2008 in the Dutch Barrett Expert Centers. We defined R1v as cancer cells touching vertical resection margins and Rx as nonassessable margins. Reassessment of R1v specimens was performed by experienced pathologists until consensus was reached regarding vertical margins. Results 101/110 included patients had macroscopically complete resections (17 T1a, 84 T1b), and 99/101 (98%) ER specimens were histologically reassessed, with R1v confirmed in 74 patients (75%), Rx in 16%, and R0 in 9%. Presence/absence of residual neoplasia could be assessed in 66/74 patients during endoscopic reassessment (52) and/or in the surgical resection specimen (14), and 33/66 (50%) had residual neoplasia. Residual neoplasia detected during endoscopy was always endoscopically visible and biopsies from a normal-appearing ER scar did not detect additional neoplasia. Of 25 patients who underwent endoscopic follow-up (median 37 months [interquartile range 12–50]), 4 developed local recurrence (16.0%), all detected as visible abnormalities. Conclusions After ER with R1v, 50% of patients had no residual neoplasia. Histological evaluation of ER margins appears challenging, as in this study 75% of documented R1v cases were confirmed during reassessment. Endoscopic reassessment 8–12 weeks after ER seems to accurately detect residual neoplasia and can help to determine the most appropriate strategy for patients with R1v. [ABSTRACT FROM AUTHOR]

The authors reflects on the study which evaluated the potential of argon plasma coagulation (APC) for Barrett's neoplasia in reducing the risk of secondary neoplasia. The study concluded that ablation of residual Barret's mucosa after focal endoscopic resection of neoplasia significantly reduced the recurrence of neoplasia. According to the authors, evaluating APC in a multicenter study is essential.

BACKGROUND : Clinical tumor stage of esophageal adenocarcinoma (EAC) is determined by endoscopic ultrasound and/or computed tomography scan, which have low accuracy for stages T1 and T2, potentially leading to overtreatment. We aimed to assess the proportion of cT2 EACs downstaged to cT1 after endoscopic reassessment (ERA) by an experienced interventional endoscopist. METHODS : We performed a prospective multicenter cohort study. Patients with cT2N0M0 EAC were included and underwent ERA. The primary outcome was proportion of cT2 EACs downstaged to cT1 after ERA. RESULTS : 15/25 included patients (60 %) were downstaged from cT2 to cT1 EAC after ERA and underwent attempted endoscopic resection. Endoscopic resection was aborted in 3/15 patients because of tumor invasion into the muscle layer; all three underwent successful surgical resection. Endoscopic resection was successful in 12/15 patients (80 %), all of whom had pT1 tumors. Overall, 10/25 (40 %) were treated with endoscopic resection alone. CONCLUSIONS : ERA downstaged about half of the cT2 tumors to cT1, rendering them suitable for endoscopic resection. ERA had substantial clinical impact on therapeutic management, preventing overtreatment in 40 % of patients. [ABSTRACT FROM AUTHOR]

Background Although endoscopic submucosal dissection (ESD) is established as first-choice treatment for early esophageal squamous cell carcinoma (ESCC) worldwide, most data are derived from Asian studies. We aimed to evaluate the long-term outcomes of ESD for patients with early ESCC in a Western cohort. Methods In this retrospective cohort study, patients with early ESCC amenable to ESD were included from four tertiary referral hospitals in the Netherlands between 2012 and 2017. All ESD procedures were performed by experienced endoscopists, after which the decision for additional treatment was made on a per-patient basis. Outcomes were curative resection rate, ESCC-specific survival, and overall survival. Results Of 68 included patients (mean age 69 years; 34 males), ESD was technically successful in 66 (97%; 95%CI 93%–100%), with curative resection achieved in 34/66 (52%; 95%CI 39%–64%). Among patients with noncurative resection, 15/32 (47%) underwent additional treatment, mainly esophagectomy (n = 10) or definitive chemoradiation therapy (n = 4). Endoscopic surveillance was preferred in 17/32 patients (53%), based on severe comorbidities or patient choice. Overall, 31/66 patients (47%) died during a median follow-up of 66 months; 8/31 (26%) were ESCC-related deaths. The 5-year overall and ESCC-specific survival probabilities were 62% (95%CI 52%–75%) and 86% (95%CI 77%–96%), respectively. Conclusion In this Western cohort with long-term follow-up, the effectiveness and safety of ESD for early ESCC was confirmed, although the rate of noncurative resections was substantial. Irrespective of curative status, the long-term prognosis of these patients was limited mainly due to competing mortality. [ABSTRACT FROM AUTHOR]

