Tami Yamashita, MD, FRCSC, Harry Henteleff, MD, MSc, FRCSC, FACS, FCCP, Drew Bethune, MD, MSc, FRCSC, FCCP, James Ellsmere, MD, MSc, FRCSC. Dalhousie University
Introduction. Endoscopic mucosal resection (EMR) is increasingly being used as first line treatment for Barrett’s esophagus (BE) with dysplastic changes and intramucosal adenocarcinoma (IMC). At our center, patients are selected for endoscopic therapy and surveillance for high-grade dysplasia and IMC using a collaborative approach between therapeutic endoscopists and thoracic surgeons. We hypothesize that our outcomes are consistent with the emerging literature supporting this strategy.
Methods. Between October 2010 to August 2014, 30 consecutive patients underwent EMR for BE with dysplastic changes and IMC. A retrospective chart review was performed on these patients to assess: complications, eradication of dysplasia, and progression of disease. EMR was performed using the Duette Multi-Band Mucosectomy device (Cook Medical, Bloomington, IN).
Results. Of the 30 study patients, 17 were referred with BE, 12 were initially referred for IMC, 1 was referred for palliative management of invasive adenocarcinoma. Of the group with BE, 15 patients had high-grade dysplasia (HGD), one patient had low-grade dysplasia and one had intermediate dysplasia. Median follow-up was 363 days.
Fifteen patients were referred with HGD, and complete eradication of dysplasia was achieved in 12 patients (80%). Three patients with HGD did not achieve pathologic remission: one died from acute leukemia, one was lost to follow-up, and one with a long segment HGD was referred for RF ablation therapy. None of the patients referred for EMR for dysplastic changes developed invasive esophageal cancer.
Of the 12 patients referred for IMC, 4 were found to have invasive adenocarcinoma based on the EMR specimen and were referred for esophagectomy. Eight patients with an EMR confirmed diagnosis of IMC were successfully managed with EMR and endoscopic surveillance, with complete eradication of dysplasia in all these patients.
Complications were minimal with 2 patients developing esophageal strictures, which were successfully managed with dilatation. There were no cases of perforation or post-operative hemorrhage.
Conclusion. Our multidisciplinary experience supports that EMR can be safely performed as a first line treatment for patients with BE with dysplastic changes and intramucosal adenocarcinoma (IMC).
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