Esophageal chromoendoscopy in Barrett's esophagus: "cons"

Endoscopic imaging in Barrett's esophagus

Barrett's esophagus is the only known precursor that predisposes patients to the development of esophageal adenocarcinoma. The current recommended surveillance method is targeted biopsies of any abnormalities followed by random four-quadrant biopsies every 2 cm using standard white light endoscopy. Compliance with this and sampling error are two of the biggest problems. Several novel imaging technologies have been developed to aid the diagnosis of early neoplasia in Barrett's esophagus. There are emerging data that some of these new modalities can increase the yield of detecting dysplasia. This review will discuss some of the present available techniques and technologies including chromoendoscopy, narrow-band imaging, autofluorescence imaging, optical coherence tomography, confocal endomicroscopy and endocytoscopy. Based on the current evidence, these imaging modalities appear to be promising as adjunctive tools to white light endoscopy. A few of them, nevertheless, remain experimental due to expense, lack of expertise, generalizability as well as reproducibility of results.

One-step circumferential endoscopic mucosal cap resection of Barrett's esophagus with early neoplasia

BACKGROUND AND OBJECTIVE

Focal endoscopic mucosal resection (EMR) of visible intraepithelial lesions arising within Barrett's esophagus (BE) may miss synchronous lesions that are not endoscopically apparent. Stepwise radical endoscopic resection would obviate this concern by removing all BE; however, it requires repeated endoscopy which may increase the risk of complications, particularly for patients with circumferential BE. The aim of the study was to evaluate the safety and efficacy of one-step complete circumferential resection of BE by cap-assisted EMR (EMR-C) among patients with circumferential BE and high-grade dysplasia or intramucosal carcinoma.

PATIENTS AND METHODS

Between January 2003 and March 2010, 47 patients with circumferential BE and biopsy-proven high-grade dysplasia or intramucosal cancer underwent EMR-C. We evaluated: (1) complete eradication of neoplasia, (2) complete eradication of metaplasia, and (3) complications including bleeding and esophageal stricture.

RESULTS

Complete eradication of neoplasia and complete eradication of metaplasia were achieved after a median follow-up of 18.4 months in 91% (43/47) of patients. After EMR-C, two patients (one IMC, one invasive cancer) underwent esophagectomy. Histology of the resected specimens showed no residual disease and a T1bN0 lesion, respectively. Two patients had progression of neoplasia. A stenosis occurred in 18 out of 45 patients (40%). All stenoses were treated with dilations and two required temporary placement of a covered stent.

CONCLUSION

One-step complete EMR-C is a safe and effective technique which can be considered in patients with early neoplastic lesions. Although 40% of patients developed dysphagia, this could well be managed endoscopically.

Chromoendoscopy

Chromoendoscopy involves the use of stains or dyes during endoscopy to improve the visualization and characterization of the gastrointestinal mucosa. Its main clinical application is the detection of dysplasia or early cancer of the gastrointestinal tract in individuals with pre-malignant conditions or hereditary and environmental factors that predispose them to cancer. The utility of chromoendoscopy has been mostly studied in squamous cell carcinoma of the esophagus, Barrett's esophagus, gastric cancer, colorectal polyps, and chronic ulcerative colitis. Although chromoendoscopy has been shown to be feasible and safe, several limitations have prevented its widespread use in endoscopy. Despite this, chromoendoscopy remains a useful adjunct to standard white light endoscopy in the visualization of mucosal lesions, which may potentially improve tissue diagnosis and impact patient care.