The Role of the Transdiaphragmatic Pressure Gradient (TGP) in the Pathophysiology of Proximal Reflux.

INTRODUCTION: An increased transdiaphragmatic pressure gradient (TGP) is a main element for distal gastroesophageal reflux disease (GERD). The role of TGP for proximal reflux is still unclear. This study aims to evaluate the presence, severity, and importance of proximal reflux in relationship to the TGP, comparing healthy volunteers, obese individuals, and patients with chronic obstructive pulmonary disease (COPD). METHODS: We studied 114 individuals comprising 19 healthy lean volunteers, 47 obese individuals (mean body mass index 45 ± 7 kg/m2), and 48 patients with COPD. All patients underwent high-resolution manometry and dual-channel esophageal pH monitoring. Esophageal motility, thoracic pressure (TP), abdominal pressure (AP), TGP, DeMeester score, and % of proximal acid exposure time (pAET) were recorded. RESULTS: Pathologic distal GERD was found in 0, 44, and 57% of the volunteers, obese, and COPD groups, respectively. pAET was similar among groups, only higher for obese individuals GERD + as compared to obese individuals GERD - and COPD GERD -. pAET did not correlate with any parameter in healthy individuals, but it correlated with AP in the obese, TP in the COPD individuals, and TGP and DeMeester score in both groups. When all individuals were analyzed as a total, pAET correlated with AP, TGP, and DeMeester score. DeMeester score was the only independent variable that correlated with pAET. CONCLUSIONS: Our results show that (a) TGP is an important mechanism associated with distal esophageal acid exposure and this fact is linked with proximal acid exposure and (b) obesity and COPD both seem to be primary causes for GERD but not directly for proximal reflux.

Disparities in Emergent Colectomy for Colorectal Cancer Contribute to Inequalities in Postoperative Morbidity and Mortality in The US Health Care System.

BACKGROUND AND AIMS: Colorectal cancer is the third most common cancer among both men and women in the United States. We aimed to determine racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer in the US Health Care system. MATERIAL AND METHODS: We performed a retrospective analysis of the National Inpatient Sample including adult patients (⩾18 years) diagnosed with colorectal cancer, and who underwent colorectal resection while admitted between 2008 and 2015. Multivariable logistic and linear regression were used to assess the association between emergent admissions, compared to elective admissions, and postoperative outcomes. RESULTS: A total of 141,641 hospitalizations were included: 93,775 (66%) were elective admissions and 47,866 (34%) were emergent admissions. Black patients were more likely to undergo emergent colectomy, compared to white patients (42% vs 32%, p < 0.0001). Medicaid and Medicare patients were also more likely to have an emergent colectomy, compared to private insurance (47% and 36% vs 25%, respectively, p < 0.0001), as were patients with low household income, compared to highest (38% vs 31%, p < 0.0001). Emergent procedures were less likely to be laparoscopic (19% vs 38%, p < 0.0001). Patients undergoing emergent colectomy were significantly more likely to have postoperative venous thromboembolism, wound complications, infection, bleeding, cardiac failure, renal failure, respiratory failure, shock, and inpatient mortality. CONCLUSION: There are significant racial and socioeconomic disparities in emergent colectomy rates for colorectal cancer. Efforts to reduce this disparity in colorectal cancer surgery patients should be prioritized to improve outcomes.

The 2018 ISDE achalasia guidelines.

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Extremes of body mass index and postoperative complications after esophagectomy.

