Socioeconomic traits and the risk of Barrett’s esophagus and gastroesophageal reflux disease: A Mendelian randomization study

BACKGROUND Previous observational studies have shown that the prevalence of gastroesophageal reflux disease(GERD)and Barrett’s esophagus(BE)is associated with socioeconomic status.However,due to the methodological limitations of traditional observational studies,it is challenging to definitively establish causality.AIM To explore the causal relationship between the prevalence of these conditions and socioeconomic status using Mendelian randomization(MR).METHODS We initially screened single nucleotide polymorphisms(SNPs)to serve as proxies for eight socioeconomic status phenotypes for univariate MR analysis.The inverse variance weighted(IVW)method was used as the primary analytical method to estimate the causal relationship between the eight socioeconomic status phenotypes and the risk of GERD and BE.We then collected combinations of SNPs as composite proxies for the eight socioeconomic phenotypes to perform multivariate MR(MVMR)analyses based on the IVW MVMR model.Furthermore,a two-step MR mediation analysis was used to examine the potential mediation of the associations by body mass index,major depressive disorder(MDD),smoking,alcohol consumption,and sleep duration.RESULTS The study identified three socioeconomic statuses that had a significant impact on GERD.These included household income[odds ratio(OR):0.46;95% confidence interval(95%CI):0.31-0.70],education attainment(OR:0.23;95%CI:0.18-0.29),and the Townsend Deprivation Index at recruitment(OR:1.57;95%CI:1.04-2.37).These factors were found to independently and predominantly influence the genetic causal effect of GERD.Furthermore,the mediating effect of educational attainment on GERD was found to be mediated by MDD(proportion mediated:10.83%).Similarly,the effect of educational attainment on BE was mediated by MDD(proportion mediated:10.58%)and the number of cigarettes smoked per day(proportion mediated:3.50%).Additionally,the mediating effect of household income on GERD was observed to be mediated by sleep duration(proportion mediated:9.75%)CONCLUSION This MR study shed light on the link between socioeconomic status and GERD or BE,providing insights for the prevention of esophageal cancer and precancerous lesions.

Artificial intelligence system for the detection of Barrett’s esophagus

BACKGROUND Barrett’s esophagus(BE),which has increased in prevalence worldwide,is a precursor for esophageal adenocarcinoma.Although there is a gap in the detection rates between endoscopic BE and histological BE in current research,we trained our artificial intelligence(AI)system with images of endoscopic BE and tested the system with images of histological BE.AIM To assess whether an AI system can aid in the detection of BE in our setting.METHODS Endoscopic narrow-band imaging(NBI)was collected from Chung Shan Medical University Hospital and Changhua Christian Hospital,resulting in 724 cases,with 86 patients having pathological results.Three senior endoscopists,who were instructing physicians of the Digestive Endoscopy Society of Taiwan,independently annotated the images in the development set to determine whether each image was classified as an endoscopic BE.The test set consisted of 160 endoscopic images of 86 cases with histological results.RESULTS Six pre-trained models were compared,and EfficientNetV2B2(accuracy[ACC]:0.8)was selected as the backbone architecture for further evaluation due to better ACC results.In the final test,the AI system correctly identified 66 of 70 cases of BE and 85 of 90 cases without BE,resulting in an ACC of 94.37%.CONCLUSION Our AI system,which was trained by NBI of endoscopic BE,can adequately predict endoscopic images of histological BE.The ACC,sensitivity,and specificity are 94.37%,94.29%,and 94.44%,respectively.

Graft dilatation and Barrett’s esophagus in adults after gastric pullup and jejunal interposition for long-gap esophageal atresia

