Randomized controlled trial of EndoRings assisted colonoscopy versus standard colonoscopy.

OBJECTIVES: The EndoRings device is a distal attachment consisting of two layers of circular flexible rings that evert mucosal folds. The aim of this study was to investigate whether EndoRing assisted colonoscopy (ER) improves polyp and adenoma detection compared to standard colonoscopy (SC). METHODS: Multicenter, parallel group, randomized controlled trial. RESULTS: Total of 556 patients randomized to ER (n = 275) or SC (n = 281). Colonoscopy completed in 532/556 (96%) cases. EndoRings removed in 74/275 (27%) patients. Total number of polyps in ER limb 582 vs. 515 in SC limb, P = 0.04. Total number of adenomas in ER limb 361 vs. 343 for SC limb, P = 0.49. A statistically significant difference in the mean number of polyps per patient in both the intention to treat (1.84 SC vs. 2.10 ER, P = 0.027) and per protocol (PP) (1.84 SC vs. 2.25 ER, P = 0.004). CONCLUSIONS: Our study shows promise for the EndoRings device to improve polyp detection.

A novel self-assembling peptide for hemostasis during endoscopic submucosal dissection: a randomized controlled trial.

BACKGROUND: Endoscopic submucosal dissection (ESD) is associated with a risk of bleeding. Bleeding is usually treated with diathermy, although this does carry a risk of mucosal thermal injury. Purastat is a topical hemostat that may be effective in controlling bleeding during ESD, thereby reducing the use of heat therapy. The aim of this study was to assess the reduction in heat therapy used in the interventional group (Purastat) compared with the control group. The secondary aims were to compare the procedure length, time for hemostasis, delayed bleeding rate, adverse events, and wound healing between the groups. METHODS: This was a single-center randomized controlled trial of 101 patients undergoing ESD. Participants were randomized to a control group where diathermy was used to control bleeding or an interventional group where Purastat could be used. Follow-up endoscopy was performed at 4 weeks to assess wound healing. RESULTS: There was a significant reduction in the use of heat therapy for intraprocedural hemostasis in the interventional group compared with controls (49.3 % vs. 99.6 %, P < 0.001). There were no significant differences in the procedure length, time for hemostasis, and delayed bleeding rate between the groups. Complete wound healing at 4 weeks was noted in 48.8 % of patients in the interventional group compared with 25.0 % of controls (P = 0.02). CONCLUSIONS: This study has demonstrated that Purastat is an effective hemostat that can reduce the need for heat therapy for bleeding during ESD. It may also have a role in improving post-resection wound healing.

Multicentre randomised controlled trial on virtual chromoendoscopy in the detection of neoplasia during colitis surveillance high-definition colonoscopy (the VIRTUOSO trial).

BACKGROUND: Longstanding colonic IBD increases the risk of developing colorectal cancer. The utility of chromoendoscopy with standard-definition white light technology has been established. However, the use of high-definition virtual chromoendoscopy (HDV) in colitis surveillance remains undefined. OBJECTIVE: To compare the performance of HDV (i-scan OE mode 2) with high-definition white light (HDWL) for detection of neoplasia in patients with IBD undergoing surveillance colonoscopy. Additionally, we assessed the utility of protocol-guided quadrantic non-targeted biopsies. DESIGN: A multioperator randomised controlled trial was carried out in two centres in the UK. Total of 188 patients (101 men, mean age 54) with longstanding ulcerative or Crohn's colitis were randomised, prior to starting the surveillance colonoscopy, to using either HDV (n=94) or HDWL (n=94) on withdrawal. Targeted and quadrantic non-targeted biopsies were taken in both arms per-randomisation protocol. The primary outcome was the difference in neoplasia detection rate (NDR) between HDV and HDWL. RESULTS: There was no significant difference between HDWL and HDV for neoplasia detection. The NDR was not significantly different for HDWL (24.2%) and HDV (14.9%) (p=0.14). All intraepithelial neoplasia (IEN) detected contained low-grade dysplasia only. A total of 6751 non-targeted biopsies detected one IEN only. The withdrawal time was similar in both arms of the study; median of 24 min (HDWL) versus 25.5 min (HDV). CONCLUSION: HDV and HDWL did not differ significantly in the detection of neoplasia. Almost all neoplasia were detected on targeted biopsy or resection. Quadrantic non-targeted biopsies have negligible additional gain. TRIAL REGISTRATION NUMBER: Clinical Trial.gov ID NCT02822352.

