Endoscopic work-up of early Barrett's neoplasia.

In recent years, endoscopic therapy of early Bar− rett’s esophagus neoplasia has become a safe and effective alternative to esophagectomy [1 ± 4]. Only patients with high−grade intraepithelial neoplasia (HGIN) or mucosal cancer are eligible for curative endoscopic treatment. Lesions that invade the submucosa are associated with a sig− nificant risk of lymph node metastases and are therefore preferably to be treated surgically. There are two main types of endoscopic therapy: endoscopic resection and endoscopic ablation. An important difference between these two modalities is that endoscopic resection permits histopathological evaluation of the resection spe− cimen, whereas this safeguard is missing with endoscopic ablation therapy. A practical ap− proach is to resect the areas with endoscopically visible lesions by endoscopic resection followed by ablation of residual Barrett’s esophagus [5± 8]. This assumes that if the histopathological evaluation of the most involved areas is favor− able, the chances that the residual Barrett’s esophagus harbors more advanced neoplasia elsewhere are small and thus additional ablation therapy without histological correlation is justi− fied. It is, therefore, crucial that the most in− volved area in the Barrett’s esophagus is indeed identified and resected rather than overlooked and ablated, since this may lead to undertreat− ment of submucosal lesions. In this review, we will discuss the endoscopic work−up for diagnosis and staging of early neo− plasia in Barrett’s esophagus (i. e., HGIN or muco− sal cancer), including the role of advanced ima− ging techniques and the importance of histopa− thological evaluation by endoscopic resection. Diagnosis ! Endoscopic detection of early neoplasia in Barrett’s esophagus The goal of endoscopic surveillance of patients with Barrett’s esophagus is the detection of early neoplastic lesions. To ensure the detection of ear− ly neoplastic lesions there are three rules that should be followed. These rules relate to the en− doscopic equipment used, the “detecting eye” of the endoscopist, and a systematic, meticulous approach.