[Intramural esophageal abscess as a complication of an eosinophilic esophagitis]. / Intramurale ösophageale Abszedierung als Komplikation einer eosinophilen Ösophagitis.

Eosinophilic esophagitis is an important differential diagnosis in the presence of dysphagia or bolus obstruction of the esophagus. Delayed diagnosis of eosinophilic esophagitis can lead to strictures of the esophagus.We report on a young patient who presented with initially unclear retrosternal symptoms to our department. The diagnosis of eosinophilic esophagitis, complicated by an intramural abscess of the esophagus, was established. After spontaneous drainage of the abscess, antibiotic therapy and subsequent remission induction of eosinophilic esophagitis with orodispersible budesonide resulted in a good therapeutic outcome.

Multimodality endoscopic eradication for neoplastic Barrett oesophagus: results of an European multicentre study (EURO-II).

OBJECTIVE: Focal endoscopic resection (ER) followed by radiofrequency ablation (RFA) safely and effectively eradicates Barrett's oesophagus (BO) containing high-grade dysplasia (HGD) and/or early cancer (EC) in smaller studies with limited follow-up. Herein, we report long-term outcomes of combined ER and RFA for BO (HGD and/or EC) from a single-arm multicentre interventional study. DESIGN: In 13 European centres, patients with BO ≤ 12 cm with HGD and/or EC on 2 separate endoscopies were eligible for inclusion. Visible lesions (<2 cm length; <50% circumference) were removed with ER, followed by serial RFA every 3 months (max 5 sessions). Follow-up endoscopy was scheduled at 6 months after the first negative post-treatment endoscopic control and annually thereafter. OUTCOMES: complete eradication of neoplasia (CE-neo) and intestinal metaplasia (CE-IM); durability of CE-neo and CE-IM (once achieved) during follow-up. Biopsy and resection specimens underwent centralised pathology review. RESULTS: 132 patients with median BO length C3M6 were included. After entry-ER in 119 patients (90%) and a median of 3 RFA (IQR 3-4) treatments, CE-neo was achieved in 121/132 (92%) and CE-IM in 115/132 patients (87%), per intention-to-treat analysis. Per-protocol analysis, CE-neo and CE-IM were achieved in 98% and 93%, respectively. After a median of 27 months following the first negative post-treatment endoscopic control, neoplasia and IM recurred in 4% and 8%, respectively. Mild-to-moderate adverse events occurred in 25 patients (19%); all managed conservatively or endoscopically. CONCLUSIONS: In patients with early Barrett's neoplasia, intensive multimodality endotherapy consisting of ER combined with RFA is safe and highly effective, and the treatment effect appears to be durable during mid-term follow-up. TRIAL REGISTRATION NUMBER: NTR 1211, http://www.trialregister.nl.

Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus.

BACKGROUND & AIMS: Barrett's esophagus-associated high-grade dysplasia is commonly treated by endoscopy. However, most guidelines offer no recommendations for endoscopic treatment of mucosal adenocarcinoma of the esophagus (mAC). We investigated the efficacy and safety of endoscopic resection in a large series of patients with mAC. METHODS: We collected data from 1000 consecutive patients (mean age, 69.1 ± 10.7 years; 861 men) with mAC (481 with short-segment and 519 with long-segment Barrett's esophagus) who presented at a tertiary care center from October 1996 to September 2010. Patients with low-grade and high-grade dysplasia and submucosal or more advanced cancer were excluded. All patients underwent endoscopic resection of mACs. Patients found to have submucosal cancer at their first endoscopy examination were excluded from the analysis. RESULTS: After a mean follow-up period of 56.6 ± 33.4 months, 963 patients (96.3%) had achieved a complete response; surgery was necessary in 12 patients (3.7%) after endoscopic therapy failed. Metachronous lesions or recurrence of cancer developed during the follow-up period in 140 patients (14.5%) but endoscopic re-treatment was successful in 115, resulting in a long-term complete remission rate of 93.8%; 111 died of concomitant disease and 2 of Barrett's esophagus-associated cancer. The calculated 10-year survival rate of patients who underwent endoscopic resection of mACs was 75%. Major complications developed in 15 patients (1.5%) but could be managed conservatively. CONCLUSIONS: Endoscopic therapy is highly effective and safe for patients with mAC, with excellent long-term results. In an almost 5-year follow-up of 1000 patients treated with endoscopic resection, there was no mortality and less than 2% had major complications. Endoscopic therapy should become the standard of care for patients with mAC.