Endoscopic full thickness resection in the colo-rectum: outcomes from the UK Registry.

BACKGROUND: Endoscopic full-thickness resection (eFTR) of the colon using the full-thickness resection device (FTRD) is a novel method for removing lesions involving, or tethered to, deeper layers of the colonic wall. The UK FTRD Registry collected data from multiple centres performing this procedure. We describe the technical feasibility, safety and early outcomes of this technique in the UK. METHODS: Data were collected and analysed on 68 patients who underwent eFTR at 11 UK centres from April 2015 to June 2019. Outcome measures were technical success, procedural time, specimen size, R0 resection, endoscopic clearance, and adverse events. Reported technical difficulties were collated. RESULTS: Indications for eFTR included non-lifting polyps (29 cases), T1 tumour resection (13), subepithelial tumour (9), and polyps at the appendix base or diverticulum (17). Target lesion resection was achieved in 60/68 (88.2%). Median specimen size was 21.7 mm (10-35 mm). Histologically confirmed R0 resection was achieved in 43/56 (76.8%) with full-thickness resection in 52/56 (92.9%). Technical difficulties occurred in 17/68 (25%) and complications in 3/68 (5.9%) patients. CONCLUSION: eFTR is a useful technique with a high success rate in treating lesions not previously amenable to endoscopic therapy. Whilst technical difficulties may arise, complication rates are low and outcomes are acceptable, making eFTR a viable alternative to surgery for some specific lesions.

A feasibility trial of Acetic acid-targeted Biopsies versus nontargeted quadrantic biopsies during BArrett's surveillance: the ABBA trial.

BACKGROUND: The aims of this study were to compare neoplasia detection rates for nontargeted biopsies (Seattle protocol) versus acetic acid-targeted biopsies (Portsmouth protocol) during Barrett's surveillance and to explore feasibility, patient/clinician experience, acceptance, and barriers/enablers to study participation and implementation of the acetic acid technique. METHODS: This was a mixed-methods feasibility study including a pilot multicenter, randomized, crossover trial with qualitative interviews. Patients under Barrett's surveillance with no history of neoplasia were included. Patients underwent two endoscopies, one with each protocol, 8 weeks apart. Outcomes included recruitment and retention rates, neoplasia yield, and number of biopsies. RESULTS: 200 patients were recruited from 6 centers, and 174 (87.0 %) underwent both procedures. Neoplasia prevalence was 4.7 % (9/192). High grade dysplasia and cancer were detected with both protocols. Five low grade dysplasias were detected (two with acetic acid, four with nontargeted biopsies; one lesion was detected with both techniques). A total of 2139 biopsies were taken in the nontargeted arm and 226 in the acetic acid arm. Both patients and clinicians found the acetic acid technique acceptable. Based on these data, a noninferiority, tandem, crossover trial would require an estimated 2828 patients. CONCLUSIONS: We demonstrated the feasibility of performing a crossover endoscopy trial in Barrett's surveillance. Low neoplasia yield makes this design necessary and qualitative results demonstrated patient and clinician acceptance. The reduced numbers of biopsies suggest that the acetic acid technique could result in cost savings, providing the lack of missed pathology can be proven in a fully powered definitive trial.

Erratum: A novel non-thermal resection tool in endoscopic management of scarred polyps.

[This corrects the article DOI: 10.1055/a-0838-5424.].

A novel non-thermal resection tool in endoscopic management of scarred polyps.

Background and study aims Scarred polyps are challenging to resect using conventional endoscopic mucosal resection (EMR) techniques. The aim of this pilot study was to assess the feasibility of the EndoRotor device in resecting scarred polyps arising from previous endoscopic resection attempts. Patients and methods This was a prospective pilot study of patients with scarred colonic polyps treated using EndoRotor carried out in two centers. Results A total of 19 patients were included in this study. The overall cure rate using EndoRotor was 84 %; 10 patients (52.6 %) achieved cure after one attempt and six patients (31.5 %) achieved cure after two attempts. A total of three patients who had polyp recurrence after the first EndoRotor resection were referred for either endoscopic submucosal dissection (2 patients) or surgery (1 patient) due to difficult access. There were no perforations, delayed bleeding, post-polypectomy syndrome or complications requiring surgery. Conclusions In this pilot study, the novel non-thermal device (EndoRotor) has been demonstrated to be a safe and effective technique in challenging management of scarred polyps. Further randomized controlled trials comparing this technique with APC, hot avulsion, ESD and endoscopic full-thickness resection are required to ascertain the utility of EndoRotor in the hands of non-expert endoscopists.

