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• W2036768248 abstract "See “Prospective, Controlled Tandem Endoscopy Study of Narrow Band Imaging for Dysplasia Detection in Barrett's Esophagus,” by Wolfsen HC, Crook JE, Krishna M, et al, on page 24.The aim of endoscopic surveillance of Barrett's esophagus (BE) is the detection of early neoplastic lesions (ie, high-grade dysplasia or intramucosal cancer) at a stage that curative treatment, preferably by endoscopic modalities, is still possible.1Ell C. May A. Pech O. et al.Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).Gastrointest Endosc. 2007; 65: 3-10Abstract Full Text Full Text PDF PubMed Scopus (463) Google Scholar, 2Gondrie J.J. Pouw R.E. Sondermeijer C.M. et al.Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system.Endoscopy. 2008; 40: 359-369Crossref PubMed Scopus (148) Google Scholar, 3Gondrie J.J. Pouw R.E. Sondermeijer C.M. et al.Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system.Endoscopy. 2008; 40: 370-379Crossref PubMed Scopus (161) Google Scholar These early lesions, however, usually present as subtle mucosal abnormalities that are difficult to detect with standard endoscopy. It is therefore advised to obtain random biopsies such as 4-quadrant biopsy every 1–2 cm during BE surveillance; however, this practice is time consuming and associated with sampling error.Several new endoscopic imaging techniques have therefore been developed with the hope of improving the efficacy of BE surveillance. These techniques can be separated into 2 categories: primary detection techniques and targeted imaging techniques.4Kara M.A. Bergman J.J. Autofluorescence imaging and narrow-band imaging for the detection of early neoplasia in patients with Barrett's esophagus.Endoscopy. 2006; 38: 627-631Crossref PubMed Scopus (75) Google Scholar The former act as “red flag techniques,” attracting the attention of the endoscopist to areas of interest in the endoscopic overview (eg, high-resolution endoscopy and autofluorescence endoscopy5Kara M.A. Peters F.P. ten Kate F.J. et al.Endoscopic video autofluorescence imaging may improve the detection of early neoplasia in patients with Barrett's esophagus.Gastrointest Endosc. 2005; 61: 679-685Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar, 6Curvers W.L. Singh R. Song L.M. et al.Endoscopic tri-modal imaging for detection of early neoplasia in Barrett's oesophagus: a multi-centre feasibility study using high-resolution endoscopy, autofluorescence imaging and narrow band imaging incorporated in one endoscopy system.Gut. 2008; 57: 167-172Crossref PubMed Scopus (266) Google Scholar). Upon their detection, these areas can then be inspected in detail using targeted imaging techniques (eg, magnification endoscopy or confocal endomicroscopy7Curvers W. Baak L. Kiesslich R. et al.Chromoendoscopy and narrow-band imaging compared with high-resolution magnification endoscopy in Barrett's esophagus.Gastroenterology. 2008; 134: 670-679Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar, 8Kiesslich R. Gossner L. Goetz M. et al.In vivo histology of Barrett's esophagus and associated neoplasia by confocal laser endomicroscopy.Clin Gastroenterol Hepatol. 2006; 4: 979-987Abstract Full Text Full Text PDF PubMed Scopus (433) Google Scholar) or simply biopsied for histologic evaluation.Narrow band imaging (NBI) is 1 of these new imaging modalities. It uses relatively simple imaging technology. Upon activation of the NBI mode, optical filters are placed in front of the standard white light source, thereby allowing passage of only small bands of blue and green light to illuminate the tissue. Because of the shorter wave length, this light only penetrates into the superficial wall layers, the target zone for early neoplastic lesions. In addition, the excitation light is highly absorbed by hemoglobin thus enhancing the visualization of mucosal and vascular patterns.9Kara M.A. Ennahachi M. Fockens P. et al.Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging.Gastrointest Endosc. 2006; 64: 155-166Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 10Kara M.A. Peters F.P. Fockens P. et al.Endoscopic video-autofluorescence imaging followed by narrow band imaging for detecting early neoplasia in Barrett's esophagus.Gastrointest Endosc. 2006; 64: 176-185Abstract Full Text Full Text PDF PubMed Scopus (200) Google ScholarStudies have shown that early BE neoplasia and nondysplastic BE have distinct mucosal and vascular patterns when visualized with NBI: Regular mucosal and vascular patterns suggest absence of neoplasia whereas irregularity and/or abnormal blood vessels are features of early neoplasia.9Kara M.A. Ennahachi M. Fockens P. et al.Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging.Gastrointest Endosc. 