A multicenter study on the role of direct retrograde cholangioscopy in patients with inconclusive endoscopic retrograde cholangiography.

BACKGROUND AND STUDY AIMS: Direct retrograde cholangioscopy (DRC) may improve the diagnostic and therapeutic yield of endoscopic retrograde cholangiography (ERC) but safety, feasibility, and outcome are unknown. PATIENTS AND METHODS: All consecutive patients who underwent DRC at three tertiary endoscopy centers for inconclusive findings at ERC were included in this retrospective analysis. Ultraslim endoscopes (FujiFilm EG 530NP; Olympus GIF XP180; GIF N180) were used by the peroral route for intubating all accessible bile ducts. Success rate, usefulness in diagnosis and therapy, and safety of DRC were assessed in terms of technical and clinical parameters and therapeutic vs. diagnostic indication. RESULTS: DRC was performed in 130 cases (89 patients). CO2 insufflation and an anchoring balloon were used in 66.9% and 97.7% of cases, respectively. Intubation of the papilla was successful in 115 of 130 (88.5%) cases, and the aim of the DRC investigation was accomplished in 105 cases (80.8%). DRC-guided biopsies were taken in 53 cases (40.8%), and a therapeutic intervention was performed in 32 cases (24.6%). The initial diagnosis was revised by DRC in 18 of 69 patients (26.1%) with indeterminate biliary stricture. Complications were observed in 10 cases (7.7%), including cholangitis (n=2; 1.5%), bleeding (n=2; 1.5%), and pain, hypoxia, bradyarrhythmia, air embolism, and perforation of an intrahepatic and an extrahepatic bile duct (1 each; 0.8%). There was no mortality associated with DRC. CONCLUSIONS: DRC was successfully performed for the diagnosis and treatment of biliary disease that had eluded diagnosis with conventional ERC. DRC impacted on clinical decision making. The complication rate was low and similar to other cholangioscopy techniques.

Efficacy, safety, and long-term results of endoscopic treatment for early stage adenocarcinoma of the esophagus with low-risk sm1 invasion.

BACKGROUND & AIMS: Patients with early-stage mucosal (T1a) esophageal adenocarcinoma (EAC) are increasingly treated by endoscopic resection. EACs limited to the upper third of the submucosa (pT1b sm1) could also be treated by endoscopy. We assessed the efficacy, safety, and long-term effects of endoscopic therapy for these patients. METHODS: We analyzed data from 66 patients with sm1 low-risk lesions (macroscopically polypoid or flat, with a histologic pattern of sm1 invasion, good-to-moderate differentiation [G1/2], and no invasion into lymph vessels or veins) treated by endoscopic therapy at the HSK Hospital Wiesbaden from 1996 through 2010. The efficacy of endoscopic therapy was assessed on the basis of rates of complete endoluminal remission (CER), metachronous neoplasia, lymph node events, and long-term remission (LTR). Safety was assessed on the basis of rate of complications. RESULTS: Remissions were assessed in 61 of the 66 patients; 53 of the 61 achieved CER (87%). Of patients with small focal neoplasias ≤2 cm, 97% achieved CER (for those with tumors ≥2 cm, 77%; P = .026). Metachronous neoplasias were observed in 10 of 53 patients (19%; 9 of the 10 underwent repeat endoscopic resection). One patient developed a lymph node metastasis (1.9%). Fifty-one patients achieved LTR (84%); 90% of those with focal lesions ≤2 cm achieved LTR after a mean follow-up period of 47 ± 29.1 months (range, 8-120 months). No tumor-associated deaths were observed, and the estimated 5-year survival rate was 84%. The rate of major complications from endoscopic resection was 1.5%, and no patients died. CONCLUSIONS: Endoscopic therapy appears to be a good alternative to esophagectomy for patients with pT1b sm1 EAC, on the basis of macroscopic and histologic analyses. The risk of developing lymph node metastases after endoscopic resection for sm1 EAC is lower than the risk of surgery.