BACKGROUND Esophageal replacement(ER)with gastric pull-up(GPU)or jejunal interposition(JI)used to be the standard treatment for long-gap esophageal atresia(LGEA).Changes of the ER grafts on a macro-and microscopic level however,are unknown.AIM To evaluate long-term clinical symptoms and anatomical and mucosal changes in adolescents and adults after ER for LGEA.METHODS A cohort study was conducted including all LGEA patients≥16 years who had undergone GPU or JI between 1985-2003 at two tertiary referral centers in the Netherlands.Patients underwent clinical assessment,contrast study and endoscopy with biopsy.Data was collected prospectively.Group differences between JI and GPU patients,and associations between different outcome measures were assessed using the Fisher’s exact test for bivariate variables and the Mann-Whitney U-test for continuous variables.Differences with a P-value<0.05 were considered statistically significant.RESULTS Nine GPU patients and eleven JI patients were included.Median age at follow-up was 21.5 years and 24.4 years,respectively.Reflux was reported in six GPU patients(67%)vs four JI patients(36%)(P=0.37).Dysphagia symptoms were reported in 64%of JI patients,compared to 22%of GPU patients(P=0.09).Contrast studies showed dilatation of the jejunal graft in six patients(55%)and graft lengthening in four of these six patients.Endoscopy revealed columnar-lined esophagus in three GPU patients(33%)and intestinal metaplasia was histologically confirmed in two patients(22%).No association was found between reflux symptoms and macroscopic anomalies or intestinal metaplasia.Three GPU patients(33%)experienced severe feeding problems vs none in the JI group.The median body mass index of JI patients was 20.9 kg/m^(2) vs 19.5 kg/m^(2) in GPU patients(P=0.08).CONCLUSION The majority of GPU patients had reflux and intestinal metaplasia in 22%.The majority of JI patients had dysphagia and a dilated graft.Follow-up after ER for LGEA is essential.

Role of artificial intelligence in Barrett’s esophagus

The application of artificial intelligence(AI)in gastrointestinal endoscopy has gained significant traction over the last decade.One of the more recent applications of AI in this field includes the detection of dysplasia and cancer in Barrett’s esophagus(BE).AI using deep learning methods has shown promise as an adjunct to the endoscopist in detecting dysplasia and cancer.Apart from visual detection and diagnosis,AI may also aid in reducing the considerable interobserver variability in identifying and distinguishing dysplasia on whole slide images from digitized BE histology slides.This review aims to provide a comprehensive summary of the key studies thus far as well as providing an insight into the future role of AI in Barrett’s esophagus.

MicroRNAs, development of Barrett’s esophagus, and progression to esophageal adenocarcinoma

Barrett's esophagus is a premalignant condition caused by gastroesophageal reflux. Once developed, it can progress through varying grades of dysplasia to esoph-ageal adenocarcinoma. Whilst it is well accepted that Barrett's esophagus is caused by gastroesophageal reflux, the molecular mechanisms of its pathogenesis and progression to cancer remain unclear. MicroRNAs (miRNAs) are short segments of RNA that have been shown to control the expression of many human genes. They have been implicated in most cellular processes, and the role of miRNAs in disease development is be-coming increasingly evident. Understanding altered miRNA expression is likely to help unravel the molecular mechanisms that underpin the development of Barrett's esophagus and its progression to cancer.

Expanding beyond endoscopy: A review of non-invasive modalities in Barrett’s esophagus screening and surveillance

Barrett’s esophagus(BE)is a condition that results from replacement of the damaged normal squamous esophageal mucosa to intestinal columnar mucosa and is the most significant predisposing factor for development of esophageal adenocarcinoma.Current guidelines recommend endoscopic evaluation for screening and surveillance based on various risk factors which has limitations such as invasiveness,availability of a trained specialist,patient logistics and cost.Trans-nasal endoscopy is a less invasive modality but still has similar limitations such as limited availability of trained specialist and costs.Non-endoscopic modalities,in comparison,require minimal intervention,can be done in an office visit and has the potential to be a more ideal choice for mass public screening and surveillance,particularly in patents at low risk for BE.These include newer generations of esophageal capsule endoscopy which provides direct visualization of BE,and tethered capsule endomicroscopy which can obtain high-resolution images of the esophagus.Various cell collection devices coupled with biomarkers have been used for BE screening.Cytosponge,in combination with TFF3,as well as EsophaCap and EsoCheck have shown promising results in various studies when used with various biomarkers.Other modalities including circulatory microRNAs and volatile organic compounds that have demonstrated favorable outcomes.Use of these cell collection methods for BE surveillance is a potential area of future research.

