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Esophageal cancer (EC) often cannot be discovered in time because of its asymptomatic or symptom-atypical characteristics in early stage. The risk and probability of lymph node metastasis and distant metastasis increase correspondingly as the cancer aggressively invades deeper layers. Treatment regimens may be shifted to surgery and chemoradiotherapy (CRT) from endoscopic eradication therapy (EET) with poor quality of life and prognosis. It is imperative to identify dysplasia and EC early and enable early curative endoscopic treatments. Newer methods have been attempted in the clinical setting to achieve early detection at a more microscopic and precise level. Newer imaging techniques and artificial intelligence (AI) technology have been involved in targeted biopsies and will gradually unveil the visualization of pathology in the future. Early detection and diagnosis are the prerequisite to choose personal and precise treatment regimens. EET has also been undergoing development and improvement to benefit more patients as the first option or the firstly chosen alternative therapy, when compared with esophagectomy. More clinical studies are needed to provide more possibilities for EET.

Background and Aim: Although endoscopic recognition of dysplasia in Barrett's esophagus is difficult, experience in recognition of early neoplastic lesions is supposed to increase the detection of early neoplastic lesions. The aim of this study was to assess the significance of dysplasia in random biopsies in Barrett's esophagus, in the absence of reported visible lesions as well as the difference in final outcome of pathology., Methods: We retrospectively identified all patients with Barrett's esophagus with suspicion of dysplasia or early adenocarcinoma who were referred to our center between February 2008 and April 2016. We analyzed all endoscopy reports, pathology reports, and referral letters from 19 different hospitals. Patients were divided into two groups, based on the presence or absence of visible lesions reported upon referral., Results: In total, 170 patients diagnosed with dysplasia or adenocarcinoma were referred to our tertiary center. Ninety-one of these referred patients were referred with dysplasia or adenocarcinoma in random biopsies, without a reported lesion during endoscopy in the referral center. During endoscopic work-up at our center, a visible lesion was detected in 44 of these 91 patients (48.4%). After endoscopic work-up and treatment, adenocarcinoma was found in an additional 21 patients. Two of these patients were initially referred with low-grade dysplasia, and 19 patients were initially referred with high-grade dysplasia. The final pathology was upstaged in 35.8% of the patients., Conclusions: The presence of any grade of dysplasia in random biopsies during surveillance in referral centers is a marker for more severe final pathology. Training in recognition of early neoplastic lesions in Barrett's esophagus imaging is recommended for endoscopists performing Barrett's surveillance.

Background: There is a large Barrett's esophagus patient population undergoing endoscopic surveillance. Methods to stratify patients into higher and lower risk groups may enable more varied surveillance intervals for patients with non-dysplastic Barrett's esophagus that could optimize use of endoscopy resources., Objective: We aimed to assess whether risk of progression to esophageal adenocarcinoma differed in patients with multiple endoscopic biopsies negative for dysplasia., Methods: We conducted a retrospective cohort study among individuals from the population-based Northern Ireland Barrett's register with a histologically confirmed diagnosis of non-dysplastic Barrett's esophagus (with intestinal metaplasia) between 1993 and 2010, who had at least one endoscopic biopsy conducted at least 12 months after diagnosis. We used Poisson regression to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for the association between number of successive endoscopies showing non-dysplastic Barrett's esophagus and risk of esophageal adenocarcinoma alone, and combined with high-grade dysplasia, at the next endoscopy., Results: We identified 1761 individuals who met our eligibility criteria. Subsequent risk of progression to esophageal adenocarcinoma was lower at the next endoscopy following two endoscopies showing non-dysplastic Barrett's esophagus (IRR 0.26, 95% CI 0.10-0.66) than following one endoscopy showing non-dysplastic Barrett's esophagus. Similar findings were apparent for risk of progression to esophageal adenocarcinoma or high-grade dysplasia (IRR 0.41, 95% CI 0.22-0.79)., Conclusion: The lower risk of malignant progression in individuals with persistent non-dysplastic Barrett's esophagus over two consecutive endoscopic biopsies but not for longer term persistence does not support hypotheses of persistence being an indicator of less biologically aggressive lesions. Instead, the initial difference may be attributable to post-endoscopy cancers and support the necessity of adhering to robust quality standards for endoscopic procedures.

Introduction: OFBO is a common occurrence in the emergency setting. Endoscopic removal via rigid or flexible oesophagoscopy is only performed following failure to pass the obstruction after a period of observation and medical management. Despite recommendations from the ESGE, there is currently a lack of high-quality evidence to support the diagnostic work-up of these patients., Purpose: The purpose of this single centre study was to assess the outcome and follow-up of this population over a 5-year period. We retrospectively collected data regarding all patients undergoing emergency oesophagoscopy between 2012-2017 and recorded their outcomes and subsequent follow-up. R esults: We found that only 33% of patients had diagnostic investigations performed post-operatively and oesophageal pathology was detected in 44% of those investigated. Eosinophilic oesophagitis was the most common diagnosis and OGD was more likely to detect pathology compared to other modalities. C onclusion: Our study suggests that our findings could have been higher had all our patients underwent further investigation. Therefore, we would recommend a diagnostic work-up in all patients following a discussion of the risks associated with an endoscopic examination. We thoroughly support further large-scale collaborative research which can shed better light of evidence on the topic.

