Bas L. A. M. Weusten

Background Surveillance recommendations for Barrett esophagus (BE) are based on BE length, since the risk of progression to dysplasia or esophageal adenocarcinoma (EAC) has been shown to increase with greater BE length. The 2023 European Society for Gastrointestinal Endoscopy (ESGE) Guideline on BE advises referral to Barrett expert centers (BECs) for surveillance of ultra-long ( ≥ 10 cm) BE. This study evaluated the outcomes of expert care for patients with ultra-long BE in the Netherlands. Methods This retrospective, nationwide cohort study including patients referred with ultra-long nondysplastic BE (NDBE) to Dutch BECs. Outcome parameters were number of cases upgraded to dysplasia/esophageal adenocarcinoma (EAC) at expert endoscopic reassessment, and number of cases with progression to high-grade dysplasia (HGD)/EAC during surveillance after a confirmed diagnosis of NDBE at expert endoscopic reassessment. Results 168 patients were referred with ultra-long NDBE, namely with Barrett length (median and interquartile range [IQR]), circumference (C) 11 cm (9–12), maximum (M) 12 cm (10–14). Upon expert endoscopic reassessment, 28 /168 (17 %) patients were diagnosed with dysplasia/EAC, among whom 5 /168 (3 %) had HGD/EAC in a visible lesion. In 11 patients no Seattle protocol biopsies were obtained, thus 129 patients had an NDBE diagnosis based on Seattle protocol biopsies. Of these, 95 /129 (74 %) had > 1 surveillance endoscopy at the BEC. During surveillance 20 patients progressed to LGD (n = 11, 12 %), HGD (n = 4, 4 %) or EAC (n = 5, 5 %); all progressors underwent endoscopic therapy. Conclusion Expert care with dedicated BE endoscopy programs and experienced endoscopists may be beneficial for patients with ultra-long BE.

Background: Screening for colorectal cancer has led to large increases in the detection of large non-pedunculated rectal polyps. Local en bloc removal is increasingly seen as the optimal approach and can be performed by surgical or endoscopic local excision, via transanal minimal invasive surgery (TAMIS) or endoscopic submucosal dissection (ESD) respectively. We hypothesised that ESD would have a non-inferior recurrence rate with less serious adverse events and lower costs than TAMIS. Methods: We performed a multicentre randomised controlled non-inferiority trial in 23 hospitals in the Netherlands. Adult patients with a non-pedunculated rectal polyp larger than two centimetres without features of deep submucosal invasion, were eligible for inclusion. Patients were randomised 1:1 to receive TAMIS or ESD, stratified for the distance from the dentate line and lesion size. The primary outcome was the intention-to-treat recurrence rate at 12 months. The non-inferiority margin was six percent. Netherlands Trial Register, NL7083. Findings: 198 patients were recruited between Jan 1, 2019, and Jan 1, 2023. 98 (57 males) were assigned to TAMIS and 100 (60 males) to ESD. For the primary outcome all randomised patients were analysed. There were six recurrences in the TAMIS arm and none in the ESD arm. The difference in recurrence rate was –6·3% in favour of ESD (95% CI [ –11·2; –1·4]). ESD cost €2,636 (95% CI [2,446; 2,826]) and TAMIS €3,340 (95% CI [3,068; 3611]. There were no treatment related deaths and no significant differences in adverse events. Interpretation: ESD should be the treatment of choice for large non-pedunculated rectal polyps.

