Non-radical, stepwise complete endoscopic resection of Barrett’s epithelium in short segment Barrett’s esophagus has a low stricture rate

Background and aims: Radical endoscopic excision of Barrett’s epithelium performing 4 – 6 endoscopic resections during the same endoscopic session results in complete Barrett’s eradication but has a high stricture rate (40 – 80 %). Therefore radiofrequency ablation is preferred after endoscopic mucosal resection (EMR) of visible nodules. We investigated the clinical outcome of non-radical, stepwise endoscopic mucosal resection with a maximum of two endoscopic resections per endoscopic session.

Methods: We analysed our prospectively maintained database of patients undergoing esophageal EMR for early neoplasia in Barrett’s esophagus from 2009 to 2014. EMR was performed using a maximum of two band ligation mucosectomies per endoscopic session; thereafter, follow-up was 3-monthly and EMR was repeated as required for Barrett’s eradication.

Results: In total, 118 patients underwent staging EMR for early Barrett’s neoplasia. Subsequently, 27 patients underwent surgery/chemotherapy due to deep submucosal or more advanced tumor stages or were managed conservatively. The remaining 91 patients with high grade dysplasia (48), intramucosal (38) or submucosal cancer (5) in the resected nodule underwent further endoscopic therapy with a mean follow-up of 24 months. Remission of dysplasia/neoplasia was achieved in 95.6 % after 12 months treatment. Stepwise endoscopic Barrett’s resection resulted in complete Barrett’s eradication in 36/91 patients (39.6 %) in a mean of four sessions; 40/91 patients (44.0 %) had a short circumferential Barrett’s segment (< 3 cm). In this group, repeated EMR achieved complete Barrett’s excision in 85.0 %. One patient developed a stricture (1.1 %), one a delayed bleeding, and there were no perforations.

Conclusion: In patients with a short Barrett’s segment, non-radical endoscopic Barrett’s resection at the time of scheduled endoscopy follow-up allows complete Barrett’s eradication with very low stricture rate.