Background: New evidence has emerged since latest guidelines on the management of paraesophageal hernia, and guideline development methodology has evolved. Members of the European Association for Endoscopic Surgery have prioritized the management of paraesophageal hernia to be addressed by pertinent recommendations. Objective: To develop evidence-informed clinical practice recommendations on paraesophageal hernias, through evidence synthesis and a structured evidence-to-decision framework by an interdisciplinary panel of stakeholders. Methods: We performed three systematic reviews, and we summarized and appraised the certainty of the evidence using the GRADE methodology. A panel of general and upper gastrointestinal surgeons, gastroenterologists and a patient advocate discussed the evidence in the context of benefits and harms, the certainty of the evidence, acceptability, feasibility, equity, cost and use of resources, moderated by a Guidelines International Network-certified master guideline developer and chair. We developed the recommendations in a consensus meeting, followed by a modified Delphi survey. Results: The panel suggests surgery over conservative management for asymptomatic/minimally symptomatic paraesophageal hernias (conditional recommendation), and recommends conservative management over surgery for asymptomatic/minimally symptomatic paraesophageal hernias in frail patients (strong recommendation). Further, the panel suggests mesh over sutures for hiatal closure in paraesophageal hernia repair, fundoplication over gastropexy in elective paraesophageal hernia repair, and gastropexy over fundoplication in patients who have cardiopulmonary instability and require emergency paraesophageal hernia repair (conditional recommendation). A strong recommendation means that the proposed course of action is appropriate for the vast majority of patients. A conditional recommendation means that most patients would opt for the proposed course of action, and joint decision-making of the surgeon and the patient is required. Accompanying evidence summaries and evidence-to-decision frameworks should be read when using the recommendations. This guideline applies to adult patients with moderate to large paraesophageal hernias type II to IV with at least 50% of the stomach herniated to the thoracic cavity. The full guideline with user-friendly decision aids is available in https://app.magicapp.org/#/guideline/j7q7Gn. Conclusion: An interdisciplinary panel provides recommendations on key topics on the management of paraesophageal hernias using highest methodological standards and following a transparent process. Guideline registration number: PREPARE-2023CN018. [ABSTRACT FROM AUTHOR]

Main Recommendations: MR1 ESGE recommends the following standards for Barrett esophagus (BE) surveillance: – a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy – photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions – use of the Prague and (for visible lesions) Paris classification – collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length. Strong recommendation, weak quality of evidence. MR2 ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised. Weak recommendation, low quality of evidence. MR3 ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient's life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4 ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist. Strong recommendation, high level of evidence. MR5 ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer. Strong recommendation, high level of evidence. MR6 ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC). Strong recommendation, moderate quality of evidence. MR7 ESGE recommends endoscopic resection as curative treatment for T1a Barrett's cancer with well/moderate differentiation and no signs of lymphovascular invasion. Strong recommendation, high level of evidence. MR8 ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers. Weak recommendation, low quality of evidence. MR9 ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion. Strong recommendation, low quality of evidence. MR10 a ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center. Strong recommendation, very low quality of evidence. b ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia. Strong recommendation, very low level of evidence. c ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE. Strong recommendation, low level of evidence. d ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions. Weak recommendation, low level of evidence. e ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia. Strong recommendation, very low level of evidence. MR11 After successful EET, ESGE recommends the following surveillance intervals: – For patients with a baseline diagnosis of HGD or EAC: at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped. – For patients with a baseline diagnosis of LGD: at 1, 3, and 5 years after last treatment, after which surveillance may be stopped. Strong recommendation, low quality of evidence. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Low-grade dysplasia (LGD) in Barrett's esophagus (BE) is associated with an increased risk of progression to high-grade dysplasia or esophageal adenocarcinoma. However, because of substantial interobserver variability in the diagnosis of LGD, a patient's management plan and health outcome depend largely on which pathologist reviews their case. This study evaluated the ability of a tissue systems pathology test that objectively risk stratifies patients with BE (TissueCypher, TSP-9) to standardize management in a manner consistent with improved health outcomes for patients with BE. METHODS: A total of 154 patients with BE with community-based LGD from the prospectively followed screening cohort of the SURF trial were studied. Management decisions were simulated 500 times with varying generalist (n516) and expert (n514) pathology reviewers to determine the most likely care plan with or without use of the TSP-9 test for guidance. The percentage of patients receiving appropriate management based on the known progression/nonprogression outcomes was calculated. RESULTS: The percentage of patients with 100% of simulations resulting in appropriate management significantly increased from 9.1% for pathology alone, to 58.4% when TSP-9 results were used with pathology, and further increased to 77.3%of patients receiving appropriate management when only TSP-9 results were used. Use of the test results also significantly increased the consistency of management decisions for patients when their slides were reviewed by different pathologists (P < 0.0001). DISCUSSION: Management guided by the TSP-9 test can standardize care plans by increasing the early detection of progressors who can receive therapeutic interventions, while also increasing the percentage of nonprogressors who can avoid unnecessary therapy and be managed by surveillance alone. [ABSTRACT FROM AUTHOR]

