A narrative review of Barrett's esophagus in 2020, molecular and clinical update.

Barrett's esophagus (BE) is a condition resulting from an acquired metaplastic epithelial change in the esophagus in response to gastroesophageal reflux. BE is the only known precursor lesion to esophageal adenocarcinoma, and can progress from non-dysplastic BE (NDBE) to low grade dysplasia (LGD) and high grade dysplasia (HGD), and ultimately invasive carcinoma. Although the risk of developing esophageal adenocarcinoma (EAC) in NBDE is less than 0.5% per year, there has been a rising incidence of EAC in Western countries, which continue to drive efforts to optimize screening and surveillance methods. The current gold standard for diagnosis is esophagogastroduodenoscopy (EGD), and there has been significant interest in alternative, minimally invasive methods for screening which would be more readily accessible in the primary care setting. Surveillance endoscopy in 3-5 years is recommended for NDBE given the low progression to EAC. The mainstay of treatment for LGD and HGD is endoscopic eradication therapy (EET). Visible lesions are treated with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Radiofrequency ablation (RFA) is considered first line therapy for flat dysplastic BE and cryotherapy has shown promising results as an alternate form of treatment for of dysplasia. The molecular progression of BE to EAC is a complex process involving multiple pathways involving genetic and epigenetic modifications. Genomic studies have further led to the understanding of the complex molecular landscape that occurs early and late in the disease process. Promising biomarker panels have been investigated to help with the diagnosis of BE as well as aid in the risk stratification of BE during surveillance. In addition, clinical prediction models have been developed to categorize BE patients in low, intermediate, and high risk for progression to HGD and EAC. Further clinical and translational research is needed to help refine markers and techniques in diagnosis, screening, and surveillance.

Is Preoperative G-Tube Use Safe for Esophageal Cancer Patients?

Objective: Gastrostomy tubes (g-tubes) have been used with caution prior to esophageal resection due to the risks of inoculation metastasis and of injury to the gastric conduit used for reconstruction. In this study, we aim to evaluate the safety of preoperative g-tube placement by comparing outcomes in patients undergoing esophageal resection with and without prior g-tube use.Method: We retrospectively reviewed our institution's database of 1113 esophagectomies performed between 1994 and 2018. We included only patients who received neoadjuvant therapy and identified 65 patients who received preoperative nutritional support through a g-tube (GT+) and 657 who did not (GT-). Demographics, postoperative complications, survival, and cancer recurrence rates were compared between GT + and GT- using Chi-squared and Kaplan-Meier survival analyses.Results: Seven-hundred twenty-two patients (122 female, 600 male) with a median age of 63.2 (28.2-86.3) met our inclusion criteria. Between GT+ (n = 65) and GT- (n = 657), there were no significant differences in anastomotic leak rates (11.5% vs 10.9%; p = 0.901), postoperative mortality (3.1% vs 3.9%; p = 0.765), or overall complications (63.1% vs 65.1%; p = 0.746). GT + was associated with a significantly lower overall survival compared to GT- (32.5 m vs 92.9 m; p = 0.003), and tumor recurrence rates were similar (30.6% vs 31.8%; p = 0.851). There were no cases documenting damage to the gastric conduit caused by prior g-tube placement.Conclusions: G-tube usage was not associated with increased tumor recurrence, anastomotic leak rates, or overall complication rates in this study. Our data suggest that g-tube usage is safe for patients with esophageal cancer requiring preoperative nutrition.

Environmental influences on the onset and clinical course of Crohn's disease-part 1: an overview of external risk factors.

The pathogenesis of Crohn's disease (CD) involves host, genetic, and environmental factors. These factors result in disturbances in the innate and adaptive immune systems and composition of the intestinal microbiota. Epidemiologic and migration studies support an environmental component in the development of CD. Environmental risk factors include childhood hygiene, air pollution, breastfeeding, smoking, diet, stress, exercise, seasonal variation, and appendectomy. This review, part 1 of a 2-part series, provides an overview of these external contributors to the development or exacerbation of CD. Part 2, which will be published in a subsequent issue, will discuss the influences of infections, vaccinations, and medications (including antibiotics, nonsteroidal anti-inflammatory agents, and oral contraceptives) on CD.

Environmental influences on the onset and clinical course of Crohn's disease-part 2: infections and medication use.

The pathogenesis of Crohn's disease (CD) involves host, genetic, and environmental factors. These factors result in disturbances in the innate and adaptive immune systems and composition of the intestinal microbiota. Epidemiologic and migration studies support an environmental component in the development of CD. Environmental risk factors include childhood hygiene, air pollution, breastfeeding, smoking, diet, stress, exercise, seasonal variation, appendectomy, medications, and infections. This 2-part series provides an overview of these external contributors to the development or exacerbation of CD. Part 1, which was published in a previous issue, focused on childhood factors, perinatal influences, and lifestyle choices. Part 2, presented here, details the effects of infections, antibiotics, nonsteroidal anti-inflammatory drugs, and oral contraceptives.