Ablation of Barrett’s esophagus using the second-generation argon plasma coagulation

Objective To investigate the efficacy and safety of the second-generation argon plasma coagulation (VIO APC) in ablation of Barrett’s esophagus. Methods Eighteen patients with Barrett’s esophagus (12 males, median age of 55 years, median length of 2.1 cm,1 low-grade dysplasia, 13 cases of short segment Barrett’s esophagus) received VIO APC, which was performed at a power setting of 40W and argon gas flow at 1.5-2.0 L/min, "forced" mode, in 1-3 sessions (mean 1.3). All the patients received treatment with high-dose proton pump inhibitors. The main complaints before ablation were upper abdominal pain in 12 patients (66%), sour regurgitation in 14 patients (77%), and dysphagia or odynophagia in 7 patients (38%). Two patients (11%) had esophageal hiatal hernia. Results The percentage of patients in whom ablation was endoscopically achieved proximal to the gastroesophageal junction was 77.8% (14/18), and histologically achieved in 66.7% (12/18). Berried glands were observed in 2 patients who had achieved endoscopic ablation, the areas of Barrett’s mucosa were reduced by more than 60% in the other 4 patients. After treatment, 4 patients had transient retrosternal pain and 3 patients had mild epigastric discomfort. One patient had small amounts of hemorrhage during the process, and it ceased after norepinephrine and thrombosin were administered through endoscope biopsy channel. No esophageal stricture or other severe adverse events was observed. During 11.8 (4-15) months’ follow-up, the patients who had achieved the complete ablation had no evidence of relapse of Barrett’s esophagus. Conclusion VIO APC with a relatively low power setting can effectively ablate the Barrett’s mucosa with special intestinal metaplasia when standard APC has been done. No severe adverse events were observed. Long-term follow-up is needed to assess cancer prevention and the durability of the neo-squamous epithelium.

Barrett’s esophagus:Review of natural history and comparative efficacy of endoscopic and surgical therapies

Barrett's esophagus(BE)is the precursor to esophageal adenocarcinoma(EAC).Progression to cancer typically occurs in a stepwise fashion through worsening dysplasia and ultimately,invasive neoplasia.Established EAC with deep involvement of the esophageal wall and/or metastatic disease is invariably associated with poor long-term survival rates.This guides the rationale of surveillance of Barrett’s in an attempt to treat lesions at an earlier,and potentially curative stage.The last two decades have seen a paradigm shift in management of Barrett’s with rapid expansion in the role of endoscopic eradication therapy(EET)for management of dysplastic and early neoplastic BE,and there have been substantial changes to international consensus guidelines for management of early BE based on evolving evidence.This review aims to assist the physician in the therapeutic decision-making process with patients by comprehensive review and summary of literature surrounding natural history of Barrett’s by histological stage,and the effectiveness of interventions in attenuating the risk posed by its natural history.Key findings were as follows.Non-dysplastic Barrett’s is associated with extremely low risk of progression,and interventions cannot be justified.The annual risk of cancer progression in low grade dysplasia is between 1%-3%;EET can be offered though evidence for its benefit remains confined to highly select settings.High-grade dysplasia progresses to cancer in 5%-10%per year;EET is similarly effective to and less morbid than surgery and should be routinely performed for this indication.Risk of nodal metastases in intramucosal cancer is 2%-4%,which is comparable to operative mortality rate,so EET is usually preferred.Submucosal cancer is associated with nodal metastases in 14%-41%hence surgery remains standard of care,except for select situations.

Barrett’s esophagus in a patient with bulimia nervosa:A case report

BACKGROUND Barrett’s esophagus is a known complication of long-standing gastroesophageal reflux disease,and it is a potential risk factor of developing esophageal adenocarcinoma.CASE SUMMARY Here,we present a case of a 47-year-old male patient referred to the gastroenterology clinic for upper endoscopy because he has a long-standing history of heartburn and vomiting after meals.On examination,he had characteristic findings of self-induced vomiting as abrasions and callosities on the dorsum of the right hand and dental erosions.A detailed history revealed that he had 17 years of binge eating with self-induced vomiting.His upper endoscopy showed gastroesophageal reflux grade D with salmon-red mucosal projections,and the biopsy revealed intestinal mucosal metaplasia.CONCLUSION This case emphasized the importance of considering upper endoscopy screening for Barrett’s esophagus in patients with eating disorders,especially those with self-induced vomiting,as in bulimia nervosa.