Objective: The purpose of this study was to explore nationwide trends in treatment and outcomes of T1N0 esophageal cancer., Background: Endoscopic treatment has become an accepted option for early-stage esophageal cancer, but nationwide utilization rates and outcomes are unknown., Methods: T1N0 esophageal cancers were identified in the National Cancer Database from 2004 to 2014. We assessed trends in treatment; compared endoscopic therapy, esophagectomy, chemoradiation, and no treatment; and performed a subgroup analysis of T1a and T1b patients from 2010 to 2014 (AJCC 7)., Results: A total of 12,383 patients with clinical T1N0 esophageal cancer were analyzed. Over a decade, use of endoscopic therapy increased from 12.7% to 33.6%, whereas chemoradiation and esophagectomy decreased, P < 0.01. The rise in endoscopic treatment of T1a disease from 42.7% to 50.6% was accompanied by a decrease in esophagectomies from 21.7% to 12.8% (P < 0.01). For T1b disease, the rise in endoscopic treatment from 16.9% to 25.1% (P = 0.03) was accompanied by decreases in no treatment and chemoradiation, whereas the rate of esophagectomies remained approximately 50%. Unadjusted median survival was longer for patients undergoing resection: esophagectomy, 98.6 months; endoscopic therapy, 77.7 months; chemoradiation, 17.3 months; no treatment, 8.2 months; P < 0.01. Risk-adjusted Cox modeling showed esophagectomy was associated with improved survival [hazard ratio (HR): 0.85], and chemoradiation (HR: 1.79) and no treatment (HR: 3.57) with decreased survival, compared to endoscopic therapy (P < 0.01)., Conclusions: Use of endoscopic therapy for T1 esophageal cancer has increased significantly: for T1a, as an alternative to esophagectomy; and for T1b, as an alternative to no treatment or chemoradiation. Despite upfront risks, long-term survival is highest for patients who can undergo esophagectomy.

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.)

The widespread adoption of high-resolution manometry (HRM) has led to a restructuring in the classification of esophageal motility disorder classification summarized in the Chicago Classification, currently in version 3.0. It has become apparent that the cardinal feature of achalasia, impaired lower esophageal sphincter relaxation, can occur in several disease phenotypes: without peristalsis, with premature (spastic) distal esophageal contractions, with panesophageal pressurization, or even with preserved peristalsis. Furthermore, despite these advances in diagnostics, no single manometric pattern is perfectly sensitive or specific for idiopathic achalasia and complimentary assessments with provocative maneuvers during HRM or interrogating the esophagogastric junction with the functional luminal imaging probe during endoscopy can be useful in clarifying equivocal or inexplicable HRM findings. Using these tools, we have come to conceptualize esophageal motility disorders as characterized by obstructive physiology at the esophagogastric junction, smooth muscle esophagus, or both. Recognizing obstructive physiology as a primary target of therapy has become particularly relevant with the development of a minimally invasive technique for performing a calibrated myotomy of the esophageal circular muscle, the POEM procedure. Now and going forward, optimal management is to render treatment in a phenotype-specific manner: e.g. POEM calibrated to patient-specific physiology for spastic achalasia and spastic disorders of the smooth muscle esophagus, more conservative strategies (pneumatic dilation) for the disorders limited to the sphincter., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Endoscopic techniques such as high-definition and optical-chromoendoscopy have had enormous impact on endoscopy practice. Since these techniques allow assessment of most subtle morphological mucosal abnormalities, further improvements in endoscopic practice lay in increasing the detection efficacy of endoscopists. Several new developments could assist in this. First, web based training tools could improve the skills of the endoscopist for enhancing the detection and classification of lesions. Secondly, incorporation of computer aided detection will be the next step to raise endoscopic quality of the captured data. These systems will aid the endoscopist in interpreting the increasing amount of visual information in endoscopic images providing real-time objective second reading. In addition, developments in the field of molecular imaging open opportunities to add functional imaging data, visualizing biological parameters, of the gastrointestinal tract to white-light morphology imaging. For the successful implementation of abovementioned techniques, a true multi-disciplinary approach is of vital importance., (Copyright © 2018 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Introduction: Gastroesophageal reflux disease (GERD) has a large economic burden with important complications that include esophagitis, Barrett's esophagus, and adenocarcinoma. Despite endoscopy, validated patient questionnaires, and traditional ambulatory pH monitoring, the diagnosis of GERD continues to be challenging. Areas covered: This review will explore the difficulties in diagnosing GERD with a focus on new developments, ranging from basic fundamental changes (histology and immunohistochemistry) to direct patient care (narrow-band imaging, impedance, and response to anti-reflux surgery). We searched PubMed using the noted keywords. We included data from full-text articles published in English. Further relevant articles were identified from the reference lists of review articles. Expert commentary: Important advances in novel parameters in intraluminal impedance monitoring such as baseline impedance monitoring has created some insight into alternative diagnostic strategies in GERD. Recent advances in endoscopic assessment of esophageal epithelial integrity via mucosal impedance measurement is questioning the paradigm of prolonged ambulatory testing for GERD. The future of reflux diagnosis may very well be without the need for currently employed technologies and could be as simple as assessing changes in epithelia integrity as a surrogate marker for GERD. However, future studies must validate such an approach.

