ASGE guideline: the role of endoscopy in the surveillance of premalignant conditions of the upper GI tract

Management strategies of Barrett's esophagus

Barrett’s esophagus is a condition resulting from chronic gastro-esophageal reflux disease with a documented risk of esophageal adenocarcinoma. Current strategies for improved survival in patients with Barrett's adenocarcinoma focus on detection of dysplasia. This can be obtained by screening programs in high-risk cohorts of patients and/or endoscopic biopsy surveillance of patients with known Barrett’s esophagus (BE). Several therapies have been developed in attempts to reverse BE and reduce cancer risk. Aggressive medical management of acid reflux, lifestyle modifications, antireflux surgery, and endoscopic treatments have been recommended for many patients with BE. Whether these interventions are cost-effective or reduce mortality from esophageal cancer remains controversial. Current treatment requires combinations of endoscopic mucosal resection techniques to eliminate visible lesions followed by ablation of residual metaplastic tissue. Esophagectomy is currently indicated in multifocal high-grade neoplasia or mucosal Barrett’s carcinoma which cannot be managed by endoscopic approach.

Current pharmacotherapy options for gastritis

INTRODUCTION

Gastritis is a broad term, which is used for different conditions by clinicians, endoscopists and pathologists. Classification strategies have led to more congruence between specialists. The histological evaluation of the gastric mucosa is mandatory for diagnosing and classifying gastritis. Main aetiologic factor is infection with Helicobacter pylori. The clinical importance of gastritis lays in the fact that it predisposes to more pronounced damage to the gastric mucosa, in particular peptic ulcer disease, and eventually atrophic gastritis, intestinal metaplasia and gastric malignancy, both adenocarcinoma and MALT lymphoma.

AREAS COVERED

This review covers the current pharmacotherapy options for different forms of gastritis. The main focus is on H. pylori-induced gastritis. Thereafter, other forms of gastritis like autoimmune gastritis and non-steroidal anti-inflammatory drug (NSAID)-related gastropathy are covered.

EXPERT OPINION

The emerging problem of antibiotic resistance requires an accurate knowledge of local eradication rates. Standard triple therapy should be abandoned in regions with high clarithromycin resistance. In these areas, sequential or quadruple therapy is best initial treatment. Further research should focus on non-invasive and effective techniques of susceptibility testing, making a tailored and cost-effective approach. Primary prevention of NSAID-related gastropathy can be enhanced by better education for clinicians and patients, so that both right prescription of gastroprotective agents as therapy adherence will improve.

Why is there a change in patterns of GE cancer?

Recent decades have seen a worrying trend in incidence rates of distal oesophageal and proximal gastric cancers. Fuelled by radical changes in lifestyle, diet, physical activity and environmental exposures, as well as an ageing population and host genetic predisposition, the incidence of oesophageal adenocarcinoma (OAC) is on the rise in Western populations. While overall incidence of gastric cancers is declining, the ageing of society means that an increase in absolute numbers is expected over coming years. Both cancers tend to present at an advanced stage, hence prognosis remains poor despite increasingly effective screening and treatment strategies. The development of gastric and oesophageal malignancies is influenced by myriad factors, not least geographical, racial and socioeconomic differences in addition to lifestyle choices. The multidimensional nature of these risk factors requires a holistic understanding of their net influence in the development of malignancy. This review explores the evidence base for established and putative risk factors in the development of gastric and oesophageal cancers. It is hoped that with a clear understanding of important risk factors, a multidisciplinary approach including effective primary prevention, regular screening of high-risk groups and continued research into the molecular biology of gastrointestinal carcinogenesis may facilitate a reduction in incidence rates, as well as early detection and optimal management of upper gastrointestinal malignancies.

The changing histological pattern of gastric polyps in an ethnically heterogeneous population

BACKGROUND AND AIM

Variation in the prevalence of various types of gastric polyps worldwide may reflect different etiologies. Here, the authors report the dynamic changes in histological distribution of gastric polyps over time and by ethnicity for individuals who underwent gastroscopies between 1994 and 2009 at two hospitals in Jerusalem, Israel. During this time period, the proportion of patients receiving proton pump inhibitors (PPIs) increased while the proportion of patients infected with Helicobacter pylori (H. pylori) decreased.

PATIENTS AND METHODS

Pathological reports of biopsies from 50,071 consecutive gastroscopies were reviewed.

RESULTS

Gastric polyps were detected in 727 individuals. The yearly prevalence of gastric polyps was ≤ 1% between 1994 and 2001 and ≥ 2% from 2004 to 2009, of which overall 66% were hyperplastic polyps and 23% fundic gland polyps (FGPs). FGPs were diagnosed exclusively in the Jewish population. From 2001 to 2004, an increase in the absolute number of newly discovered hyperplastic and FGPs per year was observed. However from 2005, a divergent trend of changes was observed: While the proportion of patients with hyperplastic polyps dropped from 0.72 during the 2001-2004 period to 0.62 during the 2005-2009 period (p = 0.02), the proportion of patients with FGPs at these time periods increased from 0.16 to 0.33 (p = 0.0001).

CONCLUSIONS

The yearly prevalence of gastric polyps in Jerusalem has recently doubled. This occurred mainly due to the increasing prevalence of FGPs. The changing epidemiology of gastric polyps is probably related to the interaction between genetic factors and fluctuating environmental factors like H. pylori infection rates and exposure to PPIs.

Longer inspection time is associated with increased detection of high-grade dysplasia and esophageal adenocarcinoma in Barrett's esophagus

BACKGROUND

Current guidelines recommend that endoscopic surveillance of Barrett's esophagus (BE) be performed by using a strict biopsy protocol. However, novel methods to improve BE surveillance are still needed.

OBJECTIVE

To evaluate the impact of Barrett's inspection time (BIT) on yield of surveillance.

DESIGN

Post hoc analysis of data obtained from a clinical trial.

SETTING

Five tertiary referral centers.

PATIENTS

Patients undergoing BE surveillance.

INTERVENTIONS

Coordinators prospectively recorded the time spent inspecting the BE mucosa with a stopwatch.

MAIN OUTCOME MEASUREMENTS

Endoscopically suspicious lesions, high-grade dysplasia (HGD)/esophageal adenocarcinoma (EAC).

RESULTS

A total of 112 patients underwent endoscopic surveillance by 11 individual endoscopists. Patients with longer BITs were more likely to have an endoscopically suspicious lesion (P < .001) and more endoscopically suspicious lesions (P = .0001) and receive a diagnosis of HGD/EAC (P = .001). There was a direct correlation between the endoscopist's mean BIT per centimeter of BE and the detection of patients with HGD/EAC (ρ = .63, P = .03). Endoscopists who had an average BIT longer than 1 minute per centimeter of BE detected more patients with endoscopically suspicious lesions (54.2% vs 13.3%, P = .04), and there was a trend toward a higher detection rate of HGD/EAC (40.2% vs 6.7%, P = .06).