Background Anastomotic leakage after esophagectomy is associated with severe morbidity. Endoscopic vacuum therapy (EVT) has gained a greater role in endoscopic treatment of these defects and is most often applied using endoscopically placed vacuum-sponges. Recently, the vacuum-stent was introduced as a new device to apply EVT, combining the benefits of negative pressure wound therapy and an intraluminal stent, while allowing for oral intake of a soft diet. Methods This video describes a patient with anastomotic leakage after esophagectomy with complicated post-surgical course, successfully treated with a vacuum-stent, including the technical aspects of the technique. First, a guidewire was placed and the vacuum-stent was advanced over the guidewire and introduced into the esophagus. The vacuum-stent was placed over the defect and deployed using the distal release system. Lastly, the vacuum-stent was connected to a vacuum pump, which was set to a pressure of -125 mmHg on the day of placement and -75 mmHg from the second day on. Generally, the vacuum-stent was removed after 7 days. If the defect persisted, another vacuum-stent was placed. Case/Results: A 65-year-old female had undergone a minimally invasive esophagectomy with gastric conduit reconstruction and intrathoracic anastomosis. Post-surgically, the patient had dysphagia due to an elongated gastric conduit, only improving after stent placement. However, this caused a stent-induced broncho-esophageal fistula and was no definite treatment. Therefore, she underwent surgery to close the fistula with a bovine patch and gastric conduit re-construction. A prophylactic vacuum-sponge was placed, but 8 days post-surgery, endoscopy showed a dislocated sponge and dehiscence of the complete anastomosis. A vacuum-stent was placed. After 3 vacuum-stents in 20 days, the defect had closed endoscopically, which was confirmed by CT-scan with oral contrast. Conclusions The vacuum-stent seems to be a safe and possibly organ-saving treatment option for anastomotic leakage after esophagectomy. Link to video: https://we.tl/t-eOVEhUiwge [ABSTRACT FROM AUTHOR]

