Effectiveness Of Endoscopic Mucosal Resection Alone For Treatment Of Neoplasia In Barrett'S Esophagus Patients

Purpose: Combined multimodal endotherapy for nodular Barrett's associated neoplasia ablation, such as endoscopic mucosal resection (EMR), and other methods for flat neoplasia ablation, such as RFA, are increasingly used. In some cases, EMR alone may be sufficient to treat the neoplasia. The aim of this study was to identify predictors of efficacy and complications of EMR in nodular Barrett's neoplasia. Methods: Consecutive patients with Barrett's neoplasia who had EMR for nodular disease from 1999-2010 were reviewed. EMR was evaluated in terms of extent: (focal-1 snare or cap EMR, multifocal <50% circumference, or multifocal >50% or circumferential) and histology results. Complete ablation of neoplasia was considered when all subsequent biopsy showed no neoplasia. Margin positivity at index EMR pathology was considered residual disease if no subsequent pathology was available. Complications were noted by both chart review and questioning during return visits. Results: We identified 139 patients who underwent EMR procedures for nodular Barrett's dysplasia or adenocarcinoma (104 male, mean age 69). One hundred and two procedures had follow up endoscopy including 82 with biopsies. The remaining procedures did not have available biopsy results due to ongoing ablation treatment. Of these 82, the initial degree of dysplasia is shown in Table 1. Overall, EMR alone resulted in complete resolution of neoplasia in more than half of patients with the highest rates among those with low grade dysplasia (Table 1). EMR further down staged almost one quarter of patients (Table 1). Resolution or down staging Barrett's neoplasia was not associated with extent of EMR (Table 2). Of the 102 procedures, immediate bleeding occurred in 8 cases and delayed bleeding in 4 (12% total), all of which was managed by endoclipping. Strictures occurred in 6 (6%) cases of which 5 responded to single dilation; 1 person required 5 dilations. Most strictures occurred after >50% EMRs. No perforations occurred.[1091] Table 1. Association between initial degree of nodular Barrett's neoplasia and change in degree of flat Barrett's neoplasia following EMR[1091] Table 2. Association between extent of EMR and change in degree of flat Barrett's neoplasia following EMRConclusion: EMR is an effective modality for Barrett's dysplasia with complete ablation or improvement in 75% of patients. Complete ablation of neoplasia or down staging was better for Barrett's low and high grade dysplasia than for carcinoma; although the sample size was too low to determine statistical significance. Bleeding and stricture are common but are typically managed without severe morbidity or mortality. The benefit of further ablation of remaining Barrett's intestinal metaplasia, although commonly practiced, requires further study. Further study is also needed on whether EMR can be extended to allow total resection of Barrett's neoplasia and metaplasia with acceptable complications.