Attitudes to out-of-programme experiences, research and academic training of gastroenterology trainees between 2007 and 2016.

OBJECTIVE: Academic medical training was overhauled in 2005 after the Walport report and Modernising Medical Careers to create a more attractive and transparent training pathway. In 2007 and 2016, national web-based surveys of gastroenterology trainees were undertaken to determine experiences, perceptions of and perceived barriers to out-of-programme research experience (OOP-R). DESIGN SETTING AND PATIENTS: Prospective, national web-based surveys of UK gastroenterology trainees in 2007 and 2016. MAIN OUTCOME MEASURE: Attitudes to OOP-R of two cohorts of gastroenterology trainees. RESULTS: Response rates were lower in 2016 (25.8% vs 56.7%) (p<0.0001), although female trainees' response rates increased (from 28.8% to 37.6%) (p=0.17), along with higher numbers of academic trainees. Over 80% of trainees planned to undertake OOP-R in both surveys, with >50% having already undertaken it. Doctor of Philosophy/medical doctorate remained the most popular OOP-R in both cohorts. Successful fellowship applications increased in 2016, and evidence of gender inequality in 2007 was no longer evident in 2016. In the 2016 cohort, 91.1% (n=144) felt the development of trainee-led research networks was important, with 74.7% (n=118) keen to get involved. CONCLUSIONS: The majority of gastroenterology trainees who responded expressed a desire to undertake OOP-R, and participation rates in OOP-R remain high. Despite smaller absolute numbers responding than in 2007, 2016 trainees achieved higher successful fellowship application rates. Reassuringly more trainees in 2016 felt that OOP-R would be important in the future. Efforts are needed to tackle potential barriers to OOP-R and support trainees to pursue research-active careers.

Improving the mucosal visualization at gastroscopy: a systematic review and meta-analysis of randomized, controlled trials reporting the role of Simethicone ± N-acetylcysteine.

BACKGROUND: The objective of this article is to study the role of Simethicone ± N-acetylcysteine in improving the mucosal visualization during oesophago-gastro-duodenoscopy (OGD). METHODS: The data retrieved from the published randomized controlled trials (RCTs) reporting the role of Simethicone ± N-acetylcysteine during OGD was analysed using the principles of meta-analysis. The summated outcome of continuous variables was expressed as standardized mean difference (SMD) and dichotomous data was presented in odds ratio (OR). RESULTS: Three RCTs on 654 patients reported OGD with and without pre-procedure oral administration of Simethicone ± N-acetylcysteine evaluating visibility as good or excellent in number during the procedure. In the random effects model analysis using the statistical software Review Manager 5.3, the use of Simethicone ± N-acetylcysteine was associated with improved (OR, 0.43; 95% CI, 0.28, 0.68; z=3.65; P=0.0003) mucosal visibility. Four RCTs on 364 patients reported OGD with and without pre-procedure oral administration of Simethicone ± N-acetylcysteine evaluating visibility score in study group. In the random effects model analysis using the statistical software Review Manager 5.3, the use of Simethicone ± N-acetylcysteine was associated with improved (SMD, -1.66; 95% CI, -1.93, -1.40; z=12.25; P=0.00001) mucosal visibility score compared to no-Simethicone group. CONCLUSIONS: The findings of current study on 1,099 patients successfully demonstrate that the pre-procedure oral administration of Simethicone ± N-acetylcysteine improves mucosal visualization and mucosal visualization score during OGD.

Acetic acid-guided biopsies in Barrett's surveillance for neoplasia detection versus non-targeted biopsies (Seattle protocol): A feasibility study for a randomized tandem endoscopy trial. The ABBA study.