Background Boerhaave syndrome is a rare disease, associated with severe morbidity and mortality. Endoscopic vacuum therapy (EVT) has gained a greater role in the treatment of transmural defects in the upper gastrointestinal tract, including Boerhaave syndrome. Recently, a vacuum-stent was introduced as a new device to apply EVT. While allowing for oral intake of a soft diet, this device combines the benefits of negative pressure wound therapy and an intraluminal stent. Methods This video describes a patient with Boerhaave syndrome, successfully treated with a vacuum-stent, including the technical aspects of the technique. First, a guidewire was placed and the vacuum-stent was advanced over the guidewire and introduced into the esophagus. The vacuum-stent was placed over the defect and deployed using the distal release system. Lastly, the vacuum-stent was connected to a vacuum pump, which was set to a pressure of -125 mmHg on the day of placement and -75 mmHg from the second day on. Generally, a vacuum-stent was removed after 7 days. If the defect persisted, another vacuum-stent was placed. Case/Results: A 36-year-old male presented with severe abdominal pain after emesis. CT-scan showed suspicion of a defect in the distal esophagus and an endoscopy was performed. Endoscopy showed a defect of 2 cm in length with moderate degree of debris. It was decided to initiate treatment with vacuum-stent. The vacuum stent was exchanged once per week and after a total of 31 days, the defect was closed, confirmed by CT-scan with oral contrast. During treatment, oral intake was extended to a soft diet. One day after removal, the patient resumed oral intake and was discharged. Conclusions The vacuum-stent seems to be a safe and possibly organ-saving treatment option for transmural defects in the upper gastrointestinal tract, including Boerhaave syndrome. Link to video: https://we.tl/t-IA5oM70TX5 [ABSTRACT FROM AUTHOR]

The rate of successful defect closure by EVT, with or without the use of other endoscopic treatment modalities, was 89 %, suggesting that EVT is an effective organ-sparing therapeutic option for these perforations, allowing invasive surgery to be avoided in the vast majority of patients. Generally, patients with defects large enough for endoscope passage with large extraluminal cavities received intracavitary therapy and patients with small defects received intraluminal therapy. 1 Trajectory of successful endoscopic vacuum therapy in a patient with Boerhaave syndrome. a,b The initial defect. c-e The defect during sponge exchange. f Successful closure of the defect. Graph Introduction Esophageal perforations can be caused by iatrogenic or non-iatrogenic means, including endoscopic procedures and Boerhaave syndrome. [Extracted from the article]

Barrett's esophagus with high-grade dysplasia and early-stage adenocarcinoma is amenable to curative treatment by endoscopic resection. Histopathological correlation has established that mucosal cancer has minimal risk of nodal metastases and that long-term complete remission can be achieved. Although surgery is the gold-standard treatment once there is submucosal involvement, even T1sm1 (submucosal invasion ≤ 500 μm) cases without additional risk factors for nodal metastases might also be cured with endoscopic resection. Endoscopic resection is foremost an initial diagnostic procedure, and once histopathological assessment confirms that curative criteria are met, it will be considered curative. Endoscopic resection may be achieved by endoscopic mucosal resection, which, although easy to perform with relatively low risk, is limited by an inability to achieve en bloc resection for lesions of size more than 1.5 cm. Conversely, the technique of endoscopic submucosal dissection is more technically demanding with higher risk of complications but is able to achieve en bloc resection for lesions larger than 1.5 cm. Endoscopic submucosal dissection would be particularly important in specific situations such as suspected submucosal invasion and lesion size more than 1.5 cm. In other situations, since endoscopic resection would always be combined with radiofrequency ablation to ablate the remaining Barrett's epithelium, piecemeal endoscopic mucosal resection would suffice since any remnant superficial invisible dysplasia would be ablated. [ABSTRACT FROM AUTHOR]

Aims: Interobserver agreement for dysplasia in Barrett's oesophagus (BO) is low, and guidelines advise expert review of dysplastic cases. The aim of this study was to assess the added value of p53 immunohistochemistry (IHC) for the homogeneity within a group of dedicated gastrointestinal (GI) pathologists. Methods and results: Sixty‐single haematoxylin and eosin (HE) slide referral BO cases [20 low‐grade dysplasia (LGD); 20 high‐grade dysplasia (HGD); and 20 non‐dysplastic BO reference cases] were digitalised and independently assessed twice in random order by 10 dedicated GI pathologists. After a ‘wash‐out’ period, cases were reassessed with the addition of a corresponding p53 IHC slide. Outcomes were: (i) proportion of ‘indefinite for dysplasia’ (IND) diagnoses; (ii) interobserver agreement; and (iii) diagnostic accuracy as compared with a consensus ‘gold standard’ diagnosis defined at an earlier stage by five core expert BO pathologists after their assessment of this case set. Addition of p53 IHC decreased the mean proportion of IND diagnoses from 10 of 60 to eight of 60 (P = 0.071). Mean interobserver agreement increased significantly from 0.45 to 0.57 (P = 0.0021). The mean diagnostic accuracy increased significantly from 72% to 82% (P = 0.0072) after p53 IHC addition. Conclusion: Addition of p53 IHC significantly improves the histological assessment of BO biopsies, even within a group of dedicated GI pathologists. It decreases the proportion of IND diagnoses, and increases interobserver agreement and diagnostic accuracy. This justifies the use of accessory p53 IHC within our upcoming national digital review panel for BO biopsy cases. [ABSTRACT FROM AUTHOR]

