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Background: Management of esophageal perforation includes open surgery, minimally invasive surgery, and endoscopic stent placement. This study analyzed initial treatment and the associated short-term outcomes., Methods: A retrospective study using the National Inpatient Sample between October 2015 and December 2019 identified adults >18 years with esophageal perforation undergoing an initial nonelective esophageal procedure categorized into either open surgery, minimally invasive surgery, or endoscopic stent placement. Patients with esophageal cancer were excluded. Baseline characteristics and the van Walraven-weighted Elixhauser Comorbidity Index were identified. Outcomes included in-hospital mortality and postintervention complications. Univariable and multivariable Cox regression was used to compare in-hospital survival., Results: In total, 3,345 patients met inclusion criteria: the median age was 62 years (interquartile range 50-72 years), and 1,310 (39%) were female. Open procedure was pursued in 2,650 (79%), minimally invasive surgery in 310 (9%), and endoscopic stent placement in 385 (12%) with no differences in van Walraven-weighted Elixhauser Comorbidity Index or mortality. Patients who underwent minimally invasive surgery had a greater proportion of gastrointestinal complications (P = .006); otherwise, there were no differences in postintervention complications. In total, 380 (11%) patients died and were significantly older, with greater van Walraven-weighted Elixhauser Comorbidity Index, and had more postintervention complications. Univariable Cox regression identified age (hazard ratio 1.95, P < .001), van Walraven-weighted Elixhauser Comorbidity Index (hazard ratio 1.06, P < .001), stent placement (hazard ratio 1.93, P = .045), and transfer from a health facility (HR 2.40, P = .049) as associated with decreased in-hospital survival. Multivariable Cox regression revealed age (hazard ratio 1.041, P < .001) and van Walraven-weighted Elixhauser comorbidity index (hazard ratio 1.055, P < .001) were associated with decreased in-hospital survival., Conclusion: Patients with esophageal perforation had an 11% in-hospital mortality rate and significant associated complications regardless of intervention. Increasing age and comorbidities are associated with poorer in-hospital survival., (Published by Elsevier Inc.)

High quality Barrett's esophagus surveillance is crucial to detect early neoplastic changes. An esophageal cell collection device (OCCD) was introduced as a triage tool for Barrett's surveillance. This study aims to evaluate whether the Scottish OCCD program (CytoSCOT) has reduced delays to Barrett's surveillance, and whether delayed surveillance negatively impacts endoscopic pathology. All patients undergoing OCCD testing for Barrett's surveillance across 11 Scottish health boards between 14/9/2020 and 13/9/2022 were identified. Patients were dichotomised into two groups (Year 1 vs. Year 2), with individual records interrogated to record demographics, recommended surveillance interval, time from last endoscopy to OCCD test, and OCCD result. Patients were deemed high-risk if the OCCD demonstrated atypia and/or p53 positivity. Further analysis was performed on patients who underwent endoscopy within 12 months of OCCD testing. A total of 3223 OCCD tests were included in the analysis (1478 in Year 1; 1745 in Year 2). In Year 1 versus Year 2, there was a longer median delay to surveillance (9 vs. 5 months; P < 0.001), increased proportion of patients with delayed surveillance (72.6% vs. 57.0%; P < 0.001), and more high-risk patients (12.0% vs. 5.3%; P < 0.001). 425/3223 patients (13.2%) were further investigated with upper gastrointestinal endoscopy, 57.9% of which were high-risk. As surveillance delay increased beyond 24 months, high-risk patients were significantly more likely to develop dysplasia or malignancy (P = 0.004). Delayed Barrett's esophagus surveillance beyond 24 months is associated with increased risk of pre-cancerous pathology. The CytoSCOT program has reduced delays in surveillance, promoting earlier detection of dysplasia and reducing burden on endoscopy services., (© The Author(s) 2024. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Despite research efforts, the causative factors that contribute to esophageal squamous cell carcinoma (ESCC) in high-risk areas have not yet been understood. In this study, we, therefore, aimed to describe the risk factors associated with ESCC and its precursor lesions., Methods: We performed an endoscopic examination of 44,857 individuals aged 40-69 years from five high incidence regions of China in 2017-2018. Participants were classified as 4 groups of normal control, esophagitis, low-grade intraepithelial neoplasia (LGIN) and high-grade intraepithelial neoplasia/esophageal squamous cell carcinoma (HGIN/ESCC) using an unconditional logistic regression determine risk factors., Results: We identified 4890 esophagitis, 1874 LGIN and 437 HGIN/ESCC cases. Crude odds ratios (ORs) and adjusted odds ratios were calculated using unconditional logistic regression. Drinking well and surface water, salty diet, and positive family history of cancer were the common risk factors for esophagitis, LGIN and HGIN/ESCC. History of chronic hepatitis/cirrhosis was the greatest risk factor of esophagitis (adjusted OR 2.96, 95%CI 2.52-3.47) and HGIN/ESCC (adjusted OR 1.91, 95%CI 1.03-3.22). Pesticide exposure (adjusted OR 1.20, 95%CI 1.05-1.37) was essential risk factor of LGIN., Conclusions: Among individuals aged 40-69 years in high incidence regions of upper gastrointestinal cancer, the results provided important epidemiological evidence for the prevention of different precancerous lesions of ESCC., (© 2021. The Author(s).)

Abstract: Peroral endoscopic myotomy (POEM) is an endoscopic alternative to surgical myotomy in patients with achalasia. This study aimed to evaluate the efficacy and clinical outcomes of POEM.A total of 20 patients with achalasia who underwent POEM between October 2016 and November 2017 were prospectively recruited. The intraoperative esophagogastric junction distensibility index (mm2/mm Hg) was measured pre- and post-myotomy using an endoluminal functional lumen imaging probe. Clinical response was defined as Eckardt score ≤3. Health-related quality of life was measured by the 36-item short-form health survey score.POEM was successfully completed in all cases. The median procedure time was 68.5 minutes (range 50.0-120.0), and the median myotomy length was 13 cm (range 11-18). Major adverse events were encountered in 2 cases. Overall, clinical responses were observed in all patients during a median follow-up of 11.9 months (range 1.2-26.2). Postoperative esophagogastric junction distensibility index was significantly higher than baseline (from 1.3 [range 0.8-6.9] to 6.3 [range 25-19.2], P < .001). The median Eckardt scores were decreased after POEM (5 [range 2-11] to 1 [range 0-3], P < .001), and the 36-item short-form health survey score was also improved significantly after POEM (67.5 [range 34.5-93.9] to 85.7 [range 53.4-93.3], P = .004).POEM is an effective treatment for achalasia, based on the improvement of both symptoms and objective measures.Clinicaltrial.gov NCT02989883., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Introduction: In a previous study we demonstrated that a simple training programme improved quality indicators of Oesophagogastroduodenoscopy (OGD) achieving the recommended benchmarks. However, the long-term effect of this intervention is unknown. The aim of this study was to assess the quality of OGDs performed 3 years after of having completed a training programme., Material and Methods: A comparative study of 2 cohorts was designed as follows: Group A included OGDs performed in 2016 promptly after a training programme and Group B with OGDs performed from January to March 2019, this group was also divided into 2 subgroups: subgroup B1 of Endoscopists who had participated in the previous training programme and subgroup B2 of Endoscopists who had not. The intra-procedure quality indicators proposed by ASGE-ACG were used., Results: A total of 1236 OGDs were analysed, 600 from Group A and 636 from Group B (439 subgroup B1 and 197 subgroup B2). The number of complete examinations was lower in Group B (566 [94.3%] vs. 551 [86.6%]; p<0.001). A significant decrease was observed in nearly all quality indicators and they did not reach the recommended benchmarks: retroflexion in the stomach (96% vs. 81%; p<0.001); Seattle biopsy protocol (86% vs. 50%; p=0.03), description of the upper GI bleeding lesion (100% vs. 62%; p<0.01), sufficient intestinal biopsy specimens (at least 4) in suspected coeliac disease (92.5% vs. 18%; p<0.001), photo documentation of the lesion (94% vs. 90%; p<0.05). Regarding the overall assessment of the procedure (including correct performance and adequate photo documentation), a significant decrease was also observed (90.5% vs. 62%; p<0.001). There were no differences between subgroups B1 and B2., Conclusions: The improvement observed in 2016 after a training programme did not prevail after 3 years. In order to keep the quality of OGDs above the recommended benchmarks, it is necessary to implement continuous training programmes., (Copyright © 2020 Elsevier España, S.L.U. All rights reserved.)

Introduction: As novel, less invasive (non)endoscopic techniques for detection of Barrett's esophagus (BE) have been developed, there is now renewed interest in screening for BE and related neoplasia. We aimed to determine public preferences for esophageal adenocarcinoma screening to understand the potential of minimally invasive screening modalities., Methods: A discrete choice experiment was conducted in 1,500 individuals, aged 50-75 years, from the general population. Individuals were repeatedly asked to choose between screening scenarios based on conventional upper endoscopy, transnasal endoscopy, nonendoscopic cell collection devices, breath analysis, and a blood test, combined with various levels of test sensitivity and specificity, and no screening. A multinomial logit model was used to estimate individuals' preferences and to calculate expected participation rates., Results: In total, 554 respondents (36.9%) completed the survey. The average predicted uptake was 70.5% (95% confidence interval: 69.1%-71.8%). Test sensitivity (47.7%), screening technique (32.6%), and specificity (19.7%) affected screening participation (all P < 0.05). A low test sensitivity had the highest impact on screening participation, resulting in a 25.0% (95% confidence interval: 22.6%-27.7%) decrease. Respondents preferred noninvasive screening tests over endoscopic and capsule-based techniques, but only if sensitivity and specificity were above 80%., Discussion: Our study suggests that individuals generally prefer noninvasive BE screening tests. However, these tests would unlikely improve screening uptake when associated with a much lower accuracy for detecting BE and esophageal adenocarcinoma compared with conventional upper endoscopy. Improving accuracy of minimally invasive screening strategies and informing the target population about these accuracies is therefore essential to maximally stimulate screening participation.

