ENDOSCOPIC SUBMUCOSAL DISSECTION FOR BARRETT'S RELATED NEOPLASIA IN THE NETHERLANDS: RESULTS OF A NATIONWIDE COHORT OF 130 CASES

Abstract

Introduction Endoscopic resection (ER) is the standard of care for early neoplasia in Barrett’s esophagus (BE). Generally, (piecemeal) ER is used to remove early neoplasia, yet the use of endoscopic submucosal dissection (ESD) is expanding. We aimed to report outcomes of all ESDs for BE neoplasia, performed in a setting of centralized care in the Netherlands. Methods Endoscopic therapy for BE neoplasia in the Netherlands is centralized in 9 expert centers with specifically and jointly trained endoscopists and pathologists. Uniformity is further ensured by a joint protocol and regular group meetings. ESD is performed for large and bulky lesions that cannot be removed with cap-based ER and/or in case of suspicion for submucosal (sm) invasion. Prospectively collected treatment/FU data are registered in a uniform database. We report efficacy and safety outcomes of all successfully completed ESD-BE cases treated in the Netherlands since 2008. En-bloc resection was defined as complete resection of the delineated target lesion in a single piece, R0-resection as absence of cancer in the vertical and lateral margin. Results A total of 130 ESDs was performed for lesions with a median diameter of 30mm (IQR 10-40) over 30% of the circumference (25-50). During median 121 min (90-180), 126/130 were removed en-bloc (97%). The remaining 4 were completely removed in piecemeal fashion. Pathology was m-EAC (48%) or sm-EAC (52%; 19% sm1 and 33% ≥sm2). Stratified for depth of invasion, the combined rate for en-bloc and R0 resection was 87% for T1a lesions (95%CI 77-94) and 49% (95%CI 37-62) for T1b lesions. After R1 resection, 29% of patients (10/34) had residual cancer at first FU, all of which were detected during the 8-12 weeks follow-up endoscopy. The remaining 71% (24/34) had no residual cancer in esophagectomy specimen (n=4) or during a median endoscopic FU of 9 months (4-22) (n=20). A total of 76 patients with en-bloc and R0 resection underwent endoscopic FU during median 17 months (IQR 8-30), with a local recurrence risk of 0% [95% CI 0-5]. In one patient, a small perforation occurred (1% [95% CI 0-4]), successfully treated with a clip. Post-procedural bleeding occurred in 4 patients (3% [ 95% CI 1-7]); esophageal stricture in 18 (13%, [95% CI 8-20]), resolved after median 3 (IQR 1-12) endoscopic dilatations. Conclusion In expert hands, ESD is safe and allows for effective removal of mucosal and submucosal esophageal adenocarcinoma. Our data suggest that histopathological R1 resection does not necessarily imply residual cancer and need for additional surgery, and underline the importance of endoscopic restaging to identify patients who do have residual cancer.