Endoscopic therapy is the treatment of choice for high grade intraepithelial neoplasia (HGIN) or early cancer (≤T1sm1) in Barrett's esophagus (BE). We prospectively evaluated the effect of endoscopic treatment on quality of life (QOL) and fear of cancer (recurrence) and compared this with the effect of Barrett's surveillance or surgery. Patients treated endoscopically for early Barrett's neoplasia (n=42, HGIN - T1sm1N0M0) were compared with three groups: patients with non-dysplastic BE undergoing surveillance (n=44); patients treated surgically for early BE neoplasia (HGIN - T2N0M0, n=21); patients treated surgically for advanced BE cancer (T1N1M0 - T3N1M0, n=19). QOL (SF-36; EORTC-QLQ-C30; EORTC-QLQ-OES18) and fear of cancer recurrence (Worry of Cancer Scale [WOCS] and the Hospital Anxiety and Depression Scale [HADS]) were measured at baseline, 2 and 6 months after treatment. The endoscopic treatment group reported significantly better QOL in both physical and mental scales of SF-36 and EORTC-QLQ-C30 and less esophageal cancer related symptoms compared to both surgical groups. The endoscopic treatment group reported significant more worry for cancer recurrence (WOCS) compared to the early surgical group. Their scores on the WOCS were comparable with the scores of the advanced surgical group. Endoscopic treatment of early esophageal cancer has less negative impact on QOL and esophageal cancer symptoms than surgery. However, endoscopically treated patients worry as much about cancer recurrence as patients treated surgically for advanced cancer. [ABSTRACT FROM AUTHOR]

Background Radiofrequency ablation (RFA) is effective for eradication of Barrett's esophagus (BE) neoplasia, but little is known on the course of pain and dysphagia after RFA. We aimed to describe the course of post-RFA symptoms and to identify possible associated risk factors. Methods In this multicenter, observational cohort study, all RFA procedures registered in a prospective database were included. Patient and treatment characteristics were collected from medical records and patients self-registered post-procedural symptoms in electronic symptom diaries for 14 days. Mixed model regression was used for the analyses. Results In total, 255 diaries were completed. Post-RFA pain was reported for 95 % (95 %CI 93–98) of procedures (median duration 14 days; 25th–75th percentiles [p25–p75] 11–14) and major pain for 64 % (95 %CI 58–69; median duration 8 days, p25–p75 3–13). Post-procedural pain significantly increased with BE length, younger age, and no prior ablation. Dysphagia was present after 83 % (95 %CI 79–88) of procedures (median duration 13 days, p25–p75 9–14). The risk of dysphagia decreased with age and increased when patients experienced more pain. Conclusions RFA treatment for BE-related neoplasia seems a significant burden for patients, and post-procedural symptoms should be taken into account when counseling patients before starting endoscopic eradication therapy. [ABSTRACT FROM AUTHOR]

A response by Roos E. Pouw and Jacques J. Bergman to a letter to the editor about their article on the properties of neosquamous epithelium after radiofrequency ablation (RFA) of Barrett's esophagus in the 2009 issue is presented.