The local control effect of esophagectomy with three-field lymph node dissection (3FLD) is reaching its limit pending technical advancement. Minimally invasive esophagectomy (MIE) by thoracotomy is slowly gaining acceptance due to advantages in short-term outcomes. Although the evidence is slowly increasing, MIE is still controversial. Also, the results of treatment by surgery alone are limiting, and multimodality therapy, which includes surgical and non-surgical treatment options including chemotherapy, radiotherapy, and endoscopic treatment, has become the mainstream therapy. Esophagectomy after neoadjuvant chemotherapy (NAC) is the standard treatment for clinical stages II/III (except for T4) esophageal cancer, whereas chemoradiotherapy (CRT) is regarded as the standard treatment for patients who wish to preserve their esophagus, those who refuse surgery, and those with inoperable disease. CRT is also usually selected for clinical stage IV esophageal cancer. On the other hand, with the spread of CRT, salvage esophagectomy has traditionally been recognized as a feasible option; however, many clinicians oppose the use of surgery due to the associated unfavorable morbidity and mortality profile. In the future, the improvement of each treatment result and the establishment of individual strategies are important although esophageal cancer has many treatment options.

Exciting new developments-pharmacologic, endoscopic, and surgical-have arisen for the treatment of many esophageal diseases. Refractory gastroesophageal reflux disease presents a therapeutic challenge, and several new options have been proposed to overcome an insufficient effectiveness of proton pump inhibitors. In patients with distal esophageal spasm, drugs and endoscopic treatments are the current mainstays of the therapeutic approach. Treatment with proton pump inhibitors (or antireflux surgery) should be considered in patients with Barrett's esophagus, since a recent meta-analysis demonstrated a 71% reduction in risk of neoplastic progression. Endoscopic resection combined with radiofrequency ablation is the standard of care in patients with early esophageal adenocarcinoma. Mucosal squamous cancer may also be treated endoscopically, preferably with endoscopic submucosal dissection. Patients with upper esophageal cancer often refrain from surgery. Robot-assisted, thoracolaparoscopic, minimally invasive esophagectomy may be an appropriate option for these patients, as the robot facilitates a good overview of the upper mediastinum. Induction chemoradiotherapy is currently considered as standard treatment for patients with advanced squamous cell carcinoma, while the role of neoadjuvant therapy for adenocarcinoma remains controversial. A system for defining and recording perioperative complications associated with esophagectomy has been recently developed and may help to find predictors of mortality and morbidity., (© 2016 New York Academy of Sciences.)

Background: With the introduction of new treatment paradigms for esophageal perforation, the management of this highly morbid condition is evolving. We reviewed our experience to investigate the modern management and outcomes of esophageal perforations with a focus on operatively repaired patients., Methods: A retrospective review of all esophageal perforations was conducted between August 2003 and January 2016., Results: A total of 48 patients were identified, with iatrogenic injury in 19 (40%), spontaneous perforation in 18 (38%), and traumatic/foreign body causes in 11 (23%). The distal esophagus was the site of perforation in 63% of the patients, and the duration of time between perforation and treatment was <24 hours in 60%. Nonoperative management was employed in 18 (38%) and operative repair in 30 (primary operative repair = 20, drainage = 4, esophagectomy = 6). Iatrogenic and traumatic perforations were more likely to be treated nonoperatively (68%), while all spontaneous perforations were treated by operative intervention. There were no complications or mortalities in the nonoperative group and only a 5% reintervention rate. In the operative group, complications occurred in 10 (33%), reinterventions in 13 (43%), and mortality in 2 (7%) patients., Conclusion: Our study highlights the importance of considering the etiology of a perforation when planning management and the success of nonoperative treatment with careful patient selection. In addition, operative repair in septic patients yielded excellent outcomes and should be the standard for comparison in future studies exploring endoscopic approaches., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Early in the twenty-first century, novel endoscopic techniques were introduced for the management of gastroesophageal reflux disease, providing minimally invasive ways to eliminate pharmacologic acid inhibition and avoid the need for anti-reflux surgery. These techniques do not significantly alter the anatomy of the gastroesophageal junction, minimizing short- and long-term adverse effects, such as dysphagia and bloating. After extensive clinical testing, many endoscopic therapies were abandoned due to either lack of durable efficacy or unfavorable safety profile. Today, only four such therapies remain clinically available, each with variable levels of clinical validation and market penetration. This review will provide an assessment of these endoscopic therapies, highlighting their respective strengths and weaknesses and their present and future applicability to patients with gastroesophageal reflux disease.