2006; 64: 155-166Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 11Sharma P. Bansal A. Mathur S. et al.The utility of a novel narrow band imaging endoscopy system in patients with Barrett's esophagus.Gastrointest Endosc. 2006; 64: 167-175Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar These studies, however, were performed by correlating magnified still images obtained with NBI with their corresponding histology and thus focused on the use of NBI as a targeted imaging technique. Whether NBI actually improves the primary detection of early neoplasia (and thus works as a red flag technique in overview) is largely unknown as of yet.In this issue of Gastroenterology, Wolfsen et al12Wolfsen et al.Gastroenterology. 2008; 134 (000–000)Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar address this issue in a blinded tandem endoscopy in 65 BE patients. Patients first underwent a standard endoscopy performed by 1 of 8 staff gastroenterologists (Figure 1) and the presence and location of areas suspicious for neoplasia were noted. Subsequently, the standard endoscope was removed and a second endoscopist, blinded to the results of the first procedure, inspected the BE using a high-definition television (HDTV)/NBI system, first in the white light mode and subsequently in the NBI mode. The HDTV/NBI endoscopy was performed by 1 of 2 endoscopists with extensive experience in NBI and early BE neoplasia (Figure 1). After the precise location of all suspicious areas detected with HDTV/NBI was noted, a study coordinator disclosed the location of abnormalities detected by the standard endoscopy to credit the detection of abnormal areas to standard endoscopy and HDTV/NBI. Subsequently, targeted biopsies were obtained from HDTV/NBI detected lesions followed by sampling of lesions detected with standard endoscopy and 4-quarter/1-cm random biopsies. The histologic findings of standard endoscopy (random biopsies and targeted biopsies) were compared with those of HDTV/NBI (targeted biopsies only). Thirty-seven patients (57%) had findings of dysplasia detected by targeted HDTV/NBI guided biopsies compared with 28 patients (43%) with standard endoscopy and random biopsies. In addition, 12 patients (18%) had a higher grade of neoplasia detected with HDTV/NBI than with standard endoscopy. These data suggest that HDTV/NBI with targeted biopsies is superior to standard endoscopy with random biopsy sampling in detecting early neoplasia in patients with BE.The study, however, has some limitations that may have biased the results. First, during the HDTV/NBI procedure, BE was inspected twice: once with HDTV endoscopy and once with NBI. Furthermore, the HDTV/NBI procedures were performed by 2 endoscopists with extensive experience in NBI and BE imaging, whereas the standard endoscopy was performed by 8 staff members from the same center who, as a group, were less experienced in this field. The difference in detection rate may thus simply reflect a more thorough inspection by more experienced endoscopists than a difference between standard endoscopy and HDTV/NBI.More important, the HDTV/NBI endoscopy included inspection of the BE with high-quality white light endoscopy. Compared with standard endoscopy, the HDTV endoscopy system uses a higher intensity white light illumination, a better quality CCD, more sophisticated postprocessing, and a special HDTV monitor on which the image is depicted as 1080 lines instead of 480 lines of a standard monitor. In our opinion, these improvements in white light imaging may be at least as important as the subsequent use of NBI. This was also demonstrated in a recent randomized, cross-over study comparing indigo carmine chromoendoscopy and NBI. In this study, all BE patients with early neoplasia were already detected after inspection with high-resolution white light endoscopy (ie, before application of the indigo carmine or activating the NBI mode).13Kara M.A. Peters F.P. Rosmolen W.D. et al.High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett's esophagus: a prospective randomized crossover study.Endoscopy. 2005; 37: 929-936Crossref PubMed Scopus (289) Google Scholar Wolfsen et al12Wolfsen et al.Gastroenterology. 2008; 134 (000–000)Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar tried to address this issue in a post hoc analysis and found that of the 12 patients that had a higher grade of dysplasia detected with HDTV/NBI, 6 were already detected during HDTV endoscopy before switching to NBI.The question thus remains whether the improved detection rate of the HDTV/NBI procedure is attributed to a more thorough inspection by more experienced endoscopists, a better quality white light endoscopy, or the use of NBI. From a clinical perspective, all these factors are important for detecting early neoplasia. Firstly, we need to develop an “imaging attitude”: The detection of early BE neoplasia starts by spending more time to look for subtle abnormalities