Quantitative attenuation analysis for identification of early Barrett's neoplasia in volumetric laser endomicroscopy

Early neoplasia in Barrett’s esophagus (BE) is difficult to detect. Volumetric laser endomicroscopy (VLE) incorporates optical coherence tomography, providing a circumferential scan of the esophageal wall layers. The attenuation coefficient (μVLE) quantifies decay of detected backscattered light versus depth, and could potentially improve BE neoplasia detection. The aim is to investigate feasibility of μVLE for identification of early BE neoplasia. In vivo and ex vivo VLE scans with histological correlation from BE patients ± neoplasia were used. Quantification by μVLE was performed manually on areas of interest (AoIs) to differentiate neoplasia from nondysplastic (ND)BE. From ex vivo VLE scans from 16 patients (13 with neoplasia), 68 AoIs were analyzed. Median μVLE values (mm−1) were 3.7 [2.1 to 4.4 interquartile range (IQR)] for NDBE and 4.0 (2.5 to 4.9 IQR) for neoplasia, not statistically different (p=0.82). Fourteen in vivo scans were used: nine from neoplastic and five from NDBE patients. Median μVLE values were 1.8 (1.5 to 2.6 IQR) for NDBE and 2.1 (1.9 to 2.6 IQR) for neoplasia, with no statistically significant difference (p=0.37). In conclusion, there was no significant difference in μVLE values in VLE scans from early neoplasia versus NDBE. Future studies with a larger sample size should explore other quantitative methods for detection of neoplasia during BE surveillance.

Management of Nodular Neoplasia in Barrett's Esophagus: Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection

Endoscopic resection has proven highly effective and safe in the removal of focal early neoplastic lesions in Barrett's esophagus and is considered the cornerstone of endoscopic treatment. Several techniques are available for endoscopic resection in Barrett's esophagus. The most widely used technique for piecemeal resection of early Barrett's neoplasia is the ligate-and-cut technique. Newer techniques such as endoscopic submucosal dissection may also play a role in the treatment of neoplastic Barrett's esophagus. Treatment of early Barrett's neoplasia should be centralized and limited to expert centers with a high-volume load and sufficient expertise in the detection and treatment of esophageal neoplasia.

[Treatment Strategy for Esophagogastric Junction Carcinoma;Highly Controversial Topic in the Upper Gastrointestinal Malignancy]

Among the 3 subtypes of adenocarcinoma of the esophagogastric junction (AEG), Siewert type I is basically consistent with esophageal adenocarcinoma arising from the Barrett epithelium( Barrett's adenocarcinoma), and type III is gastric carcinoma with esophageal invasion over the esophagogastric junction(EGJ). It is generally endorsed that type I is treated as an esophageal carcinoma, and type III as a gastric carcinoma. Siewert type II carcinoma, located just at the borderline between the esophagus and the stomach, has been a highly controversial topic regarding surgical approach, extent of esophagogastric resection and lymphadenectomy, type of reconstruction, and even the staging system. Type I is predominant in western countries and has been sharply increasing over the past 2 decades. Meanwhile, types II and III are common subtypes in Asian countries where the incidence of gastric carcinoma has long been very high. Current state of AEG and relevant issues are reviewed in this article.

Endotherapies for Barrett esophagus

Barrett esophagus (BE) is becoming an increasingly common complication. It places patients at higher risk for esophageal adenocaricnoma. Surveillance and acid suppression has been the mainstay of treatment. Recent advances in endoscopic therapies have allowed irradication of BE and reduction in cancer risk. This article reviews the available endotherapies and their efficacy.

