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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., Competing Interests: B.L.A.M. Weusten has received financial research support from Pentax Medical and Aqua Medical, and has received lecture fees from and is a consultant for Pentax Medical. J.J.G.H.M. Bergman has received financial support for institutional review board-approved research from C2Therapeutics/Pentax Medical, Medtronic, and Aqua Medical. R.E Pouw is a consultant for Medtronic BV and MicroTech Europe, and has received speaker fees from Pentax. L. van Tilburg, E.P.D. Verheij, S.E.M. van de Ven, S.N. van Munster, L. Alvarez Herrero, W.B. Nagengast, E.J. Schoon, A. Alkhalaf, L. Oudijk, S.L. Meijer, M. Jansen, M. Doukas, and A.D. Koch declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

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., Competing Interests: C.N. Frederiks has received speaker fees from Pentax Medical. R.E. Pouw is a consultant for MicroTech, and has received speaker fees from Medtronic. J.J.G.H.M. Bergman is a consultant for Boston Scientific, Cook Medical, and Medtronic, and has received research funding from Aqua Medical, Fuji Film, Olympus Endoscopy, Pentax Medical, and Medtronic. B.L.A.M. Weusten is a consultant for Pentax Medical, has received speaker fees from Pentax Medical, and has received research funding from Aqua Medical and Pentax Medical. I.N. Beaufort, A. Overwater, L.A.A. Brosens, and A.D. Koch declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Recently, endoscopic vacuum therapy (EVT) was introduced as treatment for anastomotic leakage after upper gastrointestinal (GI) surgery. The aim of this study was to describe the initial experience with EVT for anastomotic leakage after upper GI surgery in a tertiary referral center., Methods: Patients treated with EVT for anastomotic leakage after upper GI surgery were included retrospectively (January 2018-June 2021) and prospectively (June 2021-October 2021). The primary end point was the EVT success rate. Secondary end points included mortality and adverse events., Results: 38 patients were included (31 men; mean age 66 years): 27 had undergone an esophagectomy with gastric conduit reconstruction and 11 a total gastrectomy with esophagojejunal anastomosis. EVT was successful in 28 patients (74 %, 95 %CI 57 %-87 %). In 10 patients, EVT failed: deceased owing to radiation pneumonitis (n = 1), EVT-associated complications (n = 2), and defect closure not achieved (n = 7). Mean duration of successful EVT was 33 days, with a median of six EVT-related endoscopies. Median hospital stay was 45 days., Conclusion: This initial experience with EVT for anastomotic leakage after upper GI surgery demonstrated a success rate of 74 %. EVT is a promising therapy that could prevent further major surgery. More experience with the technique and its indications will likely improve success rates in the future., Competing Interests: R.E. Pouw is a consultant for MicroTech Europe and Medtronic bv., has received speakerʼs fees from Pentax, and is on the advisory board of EsoCap AG. M.I. van Berge Henegouwen is a consultant for Mylan, Johnson & Johnson, Alesi Surgical, BBraun, and Medtronic, and has received unrestricted research grants from Stryker (all fees paid to the institution). L.M.D. Pattynama, F. Daams, S.S. Gisbertz, J.J.G.H.M. Bergman, and W.J. Eshuis declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).)

