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Background: Endoscopic resection (ER) is an important treatment for high-grade intraepithelial neoplasia and early cancer in Barrett's esophagus. ER-cap requires submucosal lifting and positioning of a snare in the cap, making it technically demanding and laborious. Multiband mucosectomy (MBM) uses a modified variceal band ligator and requires no submucosal lifting or positioning of a snare. Objective: To compare ER-cap and MBM for piecemeal ER of early Barrett's neoplasia. Design: Randomized, controlled trial. Setting: Tertiary-care and community-care centers. Patients: This study involved 84 patients (64 men; median age 70 years) undergoing piecemeal ER of Barrett's neoplasia. Intervention: Piecemeal ER was performed by using ER-cap (n = 42) or MBM (n = 42). Main Outcome Measurements: Safety, efficacy, procedure time, costs. Results: Procedure time (34 vs 50 minutes; P = .02) and costs (€240 vs €322; P < .01) were significantly less with MBM compared with ER-cap. MBM resulted in smaller resection specimens than ER-cap (18 ×13 mm vs 20 × 15 mm; P < .01). Maximum thicknesses of specimens and resected submucosa were not significantly different. There were no clinically relevant bleeding episodes. Four perforations occurred, 3 with ER-cap, 1 with MBM (P = not significant). Limitations: Potential bias because of different levels of experience among participating endoscopists. Conclusion: Piecemeal ER with MBM is faster and cheaper than with ER-cap. Despite the lack of submucosal lifting, MBM appears not to be associated with more perforations. Although MBM results in slightly smaller specimens, the clinical relevance of this may be limited because depth of resections does not differ between both techniques. MBM may thus be preferred for piecemeal ER of early Barrett's neoplasia. (Clinical trial registration number: NTR1435.) [Copyright &y& Elsevier]

Background: Radiofrequency ablation (RFA) is safe and effective for eradicating Barrett''s esophagus (BE) and BE-associated early neoplasia. Most RFA studies have limited the baseline length of BE (<10 cm), and therefore little is known about RFA for longer BE. Objective: To assess the safety and efficacy of RFA with or without prior endoscopic resection (ER) for BE ≥10 cm containing neoplasia. Design: Prospective trial. Setting: Two tertiary-care centers. Patients: This study involved consecutive patients with BE ≥10 cm with early neoplasia. Intervention: Focal ER for visible abnormalities, followed by a maximum of 2 circumferential and 3 focal RFA procedures every 2 to 3 months until complete remission. Main Outcome Measurements: Complete remission, defined as endoscopic resolution of BE and no intestinal metaplasia (CR-IM) or neoplasia (CR-neoplasia) in biopsy specimens. Results: Of the 26 patients included, 18 underwent ER for visible abnormalities before RFA. The ER specimens showed early cancer in 11, high-grade intraepithelial neoplasia (HGIN) in 6, and low-grade intraepithelial neoplasia (LGIN) in 1. The worst residual histology, before RFA and after any ER, was HGIN in 16 patients and LGIN in 10 patients. CR-neoplasia and CR-IM were achieved in 83% (95% confidence interval [CI], 63%-95%) and 79% (95% CI, 58%-93%), respectively. None of the patients had fatal or severe complications and 15% (95% CI, 4%-35%) had moderate complications. During a mean (± standard deviation) follow-up of 29 (± 9.1) months, no neoplasia recurred. Limitations: Tertiary-care center, short follow-up. Conclusion: ER for visible abnormalities, followed by RFA of residual BE is a safe and effective treatment for BE ≥10 cm containing neoplasia, with a low chance of recurrence of neoplasia or BE during follow-up. [Copyright &y& Elsevier]

Background: EUS is often used for locoregional staging of early esophageal neoplasia. However, its value compared with that of endoscopic examination and diagnostic endoscopic resection (ER) may be questioned because diagnostic ER allows histological assessment of submucosal invasion and other risk factors for lymph node metastasis, eg, poor differentiation/lymphovascular invasion. Objective: To evaluate how often patients were excluded from endoscopic treatment of esophageal neoplasia based on EUS findings. Design: Retrospective cohort study. Setting: Tertiary care institution. Patients: Patients with early esophageal neoplasia. Interventions: EUS, diagnostic ER. Main Outcome Measurements: Number of patients excluded from endoscopic treatment based on EUS results. Results: A total of 131 patients were included (98 men, 33 women; age 66 ± 13 years). In 105 of 131 patients (80%), EUS findings were unremarkable. In 25 of 105 patients (24%), diagnostic ER showed submucosal invasion (n = 17), deep resection margins positive for cancer (n = 2, confirmed at surgery), or poor differentiation/lymphovascular invasion (n = 6). In 26 of 131 patients (20%), EUS findings raised the suspicion of submucosal invasion and/or lymph node metastasis. In the 14 of 26 patients (54%) with abnormal EUS findings, endoscopy results were unremarkable. Diagnostic ER showed submucosal invasion in 7 of 14 (50%) patients, whereas no lymph node metastasis risk factors were found in 7 of 14 patients (50%), who subsequently underwent curative endoscopic treatment. In 12 of 26 patients (46%) with abnormal EUS, endoscopy also raised doubts on whether curative endoscopic treatment could be achieved. After diagnostic ER, no risk factors for lymph node metastasis were found in 3 of 12 patients (25%). Limitation: Retrospective study. Conclusions: This study shows that EUS has virtually no clinical impact on the workup of early esophageal neoplasia and strengthens the role of diagnostic ER as a final diagnostic step. [Copyright &y& Elsevier]

Background: Evidence-based selection criteria for endoscopic resection (ER) of Barrett''s neoplasia are scarce. Objective: To study the histopathology of ER specimens of Barrett''s neoplasia and correlate this with endoscopic characteristics to make recommendations for patient management. Design, Setting, Interventions: Histology and correlating endoscopy reports of specimens obtained at 293 consecutive ERs performed at a Dutch tertiary referral center between 2000 and 2006 were reviewed. Main Outcome Measurements: Histologic findings in ER specimens and their relation with endoscopic characteristics. Results: A total of 150 ERs were performed for focal lesions: 16% type 0-I, 23% 0-IIa, 7% 0-IIb, 3% 0-IIc, 9% 0-IIa-IIb, and 42% 0-IIa-IIc; and 143 for flat mucosa. Histology revealed no dysplasia in 57 ERs, low-grade intraepithelial neoplasia in 52, high-grade intraepithelial neoplasia in 104, T1m in 61, and T1sm in 17; in two cancers, infiltration depth was not assessable because of artifacts. Type 0-I and 0-IIc lesions significantly more often penetrated the submucosa (P = .009): 60% were G1 cancers, 23% were G2 cancers, and 18% were G3 cancers. G2-G3 cancers significantly more often invaded the submucosa (P < .001) or had positive vertical margins (P = .015). Histology of ER specimens led to a change in diagnosis in 49% of the focal lesions and a relevant change in treatment policy in 30%. Limitations: A retrospective study. Conclusions: ER is a valuable diagnostic tool that frequently leads to a change in treatment policy. Most endoscopically resected early Barrett''s neoplasia are 0-II type, G1 mucosal neoplasia. Submucosal infiltration is more often encountered in type 0-I and 0-IIc lesions and in G2-G3 cancers. [Copyright &y& Elsevier]