New directions in endoscopic therapy of Barrett' s esophagus.

The key to prevention and early treatment of esophageal adenocarcinoma is the detection and eradication of neoplasia found in patients with Barrett's esophagus (BE). The approach to the management in BE has rapidly evolved based on the paradigm shift towards endoscopic therapy, on improved detection of neoplasia with increased appreciation for subtle lesions and enhanced endoscopic imaging modalities, and on a new set of endoscopic therapeutic modalities. This review briefly outlines the evolution of the current approach to neoplasia in BE, the appreciation for improved techniques and technologies to detect neoplasia, and the specific modalities currently used in the endoscopic treatment of Barrett's neoplasia. The goals of endoscopic therapy of Barrett's neoplasia are to preserve the esophagus while ablating or removing the entire Barrett's segment. The therapeutic modalities highlighted are endoscopic resection (endoscopic mucosal resection and endoscopic submucosal dissection), photodynamic therapy, radiofrequency ablation, and cryotherapy. Endoscopic resection is a tool to accurately provide a histological diagnosis of lesions in addition to treat neoplasia. In addition, to treating the known neoplasia, it is also important to treat the remainder of the at-risk Barrett's epithelium to address synchronous and metachronous lesions. This treatment of the entire Barrett's epithelium may be achieved with one or more modalities. With multiple endoscopic tools available, it is important to appreciate how to optimally address neoplasia in BE.

Confocal laser endomicroscopy: potential in the management of Barrett's esophagus.

Confocal laser endomicroscopy (CLE) can serve as a useful adjunct imaging modality for targeted endoscopic biopsies during surveillance of Barrett's esophagus (BE). In addition, CLE may also have potential roles during therapeutic procedures that include localization of pathology, targeting of resections, guiding which therapy to use, and determining adequacy of treatment. This case series illustrates a range of cases in which endomicroscopy was performed during the procedure and offers possibilities of real-time decision-making to select specific therapies in patients with known high-grade dysplasia (HGD) and intramucosal carcinoma in the setting of BE presented for endoscopic treatment or follow-up. Patients with BE with HGD and intramucosal carcinoma presented for management for initial treatment or follow-up. Examinations were performed sequentially with detailed white light endoscopy, narrow band imaging (NBI), acetic acid, and CLE. This is a retrospective case series describing the characteristics of the exam findings and illustrating the role of endomicroscopy on real-time case management. Seven patients with Barrett-associated neoplasia underwent endomicroscopy as part of their endoscopic examination. CLE confirmed findings of neoplasia seen with red flag techniques such as NBI, and in one case independently suggested findings of neoplasia. In the majority of cases, these findings were incorporated into the decision of which modality of treatment was used. Future prospective studies should be done to validate the role of endomicroscopy in BE.