BACKGROUND AND STUDY AIMS: Barrett's esophagus is a potentially pre-cancerous condition, affecting 375,000 people in the UK. Patients receive a 2-yearly endoscopy to detect cancerous changes, as early detection and treatment results in better outcomes. Current treatment requires random mapping biopsies along the length of Barrett's, in addition to biopsy of visible abnormalities. As only 13 % of pre-cancerous changes appear as visible nodules or abnormalities, areas of dysplasia are often missed. Acetic acid chromoendoscopy (AAC) has been shown to improve detection of pre-cancerous and cancerous tissue in observational studies, but no randomized controlled trials (RCTs) have been performed to date. PATIENTS AND METHODS: A "tandem" endoscopy cross-over design. Participants will be randomized to endoscopy using mapping biopsies or AAC, in which dilute acetic acid is sprayed onto the surface of the esophagus, highlighting tissue through an whitening reaction and enhancing visibility of areas with cellular changes for biopsy. After 4 to 10 weeks, participants will undergo a repeat endoscopy, using the second method. Rates of recruitment and retention will be assessed, in addition to the estimated dysplasia detection rate, effectiveness of the endoscopist training program, and rates of adverse events (AEs). Qualitative interviews will explore participant and endoscopist acceptability of study design and delivery, and the acceptability of switching endoscopic techniques for Barrett's surveillance. RESULTS: Endoscopists' ability to diagnose dysplasia in Barrett's esophagus can be improved. AAC may offer a simple, universally applicable, easily-acquired technique to improve detection, affording patients earlier diagnosis and treatment, reducing endoscopy time and pathology costs. The ABBA study will determine whether a crossover "tandem" endoscopy design is feasible and acceptable to patients and clinicians and gather outcome data to power a definitive trial.

International development and validation of a classification system for the identification of Barrett's neoplasia using acetic acid chromoendoscopy: the Portsmouth acetic acid classification (PREDICT).

BACKGROUND: Barrett's oesophagus is an established risk factor for developing oesophageal adenocarcinoma. However, Barrett's neoplasia can be subtle and difficult to identify. Acetic acid chromoendoscopy (AAC) is a simple technique that has been demonstrated to highlight neoplastic areas but lesion recognition with AAC remains a challenge, thereby hampering its widespread use. OBJECTIVE: To develop and validate a simple classification system to identify Barrett's neoplasia using AAC. DESIGN: The study was conducted in four phases: phase 1-development of component descriptive criteria; phase 2-development of a classification system; phase 3-validation of the classification system by endoscopists; and phase 4-validation of the classification system by non-endoscopists. RESULTS: Phases 1 and 2 led to the development of a simplified AAC classification system based on two criteria: focal loss of acetowhitening and surface patterns of Barrett's mucosa. In phase 3, the application of PREDICT (Portsmouth acetic acid classification) by endoscopists improved the sensitivity and negative predictive value (NPV) from 79.3% and 80.2% to 98.1% and 97.4%, respectively (p<0.001). In phase 4, the application of PREDICT by non-endoscopists improved the sensitivity and NPV from 69.6% and 75.5% to 95.9% and 96.0%, respectively (p<0.001). CONCLUSION: We developed and validated a classification system known as PREDICT for the diagnosis of Barrett's neoplasia using AAC. The improvement seen in the sensitivity and NPV for detection of Barrett's neoplasia in phase 3 demonstrates the clinical value of PREDICT and the similar improvement seen among non-endoscopists demonstrates the potential for generalisation of PREDICT once proven in real time.

Endocuff-assisted vs. standard colonoscopy in the fecal occult blood test-based UK Bowel Cancer Screening Programme (E-cap study): a randomized trial.

Background and study aims Up to 25 % colorectal adenomas are missed during colonoscopy. The aim of this study was to investigate whether the endocuff could improve polyp detection in an organized bowel cancer screening program (BCSP). Patients and methods This parallel group, single-blinded, randomized controlled trial included patients with positive fecal occult blood test (FOBT) who were attending for BCSP colonoscopy. The primary outcome was the number of polyps per patient. Secondary outcomes included the number of adenomas per patient, adenoma and polyp detection rates, and withdrawal times. Results A total of 534 BCSP patients were randomized to endocuff-assisted or standard colonoscopy. The mean age was 67 years and the male to female ratio was 1.8:1. We detected no significant difference in the number of polyps per patient (standard 1.8, endocuff 1.6; P = 0.44), adenomas per patient (standard 1.4, endocuff 1.3; P = 0.54), polyp detection rate (standard 69.8 %, endocuff 70.3 %; P = 0.93), adenoma detection rate (standard 63.0 %, endocuff 60.9 %; P = 0.85), advanced adenoma detection rate (standard 18.5 %, endocuff 16.9 %; P = 0.81), and cancer detection rate (standard 5.7 %, endocuff 5.3 %; P = 0.85). The mean withdrawal time was significantly shorter among patients in the endocuff group compared with the standard colonoscopy group (16.9 vs. 19.5 minutes; P < 0.005). The endocuff had to be removed in 17/266 patients (6.4 %) because of inability to pass through the sigmoid colon. Conclusions This study did not find improved polyp or adenoma detection with endocuff-assisted colonoscopy in the FOBT-positive BCSP population. A shorter withdrawal time with endocuff may reflect improved views and stability provided by the endocuff.Trial registered at ClinicalTrials.gov (NCT02529007).