Obesity has been variously associated with reduced or similar rates of postoperative complications compared to normal weight patients undergoing esophagectomy for cancer. In contrast, little is known about esophagectomy risks in the underweight population. The relationship between the extremes of body mass index (BMI) and postoperative complications after esophagectomy was evaluated. Consecutive esophagectomy patients (2000-2013) were reviewed. The patients were stratified based on BMI at the time of diagnosis: underweight (<18.5), normal (18.5-24.9), overweight (25-29.9), obese I (30-34.9), and obese II or III (≥35). Hospital length of stay as well as postoperative complications and their accordion severity grading were evaluated according to the BMI category. Of 388 patients, 78.6% were male with a median age of 62 years at the time of operation. Pathologic cancer stage was 0 to I in 53%. BMI distribution was as follows: 5.6% underweight, 28.7% normal, 31.4% overweight, 22.8% obese I, and 11.5% obese II or III. Performance status was 0 or 1 in 99.2%. Compared to normal BMI patients, underweight patients had increased pulmonary complications (odds ratio (OR) 3.32, P = 0.014) and increased other postoperative complications (OR 3.00, P = 0.043). Patients who were overweight did not have increased complications compared to normal BMI patients. BMI groups did not differ in mortality rates or complication accordion severity grading. Hospital length of stay trended toward a longer duration in the underweight population (P = 0.06). Underweight patients are at increased risk for postoperative pulmonary and other complications. Underweight patients may benefit from preoperative nutritional repletion and mitigation for sarcopenia. Aggressive postoperative pulmonary care may help reduce complications in these patients. In contrast, the operative risk in overweight and obese patients is similar to normal BMI patients.

The role of Heller myotomy and POEM for nonachalasia motility disorders.

The best-defined primary esophageal motor disorder is achalasia. However, symptoms such as dysphagia, regurgitation and chest pain can be caused by other esophageal motility disorders such as Diffuse Esophageal Spasm (DES), Nutcracker Esophagus (NE) and the Hypertensive Lower Esophageal Sphincter (HTN-LES). Most patients with DES and HTN-LES who complain of dysphagia improve after a myotomy. Patients with NE whose main complaint is chest pain, often do not have relief of the pain and can even develop dysphagia as a consequence of the myotomy. POEM is a relatively new procedure, and there are no studies with long-term follow-up and no prospective and randomized trials comparing it to surgical myotomy. Overall, the key to success is based on a complete evaluation and a careful patient selection. The best results, regardless of the technique, are in fact obtained in patients with outflow obstruction and impaired esophageal emptying, a picture similar to achalasia.

Current status of diagnosis and treatment of GERD in the United States.

Patients with suspected gastroesophageal reflux disease (GERD) should undergo a thorough preoperative workup. After establishing the diagnosis, the treatment should be individualized and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years, as the minimally invasive approach to antireflux surgery has allowed good control of reflux with a short hospital stay, fast recovery and excellent long term results. This article reviews the current status on diagnosis and treatment of GERD in the United States.

Esophageal diverticula and cancer.

Esophageal diverticula are rare. The association of cancer and diverticula has been described. Some authors adopt a conservative non-surgical approach in selected patients with diverticula whereas others treat the symptoms by diverticulopexy or myotomy only, leaving the diverticulum in situ. However, the risk of malignant degeneration should be may be taken in account if the diverticulum is not resected. The correct evaluation of the possible risk factors for malignancy may help in the decision making process. We performed a literature review of esophageal diverticula and cancer. The incidence of cancer in a diverticulum is 0.3-7, 1.8, and 0.6% for pharyngoesophageal, midesophageal, and epiphrenic diverticula, respectively. Symptoms may mimic those of the diverticulum or underlying motor disorder. Progressive dysphagia, unintentional weight loss, the presence of blood in the regurgitated material, regurgitation of peaces of the tumor, odynophagia, melena, hemathemesis, and hemoptysis are key symptoms. Risk factors for malignancy are old age, male gender, long-standing history, and larger diverticula. A carcinoma may develop in treated diverticula, even after resection. Outcomes are usually quoted as dismal because of a delayed diagnosis but several cases of superficial carcinoma have been described. The treatment follows the same principals as the therapy for esophageal cancer; however, diverticulectomy is enough in cases of superficial carcinomas. Patients must be carefully evaluated before therapy and a long-term follow-up is advisable.

Prevalence of hiatal hernia by blinded multidetector CT in patients with idiopathic pulmonary fibrosis.