Introduction: An automated risk prediction assay has previously been shown to objectively identify patients with nondysplastic Barrett's esophagus (NDBE) who are at increased risk of malignant progression. To evaluate the predictive performance of the assay in 76 patients with NDBE of which 38 progressed to high-grade dysplasia/esophageal adenocarcinoma (progressors) and 38 did not (nonprogressors) and to determine whether assessment of additional (spatial) levels per endoscopy and/or multiple (temporal) time points improves assay performance., Methods: In a blinded, nested case-control cohort, progressors and nonprogressors were matched (age, sex, and Barrett's esophagus length). All random biopsy levels from the baseline endoscopy (spatial samples) and all available previous endoscopies back to 10 years before progression (temporal samples) were assayed. Because the 1:1 ratio of progressors to nonprogressors does not reflect the real-world Barrett's population, negative and positive predictive values were adjusted for prevalence., Results: Seventy-six patients (58 men), mean age of 63 ± 9 years, were studied. A high-risk score was associated with a prevalence-adjusted annual progression rate of 6.9%. The assay identified 31% of progressors when assessing a single biopsy level from the baseline endoscopy. Sensitivity increased to 50% and 69% in spatial and temporal analyses, respectively, while specificity remained at 95%., Discussion: The assay identified a significant subset of NDBE patients who progress at a rate comparable with published estimates for expert-confirmed low-grade dysplasia. Assessing additional spatial and temporal biopsies increased the predictive accuracy, allowing for identification of most future progressors. Additional studies will evaluate the predictive performance of the assay in low-prevalence settings.

Objectives/hypothesis: Combine techniques commonly employed in the clinical workup of patients with isolated globus sensation to identify the most common pharyngoesophageal abnormality. The primary aim was to retrospectively review high-resolution manometry, pH probe testing, contrast videofluoroscopy, and endoscopy studies in patients with a primary complaint of globus sensation. The specific hypothesis was esophageal high-resolution manometry identifies the most significant proportion of abnormalities compared to all other modalities., Study Design: Retrospective cohort study., Methods: An inclusive retrospective chart review was performed for patients evaluated between 2009 and 2016 with the primary complaint of globus sensation. Age at testing, self-identified gender, associated diagnoses, and results from each modality were collected. Descriptive statistics and pairwise comparisons were performed as well as sensitivity and specificity calculations., Results: One hundred seventy-two patients met inclusion criteria. The cohort had an age range of 22.7 to 88.5 years and was predominantly female. Esophageal manometry identified abnormalities in 62.8% of patients, and pH testing identified abnormal acidification in approximately 20%. The esophagram identified abnormalities in 24% of patients, and esophagogastroduodenoscopy identified abnormalities in 22%. Modified barium swallows were normal in 93% of patients. Measures of sensitivity and specificity of other modalities were poor compared to esophageal manometry and pH testing., Conclusions: Patients with isolated globus sensation have evidence of esophageal dysmotility and laryngopharyngeal and gastroesophageal reflux disease in high proportions. Esophageal high-resolution manometry testing identifies the greatest proportion of abnormalities of the investigated modalities., Level of Evidence: 4 Laryngoscope, 130:2120-2125, 2020., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

Background & Aims: We aimed to develop and validate a deep-learning computer-aided detection (CAD) system, suitable for use in real time in clinical practice, to improve endoscopic detection of early neoplasia in patients with Barrett's esophagus (BE)., Methods: We developed a hybrid ResNet-UNet model CAD system using 5 independent endoscopy data sets. We performed pretraining using 494,364 labeled endoscopic images collected from all intestinal segments. Then, we used 1704 unique esophageal high-resolution images of rigorously confirmed early-stage neoplasia in BE and nondysplastic BE, derived from 669 patients. System performance was assessed by using data sets 4 and 5. Data set 5 was also scored by 53 general endoscopists with a wide range of experience from 4 countries to benchmark CAD system performance. Coupled with histopathology findings, scoring of images that contained early-stage neoplasia in data sets 2-5 were delineated in detail for neoplasm position and extent by multiple experts whose evaluations served as the ground truth for segmentation., Results: The CAD system classified images as containing neoplasms or nondysplastic BE with 89% accuracy, 90% sensitivity, and 88% specificity (data set 4, 80 patients and images). In data set 5 (80 patients and images) values for the CAD system vs those of the general endoscopists were 88% vs 73% accuracy, 93% vs 72% sensitivity, and 83% vs 74% specificity. The CAD system achieved higher accuracy than any of the individual 53 nonexpert endoscopists, with comparable delineation performance. CAD delineations of the area of neoplasm overlapped with those from the BE experts in all detected neoplasia in data sets 4 and 5. The CAD system identified the optimal site for biopsy of detected neoplasia in 97% and 92% of cases (data sets 4 and 5, respectively)., Conclusions: We developed, validated, and benchmarked a deep-learning computer-aided system for primary detection of neoplasia in patients with BE. The system detected neoplasia with high accuracy and near-perfect delineation performance. The Netherlands National Trials Registry, Number: NTR7072., (Copyright © 2020 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Background and Aims: This retrospective study was aimed at assessing the efficacy of endoscopic dilation for esophageal anastomotic strictures, and to compare response between caustic anastomotic strictures (CAS) and non-caustic anastomotic strictures (NCAS)., Materials and Methods: Patients with anastomotic strictures (enrolled during January 1996-December 2015) were analyzed. Short- and long-term outcomes of dilation, in terms of clinical success, refractory, and recurrent strictures were compared between NCAS and CAS. Patients with refractory and recurrent strictures were managed with adjunctive therapy including intralesional steroids. Factors predicting refractoriness at start of dilation and reasons for more than ten lifetime dilations were also evaluated., Results: Of the 142 patients, 124 (mean age-44.02; males-74) underwent dilation. Clinical success was achieved in 113 (91.3%) patients requiring a median [Interquartile range (IQR)] of 4 (2-10) sessions. The number of dilations to achieve clinical success, refractory strictures, and recurrent strictures, and the use of adjunctive therapy were significantly higher for CAS than for NCAS. Intralesional steroid use decreased periodic dilation index (PDI) significantly in CAS. Caustic etiology and starting dilation diameter of < 10 mm were found to be predictors of refractoriness, with the former alone being an independent predictor of more than ten lifetime dilations. No patient had free perforation; however, five required revision surgery., Conclusion: Patients with CAS fared worse than those with NCAS in terms of number of dilations, refractoriness, recurrence of strictures, and need of adjunctive therapy. Endoscopic dilation can successfully ameliorate dysphagia due to anastomotic strictures in a majority of patients.

Introduction: Cryotherapy is a cold-based ablative therapy used primarily as second line therapy in patients with Barrett's esophagus (BE) who have persistent dysplasia after undergoing endoscopic treatment with radiofrequency ablation (RFA). Few studies have described the use of cryotherapy as a primary treatment modality for dysplastic or neoplastic BE., Aim: To evaluate the efficacy of cryotherapy as primary treatment of dysplastic and/or neoplastic BE by conducting a systemic review and meta-analysis., Methods: A systematic search of Medline, Embase, and Web of Science was performed from January 2000 through March 2020. Articles included were observational studies and clinical trials which included patients who had biopsy confirmed dysplastic or neoplastic BE (i.e., high grade dysplasia (HGD), low grade dysplasia (LGD) or intramucosal adenocarcinoma (ImCA)), underwent ≥1 session of cryotherapy, and had a follow-up endoscopy. Primary outcomes were pooled proportions of patients achieving complete eradication of dysplasia (CE-D) and/or intestinal metaplasia (CE-IM) by using a random effects model., Results: Fourteen studies making up 405 patients with follow-up ranging from 3-54 months were included. In 13 studies, a total of 321/405 patients achieved CE-D with a pooled proportion of 84.8% (95% confidence interval [CI] 72.2-94.4), with substantial heterogeneity (I 2 = 88.3%). In 13 studies, a total of 321/405 patients achieved CE-D with a pooled proportion of 84.8% (95% confidence interval [CI] 72.2-94.4), with substantial heterogeneity (I 2 = 88.3%). Subgroup analysis of only high-quality studies revealed a pooled proportion of CE-D 91.3% (95% CI, 83.0-97.4, I 2 = 69.5%) and pooled proportion of CE-IM of 71.6% (95% CI, 59.0-82.9, I 2 = 80.9%). Adverse events were reported in 12.2% patients., Conclusion: Cryotherapy is a safe and effective primary therapy for dysplastic/early neoplastic BE. CE-D and CE-IM rates are comparable to those for other ablation modalities, including RFA. Cryotherapy should be considered for primary therapy of dysplastic BE and early esophageal neoplasia.