• References

• 1 Fitzgerald RC, di Pietro M, Ragunath K et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014; 63: 7-42
• 2 Haidry RJ, Lipman G, Banks MR et al. Comparing outcome of radiofrequency ablation in Barrett’s with high grade dysplasia and intramucosal carcinoma: a prospective multicenter UK registry. Endoscopy 2015; 47: 980-987
• 3 Shaheen NJ, Sharma P, Overholt BF et al. Radiofrequency ablation in Barrett’s esophagus with dysplasia. NEJM 2009; 360: 2277-2288
• 4 van Vilsteren FGI, Pouw RE, Seewald S et al. Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett’s oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial. Gut 2011; 60: 765-773
• 5 Kim HP, Bulsiewicz WJ, Cotton CC et al. Focal endoscopic mucosal resection before radiofrequency ablation is equally effective and safe compared with radiofrequency ablation alone for the eradication of Barrett’s esophagus with advanced neoplasia. Gastrointest Endosc 2012; 76: 733-739
• 6 Pouw RE, Wirths K, Eisendrath P et al. Efficacy of radiofrequency ablation combined with endoscopic resection for barrett’s esophagus with early neoplasia. Clin Gastroenterol Hepatol 2010; 8: 23-29
• 7 Bulsiewicz WJ, Kim HP, Dellon ES et al. Safety and efficacy of endoscopic mucosal therapy with radiofrequency ablation for patients with neoplastic Barrett’s esophagus. Clin Gastroenterol Hepatol 2013; 11: 636-642
• 8 Gray NA, Odze RD, Spechler SJ. Buried metaplasia after endoscopic ablation of Barrett’s esophagus: a systematic review. Am J Gastroenterol 2011; 106: 1899-1908
• 9 Lee JK, Cameron RG, Binmoeller KF et al. Recurrence of subsquamous dysplasia and carcinoma after successful endoscopic and radiofrequency ablation therapy for dysplastic Barrett’s esophagus. Endoscopy 2013; 45: 571-574
• 10 Alvarez Herrero L, Pouw RE, van Vilsteren FGI et al. Safety and efficacy of multiband mucosectomy in 1060 resections in Barrett’s esophagus. Endoscopy 2011; 43: 177-183
• 11 Pouw RE, Peters FP, Sempoux C et al. Stepwise radical endoscopic resection for Barrett’s esophagus with early neoplasia: report on a Brussels’ cohort. Endoscopy 2008; 40: 892-898
• 12 Sharma P, Dent J, Armstrong D et al. The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria. Gastroenterology 2006; 131: 1392-1399
• 13 Schlemper RJ, Riddell RH, Kato Y et al. The Vienna classification of gastrointestinal epithelial neoplasia. Gut 2000; 47: 251-255
• 14 Manner H, Pech O, Heldmann Y et al. The frequency of lymph node metastasis in early-stage adenocarcinoma of the esophagus with incipient submucosal invasion (pT1b sm1) depending on histological risk patterns. Surg Endosc 2015; 29: 1888-1896
• 15 Ancona E, Rampado S, Cassaro M et al. Prediction of lymph node status in superficial esophageal carcinoma. Ann Surg Oncol 2008; 15: 3278-3288
• 16 Liu L, Hofstetter WL, Rashid A et al. Significance of the depth of tumor invasion and lymph node metastasis in superficially invasive (T1) esophageal adenocarcinoma. Am J Surg Pathol 2005; 29: 1079-1085
• 17 Knyrim K, Wagner HJ, Bethge N et al. A controlled trial of an expansile metal stent for palliation of esophageal obstruction due to inoperable cancer. NEJM 1993; 329: 1302-1307
• 18 Pech O, Behrens A, May A et al. Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett’s oesophagus. Gut 2008; 57: 1200-1206
• 19 Alvarez Herrero L, van Vilsteren FGI, Pouw RE et al. Endoscopic radiofrequency ablation combined with endoscopic resection for early neoplasia in Barrett’s esophagus longer than 10 cm. Gastrointest Endosc 2011; 73: 682-690
• 20 Pouw RE, Seewald S, Gondrie JJ et al. Stepwise radical endoscopic resection for eradication of Barrett’s oesophagus with early neoplasia in a cohort of 169 patients. Gut 2010; 59: 1169-1177
• 21 Chung A, Bourke MJ, Hourigan LF et al. Complete Barrett’s excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture. Endoscopy 2011; 43: 1025-1032
• 22 Larghi A, Lightdale CJ, Ross AS et al. Long-term follow-up of complete Barrett’s eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma. Endoscopy 2007; 39: 1086-1091
• 23 Bahin FF, Jayanna M, Hourigan LF et al. Long-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett’s esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma. Gastrointest Endosc 2016; 83: 68-77
• 24 Soehendra N, Seewald S, Groth S et al. Use of modified multiband ligator facilitates circumferential EMR in Barrett’s esophagus (with video). Gastrointest Endosc 2006; 63: 847-852
• 25 Qumseya B, Panossian AM, Rizk C et al. Predictors of esophageal stricture formation post endoscopic mucosal resection. Clin Endosc 2014; 47: 155-161
• 26 Li N, Pasricha S, Bulsiewicz WJ et al. Effects of preceding endoscopic mucosal resection on the efficacy and safety of radiofrequency ablation for treatment of Barrett’s esophagus: results from the United States Radiofrequency Ablation Registry. Dis Esophagus 2016; 29: 537-543 DOI: 10.1111/dote.12386.
• 27 Haidry RJ, Butt MA, Dunn JM et al. Improvement over time in outcomes for patients undergoing endoscopic therapy for Barrett’s oesophagus-related neoplasia: 6-year experience from the first 500 patients treated in the UK patient registry. Gut 2015; 64: 1192-1199
• 28 Hanaoka N, Ishihara R, Takeuchi Y et al. Intralesional steroid injection to prevent stricture after endoscopic submucosal dissection for esophageal cancer: a controlled prospective study. Endoscopy 2012; 44: 1007-1011
• 29 Hashimoto S, Kobayashi M, Takeuchi M et al. The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection. Gastrointest Endosc 2011; 74: 1389-1393
• 30 Beye B, Barret M, Alatawi A et al. Topical hemostatic powder promotes reepithelialization and reduces scar formation after extensive esophageal mucosal resection. Dis Esophagus 2016; 29: 520-527 DOI: 10.1111/dote.12378.
• 31 Iizuka T, Kikuchi D, Yamada A et al. Polyglycolic acid sheet application to prevent esophageal stricture after endoscopic submucosal dissection for esophageal squamous cell carcinoma. Endoscopy 2015; 47: 341-344
• 32 Bahin FF, Jayanna M, Williams SJ et al. Efficacy of viscous budesonide slurry for prevention of esophageal stricture formation after complete endoscopic mucosal resection of short-segment Barrett’s neoplasia. Endoscopy 2016; 48: 71-74
• 33 Barret M, Beye B, Leblanc S et al. Systematic review: the prevention of oesophageal stricture after endoscopic resection. Aliment Pharmacol Ther 2015; 42: 20-39