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Background: A major limitation of current treatment strategies for nonmalignant upper gastrointestinal stenoses is the lack of either optical or haptic feedback during dilation. Wire guidance and fluoroscopy is often necessary to control the position., Methods: A novel device for endoscopic dilation, the BougieCap (Ovesco Endoscopy AG, Tübingen, Germany) was evaluated in a prospective multicenter trial. Primary outcome was successful dilation of stenosis and secondary outcome was alteration in dysphagia symptoms in short-term follow-up.  RESULTS:  50 patients with benign esophageal strictures were included. Endoscopic bougienage was successful in 96 %. Bougienage failed in two cases because of high resistance. Symptoms of dysphagia decreased significantly after bougienage (59.0 points at Day 0 vs. 28.6 points at Day 14; P  < 0.001). Adverse events were loss of BougieCap into the stomach in two cases; no severe adverse events were reported., Conclusions: Endoscopic treatment of benign stenoses using the BougieCap enabled direct visual control of the bougienage procedure. This might help to adapt treatment more precisely to the stricture. Symptoms of dysphagia were improved in short-term follow-up. Additional wire guidance may be used for selected cases (e. g. narrow lumen, pediatric scope)., Competing Interests: Dr. Meining is a consultant for Ovesco Endoscopy, Germany, (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: None

Background: Self-expandable metal stents (SEMSs) are effective for improving dysphagia in patients with incurable esophageal cancer but are also associated with recurrent dysphagia and adverse events. In the past decades, new SEMSs have been introduced, but also patients' risk profiles have altered. It is unknown if these changes have affected SEMS outcomes., Methods: This retrospective cohort study was conducted in a tertiary referral center in the Netherlands. Patients who underwent palliative esophageal SEMS placement for malignant dysphagia between 1994 and 2017 were included. The primary outcome was to assess shifts over time with respect to recurrent dysphagia and adverse events after SEMS placement., Results: 997 patients who underwent SEMS placement were included. Recurrent dysphagia occurred in 309 patients (31 %) and remained stable, although with a trend towards an increase over time (hazard ratio [HR] 1.02 per 1-year increase; P  = 0.05). Migration rate significantly increased over time (HR 1.04 per 1-year increase; P  = 0.01). SEMS-related complications occurred in 461 patients (46.2 %), with 207 (20.7 %) major and 336 (33.7 %) minor complications. Prior chemoradiotherapy was significantly associated with major complications (HR 1.69; P  < 0.001). Pain was the most common adverse event and showed a significant increase over time ( P  < 0.01). Factors associated with pain were prior chemoradiotherapy, absence of a fistula, axial and radial forces, and squamous cell carcinoma., Conclusions: Despite the introduction of novel esophageal SEMS designs, recurrent dysphagia has not declined over the years. Stent-related complications have increased in recent years, which seems to be mainly associated with more frequent use of chemoradiotherapy prior to SEMS placement., Competing Interests: Prof. Bruno has received personal fees as lecturer and consultant. Reports having received institutional financial support for industry and investigator initiated studies from Boston Scientific, Cook Medical, Pentax Medical and 3M. Prof. Siersema has received research support from Ella-CS, Boston Scientific USA and Cook Medical Ireland. Dr. Spaander has received institutional financial support for investigator initiated studies from Boston Scientific. The remaining authors have no competing interests to report., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Competing interests: Gunnar Loske is a consultant to Lohmann & Rauscher GmbH. Tobias Schorsch and Christian Theodor Mueller declare no conflict of interest.

Background/aims: A grading system for the endoscopic features of eosinophilic esophagitis (EoE) has recently been validated. The EoE Endoscopic Reference Score (EREFS) incorporates both inflammatory and remodeling features of EoE. High resolution impedance planimetry using the functional luminal imaging probe (FLIP) is a technique for quantification of esophageal remodeling. The aim of this study was to evaluate the association between endoscopic severity with EREFS and esophageal distensibility as measured with the FLIP., Methods: Upper gastrointestinal endoscopy with biopsies and FLIP were performed in 72 adults with EoE. Endoscopic features of edema, rings, exudates, furrows, and stricture were evaluated using the EREFS system. Esophageal distensibility metrics obtained by FLIP, including the distensibility slope and distensibility plateau, were compared with EREFS parameters. Bivariate associations between EREFS parameters and histologic eosinophil density were assessed., Results: Higher ring scores were associated with a lower distensibility plateau (rs = -0.46; P < 0.0001). An association was found between severity of exudates and eosinophil density (rs = 0.27; P = 0.02), as well as between furrows and eosinophil density (rs = 0.49; P < 0.0001). Severity of exudates and furrows, and degree of eosinophilia were not associated with the distensibility parameters., Conclusions: Endoscopic assessment of ring severity can serve as a marker for esophageal remodeling and may be useful for food impaction risk stratification in EoE. Eosinophil count was not significantly associated with esophageal distensibility, consistent with previous reports of dissociation between inflammatory activity and