Prospective multicenter trial comparing push-and-pull enteroscopy with the single- and double-balloon techniques in patients with small-bowel disorders.

OBJECTIVES: Double-balloon enteroscopy (DBE) is now an established method for diagnostic and therapeutic small-bowel endoscopy. Single-balloon enteroscopy (SBE) has been introduced to simplify the technique. A prospective randomized study was carried out to compare the two methods. METHODS: The study included 100 patients (50 in each group; 63 men, 37 women; mean age 55 years), with no previous small-bowel or colon surgery. The indications for enteroscopy were (suspected) mid-gastrointestinal bleeding, Crohn's disease, small-bowel masses, chronic diarrhea or abdominal pain or both, and other conditions. Fujinon instruments were used, with either two balloons or one. The end point of the study was complete enteroscopy as the most objective parameter. RESULTS: No severe complications such as perforation, bleeding, or pancreatitis occurred. Instrument preparation time was significantly faster with SBE than with DBE (P<0.0001). Complete enteroscopy was achieved with the DBE technique in 66% of cases (33 patients), either with the oral route alone or with combined oral and anal approaches. With the SBE technique, the complete enteroscopy rate was significantly lower at 22% (P<0.0001; 11 patients, only with oral and anal routes combined). The rate of therapeutic consequences for the patients based on diagnostic yield and negative complete enteroscopy was significantly higher (P=0.025) in the DBE group at 72%, compared with 48% in the SBE group. CONCLUSIONS: The complete enteroscopy rate was three times higher with DBE than with SBE, accompanied by a higher diagnostic yield. DBE must therefore continue to be regarded as the nonsurgical gold standard procedure for deep small-bowel endoscopy.

Long-term results of endoscopic resection in early gastric cancer: the Western experience.

OBJECTIVES: In the West, neither acute nor long-term results of endoscopic resection (ER) for early gastric cancer (EGC) have been reported in large studies. The aim of this study was to prospectively evaluate the efficacy and safety of ER in patients with EGC in a long-term follow-up (FU). METHODS: From May 1995 to October 2004, 179 patients were referred to our department for endoscopic therapy (ET) of gastric cancer (GC). Of these, 43 patients had intramucosal GC with a diameter of up to 30 mm and underwent ER with curative intent. All patients underwent a strict FU protocol at regular intervals. RESULTS: Of the 43 patients, 42 fulfilled our low-risk criteria for ET of EGC: gross tumor type I/II, intramucosal GC, diameter up to 30 mm, tumor differentiation G1/G2, and no infiltration into lymph vessels/veins. Two patients were not available for FU (remission status not evaluated). In another patient, gastric mucosa-associated lymphoid tissue lymphoma was detected simultaneously, and he was referred for surgery. 38 (97%) of the remaining 39 patients who underwent definitive ET (23 males (59%); mean age 69+/-10 years) achieved complete remission (CR) after a mean of 1.3+/-0.6 ER sessions. Minor complications (not Hb-relevant bleeding) occurred in 7 of the 39 patients (18%) and major complications (5 Hb-relevant bleeds, 1 covered perforation; all managed conservatively) in 6 patients (15%). During FUs (mean 57 months; range 5-137), recurrent or metachronous lesions were observed in 11 patients (29%). All lesions were successfully treated by repeated ET. No tumor-related deaths occurred during FU. CONCLUSIONS: Although ER for EGC in Western countries is effective, it is associated with a relevant risk of complications. In view of the possibility of recurrent or metachronous neoplasia, a strict FU protocol is mandatory.