Background: Current surveillance for Barrett's esophagus (BE), consisting of four-quadrant random forceps biopsies (FBs), has an inherent risk of sampling error. Wide-area transepithelial sampling (WATS) may increase detection of high grade dysplasia (HGD) and esophageal adenocarcinoma (EAC). In this multicenter randomized trial, we aimed to evaluate WATS as a substitute for FB., Methods: Patients with known BE and a recent history of dysplasia, without visible lesions, at 17 hospitals were randomized to receive either WATS followed by FB or vice versa. All WATS samples were examined, with computer assistance, by at least two experienced pathologists at the CDx Diagnostics laboratory. Similarly, all FBs were examined by two expert pathologists. The primary end point was concordance/discordance for detection of HGD/EAC between the two techniques., Results: 172 patients were included, of whom 21 had HGD/EAC detected by both modalities, 18 had HGD/EAC detected by WATS but missed by FB, and 12 were detected by FB but missed by WATS. The detection rate of HGD/EAC did not differ between WATS and FB ( P  = 0.36). Using WATS as an adjunct to FB significantly increased the detection of HGD/EAC vs. FB alone (absolute increase 10 % [95 %CI 6 % to 16 %]). Mean procedural times in minutes for FB alone, WATS alone, and the combination were 6.6 (95 %CI 5.9 to 7.1), 4.9 (95 %CI 4.1 to 5.4), and 11.2 (95 %CI 10.5 to 14.0), respectively., Conclusions: Although the combination of WATS and FB increases dysplasia detection in a population of BE patients enriched for dysplasia, we did not find a statistically significant difference between WATS and FB for the detection of HGD/EAC as single modality., Competing Interests: The study was financially supported by CDx Diagnostics, Inc. CDx Diagnostics supported the study personnel cost and provided the study brushes. The sponsor had no role in the design and conduct of the study or collection, management, analysis, and interpretation of the data. The sponsor was provided with a draft prior to submission and did submit feedback to the authors.R. Bisshops has received consultancy fees from CDx Diagnostics. G. de Hertogh’s employer, the University of Leuven, received payments for involvement as central pathology reader in the study. R. Kariv is supported by a grant from Pfizer. P.D. Siersema is supported by grants from Pentax, MicroTech, the Enose company, and Motus GI. K. Ragunath has received consultancy fees from CDX Diagnostics. J. Bergman, P. Bhandari, L. Correale, G. Fernández-Esparrach, R. Haidry, C. Hassan, P. Leclercq, A. Lemmers, S.L. Meijer, H. Messmann, M. Munoz-Navas, H. Neuhaus, O. Pech, A. Probst, A. Repici, E.J. Schoon, S. Seewald, S.N. van Munster, and B.L.A.M. Weusten declare that they have no conflict of interest., (Thieme. All rights reserved.)

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., Competing Interests: A. Overwater: reimbursement of study-related travel costs from Pentax Medical for an IRB-approved European, multicenter prospective study. E.J. Schoon: Speaker fee from Fujifilm, and financial support for research. J.J.G.H.M. Bergman: Unrestricted grants for research support from Medtronic, Pentax, Cernostics, Aqua Medical, Fractyl Laboratories, Endogenex, Digma Medical, Lucid, and CDx. R.E. Pouw: speaker fee from Medtronic, consultancy for MicroTech. B.L.A.M. Weusten: Financial support for research from Pentax Medical, C2Therapeutics, and Aqua Medical, and consultancy fee from Pentax Medical. S.G. Elias declares that he has no conflict of interest., (Thieme. All rights reserved.)

This ESGE Position Statement defines the expected value of artificial intelligence (AI) for the diagnosis and management of gastrointestinal neoplasia within the framework of the performance measures already defined by ESGE. This is based on the clinical relevance of the expected task and the preliminary evidence regarding artificial intelligence in artificial or clinical settings. MAIN RECOMMENDATIONS:: (1) For acceptance of AI in assessment of completeness of upper GI endoscopy, the adequate level of mucosal inspection with AI should be comparable to that assessed by experienced endoscopists. (2) For acceptance of AI in assessment of completeness of upper GI endoscopy, automated recognition and photodocumentation of relevant anatomical landmarks should be obtained in ≥90% of the procedures. (3) For acceptance of AI in the detection of Barrett's high grade intraepithelial neoplasia or cancer, the AI-assisted detection rate for suspicious lesions for targeted biopsies should be comparable to that of experienced endoscopists with or without advanced imaging techniques. (4) For acceptance of AI in the management of Barrett's neoplasia, AI-assisted selection of lesions amenable to endoscopic resection should be comparable to that of experienced endoscopists. (5) For acceptance of AI in the diagnosis of gastric precancerous conditions, AI-assisted diagnosis of atrophy and intestinal metaplasia should be comparable to that provided by the established biopsy protocol, including the estimation of extent, and consequent allocation to the correct endoscopic surveillance interval. (6) For