Objectives: Children experience serious gastrointestinal tract injuries due to consumption of caustic agents more often than adults. The aim of the study was to analyze diagnostic methods and treatment of children with esophageal burns according to the degree of the injury., Methods: Our one-center population-based retrospective cohort study included 150 children admitted between 1967 and 2018 to Clinic of Pediatric Otolaryngology, Phoniatrics and Audiology of University Children's Hospital in Lublin, Poland, due to the chemical burn of the mouth, throat, larynx, and esophagus. Each patient underwent a thorough laryngological examination and endoscopy to assess the place and degree of injury., Results: Of 150 patients, 65.3% were male and 34.7% female. The median age was 4 years and 3 months. Salivation, dysphagia, burning sensation, edema, and whitish coating on the oral mucosa, palate, and throat were the most common clinical symptoms. In addition, dyspnea and chest pain were observed in 30% of patients. Esophagus endoscopy results were: Zargar grade I burn (84.7%), grade IIA (8%), grade IIB (2.6%), grade III (0%), and grade 0 (4.7%). Treatment included antibiotics, proton pump inhibitors, analgesics, and intravenous fluid therapy. Late sequelae (scarred esophageal strictures) developed in 20 (13.3%) patients., Conclusions: Accidental intake of caustic agents is observed in young children, especially younger than the age of 5. Early esophagus endoscopy should be performed in all patients to assess the grade of injury, plan initial treatment, and predict the risk of developing complications. Early diagnosis and immediate pharmacological treatment reduce the number of late sequelae.

Symptoms of esophageal dysfunction such as food impaction are consistent with, but not diagnostic for eosinophilic esophagitis (EoE) without obtaining histology. We conducted a retrospective study to characterize patients with food impaction at a tertiary center. We hypothesized that many patients with food impaction may be lost to follow-up and that many have features suggestive of EoE. Adult patients presenting to the emergency department with esophageal food impaction were identified from an endoscopic database. Electronic medical records were manually abstracted. We examined associations between demographics, comorbid conditions, and follow-up with biopsy findings. Of 220 patients who presented to the emergency department for food impaction, 74.1% were men. Adequate follow-up was not documented in 120 (54.5%). Those lost to follow-up did not differ significantly by gender, age at symptom onset, or distance from hospital compared to those with follow-up. Esophageal biopsies were obtained in 158 (71.8%), and those with ≥15 eos/HPF were more likely to be lost to follow-up than those with <15 eos/HPF (52.8% vs. 34.8%, P < 0.05). Of those never biopsied, 79.0% were lost to follow-up and had intermediate proportions of males, food allergy, and asthma when compared to those with and without eosinophilic inflammation. Patients with food impaction commonly have EoE but are often lost to follow-up. Among those never biopsied, demographic and clinical features suggest that many may have undiagnosed EoE. Strategies for increasing use of biopsies in patients with food impaction and improving follow-up are needed to diagnose and manage EoE., (© The Author(s) 2019. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

This study aimed to compare clinical results, symptom relief, quality of life and patient satisfaction after the 2 most common procedures for achalasia treatment: laparoscopic Heller myotomy (LHM) and endoscopic balloon dilatation (EBD).Patients treated at University Hospital of Heidelberg with LHM or EBD were included. A retrospective chart review of perioperative data and a prospective follow-up of therapeutic efficiency, Gastrointestinal Quality of Life Index (GIQLI) and patient satisfaction was conducted.Follow-up data (mean follow-up: 75.1 ± 53.9 months for LHM group and 78.9 ± 45.6 months for EBD) were obtained from 36 patients (19 LHM; 17 EBD). Eckardt score (median (q1,q3): 2 (1,4) in both groups, P = .91, GIQLI (LHM: 117 (91.5, 126) vs EBD: 120 (116, 128), P = .495) and patient satisfaction (3 (2,3) vs 3 (2,4), P = .883) did not differ between groups. Fifteen patients (78.9%) in LHM group and 11 (64.7%) in EBD group (P = .562) stated they would undergo the intervention again. All patients with EBD had at least 2 dilatations (100%), whilst only 2 patients (10.5%) had dilatation after LHM (P < .001). There were no complications after EBD, but 2 after LHM (10.5%, P = .517).Both LHM and EBD are able to control symptoms and provide similar quality of life and patient satisfaction. However, reintervention rate was higher following EBD, hence LHM provided a more sustained treatment than EBD.

Objective: Surveillance interval protocols after complete remission of intestinal metaplasia (CRIM) post radiofrequency ablation (RFA) in Barrett's oesophagus (BE) are currently empiric and not based on substantial evidence. We aimed to assess the timeline, location and patterns of recurrence following CRIM to inform these guidelines., Design: Data on patients undergoing RFA for BE were obtained from prospectively maintained databases of five (three USA and two UK) tertiary referral centres. RFA was performed until CRIM was confirmed on two consecutive endoscopies., Results: 594 patients achieved CRIM as of 1 May 2017. 151 subjects developed recurrent BE over a median (IQR) follow-up of 2.8 (1.4-4.4) years. There was 19% cumulative recurrence risk of any BE within 2 years and an additional 49% risk over the next 8.6 years. There was no evidence of a clinically meaningful change in the recurrence hazard rate of any BE, dysplastic BE or high-grade dysplasia/cancer over the duration of follow-up, with an estimated 2% (95% CI -7% to 12%) change in recurrence rate of any BE in a doubling of follow-up time. 74% of BE recurrences developed at the gastro-oesophageal junction (GOJ) (24.1% were dysplastic) and 26% in the tubular oesophagus. The yield of random biopsies from the tubular oesophagus, in the absence of visible lesions, was 1% (BE) and 0.2% (dysplasia)., Conclusions: BE recurrence risk following CRIM remained constant over time, suggesting that lengthening of follow-up intervals, at least in the first 5 years after CRIM, may not be advisable. Sampling the GOJ is critical to detecting recurrence. The requirement for random biopsies of the neosquamous epithelium in the absence of visible lesions may need to be re-evaluated., Competing Interests: Competing interests: PGI: research funding from Exact Sciences, C2 Therapeutics and Medtronic; consulting: C2 Therapeutics, CSA Medical and Symple Surgical., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Quality indicators have been proposed for endoscopic eradication therapy of Barrett's esophagus (BE). One such measure suggests that complete eradication of intestinal metaplasia (CE-IM) should be achieved within 18 months of starting treatment. The aim of this study was to assess whether achievement of CE-IM within 18 months is associated with improved long-term clinical outcomes. This was a retrospective cohort study of BE patients who underwent endoscopic eradication. Time to CE-IM was recorded and categorized as ≤ or > 18 months. The main outcome measures were recurrence of IM and of dysplasia after CE-IM, defined as a single endoscopy without endoscopic evidence of BE or histologic evidence of intestinal metaplasia. Recurrence was analyzed using the Kaplan-Meier method and multivariable Cox proportional hazards modeling. A total of 290 patients were included in the analyses. The baseline histology was high-grade dysplasia or intramucosal carcinoma in 74.2% of patients. CE-IM was achieved in 85.5% of patients, and 54.1% of the cohort achieved CE-IM within 18 months. Achieving CE-IM within 18 months was not associated with reduced risk of recurrence of IM or dysplasia in both unadjusted and adjusted analyses. In this cohort, older age and increased BE length were associated with IM recurrence, and increased hiatal hernia size was associated with dysplasia recurrence. Compared to longer times, achieving CE-IM within 18 months was not associated with a reduced risk of recurrence of IM or dysplasia. Alternative evidence-based quality metrics for endoscopic eradication therapy should be identified., (© The Author(s) 2019. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus.)

Objective: Recent studies show increased serum and esophageal IgG4 in patients with eosinophilic esophagitis (EoE), suggesting a possible IgG4-involved process. The role of IgG4 in pediatric EoE has not been extensively investigated. Our aim was to analyze IgG4 in esophageal tissue in children in parallel to that in adults with EoE., Methods: In a retrospective institutional review board-approved study, we performed immunohistochemical staining of IgG4 in esophageal biopsy specimens from 39 subjects: children with EoE (n = 16), adults with EoE (n = 15), children with reflux esophagitis (n = 4), and pediatric controls (n = 4). We assessed the relationships between IgG4 staining and clinical, endoscopic, and histopathologic characteristics., Results: Patients with EoE were significantly more likely to stain positively for IgG4 than children with reflux esophagitis or controls (P = 0.015). Fifteen of 31 (48%) EoE cases stained positively for IgG4. None of the reflux esophagitis or control cases stained positively. IgG4 staining had 48% sensitivity and 100% specificity for EoE. There was a trend toward IgG4 staining being associated with foreign body/food impaction (P = 0.153). There was a strong association between distal IgG4 staining and basal zone hyperplasia (P = 0.003)., Conclusions: Our study suggests IgG4 is not a consistent finding of EoE at disease diagnosis. Although IgG4 staining was specific for EoE, it had a poor sensitivity with positive staining in only 48% of EoE patients. Further studies are warranted to fully elucidate the role of IgG4 in EoE.

Background: Cystic fibrosis (CF) patients have increased risks of gastrointestinal cancers, including esophageal adenocarcinoma. Gastroesophageal reflux disease (GERD) is highly prevalent in CF and manifests at early ages. CF patients may be at increased risk for long-term sequelae of chronic GERD, including Barrett's esophagus (BE). We aimed to assess whether patients with CF have an increased risk of BE or related neoplasia., Methods: A matched cohort study was performed of adults with and without CF who had undergone upper endoscopy. Non-CF patients were matched in a 4:1 ratio by age, sex, year of exam, and endoscopist. Odds ratios were calculated for the association between CF and BE or related neoplasia, and multivariable logistic regression modeling was performed to adjust for matching variables and additional potential confounders., Results: 122 CF patients underwent endoscopy, and 488 matched controls were identified. Seven (5.7%) CF patients had BE or related neoplasia, including one GE junction adenocarcinoma. Mean age of affected CF patients was 36.0, and 85.7% had a prior solid organ transplant. The odds of BE was significantly increased in CF patients (OR 2.91, 95% CI 1.08-7.81). The risk remained significantly increased in a multivariable model including matching variables (OR 3.32, 95% CI 1.19-9.22) and in a parsimonious model (OR 2.99, 95% CI 1.06-8.42)., Conclusions: Adults with CF have a 3-fold increased risk of BE or related neoplasia and appears to develop at younger ages. Consideration should be given to screening for BE in select CF patients, especially those who have undergone solid organ transplantation., (Copyright © 2018. Published by Elsevier B.V.)

