Photodynamic therapy for dysplastic Barrett esophagus and early esophageal adenocarcinoma

OBJECTIVE: To evaluate our results using photodynamic therapy (PDT) for the treatment of dysplasia or superficial cancer (T1 N0 M0) in patients with Barrett esophagus. PATIENTS AND METHODS: We retrospectively reviewed our clinical experience with 48 patients (34 patients with high-grade dysplasia and 14 patients with superficial cancer in Barrett esophagus) who had been referred for PDT. Initial evaluation included computed tomography and standard and high-frequency catheter endosonography. Follow-up endoscopy was performed 4 to 6 weeks after PDT with ablation of any residual glandular mucosa, using the argon plasma coagulator. Patients were then followed up indefinitely every 3 to 6 months with computed tomography, endosonography, and endoscopic surveillance. RESULTS: The median series follow-up was 18.5 months (range, 1-56 months). Apparent complete photoablation of Barrett mucosa and/or superficial neoplasm was documented in 47 of 48 cases. Complications included symptomatic strictures (11 patients), photosensitivity (7 patients), atrial fibrillation (1 patient) or recurrent congestive heart failure (1 patient), and self-limited esophageal perforation (1 patient). Failure to ablate T1 N0 M0 adenocarcinoma occurred in 1 patient. CONCLUSIONS: Porfimer sodium PDT appears to eradicate dysplastic Barrett mucosa and neoplasia. These results are promising; however, long-term studies are needed to document the efficacy of PDT in reducing the morbidity and mortality in such patients.     

套扎辅助内镜下黏膜切除术治疗Barrett食管的前瞻性研究

目的 研究套扎辅助黏膜切除治疗Barrett食管的有效性、安全性。方法 采用前瞻性研究。套扎辅助黏膜切除治疗57例Barrett食管患者。单环或多环套扎器预先吸引病灶形成假息肉,后再通电切除。切除前不予黏膜下注射。术后1个月复查胃镜。结果 57例患者接受套扎辅助黏膜切除,46例为岛型,11例为舌型。舌型组中特殊肠化、异型增生发生率高于岛型组。活检准确率为94.74%。5例术中出血。无狭窄、穿孔发生。结论 套扎辅助黏膜切除用于Barrett食管诊断治疗安全有效。     

Controversies in Barrett Esophagus

Barrett esophagus develops when metaplastic columnar epithelium predisposed to develop adenocarcinoma replaces esophageal squamous epithelium damaged by gastroesophageal reflux disease. Although several types of columnar metaplasia have been described in Barrett esophagus, intestinal metaplasia with goblet cells currently is required for a definitive diagnosis in the United States. Studies indicate that the risk of adenocarcinoma for patients with nondysplastic Barrett esophagus is only 0.12% to 0.38% per year, which is substantially lower than previous studies had suggested. Nevertheless, the incidence of esophageal adenocarcinoma continues to rise at an alarming rate. Regular endoscopic surveillance for dysplasia is the currently recommended cancer prevention strategy for Barrett esophagus, but a high-quality study has found no benefit of surveillance in preventing deaths from esophageal cancer. Medical societies currently recommend endoscopic screening for Barrett esophagus in patients with multiple risk factors for esophageal adenocarcinoma, including chronic gastroesophageal reflux disease, age of 50 years or older, male sex, white race, hiatal hernia, and intra-abdominal body fat distribution. However, because the goal of screening is to identify patients with Barrett esophagus who will benefit from endoscopic surveillance and because such surveillance may not be beneficial, the rationale for screening might be made on the basis of faulty assumptions. Endoscopic ablation of dysplastic Barrett metaplasia has been reported to prevent its progression to cancer, but the efficacy of endoscopic eradication of nondysplastic Barrett metaplasia as a cancer preventive procedure is highly questionable. This review discusses some of these controversies that affect the physicians and surgeons who treat patients with Barrett esophagus. Studies relevant to controversial issues in Barrett esophagus were identified using PubMed and relevant search terms, including Barrett esophagus, ablation, dysplasia, radiofrequency ablation, and endoscopic mucosal resection.     