acceptance of artificial intelligence for automated lesion detection in small-bowel capsule endoscopy (SBCE), the performance of AI-assisted reading should be comparable to that of experienced endoscopists for lesion detection, without increasing but possibly reducing the reading time of the operator. (7) For acceptance of AI in the detection of colorectal polyps, the AI-assisted adenoma detection rate should be comparable to that of experienced endoscopists. (8) For acceptance of AI optical diagnosis (computer-aided diagnosis [CADx]) of diminutive polyps (≤5 mm), AI-assisted characterization should match performance standards for implementing resect-and-discard and diagnose-and-leave strategies. (9) For acceptance of AI in the management of polyps ≥ 6 mm, AI-assisted characterization should be comparable to that of experienced endoscopists in selecting lesions amenable to endoscopic resection., Competing Interests: O.F. Ahmad has received speaker fees from Olympus (March 2022). G. Antonelli has received a consultancy fee from Medtronic. P. Bhandari’s department has received research grants from NEC Japan (June 2019, ongoing) and Fujifilm Europe (June 2020, ongoing). J.J.G.H.M. Bergman has received support for AI-related research in endoscopy from Olympus and and Fuijfilm; he has carried out sponsored AI-related research into Barrett’s esophagus for which the rights have been transferred to Olympus. R. Bisschops has received consultancy and speaker’s fees from Fujifilm, Pentax, and Medtronic (2015, ongoing), and provided consultancy to CDx Diagnostics (2017–2019); his department has received research grants from Pentax and Fujifilm (2015, ongoing), and from Medtronic (2018, ongoing). E. Dekker has received honoraria for consultancy from Fujifilm, Olympus, GI Supply, and PAION; she has received speakerʼs fees from Norgine, Ipsen, PAION, and Fujifilm. M. Dinis-Ribeiro has provided consultancy to Medtronic and Roche (2021–2022); his department has received support (loan for research) from Fujifilm (2021–2022); he is Co-Editor-in-Chief of Endoscopy journal. R. Eliakim has provided consultancy on various occasions to Medtronic (from 2019). I. Gralnek has provided consultancy to and been on the advisory board of Motus GI; he has provided consultancy to Boston Scientific, Clexio Biosciences, Medtronic, and Symbionix; he has received research support from Astra Zeneca and CheckCap; all during the last 3 years, 2019 to present. R.J. Haidry has received an educational grant to support research from Cook Endoscopy (2015, ongoing); his department has received an educational grant to support research from Medtronic (2018, ongoing). C. Hassan has received consulting fees and/or research grants from Alphasigma, Fujifilm, Medtronic, Norgine, Olympus, and Pentax. R. Joverʼs department has received a research grant from Medtronic (2021–2022). M.F. Kaminski has provided consultancy to Olympus (2016, ongoing) and Erbe (2021, ongoing), and has lectured for Boston Scientific (2016, ongoing) and Recordati (2020, ongoing). H. Messmann’s department has received financial and/or research support from Apollo Endosurgery, Biogen, Boston Scientific, CDx Diagnostics, Cook Medical, CSL Behring, Dr. Falk Pharma, Endo Tools Therapeutics, Erbe, Fujifilm, Hitachi, Janssen-Cilag, Medwork, Norgine, Nutricia, Olympus, Ovesco Endoscopy, Satisfai, Servier Deutschland, and US Endoscopy (in the past 3 years). Y. Mori has provided consultancy to and delivered talks for Olympus (2018–2022); he has ownership interest in Cybernet System Corporation (2020–2022). A. Repici has received research grants and speakerʼs fees from Boston Scientific (2020–2022), Fujifilm (2019–2022), and Norgine (2020–2022); he is also on an advisory board for Fujifilm (2019–2022). E. Rondonotti has been an Expert group member and speaker for Fujifilm (January–December 2021), and provided consultancy to Medtronic (July 2021–July 2022); his department received a research grant from Fujifilm (January–December 2021). Y. Saitoʼs department is conducting joint research with the NEC Corporation in developing AI for colonoscopy (April 2016–March 2023); he or his department will hold joint patents with the NEC Corporation, and five patents are pending. P. Sharma is providing consultancy services to Bausch, Boston Scientific, CDx Labs, Covidien LP, Exact Sciences, Fujifilm Medical Systems, Lucid, Lumendi, Medtronic, Phathom, Olympus, Takeda, and Samsung Bioepis (ongoing); his department is receiving research support from Cosmo Pharmaceuticals, Covidien, Docbot, ERBE, Fujifilm, Ironwood Pharmaceuticals, Olympus, and Medtronic. C. Spada has provided consultancy to Medtronic (2018–2022) and AnX Robotics (2018–2022). M. Abdelrahim, M. Areia, I. Boskoski, D. Domagk, A. Ebigbo, T. Eelbode, M. Häfner, R. Kuvaev, D. Libânio, M. Palazzo, M. Rutter, P. Sinonquel, M. Spadaccini, and A. Veitch have no competing interests., (European Society of Gastrointestinal Endoscopy. All rights reserved.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