Prevalence and risk factors for Barrett’s esophagus in Taiwan

BACKGROUND Barrett’s esophagus(BE)is a pre-malignant condition associated with the development of esophageal adenocarcinoma.The prevalence of BE in the general populations of Asian countries ranges from 0.06%to 1%.However,with lifestyle changes in Asian countries and adoption of western customs,the prevalence of BE might have increased.AIM To determine the current prevalence of BE in Taiwan,and to investigate risk factors predicting the presence of BE.METHODS This retrospective study was conducted at the Health Evaluation Center of Kaohsiung Veterans General Hospital in Taiwan.Between January 2015 and December 2015,3385 subjects undergoing routine esophagogastroduodenoscopy examinations as part of a health check-up at the Health Evaluation Center were included.Patient characteristics and endoscopic findings were carefully reviewed.Lesions with endoscopic findings consistent with BE awaiting histological evaluation were judged as endoscopically suspected esophageal metaplasia(ESEM).BE was defined based on extension of the columnar epithelium≥1 cm above the gastroesophageal junction and was confirmed based on the presence of specialized intestinal metaplasia(IM)in the metaplastic esophageal epithelium.Clinical factors of subjects with BE and subjects without BE were compared,and the risk factors predicting BE were analyzed.RESULTS A total of 3385 subjects(mean age,51.29±11.42 years;57.1%male)were included in the study,and 89 among them were confirmed to have IM and presence of goblet cells via biopsy examination.The majority of these individuals were classified as short segment BE(n=85).The overall prevalence of BE was 2.6%.Multivariate analysis disclosed that old age[odds ratio(OR)=1.033;95%confidence interval(CI):1.012-1.055;P=0.002],male gender(OR=2.106;95%CI:1.145-3.872;P=0.017),ingestion of tea(OR=1.695;95%CI:1.043-2.754;P=0.033),and presence of hiatal hernia(OR=3.037;95%CI:1.765-5.225;P<0.001)were significant risk factors predicting BE.The independent risk factor for the presence of IM in ESEM lesions was old age alone(OR=1.029;95%CI:1.006-1.053;P=0.014).CONCLUSION Current prevalence of BE among the general population in Taiwan is 2.6%.Old age,male gender,ingestion of tea and hiatal hernia are significant risk factors for BE.

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.

CDX2 Overexpression in Barrett’s Esophagus and Esophageal Adenocarcinoma

Background: Patients with Barrett’s esophagus have an increased risk of developing esophageal adenocarcinoma. Our purpose was to determine CDX2 expression in esophageal mucosa and establish a correlation between this marker and the progression of disease. Methods: We analyzed biopsies and surgical specimens from 150 patients who were divided into five groups according to histopathological diagnosis: G1, normal mucosa (n = 29);G2, esophagitis (n = 19);G3, columnar epithelium without intestinal metaplasia (n = 26);G4, Barrett’s esophagus (n = 32), and G5, adenocarcinoma (n = 44). Immuno-histochemical determination of CDX2 expression was considered positive in the presence of nuclear staining. Results: No CDX2 expression was detected in the G1 or G3 groups;5% of G2, 62.5% of G4 and 70.5% of G5 patients were CDX2 positive. There was a statistically significant difference between the G4 and G5 groups compared to the G1, G2 and G3 (p < 0.05). Conclusions: CDX2 expression was observed among patients with Barrett’s esophagus and adenocarcinoma compared to other groups. CDX2 was not expressed in the phases preceding Barrett’s esophagus, but there was no linear correlation between CDX2 expression and metaplasia-adenocarcinoma progression.

Difference of Gene Expression Profiles between Barrett’s Esophagus and Cardia Intestinal Metaplasia by Gene Chip

The difference of gene expression profile changes in Barrett＇s esophagus （BE） and cardia intestinal metaplasia （CIM） epithelium was studied and the novel associated genes were screened in the early stage by cDNA microarray. The cDNA retro-transcribed from equal quantity mRNA from BE and CIM epithelial tissues were labeled with Cy3 and Cy5 fluorescence as probes. The mixed probe was hybridized with three pieces BiostarH-40s double dot human whole gene chip. The chips were scanned with a ScanArray 4000. The acquired images were analyzed using GenePix Pro 3.0 software. It was found a total of 141 genes were screened out that exhibited differentially expression more than 2 times in all three chips. It was identified that in gene expression profiles of BE, 74 genes were up-regulated and 67 down-regulated as compared with CIM. The comparison between the difference of gene expression profile changes in BE and CIM epithelia revealed that there existed the difference between BE and CIM at gene level. 141 genes with the expression more than two time were probably related to the occurrence and development of BE and the promotion or progress in adenocarcinoma.