Early Barrett's carcinoma with "low-risk" submucosal invasion: long-term results of endoscopic resection with a curative intent.

BACKGROUND: Endoscopic therapy (ET) has become a less risky alternative to open surgery in mucosal Barrett's cancer (BC) because of the very low risk of lymph node (LN) metastasis. Recently published surgical series demonstrated that even in case of minimal submucosal invasion of BC, the risk for LN metastasis is very low. In consequence, also these patients might be eligible for curative ET. The aim of this study was to prospectively evaluate the efficacy and safety of endoscopic resection (ER) in these patients. METHODS: From September 1996 to September 2003, the suspicion or definite diagnosis of submucosal BC was made in 80 patients referred to our department. Of those, 21 patients (20 male [95.2%], mean age 62 +/- 9 yr, range 47-78) fulfilled the definition of "low-risk" submucosal cancer: invasion of the upper submucosal third (sm1), absence of infiltration into lymph vessels/veins, histological grade G1/2, and macroscopic type I/II. ET was carried out using ER with the suck-and-cut technique with or without an additive ablation of non-neoplastic remnants of Barrett's esophagus. RESULTS: One of the 21 patients was referred to surgery directly after the detection of sm1 invasion at the beginning of the study. One patient died (not tumor-related) before completion of ET. Using definitive ET, complete remission (CR) was achieved in 18 of 19 patients (95%) after a mean of 5.3 months (range 1-18) and a mean of 2.9 resections (range 1-9). Only one minor complication (bleeding without drop in hemoglobin level >2 g/dL) occurred (5% of patients). During a mean follow-up (FU) of 62 months (range 45-89), recurrent or metachronous carcinomas were found in 5 patients (28%). Repeat ET was carried out successfully using ER (4 patients) and argon plasma coagulation (1 patient). In one of the 19 patients (5%), tumor freedom had not been achieved after a total of 2 ER. This patient died of a heart attack before surgery could be performed. The calculated 5-yr survival rate of all 21 patients was 66%. No tumor-related death occurred. CONCLUSIONS: As in mucosal BC, ER is associated with favorable outcomes even in case of "low-risk" submucosal BC. Further and larger clinical trials are required before a general recommendation for ER as the treatment of choice in "low-risk" submucosal BC can be given.

Potential contribution of novel imaging modalities in non-erosive reflux disease.

Non-erosive reflux disease (NERD) is the most frequent endoscopic finding in patients with gastro-oesophageal reflux disease (GORD). Conventional white light endoscopy is an insufficient tool for diagnosing subtle changes of the oesophageal mucosa in patients with NERD. This review will discuss the diagnostic approach and endoscopic features of novel endoscopic imaging techniques such as magnification endoscopy, chromoendoscopy, narrow band imaging (NBI) and confocal laser endomicroscopy (CLE) for patients with this disorder. Magnification endoscopy alone or in combination with chromoendoscopy offers the chance for an improved detection of subtle findings in NERD. However, subtle changes such as punctuate erythema above the Z-line, pinpoint vessels, triangular indentations and other findings show a substantial inter- and intra-observer variability with unacceptably low kappa values for justifying their use as a diagnostic criterion for NERD. NBI and endomicroscopy are fascinating new tools, but access to these novel modalities in clinical practice is limited and the area to be examined is small, which makes it very time-consuming to examine the entire distal oesophagus. It remains to be proven in crossover, randomised trials that these new imaging modalities may represent a significant improvement over standard endoscopy for the diagnosis of NERD.

Management of pre-malignant and malignant lesions by endoscopic resection.