BACKGROUND : The optimal management for patients with low grade dysplasia (LGD) in Barrett's esophagus (BE) is unclear. According to the Dutch national guideline, all patients with LGD with histological confirmation of the diagnosis by an expert pathologist (i. e. "confirmed LGD"), are referred for a dedicated re-staging endoscopy at an expert center. We aimed to assess the diagnostic value of re-staging endoscopy by an expert endoscopist for patients with confirmed LGD. METHODS : This retrospective cohort study included all patients with flat BE diagnosed in a community hospital who had confirmed LGD and were referred to one of the nine Barrett Expert Centers (BECs) in the Netherlands. The primary outcome was the proportion of patients with prevalent high grade dysplasia (HGD) or cancer during re-staging in a BEC. RESULTS : Of the 248 patients with confirmed LGD, re-staging in the BEC revealed HGD or cancer in 23 % (57/248). In 79 % (45/57), HGD or cancer in a newly detected visible lesion was diagnosed. Of the remaining patients, re-staging in the BEC showed a second diagnosis of confirmed LGD in 68 % (168/248), while the remaining 9 % (23/248) had nondysplastic BE. CONCLUSION : One quarter of patients with apparent flat BE with confirmed LGD diagnosed in a community hospital had prevalent HGD or cancer after re-staging at an expert center. This endorses the advice to refer patients with confirmed LGD, including in the absence of visible lesions, to an expert center for re-staging endoscopy. [ABSTRACT FROM AUTHOR]

Background: The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett's esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed in the Netherlands.Methods: Retrospective assessment of outcomes, using treatment and follow-up data from a joint database.Results: 130/138 patients had complete ESDs, with 126/130 (97 %) en bloc resections. Median (interquartile range (IQR)) procedure time was 121 minutes (90-180). Pathology findings were high grade dysplasia (HGD) (5 %) or esophageal adenocarcinoma (EAC) T1a (43 %) or T1b (52 %; 19 % sm1, 33 % ≥ sm2). Among resections of HGD or T1a EAC lesions, 87 % (95 %CI 75 %-92 %) were both en bloc and R0; the corresponding value for T1b EAC lesions was 49 % (36 %-60 %). Among R1 resections, 10/34 (29 %) showed residual cancer, all detected at first endoscopic follow-up. The remaining 24 patients (71 %) showed no residual neoplasia. Six of these patients underwent surgery with no residual tumor; the remaining 18 underwent endoscopic follow-up during median 31 months with 1 local recurrence (annual recurrence rate 2 %). Among R0 resections, annual local recurrence rate during median 27 months was 0.5 %.Conclusion: In expert hands, ESD allows safe removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter showed R1 resection margins in 50 %, yet only one third had persisting neoplasia at follow-up. To better stratify R1 patients with an indication for additional surgery, repeat endoscopy after healing of the ESD might be a helpful possible prognostic factor for residual cancer. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive esophagectomy with two-field lymphadenectomy is standard of care for T1b esophageal adenocarcinoma (EAC) with a high risk of lymph node metastasis. Sentinel node navigation surgery (SNNS) is a well-known concept to tailor the extent of lymphadenectomy. The aim of this study was to evaluate the feasibility and safety of SNNS with a hybrid tracer (technetium-99 m/indocyanine green/nanocolloid) for patients with high-risk T1b EAC. Methods: In this prospective, multicenter pilot study, 5 patients with high-risk T1b EAC were included. The tracer was injected endoscopically around the endoscopic resection scar the day before surgery, followed by preoperative imaging (lymphoscintigraphy/SPECT-CT). During surgery, first the SNs were localized and resected based on preoperative imaging and intraoperative gammaprobe- and fluorescence-based detection, followed by esophagectomy. Primary endpoints were the percentage of patients with detectable SNs, concordance between preoperative and intraoperative SN detection, and the additive value of indocyanine green. Results: SNs could be identified and resected in all patients (median 3 SNs per patient, range 2–7). There was a high concordance between preoperative and intraoperative SN detection. In 2 patients additional peritumoral SNs were identified with fluorescence-based detection. None of the resected lymph nodes showed signs of (micro)metastases and no nodal metastases were detected in the surgical resection specimen. Conclusions: SNNS using technetium-99 m/indocyanine green/nanocolloid seems feasible and safe in patients with high-risk T1b EAC. Indocyanine green fluorescence seems to be of additive value for detection of peritumoral SNs. Whether this approach can optimize selection for esophagectomy needs to be studied in future research. [ABSTRACT FROM AUTHOR]