[The molecular genetic alterations in mucosa of intestines as markers of oncologic progression and estimate of effectiveness of anti-reflux operations in patients with Barrett's esophagus]

The development of disease of Barrett's esophagus is based on processes of metaplasia of epithelium of esophagus when as a result of reflux of gastric juice and bile acids the normal planocellular epithelium of esophagus is replaced by cylindrical epithelium of intestinal type. Thereupon, Barrett's esophagus is progressing up to dysplasia and adenocarcinoma of esophagus. The progression from precancerous states up to tumor is related to development of genome disorders in cells associated with malignant transformation. The genetic and epigenetic alterations conditioning tumor growth can be used as markers of prognosis of clinical course of disease. To receive possible markers of progression of Barrett's esophagus the study was organized concerning methylation of such genes-suppressors of tumor growth as MGMT, CDH1, p16/CDKN2A, DAPK, RAR-β and RUNX3 in patients with Barrett's esophagus and adenocarcinoma of esophagus. The effectiveness of applied anti-reflux surgical treatment was evaluated too. The abnormal methylation of studied genetic panel in patients with Barrett's esophagus prior to surgical treatment was observed reliably more frequently in altered epithelium as compared with unaltered epithelium (p<0.0001), under dysplasia as compared with metaplasia (p<0.0358) and in the presence of long (>3 cm) segments of altered epithelium as compared with short (<3 cm) segments (p=0.0068). In normal epithelium, prior to operation, abnormal methylation of panel of genes was detected in 7/60 (12%) of patients. Against the background of surgical treatment number of long and short segments of altered epithelium of esophagus reliably decreased (p<0.05). At that, in short segments after operation rate of methylation increased significantly (p=0.0068). Though after operation number of patients with Barrett's esophagus and dysplasia and metaplasia decreased, the rate of abnormal methylation in the other patients increased. It is demonstrated that anti-reflux operation ameliorates condition of mucous membrane of esophagus under Barrett's esophagus. However, in cases without regression significant increasing of rate of abnormal methylation of studied panel of genes is occurred. This is a proof that abnormal methylation of system of genes is related to worse response to application of anti-reflux surgical treatment.

Single-session endoscopic resection and focal radiofrequency ablation for short-segment Barrett's esophagus with early neoplasia

BACKGROUND AND AIMS

The management of early neoplasia in Barrett's esophagus (BE) requires endoscopic resection of visible lesions, followed by radiofrequency ablation (RFA) of the remaining BE. We evaluated the safety and efficacy of combining endoscopic resection and focal RFA in a single endoscopic session in patients with early BE neoplasia.

METHODS

This was a retrospective analysis of patients with early BE neoplasia and a visible lesion undergoing combined endoscopic resection and focal RFA in a single session. Consecutive ablation procedures were performed every 8 to 12 weeks until complete endoscopic and histologic eradication of dysplasia and intestinal metaplasia were reached.

RESULTS

Forty patients were enrolled, with a median C1M2 BE segment, a visible lesion with a median diameter of 15 mm, and invasive carcinoma in 68% of cases. Endoscopic resection was performed by using the multiband mucosectomy technique in 80% of cases, and the Barrx(90) catheter (Barrx Medical, Sunnyvale, Calif) was used for focal ablation. When an intention-to-treat analysis was used, both complete remission of all neoplasia and intestinal metaplasia were 95% after a median follow-up of 19 months. Stenoses occurred in 33% of cases and were successfully managed with a median number of 2 dilations. In 43% of patients, 1 single-session treatment resulted in complete histologic remission of intestinal metaplasia.

CONCLUSIONS

Combining endoscopic resection and focal RFA in a single session appears to be effective. Less-aggressive RFA regimens could limit the adverse event rates.

Effect of antireflux surgery for Barrett's esophagus: long-term results

INTRODUCTION

Barrett's esophagus is a metaplastic change in the lower esophagus that results from long-standing gastro-esophageal reflux disease, associated with a risk of development of esophageal adenocarcinoma. This review examines the role of antireflux surgery in the management of Barrett's esophagus.

EVIDENCE ACQUISITION

A systematic review of the EMBASE and MEDLINE databases (1974-2016) was undertaken to identify studies with long-term follow-up examining the role of antireflux surgery in Barrett's esophagus. Outcomes examined were: number of subjects, follow-up, rates of progression, regression and adenocarcinoma. Symptomatic outcomes, surgical morbidity and rates of surgical failure were included when available.