fibrostenosis in EoE. Endoscopic inflammatory features show a weak correlation with histopathology but should not replace histologic indices of inflammation., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: The transnasal endosheath endoscope is a new disposable technology with potential applicability to the primary care setting. The aim of this study was to evaluate the efficacy of transnasal endosheath endoscopy (TEE) for the detection of Barrett's esophagus, by comparing the diagnostic accuracy of TEE with that of standard endoscopy., Patients and Methods: This was a prospective, randomized, crossover study performed in a single tertiary referral center. Consecutive patients undergoing surveillance for Barrett's esophagus or referred for diagnostic assessment were recruited. All patients were randomized to undergo TEE followed by standard endoscopy or the reverse. Endoscopy experiences and patient preferences were evaluated using a questionnaire. Endoscopic and histologic diagnosis of Barrett's esophagus, and optical image quality of both endoscopic procedures, were compared., Results: A total of 21 of 25 patients completed the study. TEE had sensitivity and specificity of 100 % for an endoscopic diagnosis of Barrett's esophagus, and of 66.7 % and 100 %, respectively, for the histologic diagnosis of Barrett's esophagus. The mean optical quality of standard endoscopy was significantly better than that of TEE (7.11 ± 0.42 vs. 4.06 ± 0.27; P < 0.0001). However, following endoscopy, patients reported a significantly better experience with TEE compared with standard endoscopy (7.05 ± 0.49 vs. 4.35 ± 0.53; P = 0.0006), with 60 % preferring TEE and 25 % preferring sedated standard endoscopy., Conclusions: In this study, TEE had equal accuracy for an endoscopic diagnosis of Barrett's esophagus compared with standard endoscopy, at the expense of reduced image quality and a lower yield of intestinal metaplasia on biopsy. TEE was better tolerated and preferred by patients. Hence, TEE needs further evaluation in primary care as an initial diagnostic tool., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aims: Currently, eradication of Barrett's epithelium is preferably achieved using radiofrequency ablation (RFA) or spray cryoablation (SCA). However, both modalities suffer from drawbacks such as the need for sizing, multiple deployment steps, large controller units (RFA), imprecise dosing and need for gas-venting (SCA). The new Cryoballoon Focal Ablation System (CbFAS) may address these limitations. This study assessed the safety, feasibility, and dose response of the CbFAS in patients with flat Barrett's epithelium with or without dysplasia., Patients and Methods: In this multicenter, prospective non-randomized trial, 39 patients were each treated with one or two ablations of 6, 8, or 10 seconds. Symptoms were assessed immediately and 2 days post-cryoablation. Follow-up endoscopy was performed 6-8 weeks post-procedure to assess response. Outcome parameters were incidence of adverse events, pain, esophageal stricture formation, and ablation response by cryogen dose., Results: Of 62 ablations, 56 (10 with 6 seconds, 28 with 8 seconds, 18 with 10 seconds) were successfully performed. Six ablations failed because of device malfunction (n=3) and procedural or anatomic issues (n=3). Median procedure time was 7 minutes (interquartile range [IQR] 4-10). No major adverse events occurred; six patients experienced a minor mucosal laceration requiring no intervention. Mild pain was reported by 27% of patients immediately after cryoablation and by 14% after 2 days. No strictures were evident at follow-up.  Full squamous regeneration was seen in 47 treated areas (6 [60%] of the 6-second areas; 23 [82%] of the 8-second areas; 18 [100%] of 10-second areas)., Conclusions: Focal cryoablation of Barrett's epithelium with the CbFAS is feasible and safe, resulting in squamous regeneration in the majority of patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: Steady pressure automatically controlled endoscopy (SPACE) is a new insufflation system that provides constant carbon dioxide (CO2) insufflation pressure during prolonged procedures. The system consists of an overtube, a surgical insufflator, and a newly developed leak-proof valve. The aims of this study were to validate the feasibility and safety of SPACE for esophageal endoscopic submucosal dissection (ESD)., Patients and Methods: This was a clinical phase I trial, involving 10 patients who underwent esophageal ESD. The primary end point was the rate of adverse events within 30 days (grade 0 to 4). Secondary end points were changes in partial pressure of carbon dioxide (PaCO2) and vital signs during ESD, completion rate of ESD, and degree of abdominal distension by patient assessment and radiographic grading., Results: All adverse events were Grade 2 or less. Mild PaCO2 elevation after ESD was noted; however, no associated symptoms were reported. The procedure was completed under SPACE alone in 8 of 10 patients. Minimal post-procedural bowel distension was observed., Conclusions: In this small pilot study, SPACE was feasible and appeared to be safe. Further study with larger case numbers is required to demonstrate efficacy and safety., Clinical Trial Registration: UMIN000005434., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: A novel esophageal endoscopic submucosal dissection (ESD) technique was devised using a newly developed overtube to achieve adequate tissue traction. The aim of this study was to evaluate the feasibility and safety of this new full-traction ESD (tESD) technique., Methods: The key feature of tESD is tissue traction by grasping forceps, which is passed through the built-in side channel of the overtube. The