Prospective evaluation of the clinical utility of endoscopic submucosal dissection (ESD) in patients with Barrett’s esophagus: a Western center experience

Abstract

Background and study aims: Endoscopic submucosal dissection (ESD) carries significant advantages over endoscopic mucosal resection. As such, ESD is an established therapy for esophageal squamous cell carcinoma but there are only limited data on ESD as therapy for Barrett’s esophagus (BE). Thus, we prospectively evaluated the outcomes of ESD in patients with BE with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EAC) performed in a Western center. Patients and methods: This is a prospective cohort study. Indications for ESD included: (1) early EAC defined as lesions with intramucosal cancer or superficial submucosal invasion; (2) early EAC with positive lateral margin after EMR; and (3) nodularity with HGD that could not be removed en-bloc with EMR Results: From October 2013 to July 2015, 36 consecutive patients (median age 69, 32 males) underwent ESD at our center. Median procedure time was 88 minutes, with median maximal diameter of resected specimens of 49 mm. En-bloc, R0, and curative resection rates were 100 %, 81 %, and 69 %, respectively. Intramucosal EAC was found in 13 patients (36 %), and submucosal invasion in 13 patients (36 %). In 59 % of the cases, there was discrepancy in the pre- and post-ESD histopathologic diagnosis.Adverse events occurred in 8 patients (22 %), including one episode of bleeding treated with endoscopy and seven esophageal strictures, which were successfully managed with dilations. Conclusions: ESD for BE with HGD/early EAC is feasible and safe with resulting very high en-bloc and R0 resection rates. ESD provided for more accurate pathologic evaluation and significant discrepancy between the pre- and post-ESD histopathological diagnosis was noted.

Endoscopic submucosal dissection in the West: Current status and future directions

“…Western series of ESD for early Barrett's neoplasia have shown promising results, reporting en bloc and R0 resection rates of 90–100% and 79–81%, respectively (Table ). The overall rate of adverse events varies between 3% and 27% across different studies, less in centers with larger case load and more experienced endoscopists . One multicenter European study of 143 ESD for early Barrett's neoplasia identified 30 procedures as the threshold at which en bloc resection rates reach a plateau.…”

“…11,68 Recent gastric ESD studies from Western centers have shown comparable outcomes to that of Eastern centers, particularly in critical endpoints such as R0 resection and complications 69,70 (Table 1. 20,22,[69][70][71][72][73][74] In a prospective observational study of 191 EGC resected by ESD from a single Western referral center, en bloc and R0 resection rates of 98.4% and 90.2% for lesions meeting guideline criteria and 89.0% and 73.6% for lesions meeting expanded criteria, respectively, were achieved. Delayed bleeding rate was 6%, and perforation rate was 1%.…”

“…For example, a small prospective Italian series of 20 patients with superficial esophageal SCC resected by ESD (mean size 32 mm, range 15-60 mm) reported en bloc and R0 rates of 90%, 71 indicating it is a technically feasible indication. Western series of ESD for early Barrett's neoplasia have shown promising results, reporting en bloc and R0 resection rates of 90-100% and 79-81%, respectively 20,[72][73][74] ( Table 1). The overall rate of adverse events varies between 3% and 27% across different studies, less in centers with larger case load and more experienced endoscopists.…”

Endoscopic submucosal dissection is associated with less pathologic uncertainty than endoscopic mucosal resection in diagnosing and staging Barrett's‐related neoplasia

“…Our results add to the evidence that supports the use of ESD for the treatment of Barrett's neoplasia . The nature of EMR limits the endoscopist's ability to accurately and consistently control the depth of resection and ESD has been suggested as an alternative that allows for better visualization of depth of both the lesion and resection plane . Unfortunately, direct comparisons between ESD and EMR for the treatment of Barrett's neoplasia are limited to relatively small studies or extrapolations from treatment of superficial squamous cell carcinoma of the esophagus .…”

Barrett's esophagus: The advocacy for ESD

“…En bloc, R0, and curative resection rates were 100 %, 81 %, and 69 %, respectively. Intramucosal EAC was found in 13 patients (36 %), and submucosal invasion in 13 patients (36 %) 6. Adverse events occurred in 8 patients (22 %), including bleeding in 1 patient, which was treated with endoscopy, and esophageal strictures in 7 patients, which were successfully managed with dilatations.…”