多环黏膜切除术治疗Barrett食管的临床研究

目的研究内镜下应用多环黏膜切除术（multiband mucosectomy,MBM）治疗Barrett食管。方法采用前瞻性研究的方法,在窄波成像（narrow band imaging,NBI）下确认Barrett食管病变范围,用多环黏膜切除器吸引病灶,套扎橡皮圈后用圈套器电切。3个月复查胃镜,评估疗效。结果134例Barrett食管患者共切除病灶206块。急性并发症出血发生率6.7%（9/134）,无一例发生穿孔。术后30d内（迟发性并发症）出血发生率1.5%（2/134）,出现食管狭窄症状39.8%（53/133）;30d后（远期并发症）主要为食管狭窄,发生率2.3%（3/133）。术后3个月复查胃镜,病灶完整切除率98.5%（131/133）。结论内镜下MBM术治疗Barrett食管,简便、安全、有效。     

内镜经黏膜下隧道肿瘤切除术治疗颈部食管黏膜下良性肿瘤策略和并发症分析

目的评估内镜经黏膜下隧道肿瘤切除术(STER)治疗颈部食管黏膜下肿瘤的可行性及安全性。方法收集2017年1月至2018年1月本院收治的12例颈部食管黏膜下良性肿瘤并接受STER治疗的患者资料,分析其整块切除率、治愈性切除率、手术及住院时间、术后相关并发症。结果 12例颈部食管黏膜下肿瘤均行STER治疗,男7例,女5例,年龄(58.3±11.6)岁,病灶距门齿(19.41±0.51)cm,切除瘤体直径(16.25±6.44)mm,手术时间为(45.00±6.57)min,整块切除率91.67%(11/12),治愈性切除率100%(12/12)。术中出血1例(8.33%,1/12),无穿孔,术后有8例(66.67%,8/12)出现不同程度发热,有9例(75.00%,9/12)出现咽喉部不适或胸骨后烧灼不适,住院时间为(8.17±1.11)d,术后随访未发现病变残留、复发及食管狭窄。结论 STER治疗颈部食管黏膜下良性肿瘤是安全有效的治疗方法。     

黏膜切除治疗Barrett食管疗效及安全性的Meta分析

目的评价黏膜切除(EMR)对于Barrett食管(BE)治疗的有效性、持久性及不良事件发生率。方法计算机检索Embase、PubMed、维普、中国期刊全文数据库、万方数字化期刊全文数据库等。提取各病理类型的BE接受EMR治疗后根除肠上皮化生(CE-IM)、上皮内瘤变(CE-N)的比率,治疗随访期间肠上皮化(IM)或瘤变复发及不良事件发生率,应用R3.1.3软件合并数据进行统计学分析,计算其有效性、持久性及不良事件发生率。结果共纳入4篇研究,总病例130例。EMR治疗异型增生或黏膜内癌的BE患者中,达到CE-N为97%(95%CI:0.91~0.99),达到CE-IM为91%(95%CI:0.83~0.95),在随访过程中瘤变或IM复发率为8%,常见并发症食管狭窄与出血,其发生率分别为39%和6%。结论 EMR作为BE内镜治疗的推荐方式,其在治疗伴异型增生或黏膜内癌的BE上有确切的效果,但其并发症特别是食管狭窄发生率较高。     

Cost-effectiveness Analysis of Radiofrequency Ablation in Patients With Barrett Esophagus and High-grade Dysplasia or Low-grade Dysplasia

PurposeClinical guidelines recommend radiofrequency ablation (RFA) for eradication of Barrett esophagus in patients with low-grade dysplasia (LGD) and high-grade dysplasia (HGD), but evidence on whether RFA provides good value for money is still sparse. This study evaluates the cost-effectiveness of RFA in Italy.MethodsA Markov model was used to estimate lifelong costs and consequences of disease progression with different treatments. RFA was compared with esophagectomy in the HGD group or endoscopic surveillance in the LGD group. Clinical and quality-of-life parameters were derived from a review of the literature and expert opinions, whereas Italian national tariffs were used as a proxy for costs.FindingsRFA dominated esophagectomy in patients with HGD with a probability of 83%. For patients with LGD, RFA was more effective and more costly than active surveillance (incremental cost-effectiveness ratio, €6276 per quality-adjusted life-year). At a cost-effectiveness threshold of €15,272, the probability of RFA being the optimal strategy in this population was close to 100%. Model results were sensitive to the cost of the interventions and utility weights used in the different disease states.ImplicationsRFA is likely to be the optimal choice for patients with LGD and HGD in Italy. Italy is discussing the implementation of a national program for the health technology assessment of medical devices, requiring more studies to prove value for money of emerging technologies.     