EVIDENCE SYNTHESIS

A total of 2403 articles were identified of which 9 met the inclusion criteria for this study using the PRISMA methodology. Citation tracking identified 3 further studies for inclusion. There were 962 patients included in this study, 731 who were found to have completed endoscopic follow up with a total of 3736 years of follow up. Annual incidence of esophageal adenocarcinoma was found to be 0.18%. Thirty-five percent of patients (260 patients) had regression. Progression was seen in 8% (57 patients) postoperatively. There was no mortality.

CONCLUSIONS

There is insufficient evidence to recommend surgery over medical therapy to reduce cancer risk in Barrett's esophagus. Regression of features associated with cancer risk was more common after surgery than medical therapy. Surgery has been shown to improve patients' gastroesophageal reflux disease-specific quality of life. Long-term, antireflux surgery represents a cost effective method to manage Barrett's Esophagus with continued endoscopic surveillance.

Post-ablation surveillance in Barrett's esophagus: A review of the literature

Barrett’s esophagus (BE) is a pre-malignant condition affecting up to 15% of patients with gastroesophageal reflux disease. Neoplastic Barrett’s mucosa is defined as harboring high grade dysplasia or intra-mucosal cancer, and carries a high risk of progression to esophageal adenocarcinoma. The rising incidence of Barrett’s lesions along with the high morbidity of surgical approaches has led to the development of numerous validated endoscopic techniques capable of eradicating neoplastic mucosa in a minimally invasive manner. While there has been widespread adoption of these techniques, less is known about optimal surveillance intervals in the post-therapy period. This is due in part to limitations in current surveillance methods, questions about durability of treatment response and the risk of subendothelial progression. As we are now able to achieve organ sparing eradication of superficial neoplasia in BE, we need to also then focus our attention on how best to manage these patients after eradication is achieved. Implementing optimal surveillance practices requires additional understanding of the biology of the disease, appreciation of the limits of current tools and treatments, and exploration of the role of adjunctive technologies. The aim of this article is to provide a comprehensive review of current literature surrounding post-ablation surveillance in neoplastic BE.

Comparative diagnostic performance of volumetric laser endomicroscopy and confocal laser endomicroscopy in the detection of dysplasia associated with Barrett's esophagus

BACKGROUND AND AIMS

Probe-based confocal laser endomicroscopy (pCLE) and volumetric laser endomicroscopy (VLE) (also known as frequency domain optical coherence tomography) are advanced endoscopic imaging modalities that may be useful in the diagnosis of dysplasia associated with Barrett's esophagus (BE). We performed pCLE examination in ex-vivo EMR specimens and compared the diagnostic performance of using the current VLE scoring index (previously established as OCT-SI) and a novel VLE diagnostic algorithm (VLE-DA) for the detection of dysplasia.

METHODS

A total of 27 patients with BE enrolled in a surveillance program at a tertiary-care center underwent 50 clinically indicated EMRs that were imaged with VLE and pCLE and classified into neoplastic (N = 34; high-grade dysplasia, intramucosal adenocarcinoma) and nonneoplastic (N = 16; low-grade dysplasia, nondysplastic BE), based on histology. Image datasets (VLE, N = 50; pCLE, N = 50) were rated by 3 gastroenterologists trained in the established diagnostic criteria for each imaging modality as well as a new diagnostic algorithm for VLE derived from a training set that demonstrated association of specific VLE features with neoplasia. Sensitivity, specificity, and diagnostic accuracy were assessed for each imaging modality and diagnostic criteria.

RESULTS

The sensitivity, specificity, and diagnostic accuracy of pCLE for detection of BE dysplasia was 76% (95% confidence interval [CI], 59-88), 79% (95% CI, 53-92), and 77% (95% CI, 72-82), respectively. The optimal diagnostic performance of OCT-SI showed a sensitivity of 70% (95% CI, 52-84), specificity of 60% (95% CI, 36-79), and diagnostic accuracy of 67%; (95% CI, 58-78). The use of the novel VLE-DA showed a sensitivity of 86% (95% CI, 69-96), specificity of 88% (95% CI, 60-99), and diagnostic accuracy of 87% (95% CI, 86-88). The diagnostic accuracy of using the new VLE-DA criteria was significantly superior to the current OCT-SI (P < .01).