The 21st century offers new advances in diagnostic procedures and protocols in the management of esophageal diseases. This review highlights the most recent advances in esophageal diagnostic technologies, including clinical applications of novel endoscopic devices, such as ultrathin endoscopy and confocal laser endomicroscopy for diagnosis and management of Barrett's esophagus; novel parameters and protocols in high-resolution esophageal manometry for the identification and better classification of motility abnormalities; innovative connections between esophageal motility disorder diagnosis and detection of gastroesophageal reflux disease (GERD); impedance-pH testing for detecting the various GERD phenotypes; performance of distensibility testing for better pathophysiological knowledge of the esophagus and other gastrointestinal abnormalities; and a modern view of positron emission tomography scanning in metastatic disease detection in the era of accountability as a model for examining other new technologies. We now have better tools than ever for the detection of esophageal diseases and disorders, and emerging data are helping to define how well these tools change management and provide value to clinicians. This review features novel insights from multidisciplinary perspectives, including both surgical and medical perspectives, into these new tools, and it offers guidance on the use of novel technologies in clinical practice and future directions for research., (© 2016 New York Academy of Sciences.)

Background: Until recently, oesophagectomy was the treatment of choice for early oesophageal cancer. Endoscopic treatment has been introduced relatively recently. This observational national database study aimed to describe how endoscopic therapy has been introduced in England and to examine the safety of this approach., Methods: A population-based cohort study was undertaken of patients diagnosed with oesophageal adenocarcinoma between October 2007 and June 2009 using three linked national databases. Patients with early-stage disease (T1 tumours with no evidence of spread) were identified, along with the primary treatment modality where treatment intent was curative. Short-term outcomes after treatment and 5-year survival were evaluated., Results: Of 5192 patients diagnosed with oesophageal adenocarcinoma, 306 (5·9 per cent) were considered to have early-stage disease before any treatment, of whom 239 (79·9 per cent of 299 patients with data on treatment intent) were managed with curative intent. Of 175 patients who had an oesophagectomy, 114 (65·1 (95 per cent c.i. 57·6 to 72·7) per cent) survived for 5 years. Among these, 47 (30·3 per cent of 155 patients with tissue results available) had their disease upstaged after pathological staging; this occurred more often in patients who did not have staging endoscopic ultrasonography before surgery. Of 41 patients who had an endoscopic resection, 27 (66 (95 per cent c.i. 49 to 80) per cent) survived for 5 years. Repeat endoscopic therapy was required by 23 (56 per cent) of these 41 patients., Conclusion: Between 2007 and 2009, oesophagectomy remained the initial treatment of choice (73·2 per cent) among patients with early-stage oesophageal cancer treated with curative intent; one in five patients were managed endoscopically, and this treatment was more common in elderly patients. Although the groups had different patient characteristics, 5-year survival rates were similar., (© 2016 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Capsule endoscopy (CE) has transformed investigation of the small bowel providing a non-invasive, well tolerated means of accurately visualising the distal duodenum, jejunum and ileum. Since the introduction of small bowel CE thirteen years ago a high volume of literature on indications, diagnostic yields and safety profile has been presented. Inclusion in national and international guidelines has placed small bowel capsule endoscopy at the forefront of investigation into suspected diseases of the small bowel. Most commonly, small bowel CE is used in patients with suspected bleeding or to identify evidence of active Crohn's disease (CD) (in patients with or without a prior history of CD). Typically, CE is undertaken after upper and lower gastrointestinal flexible endoscopy has failed to identify a diagnosis. Small bowel radiology or a patency capsule test should be considered prior to CE in those at high risk of strictures (such as patients known to have CD or presenting with obstructive symptoms) to reduce the risk of capsule retention. CE also has a role in patients with coeliac disease, suspected small bowel tumours and other small bowel disorders. Since the advent of small bowel CE, dedicated oesophageal and colon capsule endoscopes have expanded the fields of application to include the investigation of upper and lower gastrointestinal disorders. Oesophageal CE may be used to diagnose oesophagitis, Barrett's oesophagus and varices but reliability in identifying gastroduodenal pathology is unknown and it does not have biopsy capability. Colon CE provides an alternative to conventional colonoscopy for symptomatic patients, while a possible role in colorectal cancer screening is a fascinating prospect. Current research is already addressing the possibility of controlling capsule movement and developing capsules which allow tissue sampling and the administration of therapy.