LIMITATIONS

Post hoc analysis of an enriched study population and experienced endoscopists at tertiary referral centers.

CONCLUSIONS

Longer time spent inspecting the BE segment is associated with the increased detection of HGD/EAC. Taking additional time to perform a thorough examination of the BE mucosa may serve as an easy and widely available method to improve the yield of BE surveillance.

Intestinal metaplasia and the risk of gastric cancer in an immigrant asian population

The development of intestinal metaplasia (IM) has been purported to be a critical step in the pathogenesis of gastric cancer. However, the natural history of IM in migrant human populations has not been well elucidated. The purpose of this study was to determine the risk of gastric cancer posed by IM in Asian immigrants undergoing gastric cancer screening. A retrospective review of Asian immigrants found to have IM during screening was conducted over an 18-month period. In total, 222 patients were found to have IM. Altogether, 24% had a history of smoking, 48% had a family history of gastric cancer, and 52% had a history of Helicobacter pylori (H. pylori) infection with a 96% eradication rate. Patients with stable IM (SIM) were then compared with those who developed high risk pathology (HRP), specifically dysplasia and/or adenocarcinoma. Thirty-five patients (16%) were included in the HRP group, 31 with dysplasia (14%) and 4 with adenocarcinoma (2%). Of those with dysplasia, 55% demonstrated regression to IM over the course of follow-up. Patients in the SIM group were more likely to be female (60% vs. 31%, P = 0.002) and more likely to have had a normal biopsy during follow-up (32% vs. 9%, P = 0.005). Odds ratios for IM stability were 3.3 (95% CI 1.5-7.0) and 5.0 (95% CI 1.5-17.1) for female gender and presence of a normal biopsy, respectively. Intestinal metaplasia in immigrant Asian populations is predominantly a stable histologic finding associated with a low rate of persistent dysplasia and adenocarcinoma.

Diagnosis and management of Barrett's esophagus

Barrett esophagus is characterized by the replacement of squamous mucosa in the esophagus by specialized intestinal metaplasia. Its clinical significance lies in it being the strongest risk factor for and known precursor for esophageal adenocarcinoma. Diagnosis requires endoscopic confirmation of columnar metaplasia in the distal esophagus and histologic confirmation of specialized intestinal metaplasia. Recommendations for the management of subjects diagnosed with Barrett esophagus include periodic endoscopic surveillance to detect the development of high-grade dysplasia or adenocarcinoma. Careful endoscopic evaluation with high-resolution endoscopy and endoscopic resection is recommended in the evaluation of subjects with high-grade dysplasia and early adenocarcinoma.

Diagnosis and management of Barrett's esophagus

Barrett esophagus is characterized by the replacement of squamous mucosa in the esophagus by specialized intestinal metaplasia. Its clinical significance lies in it being the strongest risk factor for and known precursor for esophageal adenocarcinoma. Diagnosis requires endoscopic confirmation of columnar metaplasia in the distal esophagus and histologic confirmation of specialized intestinal metaplasia. Recommendations for the management of subjects diagnosed with Barrett esophagus include periodic endoscopic surveillance to detect the development of high-grade dysplasia or adenocarcinoma. Careful endoscopic evaluation with high-resolution endoscopy and endoscopic resection is recommended in the evaluation of subjects with high-grade dysplasia and early adenocarcinoma.

Optical endomicroscopy and the road to real-time, in vivo pathology: present and future

Epithelial cancers account for substantial mortality and are an important public health concern. With the need for earlier detection and treatment of these malignancies, the ability to accurately detect precancerous lesions has an increasingly important role in controlling cancer incidence and mortality. New optical technologies are capable of identifying early pathology in tissues or organs in which cancer is known to develop through stages of dysplasia, including the esophagus, colon, pancreas, liver, bladder, and cervix. These diagnostic imaging advances, together as a field known as optical endomicroscopy, are based on confocal microscopy, spectroscopy-based imaging, and optical coherence tomography (OCT), and function as "optical biopsies," enabling tissue pathology to be imaged in situ and in real time without the need to excise and process specimens as in conventional biopsy and histopathology. Optical biopsy techniques can acquire high-resolution, cross-sectional images of tissue structure on the micron scale through the use of endoscopes, catheters, laparoscopes, and needles. Since the inception of these technologies, dramatic technological advances in accuracy, speed, and functionality have been realized. The current paradigm of optical biopsy, or single-area, point-based images, is slowly shifting to more comprehensive microscopy of larger tracts of mucosa. With the development of Fourier-domain OCT, also known as optical frequency domain imaging or, more recently, volumetric laser endomicroscopy, comprehensive surveillance of the entire distal esophagus is now achievable at speeds that were not possible with conventional OCT technologies. Optical diagnostic technologies are emerging as clinically useful tools with the potential to set a new standard for real-time diagnosis. New imaging techniques enable visualization of high-resolution, cross-sectional images and offer the opportunity to guide biopsy, allowing maximal diagnostic yields and appropriate staging without the limitations and risks inherent with current random biopsy protocols. However, the ability of these techniques to achieve widespread adoption in clinical practice depends on future research designed to improve accuracy and allow real-time data transmission and storage, thereby linking pathology to the treating physician. These imaging advances are expected to eventually offer a see-and-treat paradigm, leading to improved patient care and potential cost reduction.

VIRTUAL SLIDES

The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/5372548637202968.

Double-balloon endoscopy in clinical practice: where are we now?

Double-balloon endoscopy (DBE) was developed in 2000 for the diagnosis and treatment of small bowel diseases. Although use rates still differ between Eastern and Western countries, DBE quickly reached a broad global diffusion. Together with capsule endoscopy (CE), DBE represented 'a revolution' for the management of small bowel diseases because of its therapeutic capabilities. At present, the main indications for DBE in clinical practice are obscure gastrointestinal bleeding, Crohn's disease and familial polyposis. In the setting of obscure gastrointestinal bleeding, DBE seems to have similar diagnostic performances as capsule endoscopy, but it allows for a more definitive diagnosis and the treatment of identified lesions. The main contribution of DBE in the management of Crohn's disease patients is its therapeutic capabilities. Indeed, several recently published studies have suggested that endoscopic dilation of small bowel strictures can delay or, in the near future, could even replace surgical interventions. Also, for patients with familial polyposis syndromes, DBE can represent a viable alternative to small bowel surgery. The complication rate of DBE appears to be low; major complications, such as pancreatitis, bleeding and perforation, have been reported in approximately 1% of all diagnostic DBE whereas the complication rate for therapeutic procedures is about 5%.

