Total endoscopic resection of Barrett esophagus

Introduction

Barrett’s esophagus with high grade intraepithelial neoplasia (HGIN) is associated with disease progression of greater than 10 % per year [1]. In the context of intramucosal cancer (IMC) without deep submucosal involvement, there is no risk of distant metastasis. Endoscopic mucosal resection (EMR) is a feasible lower risk alternative to surgery for HGIN and IMC. The indications for EMR are HGIN and well or moderately differentiated IMC [2] [3].

Total endoscopic resection (TER) of all Barrett’s mucosa has the advantage over localized resection in that it removes all at-risk mucosa, thus reducing the risk of recurrent disease compared with localized resection [4] [5]. Peters et al. studied the properties of the neosquamous epithelium that regenerates after TER of Barrett’s esophagus. They used immunohistochemical staining for the proliferation marker Ki67 and p53 protein accumulation as well as fluorescent in situ hybridization for numerical chromosomal abnormalities and specific losses of tumor suppressor genes p16 and p53. Whereas all patients had multiple abnormalities in their Barrett’s esophagus prior to TER, none were found in their neosquamous epithelium after TER. This suggests that TER may indeed provide a permanent cure for early neoplasia in Barrett’s esophagus [6].

Most groups that have reported on TER have used piecemeal resection for removal of the Barrett’s esophagus. Endoscopic submucosal dissection (ESD), originally introduced for early gastric cancer [7], has been attempted in the context of intramucosal Barrett’s cancer to achieve en bloc resection [8] [9] [10] but the experience with ESD for TER is limited as yet.

References

• 1 Sharma P, McQuaid K, Dent J. et al . A critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop.  Gastroenterology. 2004;  127 310-330
• 2 Seewald S, Ang T L, Soehendra N. Endoscopic mucosal resection of Barrett’s oesophagus containing dysplasia or intramucosal cancer.  Postgrad Med J. 2007;  83 367-372
• 3 Seewald S, Omar S, Soehendra N. Endoscopic mucosectomy of the esophagus.  Am J Gastroenterol. 2007;  102 236-238
• 4 May A, Gossner L, Pech O. et al . Local endoscopic therapy for intraepithelial high grade neoplasia and early adenocarcinoma in Barrett’s esophagus: acute phase and intermediate results of a new treatment approach.  Eur J Gastroenterol Hepatol. 2002;  14 1085-1091
• 5 May A, Gossner L, Pech O. et al . Intraepithelial high grade neoplasia and early adenocarcinoma in short segment Barrett’s esophagus (SSBE): curative treatment using local endoscopic treatment techniques.  Endoscopy. 2002;  34 604-610
• 6 Peters F P, Krishnadath K K, Rygiel A M. et al . Stepwise radical endoscopic resection of the complete Barrett’s esophagus with early neoplasia successfully eradicates pre-existing genetic abnormalities.  Am J Gastroenterol. 2007;  102 1853-1861
• 7 Ono H, Inui T, Gotoda T. et al . EMR for early gastric cancer using IT knife method [in Japanese with English abstract].  Endoscopia Digestiva. 2002;  14 1737-1740
• 8 Yoshinaga S, Gotoda T, Kusano C. et al . Clinical impact of endoscopic submucosal dissection for superficial adenocarcinoma located at the esophagogastric junction.  Gastrointest Endosc. 2008;  67 202-209
• 9 Oyama T, Tomori A, Hotta K. et al . Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 Suppl 1 S67-S70
• 10 Rösch T, Sarbia M, Schumacher B. et al . Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series [including videos].  Endoscopy. 2004;  36 788-801
• 11 Deyhle P, Largiader F, Jenny S. A method for endoscopic electroresection of sessile colonic polyps.  Endoscopy. 1973;  5 38-40
• 12 Tada M, Shimada M, Murukami F. et al . Development of the strip-off biopsy [in Japanese with English abstract].  Gastroenterol Endosc. 1984;  26 833-839
• 13 Soehendra N, Binmoeller K F, Bohnacker S. et al . Endoscopic snare mucosectomy in the esophagus without any additional equipment: a simple technique for resection of flat early cancer.  Endoscopy. 1997;  29 380-383
• 14 Inoue H, Takeshita K, Hori H. et al . Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach and colon mucosal lesions.  Gastrointest Endosc. 1993;  39 58-62
• 15 Makuuchi H, Machimura T, Soh Y. Endoscopic mucosectomy for mucosal carcinomas in the esophagus.  J Jpn Gastroenterol Surg. 1991;  24 2599-2603
• 16 Chaves D M, Sakai P, Mester M. et al . A new endoscopic technique for the resection of flat polypoid lesions.  Gastrointest Endosc. 1994;  40 224-226
• 17 Fleischer D E, Wang G Q, Dawsey S. et al . Tissue band ligation followed by snare resection (band and snare): a new technique for tissue acquisition in the esophagus.  Gastrointest Endosc. 1996;  44 68-72
• 18 Soehendra N, Seewald S, Groth S. et al . Use of modified multiband ligator facilitates circumferential endoscopic mucosal resection in Barrett’s esophagus [+ video].  Gastrointest Endosc. 2006;  63 847-852
• 19 Seewald S, Akaraviputh T, Seitz U. et al . Circumferential EMR and complete removal of Barrett’s epithelium: a new approach to management of Barrett’s esophagus containing high grade intraepithelial neoplasia and intramucosal carcinoma.  Gastrointest Endosc. 2003;  57 854-859
• 20 Giovannini M, Bories E, Pesenti C. et al . Circumferential endoscopic mucosal resection in Barrett’s esophagus with high grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients.  Endoscopy. 2004;  36 782-787
• 21 Satodate H, Inoue H, Yoshida T. et al . Circumferential EMR of carcinoma arising in Barrett’s esophagus: case report.  Gastrointest Endosc. 2003;  58 288-292
• 22 Peters F P, Kara M A, Rosmolen W D. et al . Stepwise radical endoscopic resection is effective for complete removal of Barrett’s esophagus with early neoplasia: a prospective study.  Am J Gastroenterol. 2006;  101 1449-1457
• 23 Pouw R E, Gondrie J J, Herrero L A. et al . A randomized prospective trial comparing the cap-technique and multi-band mucosectomy technique for piecemeal endoscopic resection in Barrett’s esophagus.  Gastrointest Endosc. 2008;  67 AB75
• 24 Peters F P, Kara M A, Curvers W L. et al . Multiband mucosectomy for endoscopic resection of Barrett’s esophagus: feasibility study with matched historical controls.  Eur J Gastroenterol Hepatol. 2007;  19 311-315
• 25 Oyama T, Hotta K, Tomori A. Endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma and adenocarcinoma.  Gastrointest Endosc. 2007;  65 AB110
• 26 Larghi A, Lightdale C J, Ross A S. et al . Long-term follow-up of complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma.  Endoscopy. 2007;  39 1086-1091
• 27 Lopes C V, Hela M, Pesenti C. et al . Circumferential endoscopic resection of Barrett’s esophagus with high-grade dysplasia or early adenocarcinoma.  Surg Endosc. 2007;  21 820-824
• 28 Siddiqui J, Gerke H. Efficacy and safety of band ligator assisted mucosal resection to completely remove Barrett’s esophagus with high grade dysplasia or early cancer.  Gastrointest Endosc. 2008;  67 AB177
• 29 Gondrie J J, Seewald S, Pouw R E. et al . Stepwise radical endoscopic resection for complete removal of Barrett’s esophagus with early neoplasia: an international multicenter study.  Gastrointest Endosc. 2008;  67 AB175