Barrett's esophagus (BE) is a metaplastic condition that occurs secondary to gastroesophageal reflux disease. BE is also a precursor to esophageal adenocarcinoma, which, although still rare in Japan, is one of the most rapidly increasing cancers in Western countries. However, the prevalence of gastroesophageal reflux disease has increased significantly over the past few decades in Japan, possibly leading to an incremental rise in BE and the associated inherent risk of adenocarcinoma. Given the poor prognosis of advanced-stage Barrett's adenocarcinoma, endoscopic surveillance is recommended for subjects with BE to detect early neoplasias including dysplasia. However, endoscopic identification of dysplastic lesions is still not sufficiently reliable or subjective, making targeted therapy extremely difficult. Over the past few years, improvements in image resolution, image processing software, and optical filter technology have enabled identification of dysplasia and early cancer in BE patients. We retrieved as many studies on advanced endoscopic technologies in BE as possible from MEDLINE and PubMed. The present review focuses on the emergent clinically available technologies to provide an overview of the technologies, their practical applicability, current status, and future challenges., (© 2014 The Authors. Digestive Endoscopy © 2014 Japan Gastroenterological Endoscopy Society.)

The technique of endoscopic submucosal dissection (ESD), which was developed for en bloc resection of large lesions in the stomach, has been widely accepted for the treatment of the entire gastrointestinal tract. Many minimally invasive endoscopic therapies based on ESD have been developed recently. Endoscopic submucosal excavation, submucosal tunneling endoscopic resection and laparoscopic-endoscopic cooperative surgery have been used to remove submucosal tumors, especially tumors which originate from the muscularis propria of the digestive tract. Peroral endoscopic myotomy has recently been described as a scarless and less invasive surgical myotomy option for the treatment of achalasia. Patients benefit from minimally invasive endoscopic therapy. This article, in the highlight topic series, provides detailed information on the indications and treatments for esophageal diseases.

Authors analyze their 25-year experience of endoscopic treatment of benign cicatrical strictures of esophagus and esophageal anastomotic strictures. Special attention is paid to technical aspects of bouginage of critical (diameter up to 2 mm) and substantial (3-5 mm of esophagus lumen) esophageal strictures. The advantages of the bouginage in comparison with balloon dilatation are substantiated. Basic principles of jatrogeny prevention are formulated, together with demonstration of complications, caused by too long stenting of the esophagus. The important role of planned sustaining bouginage for restenosis prevention is marked. Treatment tactics by excessive long esophagus strictures is defined.

The past few years have seen a shift in focus for endoscopy research. For example, there has been a halt in the apparent revolution of natural orifice transluminal surgery (NOTES), which was long considered the most important innovation in flexible endoscopy. Other trends such as endoscopic histology are slowing down and not progressing into clinical practice. In general, the quality of endoscopic research needs to be improved, particularly in the field of diagnostics and imaging 1. Nevertheless, progress in some areas continues, albeit at a slower pace than we might like. In this review the areas of current interest are reviewed with reference to the most relevant areas of progress in recent years., (© Georg Thieme Verlag KG Stuttgart · New York.)

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

Barrett's esophagus is the precursor to esophageal adenocarcinoma, one of the most rapidly increasing cancers in the United States. Given the poor prognosis of late-stage adenocarcinoma, endoscopic surveillance is recommended for subjects with Barrett's esophagus to detect early neoplasia. Current guidelines recommend "random" four-quadrant biopsies taken every 1-2 cm throughout the Barrett's segment. However, this only samples a minority of epithelium and has been shown to miss areas of endoscopically- inapparent neoplasia (high grade dysplasia or cancer). Recent efforts have focused on developing novel diagnostic imaging technologies to detect the subtle epithelial changes associated with dysplasia and neoplasia in Barrett's esophagus. Some of these modalities serve as "red flag" technologies designed to detect areas of abnormality within large surface areas. Other technologies serve to characterize areas of visible abnormality, offering a higher spatial resolution to confirm/exclude the presence of neoplasia. This review summarizes several available and evolving imaging technologies used in the endoscopic diagnosis and surveillance of Barrett's associated neoplasia.