Hiatal hernia (HH) is associated with gastro-oesophageal reflux (GOR) and/or GOR disease and may contribute to idiopathic pulmonary fibrosis (IPF). We hypothesised that HH evaluated by computed tomography is more common in IPF than in asthma or chronic obstructive pulmonary disease (COPD), and correlates with abnormal GOR measured by pH probe testing. Rates of HH were compared in three cohorts, IPF (n=100), COPD (n=60) and asthma (n=24), and evaluated for inter-observer agreement. In IPF, symptoms and anti-reflux medications were correlated with diffusing capacity of the lung for carbon monoxide (D(L,CO)) and composite physiologic index (CPI). HH was correlated with pH probe testing in IPF patients (n=14). HH was higher in IPF (39%) than either COPD (13.3%, p=0.00009) or asthma (16.67%, p=0.0139). The HH inter-observer κ agreement was substantial in IPF (κ=0.78) and asthma (κ=0.86), and moderate in COPD (κ=0.42). In IPF, HH did not correlate with lung function, except in those on anti-reflux therapy, who had a better D(L,CO) (p<0.03) and CPI (p<0.04). HH correlated with GOR as measured by DeMeester scores (p<0.04). HH is more common in IPF than COPD or asthma. In an IPF cohort, HH correlated with higher DeMeester scores, confirming abnormal acid GOR. Presence of HH alone was not associated with decreased lung function.

Postprandial proximal gastric acid pocket in patients after distal gastrectomy.

BACKGROUND: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been noticed in the majority of normal individuals and patients with gastroesophageal reflux disease. The role of gastric anatomy, specifically the antrum, in the physiology of the PPGAP is not yet fully elucidated. This study aims to analyze the presence of PPGAP in patients submitted to distal gastrectomy. METHODS: A total of 15 patients who had a distal gastrectomy plus DII lymphadenectomy and Roux-en-Y reconstruction for gastric adenocarcinoma (mean age 64.3±8.4 years, 12 females) were studied. All patients were free of foregut symptoms after the operation. Patients underwent a high-resolution manometry. A station pull-through pH monitoring was performed from 5cm below the lower border of the lower esophageal sphincter (LBLES) to the LBLES in increments of 1cm in a fasting state and 10min after a standardized fatty meal. Postprandial proximal gastric acid pocket was defined by the presence of acid reading (pH<4) in a segment of the proximal stomach between non-acid segments distally (food) and proximally (LBLES). The PPGAP extent was recorded. The protocol was approved by local ethics committee. Key Results Acidity was not detected in the stomach of nine patients before meal. After meal, PPGAP was not found in three patients. In three patients (20%), a PPGAP was noted with an extension of 1, 1 and 3cm. CONCLUSIONS & INFERENCES: In conclusion, PPGAP is present in a minority of patients after distal gastrectomy; this finding may suggest that the gastric antrum may play a role in the genesis of the PPGAP.

Postprandial proximal gastric acid pocket and gastric pressure in patients after gastric surgery.

BACKGROUND: An unbuffered postprandial proximal gastric acid pocket (PPGAP) has been demonstrated in normal individuals (NI) and patients with gastro-esophageal reflux disease (GERD). The role of gastric anatomy and gastric motility in the physiology of the PPGAP remains elusive. This study aims to analyze the correlation of PPGAP with proximal gastric pressure after gastric surgery. METHODS: A total of 26 individuals were studied: eight patients after open Roux-en-Y gastric bypass (RYGB) for morbid obesity, six patients after laparoscopic Nissen fundoplication for GERD, seven patients after open subtotal gastrectomy for gastric cancer and five NI. Patients underwent high resolution manometry to identify the location of the lower border of the lower esophageal sphincter (LBLES) and measure gastric pressure 1, 2, 3, 4 and 5 cm below the LBLES, immediately before swallow and after the end of the LES relaxation. A station pull-through pH monitoring was performed in all but NI, from 5 cm below the LBLES to the LBLES in increments of 1 cm in a fasting state and 10 min after a standardized fatty meal. KEY RESULTS: Our results show that: (i) proximal gastric pressures are lower after swallow compared with before swallow in NI; (ii) patients after gastric surgery tend to have higher gastric pressure before and lower after swallow compared with NI and (iii) patients after RYGB with PPGAP have an increased gastric pressure after swallows in the segment where the PPGAP is noticed. CONCLUSIONS & INFERENCES: Gastric motility may play a role in the genesis of PPGAP in patients after RYGB. The contribution of gastric motility for the genesis of PPGAP is still elusive in other patients.