strength and direction of traction is controlled by rotating the overtube and by adjusting its depth. The en bloc resection rate, procedure time, adverse events, and dissected area per minute were evaluated in a porcine model (n = 10) and compared with those of conventional ESD (n = 10)., Results: tESD provided robust and adjustable tissue traction during the procedure. En bloc resection was accomplished in all lesions with no complications. Median procedure time was similar to that of the conventional technique (25 vs. 27 minutes; P = 0.4723) but the submucosal injection catheter was used less often (1.5 vs. 6; P < 0.01)., Conclusions: tESD might contribute to more efficient esophageal ESD by providing adequate tissue traction. This inexpensive technique may become an attractive option in esophageal ESD., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Study Aims: To reduce the risk of complications related to the use of knives in endoscopic submucosal dissection (ESD), we developed the Clutch Cutter which can grasp and incise targeted tissue using electrosurgical current, similarly to a biopsy technique. The study aim was to evaluate the efficacy and safety of ESD using the Clutch Cutter for early esophageal squamous cell carcinoma., Patients and Methods: ESD using the Clutch Cutter was performed on 32 consecutive patients with early esophageal squamous cell carcinoma. Therapeutic efficacy and safety were assessed., Results: All lesions were treated easily and safely without unintended incision. En bloc resection was obtained in all patients. Histologically negative margins were obtained in 26/32 patients (81%). Endoscopic perforation due to the hood in one patient (3%), mediastinitis without endoscopic perforation in one patient (3%), and post-ESD stricture in 5 patients (16%) were observed. All were successfully managed conservatively., Conclusions: ESD using the Clutch Cutter appears to be a safe, easy, and technically efficient method for resecting early esophageal squamous cell carcinomas., (© Georg Thieme Verlag KG Stuttgart · New York.)

Radiofrequency ablation (RFA) is an accepted treatment for the eradication of dysplastic Barrett's esophagus (DBE) and residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma. Circumferential balloon-based and focal catheter-based RFA devices are currently used (the Halo360 and Halo90). However, a new smaller focal ablation device (the Halo60) has been developed, which may be of benefit in patients with short tongues of Barrett's neoplasia, small residual islands, difficult anatomy, or strictures. We report the first use of this device in 17 patients with either DBE or residual Barrett's esophagus after endoscopic resection of intramucosal adenocarcinoma., (© Georg Thieme Verlag KG Stuttgart · New York.)

A novel disposable transnasal esophagoscope, the E.G. Scan (IntroMedic Co. Ltd., Seoul, Korea), was developed for the evaluation of esophageal diseases while eliminating the inconvenience associated with sterilization, portability, patient monitoring, complications, and the economic burden of sedation. The feasibility, safety, and tolerability of the first version of the E.G. Scan was evaluated in this pilot study. Nasal esophagoscopy was performed successfully in 46 patients with known or suspected esophageal diseases. At least 50% of the Z-line was visualized by the E.G. Scan in 38 (82.6%) of 46 patients. Abnormalities were identified in 27 patients: erosive esophagitis (n=18), Barrett's esophagus (n=1), esophageal varices (n=7), and esophageal candidiasis (n=1). Nasal pain was absent or mild in most patients, and adverse events were not observed. Further technical improvement of the E.G. Scan would increase the diagnostic usefulness in future clinical practice., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Multiband mucosectomy (MBM) is a relatively new technique for endoscopic resection in Barrett's esophagus. This ligate-cut technique uses a modified variceal band ligator allowing for six consecutive resections without prior submucosal lifting. The aim was to evaluate the safety of MBM and its efficacy for complete endoscopic removal of delineated target areas in Barrett's esophagus., Methods: Prospective registration of all MBM procedures in Barrett's esophagus was carried out between November 2004 and October 2009 in two hospitals. Prior to MBM, the target area was delineated with coagulation markings, followed by endoscopic resection until the delineated area was completely resected. Primary end points were acute (during procedure) plus early complications (<30 days) and the rate of complete endoscopic resection of the delineated target area., Results: A total of 243 MBM procedures, with 1060 resections, were performed in 170 patients. MBM was performed for focal lesions (n=113), for Barrett's esophagus removal as part of a (stepwise) radical endoscopic resection protocol (n=117), and as escape treatment after radiofrequency ablation (n=13). The only acute complication was bleeding (in 3%, endoscopically managed); no perforations occurred despite absence of submucosal lifting. Early complications consisted of delayed bleeding (in 2%, endoscopically managed) and stenosis, which occurred in 48% of patients treated in a (stepwise) radical resection protocol; patients treated for focal lesions or in escape treatment showed no stenosis. Complete endoscopic resection was achieved in 91% of the focal lesions, in 86% of cases treated under the (stepwise) radical endoscopic resection protocol, and 100% for escape treatment after radiofrequency ablation., Conclusion: MBM is a safe and effective technique for the removal of delineated target areas in Barrett's esophagus., (© Georg Thieme Verlag KG Stuttgart · New York.)