Endoscopic resection (ER) has gained more and more importance in the treatment of early gastrointestinal neoplasia over the last few years. The choice of the different available techniques depends on the site, the macroscopic type of the tumour and the personal experience of the endoscopist. The 'suck-and-cut' technique with ligation device or cap should be favoured to normal strip biopsy in the oesophagus because of the size of the resected specimen and its technical feasibility. A recently described method of ER in the stomach is the circumferential mucosal incision with a type of needle-knife and subsequent en-bloc resection following prior injection under the lesions. ER of high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus should be considered as the treatment of choice. First mid-term results of endoscopic therapy of early squamous-cell neoplasia in the oesophagus show promising results; however, long-term results are awaited. Studies with large numbers of patients in Japan proved the efficiency and safety of ER in low-risk early gastric carcinoma. Duodenal lesions and adenomas of the major duodenal papilla were also proved to be treated successfully by ER. In the colon, ER is used successfully for resection of adenomas and small well-differentiated or moderately differentiated carcinomas that are restricted to the mucosa. ER of gastrointestinal lesions is a safe and effective method but should be performed only by experienced endoscopists.

Photodynamic therapy of human Barrett's cancer using 5-aminolaevulinic acid-induced protoporphyrin IX: an in-vivo dosimetry study in athymic nude mice.

OBJECTIVE: There has been a dramatic increase in recent years in the incidence of Barrett's oesophagus and the oesophageal adenocarcinoma associated with it. Alongside surgical treatment for early Barrett's carcinomas, endoscopic treatment procedures such as photodynamic therapy (PDT), which have much lower complication and mortality rates, will play an increasing role in the future. In this study, the effects of light energy dose, light fractionation and oxygenation on the efficacy of PDT were investigated for the first time in an in-vivo nude mice tumour model bearing a human Barrett's carcinoma. DESIGN: A total of 387 NMRI strain (nu/nu) nude mice with thymic aplasia (total 53 controls) were transplanted with human Barrett's carcinoma and treated with laser light at 635 nm (light dose 0-200 J/cm2, fluence rate 400 mW/cm2). 5-Aminolaevulinic acid-induced protoporphyrin IX (5-ALA-PpIX) (100 mg 5-ALA/kg body weight administered orally) was used as the photosensitizer. METHODS: Fractionation studies were performed at 0, 50, 100 and 150 J/cm2. The light dose was administered in four equal fractions divided by three irradiation-free intervals of 120 s. Oxygenation studies were carried out at 150 J/cm2 with simultaneous oxygen supply of 2, 6 and 8 l oxygen/min. RESULTS: Dosimetry studies demonstrated a positive correlation between increase in light dose and tumour destruction up to 150 J/cm2 when using either continuous or fractionated light delivery. The optimal light energy dose was 150 J/cm2. Neither fractionation of light nor simultaneous oxygenation enhanced the efficacy of the PDT. CONCLUSION: This is the first study in the literature that proves the efficiency of PDT with 5-ALA-PpIX in human Barrett's adenocarcinoma and that demonstrates an exact dosimetry of the optimal light energy dose (150 J/cm2). No general recommendation can be made for the use of fractionation or oxygenation in clinical PDT.

Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach.

BACKGROUND: Radical oesophageal resection has until now been regarded as the gold standard for treatment in intraepithelial high-grade neoplasia or early adenocarcinoma of the oesophagus. However, the mortality and morbidity rates are substantial. DESIGN: A new therapeutic approach involving low-risk endoscopic therapy modalities was examined in the framework of a prospective study. PATIENTS: A total of 115 patients with intraepithelial high-grade neoplasia (19) and early adenocarcinoma (96) in Barrett's oesophagus. METHODS: Endoscopic mucosal resection (EMR) was used in 70 patients, and photodynamic therapy (PDT) was used in 32 patients. The two procedures were combined in ten patients. Three patients underwent primary treatment with argon plasma coagulation (APC). The average follow-up was 34 +/- 10 months (range 24-60 months). RESULTS: Complete local remission was achieved in 98%. The overall complication rate was 9.5%. Major complications, such as perforation and severe bleeding, did not occur. Minor complications included not haemoglobin relevant bleeding (drop of haemoglobin less than 2 g/dl) (5) and stenosis (3) after EMR, and long-lasting odynophagia (1) and sunburn (2) after PDT. In all, 13 patients have died so far, but in only one case due to the underlying disease. The calculated overall 3-year survival rate is 88%. During the follow-up period, a 30% rate of metachronous lesions was observed; endoscopic therapy was performed successfully in all but one of these patients. CONCLUSIONS: These good acute-phase and intermediate results, along with low morbidity rates and no mortality, suggest that the organ-preserving local endoscopic procedure including EMR and PDT is an attractive alternative to oesophageal resection. Therefore, endoscopic therapy might replace radical oesophageal resection in future in cases of intraepithelial high-grade neoplasia and early mucosal adenocarcinoma in Barrett's oesophagus.