than to rush into obtaining random biopsies, after which bleeding will obscure further visualization of lesions. Second, we need to train our “imaging eye” to better recognize the subtle changes that accompany early neoplastic changes in the gastrointestinal tract. With the current quality of white light endoscopy, the eye of the endoscopist has become the weakest link in the detection chain. Most early lesions can be detected if we simply recognize them as such: We do not detect what we see, we only detect what we recognize. The International Working Group for Classification of Oesophagitis, the same group that developed and validated the LA classification for erosive esophagitis and the Prague C&M classification for grading the extent of BE,14Sharma P. Dent J. Armstrong D. et al.The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria.Gastroenterology. 2006; 131: 1392-1399Abstract Full Text Full Text PDF PubMed Scopus (793) Google Scholar is currently working on teaching materials in this respect. Only if we spend more time looking than biopsying and know how to recognize early lesions, the imaging technology itself can make a difference.So is NBI helpful in this respect? The simplistic view on this is as follows: We know that NBI improves the mucosal and vascular imaging, and therefore we can see things that are less obvious with white light endoscopy. If so, then NBI is a helpful tool for detecting early neoplasia. The critical view, however, may be different. Indeed, NBI provides us with more a detailed view of the mucosa, but we are seeing things with which we are not familiar. Inspection with NBI thus forces us to go into an “imaging mode” instead of rushing into the “random biopsy mode.” In addition, the interpretation of mucosal and vascular patterns with NBI is not straightforward. As a result, we switch back and forth between NBI and HDTV endoscopy given the greater familiarity with white light endoscopy images. Suspicious areas will thus be inspected in detail with HDTV endoscopy and consequently we will learn what early neoplasia look like with white light endoscopy. The use of NBI thus may improve the detection and characterization of early neoplastic lesions, but it also forces the endoscopist to take on an “imaging attitude” and improves the “imaging eye” for recognizing early neoplasia with HDTV endoscopy.Does this mean that if we are better trained and more dedicated, HDTV/NBI allows us to stop taking random biopsies? The Wolfsen et al12Wolfsen et al.Gastroenterology. 2008; 134 (000–000)Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar paper may suggest so; targeted biopsies after HDTV/NBI detected more dysplasia than standard endoscopy and random biopsies. These findings are paralleled by endoscopic surveillance of longstanding ulcerative colitis where the contribution of random biopsies on top of good quality imaging is negligible.15Hurlstone D.P. Sanders D.S. Lobo A.J. et al.Indigo carmine-assisted high-magnification chromoscopic colonoscopy for the detection and characterisation of intraepithelial neoplasia in ulcerative colitis: a prospective evaluation.Endoscopy. 2005; 37: 1186-1192Crossref PubMed Scopus (248) Google Scholar The question than rises what to do if HDTV/NBI does not show any visible abnormalities? In the Wolfsen et al study, a high-risk population of BE patients was studied and 57% had dysplasia. In daily practice, the majority of our BE patients will not have dysplasia and will not show lesions that can be targeted for biopsy. In the current guidelines, the length of the surveillance interval is determined by the histologic outcome of the procedure. Some kind of tissue sampling is thus likely to be required for subsequent risk stratification of these patients.The Wolfsen et al study shows us the complexity of interpreting studies on new imaging technology for detecting early neoplasia in the esophagus. This dedicated study and the well-balanced discussion of its results is a step on the way from standard endoscopy with random sampling to multimodality imaging by endoscopists who, as a result, will be looking longer, seeing better, and recognizing more. See “Prospective, Controlled Tandem Endoscopy Study of Narrow Band Imaging for Dysplasia Detection in Barrett's Esophagus,” by Wolfsen HC, Crook JE, Krishna M, et al, on page 24. See “Prospective, Controlled Tandem Endoscopy Study of Narrow Band Imaging for Dysplasia Detection in Barrett's Esophagus,” by Wolfsen HC, Crook JE, Krishna M, et al, on page 24. See “Prospective, Controlled Tandem Endoscopy Study of Narrow Band Imaging for Dysplasia Detection in Barrett's Esophagus,” by Wolfsen HC, Crook JE, Krishna M, et al, on page 24. The aim of endoscopic surveillance of Barrett's esophagus (BE) is the detection of early neoplastic lesions (ie, high-grade dysplasia or intramucosal cancer) at a stage that curative treatment, preferably by endoscopic modalities, is still possible.1Ell C. May A. Pech O. et al.Curative endoscopic resection of early esophageal adenocarcinomas (Barrett's cancer).Gastrointest Endosc. 