CONCLUSION

The use of a new VLE-DA showed enhanced diagnostic performance for detecting BE dysplasia ex vivo compared with the current OCT-SI. Further validation of this algorithm in vivo is warranted.

ANTIREFLUX RESECTION OF MUCOUS MEMBRANE OF ESOPHAGOGASTRIC ANASTOMOSIS IN TREATMENT OF BARRETT’S ESOPHAGUS: INITIAL EXPERIENCE

Antireflux resection of mucous membrane of esophagogastric anastomosis (ARMS) was performed on 6 patients with typical symptoms of gastroesophageal reflux disease (GERD). The patients had a short segment of сolumnar-celled metaplasia (1-2 cm) without radiological and endoscopic signs of hiatal hernia. All the patients received medicamentous therapy by antisecretory agents more than 3 years. The operation included the endoscopic resection of2/3 circle of mucous membrane of esophagogastric anastomosis and resection of the area of columnar-celled metaplasia. The results of treatment were assessed during 3-7 months after ARMS. There was noted an absence of clinical manifestations of GERD, regression of inflammatory signs of mucous coat of esophagus in 4 out of 6 patients. Symptoms of GERD remained in 2 patients, although the intensity of signs significantly decreased.

[Clinical study of argon plasma coagulation combined with laparoscopic hiatal hernia repair and fundoplication in the treatment of hiatal hernia with Barrett esophagus]

OBJECTIVE

To investigate the clinical efficacy of argon plasma coagulation (APC) combined with laparoscopic hiatal hernia repair and fundoplication in the treatment of hiatal hernia associated with Barrett esophagus.

METHODS

A total of 61 cases of hiatal hernias with Barrett esophagus from June 2010 to January 2014 in the Department of Minimal Invasive Surgery, Hernia and Abdominal wall Surgery, People's Hospital of Xinjiang Uyhur Autonomous Region were prospectively enrolled and were randomly allocated into two groups by computer system. Twenty-nine patients received esomeprazole 40 mg/d after APC treatment for 8 weeks (APC with medicine group). Thirty-two patients underwent laparoscopic hiatal hernia repair and Nissen fundoplication after APC treatment (APC with surgery group). All the patients were reviewed by gastroscope and pathologic examination at half a year and one year after operation respectively. Differences of disease improvement and recurrence between the two groups were evaluated.

RESULTS

In APC with medicine group, the Barrett's esophagus was relieved after one or two times of APC treatment, however, gastroscope and pathology revealed recurrence of Barrett's esophagus in 7 cases at half a year, and cumulative 16 cases of recurrences were detected after one year follow-up(16/29, 55.2%). In APC with surgery group, only one patient had recurrent Barrett's esophagus at half a year, and a total of two at one year follow-up by gastroscope examination(2/32, 6.3%). Significantly low recurrence rate of Barrett's esophagus was observed in APC with surgery group compared to APC with medicine group(P<0.01). Furthermore, recurrent hiatal hernia was detected in only one case in APC with surgery group. No esophageal cancer was found in both groups during follow-up.

CONCLUSION

APC combined with laparoscopic hiatal hernia repair and fundoplication is an ideal method for patients with hiatal hernia and Barrett's esophagus.

[A Case of Synchronous Multiple Esophageal Cancers Composed of Squamous Cell Carcinoma and Barrett's Adenocarcinoma]

A 67-year-old man was admitted to our hospital for treatment for multiple superficial esophageal cancers. Screening upper gastrointestinal endoscopy examination revealed a superficial squamous cell carcinoma (SCC) at the middle thoracic esophagus and Barrett's epithelium and a superficial adenocarcinoma at the abdominal esophagus. We performed a subtotal esophagectomy with gastric tube reconstruction via the retrosternal route. Pathological examination revealed a Barrett's adenocarcinoma at the abdominal esophagus. Esophageal cancer is thought to be a multicentric disease, and we sometimes find multiple esophageal cancers. In Japan, most cases of multiple esophageal cancers are composed of SCCs, and the occurrence of multiple esophageal cancers composed of SCC and Barrett's adenocarcinoma is rare. In contrast, the number of the patients with Barrett's esophagus is increasing, and the number of the patients with Barrett's adenocarcinoma also seems to be on the rise. Therefore, it is important be aware of the possibility of multiple esophageal cancers composed of SCC and Barrett's adenocarcinoma while making diagnoses.

