Endoscopic submucosal dissection for Barrett's esophagus: not ready for prime time

Last Updated: 2016-02-10

By Will Boggs MD

NEW YORK (Reuters Health) - Endoscopic submucosal dissection (ESD) offers higher rates of complete resection of Barrett's esophagus than the more widely used endoscopic mucosal resection (EMR), but at the cost of longer operation times and higher severe adverse event rates, researchers from Germany report.

Unlike EMR, ESD allows en-bloc resection of large neoplastic lesions. In one earlier trial, ESD showed promising results in early Barrett's esophagus.

Dr. Horst Neuhaus from Evangelisches Krankenhaus Düsseldorf and colleagues compared the efficacy and safety of ESD with EMR for the treatment of focal elevated or depressed lesions of high-grade intraepithelial neoplasia (HGIN) or early adenocarcinoma (EAC) in a randomized trial of 40 patients with Barrett's esophagus.

The mean procedural time was more than twice as long for ESD as for EMR (54 min vs. 22 min, p<0.001), and ESD was technically more demanding than EMR, the researchers report in Gut, online January 22.

Complete resection (R0) rates were much higher with ESD (10/17, 58.8%) than with EMR (2/17, 11.8%; p=0.01), as were curative resection rates (52.9% vs. 11.8%; p=0.03).

This did not translate into differences in complete remission rates at three months, however, which were similar after ESD (15/16, 93.8%) and EMR (16/17, 94.1%; p=1.0).

ESD was complicated by transmural tears in three patients and perforation in two cases, whereas there were no serious adverse events recorded for EMR.

"In spite of initial technical advantages, ESD does not seem to offer clinical advantages over EMR in terms of need for surgery, neoplasia remission, and early recurrence rates," the researchers conclude. "Large volume randomized controlled trials would be required to verify significant differences with an adequate statistical power."

Dr. Roos E. Pouw from Academic Medical Center in Amsterdam, the Netherlands, who was not involved in the new work, recently reported that combined endoscopic resection and focal radiofrequency ablation in a single session was effective for short-segment Barrett's esophagus.

He told Reuters Health by email, "ESD achieves higher R0 resection rates, but in Barrett's this may not be relevant, since most patients receive additional ablation anyway and residual neoplastic rests will be ablated anyhow. Since ESD is more time consuming and may result in severe adverse events, I think EMR for flat type lesions in Barrett's is still preferable."

"ESD should be considered for a small selection of patients and should only be performed in specialized centers by endoscopists with experience in this technique," Dr. Pouw concluded.

Dr. Kerry Dunbar from the University of Texas Southwestern Medical Center, Dallas, who studied endoscopic options for treating dysplasia in Barrett's esophagus, agreed.

"EMR is widely accepted for treatment of Barrett's esophagus (BE) with high grade dysplasia and early cancers, and is recommended in multiple gastroenterology society guidelines for treatment of BE with neoplasia," she told Reuters Health by email. "EMR also has an important role in staging patients with early Barrett's cancers, and is used to help determine which patients can be treated endoscopically and which need surgery."

"ESD has been studied at a few expert Barrett's centers around the world, but has not gained wide acceptance," she said. "ESD is technically challenging, and in some cases (such as in this research study), the rate of adverse events and serious adverse events is higher with ESD than EMR."

"Most patients can be successfully treated with a combination of EMR with radiofrequency ablation (RFA) of any remaining Barrett's esophagus," Dr. Dunbar concluded. "Regardless of the type of endoscopic treatment, all patients need follow-up endoscopy to check for residual neoplasia and Barrett's esophagus, and should remain in an endoscopic surveillance program."

Dr. Neuhaus did not respond to a request for comments.

SOURCE: bit.ly/1Q8BIRb

Gut 2016.