Comparison of complete resection between EMR and ESD of early cancer T1 ≤ 2cm of the upper gastrointestinal tract

Introduction: Local treatment for early cancer of the oesophagus and stomach by endoscopic mucosal resection (EMR) has been accepted as a standard treatment strategy for selected cases. The specific indications for endoscopic resection by EMR have been intramucosal carcinoma of less than 2cm in diameter. Endoscopic submucosal dissection (ESD) is a new technique developed to obtain one piece resection even for large, ulcerative lesions or lesions at a difficult localisation.

Aims and methods: The present study aims to identify the technical feasibility of complete resection of early cancer of the upper GI in comparison of EMR to ESD in particular of lesions smaller than 2cm in diameter. From all patients with early cancer of the upper GI treated endoscopically in our department during the study period of two years (April 2005– April 2007) we reviewed those 21 patients with lesions smaller than 2cm in diameter who underwent EMR or ESD.

EMR: EMR was performed with a cap or ligation technique (Olympus/Cook) by piecemeal resection. 15 patients were treated by this method in the oesophagus, at the oesophago-gastric junction or in the stomach.

ESD: ESD was performed with IT-knife or/and Hook-knife (Olympus) by en-bloc resection. 6 patients were treated by this method in the stomach (2 upper third, 4 lower third).

Discussion and Results: During the study period of two years we identified 21 lesions with early cancer of the stomach, oesophagus or oesophago-gastric junction (n=21, lesions smaller than 2cm).

EMR: 15 patients underwent EMR of early cancer using piecemeal resection: 6 located in the oesophagus, 5 located in the oesophago-gastric junction, 4 located in the stomach. Complete resection (curative, tumour-free margin) by EMR was possible in 4 patients (27%), incomplete resection (non curative, non tumour-free margin) appeared in 4 cases (27%), we were not able to evaluate the margin of lesions of 7 patients (46%). The local tumour recurrence of a follow up over two years was 4 of 15 patients (27%).

ESD: 6 patients underwent ESD of early cancer located in the stomach using the Hook-knife or/and the IT-knife by en-bloc resection. Complete resection by ESD was possible in 5 patients (83%), incomplete resection did not appear, in one case we were not able to evaluate the margin of lesion (17%). There was no local tumour recurrence of a follow up over one year.

Conclusions: In Europe lots of early cancer are smaller than 2cm. The present study shows a better local complete en-bloc resection and a lower local recurrence by ESD in comparison to EMR for lesions smaller than 2cm in diameter in the upper gastrointestinal tract.

Keywords: EMR, ESD, T1 cancer, upper gastrointestinal tract