Barrett's esophagus: endoscopic resection.

In experienced hands, ER is a safe method of resecting dysplastic lesions and early carcinomas of the GI tract, and it has decisive advantages compared with other local endoscopic treatment procedures (such as thermal destruction and PDT). The opportunity for histological processing of the resected specimen provides information regarding the depth of invasion of the individual layers of the GI tract wall. Additionally, it has advantages regarding excision with healthy margins. This means that even when there is infiltration of the submucosa that has not been detected before treatment--in which case local endoscopic therapy is no longer appropriate--a patient with early Barrett's cancer still is able to undergo surgical resection. As was shown recently, the morbidity and mortality of ER are significantly dependent on the frequency with which esophagectomy is performed in each center. When there were more than 20 procedures of this type per year, the surgical mortality was 8%, whereas in centers conducting fewer than 10 procedures per year the rate was 21%. In view of the consequent claim that ER should only be performed at high-volume centers, curative endoscopic treatment of early esophageal carcinomas also should be performed only in centers with a similar frequency to that of the surgical high-volume centers. It is only in these conditions that the conclusion is defensible that patients with HGIN or mucosal Barrett's carcinoma should undergo ER with curative intent instead of radical ER. Randomized and controlled studies comparing radical esophagectomy with endoscopic therapy are desirable, but they are difficult to conduct, not least because valid 5-year survival data show no significant difference between patients who have undergone endoscopic treatment for early Barrett's cancers and the average German population of the same age and sex.

Conclusions from the histological diagnosis of low-grade intraepithelial neoplasia in Barrett's oesophagus.

OBJECTIVE: It is well known that low-grade intraepithelial neoplasia (LGIN) in Barrett's oesophagus (BE) might progress to high-grade intraepithelial neoplasia (HGIN) or carcinoma. Since accurate diagnosis of LGIN is difficult, general pathologists are frequently uncertain about the diagnosis of LGIN and its follow-up risks. The purpose of this study was to analyse the divergence between the diagnoses of general and specialized gastrointestinal pathologists. MATERIAL AND METHODS: Fifty consecutive patients with a previous diagnosis of LGIN in BE, made by a general pathologist, were included in our study. The histopathological slides of every patient were reassessed in a blinded fashion by two specialized gastrointestinal (GI) pathologists. Inter-observer variability was calculated using kappa statistics. RESULTS: LGIN was confirmed by specialized pathologists in only 25/50 patients (50%). Twenty-one patients (42%) had Barrett's metaplasia without intraepithelial neoplasia and in 4 patients (8%) HGIN or Barrett's carcinoma (BC) was revealed. Inter-observer agreement between the general and specialized pathologists for the diagnosis of LGIN was poor (kappa = - 0.17) and good between both of the specialized pathologists (kappa = 0.69). Patients with HGIN/BC were treated by endoscopic resection or surgery. In patients with LGIN, ablative therapy was performed. Complete response was achieved in 25 patients, but 3 patients developed HGIN and 1 patient developed BC after 10+/-3.6 months. CONCLUSIONS: BE with LGIN is difficult to diagnose. Inter-observer variability is unacceptable between general and specialized pathologists and therefore when diagnosing LGIN a second opinion should always be sought by a specialized GI pathologist. Ablation therapy seems to be effective in patients with LGIN, but follow-up endoscopies are necessary to detect metachronous neoplasia.