2007; 65: 3-10Abstract Full Text Full Text PDF PubMed Scopus (463) Google Scholar, 2Gondrie J.J. Pouw R.E. Sondermeijer C.M. et al.Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system.Endoscopy. 2008; 40: 359-369Crossref PubMed Scopus (148) Google Scholar, 3Gondrie J.J. Pouw R.E. Sondermeijer C.M. et al.Effective treatment of early Barrett's neoplasia with stepwise circumferential and focal ablation using the HALO system.Endoscopy. 2008; 40: 370-379Crossref PubMed Scopus (161) Google Scholar These early lesions, however, usually present as subtle mucosal abnormalities that are difficult to detect with standard endoscopy. It is therefore advised to obtain random biopsies such as 4-quadrant biopsy every 1–2 cm during BE surveillance; however, this practice is time consuming and associated with sampling error. Several new endoscopic imaging techniques have therefore been developed with the hope of improving the efficacy of BE surveillance. These techniques can be separated into 2 categories: primary detection techniques and targeted imaging techniques.4Kara M.A. Bergman J.J. Autofluorescence imaging and narrow-band imaging for the detection of early neoplasia in patients with Barrett's esophagus.Endoscopy. 2006; 38: 627-631Crossref PubMed Scopus (75) Google Scholar The former act as “red flag techniques,” attracting the attention of the endoscopist to areas of interest in the endoscopic overview (eg, high-resolution endoscopy and autofluorescence endoscopy5Kara M.A. Peters F.P. ten Kate F.J. et al.Endoscopic video autofluorescence imaging may improve the detection of early neoplasia in patients with Barrett's esophagus.Gastrointest Endosc. 2005; 61: 679-685Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar, 6Curvers W.L. Singh R. Song L.M. et al.Endoscopic tri-modal imaging for detection of early neoplasia in Barrett's oesophagus: a multi-centre feasibility study using high-resolution endoscopy, autofluorescence imaging and narrow band imaging incorporated in one endoscopy system.Gut. 2008; 57: 167-172Crossref PubMed Scopus (266) Google Scholar). Upon their detection, these areas can then be inspected in detail using targeted imaging techniques (eg, magnification endoscopy or confocal endomicroscopy7Curvers W. Baak L. Kiesslich R. et al.Chromoendoscopy and narrow-band imaging compared with high-resolution magnification endoscopy in Barrett's esophagus.Gastroenterology. 2008; 134: 670-679Abstract Full Text Full Text PDF PubMed Scopus (153) Google Scholar, 8Kiesslich R. Gossner L. Goetz M. et al.In vivo histology of Barrett's esophagus and associated neoplasia by confocal laser endomicroscopy.Clin Gastroenterol Hepatol. 2006; 4: 979-987Abstract Full Text Full Text PDF PubMed Scopus (433) Google Scholar) or simply biopsied for histologic evaluation. Narrow band imaging (NBI) is 1 of these new imaging modalities. It uses relatively simple imaging technology. Upon activation of the NBI mode, optical filters are placed in front of the standard white light source, thereby allowing passage of only small bands of blue and green light to illuminate the tissue. Because of the shorter wave length, this light only penetrates into the superficial wall layers, the target zone for early neoplastic lesions. In addition, the excitation light is highly absorbed by hemoglobin thus enhancing the visualization of mucosal and vascular patterns.9Kara M.A. Ennahachi M. Fockens P. et al.Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging.Gastrointest Endosc. 2006; 64: 155-166Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 10Kara M.A. Peters F.P. Fockens P. et al.Endoscopic video-autofluorescence imaging followed by narrow band imaging for detecting early neoplasia in Barrett's esophagus.Gastrointest Endosc. 2006; 64: 176-185Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar Studies have shown that early BE neoplasia and nondysplastic BE have distinct mucosal and vascular patterns when visualized with NBI: Regular mucosal and vascular patterns suggest absence of neoplasia whereas irregularity and/or abnormal blood vessels are features of early neoplasia.9Kara M.A. Ennahachi M. Fockens P. et al.Detection and classification of the mucosal and vascular patterns (mucosal morphology) in Barrett's esophagus by using narrow band imaging.Gastrointest Endosc. 2006; 64: 155-166Abstract Full Text Full Text PDF PubMed Scopus (297) Google Scholar, 11Sharma P. Bansal A. Mathur S. et al.The utility of a novel narrow band imaging endoscopy system in patients with Barrett's esophagus.Gastrointest Endosc. 