Endoscopic therapies for Barrett's-associated dysplasia: a new paradigm for a new decade

The emergence of endoscopic therapies for Barrett's esophagus (BE)-associated dysplasia has significantly altered the management of this complex disease. Over the past decade, there has been a paradigm shift from that of pure surveillance to a more therapeutic approach in eradicating dysplastic BE. This strategy includes less invasive options than esophagectomy for high-grade dysplasia and early eradication of confirmed low-grade dysplasia. Although multiple modalities exist for endoscopic therapy, endoscopic mucosal resection coupled with radiofrequency ablation appears to be the most effective therapy, with minimal complications. Recent advances in endoscopic eradication therapies for dysplastic BE have fueled excitement for a significant weapon against the rising incidence of esophageal cancer.

Barrett's Esophagus: Emerging Knowledge and Management Strategies

The incidence of esophageal adenocarcinoma (EAC) has increased exponentially in the last 3 decades. Barrett's esophagus (BE) is the only known precursor of EAC. Patients with BE have a greater than 40 folds higher risk of EAC compared with the general population. Recent years have witnessed a revolution in the clinical and molecular research related to BE. However, several aspects of this condition remain controversial. Data regarding the true prevalence of BE have varied widely. Recent studies have suggested a lower incidence of EAC in nondysplastic BE (NDBE) than previously reported. There is paucity of prospective data showing a survival benefit of screening or surveillance for BE. Furthermore, the ever-increasing emphasis on healthcare cost containment has called for reexamination of the screening and surveillance strategies for BE. There is a need for identification of reliable clinical predictors or molecular biomarkers to risk-stratify patients who might benefit the most from screening or surveillance for BE. Finally, new therapies have emerged for the management of dysplastic BE. In this paper, we highlight the key areas of controversy and uncertainty surrounding BE. The paper discusses, in detail, the current literature about the molecular pathogenesis, biomarkers, histopathological diagnosis, and management strategies for BE.

Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in short-segment Barrett's esophagus

BACKGROUND

Whether early Barrett's neoplasia has a predilection for particular spatial locations in shorter segment disease is currently unknown. Anatomic factors may play a role in lesion location because of differing levels of mucosal acid exposure.

OBJECTIVE

To identify high-risk lesion locations, which has important implications for surveillance strategies.

DESIGN

We interrogated a prospectively maintained database of patients who underwent endoscopic resection (ER) for Barrett's neoplasia at 2 Australian tertiary centers. Lesions targeted for ER were characterized and their location in the distal esophagus was noted as on a clock face. A Z test of proportions was used to test for deviation from uniformity in the distribution of lesions.

SETTING

Two Australian tertiary centers.

PATIENTS

Patients who underwent ER for Barrett's neoplasia.

MAIN OUTCOME MEASUREMENTS

Lesion location in the distal oesophagus, resected specimen histology.

RESULTS

A total of 146 consecutive patients had ER for biopsy-proven high-grade dysplasia or esophageal adenocarcinoma. A total of 75 patients had Barrett's segment length of 5 cm or less and a visible lesion. Five patients had 2 visible lesions giving a total of 80 lesions. ER of 66 lesions (82.5%) led to the identification of advanced pathology: 37 high-grade dysplasia (46%), 24 mucosal adenocarcinoma (30%), 5 submucosal adenocarcinoma (6%). Of a total of 80 lesions, 43 (53.8%) (95% CI, 42.9%-64.7%) were centered within the 2- to 5-o'clock arc, comprising 25% of the circumference. This area also accounted for 36 (54.5%) of the 66 lesions with advanced histology (95% CI, 42.5%-66.5%). All confidence intervals lie wholly above the 25% expected in a uniform circular distribution (P < .05).

LIMITATIONS

Observational study in a tertiary center.

CONCLUSIONS

In Barrett's maximal segments of 5 cm or less, the 2- to 5-o'clock arc, accounts for approximately 50% of macroscopically visible lesions and associated early neoplasia. This finding has important implications for surveillance strategies.

Helpfulness of the combination of acetic acid and FICE in the detection of Barrett's epithelium and Barrett's associated neoplasias

AIM: To investigate the mucosal morphology in Barrett’s oesophagus by chromo and magnifying endoscopy.

METHODS: A prospective pilot study at a tertiary medical centre was conducted to evaluate the use of acetic acid pulverisation combined with virtual chromoendoscopy using Fujinon intelligent chromoendoscopy (FICE) for semiological characterization of the mucosal morphology in Barrett’s oesophagus and its neoplastic complications. Upper endoscopy using high definition white light, 2% acid acetic pulverisation and FICE with high definition videoendoscopy were performed in 20 patients including 18 patients who presented with aspects of Barrett’s oesophagus at endoscopy examination. Two patients used as controls had normal endoscopy and histological results. Prospectively, videos were watched blind from histological results by three trained FICE technique endoscopists.

RESULTS: The videos of patients with high-grade dysplasia showed an irregular mucosal pattern in 14% using high definition white light endoscopy and in 100% using acid acetic-FICE combined. Videos did not identify irregular vascular patterns using high definition white light endoscopy, while acid acetic-FICE combined visualised one in 86% of cases.

CONCLUSION: Combined acetic acid and FICE is a promising method for screening high-grade dysplasia and early cancer in Barrett’s oesophagus.

Follow-up of intestinal metaplasia in the stomach: When, how and why

Gastric cancer remains the second most frequent cause of cancer-related mortality in the world. Screening programs in some Asian countries are impractical in the majority of other countries worldwide. Therefore, follow-up of precancerous lesions is advisable for secondary gastric cancer prevention. Intestinal metaplasia (IM) is recognized as a precancerous lesion for gastric cancer, increasing the risk by 6-fold. IM is highly prevalent in the general population, being detected in nearly 1 of every 4 patients undergoing upper endoscopy. The IM prevalence rate is significantly higher in patients with Helicobacter pylori (H. pylori) infection, in first-degree relatives of gastric cancer patients, in smokers and it increases with patient age. IM is the “breaking point” in the gastric carcinogenesis cascade and does not appear to regress following H. pylori eradication, although the cure of infection may slow its progression. Gastric cancer risk is higher in patients with incomplete-type IM, in those with both antral and gastric body involvement, and the risk significantly increases with IM extension over 20% of the gastric mucosa. Scheduled endoscopic control could be cost-effective in IM patients, depending on the yearly incidence of gastric cancer in IM patients, the stage of gastric cancer at diagnosis discovered at surveillance, and the cost of endoscopy. As a pragmatic behavior, yearly endoscopic control would appear justified in all IM patients with at least one of these conditions: (1) IM extension > 20%; (2) the presence of incomplete type IM; (3) first-degree relative of gastric cancer patients; and (4) smokers. In the remaining IM patients, a less intensive (2-3 years) could be proposed.

