Resection of lesions in the upper gastrointestinal tract: Results of one year of endoscopic mucosal resection and endoscopic submucosal dissection in a non-academic centre

Introduction: Endoscopic Resection of early neoplasias and their precursor lesions in the upper gastrointestinal tract has become standard in many endoscopy units. We report on the results, complications and outcome of patients referred to a non-academic centre for endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) of upper GI lesions within one year.

Patients and Methods: Between February 2010 and February 2011 a total of 16 patients (eleven female, five male, mean age=69 years) were referred for endoscopic resection of lesions in the esophagus, stomach or duodenum. We performed ESD in two cases, Cap-EMR (C-EMR) in six cases and EMR after submucosal injection using a standard snare in eight cases, respectively. Indications for resection included Barrett's esophagus with HGIN (n=4), esophageal papilloma (n=1), cardia polyps (n=2), gastric adenoma (n=5), polypoid lesions of the stomach (n=2) and duodenal adenoma (n=2). All procedures were performed under deep sedation using propofol.

Results: All lesions could be resected successfully. Minor complications consisted of bleeding in 7 cases (44%); all bleedings were treated successfully using clips, argon plasma coagulation, coagrasper forceps or a combination of two methods. Most bleedings occurred during C-EMR (n=4). One patient had to undergo a second procedure because of a drop of serum hemoglobin after resection of a large duodenal adenoma;

a visible vessel without active bleeding was treated with clips. Final diagnosis based on the resected specimen differed in 4 cases (25%) from the initial diagnosis: in a patient referred for the removal of a gastric adenoma final diagnosis after ESD was Ménétrier's disease, on case of suspected Barrett's with HGIN was invasive cancer (pT1a), another case of suspected Barrett's with HGIN was downstaged to LGIN after resection, another one to Barrett's without dysplasia.

Discussion: EMR and ESD are established methods for the resection of early cancer and precursor lesions in the upper gastrointestinal tract. Unlike in Asia, case load in Western countries is still low: in a recent European survey (Ribeiro-Mourã et al., Endoscopy 2010) the mean number of ESD's performed annually in major European centres is four. Our data show that a small specialized centre can perform a reasonable amount of procedures in a year, yielding good results. As far as data is available, no recurrence of disease occured over the follow-up period. Minor complications, mostly bleeding, occured frequently (44%), a good knowledge of relevant techniques for hemostasis is therefore mandatory. However, serious adverse events seem to be rare. As already known, staging of Barrett's esophagus can be challenging based on biopsies. In fact, in 3 out of 4 patients with Barrett's esophagus final diagnosis was different from the one leading to endoscopic intervention. Because of the relatively low numbers performed by Western endoscopists, specialized centres are needed in order to obtain satisfactory results.