Endoscopic mucosal resection of early cancer and high-grade dysplasia in Barrett's esophagus☆

Abstract 

Background & Aims: In view of the mortality and morbidity rates of esophagectomy and the relatively large group of inoperable patients, local therapeutic techniques are required for high-grade dysplasia and early Barrett's cancer. Methods: A prospective investigation of endoscopic mucosal resection was conducted in 64 patients (mean age, 65 ± 10 years) who had early carcinoma (61 patients) or high-grade dysplasia (3 patients) in Barrett's esophagus. Thirty-five patients met the criteria for low risk: macroscopic types I, IIa, IIb, and IIc; lesion diameter up to 20 mm; mucosal lesion; and histological grades G1 and G2 and/or high-grade dysplasia (group A). The remaining 29 patients were included in group B (high risk). Results: A total of 120 resections were performed, with no technical problems encountered. The mean number of treatment sessions per patient was 1.3 ± 0.6 in group A and 2.8 ± 2.0 in group B (P < 0.0005). Only one major complication occurred, a case of spurting bleeding, which was managed endoscopically. Complete local remission was achieved significantly earlier (P = 0.008) in group A than in group B. In May 1999, complete remission had been achieved in 97% of the patients in group A and in 59% of those in group B; however, 1 patient in group A and 9 in group B are still undergoing treatment or awaiting the first check-up. During a mean follow-up of 12 ± 8 months, recurrent or metachronous carcinomas were found in 14%. Conclusions: Endoscopic mucosal resection of early carcinoma in Barrett's esophagus is associated with promisingly low morbidity and mortality rates. The procedure may offer a new minimally invasive therapeutic alternative to esophagectomy, especially in low-risk situations. Comparisons with surgical results will need to be done when the long-term results of this procedure become available.

GASTROENTEROLOGY 2000;118:670-677

Abbreviations:  CLR , complete local remission, EC , early carcinoma, EMR , endoscopic mucosal resection, HGD , high-grade dysplasia, PDT , photodynamic therapy