2006; 64: 167-175Abstract Full Text Full Text PDF PubMed Scopus (321) Google Scholar These studies, however, were performed by correlating magnified still images obtained with NBI with their corresponding histology and thus focused on the use of NBI as a targeted imaging technique. Whether NBI actually improves the primary detection of early neoplasia (and thus works as a red flag technique in overview) is largely unknown as of yet. In this issue of Gastroenterology, Wolfsen et al12Wolfsen et al.Gastroenterology. 2008; 134 (000–000)Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar address this issue in a blinded tandem endoscopy in 65 BE patients. Patients first underwent a standard endoscopy performed by 1 of 8 staff gastroenterologists (Figure 1) and the presence and location of areas suspicious for neoplasia were noted. Subsequently, the standard endoscope was removed and a second endoscopist, blinded to the results of the first procedure, inspected the BE using a high-definition television (HDTV)/NBI system, first in the white light mode and subsequently in the NBI mode. The HDTV/NBI endoscopy was performed by 1 of 2 endoscopists with extensive experience in NBI and early BE neoplasia (Figure 1). After the precise location of all suspicious areas detected with HDTV/NBI was noted, a study coordinator disclosed the location of abnormalities detected by the standard endoscopy to credit the detection of abnormal areas to standard endoscopy and HDTV/NBI. Subsequently, targeted biopsies were obtained from HDTV/NBI detected lesions followed by sampling of lesions detected with standard endoscopy and 4-quarter/1-cm random biopsies. The histologic findings of standard endoscopy (random biopsies and targeted biopsies) were compared with those of HDTV/NBI (targeted biopsies only). Thirty-seven patients (57%) had findings of dysplasia detected by targeted HDTV/NBI guided biopsies compared with 28 patients (43%) with standard endoscopy and random biopsies. In addition, 12 patients (18%) had a higher grade of neoplasia detected with HDTV/NBI than with standard endoscopy. These data suggest that HDTV/NBI with targeted biopsies is superior to standard endoscopy with random biopsy sampling in detecting early neoplasia in patients with BE. The study, however, has some limitations that may have biased the results. First, during the HDTV/NBI procedure, BE was inspected twice: once with HDTV endoscopy and once with NBI. Furthermore, the HDTV/NBI procedures were performed by 2 endoscopists with extensive experience in NBI and BE imaging, whereas the standard endoscopy was performed by 8 staff members from the same center who, as a group, were less experienced in this field. The difference in detection rate may thus simply reflect a more thorough inspection by more experienced endoscopists than a difference between standard endoscopy and HDTV/NBI. More important, the HDTV/NBI endoscopy included inspection of the BE with high-quality white light endoscopy. Compared with standard endoscopy, the HDTV endoscopy system uses a higher intensity white light illumination, a better quality CCD, more sophisticated postprocessing, and a special HDTV monitor on which the image is depicted as 1080 lines instead of 480 lines of a standard monitor. In our opinion, these improvements in white light imaging may be at least as important as the subsequent use of NBI. This was also demonstrated in a recent randomized, cross-over study comparing indigo carmine chromoendoscopy and NBI. In this study, all BE patients with early neoplasia were already detected after inspection with high-resolution white light endoscopy (ie, before application of the indigo carmine or activating the NBI mode).13Kara M.A. Peters F.P. Rosmolen W.D. et al.High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in Barrett's esophagus: a prospective randomized crossover study.Endoscopy. 2005; 37: 929-936Crossref PubMed Scopus (289) Google Scholar Wolfsen et al12Wolfsen et al.Gastroenterology. 2008; 134 (000–000)Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar tried to address this issue in a post hoc analysis and found that of the 12 patients that had a higher grade of dysplasia detected with HDTV/NBI, 6 were already detected during HDTV endoscopy before switching to NBI. The question thus remains whether the improved detection rate of the HDTV/NBI procedure is attributed to a more thorough inspection by more experienced endoscopists, a better quality white light endoscopy, or the use of NBI. From a clinical perspective, all these factors are important for detecting early neoplasia. Firstly, we need to develop an “imaging attitude”: The detection of early BE neoplasia starts by spending more time to look for subtle abnormalities than to rush into obtaining random biopsies, after which bleeding will obscure further visualization of lesions. Second, we need to train our “imaging eye” to better recognize the subtle changes that accompany early neoplastic changes in the gastrointestinal tract. With the current quality of white light endoscopy, the eye of the endoscopist has become the weakest link in the detection chain. Most early lesions can be detected if we simply recognize them as such: We do not detect what we see, we only detect what we recognize. The International Working Group for Classification of Oesophagitis, the same group that developed and validated the LA classification for erosive esophagitis and the Prague C&M classification for grading the extent of BE,14Sharma P. Dent J. Armstrong D. et al.The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria.Gastroenterology. 