Laparoscopic transhiatal approach for resection of an adenocarcinoma in long-segment Barrett’s esophagus

Barrett’s esophagus (BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcinoma arising in long-segment BE (LSBE) associated with a hiatal hernia that was successfully treated with a laparoscopic transhiatal approach (LTHA) without thoracotomy. The patient was a 42-year-old male who had previously undergone laryngectomy and tracheal separation to avoid repeated aspiration pneumonitis. An ulcerative lesion was found in a hiatal hernia by endoscopy and superficial esophageal cancer was also detected in the lower thoracic esophagus. The histopathological diagnosis of biopsy samples from both lesions was adenocarcinoma. There were difficulties with the thoracic approach because the patient had severe kyphosis and muscular contractures from cerebral palsy. Therefore, we performed subtotal esophagectomy by LTHA without thoracotomy. Using hand-assisted laparoscopic surgery, the esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. A hernial sac was identified on the cranial side of the right crus of the diaphragm and carefully separated from the surrounding tissues. Abruption of the thoracic esophagus was performed up to the level of the arch of the azygos vein via LTHA. A cervical incision was made in the left side of the permanent tracheal stoma, the cervical esophagus was divided, and gastric tube reconstruction was performed via a posterior mediastinal route. The operative time was 175 min, and there was 61 mL of intra-operative bleeding. A histopathological examination revealed superficial adenocarcinoma in LSBE. Our surgical procedure provided a good surgical view and can be safely applied to patients with a hiatal hernia and kyphosis.

Recent developments in pathogenesis, diagnosis and therapy of Barrett's esophagus

The burden of illness from esophageal adenocarcinoma continues to rise in the Western world, and overall prognosis is poor. Given that Barrett’s esophagus (BE), a metaplastic change in the esophageal lining is a known cancer precursor, an opportunity to decrease disease development by screening and surveillance might exist. This review examines recent updates in the pathogenesis of BE and comprehensively discusses known risk factors. Diagnostic definitions and challenges are outlined, coupled with an in-depth review of management. Current challenges and potential solutions related to screening and surveillance are discussed. The effectiveness of currently available endoscopic treatment techniques, particularly with regards to recurrence following successful endotherapy and potential chemopreventative agents are also highlighted. The field of BE is rapidly evolving and improved understanding of pathophysiology, combined with emerging methods for screening and surveillance offer hope for future disease burden reduction.

[Radiofrequency ablation for Barrett's esophagus. Preliminary experience]

Endoscopic radiofrequency ablation makes use of warm energy to ablate the esophagus's surface where the epithelial anomaly is located.

PATIENTS AND METHODS

50 adults patients with the diagnosis of EB according to Vienna Classification were included.

OBJECTIVES

To evaluate the security and efficacy of ARF in patients with EB.

RESULTS

50 ARF treated patients were included with a medium follow up of 18 months. The median age was 58 years. 1.4 sessions of ARF perpatient were made to obtain EB erradication. The procedure morbidity was 6%, the more frequent complication was the esophageal stenosis (two cases). During the follow up, intestinal metaplasia recurrence was not observed.

CONCLUSIONS

In the experience of our team, ARF is a secure procedure with low morbidity. These observations added to the published results help to evaluate the currentfollow up protocols.

Recurrent intestinal metaplasia after radiofrequency ablation for Barrett's esophagus: endoscopic findings and anatomic location

BACKGROUND

Radiofrequency ablation (RFA) is a safe and effective treatment for Barrett's esophagus (BE) that results in high rates of complete eradication of intestinal metaplasia (CEIM). However, recurrence is common after CEIM, and surveillance endoscopy is recommended. Neither the anatomic location nor the endoscopic appearance of these recurrences is well-described.

OBJECTIVE

Describe the location of histologic specimens positive for recurrence after CEIM and the testing performance of endoscopic findings for the histopathologic detection of recurrence.