Focal cryoballoon ablation (FCBA) is a relatively new modality for treatment of Barrett esophagus (BE)-related neoplasia. This study evaluated the efficacy and safety of FCBA for BE. Patients with BE segments (Prague classification C≤2M≤5) with dysplasia or early cancer were eligible for inclusion. Following endoscopic resection of visible lesions, FCBA was performed at 3-month intervals until complete eradication of BE (maximum five sessions). After ≥2 FCBA sessions, add-on treatment was allowed. Follow-up endoscopy was scheduled at 6 months and annually thereafter. Outcomes were complete eradication of endoscopically visible BE (CE-BE), intestinal metaplasia (CE-IM), and dysplasia (CE-D), durability of treatment response, and adverse events. 107 patients (mean age 65 years, 91 males, median BE C0M2) were included. Endoscopic resection was performed at entry in 65% (69/107). Patients received a median of 2 FCBA treatments. Add-on treatment was performed in 40% (43/107), mainly APC for small remaining islands (38%; 41/107). CE-BE and CE-D were achieved in 94% (101/107; 95%CI 90%–98%) and CE-IM in 91% (97/107; 95%CI 85%–95%), per intention-to-treat analysis. In per-protocol analysis, CE-BE and CE-D was achieved in 100% (101/101; 95%CI 100%–100%), and CE-IM in 96% (97/101; 95%CI 92%–99%). After a median follow-up of 18 months, 96% (97/101; 95%CI 92%–99%) remained free of endoscopically visible BE. Esophageal stricture was the most common adverse event, in 13% (13/101; 95%CI 6%–20%). FCBA was highly effective in selected patients with BE of limited length, although the potential risk for stricture formation warrants further research.

Background Computer-aided detection (CADe) systems may improve detection of Barrett’s neoplasia. Most CADe systems are developed with data from expert centers, unrepresentative of heterogeneous imaging conditions in community hospitals, and therefore may underperform in routine practice. We aimed to develop a robust CADe system (CADe 2.0) and compare its performance to a previously published system (CADe 1.0) under heterogeneous imaging conditions representative of real-world clinical practice. Method CADe 2.0 was improved through a larger and more diverse training dataset, optimized pretraining, data augmentation, ground truth use, and architectural adjustments. CADe systems were evaluated using three prospective test sets. Test set 1 comprised 428 Barrett’s videos (114 patients across five referral centers). Test set 2 addressed endoscopist-dependent variation (e. g. mucosal cleaning and esophageal expansion), with paired subsets of high, moderate, and low quality images (122 patients). Test set 3 addressed endoscopist-independent variation, with 16 paired subsets of 396 images (122 patients), each being based on a different software image-enhancement setting. Results CADe 2.0 outperformed CADe 1.0 on all three test sets. In test set 1, sensitivity increased significantly from 87 % to 96 % (P = 0.02), while specificity remained comparable (73 % vs. 74 %; P = 0.73). In test set 2, CADe 2.0 consistently surpassed CADe 1.0 across all image quality levels, with the largest performance gains observed on lower quality images (sensitivity 78 % vs. 61 %; specificity 89 % vs. 77 %; area under the curve 89 % vs. 75 %). In test set 3, CADe 2.0 showed improved performance and displayed reduced performance variability across enhancement settings. Conclusion Based on several key improvements, CADe 2.0 demonstrated increased detection rates and better robustness to data heterogeneity, making it ready for clinical implementation.