2006; 131: 1392-1399Abstract Full Text Full Text PDF PubMed Scopus (793) Google Scholar is currently working on teaching materials in this respect. Only if we spend more time looking than biopsying and know how to recognize early lesions, the imaging technology itself can make a difference. So is NBI helpful in this respect? The simplistic view on this is as follows: We know that NBI improves the mucosal and vascular imaging, and therefore we can see things that are less obvious with white light endoscopy. If so, then NBI is a helpful tool for detecting early neoplasia. The critical view, however, may be different. Indeed, NBI provides us with more a detailed view of the mucosa, but we are seeing things with which we are not familiar. Inspection with NBI thus forces us to go into an “imaging mode” instead of rushing into the “random biopsy mode.” In addition, the interpretation of mucosal and vascular patterns with NBI is not straightforward. As a result, we switch back and forth between NBI and HDTV endoscopy given the greater familiarity with white light endoscopy images. Suspicious areas will thus be inspected in detail with HDTV endoscopy and consequently we will learn what early neoplasia look like with white light endoscopy. The use of NBI thus may improve the detection and characterization of early neoplastic lesions, but it also forces the endoscopist to take on an “imaging attitude” and improves the “imaging eye” for recognizing early neoplasia with HDTV endoscopy. Does this mean that if we are better trained and more dedicated, HDTV/NBI allows us to stop taking random biopsies? The Wolfsen et al12Wolfsen et al.Gastroenterology. 2008; 134 (000–000)Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar paper may suggest so; targeted biopsies after HDTV/NBI detected more dysplasia than standard endoscopy and random biopsies. These findings are paralleled by endoscopic surveillance of longstanding ulcerative colitis where the contribution of random biopsies on top of good quality imaging is negligible.15Hurlstone D.P. Sanders D.S. Lobo A.J. et al.Indigo carmine-assisted high-magnification chromoscopic colonoscopy for the detection and characterisation of intraepithelial neoplasia in ulcerative colitis: a prospective evaluation.Endoscopy. 2005; 37: 1186-1192Crossref PubMed Scopus (248) Google Scholar The question than rises what to do if HDTV/NBI does not show any visible abnormalities? In the Wolfsen et al study, a high-risk population of BE patients was studied and 57% had dysplasia. In daily practice, the majority of our BE patients will not have dysplasia and will not show lesions that can be targeted for biopsy. In the current guidelines, the length of the surveillance interval is determined by the histologic outcome of the procedure. Some kind of tissue sampling is thus likely to be required for subsequent risk stratification of these patients. The Wolfsen et al study shows us the complexity of interpreting studies on new imaging technology for detecting early neoplasia in the esophagus. This dedicated study and the well-balanced discussion of its results is a step on the way from standard endoscopy with random sampling to multimodality imaging by endoscopists who, as a result, will be looking longer, seeing better, and recognizing more. Prospective, Controlled Tandem Endoscopy Study of Narrow Band Imaging for Dysplasia Detection in Barrett's EsophagusGastroenterologyVol. 135Issue 1PreviewBackground & Aims: High-resolution endoscopy with narrow band imaging (NBI) enhances the visualization of mucosal glandular and vascular structures. This study assessed whether narrow band targeted biopsies could detect advanced dysplasia using fewer biopsy samples compared with standard resolution endoscopy. Methods: We conducted a prospective, blinded, tandem endoscopy study in a tertiary care center with 65 patients with Barrett's esophagus undergoing evaluation for previously detected dysplasia. Full-Text PDF" @default.
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• W2036768248 title "Multimodality Imaging in Barrett's Esophagus: Looking Longer, Seeing Better, and Recognizing More" @default.
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