Background: Endoscopic eradication therapy with radiofrequency ablation (RFA) is effective in most patients with Barrett's esophagus (BE). However, some patients experience poor healing and/or poor squamous regeneration. We evaluated incidence and treatment outcomes of poor healing and poor squamous regeneration.Methods: We included all patients treated with RFA for early BE neoplasia from a nationwide Dutch registry based on a joint treatment protocol. Poor healing (active inflammatory changes or visible ulcerations ≥ 3 months post-RFA), poor squamous regeneration (< 50 % squamous regeneration), and treatment success (complete eradication of BE [CE-BE]) were evaluated.Results: 1386 patients (median BE C2M5) underwent RFA with baseline low grade dysplasia (27 %), high grade dysplasia (30 %), or early cancer (43 %). In 134 patients with poor healing (10 %), additional time and acid suppression resulted in complete esophageal healing, and 67/134 (50 %) had normal squamous regeneration with 97 % CE-BE. Overall, 74 patients had poor squamous regeneration (5 %). Compared with patients with normal regeneration, patients with poor squamous regeneration had a higher risk for treatment failure (64 % vs. 2 %, relative risk [RR] 27 [95 % confidence interval [CI] 18-40]) and progression to advanced disease (15 % vs. < 1 %, RR 30 [95 %CI 12-81]). Higher body mass index, longer BE segment, reflux esophagitis, and < 50 % squamous regeneration after baseline endoscopic resection were independently associated with poor squamous regeneration in multivariable logistic regression.Conclusions: In half of the patients with poor healing, additional time and acid suppression led to normal squamous regeneration and excellent treatment outcomes. In patients with poor squamous regeneration, however, the risk for treatment failure and progression to advanced disease was significantly increased. [ABSTRACT FROM AUTHOR]

Background: The novel 180° cryoballoon (CbAS180) enables semicircumferential treatment over a length of 3 cm per application. This first-in-human study evaluates its feasibility, efficacy, and safety for the treatment of Barrett's esophagus (BE) neoplasia.Methods: This multicenter study consisted of dose-finding and extension phases. Dose-finding started with the lowest dose possible (1.0 mm/s). For each dose, six patients were treated circumferentially over a 3-cm length. The dose was increased until the median BE regression was ≥ 60 % without serious adverse events (SAEs). In the extension phase, the dose was confirmed in 19 new patients. The outcomes were technical success, BE regression after one treatment, and SAEs.Results: 25 patients (median Prague C0M3) were included (6 dose-finding/19 extension). In two patients, the CbAS180 could not be applied because of unstable balloon positioning. The technical success rate was 96 % (22 /23). In the six dose-finding patients, the starting dose resulted in median BE regression of 94 % (95 % confidence interval [CI] 60 %-97 %) without SAEs and was thus considered effective. Overall median BE regression was 80 % (95 %CI 60 %-90 %).Conclusion: Single-session CbAS180 seems feasible, safe, and effective, and is a promising technique for the treatment of patients with BE neoplasia. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Low-grade dysplasia (LGD) is the best predictor of neoplastic progression in Barrett's esophagus (BE). Most LGD cases are downstaged to nondysplastic (ND) BE on expert pathologist review, which is prone to interobserver variation and not widely available. Recent studies indicate that a risk prediction assay (TissueCypher) risk stratifies patients with NDBE for neoplastic progression. We aimed to investigate whether this risk prediction assay predicts neoplastic progression in BE patients with LGD. METHODS: A blinded, retrospective cohort study was derived from the screening cohort of a randomized controlled trial of SURveillance vs RadioFrequency ablation for BE patients with LGD. Hematoxylin and eosin and p53 immunohistochemistry slides from the first endoscopy with LGD were independently reviewed by 3 expert pathologists and tested by the risk prediction assay. Revision diagnoses of NDBE were considered low risk, although indefinite for dysplasia, and LGD were considered high risk for progression. RESULTS: A total of 155 BE patients (123 men), mean age 61 ± 10 years, were analyzed. Thirty-four patients (22%) progressed to high-grade dysplasia/esophageal adenocarcinoma (median time 2.4 years) and 121 did not progress (median high-grade dysplasia/esophageal adenocarcinoma-free surveillance 7.9 years). The risk prediction assay sensitivity was 68% vs 76% for the 3 pathologists, and specificity was 79% vs 64%-77.0% for the pathologists. The assay detected 50%-56% of progressors that were downstaged to NDBE by the pathologists. DISCUSSION: The risk prediction assay provided significant risk stratification in BE patients with LGD and identified progressors that the experts downstaged to NDBE. This objective assay provides an effective solution to the lack of standardization of expert pathology review of LGD. [ABSTRACT FROM AUTHOR]