Esophageal squamous cell carcinoma - precursor lesions and early diagnosis

Squamous cell carcinoma of the esophagus (SCCE) carries a poor prognosis due to late diagnosis. Early detection is highly desirable, since surgical and endoscopic resection offers the only possible cure for esophageal cancer. Population screening should be undertaken in high risk areas, and in low or moderate risk areas for people with risk factors (alcoholics, smokers, mate drinkers, history of head and neck cancer, achalasia and lye stricture of the esophagus). Esophageal balloon cytology is an easy and inexpensive sampling technique, but the current methods are insufficient for primary screening due to sampling errors. Conventional endoscopy with biopsy remains the standard procedure for the identification of pre-malignant and early malignant changes in esophageal mucosa and endoscopic detection. It may be enhanced by several techniques such as dye and optic chromoendoscopy, magnifying endoscopy, and optical-based spectroscopic and imaging modalities. Since more than 80% of SCCE deaths occur in developing countries, where expensive techniques such as narrow band imaging (NBI) and autofluorescence imaging are unavailable, the most cost-effective tool for targeting biopsies may be Lugol dye chromoendoscopy, since it is easy, accurate, inexpensive and available worldwide. In ideal conditions, or in developed countries, is it reasonable to think that optimal detection will require a combination of techniques, such as the combination of Lugol’s chromoendoscopy and NBI to identify esophageal areas that require further characterization by a high resolution technique. The efficacy and cost-effectiveness will determine whether these modalities will become part of standard endoscopy practice.

Hepatocyte paraffin 1 antigen as a biomarker for early diagnosis of Barrett esophagus

We evaluated hepatocyte paraffin 1 (HepPar1) antigen expression, a sensitive marker of small intestinal differentiation, in combination with morphologic features to demonstrate intestinal differentiation in cases equivocal for Barrett esophagus (BE). Clinicopathologic features and HepPar1 expression were recorded for 54 BE cases, 45 consistent with reflux esophagitis (RE) cases, and 65 "suspicious" for BE (SBE) cases. The SBE category included RE cases with 2 or more morphologic changes associated with BE or metaplastic reaction to injury (eg, multilayered epithelium, squamous islands, goblet cell mimickers, pancreatic metaplasia). HepPar1 was expressed in all 54 BE cases, 4 of 45 RE cases, and 24 of 65 SBE cases. In SBE cases, 2 or more morphologic changes were associated with HepPar1 expression in 37% of cases (24/65), 3 or more features in 59% (13/22), and 4 or more features in 100% (4/4) (P ≤ .004). The combination of certain morphologic changes and HepPar1 expression in clinically suspicious distal esophageal biopsy cases without goblet cells supports the presence of evolving intestinal metaplasia.

Overutilization of endoscopic surveillance in nondysplastic Barrett's esophagus: a multicenter study

BACKGROUND

Guidelines suggest that patients with nondysplastic Barrett's esophagus (BE) undergo endoscopic surveillance every 3 to 5 years, but actual use of surveillance endoscopy and the determinants of variation in surveillance intervals are not known.

OBJECTIVE

To measure use of surveillance endoscopy and its variation in patients with nondysplastic BE.

DESIGN

Multicenter, cross-sectional study.

SETTING

Three sites in Arizona, Minnesota, and North Carolina.

PATIENTS

This study involved patients who had prevalent BE without a history of high-grade dysplasia or esophageal adenocarcinoma.

INTERVENTION

Participants were given validated measures of quality of life, numeracy, and cancer risk perception, and the total number of prior endoscopic surveillance examinations was measured.

MAIN OUTCOME MEASUREMENTS

Oversurveillance was defined as >1 surveillance examination per 3-year period.

RESULTS

Among 235 patients with nondysplastic BE, 76% were male and 94% were white. The average (± standard deviation [SD]) duration of BE was 6.5 ± 5.9 years. The mean (± SD) number of endoscopies per 3-year period was 2.7 ± 2.6. Oversurveillance was present in 65% of participants, resulting in a mean of 2.3 excess endoscopies per patient. Neither numeracy skills nor patient perception of cancer risk were associated with oversurveillance.

LIMITATIONS

Endoscopies were measured by patient report, which is subject to error. Results may be generalizable only to patients seen in academic centers.

CONCLUSION

Most patients with nondysplastic BE had more surveillance endoscopic examinations than is recommended by published guidelines. Patient factors did not predict oversurveillance, indicating that other factors may influence decisions about the interval and frequency of surveillance examinations.

Selected disorders of malabsorption

Malabsorption syndrome encompasses numerous clinical entities that result in chronic diarrhea, abdominal distention, and failure to thrive. These disorders may be congenital or acquired and include cystic fibrosis and Shwachman-Diamond syndrome; the rare congenital lactase deficiency; glucose-galactose malabsorption; sucrase-isomaltase deficiency; adult-type hypolactasia leading to acquired lactose intolerance. The pathology may be due to impairment in absorption or digestion of nutrients resulting in Nutritional deficiency, gastrointestinal symptoms, and extra gastrointestinal symptoms. Treatment is aimed at correcting the deficiencies and symptoms to improve quality of life. Common disorders of malabsorption celiac disease, pernicious anemia, and lactase deficiency are discussed in this article.

Advances in research and diagnosis of early gastric cancer

The overall prognosis of gastric cancer is generally poor due to late presentation and diagnosis. When detected early, the prognosis of gastric cancer is excellent, and curative endoscopic resection may be possible, without the need for surgery. Careful endoscopic examination is important so as to avoid missed lesions. Besides the endoscopic screening for gastric cancer, other screening methods are also used in different countries and areas. This also provides us different avenues for the diagnosis of early gastric cancer.

Barrett's esophagus: surveillance and reversal

The following on surveillance and reversal of Barrett's esophagus (BE) includes commentaries on criteria for surveillance even when squamous epithelium stains normally with a variety of biomarkers; the long-term follow-up of surgery versus endoscopic ablation of BE; the recommended surveillance intervals in patients without dysplasia; the sampling problems related to anatomic changes following fundoplication; the value of tissue spectroscopy and optical coherence tomography; the cost-effectiveness of biopsy protocols for surveillance; the quality of life of Barrett's patients; and risk stratification and surveillance strategies.