Oesophageal adenocarcinoma, a highly fatal cancer, has risen in incidence in Western societies, but it is unclear whether this is due to increasing incidence of its pre-cursor condition, Barrett's oesophagus (BO) or whether the proportion of BO patients undergoing malignant progression has increased in the face of unchanged BO incidence. Data from population-based studies of BO incidence is limited, with equivocal results to date difficult to distinguish from changes in endoscopic practices. The aim of this study was to assess population trends in Barrett's oesophagus (BO) diagnoses in relation to endoscopy and biopsy rates over a 13 year period. The Northern Ireland Barrett's oesophagus Register (NIBR) is a population-based register of all 9,329 adults diagnosed with columnar epithelium of the oesophagus in Northern Ireland between 1993 and 2005, of whom 58.3% were male. European age-standardised annual BO incidence rates were calculated per 100,000 of the population, per 100 endoscopies and per 100 endoscopies including an oesophageal biopsy. Average annual BO incidence rates rose by 159% during the study period, increasing from 23.9/100,000 during 1993-1997 to 62.0/100,000 during 2002-2005. This elevation far exceeded corresponding increases in rates of endoscopies and oesophageal biopsies being conducted. BO incidence increased most markedly in individuals aged < 60 years, and most notably amongst males aged < 40 years. This study points towards a true increase in the incidence of BO which would appear to be most marked in young males. These findings have significant implications for future rates of oesophageal adenocarcinoma and surveillance programmes.

The past decade has led to marked improvements in our understanding regarding the pathogenesis and risk of progression of Barrett's esophagus (BE), enhanced imaging technology to improve dysplasia detection, and the development and refinement of endoscopic techniques, such as mucosal ablation and endoscopic mucosal resection(EMR), to eradicate BE. However, many questions remain including identifying which, if any, candidates are most appropriate for screening for BE; how to improve current surveillance protocols; predicting which patients with BE will develop neoplastic progression; identifying the most appropriate candidates for endoscopic eradication therapy; developing algorithms for appropriate management posteradication; and understanding the potential role of chemoprophylaxis. This article describes potential future advances regarding screening, surveillance, risk stratification, endoscopic eradication therapies, and chemoprevention and provides a potential future management strategy for patients with BE., (Published by Elsevier Inc.)

The authors present results of examination and treatment of 272 patients with Zenker diverticulums of different localization. Features and problems in fibroesophagoscopy in patients with Zenker diverticulum are discussed. Surgical interventions with endoscopic assistance were fulfilled in 37 patients with diverticulum. A new way of endoscopic management of Zenker diverticulum using preparation "Disport" and the method of endoscopic incision of cricofaringeal muscle are proposed. Good clinical results of the treatment were obtained.

Natural orifice transluminal endoscopic surgery (NOTES) proposes the possibility of less-invasive, incisionless surgery. Initially conceived to replace abdominal procedures, more recently interest has focused on mediastinal and thoracic procedures as possible logical applications of transluminal approaches. A survey of the literature as well as the author's own experience is performed, examining experimental and increasingly human use of mediastinal and thoracoscopic flexible endoscopy. Issues regarding instrumentation, orientation, and best access are discussed. The literature describes both direct transesophageal access to the mediastinum and pleural cavities and submucosal flap access. Other techniques include transgastric, transvesicular, and percutaneous access via a neck incision. Overall, the early results of transesophageal Heller myotomy show the most promise for early clinical adoption. NOTES has an interesting role in thoracic and mediastinal surgery. Although initially thought of as a highly improbable application, the "home run" of per-oral endoscopic myotomy is indicating that the thorax may be one of the most useful places for NOTES., (Copyright © 2010 Elsevier Inc. All rights reserved.)

The key to prevention and early treatment of esophageal adenocarcinoma is the detection and eradication of neoplasia found in patients with Barrett's esophagus (BE). The approach to the management in BE has rapidly evolved based on the paradigm shift towards endoscopic therapy, on improved detection of neoplasia with increased appreciation for subtle lesions and enhanced endoscopic imaging modalities, and on a new set of endoscopic therapeutic modalities. This review briefly outlines the evolution of the current approach to neoplasia in BE, the appreciation for improved techniques and technologies to detect neoplasia, and the specific modalities currently used in the endoscopic treatment of Barrett's neoplasia. The goals of endoscopic therapy of Barrett's neoplasia are to preserve the esophagus while ablating or removing the entire Barrett's segment. The therapeutic modalities highlighted are endoscopic resection (endoscopic mucosal resection and endoscopic submucosal dissection), photodynamic therapy, radiofrequency ablation, and cryotherapy. Endoscopic resection is a tool to accurately provide a histological diagnosis of lesions in addition to treat neoplasia. In addition, to treating the known neoplasia, it is also important to treat the remainder of the at-risk Barrett's epithelium to address synchronous and metachronous lesions. This treatment of the entire Barrett's epithelium may be achieved with one or more modalities. With multiple endoscopic tools available, it is important to appreciate how to optimally address neoplasia in BE.

The diagnosis and treatment of esophageal diseases have undergone major changes over the last several years, and these are expected to continue. This article highlights these changes.