Background Transmural defects in the upper gastro-intestinal (GI) tract (anastomotic leak, Boerhaave syndrome, iatrogenic defects) are associated with severe morbidity. Recently, a vacuum-stent was introduced as novel treatment device, combining the benefits of negative pressure wound therapy and an intraluminal stent, while allowing for oral intake of a soft diet. The aim of this prospective case series was to describe the first experiences with the vacuum-stent for the upper GI tract in an academic hospital. Methods All patients treated with a vacuum-stent between March 2022 and March 2023 were included. Patients who were already treated with vacuum-sponge and received a vacuum-stent when it became available were also included. Outcome measures included successful closure of the defect, adverse events, number of EVT-related endoscopies and treatment duration. Results 23 patients were included (18 male, median age 65 years). Fourteen patients had anastomotic leakage after esophagectomy, five patients an iatrogenic perforation and four had Boerhaave syndrome. Twelve patients were treated with vacuum-stent alone and eleven with a combination of vacuum-stent and vacuum-sponge (Table 1), which was mostly due to the later availability of or limited experience during the implementation period of the vacuum-stent. Success rate was 91%, median 4 (IQR 3–8) EVT-related endoscopies were performed during median 14 (IQR 12–31) days of treatment in successful cases. During median 120 (IQR 15–221) days follow-up, four patients developed an anastomotic stricture treated with endoscopic dilation. No other adverse events were observed. Conclusion The vacuum-stent combines the benefits of EVT and an intraluminal stent and shows great feasibility and efficacy in treatment of transmural defects in the upper GI tract. More research is necessary, as this device could possibly prevent major (re-)surgery in these patients. [ABSTRACT FROM AUTHOR]

B Impact of expert center endoscopic assessment of confirmed low grade dysplasia in Barrett's esophagus diagnosed in community hospitals b Nieuwenhuis EA, van Munster SN, Curvers WL et al. Correct is: Impact of expert center endoscopic assessment of confirmed low grade dysplasia in Barrett's esophagus diagnosed in community hospitals.. This was corrected in the online version on August 5, 2022. [Extracted from the article]

Patient selection is suboptimal in most studies focused on identifying biological markers for neoplastic progression in Barrett's esophagus (BE). This study aims to describe a stringently selected community-based case-control cohort of non-dysplastic BE (NDBE) patients who progressed to high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) and BE patients who never progressed to be used for future biomarker studies. We identified all patients referred for endoscopic work-up of BE neoplasia at three tertiary referral centers for treatment of BE neoplasia between 2000 and 2013. We performed a detailed registration of any endoscopic surveillance history before neoplastic progression. Controls were selected from a retrospective BE surveillance registration in 10 community hospitals. A total of 887 patients were referred for endoscopic work-up of BE neoplasia. Based on predefined selection criteria, we identified 165 progressor patients (82% men; mean age 55 years ± 10.4) with a baseline endoscopy demonstrating NDBE > 2 years before neoplastic progression. Using the same predefined selection criteria, 723 nonprogressor patients (67% men; mean age 57 years ± 11.3) with >2 years of endoscopic surveillance were identified. Median length of the BE segment was 5 cm (IQR 4–7) in progressors and 4 cm (IQR 2–6) in controls. Median duration of surveillance was 89 months (IQR 54–139) in progressors and 76 months (IQR 47–116) in nonprogressors. Paraffin embedded biopsies are available for biomarker research in all patients. Ethical approval was obtained and material transfer agreements were signed with all 58 contributing pathology labs. This is the largest community-based case-control cohort of BE patients with and without progression to early neoplasia. The stringent selection criteria and the availability of paraffin embedded biopsy specimens make this a unique cohort for biomarker studies. [ABSTRACT FROM AUTHOR]