Factors associated with esophageal stricture formation after endoscopic mucosal resection for neoplastic Barrett's esophagus

BACKGROUND

EMR for early neoplastic Barrett's esophagus is gaining favor over esophagectomy. Esophageal stricture development has been reported as a common complication of EMR, photodynamic therapy, and combination endoscopic therapy.

OBJECTIVE

To determine clinical and procedural predictors of symptomatic stricture formation after EMR.

DESIGN

Retrospective analysis.

SETTING

Tertiary-care referral university hospital.

PATIENTS

Data were retrospectively reviewed on 73 patients at our institution who underwent EMR monotherapy for Barrett's esophagus with high-grade dysplasia or intramucosal cancer since January 2006.

INTERVENTION

EMR.

MAIN OUTCOME MEASUREMENTS

Symptomatic esophageal stricture formation.

RESULTS

Symptomatic esophageal stricture formation was noted in 24.7% of patients undergoing EMR. Stricture formation on univariate analysis was associated with percentage of circumference of esophageal lumen resected, total pieces resected, number of EMR sessions, and tobacco use. A threshold effect was found at 50% of esophageal circumference resected (66.7% vs 27.2% developed strictures above and below the threshold, respectively; P = .004). A 25-pack-year or greater history of tobacco use had a threshold effect on esophageal stricture formation (77.8% vs 7.2% developed strictures above and below the threshold, respectively; P = .02). In multivariate analysis, resection of >50% of the circumference was strongly associated with stricture formation (odds ratio [OR] 4.17; 95% confidence interval [CI], 1.27-13.7). A 25-pack-year or greater history of tobacco use also trended toward stricture formation (OR 3.33; 95% CI, 0.929-12.1).

LIMITATIONS

Retrospective design, sample size.

CONCLUSION

Resection of at least 50% of the esophageal mucosal circumference is strongly associated with stricture formation. Patients with strong histories of tobacco use also may be more likely to develop esophageal strictures following EMR.

Hereditary colon cancer syndromes

Colon cancer is associated with a family history in up to 25% of cases. As many as 5% are associated with an established hereditary syndrome, demonstrating the profound influence of inheritable genetic mechanisms in the development of this disease. These syndromes confer a diverse spectrum of risk, age of presentation, endoscopic and histological findings, extracolonic manifestations, and modes of inheritance. As the molecular characteristics of these disorders become better described, enhanced genotype-phenotype correlations may offer a more targeted approach to diagnosis, screening, and surveillance. While the strategies for diagnosis and management of familial adenomatous polyposis (FAP) and Lynch syndrome are more established, the approach to newly recognized syndromes such as MUTYH-associated polyposis (MAP) and hyperplastic polyposis syndromes continues to evolve. Effective cancer prevention in affected individuals and at-risk family members first requires timely recognition of these hereditary colon cancer syndromes followed by integration of genetic testing and clinical examinations.

A single-institution review of 157 patients presenting with benign and malignant tumors of the ampulla of Vater: management and outcomes

BACKGROUND

Although benign ampullary tumors are removed endoscopically, due to their potential to progress to malignant disease, the favored treatment for adenocarcinoma is pancreaticoduodenectomy. We reviewed our institution's experience in order to identify which patients were at highest risk of disease progression following surgical resection, as well as evaluate whether localized T1 tumors are best treated by pancreaticoduodenectomy.

METHODS

We retrospectively reviewed 157 patients who presented with an ampullary mass, from 2001 to 2010, and identified 51 with benign adenoma and 106 with adenocarcinoma.

RESULTS

Patients with malignant tumors most often presented with larger tumors and jaundice, which alone was predictive of survival (OR = 67). Forty-five percent of patients with pathologically confirmed T1 tumors had positive lymph nodes and median survival was modest at 60 months. Lymph node involvement was predictive of recurrence and decreased survival.

CONCLUSION

Patients with malignant tumors often present with jaundice and larger tumors. These findings should warrant suspicion for cancer and expedited preoperative workup. Based on our finding that nearly half the patients with T1 tumors had positive lymph nodes, we recommend pancreaticoduodenectomy for any patient with biopsy proven adenocarcinoma who is a suitable candidate for surgery.

Endoscopic management of Barrett esophagus

Endoscopy has a vital role in the diagnosis, screening, surveillance and treatment of Barrett esophagus. Over the past few decades, tremendous advances have been made in endoscopic technology, and the management of dysplasia and early cancer in Barrett esophagus has changed radically from being surgical to organ-sparing endoscopic therapy. Proper endoscopic techniques and systematic biopsy protocols improve dysplasia detection, and endoscopic surveillance improves outcomes in patients with Barrett esophagus and dysplasia. Endoscopic treatment can be tissue acquiring (as in endoscopic mucosal resection and endoscopic submucosal dissection) or ablative (as with photodynamic therapy, radiofrequency ablation and cryotherapy). Treatment is usually multimodal, combining endoscopic resection of visible lesions with one or more mucosal ablation techniques, followed by long-term surveillance. Such treatment is safe and effective. Shared decision-making between the patient and physician is important while considering treatment for dysplasia in Barrett esophagus. Issues such as durability of response, importance of subsquamous Barrett epithelium and the optimal management strategy in patients with low-grade dysplasia and nondysplastic Barrett esophagus need to be studied further. Development of safer wide-field resection techniques, which would effectively remove all Barrett esophagus and obviate the need for long-term surveillance, is needed.

Gastroesophageal reflux disease and Barrett's esophagus

Gastroesophageal reflux disease is the most common gastrointestinal diagnosis recorded during visits to outpatient clinics. The spectrum of injury includes esophagitis, stricture, the development of columnar metaplasia in place of the normal squamous epithelium (Barrett's esophagus), and adenocarcinoma. Barrett's esophagus is a premalignant lesion detected in the majority of patients with esophageal and gastroesophageal adenocarcinoma. The incidence of these cancers has been increasing in the United States and they are associated with a low rate of survival (5-year survival rate, 15-20%). When symptoms of gastroesophageal reflux disease are typical and the patient responds to therapy, no diagnostic tests are necessary to verify the diagnosis. Endoscopy is the primary test in patients whose condition is resistant to empirical therapy but its yield in this setting is low because of the poor correlation between symptoms attributed to the condition and endoscopic features of the disease. Clinical experience suggests that lifestyle modifications may be beneficial for gastroesophageal reflux disease although trials of the clinical efficacy of dietary or behavioral changes are lacking. Abundant data from randomized trials show benefits of inhibiting gastric acid secretion and suggest that proton-pump inhibitors are superior to H2-blockers and that both are superior to placebo. In patients with Barrett's esophagus, antireflux interventions are intended to control symptoms of reflux and promote healing of the esophageal mucosa. If a patient has symptoms refractory to proton-pump inhibitors or cannot tolerate such therapy, antireflux surgery, most commonly Nissen fundoplication, may be an alternative management approach. In patients with high-grade dysplasia, endoscopic therapies or surgical resection must be considered.

