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Combining endoscopic submucosal dissection and endoscopic mucosal resection to treat neoplasia in Barrett’s esophagus

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Abstract

Background and aims

Piecemeal endoscopic mucosal resection (EMR) is the standard treatment of nodular Barrett’s esophagus dysplasia and T1a cancer. Piecemeal resection may be incomplete and makes precise histologic assessment difficult. Endoscopic submucosal dissection (ESD) is a technique that enables en-bloc resection but has not gained widespread acceptance due to its technical difficulty, risk and long procedure time.

Methods

We developed a protocol consisting of a combination of a limited ESD with supplementary EMR in the same session if necessary, designed to increase en-bloc resection of the most worrisome neoplastic area while maximizing the rate of complete resection of dysplasia. Records of consecutive patients referred for treatment during a 2-year period were reviewed.

Results

Eleven patients were treated: two with ESD and nine with combined ESD/EMR. Eight patients had mucosal lesions; three patients had submucosally invasive cancer and were referred to surgery. Five of the 8 mucosal lesions were removed en-bloc by ESD with dysplasia-free margins. Two patients with T1a cancer had low-grade dysplasia in the ESD margins and removal of all dysplasia on EMR. One patient with T1a cancer had high-grade dysplasia in the ESD margins and on EMR. He required a second endoscopy to remove residual neoplasia. There were no adverse events. The mean procedure time was 66.4 ± 15.1 min.

Conclusions

Combining a limited ESD with EMR in the same session enables efficient treatment of visible dysplastic lesions in Barrett’s esophagus.

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Abbreviations

EMR:

Endoscopic mucosal resection

ESD:

Endoscopic submucosal dissection

RFA:

Radiofrequency ablation

LGD:

Low-grade dysplasia

HGD:

High-grade dysplasia

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Authors and Affiliations

  1. Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA

    Ian Holmes

  2. Department of Gastroenterology, Stanford University School of Medicine, Stanford, CA, USA

    Tressia Hing & Shai Friedland

  3. VA Palo Alto Health Care System, 711 Middlefield Road, Palo Alto, CA, 94301, USA

    Shai Friedland

Authors
  1. Ian Holmes
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  2. Tressia Hing
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  3. Shai Friedland
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Corresponding author

Correspondence to Shai Friedland.

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Disclosure

Ian Holmes, Tressia Hing and Shai Friedland have no conflicts of interest or financial ties to disclose.

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Holmes, I., Hing, T. & Friedland, S. Combining endoscopic submucosal dissection and endoscopic mucosal resection to treat neoplasia in Barrett’s esophagus. Surg Endosc 30, 5330–5337 (2016). https://doi.org/10.1007/s00464-016-4885-y

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  • DOI: https://doi.org/10.1007/s00464-016-4885-y

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