The impact of different random biopsy techniques for Barrett esophagus (BE) surveillance on histopathological quality is unclear. We compared the double- vs. single-biopsy method and advance-and-close vs. turn-and-suction technique. In a multicenter, factorial design trial (Part I), BE patients were randomly assigned to the double- or single-biopsy method and advance-and-close or turn-and-suction technique (1:1:1:1). In a before–after study (Part II), the optimal biopsy method and technique were implemented in clinical practice. The primary end point in both parts was biopsy size. In Part I (107 patients, 1024 biopsies), single-method biopsies were 25% larger than double-method biopsies (3.34 mm² [95%CI 3.10–3.57] vs. 2.68 mm² [95%CI 2.45–2.92]; P < 0.001). Mean (95%CI) biopsy size was 2.95 mm² (2.72–3.19) and 3.08 mm² (2.85–3.31) with advance-and-close and turn-and-suction techniques, respectively (P = 0.44). The interaction term between the co-primary comparisons was P = 0.08. Mean (95%CI) biopsy size for double-biopsy + advance-and-close, double-biopsy + turn-and-suction, single-biopsy + advance-and-close, and single-biopsy + turn-and-suction was 2.77 mm² (2.44–3.09), 2.61 mm² (2.29–2.93), 3.14 mm² (2.81–3.46), and 3.54 mm² (3.22–3.86), respectively. In Part II, 46 and 44 patients were included before and after implementation of the single-biopsy method and turn-and-suction technique, in whom this combination was used in 16/46 (35%) and 44/44 (100%) patients, respectively. Mean (95%CI) biopsy size increased by 18%, from 3.31 mm² (2.95–3.68) to 3.90 mm² (3.50–4.29; P = 0.03). BE surveillance biopsies should be taken with the single-biopsy method and turn-and-suction technique to increase biopsy size. BE surveillance biopsies should be taken with the single-biopsy method and turn-and-suction technique to increase biopsy size. Received: 09 October 2024 Accepted after revision: 05 March 2025 Article published online: 24 June 2025 © 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Although endoscopic resection (ER) is recommended as first-choice treatment for early esophageal neoplasia, patients with esophageal varices are considered a high-risk group owing to an increased risk of bleeding. This systematic review aimed to evaluate the effectiveness and safety of ER in this specific patient category.We searched for studies reporting on clinical outcomes of ER in the presence of esophageal varices, irrespective of study design or follow-up time. End points included the incidence of prophylactic measures to reduce the risk of variceal hemorrhage, radical and curative resection rates, and adverse events.After screening 2371 studies, 42 studies (including our own unpublished cohort) with a total of 186 patients were included in this systematic review. Endoscopic band ligation (72/186; 39%) and endoscopic injection sclerotherapy (22/186; 12%) were the prophylactic measures most widely adopted to eradicate varices prior to ER. Other frequently described prophylactic measures included direct varix coagulation during ER (18/186; 10%) and the placement of a transjugular intrahepatic portosystemic shunt prior to ER (9/186; 5%). While the radical and curative resection rates were high (86% and 72%, respectively), the periprocedural and delayed bleeding risks were reported to be relatively low (6% and 3%, respectively). In all studies, no procedure-related mortality was observed.ER appeared to be a safe and effective treatment option in selected patients with concurrent early esophageal neoplasia and esophageal varices, provided that a tailored approach of adequate prophylactic measures to prevent bleeding is applied.