Background and Aims: Despite rising incidence of eosinophilic esophagitis (EoE), data on the follow-up and treatment outcomes in pediatric patients are scarce. Therefore, the aim of this study was to present data on the treatment outcomes in children diagnosed with EoE who were treated in a tertiary medical center., Patients and Methods: A retrospective study involving patients younger than 18 years who were diagnosed with EoE in our center between January 2011 and June 2017., Results: Thirty-two patients met inclusion criteria and were followed up for a mean of 3 years (range 0.5-6.8). Six months after the diagnosis, 28 (87.5%) children were still followed up; 21 (75%) were in clinical remission, including 10 (36%) who were in histological remission. After 12 months, 27 patients were still followed up; 21 (78%) achieved clinical remission, including 10 (37%) with histological remission. During follow-up, three patients developed gastroesophageal reflux disease (GERD). There was no difference in body mass index (BMI) Z score between baseline and 12 months follow-up (median - 0.3 vs - 0.3 SD, p = 0.862)., Conclusions: Absence of symptoms does not indicate mucosal healing; therefore, patients should be followed up endoscopically. Additionally, despite restricted diet, nutritional status remains unaffected. Finally, patients with EoE can develop significant GERD even years after the EoE diagnosis.

Purpose: The aim was to investigate the current status of esophageal endoscopy, including the evaluation of smoking and alcohol consumption, in Japan., Methods: A total of 47,441 patients who underwent 69,748 sessions of esophageal endoscopy were registered in the Japan Endoscopy Database between January 2015 and March 2017. The study variables were as follows: (1) methods for monitoring the esophagus and the time required for monitoring and (2) the status of smoking and alcohol consumption in patients with esophageal cancer and head and neck cancer., Results: Image-enhanced endoscopy was performed in 10.6%, Lugol chromoendoscopy in 4.1%, and magnifying endoscopy in 3.2%. The mean time required for gastrointestinal endoscopy was 10 min 58 s. The mean examination times in patients with or without monitoring of the head and neck were 10 min 51 s and 11 min 13 s, respectively. In 57.0% of the patients with esophageal cancer, the head and neck were monitored at the time of gastrointestinal endoscopy. The proportion of current smokers (esophageal cancer: 16.8-4.7%; head and neck cancer: 24.3-9.3%) and addicted drinkers (esophageal cancer: 52.3-40.8%; head and neck cancer: 50.2-47.3%) were lower at the second or subsequent endoscopy than at the initial endoscopy., Conclusions: The new strategy for esophageal endoscopy has led to an evolutionary change in Japan. The patients with esophageal cancer and head and neck cancer who underwent a second or subsequent endoscopy had lower incidences of smoking and alcohol consumption, although the incidences remained high.

Background/aims: Endoluminal functional lumen imaging probe (EndoFLIP) is a modality that enables clinicians to measure volume-controlled distension of the esophagus. This study aimed to assess the utility of EndoFLIP in patients who had achalasia treated with peroral endoscopic myotomy (POEM). We hypothesized that improvement in the distensibility index (DI) is correlated with the postoperative clinical outcome of POEM., Methods: Patients who underwent POEM for achalasia at Cha Bundang Medical Center were included. Physiological measurements of the lower esophageal sphincter (LES) pressure before and after POEM were assessed using EndoFLIP. Patients' symptoms were recorded using the Eckardt score., Results: A total of 52 patients with achalasia were included in this study. Patients with a post-POEM DI below 7 (30 or 40 mL) had a significantly higher rate of incomplete response after POEM (p=0.001). Changes in LES pressure or integrated relaxation pressure after POEM were also significantly associated with an incomplete response (p=0.026 and p=0.016, respectively). Multivariate analysis showed that post-POEM DI ＜7 was the most important predictor of an incomplete response after POEM (p=0.004)., Conclusions: Lower post-POEM DI values were associated with an incomplete post-POEM response. Therefore, post-POEM DI at the esophagogastric junction using EndoFLIP is a useful index for predicting the clinical outcome of POEM in patients with achalasia.

Background: The incidence of esophageal adenocarcinoma in Europe and the United States rapidly increased from the latter half of the 1970s and exceeded that of esophageal squamous cell carcinoma in the latter half of the 1990s, currently accounting for approximately 60% of all esophageal carcinomas. Recently, its incidence has also increased in Japan, raising concerns that it will follow a course similar to that in Europe and the United States., Summary: The incidence of esophageal adenocarcinoma in Japan was about 2% until the 1990s, but in recent years, it has risen to 6.5-7.1%. Causes include the increase in the incidence of obesity due to changes in eating habits with resultant increases in the incidence of hiatal hernia and reflux esophagitis, a decrease in the rate of Helicobacter pylori infection, and the increased interest of physicians in the gastroesophageal junction. The number of gastroesophageal reflux disease patients in Japan rapidly increased from the 1990s, which accordingly increased the number of Barrett's esophageal adenocarcinoma patients from the latter half of the 1990s. Tabulation and analysis of 1,794 reported cases of Barrett's esophageal adenocarcinoma in Japan showed that superficial cancers accounted for 77.6%, and that the concomitant rates of hiatal hernia and reflux esophagitis were high at 87 and 70% respectively. Key Message: The future trend in the incidence of Barrett's esophageal adenocarcinoma in Japan will depend on the increase in the incidence of reflux esophagitis, which is essential for the development of Barrett's esophagus and Barrett's esophageal carcinoma. The obesity rate is lower in Japan than that in Europe and the United States, and the incidence and severity of reflux esophagitis are low. We expect that the incidence of Barrett's esophageal adenocarcinoma in Japan will not rise as high as in Europe and the United States, and will remain below 10%., (© 2018 Japanese Gastroenterological Association Published by S. Karger AG, Basel.)

Progression from Barrett's esophagus (BE) to esophageal adenocarcinoma (EAC) is uncommon but the consequences are serious. Predictors of progression are essential to optimize resource utilization. This study assessed the utility of a promising panel of biomarkers applicable to routine paraffin embedded biopsies (FFPE) to predict progression of BE to EAC in a large population-based, nested case-control study.We utilized the Amsterdam-based ReBus nested case-control cohort. BE patients who progressed to high-grade dysplasia (HGD)/EAC (n = 130) and BE patients who never progressed (n = 130) were matched on age, sex, length of the BE segment, and duration of endoscopic surveillance. All progressors had minimum 2 years of endoscopic surveillance without HGD/EAC to exclude prevalent neoplasia. We assessed abnormal DNA content, p53, Cyclin A, and Aspergillus oryzae lectin (AOL) in FFPE sections. We performed conditional logistic regression analysis to estimate odds ratio (OR) of progression based on biomarker status.Expert LGD (OR, 8.3; 95% CI, 1.7-41.0), AOL (3 vs. 0 epithelial compartments abnormal; OR, 3.6; 95% CI, 1.2-10.6) and p53 (OR, 2.3; 95% CI, 1.2-4.6) were independently associated with neoplastic progression. Cyclin A did not predict progression and DNA ploidy analysis by image cytometry was unsuccessful in the majority of cases, both were excluded from the multivariate analysis. The multivariable biomarker model had an area under the receiver operating characteristic curve of 0.73.Expert LGD, AOL, and p53 independently predict neoplastic progression in BE patients and are applicable to routine practice. These biomarkers can aid in selecting patients for endoscopic ablation or more intensive surveillance.

Objective: Cricopharyngeal webs (CPW) are a frequent cause of solid food dysphagia. They are difficult to diagnose and are often missed on swallowing fluoroscopy. The prevalence of CPWs is uncertain. The purpose of this study was to determine the prevalence of CPWs in elderly cadavers., Methods: Direct laryngoscopy and cervical esophagoscopy were performed in 19 embalmed cadavers by independent two-clinician consensus. Cadaver demographics and the presence and laterality of a CPW were recorded. The prevalence of CPW was calculated, and the size of the cricopharyngeus muscle (CPM) was quantified., Results: The mean age of the cohort was 83 ( ± 12) years. Fifty-three percent were female, and the mean body mass index was 19.7 ( ± 3). The causes of death were cardiovascular disease (10 of 19), cancer (5 of 19), and respiratory failure (4 of 19). A CPW was present in 68% (13 of 19) of cadavers. Forty-seven percent (9 of 19) had a unilateral web, and 21% (4 of 19) had a bilateral web. There was no laterality predominance (P > 0.05). Forty-two percent (8 of 19) had no CPM prominence; 32% (6 of 19) had a small/moderate CPM prominence; and 26% (5 of 19) had a significant CPM prominence., Conclusion: The prevalence of cricopharyngeal webs in elderly cadavers is high (68%). The clinician should maintain a high index of suspicion for CPWs in patients with no other identifiable etiology of solid food dysphagia., Level of Evidence: 3b Laryngoscope, 129:63-66, 2019., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Introduction:: The aim of this study was to evaluate the current indications for and clinical factors influencing the use of transnasal esophagoscopy (TNE)., Methods:: An online survey was sent to American Broncho-Esophagological Association members, including questions on demographics, indications, and factors influencing the use of TNE., Results:: Sixty of 251 members (24%) completed the survey. Ninety-three percent of respondents reported academic practices, while 98% practice in medium to large urban settings. Thirty-five (58%) completed laryngology fellowships. Mean monthly TNE procedure count was 7.15 (range, <1-35). The most common indications were dysphagia (82%), biopsy (50%), and laryngopharyngeal reflux (47%). Chronic cough, head and neck cancer screening, gastroesophageal reflux (GER), and tracheoesophageal puncture were also commonly reported indications (44% each). For laryngopharyngeal reflux and GER, most respondents perform TNE for recalcitrant disease following a medical trial of at least 3 months. Long-standing GER symptoms, documentation of GER on pH and impedance testing, and abnormal findings on previous esophagoscopy lead to greater TNE use. Specific dysphagia indications included abnormal esophagographic findings (70%), history or examination localizing to the esophagus (60%), solid dysphagia only (53%), and solid and/or liquid dysphagia (40%). The primary sites most likely to prompt TNE use for head and neck cancer surveillance were the esophagus (92.3%) and hypopharynx (84.6%). Balloon dilation was the most common indication for which respondents do not currently perform TNE but would like to (n = 8)., Conclusions:: TNE indications have not been well established. According to respondents from the American Broncho-Esophagological Association, TNE is most commonly used for dysphagia and laryngopharyngeal reflux and slightly less so for GER and head and neck cancer screening and surveillance. Several clinical indicators were identified that influence the decision to perform TNE.

