166 Endoscopic Submucosal Dissection for Barrett's High Grade Dysplasia or Early Adenocarcinoma: A U.S. Single Center's Experience

Abstract

Endoscopic submucosal dissection (ESD) is an emerging treatment option for early gastrointestinal neoplasia. This technique is not currently widespread in the U.S. due to its complexity, and lack of training and device availability. Data on its safety and efficacy in the U.S. is also lacking. To report the safety and efficacy of ESD for a treatment of Barrett's high grade dysplasia (HGD) or early adenocarcinoma (EAC). Prospective collection of patients who underwent ESD for Barrett's nodular HGD or EAC from 6/2007 to 10/2010. Large lesions unfit for endoscopic mucosal resection or lesions with suspected deeper invasion were treated with ESD. Informed consent was obtained from all patients including the use of ESD knives and the technique. ESD was performed with saline-epinephrine-methylcellulose solution. Various ESD knives were used. When performing ESD, it was aimed to remove half to 2/3 of circumference of Barrett's inclusive of the HGD or EAC. For Barrett's greater than 6cm, mostly the lesion with wide margin was targeted and removed en bloc. Final pathology was recorded. Patients underwent scheduled post resection surveillance endoscopy and radiological studies. Nineteen patients (17M:2F, median age 64) underwent ESD for HGD (N=9) and EAC (N=10). The median length of Barrett's length 4cm (range 1-14) and the size of the lesion was 20mm (range 5 to 50). Macroscopic types were IIa (N=11), IIb (N=1), IIa+IIc (N=5), Is (N=1) and Ip (N=1). EUS stage was mucosal in 13, suspected submucosal invasion in 4, definite submucosal invasion in 2. Median procedure time for ESD was 117 minutes (25-229). There was no perforation or significant bleeding. Median length of removal was 6cm (4-15) and surface area of specimen was 18cm2 (5-47). Final pathology was HGD in 4 and EAC in 15; 5 were upgraded from HGD. There were 3 submucosal invasions, of which 2 were diagnosed preoperatively by EUS. Four suspected submucosal invasion by probe EUS were mucosal cancers. Three resections (16%) had positive lateral margin with HGD, but none had EAC at lateral margins. Deep margin was positive in poorly differentiated adenocarcinoma with submucosal invasion (N=1, 5%). Dysphagia developed in 4/19 (21%) and resolved with endoscopic dilations. Two patients subsequently had additional treatments (surgery 1, chemoradiation 1). Remaining 17/19 patients are free of HGD or EAC with a median follow up of 315 days (7-1059). In this single operator experience, ESD was feasible and safe in Barrett's patients with HGD with larger dysplastic area and early adenocarcinoma. ESD provides en bloc pathological specimen for accurate pathological diagnosis and staging with acceptable stricture rate if not circumferential. Safety and efficacy requires confirmation in larger scale studies for widespread application of ESD.