Ampullary adenoma

Ampullary adenoma is a premalignant lesion involving the major papilla and surrounding mucosa of the second duodenum. These lesions may arise sporadically or in the setting of familial adenomatous polyposis syndrome. Ampullary adenoma may be found because of symptoms, at the time of adenomatous polyposis syndrome surveillance, or incidentally when upper endoscopy is performed for other reasons. Management options include observation, local or extended surgical resection (including pancreaticoduodenectomy), and endoscopic resection. Endoscopic resection is being performed more often and involves techniques similar to those of colonoscopic polypectomy. Preventing post-endoscopic resection pancreatitis is important and can be achieved with placement of temporary pancreatic duct stents.

[Pathology and pathobiology of the gastric carcinoma]

Recent epidemiological studies in Serbia revealed that gastric carcinoma is the third and the fifth main cause of cancer morbidity in men and women, respectively. Despite the declining incidence of gastric cancer, it remains the second most common cause of cancer-related deaths as it is worldwide. A well-defined carcinogenic inflammation-metaplasia-dysplasia-cancer sequence typically precedes the development of most gastric adenocarcinomas. Alterations such as gastric mucosal atrophy and intestinal metaplasia are merely markers of increased risk, while gastric epithelial dysplasia (GED) represent a direct precursor of cancer. DNA damage and increased mucosal proliferation secondary to H pylori infection, combined with a suitable host susceptibility phenotype (eg, genetic polymorphisms in interleukin IL-1B, IL-1RN, and tumor necrosis factor a TNF-alpha genes), are important factors in this progression pathway. However, only a small minority of patients infected with H. pylori eventually develops gastric cancer, and eradication of H pylori in these patients does not seem to eliminate the risk of cancer completely. It has been shown that atrophy may be a better indicator of risk of cancer than intestinal metaplasia, and remains to be validated in routine clinical practice according to recent proposal for new quantitative methods. It is often associated with pseudopyloric gland metaplasia in the gastric corpus mucosa, which expresses a type of trefoil peptide, the spasmolytic polypeptide (termed spasmolytic polypeptide-expressing metaplasia or SPEM) and has been shown to be linked more closely to gastric cancer than intestinal metaplasia. Better histological characterization of adenomatous (or type I), hyperplastic (foveolar or type II) and tubule-neck (mucocellular or type III) GED, two-tiered grading system (low and high grade dysplasia) as well as the introduction of Padova and Vienna international classifications of dysplasia seem to be more helpful in GED surveillance and comparative studies. A combination of histopathological features, serum markers such as pepsinogen I, and molecular tests that analyze host susceptibility polymorphisms and bacterial virulence factors, may allow development of strategies for early detection of cancer in the future. At present, pathobiology of gastric cancerogenesis is far from known, despite the progressive knowledge on predisposing environmental conditions and genetic and epigenetic abnormalities, including tumour suppressor genes, oncogenes, microsatellite instability and hypermethylation or the significance of E-cadherin mutational status association with hereditary diffuse gastric cancer syndrome. Recent evidence regarding the importance of several histopathologically derived prognostic factors, such as resection margin status and lymph node metastases and their implications have also been discussed. We aim to review these aspects, with special relevance to gastric cancer specimen reporting.

Development of type I gastric carcinoid in patients with chronic atrophic gastritis

BACKGROUND

Long-term observational studies assessing the incidence of type I gastric carcinoid (typeIGC) in patients with chronic atrophic gastritis are few.

AIM

To evaluate the occurrence of typeIGC at diagnosis and during follow-up and to identify patient features associated with the presence of typeIGC in a cohort of chronic atrophic gastritis patients.

METHODS

Three hundred and sixty-seven chronic atrophic gastritis patients [245 women, age 54 (18-79) years] underwent regular follow-up by gastroscopy. The incidence of typeIGC was determined in chronic atrophic gastritis patients with at least 2 years of follow-up (n = 214). Baseline clinical and histological features were analysed as factors associated with the presence of typeIGC by univariate analysis.

RESULTS

Type I gastric carcinoid was diagnosed in nine (2.4%) patients at the moment when chronic atrophic gastritis was diagnosed. After 1463 person-years, six patients developed typeIGC with an annual incidence rate (person-year) of 0.4%. Patients with typeIGC had significantly higher levels of gastrin, chromogranin A and more frequently the presence of body polyps and ECL-dysplasia compared with chronic atrophic gastritis patients without typeIGC.

CONCLUSIONS

This cohort study shows that typeIGC is a rare complication in patients with chronic atrophic gastritis, and the presence of body polyps and ECL-dysplasia at gastroscopic/histologic evaluation is strongly associated with the presence of typeIGC.

Treatment and surveillance strategies in achalasia: an update

Controversy exists with regard to the optimal treatment for achalasia and whether surveillance for early recognition of late complications is indicated. Currently, surgical myotomy and pneumatic dilation are the most effective treatments for patients with idiopathic achalasia, and a multicenter, randomized, international trial has confirmed similar efficacy of these treatments, at least in the short term. Clinical predictors of outcome, patient preferences and local expertise should be considered when making a decision on the most appropriate treatment option. Owing to a lack of long-term benefit, endoscopic botulinum toxin injection and medical therapies are reserved for patients of advanced age and those with clinically significant comorbidites. The value of new endoscopic, radiologic or surgical treatments, such as peroral endoscopic myotomy, esophageal stenting and robotic-assisted myotomy has not been fully established. Finally, long-term follow-up data in patients with achalasia support the notion that surveillance strategies might be beneficial after a disease duration of more than 10-15 years.

[Endoscopic technique in endobrachyoesophagus diagnosis: Chromoendoscopy and acetic acid]

Screening for complications of neoplastic Barrett's oesophagus requires a tedious blind standardized protocol biopsies quadrant every 1 to 2cm depending on the morphology of the Barrett's epithelium (Protocol of Seattle). To achieve that biopsies targeted to areas suspicious of dysplasia, a method of high sensitivity is required. Chromoendoscopy has been developed in this direction. Acetic acid combined with high resolution endoscopy and zooming represents an aid in the preparation of the oesophageal mucosa for visualization of suspicious anomalies. It is safe, cheap and easy to use. Acetic acid has proven its value in improving the visibility of the pit pattern. Several vital dyes have been tested, including methylene blue, indigo carmine and crystal violet, with mixed results. The FICE(®) and NBI(®), immediate, reversible and attractive virtual chromoendoscopy techniques represent interesting tools for improving sensitivity in screening for Barrett's oesophagus and its complications. Confocal endomicroscopy, which is similar as a "per-endoscopic real time histological examination", seems to be equally a promising technique in detection of Barrett's oesophagus associated neoplasia. But these tools which are capable of improvement so far, have not proved their use on a large population. For this, the systematic biopsy protocol Seattle remains the "gold standard" in monitoring the Barrett's oesophagus.