DESIGN

Retrospective cohort.

SETTING

Single referral center.

PATIENTS

A total of 198 patients with BE with at least 2 surveillance endoscopies after CEIM.

INTERVENTIONS

RFA, EMR, surveillance endoscopy.

MAIN OUTCOME MEASUREMENTS

The anatomic location and histologic grade of recurrence.

RESULTS

In a mean 3.0 years of follow-up, 32 (16.2%; 95% confidence interval [CI], 11.0%-22.0%) patients had recurrence of disease, 5 (2.5%; 95% CI, 0.3%-4.7%) of whom progressed beyond their worst before-treatment histology. Recurrence was most common at or near the gastroesophageal junction (GEJ). Recurrence>1 cm proximal to the GEJ always was accompanied by endoscopic findings, and random biopsies in these areas detected no additional cases. The sensitivity of any esophageal sign under high-definition white light or narrow-band imaging for recurrence was 59.4% (42.4%, 76.4%), and the specificity was 80.6% (77.2%, 84.0%).

LIMITATIONS

Single-center study.

CONCLUSION

Recurrent intestinal metaplasia often is not visible to the endoscopist and is most common near the GEJ. Random biopsies>1 cm above the GEJ had no yield for recurrence. In addition to biopsy of prior EMR sites and of suspicious lesions, random biopsies oversampling the GEJ are recommended.

Trefoil Factor Expression in a Human Model of the Early Stages of Barrett's Esophagus

BACKGROUND

Trefoil proteins are believed to have an important role in mucosal protection and repair in the gastrointestinal tract. They are well recognized in Barrett's esophagus and considered a potential biomarker for the condition. Metaplasia occurring in the esophageal remnant after esophagectomy is a human model for the early stages of development of Barrett's esophagus.

AIMS

To assess expression of trefoil proteins in post-esophagectomy columnar epithelium and to use trefoils as a molecular tool to understand regenerative mucosa in the esophagus.

METHODS

Patients with columnar metaplasia in the esophageal remnant were recruited from a large esophago-gastric cancer center. Trefoil factor expression was determined using immunohistochemical techniques.

RESULTS

Samples were obtained from 37 patients. TFF1 and TFF2 were expressed by all samples in a similar pattern to that described in studies of sporadic Barrett's esophagus. TFF3 was less widely expressed and was significantly associated with time elapsed between surgery and endoscopy. Median time from surgery to endoscopy was 8.1 years for patients with TFF3 expression versus 3.4 years for those without (p = 0.004).

CONCLUSIONS

Widespread expression of trefoils in this environment suggests that these proteins have an important role in development of Barrett's metaplasia. TFF3 expression may be absent in the early stages of metaplasia and may represent more established columnar epithelium. Biopsy samples from post-esophagectomy patients provide a valuable resource to study the early stages of Barrett's esophagus.

The Durability of Endoscopic Therapy for Treatment of Barrett's Metaplasia, Dysplasia, and Mucosal Cancer After Nissen Fundoplication

INTRODUCTION

Radiofrequency ablation (RFA) ± endoscopic resection (EMR) is an established treatment strategy for neoplastic Barrett's and intramucosal cancer. Most patients are managed with proton pump inhibitors. The incidence of recurrent Barrett's metaplasia, dysplasia, or cancer after complete eradication is up to 43 % using this strategy. We hypothesize the addition of fundoplication should result in a lower recurrence rates after complete eradication.

METHODS

Multi-institutional retrospective review of patients undergoing endotherapy followed by Nissen fundoplication

RESULTS

A total of 49 patients underwent RFA ± EMR followed by Nissen fundoplication. Complete remission of intestinal metaplasia (CR-IM) was achieved in 26 (53 %) patients, complete remission of dysplasia (CR-D) in 16 (33 %) patients, and 7 (14 %) had persistent neoplastic Barrett's. After fundoplication, 18/26 (70 %) remained in CR-IM. An additional 10/16 CR-D achieved CR-IM and 4/7 with persistent dysplasia achieved CR-IM. One patient progressed to LGD while no patient developed HGD or cancer.

