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These are exciting times in the management of Barrett's oesophagus. The emergence of large multicentre consortia, along with new imaging and treatment modalities that utilise ever-improving study design are all welcome developments in the face of the continuing increase in the incidence of oesophageal adenocarcinoma. From a diagnostic, staging and treatment perspective, endoscopic mucosal resection (EMR) has emerged as a critical tool in the management of patients with both high-grade dysplasia and early carcinoma. Tumour staging with EMR is accurate when compared with surgical pathology following oesophagectomy: negative margins on EMR specimens correlate well with absence of residual disease at the time of surgery but submucosal involvement is associated with predictable rates of residual disease and/or lymph node metastases at the time of surgery.1 Furthermore EMR will change the diagnosis in approximately 50% of patients when compared to endoscopic biopsies, given the larger tissue sample available for review by the pathologist.2 Inter-observer agreement among pathologists is improved as well.
EMR is clearly a therapeutic option for high-grade dysplasia and intramucosal carcinoma with low risk characteristics that have been well described previously by the Wiesbaden group.3 However, EMR, when used as a standalone therapy for early neoplasia in Barrett's oesophagus, is limited by the subsequent development of metachronous lesions in approximately 21% of patients.4 A number of risk factors for recurrence have been identified with perhaps the most important being the lack of treatment of the residual at risk mucosa.4 There are currently two options to deal with the remaining at risk mucosa: focal EMR accompanied by endoscopic ablation of …