Yeah, we are going to Germany next to Dr. Horst Neuhaus from Dusseldorf for more imaging of Barrett's esophagus. Dr. Neuhaus, can you hear us? Yes, it's a pleasure to participate in your course. And I have the pleasure to work with Ute and Natasha and our patient who is 66 years old and he had occasionally heartburn until September this year. In October, heartburn got more severe and he underwent his first gastroscopy in his life and they diagnosed severe reflux esophagitis but also Barrett's epithelium and they took a couple of biopsies also from the inflamed areas showing adeno in some of the specimen Barrett's adenocassinoma, well differentiated. So then the patient was scheduled for referral to our unit for further evaluation and treatment but we recommended first to treat him with PPI for about four weeks and now luckily the inflammation disappeared and this is I think mandatory because before considering evaluation and treatment you shouldn't have any inflammation otherwise also his pathological evaluation is difficult. So I'm using Olympus scope and this is the new ADIS-1 technology so the processor and light source is within a single machine and this has a cross compatibility to Lucera. This is the black and white chip technology which is used in Japan and in the UK so our friends from the UK are always a little bit different from the rest of Europe because we use the color chip technology Xsera as you do in the states but the nice technology now allows to use both technologies Lucera as well as Xsera and we will demonstrate two cases with Lucera this in this case and you see a nice panel here I can switch different modes for changing the optical technologies for video recording and so on I will show you in more details now please show the endoscopic image. So this is from the Lucera series the GIF XZ1200 a zoom endoscope so this is obviously a regular squamous cell part of the oesophagus and we nicely see in white light the reddish tongue of Barrett's extending from 34 to 39 four centimeter tongues and one centimeter circumferential so this is the proximal end firstly we use the Prague classification and this is the EG junction you can nicely see the upper folds of the stomach and also the shape of the Barrett's and some palisades vessels here so I can now magnify a little bit you nicely see the junction between the pits of the gastric mucosa and Barrett's. Now the next step is to identify neoplastic lesion so this is white light technology so do you see any suspicious lesion maybe at nine o'clock but maybe also from four o'clock to six o'clock so now I switch to TXI this is a new mode which means texture and color enhancement so this enhances the different reddish colors and this should improve detection so this may be used as a new white light technology so this is still without magnification let's see I freeze the image for you yeah and here maybe you can notice that we have a slight elevation and irregularity at 10 o'clock we don't see any more alteration or erosions now this is suspicious and we scan now for detection we scan the mucosa with slightly used magnification I have a distance cap with two millimeters extending from the tip so four millimeters for therapeutic interventions two millimeters for diagnostic to stabilize the position of the scope and I already scanned the whole area so we can come back here to the initially suspicious part here but I don't see really there are some irregularities here but multiple biopsies were taken I don't think that this is malignant but we have to re-evaluate and NBI all other areas are normal and now I switch to NBI neuroband imaging which you may well know which is much brighter with AVIX X1 and again. Can you show us the top on the regular pattern first please? Pardon me? So yeah on the proximal barrettes can you show us the regular the normal barrettes pattern? Yes I do. Oh perfect. So this is regular you see nicely the tubular part and also the vessels alongside the mucosal pits this is normal this is normal it's it's a little bit different from but the vessels are still so according to the bing classification the mucosa is a little structure is a little bit different from from 12 o'clock but the vascular pattern is normal so this is the most suspicious part here yes look here you can nicely see the and delineate this is of course important firstly yeah here there's no pit pattern we lost this the surface structure here so we can magnify up to 120 fold underwater yeah you can nicely see that the tubular structure completely disappears we have irregular vessels and horse what you're also showing there right at the one o'clock position on that there is a regular pattern and that changes so you can actually see the exact lesion as you're nicely demonstrating yes the market yes and also consider that at from nine o'clock to 12 o'clock we have the squamous cell epithelium which also looks suspicious they took probably biopsies here so in any case the lesion has to be removed including I think it's growing under the squamous cell epithelium here go ahead that's a nice demonstration of sort of that squamous overlying the barrett's right there at 11 to 12 o'clock where you can almost see there's just a thin sheen of the squamous over that lesion um so of course before we move to torston i know you want to show us another case um one can you tell us the plan for this patient is it emr or esd and second can you briefly talk about rdi i know you're not showing it but if you can educate us about rdi this is a type 2a flat elevation extremely unlikely that this is a that we have a submucosal invasion here and this should be a good candidate for emr for on block emr we will probably use the captivator and then we do mapping biopsies again from the remaining barretts and if there is no additional cancer and i think we excluded this because i took more time before then the remaining barrett will be ablated either by cryo you're participating in a european study or by rfa so this was our first case and now torston beiner will show you exera in another case which is a little bit more advanced but the message is take your time many are too much focused on resection techniques many many courses on esd and so on but the diagnostic approach is extremely important because when you not delineate lesions and characterize before then you may resect the wrong part or achieve incomplete resection very important to spend your time in the precise diagnosis horse before we move can you just give us 30 seconds on rdi by the way by the way this this is another lesion here i just see which is close to the others can you see nicely very small the irregular tortuous vessel vessels the delineation mark the demarcation line to the regular mucosa this has a just two millimeters in diameter yep very nice uh thank you very much horse so we'll move to torston and look at the case and we'll see you for the q a session horse if you're available okay yes okay thank you thank you

Barrett's esophagus

reflux esophagitis

adenocarcinoma

PPI treatment

ADIS-1 technology