Mo1239 COMPARATIVE OUTCOMES OF CAP ASSISTED ENDOSCOPIC RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION IN PATIENTS WITH DYSPLASTIC BARRETT'S ESOPHAGUS AND INTRAMUCOSAL ADENOCARCINOMA

Abstract

Endoscopic eradication therapy (EET) is the standard of care for the treatment of Barrett’s Esophagus (BE) with dysplasia and intramucosal esophageal adenocarcinoma (EAC). Cap assisted endoscopic resection (cEMR) leads to piecemeal resection in larger lesions. Endoscopic submucosal dissection (ESD) allows for the en bloc removal of larger lesions. Both approaches are followed by mucosal ablation to achieve complete eradication of dysplasia and intestinal metaplasia. Limited data is available for the efficacy of these two approaches followed by mucosal ablation. We studied the outcomes of patients treated with these modalities at our institution, focusing on rates of complete remission of intestinal metaplasia (CRIM) and dysplasia (CRD). We queried a prospectively maintained database of all patients at our institution undergoing EMR and ESD for dysplastic/neoplastic BE and abstracted relevant demographic and clinical data. Only patients with at least one endoscopic follow up were included. Our primary outcome was the achievement of CRIM, defined as the absence of intestinal metaplasia on at least one follow up EGD at 2 years. Secondary outcomes included rates of complete remission of dysplasia (CRD), defined as the absence of dysplastic BE on at least one follow up EGD and rates of complications. All pathology was read by expert gastrointestinal pathologists. Time dependent analyses were conducted to compare outcomes in the two groups. A total of 633 patients, of whom 447 that underwent cEMR and 89 that underwent ESD were included. 447 (100%) and 59 (66.3%) in the cEMR group and ESD groups underwent ablation (either radiofrequency ablation or cryotherapy) post endoscopic resection. Demographic and clinical variables are displayed in Table 1. The ESD group had a higher proportion of EAC patients (48.3% vs 20.1%, p<0.05) but proportions of HGD+EAC were similar in both groups. More complications were associated with the EMR group, driven mainly by post-procedural bleeding rates. Rates of CRD were lower in the EMR group at 6 months but were comparable at 12 and 24 months (see table 1 and Figure 1). Rates of CRIM were comparable between the two groups at 12 and 24 months. A multivariate model (adjusting for age, gender, BMI, smoking status, length of BE, presence of hiatal hernia, and initial histology) showed that EMR was associated with a lower likelihood of achieving CRD (HR 0.487, 95% CI: 0.337-0.703, p <0.0001), but not CRIM at 2 years (HR 0.895, 95% CI: 0.537-1.491, p=.67). EMR and ESD both appear to be effective in the treatment of BE related neoplasia. ESD is safe when performed by expert endoscopists. While there is a higher likelihood of achieving CRD earlier in patients with ESD, both resection techniques when combined with endoscopic ablation appear equally efficacious in achieving CRIM at 24 months.Comparison of baseline characteristics and outcomes (CRIM, CRD and complications) in the two groups.View Large Image Figure ViewerDownload Hi-res image Download (PPT)