Current state of endoscopic therapies in Barrett's esophagus and esophageal cancer

Barrett's esophagus (BE) is a premalignant condition that predisposes patients to esophageal adenocarcinoma. This risk increases with increasing dysplasia, especially in patients with BE and high-grade dysplasia. Radical esophagectomy had long been the only option for these patients; however, it has been associated with significant morbidity and mortality. Endoscopic therapies have been increasingly used as an alternative to radical esophagectomy given the minimally invasive nature and tolerability of the procedure relative to surgery. Currently, the most widely used endoscopic therapies include endoscopic mucosal resection, photodynamic therapy, CryoSpray ablation, and radiofrequency ablation. Retrospective and prospective studies on the use of each of these modalities in patients with nondysplastic BE, dysplastic BE, and early esophageal cancer have demonstrated their effectiveness in eradication of dysplasia with or without reversion of Barrett's epithelium to normal squamous epithelium of the esophagus. These modalities are well tolerated, safe, and have few side effects. Ultimately, more research is needed regarding their ability to fully displace surgical intervention as the gold standard, although at this point their role in poor operative candidates or patients seeking conservative approaches remains promising.

Endoscopy in the diagnosis and management of motility disorders

BACKGROUND

Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer).

AIMS

The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders.

METHODS

We performed a literature review in PubMed.

RESULTS

Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist.

CONCLUSIONS

This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.

Editorial: should women with heartburn undergo screening upper endoscopy for prevention of cancer?

Esophageal adenocarcinoma (EAC) is a rare disease which is much more common in men than in women. For any given age, women with gastroesophageal reflux disease (GERD) symptoms actually have a lower risk of EAC than men without GERD symptoms. The cause of the difference in incidence rates between men and women is unclear and not accounted for by differential distribution of known risk factors. Despite the long-recognized difference in incidence between men and women, neither societal guidelines nor physician practice take into account this difference, leading to illogical use of health-care resources. Given the epidemiology of EAC, the yield of endoscopic screening examinations in those under 50, and in women, regardless of age or GERD symptoms, is exceedingly low, and may approximate the low risk of the endoscopic procedure itself. Recommending organizations should consider the epidemiology of EAC when making screening recommendations.

Endoscopic trimodal imaging versus standard video endoscopy for detection of early Barrett's neoplasia: a multicenter, randomized, crossover study in general practice

BACKGROUND

Endoscopic trimodal imaging (ETMI) may improve detection of early neoplasia in Barrett's esophagus (BE). Studies with ETMI so far have been performed in tertiary referral settings only.

OBJECTIVE

To compare ETMI with standard video endoscopy (SVE) for the detection of neoplasia in BE patients with an intermediate-risk profile.

DESIGN

Multicenter, randomized, crossover study.

SETTING

Community practice.

PATIENTS AND METHODS

BE patients with confirmed low-grade intraepithelial neoplasia (LGIN) underwent both ETMI and SVE in random order (interval 6-16 weeks). During ETMI, BE was inspected with high-resolution endoscopy followed by autofluorescence imaging (AFI). All visible lesions were then inspected with narrow-band imaging. During ETMI and SVE, visible lesions were sampled followed by 4-quadrant random biopsies every 2 cm.

MAIN OUTCOME MEASUREMENTS

Overall histological yield of ETMI and SVE and targeted histological yield of ETMI and SVE.

RESULTS

A total of 99 patients (79 men, 63±10 years) underwent both procedures. ETMI had a significantly higher targeted histological yield because of additional detection of 22 lesions with LGIN/high-grade intraepithelial neoplasia (HGIN)/carcinoma (Ca) by AFI. There was no significant difference in the overall histological yield (targeted+random) between ETMI and SVE. HGIN/Ca was diagnosed only by random biopsies in 6 of 24 patients and 7 of 24 patients, with ETMI and SVE, respectively.

LIMITATIONS

Inspection, with high-resolution endoscopy and AFI, was performed sequentially.

CONCLUSION

ETMI performed in a community-based setting did not improve the overall detection of dysplasia compared with SVE. The diagnosis of dysplasia is still being made in a significant number of patients by random biopsies. Patients with a confirmed diagnosis of LGIN have a significant risk of HGIN/Ca. (

CLINICAL TRIAL REGISTRATION NUMBER

ISRCTN91816824; NTR867.).

Global epidemiology of Barrett's esophagus

Barrett's esophagus (BE) is defined as a metaplastic change of the distal esophageal epithelium from squamous to columnar type epithelium with the presence of intestinal metaplasia. There is a striking geographic variation in the prevalence rates of BE. Most epidemiological data on BE are derived from patients undergoing endoscopy and do not reflect prevalence rates in the general population. BE is much more common in the West when compared with Asia and Africa. Although BE is less common in Asia, the demographics are similar to the West, being predominantly found in older men with longer duration of reflux symptoms. Some studies from the West have suggested an increase in prevalence rates of BE. An increase in prevalence rates will have significant implications for health resource utilization and costs, due to the small but significant risk of developing esophageal adenocarcinoma. Endoscopic surveillance with the aim of detecting early lesions has been advocated. Compared with conventional white-light endoscopy with blind four-quadrant biopsies, the use of image-enhanced endoscopy, including chromoendoscopy, may improve detection of subtle mucosal irregularities and facilitate targeted biopsies. However, a truly cost-effective surveillance strategy remains to be determined.

Barrett's esophagus surveillance: When, how often, does it work?

Barrett's esophagus is a well-known risk factor for the development of esophageal adenocarcinoma. Current practice guidelines recommend endoscopic surveillance of patients with Barrett's esophagus in an attempt to detect cancer at an early and potentially curable stage. This review addresses the rationale behind surveillance and criteria for inclusion of patients in surveillance programs as well as the appropriate technique and intervals that should be used. This work addresses other key topics in Barrett's esophagus surveillance, including the efficacy of surveillance programs, physician compliance with surveillance guidelines, cost-effectiveness of surveillance programs, and areas for future research.

