The incidence of esophageal adenocarcinoma (EAC) is rising despite a better understanding of the natural history of Barrett’s esophagus (BE) as a precursor lesion for EAC. 1 Surveillance is recommended once the diagnosis of BE is established, and endoscopic eradication therapy is reserved for treatment of dysplasia or early neoplasia. 2 In recent years, significant clinical and technologic advances have been made in endoscopic methods for the diagnosis and treatment of early esophageal adenocarcinomas arising in Barrett’s esophagus. 3 , 4 , 5 In the current issue of Gastrointestinal Endoscopy , Kamboj et al 6 show that using a synergistic combination ...

Much effort during the past 2 decades has focused on developing novel imaging techniques to enable real-time “optical biopsy” during endoscopy. The ASGE’s Preservation and Incorporation of Valuable Endoscopic Innovations initiative recommends appropriate thresholds for application of novel imaging, particularly narrow-band imaging, when trained endoscopists evaluate BE and small colon polyps.40,41 Although narrow-band imaging has been available in most endoscopy units for many years, its application for management of BE in routine practice is still unclear. In 2017, a retrospective analysis of BE detection before and after the institution of a novel imaging– directed biopsy program did ...

Background and Aims Volumetric laser endomicroscopy (VLE) is a new wide-field advanced imaging technology for Barrett’s esophagus (BE). No data exist on incremental yield of dysplasia detection. Our aim is to report the incremental yield of dysplasia detection in BE using VLE. Methods This is a retrospective study from a prospectively maintained database from 2011 to 2017 comparing the dysplasia yield of 4 different surveillance strategies in an academic BE tertiary care referral center. The groups were (1) random biopsies (RB), (2) Seattle protocol random biopsies (SP), (3) VLE without laser marking (VLE), and (4) VLE with laser marking ...

In this issue of Gastrointestinal Endoscopy, Swager et al 1 deal with the issue of a novel technology for Barrett’s esophagus surveillance, reporting the performance of a computer-aided volumetric laser endomicroscopy (VLE) algorithm for early detection of high-grade dysplasia/esophageal adenocarcinoma (HGD/EAC) in Barrett’s esophagus (BE). The authors compared the performance of a computer-aided algorithm versus a clinical algorithm using VLE. Volumetric laser endomicroscopy is a novel advanced imaging technology able to capture esophageal wall images up to 3 mm below the mucosa with a 7-μ resolution in real time. The system consists of a disposable balloon ...

Background and Aims Volumetric laser endomicroscopy (VLE) is an advanced imaging system that provides a near-microscopic resolution scan of the esophageal wall layers up to 3-mm deep. VLE has the potential to improve detection of early neoplasia in Barrett’s esophagus (BE). However, interpretation of VLE images is complex because of the large amount of data that need to be interpreted in real time. The aim of this study was to investigate the feasibility of a computer algorithm to identify early BE neoplasia on ex vivo VLE images. Methods We used 60 VLE images from a database of high-quality ex ...

Patients with Barrett's esophagus (BE) are at an increased risk for the development of esophageal adenocarcinoma. This risk is relatively low in patients with nondysplastic BE (∼0.1%-0.3% per year) but much higher in patients with BE and high-grade dysplasia (∼6% per year). Several gastroenterology societies recommend interval surveillance for patients with nondysplastic BE, whereas endoscopic eradication therapy is reserved for patients with BE and associated dysplasia or early neoplasia. 1 , 2 , 3 The accurate detection of dysplasia associated with BE is therefore instrumental to the management of this disease. The established surveillance biopsy protocol consists of ...

Background and Aim Volumetric laser endomicroscopy (VLE) provides a circumferential scan of the esophageal wall layers and has potential to improve detection of neoplasia in Barrett’s esophagus (BE). The novel VLE laser marking system enables direct in vivo marking of suspicious areas as identified on VLE. These laser marked areas can subsequently be targeted for biopsies. The aim was to evaluate the visibility and positional accuracy of laser marks (LMs) in different esophageal tissue types on white light endoscopy (WLE) and VLE. Methods Patients with BE with or without neoplasia underwent imaging with VLE. Protocol refinements were practiced in ...