Curative treatment for high-grade intraepithelial neoplasia in Barrett's esophagus

BACKGROUND AND STUDY AIMS: The incidence of premalignant and malignant lesions in specialized intestinal metaplasia of the esophagus has increased dramatically in the industrialized world in recent years. This report evaluates the efficacy and safety of local endoscopic therapy for high-grade intraepithelial neoplasia (HGIN) in Barrett's esophagus. PATIENTS AND METHODS: Over a 5-year period between October 1996 and September 2001, a total of 379 patients were referred with a suspicion of early Barrett's cancer. In a prospective study, 44 patients with HGIN in Barrett's esophagus were selected for local endoscopic treatment. Endoscopic resection was carried out in 14 patients in whom the HGIN was re-detectable, and 27 patients in whom the HGIN was not re-detectable underwent photodynamic therapy (PDT). Endoscopic resection and PDT were combined in three patients. RESULTS: Complete remission was achieved in 43 of the 44 patients (97.7 %). No major complications occurred. A mean of 1 session was needed to achieve complete local remission. During a mean follow-up period of 36 months (range 7 - 61 months), recurrent or metachronous lesions were observed in six patients (17.1 %), all of whom received a second successful endoscopic treatment. CONCLUSIONS: Endoscopic therapy is a safe alternative treatment regimen for HGIN in Barrett's esophagus, providing a middle way between the widely promulgated options of a "watch-and-wait" policy and radical esophagectomy.     

High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett's esophagus: a prospective randomized crossover study

BACKGROUND AND STUDY AIMS: High-resolution endoscopy (HRE) may improve the detection of early neoplasia in Barrett's esophagus. Indigo carmine chromoendoscopy (ICC) and narrow-band imaging (NBI) may be useful techniques to complement HRE. The aim of this study was to compare HRE-ICC with HRE-NBI for the detection of high-grade dysplasia or early cancer (HGD/EC) in patients with Barrett's esophagus. PATIENTS AND METHODS: Twenty-eight patients with Barrett's esophagus underwent HRE-ICC and HRE-NBI (separated by 6 - 8 weeks) in a randomized sequence. The two procedures were performed by two different endoscopists, who were blinded to the findings of the other examination. Targeted biopsies were taken from all detected lesions, followed by four-quadrant biopsies at 2-cm intervals. Biopsy evaluation was supervised by a single expert pathologist, who was blinded to the imaging technique used. RESULTS: Fourteen patients were diagnosed with HGD/EC. The sensitivity for HGD/EC was 93 % and 86 % for HRE-ICC and HRE-NBI, respectively. Targeted biopsies had a sensitivity of 79 % with HRE alone. HGD was diagnosed from random biopsies alone in only one patient. ICC and NBI detected a limited number of additional lesions occult to HRE, but these lesions did not alter the sensitivity for identifying patients with HGD/EC. CONCLUSIONS: In most patients with high-grade dysplasia or early cancer in Barrett's esophagus, subtle lesions can be identified with high-resolution endoscopy. Indigo carmine chromoendoscopy and narrow-band imaging are comparable as adjuncts to high-resolution endoscopy.     

Long-Segment early squamous cell carcinoma of the proximal esophagus: curative treatment and long-term follow-up after 5-aminolevulinic acid (5-ALA)-photodynamic therapy

Photodynamic therapy (PDT) is an established treatment for the ablation of dysplastic Barrett's epithelium and early esophageal carcinoma, but no data have been published on curative 5-aminolevulinic acid (5-ALA)-PDT for long-segment early esophageal cancer with infiltration of the upper sphincter. We describe successful curative treatment of an unusual early long-segment squamous cell carcinoma (uT1a,N0) of the proximal esophagus (18 - 28 cm aborally), with three sessions of 5-ALA-PDT. Endoscopic and endosonographic follow-up macroscopically showed a complete remission of the tumor, proven by biopsy showing total histological ablation. After a follow-up period of 23 months, there has been no indication of tumor recurrence. Early superficial (< 3 mm) squamous cell carcinomas of the esophagus can be ablated completely by 5-ALA-PDT. However, long-term follow-up is required in order to prove the effectiveness of endoscopic ablation therapy for early esophageal cancer.     