Early squamous neoplasia of the esophagus: The endoscopic approach to diagnosis and management.

Considerable focus has been placed on esophageal adenocarcinoma in the last 10 years because of its rising incidence in the West. However, squamous cell cancer (SCC) continues to be the most common type of esophageal cancer in the rest of the world. The detection of esophageal SCC (ESCC) in its early stages can lead to early endoscopic resection and cure. The increased incidence of ESCC in high-risk groups, such as patients with head and neck squamous cancers, highlights the need for screening programs. Lugol's iodine chromoendoscopy remains the gold standard technique in detecting early ESCC, however, safer techniques such as electronic enhancement or virtual chromoendoscopy would be ideal. In addition to early detection, these new "push-button" technological advancements can help characterize early ESCC, thereby further aiding the diagnostic accuracy and facilitating resection. Endoscopic resection (ER) of early ESCC with negligible risk of lymph node metastases has been widely accepted as an effective therapeutic strategy because it offers similar success rates when compared to esophagectomy, but carries lesser morbidity and mortality. Endoscopic submucosal dissection (ESD) is the preferred technique of ER in lesions larger than 15 mm because it provides higher rates of en bloc resections and lower local recurrence rates when compared to endoscopic mucosal resection (EMR).

Complex early Barrett's neoplasia at 3 Western centers: European Barrett's Endoscopic Submucosal Dissection Trial (E-BEST).

BACKGROUND AND AIMS: Endoscopic submucosal dissection (ESD) is an effective technique to resect early Barrett's neoplasia and has advantages over conventional EMR in that it enables en-bloc resection and accurate histopathologic analysis of cancer resection margins. However, its long learning curve and higher adverse event rate have tempered its uptake in the West. We aimed to analyze the safety and efficacy of ESD when used to resect complex Barrett's neoplasia. The primary endpoint was the en-bloc and R0 resection rate. METHODS: This was a retrospective analysis of 143 ESDs for Barrett's neoplasia performed in 3 tertiary referral centers from 2008 to 2016. RESULTS: The mean lesion size was 31.1 mm (range, 5-90) and median follow-up time 21.6 months (interquartile range, 11.0-32.6). In total, 24.5% of lesions (35/143) were scarred after previous endoscopic resection, surgery, or radiotherapy. The en-bloc resection rate was 90.8% and R0 resection rate 79% in this series. The overall adverse event rate was 3.5% (1.4% bleeding, 0% perforation, and 2.1% stricture formation). The expanded curative resection rate was 65.8%, reflecting the R0 resection rate and proportion of cases with more advanced disease. Submucosal cancer was identified as a significant factor affecting the R0 resection rate. CONCLUSION: We demonstrated the feasibility and safety of ESD in the West for resection of complex Barrett's neoplasia including large, nodular, or scarred lesions. This is a safe and effective technique with a low adverse event rate when performed by an experienced operator. The en-bloc resection rate reached a plateau once 30 procedures had been performed.

Development and validation of a training module on the use of acetic acid for the detection of Barrett's neoplasia.

Background and study aims Acetic acid chromoendoscopy (AAC) enhances the ability to correctly identify Barrett's neoplasia, and is increasingly used by both expert and nonexpert endoscopists. Despite its increasing use, there is no validated training strategy to achieve competence. The aims of our study were to develop a validated training tool in AAC-assisted lesion recognition, to assess endoscopists' baseline knowledge of AAC-assisted lesion recognition, and to evaluate the efficacy and impact of this training tool. Methods A validated assessment of 40 images and 20 videos was developed. A total of 13 endoscopists with experience of Barrett's endoscopy but no formal training in AAC were recruited to the study. Participants underwent: baseline assessment 1, online training, assessment 2, interactive seminar, assessment 3. Results Baseline assessment demonstrated a sensitivity of 83 % and a negative predictive value (NPV) of 83 %. The online training intervention significantly improved sensitivity to 95 % and NPV to 94 % (P < 0.01). Further improvement was seen after a 1-day interactive seminar including live cases, with sensitivity increasing to 98 % and NPV to 97 %. Conclusions The data demonstrate the need for training in AAC-assisted lesion recognition as baseline performance, even by Barrett's experts, was poor. The online training and testing tool for AAC for Barrett's neoplasia was successfully developed and validated. The training intervention improved performance of endoscopists to meet ASGE PIVI standards. The training tool increases the endoscopist's degree of confidence in the use of AAC. The training tool also leads to shift in attitudes of endoscopists from Seattle protocol towards AAC-guided biopsy protocol for Barrett's surveillance.