Main Recommendations: MR1 ESGE recommends the following standards for Barrett esophagus (BE) surveillance:– a minimum of 1-minute inspection time per cm of BE length during a surveillance endoscopy– photodocumentation of landmarks, the BE segment including one picture per cm of BE length, and the esophagogastric junction in retroflexed position, and any visible lesions– use of the Prague and (for visible lesions) Paris classification– collection of biopsies from all visible abnormalities (if present), followed by random four-quadrant biopsies for every 2-cm BE length.Strong recommendation, weak quality of evidence. MR2 ESGE suggests varying surveillance intervals for different BE lengths. For BE with a maximum extent of ≥ 1 cm and < 3 cm, BE surveillance should be repeated every 5 years. For BE with a maximum extent of ≥ 3 cm and < 10 cm, the interval for endoscopic surveillance should be 3 years. Patients with BE with a maximum extent of ≥ 10 cm should be referred to a BE expert center for surveillance endoscopies. For patients with an irregular Z-line/columnar-lined esophagus of < 1 cm, no routine biopsies or endoscopic surveillance are advised.Weak recommendation, low quality of evidence. MR3 ESGE suggests that, if a patient has reached 75 years of age at the time of the last surveillance endoscopy and/or the patient’s life expectancy is less than 5 years, the discontinuation of further surveillance endoscopies can be considered. Weak recommendation, very low quality of evidence. MR4 ESGE recommends offering endoscopic eradication therapy using ablation to patients with BE and low grade dysplasia (LGD) on at least two separate endoscopies, both confirmed by a second experienced pathologist.Strong recommendation, high level of evidence. MR5 ESGE recommends endoscopic ablation treatment for BE with confirmed high grade dysplasia (HGD) without visible lesions, to prevent progression to invasive cancer.Strong recommendation, high level of evidence. MR6 ESGE recommends offering complete eradication of all remaining Barrett epithelium by ablation after endoscopic resection of visible abnormalities containing any degree of dysplasia or esophageal adenocarcinoma (EAC).Strong recommendation, moderate quality of evidence. MR7 ESGE recommends endoscopic resection as curative treatment for T1a Barrett’s cancer with well/moderate differentiation and no signs of lymphovascular invasion.Strong recommendation, high level of evidence. MR8 ESGE suggests that low risk submucosal (T1b) EAC (i. e. submucosal invasion depth ≤ 500 µm AND no [lympho]vascular invasion AND no poor tumor differentiation) can be treated by endoscopic resection, provided that adequate follow-up with gastroscopy, endoscopic ultrasound (EUS), and computed tomography (CT)/positrion emission tomography-computed tomography (PET-CT) is performed in expert centers.Weak recommendation, low quality of evidence. MR9 ESGE suggests that submucosal (T1b) esophageal adenocarcinoma with deep submucosal invasion (tumor invasion > 500 µm into the submucosa), and/or (lympho)vascular invasion, and/or a poor tumor differentiation should be considered high risk. Complete staging and consideration of additional treatments (chemotherapy and/or radiotherapy and/or surgery) or strict endoscopic follow-up should be undertaken on an individual basis in a multidisciplinary discussion.Strong recommendation, low quality of evidence. MR10 a ESGE recommends that the first endoscopic follow-up after successful endoscopic eradication therapy (EET) of BE is performed in an expert center.Strong recommendation, very low quality of evidence. b ESGE recommends careful inspection of the neo-squamocolumnar junction and neo-squamous epithelium with high definition white-light endoscopy and virtual chromoendoscopy during post-EET surveillance, to detect recurrent dysplasia.Strong recommendation, very low level of evidence. c ESGE recommends against routine four-quadrant biopsies of neo-squamous epithelium after successful EET of BE.Strong recommendation, low level of evidence. d ESGE suggests, after successful EET, obtaining four-quadrant random biopsies just distal to a normal-appearing neo-squamocolumnar junction to detect dysplasia in the absence of visible lesions.Weak recommendation, low level of evidence. e ESGE recommends targeted biopsies are obtained where there is a suspicion of recurrent BE in the tubular esophagus, or where there are visible lesions suspicious for dysplasia.Strong recommendation, very low level of evidence. MR11 After successful EET, ESGE recommends the following surveillance intervals:– For patients with a baseline diagnosis of HGD or EAC:at 1, 2, 3, 4, 5, 7, and 10 years after last treatment, after which surveillance may be stopped.– For patients with a baseline diagnosis of LGD:at 1, 3, and 5 years after last treatment, after which surveillance may be stopped.Strong recommendation, low quality of evidence.

Background: Selective lymphadenectomy using sentinel node-navigated surgery (SNNS) might offer a less invasive alternative to esophagectomy in patients with high-risk T1 esophageal adenocarcinoma (EAC). The aim of this study was to evaluate the feasibility and safety of a new treatment strategy, consisting of radical endoscopic resection of the tumor followed by SNNS. Methods: In this multicenter pilot study, ten patients with a radically resected high-risk pT1cN0 EAC underwent SNNS. A hybrid tracer of technetium-99m nanocolloid and indocyanine green was injected endoscopically around the resection scar the day before surgery, followed by preoperative imaging. During surgery, sentinel nodes (SNs) were identified using a thoracolaparoscopic gammaprobe and fluorescence-based detection, and subsequently resected. Endpoints were surgical morbidity and number of detected and resected (tumor-positive) SNs. Results: Localization and dissection of SNs was feasible in all ten patients (median 3 SNs per patient, range 1–6). The concordance between preoperative imaging and intraoperative detection was high. In one patient (10%), dissection was considered incomplete after two SNs were not identified intraoperatively. Additional peritumoral SNs were resected in four patients (40%) after fluorescence-based detection. In two patients (20%), a (micro)metastasis was found in one of the resected SNs. One patient experienced neuropathic thoracic pain related to surgery, while none of the patients developed functional gastroesophageal disorders. Conclusions: SNNS appears to be a feasible and safe instrument to tailor lymphadenectomy in patients with high-risk T1 EAC. Future research with long-term follow-up is warranted to determine whether this esophageal preserving strategy is justified for high-risk T1 EAC.