We analyzed retrospectively the outcomes in long gap Gross type C esophageal atresia. We hypothesized that outcomes in type C (long gap) atresia differ from type C (normal gap) and be similar with outcomes in Gross type A and B esophageal atresia. Location of the distal tracheoesophageal fistula (TEF) at the carina was chosen as the hallmark of type C atresia (long gap). We compared the type of esophageal repair, major reoperations for anastomotic complications and gastroesophageal reflux, and long-term mucosal changes between type C (normal gap), type C (long gap), and type A/B. We analyzed the hospital charts of 247 successive patients from 1984 to 2014 who either underwent repair of esophageal atresia in our institution (n = 232) or were referred from elsewhere because of anastomotic complications (n = 15). Among the 232 patients of our institution, 181 had type C and 21 type A or B esophageal atresia. Twenty-two (12%) of type C patients had TEF at the carina and were considered as type C (long gap). The referred patients included a disproportionately high number (42%) of patients with type C (long gap). We attempted primary anastomosis in 98% of patients with type C (normal gap), in 95% with type C (long gap), and 53% with type A/B underwent delayed primary anastomosis. Leakage after primary anastomosis occurred in 40% of patients with type A/B and in 23% with type C (long gap) compared with 6% in patients with type C (normal gap) (P < 0.05). Recalcitrant anastomotic stricture that eventually required esophageal resection occurred in 30% of patients with type A/B and in 18% with type C (long gap) compared with 3% in patients with type C (normal gap) (P < 0.05). The overall rate of major reoperations for anastomotic complications after primary anastomosis, type A/B (36%), type C (long gap) (27%), and antireflux surgery, type A/B (100%) and type C (long gap) (61%) were higher than in type C (normal gap), (9% and 24%), (P < 0.05 in both). Ten (47%) patients with type A/B esophageal atresia (primary anastomosis not possible n = 10), three (14%) with type C (long gap) (primary anastomosis not possible n = 1, significant loss of esophageal length after complications n = 2) and two (1%) with type C (normal gap) (significant loss of esophageal length after complications n = 2) underwent esophageal reconstruction. Endoscopic follow-up, median length 7.0 (IQR: 3.0-14) years, disclosed gastric metaplasia in 31% and 33% of patients with type A/B and type C (long gap) compared with 11% in type C (normal gap) (P < 0.05). Intestinal metaplasia was found in one patient type C (normal gap) (0.7%) and one with type C (long gap) (5.6%), (P = 0.21), only. The outcomes of type C (long gap) esophageal atresia are associated with more frequent complications, gastroesophageal reflux and esophageal mucosal changes than outcomes in type C (normal gap). Outcomes in type C (long gap) esophageal atresia resemble those in type A/B. The percentage of patients who remain with their native esophagus is, however, higher in type C (long gap) atresia (86%) than in type A/B (53%).

Background & Aims: Barrett's esophagus (BE) recurs in 25% or more of patients treated successfully with radiofrequency ablation (RFA), so surveillance endoscopy is recommended after complete eradication of intestinal metaplasia (CEIM). The frequency of surveillance is informed only by expert opinion. We aimed to model the incidence of neoplastic recurrence, validate the model in an independent cohort, and propose evidence-based surveillance intervals., Methods: We collected data from the United States Radiofrequency Ablation Registry (US RFA, 2004-2013) and the United Kingdom National Halo Registry (UK NHR, 2007-2015) to build and validate models to predict the incidence of neoplasia recurrence after initially successful RFA. We developed 3 categories of risk and modeled intervals to yield 0.1% risk of recurrence with invasive adenocarcinoma. We fit Cox proportional hazards models assessing discrimination by C statistic and 95% confidence limits., Results: The incidence of neoplastic recurrence was associated with most severe histologic grade before CEIM, age, endoscopic mucosal resection, sex, and baseline BE segment length. In multivariate analysis, a model based solely on most severe pre-CEIM histology predicted neoplastic recurrence with a C statistic of 0.892 (95% confidence limit, 0.863-0.921) in the US RFA registry. This model also performed well when we used data from the UK NHR. Our model divided patients into 3 risk groups based on baseline histologic grade: non-dysplastic BE; indefinite for dysplasia, low-grade dysplasia, and high-grade dysplasia; or intramucosal adenocarcinoma. For patients with low-grade dysplasia, we propose surveillance endoscopy at 1 and 3 years after CEIM; for patients with high-grade dysplasia or intramucosal adenocarcinoma, we propose surveillance endoscopy at 0.25, 0.5, and 1 year after CEIM, then annually., Conclusion: In analyses of data from the US RFA and UK NHR for BE, a much-attenuated schedule of surveillance endoscopy would provide protection from invasive adenocarcinoma. Adherence to the recommended surveillance intervals could decrease the number of endoscopies performed yet identify unresectable cancers at rates less than 1/1000 endoscopies., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Over the coming years octogenarians will make up an increasingly large proportion of the population. With the rise in octogenarians more paraesophageal hiatal hernias may be identified. In research for the optimal treatment for paraesophageal hiatal hernias, octogenarians are often omitted and the optimal surgical strategy for this patient group remains unclear. A systematic search in PubMed, Embase, and The Cochrane Library was conducted, including articles compromising 'surgery,' 'paraesophageal hiatal hernia,' and 'octogenarians.' Selection of articles was based on independent review by two authors. Alongside, a retrospective cohort study was conducted including all type II-IV hiatal hernia repairs performed in the VU Medical Center in Amsterdam, The Netherlands, from 2005 to 2015. A total of 486 papers were eligible for selection. After careful selection, a total of eight articles were included. All articles were retrospective cohort studies describing different proportions of octogenarians. The populations and surgical techniques were very heterogeneous. Elective paraesophageal hiatal hernia repair was performed safely in symptomatic octogenarians in all studies. Additional analysis of 84 patients, of which 9.5% octogenarians, was performed at our tertiary referral center. A larger hernia type, more acute interventions and a higher morbidity and mortality rate was observed in octogenarians compared to patients aged <80 years. In conclusion, elective paraesophageal hiatal hernia repair can be performed in octogenarians, especially in patients without comorbidity. Findings suggest improvement in symptoms in short-term follow up, with minimal morbidity and mortality. With regard to surgical techniques, laparoscopy and fundoplication were performed safely. Octogenarians need to be included in future clinical trials to further evaluate the optimal surgical intervention. Preoperative risk assessment by clinical prediction rules should guide operative intervention, in order to evaluate risks and benefits in this challenging population.

Endoscopic submucosal dissection (ESD) has evolved into a viable treatment modality for superficial esophageal cancer. ESD offers a distinct advantage given the ability to perform en bloc resection enabling accurate histopathologic assessment. Data from published literature has established ESD as the preferred option in the treatment of superficial squamous cell carcinoma with complete resection rates of 78-100%, and a low rate recurrence of 0-2.6%. En bloc resection for esophageal SCC is curative for tumors with M1 (intrapethelial) or M2 (invasion into the lamina propria) involvement with no lymphovascular invasion. Tumors that contain lymphovascular invasion or submucosal invasion greater than 200 μm should be treated as advanced carcinomas due to the increased risk of lymph node metastasis. In contrast, the role of ESD in Barrett's esophagus is more limited due to the high rate of efficacy of EMR. A randomized control trial comparing EMR and ESD strategies found a higher R0 resection rate for ESD, but no significant difference in complete remission from neoplasia at 3 month follow up. Endoscopic ultrasound (EUS) has a limited role in the evaluation of superficial esophageal cancer. Alternatively, detailed endoscopic assessment along with magnification endoscopy or narrow band imaging, may provide greater utility than EUS. The most common adverse events of ESD in the esophagus include perforation and stricture. Perforation can often be managed by defect closure along with non-operative conservative management. Steroid administration with either topical or local injection can be effective management in stricture prevention. Continued refinement of ESD technique and innovation will overcome some of the current limitations of ESD and enable curative resection of superficial esophageal cancer as an alternative to invasive surgery.