When did the esophagus start shrinking? The history of the short esophagus.

Even though the history of this condition extends for almost 100 years, the short esophagus (SE) is still one of the most controversial topics in esophageal surgery with its existence still denied by some distinguished surgeons. We reviewed the evolution behind the diagnosis and treatment of the SE and the persons who wrote its history, from the first descriptions by radiologists, endoscopists, and surgeons to modern treatment.

The evolution of oesophageal function testing and its clinical applications in the management of patients with oesophageal disorders.

The last decade has brought significant technical advances in laparoscopic surgery. In this constantly evolving technological climate, less told is the story of the evolution of diagnostic technology that improved the clinical management of patients with oesophageal disorders. The successful outcome of the laparoscopic treatment of oesophageal disorders is due to a combination of three different factors: the skills and the ability of the foregut surgeon, the high volume of referral, the expertise in the critical evaluation of the oesophageal function tests. This is an art per se, and it is rarely acknowledged in the achievement of the excellent results of surgery. Oesophageal function testing provides the clinician with information that cannot be obtained by the clinical, endoscopic, and radiological evaluation of patients. This expertise, intimately coupled with the other factors, allows the surgeon to better understand the pathophysiology of these diseases and to provide the optimal management. Therefore, it is essential to understand the evolution that this technology is currently undergoing, and how these changes are expanding the current indications for antireflux surgery by identifying additional predictors of successful outcome.

[Laparoscopic Heller myotomy for esophageal achalasia. Is a fundoplication necessary?]. / Miotomia laparoscopica secondo Heller per acalasia esofagea. C'è bisogno di una fundoplicatio?

The last decade has witnessed radical changes in the treatment of esophageal achalasia due to the development of minimally invasive techniques. Because of the high success rate of the laparoscopic Heller myotomy, a radical shift in the treatment algorithm of these patients has occurred, and today this is the preferred treatment modality for achalasia. This remarkable change is due to the recognition by gastroenterologists and patients that a laparoscopic Heller myotomy outperforms pneumatic dilatation and intra-sphincteric injection of botulinum toxin injection. While there is agreement about the technique of the myotomy per se, some questions still linger about the need for a fundoplication after the myotomy. The following review describes the data present in the literature in order to identify the best procedure that can achieve relief of dysphagia while avoiding development of gastroesophageal reflux.

Outcomes after laparoscopic Nissen fundoplication are not influenced by the pattern of reflux.

The purpose of this study was to compare the outcomes of patients with different types of gastroesophageal reflux disease (upright, supine, or bipositional) after laparoscopic Nissen fundoplication and determine if patients with upright reflux have worse outcomes. Two hundred and twenty-five patients with reflux confirmed by 24-h pH monitoring were divided into three groups based on the type of reflux present. Patients were questioned pre- and post-fundoplication regarding the presence and duration of symptoms (heartburn, regurgitation, dysphagia, cough and chest pain). Symptoms were scored using a 5-point scale, ranging from 0 (no symptom) to 4 (disabling symptom). Esophageal manometry and pH results were also compared. There was no statistically significant difference in lower esophageal sphincter length, pressure or function between the three groups. There was no significant difference in any of the postoperative symptom categories between the three groups. The type of reflux identified preoperatively does not have an adverse effect on postoperative outcomes after Nissen fundoplication and should not discourage physicians from offering antireflux surgery to patients with upright reflux.

Side-to-side stapled intra-thoracic esophagogastric anastomosis reduces the incidence of leaks and stenosis.