Autofluorescence and narrow band imaging in Barrett's esophagus

This review discusses the application of 2 novel imaging techniques in Barrett's esophagus: autofluorescence imaging and narrow band imaging (NBI). Autofluorescence as well as NBI may help to direct endoscopic therapy for early neoplasia in Barrett's esophagus; their value in daily practice, however, seems to be limited and needs further evaluation.

Advances in endoscopic diagnosis and treatment of Barrett's esophagus

Barrett's esophagus (BE) is defined as abnormal specialized columnar metaplasia with intestinalization in place of the normal squamous esophageal epithelium. Gastroesophageal reflux disease is a known risk factor for BE; nonetheless BE is also detected in asymptomatic individuals. Other risk factors for BE include smoking, male gender, age over 50 and obesity. Patients diagnosed with BE (without dysplasia) are recommended to undergo endoscopic surveillance every 3-5 years. Advances in imaging techniques (such as narrow band imaging, autofluorescence imaging and confocal laser endomicroscopy) have the potential to improve the detection of dysplasia and early cancer, thus making surveillance a more cost-effective endeavor. Patients with high grade dysplasia (HGD) and early cancer have a high rate of progression to invasive adenocarcinoma and traditionally these patients were treated with esophagectomy. The rapid advancement of endoscopic therapeutic techniques along with a low risk of complications have made endoscopic therapy an acceptable alternative to an esophagectomy in patients with HGD and early cancer. Several endoscopic treatment techniques such as endoscopic mucosal resection, multipolar electrocoagulation, photodynamic therapy, argon plasma coagulation, cryotherapy, and radiofrequency ablation have been studied for endoscopic treatment.

Appropriate use of endoscopy in the diagnosis and treatment of gastrointestinal diseases: up-to-date indications for primary care providers

The field of endoscopy has revolutionized the diagnosis and treatment of gastrointestinal (GI) diseases in recent years. Besides the ‘traditional’ endoscopic procedures (esophagogastroduodenoscopy, colonoscopy, flexible sigmoidoscopy, and endoscopic retrograde cholangiopancreatography), advances in imaging technology (endoscopic ultrasonography, wireless capsule endoscopy, and double balloon enteroscopy) have allowed GI specialists to detect and manage disorders throughout the digestive system. This article reviews various endoscopic procedures and provides up-to-date endoscopic indications based on the recommendations of American Society for Gastrointestinal Endoscopy and American Cancer Society for primary care providers in order to achieve high-quality and cost-effective care.

Randomized comparison of 3 different-sized biopsy forceps for quality of sampling in Barrett's esophagus

BACKGROUND

Several types of forceps are available for use in sampling Barrett's esophagus (BE). Few data exist with regard to biopsy quality for histologic assessment.

OBJECTIVE

To evaluate sampling quality of 3 different forceps in patients with BE.

DESIGN

Single-center, randomized clinical trial.

PATIENTS

Consecutive patients with BE undergoing upper endoscopy.

INTERVENTIONS

Patients randomized to have biopsy specimens taken with 1 of 3 types of forceps: standard, large capacity, or jumbo.

MAIN OUTCOME MEASUREMENTS

Specimen adequacy was defined a priori as a well-oriented biopsy sample 2 mm or greater in diameter and with at least muscularis mucosa present.

RESULTS

A total of 65 patients were enrolled and analyzed (standard forceps, n = 21; large-capacity forceps, n = 21; jumbo forceps, n = 23). Compared with jumbo forceps, a significantly higher proportion of biopsy samples with large-capacity forceps were adequate (37.8% vs 25.2%, P = .002). Of the standard forceps biopsy samples, 31.9% were adequate, which was not significantly different from specimens taken with large-capacity (P = .20) or jumbo (P = .09) forceps. Biopsy specimens taken with jumbo forceps had the largest diameter (median, 3.0 mm vs 2.5 mm [standard] vs 2.8 mm [large capacity]; P = .0001). However, jumbo forceps had the lowest proportion of specimens that were well oriented (overall P = .001).

LIMITATIONS

Heterogeneous patient population precluded dysplasia detection analyses.

CONCLUSIONS

Our results challenge the requirement of jumbo forceps and therapeutic endoscopes to properly perform the Seattle protocol. We found that standard and large-capacity forceps used with standard upper endoscopes produced biopsy samples at least as adequate as those obtained with jumbo forceps and therapeutic endoscopes in patients with BE.

Editorial: Cancer surveillance in achalasia: better late than never?

Patients with achalasia have an increased risk for the development of esophageal squamous cell cancer. Endoscopic surveillance in long-standing achalasia has been advocated by some, but the most recent American Society of Gastrointesinal Endoscopy guidelines regard current data as insufficient to support such an approach. In this issue of the American Journal of Gastroenterology, Leeuwenburgh and colleagues report on the results of a long-term prospective study with fixed surveillance intervals. The authors confirm earlier observations of an increased cancer risk after 10 years of symptomatic achalasia. Despite some limitations, this study and earlier data suggest that it might be worthwhile to consider endoscopic surveillance in patients with long-standing achalasia.

Long-term esophageal cancer risk in patients with primary achalasia: a prospective study

OBJECTIVES

Achalasia patients are considered at increased risk for esophageal cancer, but the reported relative risks vary. Identification of this risk is relevant for patient management. We performed a prospective evaluation of the esophageal cancer risk in a large cohort of achalasia patients with long-term follow-up.

METHODS

Between 1975 and 2006, all patients diagnosed with primary achalasia in our hospital were treated and followed by the same protocol. After graded pneumatic dilatation, all patients were offered a fixed surveillance protocol including gastrointestinal endoscopy with esophageal biopsy sampling.

RESULTS

We surveyed a cohort of 448 achalasia patients (218 men, mean age 51 years at diagnosis, range 4-92 years) for a mean follow-up of 9.6 years (range 0.1-32). Overall, 15 (3.3%) patients (10 men) developed esophageal cancer (annual incidence 0.34 (95% confidence interval 0.20-0.56)). The mean age at cancer diagnosis was 71 years (range 36-90) after a mean of 11 years (range 2-23) following initial presentation, and a mean of 24 years (range 10-43) after symptom onset. The relative hazard rate of esophageal cancer was 28 (confidence interval 17-46) compared with an age- and sex-identical population in the same timeframe. Five patients received a potential curative treatment.

CONCLUSIONS

Although the gastro-esophageal cancer risk in patients with longstanding achalasia is much higher than in the general population, the absolute risk is rather low. Despite structured endoscopical surveillance, most neoplastic lesions remain undetected until an advanced stage. Efforts should be made to identify high-risk groups and develop adequate surveillance strategies.