Background & Aims: Guidelines recommend endoscopic surveillance of patients with Barrett's esophagus (BE) to identify those with dysplasia (a precursor of carcinoma) or early-stage esophageal adenocarcinoma (EAC) who can be treated endoscopically. However, it is unclear whether surveillance increases survival times of patients with BE. We performed a systematic review and meta-analysis to qualitatively and quantitatively examine evidence for the association of endoscopic surveillance in patients with BE with survival and other outcomes., Methods: We searched publication databases for studies reporting the effects of endoscopic surveillance on mortality and other EAC-related outcomes. We reviewed randomized controlled trials, case-control studies, studies comparing patients with BE who received regular surveillance with those who did not receive regular surveillance, and studies comparing outcomes of patients with surveillance-detected EAC vs symptom-detected EACs. We performed a meta-analysis of surveillance studies to generate summary estimates using a random effects model. The primary aim was to examine the association of BE surveillance on EAC-related mortality. Secondary aims were to examine the association of BE surveillance with all-cause mortality and EAC stage at time of diagnosis., Results: A single case-control study did not show any association between surveillance and EAC-related mortality. A meta-analysis of 4 cohort studies found that lower EAC-related and all-cause mortality were associated with regular surveillance (relative risk, 0.60; 95% CI, 0.50-0.71; hazard ratio, 0.75; 95% CI, 0.59-0.94). Meta-analysis of 12 cohort studies showed lower EAC-related and all-cause mortality among patients with surveillance-detected EAC vs symptom-detected EAC (relative risk, 0.73; 95% CI, 0.57-0.94; hazard ratio, 0.59; 95% CI, 0.45-0.76). Lead- and length-time bias adjustment substantially attenuated/eliminated the observed benefits. Surveillance was associated with detection of EAC at earlier stages. A randomized trial is underway to evaluate the effects of endoscopic surveillance on mortality in patients with BE., Conclusions: In a systematic review and meta-analysis of the effects of surveillance in patients with BE, surveillance as currently performed was associated with detection of earlier-stage EAC and may provide a small survival benefit. However, the effects of confounding biases on these estimates are not fully defined and may completely or partially explain the observed differences between surveyed and unsurveyed patients., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Radiofrequency ablation of Barrett's esophagus with low-grade dysplasia is recommended in recent American College of Gastroenterology guidelines, with endoscopic surveillance considered a reasonable alternative. Few studies have directly compared outcomes of radiofrequency ablation to surveillance and those that have are limited by short duration of follow-up. This study aims to compare the long-term effectiveness of radiofrequency ablation versus endoscopic surveillance in a large, longitudinal cohort of patients with Barrett's esophagus, and low-grade dysplasia.We conducted a retrospective analysis of patients with confirmed low-grade dysplasia at a single academic medical center from 1991 to 2014. Patients progressing to high-grade dysplasia or esophageal adenocarcinoma within one year of index LGD endoscopy were defined as missed dysplasia and excluded. Risk factors for progression were assessed via Cox proportional hazards model. Comparison of progression risk was conducted using a Kaplan-Meier analysis. Subset analyses were conducted to examine the effect of reintroducing early progressors and excluding patients diagnosed prior to the advent of ablative therapy. Of 173 total patients, 79 (45.7%) underwent radiofrequency ablation while 94 (54.3%) were untreated, with median follow up of 90 months. Seven (8.9%) patients progressed to high-grade dysplasia or adenocarcinoma despite ablation, compared with 14 (14.9%) undergoing surveillance (P = 0.44). This effect was preserved when patients diagnosed prior to the introduction of radiofrequency ablation were excluded (8.9% vs 13%, P = 0.68). Reintroduction of patients progressing within the first year of follow-up resulted in a trend toward significance for ablation versus surveillance (11.1% vs 23.8%, P = 0.053).In conclusion, progression to high-grade dysplasia or adenocarcinoma was not significantly reduced in the radiofrequency ablation cohort when compared to surveillance. Despite recent studies suggesting the superiority of radiofrequency ablation in reducing progression, diligent endoscopic surveillance may provide similar long-term outcomes.

Although no consensus is available on the treatment of esophageal squamous cell carcinoma (ESCC) invading adjacent organs (T4), establishing effective induction treatments is crucial to altering an unresectable status and achieving curative resection. Here, we evaluated the efficacy of chemotherapy using 5-fluorouracil, cisplatin, and docetaxel (DCF) as the initial induction treatment for T4 ESCC. Fifty patients without distant metastasis who underwent initial induction chemotherapy using DCF for T4 ESCC were propensity score-matched with 50 patients who underwent radiotherapy concurrent with cisplatin and 5-fluorouracil (CRT). In the DCF group, 24 (48.0%) patients underwent surgery, achieving a 64% clinical response rate compared to 72.0% for induction CRT. CRT was also performed in another 24 (48.0%) patients in the DCF group in whom surgical resection was not indicated. The DCF group had significantly higher overall resectability than the CRT group (78.0% vs. 48.0%, P = 0.0017). The esophageal perforation rate during induction treatments was significantly lower in the DCF group than the CRT group (4.0% vs. 18.0%, P = 0.0205). Prognosis was significantly better in the DCF group than the CRT group (5-year cancer-specific survival 42.1% vs. 22.2%, P = 0.0146). Thus, induction DCF chemotherapy in patients with T4 ESCC reduced esophageal perforation and increased overall resectability, leading to better survival than CRT alone. Therefore, DCF chemotherapy may be an effective and safe option for initial induction treatment of T4 ESCC.

Objective: To assess geographical sociodemographic differences in the pediatric esophageal foreign body population of Los Angeles., Methods: We retrospectively reviewed the medical records of 128 consecutive pediatric patients at Children's Hospital Los Angeles (CHLA) from 2014 to 2017 with a diagnosis of a retained foreign body in the esophagus removed by rigid or flexible esophagoscopy. Sociodemographic information including zip code of residence was extracted and analyzed with Chi-square, Fisher's exact test, and multivariable logistic regression., Results: The average age of patients with a retained esophageal foreign body in this study was 2.5 years old, 52.3% were male, 91.4% had no past medical history, 53.1% were Hispanic, 82.0% had public health insurance, and 63.3% were transfers from an outside hospital. The most common foreign body removed was a coin. There were no significant differences in gender, race, type of health insurance, or income between patients that lived within 10 miles of CHLA versus farther than 10 miles. On multivariable analysis, zip codes with a high volume of esophageal foreign bodies were more likely to be lower income neighborhoods. Gender, race, type of health insurance, and distance from CHLA were not risk factors for zip codes with a high volume of esophageal foreign bodies., Conclusion: Geographic areas in the greater Los Angeles community with a high volume of retained esophageal foreign bodies requiring endoscopic removal at our institution are associated with lower income neighborhoods. Further studies should be performed to better understand health disparities within the U.S. pediatric esophageal foreign body population., (Copyright © 2018. Published by Elsevier B.V.)

Barrett's esophagus with high-grade dysplasia (BEHGD) and intramucosal esophageal adenocarcinoma (IMC) can be treated by radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR). Efficacy of RFA and EMR in academic medical centers has been demonstrated in previous studies. However, the clinical effectiveness of this approach in community clinical practice is not fully established.All patients with biopsy-proven BEHGD and IMC (T1a), who were treated endoscopically between 2007 and 2014, were prospectively enrolled. Treatment algorithms were determined by consensus opinion after presentation at gastrointestinal tumor board. Patients underwent EMR and/or RFA until eradication-of-dysplasia and complete remission of intestinal metaplasia (CRIM) was achieved. Patients were then enrolled in an endoscopic surveillance program.A total of 60 patients underwent endoscopic therapy for BEHGD (32) or IMC (28). Median length BE was 4 cm. Forty-six patients had EMR. Median treatment interval was nine months. Median follow-up was 33 months (Interquartile range: 16-50). Fifty-five (92%) patients achieved eradication-of-dysplasia and 52(87%) CRIM. One patient with BEHGD did not achieve any benefit six months into treatment. Nine (15%) patients relapsed after CRIM with nondysplastic-BE (6), BE with low-grade dysplasia (1), and BEHGD (2). After retreatment, eradication-of-intestinal metaplasia was achieved in five patients. BE length was a negative predictor for achieving CRIM (OR 0.81; P = 0.04). There were no procedure-related severe complications. Eleven patients with prior EMR developed symptomatic strictures, which were all successfully dilated.Endoscopic management of BEHGD and IMC can be safely and effectively performed in a community clinical practice similarly to high-volume academic medical centers when performed by advanced endoscopists following multidisciplinary approach., (© The Authors 2017. Published by Oxford University Press on behalf of International Society for Diseases of the Esophagus. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Aim: To evaluate the accuracy of endoscopic ultrasound (EUS) in early esophageal cancer (EC) performed in a high-volume tertiary cancer center., Methods: A retrospective review of patients undergoing esophagectomy was performed and patients with cT1N0 and cT2N0 esophageal cancer by EUS were evaluated. Patient demographics, tumor characteristics, and treatment were reviewed. EUS staging was compared to surgical pathology to determine accuracy of EUS. Descriptive statistics was used to describe the cohort. Student's t test and Fisher's exact test or χ 2 test was used to compare variables. Logistic regression analysis was used to determine if clinical variables such as tumor location and tumor histology were associated with EUS accuracy., Results: Between 2000 and 2015, 139 patients with clinical stageIorIIA esophageal cancer undergoing esophagectomy were identified. There were 25 (18%) female and 114 (82%) male patients. The tumor location included the middle third of the esophagus in 11 (8%) and lower third and gastroesophageal junction in 128 (92%) patients. Ninety-three percent of patients had adenocarcinoma. Preoperative EUS matched the final surgical pathology in 73/139 patients for a concordance rate of 53%. Twenty-nine patients (21%) were under-staged by EUS; of those, 19 (14%) had unrecognized nodal disease. Positron emission tomography (PET) was used in addition to EUS for clinical staging in 62/139 patients. Occult nodal disease was only found in 4 of 62 patients (6%) in whom both EUS and PET were negative for nodal involvement., Conclusion: EUS is less accurate in early EC and endoscopic mucosal resection might be useful in certain settings. The addition of PET to EUS improves staging accuracy., Competing Interests: Conflict-of-interest statement: We have no financial relationships to disclose.

