Chapter 9 – Enhanced Imaging of the Esophagus: Confocal Laser Endomicroscopy

Confocal laser endomicroscopy (CLE) provides real-time microscopic imaging within the esophagus after administration of fluorescein. It permits immediate diagnosis of Barrett’s esophagus and associated intraepithelial neoplasia (dysplasia). Multiple trials have evaluated the accuracy of both CLE systems (endoscope-integrated CLE and probe-based CLE) in Barrett’s patients. CLE requires a thorough knowledge of mucosal pathology, but training sets based on a pattern recognition approach demonstrate that gastroenterologists can achieve good accuracy rates. Accuracy of predicting neoplasia is sufficient to allow for the use of optical biopsies instead of physical pinch biopsies according to the Seattle protocol in some but not all trials. A major advantage is the ability to use CLE for immediate targeted resection of suspicious lesions without the need to wait for histopathology results. CLE use for screening after circumferential radiofrequency ablation therapy has so far not met the clinical needs. In addition, many of the classical risk factors that are needed to determine if a local endoscopic resection is feasible and can be considered curative cannot (yet) be assessed by CLE. Molecular imaging using CLE aims at further optimization of lesion characterization but still mandates further clinical evaluation.