Abstract Background and Aims Targeting neoplasia in Barrett’s esophagus (BE) is challenging. Volumetric laser endomicroscopy (VLE) is a new imaging technique that allows for real time cross-sectional microstructure imaging that can detect BE neoplasia. The interobserver agreement among users in practice is unknown. Methods Eight high-volume users of VLE from different academic centers in the United States evaluated 120-stored VLE images blinded to the endoscopic and clinical findings. There were 30 images for each tissue type: gastric cardia, esophageal squamous mucosa, non-neoplastic BE, and neoplastic BE. Each image with BE had corresponding histology confirming the tissue diagnosis. Each normal ...

Background & Aims Probe-based confocal laser endomicroscopy (pCLE) and volumetric laser endomicroscopy (VLE) are advanced endoscopic imaging modalities that may be useful in the diagnosis of dysplasia associated with Barrett’s esophagus (BE). We performed pCLE examination in ex-vivo endoscopic mucosal resection (EMR) specimens and compared the diagnostic performance of using the current VLE scoring index (OCT-SI) and a novel VLE diagnostic algorithm (VLE-DA) for the detection of dysplasia. Methods 27 patients with BE enrolled in a surveillance program at a tertiary center underwent 50 clinically indicated EMRs that were imaged with VLE and pCLE and classified into neoplastic (N=34 ...

A 64-year-old man underwent esophagoscopy 15 months earlier, which diagnosed long-segment Barrett’s esophagus. Examination of random biopsy specimens yielded a diagnosis of intestinal metaplasia, with 1 biopsy specimen as indefinite for dysplasia. Two subsequent esophagoscopies were performed 6 months apart, and random biopsy specimens were negative for dysplasia. The patient was referred for volumetric laser endomicroscopy (VLE) (NVisionVLE, NinePoint Medical, Cambridge, Mass). At esophagoscopy, high-definition white-light endoscopy showed a 7-cm segment of flat salmon-colored mucosa (Prague class C6M7) ( A ).

Background and Aims The prevalence and clinical relevance of buried Barrett’s glands (BB) after radiofrequency ablation (RFA) in Barrett’s esophagus (BE) are debated. Recent optical coherence tomography studies demonstrated a high prevalence of BBs. Direct histological correlation, however, has been lacking. Volumetric laser endomicroscopy (VLE) is a second-generation optical coherence tomography system capable of scanning a large surface of the esophageal wall layers with low-power microscopy resolution. The aim was to evaluate whether post-RFA subsquamous glandular structures (SGSs), detected with VLE, actually correspond to BBs by pursuing direct histological correlation with VLE images. Methods In vivo VLE was ...

Background Volumetric laser endomicroscopy (VLE) produces high-resolution, cross-sectional surface, and subsurface images for detecting neoplasia, targeting biopsies, and guiding real-time treatment. Objective To evaluate the safety and feasibility of the Nvision VLE system. Design Prospective, multicenter study. Setting Tertiary-care medical centers. Patients One hundred patients with suspected Barrett’s esophagus, including 52 patients with prior endotherapy. Interventions The first-generation Nvision VLE Imaging System, a balloon-centered, rotating optical probe provided images of the mucosa and submucosa through a 6-cm segment length and 360° scan of the distal esophagus. Main Outcome Measurements Acquisition of a complete, 6-cm scan from the distal esophagus ...

Optical coherence tomography (OCT) provides imaging depth down to 3 mm and resolution of 7 μm over a 6-cm length over a 90 second scan. It is used to analyze tissue microstructure to scan for any potential abnormalities in the esophagus. As of now, the utility of OCT in assessing the esophageal muscular layers in achalasia patients after a peroral endoscopic myotomy (POEM) procedure has not been assessed. We present a case in which this device was used for this indication.

During endoscopic surveillance and treatment in Barrett’s esophagus, the endoscopist may use a combination of tools to assist in targeting biopsies and endoscopic resections in order to diagnose and treat Barrett’s esophagus–associated neoplasia. There is a concern for subepithelial metaplasia or neoplasia in both naïve and previously treated Barrett’s esophagus. Tools to characterize so-called buried disease may allow for improved detection of occult disease. Optical biopsy with volumetric laser endomicroscopy, or VLE, is based on optical coherence tomography.

This video (, available online at www.giejournal.org) describes the optical frequency domain interferometry (OFDI) imaging technique, which is a U.S. Food and Drug Administration–approved and commercially available second-generation of optical coherence tomography, and its close correlation with endoscopic views and histopathology results in patients with Barrett's esophagus.