Objectives: To assess the role of day-care management of upper aerodigestive tract (UADT) panendoscopy and to study criteria for conventional hospital admission and reasons for conversion., Patients and Methods: Retrospective study, from January 2011 to May 2013. Inclusion criteria UADT panendoscopy for carcinoma assessment. Study variables, age, gender, tumor location, reason for panendoscopy, TNM stage, previous external radiotherapy, home-to-hospital distance and Apfel, Detsky and ASA scores. A day-care and a conventional admission group were compared using Fisher's test for ASA score, student's test for age and Pearson's chi 2 test for the other variables., Results: Four hundred and thirty-six panendoscopies were performed: 252 in day-care, including 4 cases of conversion and 184 with conventional admission. There were no significant differences between groups for age, gender, tumor location, TNM stage, reason for panendoscopy, previous external radiotherapy, home-to-hospital distance or Apfel score. A significant difference was observed for ASA score (P<0.0001) and Detsky score (P=0.03). In 39% of cases, the reason for hospital admission without criteria defined by the French Society of Anesthesia and Intensive Care Medicine (SFAR) and French Health Authority (HAS) was the patient's refusal of day care. In 10% of conventional admissions, day-care was not implemented because of psychosocial factors., Conclusion: Day-care management is appropriate for UADT panendoscopy in selected patients. The reasons for the high rate of patient refusal should be studied., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Background: The routine use of esophagogastroduodenoscopy (EGD) before laparoscopic Roux-en-y gastric bypass (LRYGB) is debatable. Various studies have reported high diagnostic yield of routine EGD before LRYGB to detect pathologies that could alter surgical management. However, other studies have found that preoperative EGD did not identify significant pathologies that changed clinical management; therefore, it is not indicated in asymptomatic patients., Objectives: We aimed to study the utility of routine EGD in patients before LRYGB., Setting: Academic teaching hospital, (Royal Alexandra Hospital, Canada)., Methods: A retrospective review of patients undergoing LRYGB with 1 surgeon at our hospital from May 2014 to March 2016 was completed. EGD findings were compared with surgical gastrojejunal specimen pathology and postoperative complications., Results: There were 116 patients who underwent EGD before LRYGB with 113 reported EGDs, of which 46.0% were normal, 40.7% had findings that did not result in a change of management, and 13.3% had findings resulting in a change of management. In the gastrojejunal specimen, 16 patients (14.2%) were found to have chronic gastritis. The relative risk of patients having gastrojejunal gastritis was 5.1 (P<.0005) for patients with gastritis on EGD and 5.1 (P<.0005) for patients with Helicobacter pylori infection on EGD. After surgery, 18 patients (15.9%) had complications. Preoperative EGD findings were not associated with postoperative complications., Conclusion: Based on the findings from this study, we recommend using less invasive screening in the routine workup of patients awaiting LRYGB and reserving EGD for symptomatic patients., (Copyright © 2017 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Esophagogastroduodenoscopy (EGD) has become a key element in the diagnosis and therapy of many gastrointestinal diseases affecting children. The aim of this study was to evaluate predictors of positive outcomes in children undergoing their first diagnostic EGD with biopsies at a single center., Results: This retrospective study was based on findings from existing EGD and histopathological reports. All procedures were performed between July 2006 and July 2013. Details of each patient's clinical presentation and EGD were abstracted from medical records to determine the predictors of positive EGD outcomes. A total of 1133 records of patients between the ages of 0 and 18 years old were evaluated. Of these patients, 51.5% (n = 573) were female and 24.5% (n = 278) were younger than 4 years old. The mean age at the time of EGD was 9.6 ± 5.7 years (mean ± standard deviation). The most common indications for the procedure were abdominal pain (54.9%) and emesis (31.9%). The overall prevalence of any endoscopic abnormality was 54.5% and the overall prevalence of any histological abnormality was 59.1%. A multivariate logistic regression found that patients 12 years or older (odds ratio, OR = 1.46; 95% confidence interval, CI 1.31-1.63), African-American race (OR = 2.20; 95% CI 1.45-3.34), dysphagia (OR = 1.96; 95% CI 1.28-3.00) and positive celiac antibodies (OR = 2.25; 95% CI 1.52-3.34) were all significant independent predictors of a positive EGD outcome., Conclusions: Several clinical variables were found to be independent predictors of positive EGD outcomes in children and adolescents. Prospective studies using standardized definitions of clinical variables and endoscopy outcomes are needed to further understand predictors of positive EGDs.

Introduction: Esophagitis dissecans superficialis (EDS) is a rare desquamative disorder of the eso-phagus, characterized by sloughing of the superficial mucosa. It is a benign entity of uncertain etiology. Most cases of EDS are idiopathic but can be caused by medications, hot beverages, chemical irritants, celiac disease and many skin conditions., Aim: Knowing that few case series have described this entity, we decided to review all the cases diagnosed in our center to characterize them., Methods: The pathological institutional database of Erasme University Hospital (Brussels, Belgium) was searched for the diagnosis of EDS. We reviewed retrospectively the clinical and endoscopic findings as well as histological features of all cases of EDS (Table 1). During this period of time, 21497 upper gastrointestinal endoscopies have been performed in our institution., Results: From January 2010 to September 2016, we identified 7 cases of EDS diagnosed in our institution in this time period. During the same period, 21497 upper gastrointestinal endoscopies were performed (incidence 0.03%). Endoscopic findings evoked in 2 patients a suspicion of an esophageal tumor; the first one was described as a raised detached lesion of the distal third of the esophagus with suspicion of squamous cell carcinoma (Fig. 1) and the second as a suspected tumor of the proximal third of the esophagus (Fig. 2). For other patients, EDS was misdiagnosed as unspecific esophagitis in 2, reflux or mycotic esophagitis in 2. Only one patient was suspected to have sloughing esophagitis.Histologic features present in all of those cases were characterized by the presence of a sloughing and necrosis of the superficial layer of the esophageal squamous epithelium with negative anti HSV and anti CMV antibodies, negative periodic acid Schiff stain for fungal infections as well as absence of signs of dysplasia or signs of malignancy. In 2 patients, there was a presence of multiple bacterial colonies on the superficial epithelium. Acute inflammation was reported in 4 of the patients with the presence of eosinophils in the superficial epithelium described in 2 of these patients and of polymorphonuclear leukocytes in 2 other patients (Fig. 3).An endoscopic follow up 2 months after PPI treatment performed in 3 patients, 2 of them had an atypical endoscopic presentation with suspicion of a tumor on endoscopic examination showed a complete resolution of the esophageal lesions was observed in these patients., Conclusion: EDS is a rare benign entity that endoscopists must be aware of in order not to mistake it for other entities such as esophagitis or squamous cell carcinoma. The diagnosis is based on biopsies. The prognosis is good after stopping the causative agent., (© Acta Gastro-Enterologica Belgica.)

Objective: To analyze the efficacy of endoscopic screening for esophageal cancer in high risk population from high risk areas in order to provide scientific basis for evaluation of the results of early diagnosis and treatment of esophageal cancer. Methods: Ten high incidence cities and counties of esophageal cancer in Sichuan province were included in this study. Subjects aged 40-69 years were selected to participate in the endoscopic screening based on the cluster sampling, and the screening-positive subjects were further confirmed by pathological examination. Results: A total of 105 561 subjects were screened during 2006-2014 in 10 cities and counties in Sichuan Province. The detection rate of precancerous lesions was 5.53% (5 841/105 561), and the positive detection rate was 1.13% (1 193/105 561). The overall detection rates of low-grade hyperplasia, moderate hyperplasia, high-grade hyperplasia/carcinoma in situ, early esophageal cancer and invasive carcinoma were 3.87% (4 089/105 561), 1.66% (1 752/105 561), 0.77% (816/105 561), 0.08% (84/105 561) and 0.28% (293/105 561), respectively. The detection rates of all lesions in males were significantly higher than those in females ( P <0.05), and were gradually increased with age ( P <0.05). Conclusions: At these ten cities and counties in Sichuan Province with high incidence of esophageal cancer, the endoscopic screening has good effect. There are considerable numbers of patients aged 40-69 with precancerous lesions from the high risk areas. Improving the follow-up work of the population with precancerous lesions will achieve better results of early diagnosis and early treatment.