Trans-hiatal esophagectomy with a hand-sewn anastomosis was for 2 decades the preferred approach in our institution for patients with esophageal cancer. In our experience, this anastomotic technique was associated with a 12% leak rate and a 48% rate of stricture requiring dilatation. We sought to determine if a side-to-side intra-thoracic anastomosis was associated with a lower rate of anastomotic stricture and leak. Thirty-three consecutive patients with distal esophageal cancer or Barrett's esophagus with high grade dysplasia underwent a trans-thoracic esophagectomy with a side-to-side stapled intra-thoracic anastomosis. The overall morbidity was 27%, with no anastomotic stricture or leaks. One patient died (3%). The median time to the resumption of an oral diet was 7 days (range 5-28), and the median length of stay in hospital was 9 days (range 6-45). Trans-thoracic esophagectomy with a side-to-side stapled anastomosis is safe and it is associated with a very low rate of anastomotic complications. We consider this to be the procedure of choice for patients with distal esophageal cancers.

Antireflux surgery for patients with end-stage lung disease before and after lung transplantation.

BACKGROUND: Gastroesophageal reflux disease (GERD) is prevalent among patients with end-stage lung disease (ESLD). This disease can lead to microaspiration and may be a risk factor for lung damage before and after transplantation. A fundoplication is the best way to stop reflux, but little is known about the safety of elective antireflux surgery for patients with ESLD. This study aimed to report the safety of laparoscopic fundoplication for patients with ESLD and GERD before or after lung transplantation. METHODS: Between January 1997 and January 2007, 305 patients were listed for lung transplantation, and 189 patients underwent the procedure. In 2003, routine esophageal studies were added to the pretransplantation evaluation. After the authors' initial experience, gastric emptying studies were added as well. RESULTS: A total of 35 patients with GERD or delayed gastric emptying were referred for surgical intervention. A laparoscopic fundoplication was performed for 32 patients (27 total and 5 partial). For three patients, a pyloroplasty also was performed. Two patients had a pyloroplasty without fundoplication. Of the 35 operations, 15 were performed before and 20 after transplantation. Gastric emptying of solids or liquids was delayed in 12 (92%) of 13 posttransplantation studies and 3 (60%) of 5 pretransplantation studies. All operations were completed laparoscopically, and 33 patients recovered uneventfully (94%). The median hospital length of stay was 2 days (range, 1-34 days) for the patients admitted to undergo elective operations. Hospitalization was not prolonged for the three patients who had fundoplications immediately after transplantation. CONCLUSIONS: The results of this study show that laparoscopic antireflux surgery can be performed safely by an experienced multidisciplinary team for selected patients with ESLD before or after lung transplantation, and that gastric emptying is frequently abnormal and should be objectively measured in ESLD patients.

Routine upper GI series after gastric bypass does not reliably identify anastomotic leaks or predict stricture formation.

BACKGROUND: Many surgeons who perform Roux-en-Y gastric bypass (RYGB) for morbid obesity routinely obtain an upper gastrointestinal (GI) series in the early postoperative period to search for anastomotic leaks and signs of stricture formation at the gastrojejunostomy. We hypothesized that this practice is unreliable. METHODS: We analyzed 654 consecutive RYGBs, of which 63% were completed laparoscopically. An upper GI series was obtained in 634 (97%) patients. The radiographic findings (leak or delayed emptying) were compared with clinical outcomes (leak or stricture formation) to calculate the sensitivity and specificity. Univariate analysis identified risk factors for leaks or stricture formation; events were too few for multivariate analysis. RESULTS: Of 634 routine upper GI series, anastomotic leaks at the gastrojejunostomy were diagnosed in 5 (0.8%); 2 of these 5 were later reinterpreted as artifacts. Four leaks were not seen on the initial upper GI series, yielding an overall sensitivity of 43% and a positive predictive value (PPV) of 60%. Univariate analysis showed that cases done early (odds ratio [OR] 5.4 for the first 100 cases, p = 0.02) and prolonged operating time (OR 7.8 for cases >or= 300 min, p = 0.01) were associated with leaks. Emptying into the Roux-en-Y limb was delayed in 127 (20%) of the upper GI series. Strictures requiring dilatation developed in 16 (2.4%) patients. The PPV of delayed emptying for stricture formation was 6%. Risk factors for stricture formation included stapled anastomosis (OR 7.8, p = 0.002), surgeon inexperience (OR 2.9 for first 50 cases, p = 0.04), and delayed emptying (OR 3.3; p = 0.02). CONCLUSIONS: Because the incidence of anastomotic complications and the sensitivity of upper GI series were both low, routine upper GI series did not reliably identify leaks or predict stricture formation. A selective approach, whereby imaging is reserved for patients with clinical evidence of a leak or stricture, may be more appropriate.

