Assessment of Endoscopic Submucosal Dissection for Early Barrett’s Neoplasia

Although the results of ESD were generally positive in managing Barrett's neoplasia, procedural improvements are needed ESD is to replace piecemeal endoscopic mucosal resection.

Although the results of endoscopic submucosal dissection (ESD) were generally positive in managing Barrett’s neoplasia, procedural improvements are needed if the procedure is to replace piecemeal endoscopic mucosal resection, according to study results published in the United European Gastroenterology Journal.

Researchers aimed to assess the safety and effectiveness of ESD as a treatment for visible lesions in early Barrett’s neoplasia. The retrospective study included 69 consecutive patients with lesions larger than 10 mm and/or submucosal ingrowth who were treated via esophageal ESD since January 2012. In patients with preoperative histology indicative of invasive adenocarcinoma or worrisome endoscopic features, oncologic workups were performed and included endoscopic ultrasound and thoraco-abdomino-pelvic computed tomography scan.

Between February 2012 and January 2015, 35 patients (mean age 66.2±12) had 36 lesions resected. Patient history included both chronic alcohol abuse and tobacco smoking (11.6% and 45.7% of patients, respectively). Nearly 70% (68.6%) of patients had a major comorbid condition, and 45.7% reported heartburn or regurgitations. The mean time since Barrett’s esophagus diagnosis was 3.6±5 years, with 65.7% of patients diagnosed within the previous year.

Across 36 ESDs, investigators noted a 91.7% (33/36) success rate. The mean size of resection specimens was 50.6±22 mm with a range from 10 to 100 mm. In 27.8% (10/36) of cases, specimens exceeded three-fourths of the esophageal circumference.

Four patients experienced early procedure-related complications, including perforation (3 cases) and anesthesia complications (2 cases). Perforations were conservatively managed, with endoclips, nil per os, intravenous proton pump inhibitors, broad-spectrum antibiotics, and 24- to 48-hour surveillance in the intensive care unit. Two patients experienced late complications of esophageal strictures, managed through endoscopic dilation.

In 80.5% of the cases, the resected specimens contained invasive adenocarcinoma. Mean lesion size was 12±15 mm with a range from 2 to 90 mm. R0 resection rate of carcinomas was 72.4%, with vertical and lateral margins containing adenocarcinoma in 20.7% and 17.2% of cases. 

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The investigators observed no 30-day mortality. After a mean follow-up time of 12.9±9 months, 48.6% of patients required additional treatment, including 25.7% with deep submucosal adenocarcinoma or R1 endoscopic resection.

“There is currently no established role for a routine use of ESD in the care of early Barrett’s cancer,” the researchers concluded. “However, ESD might be preferable for the resection of lesions larger than 15 mm, pretreated and/or poorly lifting, too bulky to consider resection with a cap-based technique, or suspicious for submucosal invasion.”

They added, “Prospective randomized trials are needed to compare endoscopic mucosal resection and ESD, starting with those specific indications.”

Reference Barret M, Cao DT, Beuvon F, et al. Endoscopic submucosal dissection for early Barrett’s neoplasia [published online September 24, 2015]. United European Gastroenterol J. doi: 10.1177/2050640615608748