Advanced imaging in surveillance of Barrett’s esophagus: Is the juice worth the squeeze?

Esophageal cancer is on the rise.The known precursor lesion is Barrett’s esophagus(BE).Patients with dysplasia are at higher risk of developing esophageal cancer.Currently the gold standard for surveillance endoscopy involves taking targeted biopsies of abnormal areas as well as random biopsies every 1-2 cm of the length of the Barrett’s.Unfortunately studies have shown that this surveillance can miss dysplasia and cancer.Advanced imaging technologies have been developed that may help detect dysplasia in BE.This opinion review discusses advanced imaging in BE surveillance endoscopy and its utility in clinical practice.

Management of Barrett’s esophagus with dysplasia refractory to radiofrequency ablation

Radiofrequency ablation(RFA)is very effective for eradication of flat Barrett’s mucosa in dysplastic Barrett’s esophagus after endoscopic resection of raised lesions.However,in a minority of the time,RFA may be ineffective at eradication of the Barrett’s mucosa.Achieving complete eradication of intestinal metaplasia can be challenging in these patients.This review article focuses on the management of patients with dysplastic Barrett’s esophagus refractory to RFA therapy.Management strategies discussed in this review include optimizing the RFA procedure,optimizing acid suppression(with medical,endoscopic,and surgical management),cryotherapy,hybrid argon plasma coagulation,and EndoRotor resection.

Endoscopic ultrasound fine needle aspiration vs fine needle biopsy for pancreatic masses,subepithelial lesions,and lymph nodes

Endoscopic ultrasound tissue acquisition,in the form of both fine needle aspiration(EUS-FNA)and fine needle biopsy(EUS-FNB),is utilized for pancreatic mass lesions,subepithelial lesions,and lymph node biopsy.Both procedures are safe and yield high diagnostic value.Despite its high diagnostic yield,EUS-FNA has potential limitations associated with cytological aspirations,including inability to determine histologic architecture,and a small quantitative sample for further immunohistochemical staining.EUS-FNB,with its larger core biopsy needle,was designed to overcome these potential limitations.However,it remains unclear which technique should be used and for which lesions.Comparative trials are plagued by heterogeneity at every stage of comparison;including variable needles used,and different definitions of endpoints,which therefore limit generalizability.Thus,we present a review of prospective trials,systematic reviews,and meta-analyses on studies examining EUS-FNA vs EUSFNB.Prospective comparative trials of EUS-FNA vs EUS-FNB primarily focus on pancreatic mass lesions,and yield conflicting results in terms of demonstrating the superiority of one method.However,consistent among trials is the potential for diagnosis with fewer passes,and a larger quantity of sample achieved for next generation sequencing.With regard to subepithelial lesions and lymph node biopsy,fewer prospective trials exist,and larger prospective studies are necessary.Based on the available literature,we would recommend EUS-FNB for peri-hepatic lymph nodes.