Knife-assisted snare resection (KAR) of large and refractory colonic polyps at a Western centre: Feasibility, safety and efficacy study to guide future practice.

OBJECTIVE: Endoscopic mucosal resection (EMR) is widely practiced in western countries. Endoscopic submucosal dissection (ESD) is very effective for treating complex polyps but colonic ESD in the western setting remains challenging. We have developed a novel technique of knife-assisted snare resection (KAR) for the resection of these complex lesions. Here we aim to describe the technique, evaluate its outcomes, identify outcome predictors and define its learning curve. METHODS: We conducted a prospective cohort study of patients who had large and refractory polyps resected by KAR at our institution from 2007 to 2013. Polyp characteristics and procedure details were recorded. Endoscopic follow-up was performed to identify recurrence. RESULTS: A total of 170 patients with polyps 20-170 mm in size were treated by KAR and followed up for a mean of 31.5 months (range 12-84 months). 29% of the polyps were >50 mm, 22% had fibrosis from previous unsuccessful interventions and 25% were in the right colon. The perforation rate (1.2%) and bleeding rate (4.7%) were acceptable and managed conservatively in most patients. Recurrence rate after the first attempt was 13.1%. Recurrence was significantly increased by polyp size >50 mm (p = 0.008; OR 5.03, 95% CI 1.54-16.48), presence of fibrosis (p = 0.002; OR 6.59, 95% CI 1.97-22.07) and piecemeal resection (p < 0.001; OR 0.31, CI 0.078-1.12). Cure rates were 87% after the first attempt, improving to 95.6% with further attempts. En bloc resection rate showed a linear increase and reached almost 80% as the endoscopist's cumulative experience approached 100 cases. CONCLUSION: This is the largest reported Western series on KAR in the colon. We have demonstrated the feasibility, efficacy and safety of this technique in the treatment of complex polyps, with or without fibrosis and at all sites. KAR has shown better outcomes than either EMR or ESD. We have also managed to identify significant outcome predictors and define the learning curve.

Acetic acid chromoendoscopy: Improving neoplasia detection in Barrett's esophagus.

Barrett's esophagus (BE) is an important condition given its significant premalignant potential and dismal five-year survival outcomes of advanced esophageal adenocarcinoma. It is therefore suggested that patients with a diagnosis of BE undergo regular surveillance in order to pick up dysplasia at an earlier stage to improve survival. Current "gold-standard" surveillance protocols suggest targeted biopsy of visible lesions followed by four quadrant random biopsies every 2 cm. However, this method of Barrett's surveillance is fraught with poor endoscopist compliance as the procedures are time consuming and poorly tolerated by patients. There are also significant miss-rates with this technique for the detection of neoplasia as only 13% of early neoplastic lesions appear as visible nodules. Despite improvements in endoscope resolution these problems persist. Chromoendoscopy is an extremely useful adjunct to enhance mucosal visualization and characterization of Barrett's mucosa. Acetic acid chromoendoscopy (AAC) is a simple, non-proprietary technique that can significantly improve neoplasia detection rates. This topic highlight summarizes the current evidence base behind AAC for the detection of neoplasia in BE and provides an insight into the direction of travel for further research in this area.

Advances in the endoscopic diagnosis and treatment of Barrett's neoplasia.

Barrett's oesophagus is a well-recognised precursor of oesophageal adenocarcinoma. The incidence of oesophageal adenocarcinoma is continuing to rise in the Western world with dismal survival rates. In recent years, efforts have been made to diagnose Barrett's earlier and improve surveillance techniques in order to pick up cancerous changes earlier. Recent advances in endoscopic therapy for early Barrett's cancers have shifted the paradigm away from oesophagectomy and have yielded excellent results.