Advances in the therapy of Barrett’s Esophagus

The rising incidence of esophageal adenocarcinoma（EAC） in the world has led to continued interest in its precursor lesion, Barrett＇ s esophagus（BE）. This review endeavors to summarize the recent advances in the therapy of BE with an emphasis on novel endoscopic therapies.

Barrett’s esophagus following treatment of achalasia with botulinum toxin

Achalasia is an uncommon primary motor disorder of the esophagus with an annual incidence of 0.8/100,000. Very few cases of coexistent Barrett’s esophagus (BE) and achalasia in patients without prior surgical myotomy or pneumatic dilation have been reported. We report the case of a 65 year old female who was diagnosed with achalasia in June 2002. Endoscopy at that time revealed biopsy-confirmed normal esophageal mucosa. The patient subsequently underwent two trials of botox injection with progressively worsening dysphagia. A repeat endoscopy two years later showed a short segment of salmon-colored mucosa in the distal esophagus which was biopsy-confirmed Barrett’s epithelium with no dysplasia. The patient eventually underwent laparoscopic Heller myotomy and Toupet fundoplication. Postoperatively, she recovered well and with significant alleviation of her dysphagia. This study reviews reported cases of coexistent achalasia and BE, and discusses possible etiologies of concurrent BE and achalasia, and implications for treatment.

Proximal and distal esophageal sensitivity is decreased in patients with Barrett’s esophagus

AIM: To investigate sensations to multimodal pain stimulation in the metaplastic and normal parts of the esophagus in patients with Barrett’s esophagus (BE). METHODS: Fifteen patients with BE and 15 age-matched healthy volunteers were subjected to mechanical, thermal and electrical pain stimuli of the esophagus. Both the metaplastic part and the normal part (4 and 14 cm, respectively, above the esophago-gastric junction) were examined. At sensory thresholds the stimulation intensity, referred pain areas, and evoked brain potentials were recorded. RESULTS: Patients were hyposensitive to heat stimulation both in the metaplastic part [median stimulation time to reach the pain detection threshold: 15 (12-34) s vs 14 (6-23) s in controls; F = 4.5, P = 0.04] and the normal part of the esophagus [median 17 (6-32) s vs 13 (8-20) s in controls; F = 6.2, P = 0.02]. Furthermore, patients were hyposensitive in the metaplastic part of the esophagus to mechanical distension [median volume at moderate pain: 50 (20-50) mL vs 33 (13-50) mL in controls; F = 5.7, P = 0.02]. No indication of central nervous system abnormalities was present, as responses were comparable between groups to electrical pain stimuli in the metaplastic part [median current evoking moderate pain: 13 (6-26) mA vs 12 (9-24) mA in controls; F = 0.1, P = 0.7], and in the normal part of the esophagus [median current evoking moderate pain: 9 (6-16) mA, vs 11 (5-11) mA in controls; F = 3.4, P = 0.07]. Furthermore, no differences were seen for the referred pain areas (P-values all > 0.3) or latencies and amplitudes for the evoked brain potentials (P-values all > 0.1). CONCLUSION: Patients with BE are hyposensitive both in the metaplastic and normal part of esophagus likely as a result of abnormalities affecting peripheral nerve pathways.

Endoscopic mucosal resection of large hyperplastic polyps in 3 patients with Barrett’s esophagus

AIM: To report the endoscopic treatment of large hyperplastic polyps of the esophagus and esophago- gastric junction (EGJ) associated with Barrett’s esophagus (BE) with low-grade dysplasia (LGD), by endoscopic mucosal resection (EMR). METHODS: Cap fitted EMR (EMR-C) was performed in 3 patients with hyperplastic-inflammatory polyps (HIPs) and BE. RESULTS: The polyps were successfully removed in the 3 patients. In two patients, with short segment BE (SSBE) (≤ 3 cm), the metaplastic tissue was completely excised. A 2 cm circumferential EMR was performed in one patient with a polyp involving the whole EGJ. A simultaneous EMR-C of a BE-associated polypoid dysplastic lesion measuring 1 cm x 10 cm, was also carried out. In the two patients, histologic assessment detected LGD in BE. No complications occurred. Complete neosquamous re- epithelialization occurred in the two patients with SSBE. An esophageal recurrence occurred in the remaining one and was successfully retreated by EMR. CONCLUSION: EMR-C appears to be a safe and effective method for treating benign esophageal mucosal lesions, allowing also the complete removal of SSBE.

