Complete circumferential endoscopic submucosal dissection for early Barrett’s neoplasia

Abstract

Background and aimsEndoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of esophageal neoplasia in the western world. Contrary to Asia, the majority of esophageal cancers in North America are associated with Barrett’s esophagus. Patients with circumferential advanced neoplasia were previously managed by esophagectomy. Increased experience with ESD has allowed for an endoscopic alternative. We aim to present our experience with complete circumferential esophageal ESD at a North American referral center. MethodsAll patients undergoing 100% circumferential esophageal ESD between Oct 2016 and Jan 2023 at a single tertiary care center in Canada were included in the cohort. Demographic, procedural data and lesion characteristics are presented in this series. ResultsEleven patients underwent 100% circumferential esophageal ESD during this period for Barrett’s neoplasia. All patients had technically successful procedures with en bloc resection. Nine patients (82%) had R0 resections, defined as clear lateral and deep margins on histologic examination. Two patients had positive deep margins on histologic examination and proceeded to esophagectomy. Seven patients (64%) had adenocarcinoma on final pathology, of which 6 (86%) had upstaging from their initial biopsy.The median area of resected specimen was 48cm2 (IQR 26-80) and the median procedure time was 231 minutes (IQR 180-246). Procedural efficiency was 4.0 min/cm2 (IQR 2.7-5). Two patients (18%) developed refractory strictures following the procedure, which were endoscopically managed to resolution. ConclusionMultifocal dysplastic Barrett’s esophagus remains a challenging entity to treat. Circumferential ESD is a possible therapeutic option, with high procedural success and low adverse outcomes. This should be balanced against the risk of stricture development, as the optimal post procedural prophylaxis regimen is investigated.