Effect of partial and total laparoscopic fundoplication on esophageal body motility.

BACKGROUND: Abnormal esophageal body motility often accompanies gastroesophageal reflux disease (GERD). Although the effect of surgery on the pressure and behavior of the lower esophageal sphincter (LES) has been extensively studied, it still is unclear whether a successful fundoplication improves esophageal peristalsis. METHODS: The pre- and postoperative esophageal manometries of 71 patients who underwent a successful laparoscopic fundoplication (postoperative DeMeester score < 14.7) were reviewed. The patients were grouped according to the type of fundoplication (partial vs total) and preoperative esophageal peristalsis (normal vs abnormal): group A (partial fundoplication and abnormal esophageal peristalsis; n = 16), group B (total fundoplication and normal peristalsis; n = 41), and group C (total fundoplication and abnormal peristalsis; n = 14). RESULTS: The LES pressure was increased in all the groups. A significant increase in amplitude of peristalsis was noted in groups A and C. Normalization of peristalsis was achieved in 31% of the group A patients and 86% of the group C patients. No changes occurred in group B. CONCLUSIONS: Laparoscopic fundoplication increased LES pressure and the strength of esophageal peristalsis in patients with abnormal preoperative esophageal motility. A total fundoplication resulted in normalization of peristalsis in the majority of patients.

Endoscopic ablation of intestinal metaplasia containing high-grade dysplasia in esophagectomy patients using a balloon-based ablation system.

BACKGROUND: This study aimed to determine the optimal treatment parameters for the ablation of intestinal metaplasia (IM) containing high-grade dysplasia (HGD) using a balloon-based ablation system for patients undergoing esophagectomy. METHODS: Immediately before esophagectomy, patients underwent ablation of circumferential segments of the esophagus containing IM-HGD using the HALO360 system. The treatment settings were randomized to 10, 12, or 14 J/cm2 for two, three, or four applications. After esophagectomy, multiple sections from ablation zones were microscopically evaluated. Histologic end points included maximum ablation depth (histologic layer) and complete ablation of all IM-HGD (yes/no). RESULTS: Eight men with a mean age of 57 years (range, 45-71 years) were treated, and 10 treatment zones were created. There were no device-related adverse events. At resection, there was no evidence of a transmural thermal effect. Grossly, ablation zones were clearly demarcated sections of ablated epithelium. The maximum ablation depth was the lamina propria or muscularis mucosae. The highest energy (14 J/cm2, 4 applications) incurred edema in the superficial submucosa, but no submucosa ablation. Complete ablation of IM and HGD occurred in 9 of 10 ablation zones (90%), defined as complete removal of the epithelium with only small foci of "ghost cells" representing nonviable, ablated IM-HGD and demonstrating loss of nuclei and cytoarchitectural derangement. One focal area of viable IM-HGD remained at the margin of one ablation zone (12 J/cm2, 2 applications) because of incomplete overlap. CONCLUSION: Complete ablation of IM-HGD without ablation of submucosa is possible using the HALO360 system. Ablation depth is dose related and limited to the muscularis mucosae. In one patient, small residual foci of IM-HGD at the edge of the ablation zone were attributable to incomplete overlap, which can be avoided. This study, together with nonesophagectomy IM-HGD trials currently underway, will identify the optimal treatment parameters for IM-HGD patients who would otherwise undergo esophagectomy or photodynamic therapy.