Abstract
We are kicking off 2023 with a focus on Barrett’s Esophagus (BE) and esophageal adenocarcinoma (EAC). The themes of this issue are how we can do better as physicians and endoscopists and finally move the needle to impact the incidence and outcomes of this devastating cancer. Do we need to refine our diagnostic criteria for Barrett’s? Can we implement and operationalize a true screening program? How can we make our surveillance programs more effective? We have a lineup of excellent contributions from our gastroenterology, surgery, and pathology colleagues to provide insight into these topics.
The issue starts by getting into the nitty gritty of the definition of BE and whether <1 cm of columnar lined esophagus without the histological presence of intestinal metaplasia with goblet cells is clinically significant. This has implications for surveillance and cost. Dr. Pech summarizes the data on rates of progression to malignancy and how this informs varying international society guidelines. 1 A provocative commentary by Dr. Chandrosoma asks us to rethink this definition of BE to not require a specific length or intestinal metaplasia. 2
We are fortunate to have a fantastic comprehensive review of the literature by Dr. Holmberg and Dr. Lagergren on the epidemiology of BE and EAC. 3 The article comments that the rising incidence is likely a result of increasing risk factors such as GERD and obesity worldwide, and less protective effect from H. pylori. How to address this growing problem? Dr. Zhang and Dr. Kahn provides important insight on the rational, limitations, and feasibility of developing a BE/EAC screening program. 4 At the present time we are overly reliant on GERD to identify at risk patients (while a large proportion of BE and EAC patients report never having GERD), and screening according to current criteria misses cases. Resource utilization, cost, partnership with primary care, and patient counseling will be of critical importance.
What are other ways to reduce mortality from BE/EAC? Perhaps our surveillance intervals are too long and should be changed, or perhaps our current surveillance programs are doomed and we need to start incorporating risk stratification models and precision medicine for surveillance to be more effective.5,6 Our practices should reflect the true risk of BE transforming to EAC and we are beginning to incorporate biomarkers into the discussion. 7 Finally, we can’t over emphasize the importance of a high-quality endoscopic examination and look forward to new technologies and artificial intelligence to help improve dysplasia detection in BE.8,9 This issue also contains fantastic complementary articles on screening for foregut cancers in Lynch syndrome and surveillance after surgery.10,11
We are pleased to publish 4 original research articles this month and 1 original review as our journal continues to grow. Dr. Poggi et al share their experience with pre procedure diagnostic testing in a large cohort of bariatric surgery patient. 12 A novel review on postoperative gastric dysfunction by Dr. Carson and Dr. O’Grady is an excellent contribution to the literature, along with Dr. Till and Dr. Okusanya’s review of the epidemiology and trends in surgical paraesophageal hernias.13,14 Dr. Iyer and Kunkel describe the impact of an inlet patch on patients with advanced pulmonary disease and after transplant and the role of ablation. 15 Dr. Ma and Dr. Yadlapati share their fantastic study showing that patients with elevated salivary pepsin have increased oral microbiome diversity, which may have implications for GERD. 16
We are excited for the continued growth of our journal Foregut and hope you enjoy reading this issue as much as we did. 17