Objectives/hypothesis: Visualization by endoscopy is essential in the diagnosis of upper aerodigestive tract lesions. Recent studies showed that narrow band imaging (NBI) increases the diagnostic potential of conventional white light imaging (WLI) by highlighting the superficial vessels. The objective of this study was to evaluate whether the use of NBI would influence inter- and intraobserver agreement while making diagnostic decisions using rigid endoscopy of the upper aerodigestive tract., Study Design: Retrospective study., Methods: One hundred routinely collected pictures of laryngeal, hypopharyngeal, and oropharyngeal lesions were used. Rigid endoscopies and patient data collection were performed according to standard protocol. Twelve observers, grouped in different levels of experience, assessed all lesions twice with a 2 to 4 week interval. Fleiss and Cohen's kappa (κ) values were calculated to assess inter- and intraobserver agreement., Results: Overall interobserver agreement increased from κ = 0.34 to κ = 0.40 by adding NBI to WLI (WLI and WLI + NBI, respectively). In experienced observers, an improvement from κ = 0.39 to κ = 0.43 was observed; in less-experienced observers an improvement from κ = 0.30 to κ = 0.37 was observed. Overall intraobserver agreement increased from moderate (κ = 0.54) to substantial (κ = 0.63) with addition of NBI. Intraobserver agreement for less-experienced observers improved remarkably when WLI was combined with NBI (κ = 0.51 vs. κ = 0.67)., Conclusions: Addition of NBI during rigid endoscopies of the upper aerodigestive tract led to improvement of both inter- and intraobserver agreement., Level of Evidence: 4 Laryngoscope, 126:2276-2281, 2016., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To determine the sensitivity and specificity for assessing pharyngeal residue, laryngeal penetration, and tracheal aspiration when comparing findings from the Static Endoscopic Evaluation of Swallowing (SEES) with findings from the Videofluoroscopic Swallow Study (VFSS)., Methods: Retrospective study at a tertiary academic medical center. Records were reviewed consecutive outpatients who underwent both SEES and VFSS evaluations. Video segments from SEES and VFSS examinations were blindly judged by experienced clinicians on a categorical/ordinal rating form for the absence, quantitative presence, and location of postswallow residue, penetration, and aspiration. Statistical analysis was performed to identify intra- and interrater reliability and correlation between SEES and VFSS findings., Results: Thirty-nine patients were identified who met the above inclusion criteria, for a total of 206 video segments. Inter- and intrarater reliability was judged by Cronbach's alpha to be good to excellent. SEES findings revealed statistically significant correlations with VFSS findings (P < 0.001) with the absence, quantitative presence, and location of thin liquid and solid swallow residue, penetration, and aspiration. In addition, SEES was more sensitive to the presence of liquid residue, penetration, and aspiration than VFSS., Conclusion: SEES is an endoscopic screening procedure that strengthens the clinical swallowing evaluation by documenting the presence or absence of postswallow residue, penetration, and aspiration. Accurate identification of a patient's risk for aspiration helps to direct further workup. It is an expedient, repeatable, and clinical relevant procedure that can be easily incorporated into a clinician's practice., Level of Evidence: 4. Laryngoscope, 126:2291-2294, 2016., Competing Interests: The authors in this study certify that they have no non-financial interest in the subject matter or materials discussed in this manuscript., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives: Routine oesophago-gastro-duodenoscopy (OGD) pre-liver transplantation (LT) for evaluation and management of gastrointestinal (GI) pathology, in particular GI varices secondary to portal hypertension, is common practice in adult LT programmes. There is no universal consensus for this practice in children. We report our endoscopic experience in children with end-stage liver disease (ESLD) pre-LT., Methods: Retrospective audit of LT database and review of OGD findings of patients who had undergone endoscopy preceding LT., Results: Of 69 patients with ESLD, 50 (72.4%) had pre-LT OGD, 37 of which were done electively, whereas the remaining 13 were event driven. Forty-eight (96%) patients who underwent OGD had abnormalities, in which 38 (76%) patients had varices and 23 (46%) had portal hypertensive gastropathy. Eleven (22%) patients required therapeutic intervention at initial OGD either with endoscopic variceal band ligation or endoscopic sclerotherapy. Compared with the group who underwent elective OGDs, the group who had event-driven OGDs had a significantly higher requirement for endoscopic intervention (P < 0.0001), occurrence of rebleeding (P < 0.029) and requirement for repeat OGDs (P = 0.014). There was no significant difference in terms of patient (P = 0.2746) or graft survival (P = 0.3192) between the 2 groups., Conclusions: The role of pre-LT OGDs in patients with ESLD associated with portal hypertension is possibly limited to control of bleeding during episodes of GI bleed, where the aim would be to stabilize the patient until eventual LT. Multicentre prospective studies are required to provide more evidence on the use of routine endoscopy for pre-LT assessment in children.

This prospective population-based study was designed to evaluate treatment choices in patients with new manometrically diagnosed achalasia and their outcomes. Patients referred to the esophageal function laboratory were enrolled after a new manometric diagnosis of achalasia. Patients completed an initial achalasia symptom score validated questionnaire on their symptom severity, duration, treatment pre-diagnosis and Medical Outcomes Study 36-item Short-Form (SF-36) survey. Treatment decisions were made by the referring physician and the patient. Follow-up questionnaires were completed every 3 months for 1 year. Patients who chose not to undergo treatment at 1-year follow-up completed another questionnaire after 5 years. Between January 2004 and January 2005, 83 of 124 eligible patients were enrolled. Heller myotomy was performed on 31 patients, three patients received botulinum toxin injections, and 25 patients received 29 pneumatic balloon dilatations. Twenty-four patients chose to receive no treatment. Following treatment, patients treated with surgery, dilatation and botulinum toxin had an average improvement in achalasia symptom score of 23 +/- 12.2, 17 +/- 10.9, and 9 +/- 14, respectively. Patients receiving no treatment had worsening symptoms with a symptom score change of -3.5 +/- 11.4. Surgery and dilatation resulted in significant improvement (P < 0.01) relative to no treatment. In univariate logistic regression, symptom severity score (odds ratio [OR] 1.04, 95% confidence interval [CI] 1.00 to 1.08), sphincter tone (OR 1.04, 95% CI 1.00 to 1.09), difficulty swallowing liquids (OR 3.21, 95% 1.15 to 8.99), waking from sleep (OR 2.75, 95% 1.00 to 7.61), and weight loss (OR 5.99, 95% CI 1.93 to 18.58) were all significant in predicting that patients would select treatment. In the multivariate analysis, older age (OR 1.05, 95% CI 1.01 to 1.09) and weight loss (OR 3.91, 95% CI 1.02 to 15.2) were statistically significant for undergoing treatment. At 5 years, five (21%) of those who had initially declined treatment at 1 year ultimately chose a treatment. Patients who finally chose Heller myotomy had lower mental component dimension scores on the SF-36 at 1 year than those who did not. This study shows that almost one third of patients with manometrically diagnosed achalasia choose not to undergo treatment within 1 year of their diagnosis. Patients who are more symptomatic appear to be more likely to undergo treatment by univariate analysis. In multivariate analysis, increasing age and weight loss are predictive of those who will undergo treatment, with weight loss having the greatest influence. Patients who choose not to undergo treatment make lifestyle changes to maintain their quality of life, and only a minority of them ultimately undergo treatment., (© 2015 International Society for Diseases of the Esophagus.)

Background: Peroral endoscopic myotomy (POEM) is a novel surgical option for the treatment of achalasia. Most centers perform a routine esophagram on postoperative day (POD) #1 to rule esophageal perforation and leaks. In this study, we sought to determine the clinical utility of routine contrast studies post-POEM., Methods: POEM was performed using an anterior submucosal tunnel and selective myotomy of the circular muscle layer. A routine contrast esophagram was obtained on POD #1. We conducted a retrospective review of the radiologists' interpretations of these studies and compared them to patient's clinical course., Results: Seventy-eight patients were included. Among these, two complications occurred. One patient was non-compliant with postoperative nil per os orders and developed epigastric pain suspicious for a leak that was demonstrated on esophagram. Another patient had subcutaneous emphysema on POD #1 esophagram, a finding that was also present on physical examination, without esophageal leakage. Another esophagram in an asymptomatic patient was suspicious for submucosal tunnel hematoma which prompted a return to the operating room with negative results. Overall, 56 patients had abnormal studies. POD #1 esophagram demonstrated a sensitivity of 100 % and specificity of 45 % in identifying clinically significant complications., Conclusions: In this series, we found routine esophagram to have a high sensitivity but a very low specificity in detecting clinically significant complications. Routine esophagram after POEM may not be necessary.

Introduction: Neoplastic changes (mild or high grade intraepithelial neoplasia (L- or HGIEN) or early cancer) in Barrett esophagus are treated with various methods. This study compares clinical-economical aspects of sole stepwise radical endoscopic resection (SRER) against combination treatment with EMR (Endoscopic mucosal resection) and RFA (radiofrequency ablation)., Material and Methods: Based on clinical data from a randomized controlled trial 1 we developed an economic model for costs of treatment according to the German Hospital Remuneration System (G-DRG). Our calculating incorporated initial treatment costs and the cost of treating complications (both paid via G-DRG)., Results: Medical and economically, the treatment with EMR + RFA advantages over sole SRER treatment 1. The successful complete resection or destruction of neoplastic intestinal metaplastic tissue is similar in both procedures. Acute complications (24 vs. 13 % in SRER EMR + RFA) and late complications (88 vs. 13 % in SRER EMR + RFA) are significantly more likely in sole SRER than in the EMR + RFA., Discussion: While SRER initially appears more cost-effective as a sole therapy, cost levels move significantly above EMR+RFA due to higher complication rates and following procedures costs. Overall, the costs of treatment was € 13 272.11 in the SRER group and € 11 389.33 in the EMR + RFA group. The EMR + RFA group thus achieved a cost advantage of € 1882.78. The study shows that the treatment of neoplastic Barrett esophagus with EMR + RFA is also appropriate in economic terms., (© Georg Thieme Verlag KG Stuttgart · New York.)