Radiofrequency ablation is effective for the treatment of high-grade dysplasia in Barrett's esophagus after failed photodynamic therapy

Endoscopic radiofrequency ablation (RFA) is an effective treatment for high-grade dysplasia in Barrett's esophagus in ablation-na?ve patients, but no studies have evaluated its use in patients in whom ablative therapy has previously failed. We describe 14 patients with residual high-grade dysplasia following aminolevulinic acid or Photofrin (porfimer sodium) photodynamic therapy (PDT). An overall complete reversal of dysplasia was achieved in 86?% with a combination of RFA and rescue endoscopic mucosal resection. The median total follow-up is 19 months. The rate of strictures was 7?% (1/14) and there was a low rate of buried glands (0.5?% follow-up biopsies). These data suggest RFA is both safe and effective for eradication of high-grade dysplasia in patients in whom PDT has failed.     

Photodynamic therapy and endoscopic mucosal resection for Barrett's dysplasia and early esophageal adenocarcinoma

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic ablation with porfimer sodium photodynamic therapy (PDT) have recently been combined to improve the accuracy of histologic staging and remove superficial carcinomas. MATERIALS AND METHODS: All patients with Barrett's esophagus and high-grade dysplasia were evaluated with computed tomography and endosonography. Patients with nodular or irregular folds underwent EMR followed by PDT. RESULTS: In three patients, endoscopic mucosal resection upstaged the diagnosis to mucosal adenocarcinoma (T1N0M0). PDT successfully ablated the remaining glandular mucosa. Complications were limited to transient chest discomfort and odynophagia. CONCLUSIONS: The use of EMR resection in Barrett's high-grade dysplasia patients with mucosal irregularities resulted in histologic upstaging to mucosal adenocarcinoma, requiring higher laser light doses for PDT. PDT after EMR appears to be safe and effective for the complete elimination of Barrett's mucosal adenocarcinoma. EMR should be strongly considered for Barrett's dysplasia patients being evaluated for endoscopic ablation therapy.     

Argon plasma coagulation in the treatment of Barrett's high-grade dysplasia and in situ adenocarcinoma

BACKGROUND AND STUDY AIMS: Endoscopic therapy of high-grade dysplasia (HGD) and superficial adenocarcinoma associated with Barrett's esophagus (BE), using Nd:YAG laser, KTP laser, or photodynamic therapy (PDT), has been reported to be effective in a curative role. Argon plasma coagulation (APC) appears to be effective in the eradication of nondysplastic Barrett's mucosa, but no results are available in the management of early neoplasms complicating BE. We report our initial experience in the application of APC in this indication. PATIENTS AND METHODS: Ten patients (mean age 74.2) with histologically proven HGD (n = 7) or in situ adenocarcinoma (n = 3) associated with BE (mean length 6 cm) and unfit for surgery were treated using APC and high-dose omeprazole (40 mg daily) until squamous re-epithelialization or complete eradication of the initially apparent lesions. Endoscopic follow-up was maintained at every 3 months. RESULTS: Complete eradication of HGD and in situ adenocarcinoma was achieved after a mean number of 3.3+/-1.5 APC sessions in 8/10 patients (80%). The eight patients with complete clearance of the neoplastic areas did not show any evidence of local recurrence during a median follow-up of 24 months (range 12-36 months). One patient with initial HGD had persistence of HGD 30 months after initial diagnosis, and one patient progressed to invasive adenocarcinoma after failure of APC and PDT. CONCLUSIONS: APC is safe and effective in the management of HGD and in situ adenocarcinoma associated with BE, and might represent an interesting alternative in selected patients who are not candidates for surgery.     

Mucosectomy for high‐grade dysplasia in Barrett's esophagus

Reports on the natural history of high‐grade dysplasia (HGD) are sometimes contradictory, but suggest that 10–30% of patients with HGD in Barrett's esophagus (BE) will develop a demonstrable malignancy within five years of the initial diagnosis. Surgery has to be considered the best treatment for HGD or superficial carcinoma, but is contraindicated in patients with severe comorbidities. Non‐surgical treatments such as intensive endoscopic surveillance, endoscopic ablative therapies, and endoscopic mucosal resection (EMR) have been proposed. EMR is a newly developed procedure promising to become a safe and reliable non‐operative option for the endoscopic removal of HGD or early cancer within BE. It is important to assess the depth of invasion of the lesion and lymph node involvement before choosing EMR. This technique permits more effective staging of disease obtaining a large sample leading to a precise assessment of the depth of malignant invasion. Complications such as bleeding and perforation may occur, but can be treated endoscopically. Trials are needed to compare endoscopic therapy with surgical resection to establish clear criteria for EMR and ablative therapies.     

