Endoscopic Resection and Ablation in Barrett’s Oesophagus
follow-up, but recurrences or metachronous neoplasia are the major problem with endoscopic therapy in early Barrett’s neoplasia. However, successful repeat endoscopic treatment is usually possible in almost all patients.
The reasons for the high rate of recurrence appear to be related to the fact that the residual Barrett’s metaplasia seems to have an increased risk of malignant transformation due to genetic abnormalities not influenced by focal endoscopic treatment. A number of risk factors for recurrence have been identified with perhaps the most important being the lack of treatment of the residual at-risk mucosa.28
However,
the results were also able to demonstrate that ablative therapy of the remaining non-dysplastic Barrett’s epithelium after successful ER could significantly decrease the risk.
Those results were confirmed in a prospective randomised trial by our group comparing ER of all neoplastic lesions followed by ablation of the non-dysplastic Barrett’s epithelium with APC and follow-up alone.29 These data clearly demonstrate that ablative treatment of the remaining non-dysplastic Barrett’s epithelium after successful ER of all detectable neoplastic lesions can significantly reduce the recurrence rate and should always be performed. For ablation, either APC (e.g. for short-segment Barrett’s) or RFA (especially in long-segment Barrett’s) may be chosen.
Complete Circumferential Endoscopic Resection Another concept to reduce the rate of recurrent malignancy after successful ER is complete circumferential ER. Circumferential ER has the goal of completely resecting the Barrett’s segment with concomitant histological confirmation of the underlying mucosal abnormalities. Studies to date suggest that circumferential ER results in complete remission of intra-epithelial neoplasia and Barrett’s epithelium in 75–100% of patients. The largest US series on circumferential ER, published by Chennat et al., reported on the results in 33 patients with high-grade dysplasia (HGD) and 16 patients with mucosal cancer.30
Complete eradication of neoplasia and
Barrett’s epithelium could be achieved in all except one of the 32 patients who completed treatment. Symptomatic oesophageal stenosis developed in 37% of patients, all of whom could be managed endoscopically. No other severe complications were observed.
A recent multicentre European cohort study provides the largest experience with this technique. A total of 169 patients with HGD or early carcinoma in Barrett’s oesophagus with a segment length <5cm underwent complete ER of their Barrett’s segment with elimination of neoplasia in 97.6%, and all intestinal metaplasia in 85.2% at the end of the treatment phase.31
At the completion of follow-up (median
27 months), remission of neoplasia was maintained in 97.5% and complete elimination of intestinal metaplasia was accomplished in 85%. The recurrence rate for metachronous disease was 1.8% and complications included perforation in 1%, delayed bleeding in 1% and strictures requiring dilation in 50% of the study population.
One of the major advantages of radical ER of neoplastic Barrett’s oesophagus is the possibility that the whole Barrett’s segment can be evaluated by the pathologist in order to detect and stage even
1. Kara MA, Peters FP, Rosmolen WD, et al., High-resolution endoscopy plus chromoendoscopy or narrow-band imaging in barrett’s esophagus: a prospective randomized crossover study, Endoscopy, 2005;37:929–36.
Comparisons with Surgical Therapy
There are no randomised controlled trials that have compared endoscopic with surgical approaches for the management of HGIN and early carcinoma. A number of observational studies suggest that long-term survival of the two techniques is similar.35–37
However,
cancer may develop during follow-up of endoscopically treated patients in up to approximately 12%.35
On the other hand, radical
oesophageal resection is known to carry a substantial risk of morbidity and mortality even in high-volume centres. n
2. Pohl J, Pech O, May A, et al., Incidence of macroscopically occult neoplasias in Barrett’s esophagus: are random biopsies dispensable in the era of advanced endoscopic imaging? Am J Gastroenterol, 2010;105:2350–6.
3. Zuccaro G Jr, Rice TW, Vargo JJ, et al., Endoscopic ultrasound errors in esophageal cancer, Am J Gastroenterol, 2005;100:601–6.
4. May A, Guenther E, Roth F, et al., Accuracy of staging in early esophageal cancer using high resolution endoscopy
EUROPEAN GASTROENTEROLOGY & HEPATOLOGY REVIEW 137
endoscopically inapparent neoplasia. The downside of complete radical ER of the whole Barrett’s segment is the high stricture rate associated with this method, requiring repeated dilatation. Therefore, a combination of ER of all visible neoplastic lesions followed by thermal ablation of the remaining Barrett’s epithelium seems to be the best treatment strategy at present by combining the positive effect of tissue acquisition with a low complication rate associated with ablation. Cancer risk is attenuated but not fully eliminated and meticulous long-term follow-up is required.
Endoscopic Submucosal Dissection
There is almost no experience with ESD in patients with early Barrett’s neoplasia. In a small series by Kakushima et al., ESD was performed in 30 patients with tumours of the oesophagogastric junction.32
Only four
of the patients had early Barrett’s cancer. The average maximum diameters of the lesions and resected specimens were 22.4 and 40.6mm, respectively. The R0 resection rate (tumour-free vertical and lateral margins) was 97% (29 of 30). Another series from Japan reported on ESD of superficial adenocarcinoma of the oesophagogastric junction.33
ESD was performed in 25 cancers in
24 patients. The en bloc resection rate was 100% in this series, but only 72% of lesions were judged as a curative resection. No recurrences were observed in this group during a median follow-up of 30.1 months.
The results of a prospective randomised trial from Belgium comparing cap ER with ESD in patients with early Barrett’s neoplasia have been published in abstract form.34
Twenty-five patients were included in
each group. Larger neoplastic lesions in the ER group had to be resected by piecemeal technique. On the other hand, the R0 resection rate was 64% in the ESD group. However, complete resection of all neoplasia was achieved in both groups and recurrences were observed in both groups after a follow-up of 15 months. Perforations occurred in two and one patient in the ESD and ER groups, respectively. Strictures were observed in significantly more patients in the ESD group than in the ER group (44 versus 20%).
Although ESD is theoretically the ideal treatment technique in patients with early Barrett’s neoplasia, data so far do not support its use for Barrett’s neoplasia outside of prospective studies. The outcome after ESD does not seem to be better than that obtained with conventional ER (suck-and-cut ER). It is questionable whether ESD, a demanding, time-consuming technique with a flat learning curve and a high complication rate, can significantly improve the excellent results of ER combined with ablation with remission rates of more than 90% already achieved by many Western groups.
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