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., Competing Interests: Dr. Weusten has received financial support for IRB-approved research from C2Therapeutics/Pentax Medical, and Aqua Medical. Dr. Bergman has received financial support for IRB-approved research from C2Therapeutics/Pentax Medical, Medtronic, and Aqua Medical. The remaining authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by/4.0/).)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background: Estimates on miss rates for upper gastrointestinal neoplasia (UGIN) rely on registry data or old studies. Quality assurance programs for upper GI endoscopy are not fully established owing to the lack of infrastructure to measure endoscopists' competence. We aimed to assess endoscopists' accuracy for the recognition of UGIN exploiting the framework of artificial intelligence (AI) validation studies., Methods: Literature searches of databases (PubMed/MEDLINE, EMBASE, Scopus) up to August 2020 were performed to identify articles evaluating the accuracy of individual endoscopists for the recognition of UGIN within studies validating AI against a histologically verified expert-annotated ground-truth. The main outcomes were endoscopists' pooled sensitivity, specificity, positive and negative predictive value (PPV/NPV), and area under the curve (AUC) for all UGIN, for esophageal squamous cell neoplasia (ESCN), Barrett esophagus-related neoplasia (BERN), and gastric adenocarcinoma (GAC)., Results: Seven studies (2 ESCN, 3 BERN, 1 GAC, 1 UGIN overall) with 122 endoscopists were included. The pooled endoscopists' sensitivity and specificity for UGIN were 82 % (95 % confidence interval [CI] 80 %-84 %) and 79 % (95 %CI 76 %-81 %), respectively. Endoscopists' accuracy was higher for GAC detection (AUC 0.95 [95 %CI 0.93-0.98]) than for ESCN (AUC 0.90 [95 %CI 0.88-0.92]) and BERN detection (AUC 0.86 [95 %CI 0.84-0.88]). Sensitivity was higher for Eastern vs. Western endoscopists (87 % [95 %CI 84 %-89 %] vs. 75 % [95 %CI 72 %-78 %]), and for expert vs. non-expert endoscopists (85 % [95 %CI 83 %-87 %] vs. 71 % [95 %CI 67 %-75 %])., Conclusion: We show suboptimal accuracy of endoscopists for the recognition of UGIN even within a framework that included a higher prevalence and disease awareness. Future AI validation studies represent a framework to assess endoscopist competence., Competing Interests: J.J.G.H.M. Bergman has received grants and personal fees from Olympus, Fujifilm, and Pentax Endoscopy outside of the submitted work. P. Sharma has received personal fees from Olympus and Boston Scientific, and grants from CDx, US Endoscopy, Medtronic, Ironwood, Erbe, and Fujifilm outside of the submitted work. C. Hassan has received personal fees from Medtronic, Fujifilm, and Olympus outside of the submitted work. M. Dinis-Ribeiro has received grants from Olympus and Fujifulm outside of the submitted work. Y. Mori has received personal fees from Olympus Corp. and Cybernet System Corp. outside of the submitted work. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Lymph node metastasis (LNM) is possible after endoscopic resection of early esophageal adenocarcinoma (EAC). This study aimed to develop and internally validate a prediction model that estimates the individual risk of metastases in patients with pT1b EAC., Methods: A nationwide, retrospective, multicenter cohort study was conducted in patients with pT1b EAC treated with endoscopic resection and/or surgery between 1989 and 2016. The primary end point was presence of LNM in surgical resection specimens or detection of metastases during follow-up. All resection specimens were histologically reassessed by specialist gastrointestinal pathologists. Subdistribution hazard regression analysis was used to develop the prediction model. The discriminative ability of this model was assessed using the c-statistic., Results: 248 patients with pT1b EAC were included. Metastases were seen in 78 patients, and the 5-year cumulative incidence was 30.9 % (95 % confidence interval [CI] 25.1 %-36.8 %). The risk of metastases increased with submucosal invasion depth (subdistribution hazard ratio [SHR] 1.08, 95 %CI 1.02-1.14, for every increase of 500 μm), lymphovascular invasion (SHR 2.95, 95 %CI 1.95-4.45), and for larger tumors (SHR 1.23, 95 %CI 1.10-1.37, for every increase of 10 mm). The model demonstrated good discriminative ability (c-statistic 0.81, 95 %CI 0.75-0.86)., Conclusions: A third of patients with pT1b EAC experienced metastases within 5 years. The probability of developing post-resection metastases was estimated with a personalized predicted risk score incorporating tumor invasion depth, tumor size, and lymphovascular invasion. This model requires external validation before implementation into clinical practice., Competing Interests: A. D. Koch has received consultancy fee from ERBE Elektromedizin and Pentax Medical. He has received research support from Dr Falk Pharma. M. J. Bruno is a consultant for Boston Scientific, Cook Medical and Pentax Medical. He has received support for industry and investigator initiated studies from Boston Scientific, Cook Medical, Pentax Medical, Mylan, ChiRoStim and 3M. M. I van Berge Henegouwen is consultant for Mylan, Johnson & Johnson, Alesi Surgical and Medtronic, and received research grants from Olympus and Stryker., (Thieme. All rights reserved.)