Oligomicroarray-based primary study of gene expression profile changes in Barrett’s esophagus

Objective: To analyze the differential expression genes (DEGs) between Barrett’s esophagus (BE) and normal esophagus mucosa and explore the target genes related to the development and progression of BE. Methods: The total RNAs of matched BE and normal esophagus mucosa of BE patients were isolated using one step Trizol method. Matched RNAs were qualified using 10 g/L agarose gel electrophoresis. cRNAs were synthesized, fluorescence labeled and purified after total RNAs were purified. The RNAs of BE and normal esophagus mucosa were hybridized with Agilent oligomicroarray (30 968 probes). The fluorescence intensity features were detected by Agilent scanner and quantified by feature extraction software. Results: (1) The total RNA, reverse transcription product and fluorescence labeled cRNA were all of high quality; (2) There were 142 up-regulated genes and 284 down-regulated genes among 2-fold DEGs. Conclusion: Microarray-based studies are feasible in endoscopically obtained tissues. Many BE-associated genes are screened by the high-throughput gene chip. The development and progression of BE is a complicated process involving multiple genes and multiple procedures, and functional study of these genes may help to identify the key genes or pathways involved in the pathogenesis and development of BE.

Impact of gastroesophageal reflux control through tailored proton pump inhibition therapy or fundoplication in patients with Barrett's esophagus

AIM To determine the impact of upwards titration of proton pump inhibition(PPI) on acid reflux, symptom scores and histology, compared to clinically successful fundoplication.METHODS Two cohorts of long-segment Barrett's esophagus(BE) patients were studied. In group 1(n = 24), increasing doses of PPI were administered in 8-wk intervals until acid reflux normalization. At each assessment, ambulatory 24 h p H recording, endoscopy with biopsies and symptom scoring(by a gastroesophageal reflux disease health related quality of life questionnaire, GERD/HRLQ) were performed. Group 2(n = 30) consisted of patients with a previous fundoplication. RESULTS In group 1, acid reflux normalized in 23 of 24 patients, resulting in improved GERD/HRQL scores(P = 0.001), which were most pronounced after the starting dose of PPI(P < 0.001). PPI treatment reached the same level of GERD/HRQL scores as after a clinically successful fundoplication(P = 0.5). Normalization of acid reflux in both groups was associated with reduction in papillary length, basal cell layer thickness, intercellular space dilatation, and acute and chronic inflammation of squamous epithelium. CONCLUSION This study shows that acid reflux and symptom scores co-vary throughout PPI increments in long-segment BE patients, especially after the first dose of PPI, reaching the same level as after a successful fundoplication. Minor changes were found among GERD markers at the morphological level.

Efficacy and safety of liquid nitrogen cryotherapy for treatment of Barrett's esophagus

AIM To evaluate the efficacy and safety of liquid nitrogen cryotherapy as a primary or rescue treatment for BE,with and without dysplasia,or intramucosal adenocarcinoma (IMC).METHODS This was a retrospective,single-center study carried out in a tertiary care center including 45 patients with BE who was treatment-na?ve or who had persistent intestinal metaplasia(IM),dysplasia,or IMC despite prior therapy.Barrett's mucosa was resected via EMR when clinically appropriate,then patients underwent cryotherapy until eradication or until deemed to have failed treatment.Surveillance biopsies were taken at standard intervals.RESULTS From 2010 through 2014,33 patients were studied regarding the efficacy of cryotherapy.Overall,29 patients (88%) responded to cryotherapy,with 84% having complete regression of all dysplasia and cancer.Complete eradication of cancer and dysplasia was seen in 75% of subjects with IMC; the remaining two subjects did not respond to cryotherapy.Following cryotherapy,15 patients with high-grade dysplasia (HGD) had 30% complete regression,50% IM,and 7% low-grade dysplasia (LGD); one subject had persistent HGD.Complete eradication of dysplasia occurred in all 5 patients with LGD.In 5 patients with IM,complete regression occurred in 4,and IM persisted in one.In 136 cryotherapy sessions amongst 45 patients,adverse events included chest pain (1%),stricture (4%),and one gastrointestinal bleed in a patient on dual antiplatelet therapy who had previously undergone EMR.CONCLUSION Cryotherapy is an efficacious and safe treatment modality for Barrett's esophagus with and without dysplasia or intramucosal adenocarcinoma.