Prospective evaluation of a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal endoscopy.

OBJECTIVE: The aim of this study was to prospectively evaluate a new high-power argon plasma coagulation system (hp-APC) in therapeutic gastrointestinal (GI) endoscopy. MATERIAL AND METHODS: From February to June 2005, 216 patients (167 M (77.3%), mean age 66 years) underwent treatment with hp-APC in a total of 275 sessions. Main indications were additive ablation therapy in Barrett's esophagus, palliative treatment of esophageal cancer, gastric polyps/carcinomas, angiodysplasias, Zenker's diverticula, and duodenal adenomas. The new hp-APC device (VIO 300 D with APC 2) was used (15-120 W) in upper GI endoscopy, push-enteroscopy, and double-balloon enteroscopy. RESULTS: The mean number of treatment sessions required was 1.7 (1-5). For palliative tumor ablation in the esophagus, the number of sessions was 2.3 (1-5). Minor complications (pain, dysphagia, neuromuscular irritation, asymptomatic gas accumulation in the intestinal wall) were observed in 29/216 patients (13.4%). Major complications (perforation, stenosis occurred) in 2 patients (0.9%). CONCLUSIONS: Hp-APC appears to be safe and effective in the treatment of various GI condition using different types of endoscopes including double-balloon enteroscopy. Because of the low number of treatment sessions required, hp-APC could be used as an alternative to Nd:YAG laser treatment in tumor debulking.

Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).

BACKGROUND: In view of the increasing incidence of adenocarcinoma in Barrett's esophagus and the mortality and high morbidity rates associated with surgical therapy for this condition, safe and effective but less invasive methods of treatment are needed. OBJECTIVE: To evaluate efficacy and safety of endoscopic resection in these patients. DESIGN: Single-center prospective study. SETTING: Teaching hospital, conducted between October 1996 and September 2003. PATIENTS: A total of 100 consecutive patients (mean age, 62.1 +/- 10.9 years; range, 31-86 years) with low-risk adenocarcinoma of the esophagus (macroscopic types I, IIa, IIb, and IIc; lesion diameter up to 20 mm; mucosal lesion without invasion into lymph vessels and veins; and histologic grades G1 and G2) arising in Barrett's metaplasia. INTERVENTIONS: Endoscopic resection with the suck-and-cut technique. MAIN OUTCOME MEASUREMENTS: Complete local remission. RESULTS: A total of 144 resections (1.47 per patient) were performed without technical problems. No major complications and only 11 minor ones (bleedings without decrease of Hb >2 g/dL; treated with injection therapy) occurred. Complete local remission was achieved in 99 of the 100 patients after 1.9 months (range, 1-18 months) and a maximum of 3 resections. During a mean follow-up period of 36.7 months, recurrent or metachronous carcinomas were found in 11% of the patients, but successful repeat treatment with endoscopic resection was possible in all of these cases. The calculated 5-year survival rate was 98%. Two patients died of other causes. LIMITATIONS: Nonblinded, nonrandomized study. CONCLUSIONS: Endoscopic resection is associated with favorable outcomes for low-risk patients with early esophageal adenocarcinoma (Barrett's carcinoma).

The impact of endoscopic ultrasound and computed tomography on the TNM staging of early cancer in Barrett's esophagus.