Background: Endoscopic cryoablation for Barrett's esophagus (BE) might offer advantages over heat-based ablation. Focal cryoballoon ablation has been promising for short-segment BE, whereas the novel 90°-swipe cryoballoon ablation system (CbSAS 90 ) ablates larger areas in a single step (90° over 3 cm). The system allows for dose adjustment. CbSAS 90 has been feasible and safe in animal and pre-esophagectomy studies. This is the first clinical study to assess feasibility, safety, and efficacy of CbSAS 90 for eradication of dysplastic BE., Methods: In this prospective study in dysplastic BE patients, dose finding started with semi-circumferential treatment at 0.8 mm/s (dose 1). The dose was escalated by reducing speed by 0.1 mm/s in six patients until BE surface regression was ≥ 80 % without complications ("effective dose"). The effective dose was subsequently confirmed with circumferential treatment in 12 new patients. Post-procedural pain (0 - 10) and dysphagia (0 - 4) were evaluated. Outcomes were feasibility, safety, and BE surface regression., Results: 25 patients were included, with technically successful treatment in 92 % (95 %CI 73 % - 99 %). Median (95 %CI) BE surface regression was 78 % (50 % - 85 %) for dose 1 and 85 % (55 % - 95 %) for dose 2 (0.7 mm/s), which was defined as the effective dose. Circumferential treatment resulted in 93 % (88 % - 96 %) regression. Two of 12 patients with circumferential treatment developed strictures that required dilation. Median pain and dysphagia scores were low (0 - 3 and 0, respectively)., Conclusions: CbSAS 90 was feasible and effective for ablating larger BE areas. The optimal dose for circumferential treatment that balances safety and efficacy requires further evaluation., Competing Interests: Professor Bergman has received support for clinical studies from Boston Scientific. Professor Weusten has received speaker fees and financial support for IRB-approved studies from Pentax Medical of America, Inc., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and aims  Endoscopic treatment of Barrett's esophagus (BE) consists of endoscopic resection of visible lesions followed by radiofrequency ablation (RFA) for any remaining flat BE. Because RFA is only justified in flat BE, detection of neoplastic lesions (high grade dysplasia [HGD] and early adenocarcinoma [EAC]) is crucial. We hypothesized that the detection of visible lesions containing HGD or EAC would be superior in BE expert centers compared with community hospitals, thereby supporting centralization of therapy for BE-related neoplasia. Methods  Patients referred with histologically proven HGD or EAC to two Dutch BE expert centers were included. Referral letters, and endoscopy and pathology reports were reviewed for the description of the BE, presence of lesions, and histopathological analysis of target and random tissue sampling. Primary outcome was the endoscopic detection rate of lesions containing histopathologically proven neoplasia (HGD and/or EAC) in community and expert centers. Results  There were 198 patients referred from 37 community hospitals (median referral time 55 days [interquartile range 33 - 85]). Detection rates for visible lesions were 60 % in community centers (75 % in patients with a biopsy diagnosis of EAC, 47 % in HGD) and 87 % in expert centers (98 % in EAC, 75 % in HGD); P  < 0.001. Even with HGD/EAC on random biopsies from the index endoscopy, the yield at repeat endoscopy was < 50 % in community hospitals. In 79 patients referred solely because of random biopsy results, a lesion requiring endoscopic resection or surgery was found in 76 % by the expert endoscopists. Conclusions  Endoscopists at community hospitals detect neoplastic lesions at a significantly lower rate. These data support the value of BE expert centers for work-up and further treatment of BE., (© Georg Thieme Verlag KG Stuttgart · New York.)