Endoscopic submucosal dissection vs. endoscopic mucosal resection for early Barrett's neoplasia in the West: a retrospective study

Abstract

Background The difference in clinical outcomes after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for early Barrett's esophagus (BE) neoplasia remains unclear. We compared the recurrence/residual tissue rates, resection outcomes, and adverse events after ESD and EMR for early BE neoplasia. Methods We included patients who underwent EMR or ESD for BE-associated high grade dysplasia (HGD) or T1a esophageal adenocarcinoma (EAC) at eight academic hospitals. We compared demographic, procedural, and histologic characteristics, and follow-up data. A time-to-event analysis was performed to evaluate recurrence/residual disease and a Kaplan–Meier curve was used to compare the groups. Results 243 patients (150 EMR; 93 ESD) were included. EMR had lower en bloc (43 % vs. 89 %; P < 0.001) and R0 (56 % vs. 73 %; P = 0.01) rates than ESD. There was no difference in the rates of perforation (0.7 % vs. 0; P > 0.99), early bleeding (0.7 % vs. 1 %; P > 0.99), delayed bleeding (3.3 % vs. 2.1 %; P = 0.71), and stricture (10 % vs. 16 %; P = 0.16) between EMR and ESD. Patients with non-curative resections who underwent further therapy were excluded from the recurrence analysis. Recurrent/residual disease was 31.4 % [44/140] for EMR and 3.5 % [3/85] for ESD during a median (interquartile range) follow-up of 15.5 (6.75–30) and 8 (2–18) months, respectively. Recurrence-/residual disease-free survival was significantly higher in the ESD group. More patients required additional endoscopic resection procedures to treat recurrent/residual disease after EMR (EMR 24.2 % vs. ESD 3.5 %; P < 0.001). Conclusions ESD is safe and results in more definitive treatment of early BE neoplasia, with significantly lower recurrence/residual disease rates and less need for repeat endoscopic treatments than with EMR.

Today’s Mistakes and Tomorrow’s Wisdom in Endoscopic Treatment and Follow-Up of Barrett’s Esophagus

“…ESD has become the standard of care for the resection of esophageal squamous cell neoplasia and gastric adenocarcinoma, considering the virtual local recurrence rate, but also the optimal histological analysis allowed by an en bloc-resected specimen [21]. While an underpowered randomized controlled trial demonstrated the absence of clinical benefit of ESD in the routine management of early Barrett’s neoplasia [22], a number of large retrospective studies confirmed the safety of ESD in this indication with 89%–93% en bloc, 73%–79% R0, and 65%–66% curative resection rates, at the cost of 0%–1.5% perforations, 1.4–2.1% delayed bleeding, and 2.1%–16% stricture rates [23-25]. Thus, the safety profile is similar to EMR, with a possible benefit in terms of histological analysis of esophageal adenocarcinomas [5], but longer procedural times (over 60 mn in most publications).…”

Effect of endoscopic mucosal resection and endoscopic submucosal dissection on postoperative wound bleeding‐related complications in patients with superficial esophageal cancer: A meta‐analysis

“…Nevertheless, there is evidence that ESD is associated with an increased incidence of complications, including hemorrhage, perforation, and postoperative stricture of the esophagus because of the complex surgical procedures 26 . So far, a number of studies have shown that ESD is safer than EMR in treating early‐stage esophagus carcinoma, but their findings are inconsistent with each other 27–29 . As far as we know, no specific comparison between ESD and EMR systems has been conducted with specific comparisons between ESD and EMR in treating early‐stage carcinoma of esophagus.…”

“… 26 So far, a number of studies have shown that ESD is safer than EMR in treating early‐stage esophagus carcinoma, but their findings are inconsistent with each other. 27 , 28 , 29 As far as we know, no specific comparison between ESD and EMR systems has been conducted with specific comparisons between ESD and EMR in treating early‐stage carcinoma of esophagus. To establish a clinical basis for treating superficial esophagus carcinoma under endoscopy, a meta trials were conducted to assess the impact of ESD and EMR in wound complication on early stages of esophagus carcinoma.…”

Mechanisms of esophageal stricture after extensive endoscopic resection: a transcriptomic analysis

“…Endoscopic resection, with endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), is the mainstay of management of early esophageal neoplasia 1 . While early adverse events (AEs) such as bleeding or perforations occur infrequently ( < 2 %), post-endoscopic esophageal strictures remains a concern in 10 % to 20 % of patients 2 3 . Post-endoscopic esophageal strictures occur in up to 90 % of the patients when the resected circumference exceeds 75 % of the esophageal lumen 4 5 6 ; however, the pathophysiology of these strictures is poorly understood.…”