Endoscopic submucosal dissection (ESD) for Barrett’s esophagus (BE)-related early neoplasia after standard endoscopic management is feasible and safe

Abstract

Background and study aims There is little data on the feasibility and safety of endoscopic submucosal dissection (ESD) as a salvage treatment for Barrett’s esophagus (BE)-related neoplasia after standard endoscopic treatments.

Patients and methods A multicenter retrospective analysis on patients who underwent ESD for BE was performed. The primary endpoint was effectiveness of obtaining en-bloc resection in salvage as compared to non-salvage treatments.

Results Median age was 71 (IQR 55 – 79) years. Twelve (37%) of 32 patients underwent salvage ESD. Median resection time was 100 (IQR 60 – 136) minutes. En-bloc resection was achieved in 31 patients (97 %). Complete R0 resection was obtained in 75 % in the salvage group and 80 % in the non-salvage group (P = 1.00). In seven patients (22 %), the pre-ESD diagnosis was upgraded on post-ESD histopathology (1 low-grade dysplasia to high grade dysplasia [HGD], 4 HGD to early esophageal carcinoma (EAC), and 2 intramucosal EAC to invasive EAC). No perforations occurred in either group. Two late adverse events occurred, both in the salvage group (P = 0.133). Delayed bleeding occurred in a patient who had just resumed warfarin and stricture occurred in a patient who had a circumferential resection requiring serial dilation and stent placement.

Conclusions Our cohort study demonstrated that ESD as salvage therapy for BE related neoplasia is feasible and safe, achieving similar high rates of en-bloc resection and complete R0 resection as in treatment-naïve patients. Referral to an expert center performing ESD should be considered for patients with recurrence or progression following endoscopic mucosal resection or ablation therapy.

• References

• 1 Shaheen NJ, Falk GW, Iyer PG. et al. ACG Clinical Guideline: Diagnosis and Management of Barrett’s Esophagus. Am J Gastroenterol 2016; 111: 30-50
• 2 Cao Y, Liao C, Tan A. et al. Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract. Endoscopy 2009; 41: 751-757
• 3 Wang J, Ge J, Zhang XH. et al. Endoscopic submucosal dissection versus endoscopic mucosal resection for the treatment of early esophageal carcinoma: a meta-analysis. Asian Pac J Cancer Prev 2014; 15: 1803-1806
• 4 Yang D, Zou F, Xiong S. et al. Endoscopic submucosal dissection for early Barrettʼs neoplasia: a meta-analysis. Gastrointest Endosc 2018; 87: 1383-1393
• 5 ASGE Sandards of Practice Committee. The management of antithrombotic agents for patients undergoing GI endoscopy. Gastrointest Endosc 2016; 83: 3-16
• 6 Bulsiewicz WJ, Dellon ES, Rogers AJ. et al. The impact of endoscopic ultrasound findings on clinical decision making in Barrettʼs esophagus with high-grade dysplasia or early esophageal adenocarcinoma. Dis Esophagus 2014; 27: 409-417
• 7 Bartel MJ, Wallace TM, Gomez-Esquivel RD. et al. Role of EUS in patients with suspected Barrettʼs esophagus with high-grade dysplasia or early esophageal adenocarcinoma: impact on endoscopic therapy. Gastrointest Endosc 2017; 86: 292-298
• 8 Wani S, Abrams J, Edmundowicz SA. et al. Endoscopic mucosal resection results in change of histologic diagnosis in Barrettʼs esophagus patients with visible and flat neoplasia: a multicenter cohort study. Dig Dis Sci 2013; 58: 1703-1709
• 9 American Gastroenterological Association Medical Position Statement on the Management of Barrett’s Esophagus. Gastroenterology 2011; 140: 1084-1091
• 10 European Society of Gastrointestinal Endoscopy. Endoscopic management of Barrett’s esophagus: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2017; 49: 191-198
• 11 Tomizawa Y, Iyer PG, Wong Kee Song LM. et al. Safety of endoscopic mucosal resection for Barrettʼs esophagus. Am J Gastroenterol 2013; 108: 1440-1447
• 12 Pech O, Behrens A, May A. et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrettʼs oesophagus. Gut 2008; 57: 1200-1206
• 13 Tomizawa Y, Konda VJA, Coronel E. et al. Efficacy, durability, and safety of complete endoscopic mucosal resection of Barrett esophagus: a systematic review and meta-analysis. J Clin Gastroenterol 2018; 52: 210-216
• 14 Yang D, Coman RM, Kahaleh M. et al. Endoscopic submucosal dissection for Barrettʼs early neoplasia: a multicenter study in the United States. Gastrointest Endosc 2017; 86: 600-607
• 15 Subramaniam S, Chedgy F, Longcroft-Wheaton G. et al. Complex early Barrettʼs neoplasia at 3 Western centers: European Barrettʼs Endoscopic Submucosal Dissection Trial (E-BEST). Gastrointest Endosc 2017; 86: 608-618
• 16 Terheggen G, Horn EM, Vieth M. et al. A randomised trial of endoscopic submucosal dissection versus endoscopic mucosal resection for early Barrettʼs neoplasia. Gut 2017; 66: 783-793
• 17 Matsumoto A, Tanaka S, Oba S. et al. Outcome of endoscopic submucosal dissection for colorectal tumors accompanied by fibrosis. Scand J Gastroenterol 2010; 45: 1329-1337
• 18 Subramaniam S, Kandiah K, Chedgy F. et al. The safety and efficacy of radiofrequency ablation following endoscopic submucosal dissection for Barrettʼs neoplasia. Dis Esophagus 2018;