Mucosectomy for high-grade dysplasia in Barrett's esophagus.

Reports on the natural history of high-grade dysplasia (HGD) are sometimes contradictory, but suggest that 10-30% of patients with HGD in Barrett's esophagus (BE) will develop a demonstrable malignancy within five years of the initial diagnosis. Surgery has to be considered the best treatment for HGD or superficial carcinoma, but is contraindicated in patients with severe comorbidities. Non-surgical treatments such as intensive endoscopic surveillance, endoscopic ablative therapies, and endoscopic mucosal resection (EMR) have been proposed. EMR is a newly developed procedure promising to become a safe and reliable non-operative option for the endoscopic removal of HGD or early cancer within BE. It is important to assess the depth of invasion of the lesion and lymph node involvement before choosing EMR. This technique permits more effective staging of disease obtaining a large sample leading to a precise assessment of the depth of malignant invasion. Complications such as bleeding and perforation may occur, but can be treated endoscopically. Trials are needed to compare endoscopic therapy with surgical resection to establish clear criteria for EMR and ablative therapies.     

Endoscopic ablation of Barrett's neoplasia with a new focal radiofrequency device: initial experience with the Halo60

Radiofrequency ablation (RFA) is an accepted treatment for the eradication of dysplastic Barrett's esophagus (DBE) and residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma. Circumferential balloon-based and focal catheter-based RFA devices are currently used (the Halo360 and Halo90). However, a new smaller focal ablation device (the Halo60) has been developed, which may be of benefit in patients with short tongues of Barrett's neoplasia, small residual islands, difficult anatomy, or strictures. We report the first use of this device in 17 patients with either DBE or residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma.     

Circumferential endoscopic mucosal resection in Barrett's esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients

BACKGROUND AND STUDY AIMS: Treatment by endoscopic mucosal resection (EMR) has been established for early lesions in Barrett's esophagus. However, the remaining Barrett's esophagus epithelium remains at risk of developing further lesions. The aim of this study was to evaluate the efficacy of circumferential endoscopic mucosectomy (circumferential EMR)s in removing not only the index lesion (high-grade intraepithelial neoplasia (HGIN) or mucosal cancer), but also the remaining Barrett's esophagus epithelium. PATIENTS AND METHODS: A total of 21 patients were included in the study (11 men, 10 women), who had Barrett's esophagus and either HGIN (n = 12) or mucosal cancer (n = 9). Of the patients, 17/21 were at high surgical risk and five had refused surgery. On the basis of preprocedure endosonography their lesions were classified as T1N0 (n = 19) or T0N0 (n = 2). The lesions and the Barrett's esophagus epithelium were removed by polypectomy after submucosal injection of 10-15 ml of saline; a double-channel endoscope was used in 15/21 cases. Circumferential EMR was performed in two sessions, the lesion and the surrounding half of the circumferential Barrett's esophagus mucosa being removed in the first session. In order to prevent the formation of esophageal stenosis, the second half of the Barrett's esophagus mucosa was resected 1 month later. RESULTS: Complications occurred in 4/21 patients (19 %), consisting of bleeding which was successfully managed by endoscopic hemostasis in all cases. No strictures were observed during follow-up (mean duration 18 months) and endoscopic resection was considered complete in 18/21 patients (86 %). For three patients, histological examination showed incomplete removal of tumor: one of these underwent surgery; two received chemoradiotherapy, and showed no evidence of residual tumor at 18 months' and 24 months' follow-up, respectively. Two patients in whom resection was initially classified as complete later presented with local recurrence and were treated again by EMR. Barrett's esophagus mucosa was completely replaced by squamous cell epithelium in 15/20 patients (75 %). CONCLUSIONS: Circumferential EMR is a noninvasive treatment of Barrett's esophagus with HGIN or mucosal cancer, with a low complication rate and good short-term clinical efficacy. Further studies should focus on long-term results and on technical improvements.     