INTRODUCTION: Computed tomography (CT) and endoscopic ultrasound (EUS) are part of the regular staging protocol in esophageal cancer. The value of the two methods was assessed in patients with early cancer in Barrett's esophagus. METHODS: One hundred consecutive patients (median age 64 yr, interquartile range [IQR] 58-72) with suspected early cancer in Barrett's esophagus who were referred to our hospital for endoscopic therapy were prospectively included in a standardized staging program with upper gastrointestinal endoscopy, EUS (7.5 MHz in all cases plus 12.5 or 20 MHz for elevated and/or depressed lesions), CT of the chest and upper abdomen, and abdominal ultrasonography. The results were summarized in accordance with the TNM classification. On the basis of the lymph node findings on CT and/or EUS, the patients were assigned to three categories: C1, no suspicious lymph nodes; C2, paraesophageal lymph nodes < or =1 cm in size at the tumor level, lymph nodes > or =1 cm in size not at the tumor level in the mediastinum or celiac trunk; and C3, paraesophageal lymph nodes > 1 cm in size at the tumor level. The EUS and CT findings were checked every 6 months in patients who underwent endoscopic treatment. Surgical resection was scheduled in operable patients if staging showed a T category higher than T1 and/or the lymph node staging was assessed as C3. Patients with suspected submucosal infiltration underwent diagnostic endoscopic resection, and if submucosal involvement was confirmed were referred for surgery. RESULTS: The median follow-up period was 25 months (IQR 19.5-30.0). The T category diagnosed with CT was < or = T1 in all patients. On EUS, the T category was classified as T1 in 92% of cases (N = 92) and as > T1 in 8% (N = 8, p < 0.05). Enlarged lymph nodes (C2 and C3) were detected in 45% of the patients. Significantly more C2 lymph nodes were diagnosed with EUS than CT (28 vs 19, p < 0.05). Lymph nodes at the level with the highest suspicion, C3, were detected using CT in only three of nine cases. Sensitivity of CT for N staging was not acceptable compared with EUS (38%vs 75%). No extranodal metastases were found on CT. CONCLUSIONS: In suspected early cancer in Barrett's esophagus, EUS is superior to CT for T staging and N staging. As CT had no influence on the TNM classification in any of these patients, it may be possible to dispense with this method as a staging procedure in patients with cancer in Barrett's esophagus. By contrast, EUS is required in order to differentiate between patients with cancer in Barrett's esophagus in whom endoscopic therapy is suitable and those in whom surgical treatment is required.

In vivo histology of Barrett's esophagus and associated neoplasia by confocal laser endomicroscopy.

BACKGROUND & AIMS: Confocal laser endomicroscopy allows subsurface analysis of the intestinal mucosa and in vivo histology during ongoing endoscopy. Here, we have applied this technique to the in vivo diagnosis of Barrett's epithelium and associated neoplasia. METHODS: Fluorescein-aided endomicroscopy was performed by applying the endomicroscope over the whole columnar-lined lower esophagus. Images obtained within 1 cm of the columnar-lined lower esophagus were stored digitally and a targeted biopsy examination or endoscopic mucosal resection of the examined areas was performed. In vivo histology was compared with the histologic specimens. All digitally stored images were re-assessed by a blinded investigator by the confocal Barrett classification system to predict histology. Intraobserver and interobserver variations of the involved endoscopists were evaluated by using kappa statistics. RESULTS: Endomicroscopy allowed distinguishing between different types of epithelial cells and detected cellular and vascular changes in Barrett's epithelium at high resolution during ongoing endoscopy in 63 patients. Barrett's esophagus and associated neoplasia could be predicted with a sensitivity of 98.1% and 92.9% and a specificity of 94.1% and 98.4%, respectively (accuracy, 96.8% and 97.4%). The mean kappa value for interobserver agreement for the prediction of histopathological diagnosis was .843, whereas the intraobserver agreement showed a mean kappa value of .892. CONCLUSIONS: Fluorescence-aided endomicroscopy of Barrett's esophagus allows in vivo histology of the mucosal layer during ongoing endoscopy. Gastric and Barrett's epithelium and Barrett's-associated neoplastic changes can be diagnosed with high accuracy. Thus, endomicroscopy may be helpful in the management of patients with Barrett's esophagus.