CONCLUSION

Endoscopic therapy for Barrett's dysplasia and/or intramucosal cancer followed by fundoplication results in similar durability of CR-IM to patients being managed with PPIs alone after endoscopic therapy. However, fundoplication may be superior in preventing further progression of disease and the development of cancer. Fundoplication is an important strategy to achieve and maintain CR-IM, and facilitate eradication of persistent dysplasia.

Treatment of Barrett's esophagus: update on new endoscopic surgical modalities

Barrett's esophagus represents a premalignant condition, which is strongly associated with the incidence of esophageal adenocarcinoma. Currently, there are no validated markers to extract exactly that certain patient that will proceed to neoplastic progression. Therefore, therapeutic options have to include a larger population to provide prophylaxis for affected patients. Recently developed endoscopic therapeutic approaches offer treatment options for prevention or even treatment of limited esophageal adenocarcinoma. At present, high eradication rates of intestinal metaplasia as well as dysplasia are observed, whereas low complication rates offer a convenient safety profile. These striking new methods symbolize a changing paradigm in a field, where minimal-invasive tissue ablating methods and tissue preserving techniques have led to modified regimens. This review will focus on current standards and newly emerging methods to treat Barrett's esophagus and its progression to cancer and will highlight their evolution, potential benefits and their limitations.

A relation between cell cycle and intestinal metaplasia in oesophageal biopsies using optical and digital microscopy

Protein expression changes in relation to cell cycles provide important information, and it may represent a new method for an early diagnosis of metaplasia - dysplasia - adenocarcinoma sequence. We investigated potential changes in cell cycle genes such as protooncogenes (PCNA, EGFR), tumour suppressor gene (p53), apoptotic TUNNEL (Tdt mediated dUTP nick and labelling) gene, as well as small intestinal mucus antigen (SIMA) and large intestinal mucus antigen (LIMA), which accumulates in metaplastic epithelium due to the inflammatory process in routine oesophageal biopsies using immunohistochemistry. Oesophageal biopsies were taken from patients with Barrett's oesophagus (n = 30), reflux oesophagitis (n = 30), healthy oesophagus (n = 30) and healthy cardia (n = 10). Immunohistochemical signalling was carried out by Streptavidin-Biotin-AEC (aminoetil-carbazol). Expression of PCNA was statistically significantly lower in healthy oesophagus (p < 0.05) versus reflux oesophagitis and Barrett's oesophagus. However, no significant change was detected in the expression of SIMA and LIMA in intestinal metaplasia. Further, EGFR, p53 and TUNNEL levels were significantly different in healthy versus Barrett's oesophagus. Manual counting using virtual microscopy was comparable with the result using conventional light microscopy, but the former is significantly quicker. There was no difference between manual and automated cell counting (p > 0.05).

Barrett's oesophagus: treatment with surgery

Barrett's oesophagus develops as a consequence of gastro-oesophageal reflux disease and may progress to oesophageal adenocarcinoma. Antireflux surgery is an option for patients with reflux disease, but the efficacy and impact on the natural history of disease in patients with Barrett's oesophagus is controversial. This review addresses the existing data on these important issues.

Endoscopic therapy for Barrett's oesophagus

Barrett's oesophagus (BO) is thought to progress through the development of dysplasia (low grade and high grade) to oesophageal adenocarcinoma, a lethal cancer with poor survival. The overall goal of endoscopic therapy of BO is to eliminate metaplastic and dysplastic epithelium, to prevent and/or reduce the risk of progression to OAC. Endoscopic therapy techniques can be divided into two broad complementary techniques: tissue acquiring (endoscopic mucosal resection and endoscopic submucosal dissection) and ablative. Endoscopic therapy has been established as safe and effective for the subjects with intra-mucosal cancer (IMC), high-grade dysplasia (HGD) and more recently in treating low-grade dysplasia (LGD). Challenges to endoscopic therapy are being recognized, such as incomplete response and recurrence. While eradication of intestinal metaplasia is the immediate goal of endoscopic therapy, surveillance must continue after complete elimination of intestinal metaplasia, to detect and treat recurrences.