Background Biopsy surveillance protocols for the assessment of Barrett's esophagus can be subject to sampling errors, resulting in diagnostic uncertainty. Optical coherence tomography is a cross-sectional imaging technique that can be used to conduct volumetric laser endomicroscopy (VLE) of the entire distal esophagus. We have developed a biopsy guidance platform that places endoscopically visible marks at VLE-determined biopsy sites. Objective The objective of this study was to demonstrate in human participants the safety and feasibility of VLE-guided biopsy in vivo. Design A pilot feasibility study. Setting Massachusetts General Hospital. Patients A total of 22 participants were enrolled from January ...

The American Society for Gastrointestinal Endoscopy (ASGE) Technology Committee provides reviews of new or emerging endoscopic technologies that have the potential to have an impact on the practice of GI endoscopy. Evidence-based methodology is used, using a MEDLINE literature search to identify pertinent preclinical and clinical studies on the topic, and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported adverse events of a given technology. Both are supplemented by accessing the “related articles” feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical ...

Controversy continues on the issue of whether non-neoplastic Barrett's esophagus and Barrett's esophagus with premalignant lesions such as low-grade intraepithelial neoplasia (LGIN) and high-grade intraepithelial neoplasia (HGIN) should be eradicated endoscopically by using ablative methods. The main argument in the past for endoscopic ablation using photodynamic therapy (PDT) or argon plasma coagulation (APC) was that it is capable of preventing cancer, against the background of the dramatic increase in the incidence of esophageal adenocarcinoma during the past few decades. There is no doubt that Barrett's esophagus is a precancerous lesion, and Barrett's with premalignant lesions in ...

Background The precise assessment of superficial esophageal squamous cell carcinomas (SESCCs) limited to the epithelium (EP) or lamina propria mucosa (LPM), the standard indication for endoscopic resection, is important to ensure good outcomes of endoscopic resection. With regard to tomographic imaging techniques, although the accuracy of EUS is practically insufficient, we previously demonstrated that high-resolution optical coherence tomography (OCT) might enable precise assessment for staging in a noninvasive and real-time manner. Objective To clarify the accuracy of the preoperative staging of SESCCs by using OCT compared with that by using 20-MHz probe-type EUS. Design A prospective study. Setting An academic ...

Background Radiofrequency ablation (RFA) is effective for treating Barrett's esophagus (BE) but often involves multiple endoscopy sessions over several months to achieve complete response. Objective Identify structural markers that correlate with treatment response by using 3-dimensional (3-D) optical coherence tomography (OCT; 3-D OCT). Design Cross-sectional. Setting Single teaching hospital. Patients Thirty-three patients, 32 male and 1 female, with short-segment (<3 cm) BE undergoing RFA treatment. Intervention Patients were treated with focal RFA, and 3-D OCT was performed at the gastroesophageal junction before and immediately after the RFA treatment. Patients were re-examined with standard endoscopy 6 to 8 weeks later ...

Barrett's esophagus is a risk factor for esophageal adenocarcinoma, a tumor whose frequency has increased more than sevenfold over the past few decades in the United States. The metaplastic mucosa of Barrett's esophagus, which predisposes to malignancy, can be destroyed by the modern endoscopic technique of radiofrequency ablation (RFA). In RFA, an endoscope is used to position a device that delivers radiofrequency energy to the Barrett's metaplasia to inflict a lethal thermal injury to the metaplastic cells. Patients are treated with proton pump inhibitors to control acid reflux, and the ablated Barrett's epithelium heals with the ...

Background: Radiofrequency ablation (RFA) is an endoscopic technique used to eradicate Barrett's esophagus (BE). However, such ablation can commonly lead to neosquamous epithelium overlying residual BE glands not visible by conventional endoscopy and may evade detection on random biopsy samples.Objective: To demonstrate the capability of endoscopic 3-dimensional optical coherence tomography (3D-OCT) for the identification and characterization of buried glands before and after RFA therapy.Design: Cross-sectional study.Setting: Single teaching hospital.Patients: Twenty-six male and 1 female white patients with BE undergoing RFA treatment.Interventions: 3D-OCT was performed at the gastroesophageal junction in 18 patients before attaining complete ...

A 30-year-old white man with established Barrett's esophagus (BE) and continued symptoms of chronic severe heartburn, persistent cough, throat irritation, and asthma was referred for surveillance EGD...