There have been many developments in endoscopy-based imaging for the detection of Barrett's syndrome, dysplasia, and neoplasia in patients with Barrett's esophagus. This article reviews the studies on and compares the efficacy of several important endoscopic imaging modalities. Some of these technologies have already achieved regulatory approval, commercial availability, and establishment of clinical utility and practical application. The future of imaging for Barrett's syndrome likely rests with the development of molecular targeting with dysplasiatargeted probes that have been conjugated to dyes or nanoparticles.

Endoscopic therapies for the treatment of complicated Barret's esophagus should be embraced by the surgical community. While esophagectomy remains the standard of care for early esophageal neoplasia in many centers, endoscopic techniques are being increasingly utilizid. As refinements in both endoscopic and surgical approaches continue to evolve, accurate and contempary assessments of outcomes are critical in assuring that each is applied in appropriate circumstances.

Oesophageal adenocarcinoma is a rare cancer; however, it is the most rapidly increasing cancer in the western world. Barrett's oesophagus is the only recognised precursor and is associated with the majority of cases of adenocarcinoma. The role of screening and surveillance in patients with Barrett's oesophagus remains controversial. There is insufficient evidence to show that screening improves survival and is cost-effective. Indirect evidence suggests that patients diagnosed with cancer while undergoing surveillance endoscopy are diagnosed at an earlier stage and have an improved survival. The problems with current surveillance techniques include lack of data on natural history of Barrett's oesophagus, test invasiveness, costs, lack of standardisation and validation of biopsy and treatment protocols, and endoscopy intervals. The use of novel endoscopic techniques and biomarkers combined with better identification of high-risk groups could make screening and surveillance a cost-effective practice in the future.

In the 1960s, the revolution in the diagnosis and management of gastrointestinal diseases began with the introduction of the first flexible fiber endoscope. Since then, the technologies have evolved greatly. Particularly in recent years, much emphasis has been placed on developing new gastrointestinal endoscopy technologies or techniques in order to provide a precise and even a "real time" endoscopic diagnosis. Magnification and high-resolution endoscopy, chromoendoscopy, and narrow band imaging stand at the forefront of the novel endoscopic techniques for the diagnosis of conditions such as squamous cell carcinoma, Barrett's esophagus, and gastroesophageal reflux disease. This review summarizes the recent advances in esophageal imaging and its practical applications for clinicians.

Purpose of Review: Gastroesophageal reflux disease is a very common disorder. Proton pump inhibitors are the highly successful mainstay of medical gastroesophageal reflux disease treatment. However, some limitations of proton pump inhibitor therapy continue to drive studies that aim at better understanding and managing manifestations of gastroesophageal reflux disease. This review summarizes recent progress in our understanding of the pathophysiology and treatment of gastroesophageal reflux disease., Recent Findings: Recent studies have demonstrated a potential role of increased gastric acid secretion in gastroesophageal reflux disease, a factor largely neglected during the last decade. Failure to respond adequately to proton pump inhibitor therapy has been attributed to diagnostic inaccuracy, to nocturnal acid breakthrough, to ongoing non-acid reflux and to esophageal hypersensitivity. The relevance of nocturnal acid breakthrough has been recently challenged. Transient lower esophageal sphincter relaxations are a major mechanism of gastroesophageal reflux disease; inhibition of transient lower esophageal sphincter relaxations is a potentially important therapeutic target. Recent studies have focused on GABA receptor stimulation using baclofen or sodium valproate. The role of esophageal body peristalsis in the clearance of reflux events has been questioned. Endoscopic antireflux therapies aim at perendoscopic reinforcement of the antireflux barrier as a novel therapeutic approach to gastroesophageal reflux disease. At present, long-term and controlled data are scarce. Recent observations have challenged the long-term efficacy of surgical antireflux therapy., Summary: Increased understanding of the pathophysiology of gastroesophageal reflux disease may lead to new or improved treatments. Major advances have been made in the role of gastric acid secretion, the control of transient lower esophageal sphincter relaxations and mechanisms underlying esophageal hypersensitivity. Recent studies have highlighted some shortcomings of proton pump inhibitor therapy and of antireflux surgery. Novel approaches are treatments aimed at decreasing transient lower esophageal sphincter relaxations and endoscopic antireflux procedures. Large-scale controlled studies are lacking for both treatments.