胃食管反流病合并食管裂孔疝患者的临床特点分析

目的分析胃食管反流病(GERD)合并食管裂孔疝(HH)患者的临床特点及其危险因素。方法回顾性分析2018年1月-2019年3月在宁夏回族自治区人民医院消化内科诊断为GERD合并HH的40例患者并作为研究组,另外40例GERD未合并HH的患者为对照组,比较两组患者的基本临床资料、内镜分级、Barrett食管发生率。结果研究组患者的年龄、体重、吸烟史、糖尿病与对照组比较,差异均有统计学意义(P<0.05),两组性别、饮酒史和冠心病比较,差异均无统计学意义(P>0.05);研究组食管外症状较多见,内镜下分级仅有C级与对照组比较差异有统计学意义(P<0.05);A级、B级、D级两组差异无统计学意义(P>0.05);两组Barrett食管发生率比较,差异有统计学意义(P<0.05)。结论GERD合并HH与年龄、体重、吸烟史、糖尿病有关,且其会使Barrett食管发生率升高,积极防控可改变的因素对该类患者可能有一定的好处。     

Autofluorescence endoscopy in surveillance of Barrett's esophagus: a multicenter randomized trial on diagnostic efficacy

BACKGROUND AND STUDY AIMS: The reference surveillance method in patients with Barrett's esophagus is careful endoscopic observation, with targeted as well as random four-quadrant biopsies. Autofluorescence endoscopy (AFE) may make it easier to locate neoplasia. The aim of this study was to elucidate the diagnostic accuracy of surveillance with AFE-guided plus four-quadrant biopsies in comparison with the conventional approach. PATIENTS AND METHODS: A total of 187 of 200 consecutive Barrett's esophagus patients who were initially enrolled (73 % male, mean age 67 years, mean Barrett's segment length 4.6 cm), who underwent endoscopy for Barrett's esophagus in four study centers, were randomly assigned to undergo either AFE-targeted biopsy followed by four-quadrant biopsies or conventional endoscopic surveillance, also including four-quadrant biopsies (study phase 1). After exclusion of patients with early cancer or high-grade dysplasia, who underwent endoscopic or surgical treatment, as well as those who declined to participate in phase 2 of the study, 130 patients remained. These patients were examined again with the alternative method after a mean of 10 weeks, using the same methods described. The main study parameter was the detection of early cancer/adenocarcinoma or high-grade dysplasia (HGD), comparing both approaches in study phase 1; the secondary study aim in phase 2 was to assess the additional value of the AFE-guided approach after conventional surveillance, and vice versa. Test accuracy measures were derived from study phase 1. RESULTS: In study phase 1, the AFE and conventional approaches yielded adenocarcinoma/HGD rates of 12 % and 5.3 %, respectively, on a per-patient basis. With AFE, four previously unrecognized adenocarcinoma/HGD lesions were identified (4.3 % of the patients); with the conventional approach, one new lesion (1.1 %) was identified. Of the 19 adenocarcinoma/HGD lesions detected during AFE endoscopy in study phase 1, eight were visualized, while 11 were only detected using untargeted four-quadrant biopsies (sensitivity 42 %). Of the 766 biopsies classified at histology as being nonneoplastic, 58 appeared suspicious (specificity 92 %, positive predictive value 12 %, negative predictive value 98.5 %). In study phase 2, AFE detected two further lesions in addition to the initial alternative approach in 3.2 % of cases, in comparison with one lesion with conventional endoscopy (1.7 %). CONCLUSIONS: In this referral Barrett's esophagus population with a higher prevalence of neoplastic lesions, the AFE-guided approach improved the diagnostic yield for neoplasia in comparison with the conventional approach using four-quadrant biopsies. However, AFE alone was not suitable for replacing the standard four-quadrant biopsy protocol.     

Follow-up for high-grade dysplasia in Barrett's esophagus

This article will focus on the value of endoscopic follow-up for patients with high-grade dysplasia (HGD). Because the diagnosis of HGD in Barrett's esophagus is not a simple straightforward task, the article first will discuss the controversies regarding the histological diagnosis, followed by a discussion of the importance of endoscopic imaging for making the clinical diagnosis of HGD, and a systematic review of the literature relating to the presence of synchronous cancers in patients with HGD and the occurrence of cancer during endoscopic follow-up in these patients (metachronous cancers). Furthermore, the article will also discuss endoscopic techniques currently available for surveillance of these patients and make recommendations regarding surveillance intervals and the optimal biopsy protocol.