Purpose of This Review: Endoscopic esophageal interventions form an important part of gastrointestinal endoscopy. This article reviews the most notable results of esophageal endoscopy and interventions published in 2004., Recent Findings: Both argon plasma coagulation and photodynamic therapy were shown to have high success rates in removing Barrett's epithelium. After ablative treatment, residual Barrett's esophagus still poses an increased esophageal cancer risk and is a concern. Endoscopic resection is now an accepted alternative to surgical resection of early-stage squamous cell and adenocarcinoma of the esophagus. Four studies convincingly demonstrated that covered plastic stents could be used in the initial therapy of patients with refractory benign esophageal strictures, and anastomotic leaks after esophageal surgery. Evidence was presented that intraluminal radiotherapy (brachytherapy) is a valuable alternative to stent placement in patients with malignant dysphagia. It has become clear that injections with botulinum toxin at the gastroesophageal junction in patients with achalasia are often only temporarily effective. It was shown that endoluminal gastroplication produced good symptomatic results; however, data on the reduction of esophageal acid exposure were less impressive. Finally, the first results of endoscopic implantation of expandable antireflux prostheses (Gatekeeper Reflux Repair System, Medtronic Europe, Tolochenaz, Switzerland) in the distal esophageal submucosa were reported., Summary: In 2004, new data on available esophageal therapeutic techniques became available. In addition, new information on an old established technique (brachytherapy for malignant dysphagia) and a new device (Gatekeeper system for the prevention of reflux) were presented.

Gastroesophageal reflux disease is a common disorder often requiring chronic treatment. Joining the conventional options of antisecretory medications and fundoplication, endoluminal therapies have emerged in recent years. These techniques have entered US and European markets, claiming effectiveness comparable with antireflux surgery. Nevertheless, a paucity of data is available to support that efficacy, even as more devices are coming onto the market. This review examines published reports of endoluminal reflux therapies from January 2004 to January 2005. After another year, there are still no compelling data supporting the efficacy of any of the available endoluminal treatments.

The current surveillance strategies for patients with a Barrett's oesophagus are hampered by the poor endoscopic visibility of early neoplastic lesions, the sampling error of random biopsies, the subjectivity of the histological evaluation, and the low incidence of carcinoma. New endoscopic techniques are available for a more reliable evaluation of a Barrett's oesophagus: high-resolution endoscopy, chromoendoscopy, fluorescence endoscopy and optical coherence tomography. The use of molecular markers will probably lead to a better risk stratification of patients. Detection of aneuploid cell populations and assessment of an increase of the number of cells in the S- and G2-phase are possible with DNA flow cytometry; flow cytometric abnormalities may be a more reliable predictor of carcinoma than histological assessment. A combined approach with the new endoscopic techniques and molecular markers may lead to a more efficient and cost-effective surveillance programme.

Background: The last twenty years have seen significant changes in both the incidence and treatment of gastro-oesophageal disorders as well as a process of subspecialisation in general surgery. The aim of this study is to identify the changes in gastro-oesophageal surgery in Scotland during this period., Methods: A retrospective analysis of three years of data, taken over a 20-year period (1977, 1987 and 1997) obtained from the Information and Statistics Division of the Scottish National Health Service, examining the number of patients with oesophageal cancer, gastric cancer and gastro-oesophageal reflux disease (GORD) treated by general and thoracic surgeons., Results: There was a significant increase (p=0.001, chi2) in the number of patients with oesophageal cancer (2.52-fold) and gastric cancer (1.4-fold) treated by general compared with thoracic surgeons. Since 1977, the overall operability for oesophageal cancer has remained unchanged, while a significant decrease in the overall operability of gastric cancer was noted (p<0.001, chi2). There was a 3-fold increase in the incidence of GORD with a significant increase (p<0.001, chi2) of those treated surgically. Since 1977, there has also been a significant shift of workload from thoracic to general surgical units., Conclusions: Scotland has seen a consistent increase in the surgical workload generated by gastro-oesophageal malignancies over the last three decades without any improvement in the operability rate. Surgically treated GORD has also increased, probably due to the introduction of minimally invasive techniques. These trends have implications on healthcare planning, resource allocation and surgical training. Appropriate resources and trainees should follow the patients to those units carrying out this activity. Further centralisation of these services is likely to follow.

Paediatric surgery has been grappling with oesophageal atresia with or without tracheo-oesophageal fistula for over 300 years. A very brief resume of the history of evolution of its treatment, anatomical types, clinical features and basic principles of treatment have been outlined. The immediate and long term complications have also been highlighted. The results of surgical treatment of this birth defect have tremendously improved in developed countries over last two decades, but the results in developing countries are yet to match that. The prevalent reasons for this discrepancy are also discussed.

Most bronchoscopies and esophagoscopies are currently performed with flexible instruments by the respective specialist. Thus the field of bronchoesophagology is in danger of being fragmented; neither the pneumologist nor the gastroenterologist have the complete overview of the upper respiratory and digestive tract. This review shows that number of pathologic conditions in the ENT area and the mediastinum involve the upper respiratory as well as the digestive tract, and thus underscore the need for combined tracheobronchial and esophageal endoscopy. Mastering of rigid and flexible endoscopy is mandatory to be efficient in diagnostic and therapeutic broncho-esophagoscopy. The ENT specialist is in the best position to maintain an overview of this whole field. New developments in broncho-esophagoscopy are presented and discussed in terms of cost effectiveness.