ORLANDO — Endoscopic mucosal resection of Barrett's esophagus can provide a safe and effective alternative to esophagectomy, according to a retrospective study of long-term clinical experience at the University of Chicago Medical Center.
The endoscopic technique also allows clinicians to downstage or upstage patients with high-grade dysplasia and/or intramucosal carcinoma, and thereby determine who requires additional treatment, Dr. Jennifer S. Chennat said.
The most common adverse event, symptomatic esophageal stenosis, affected 14 of the 48 patients (29%) in the study. All these patients were treated effectively with endoscopic dilation, Dr. Chennat said at the annual meeting of the American College of Gastroenterology. There were no perforations or uncontrolled bleeding events.
“Esophagectomy has been the standard of care but is associated with high morbidity and mortality,” said Dr. Chennat, an internist at the Center for Endoscopic Research and Therapeutics at the University of Chicago Medical Center. “There is a recent paradigm shift in management of Barrett's esophagus.” That is why she and her colleagues decided to study long-term experience with endoscopic mucosal resection at their institution.
All patients were referred to the University of Chicago for complete endoscopic mucosal resection of their Barrett's endothelium between August 2003 and May 2008. The majority, 33 patients, presented with a diagnosis of high-grade dysplasia, another 8 were diagnosed with intramucosal carcinoma, and 7 had both.
The cohort included 36 men and 12 women with a mean age of 67 years. Mean length of Barrett's esophagus was 3.7 cm (range, 2–14 cm).
All received high-dose proton pump inhibitor therapy. Staging endoscopic ultrasound was used to exclude invasive disease or suspicious lymphadenopathy. All patients also had a baseline examination for visible lesions using high-definition white light endoscopy and narrow-band imaging.
Dr. Chennat and her colleagues changed some of the diagnoses. The endoscopic mucosal resection upstaged baseline pathology in 8 patients and downstaged initial findings for 13 patients, she said.
The investigators determined that 8 patients had Barrett's esophagus with no cancer or dysplasia, 27 had high-grade dysplasia, and 8 had intramucosal carcinoma. Another five patients had advanced pathology: Three had superficial submucosal invasion, and two had intramucosal carcinoma with lymphatic channel invasion.
All five of these patients were referred for esophagectomy; three had the surgery and two declined, opting to continue endoscopic management.
Endoscopy was repeated every 3–6 months to gauge the need for additional mucosal resection and to obtain surveillance biopsies. Patients were followed every 12 months once no residual Barrett's esophagus was detected. A total of 104 endoscopic mucosal resections were performed.
Twenty-three patients completed treatment after an average of two sessions. Surveillance biopsies revealed normal squamous endothelium for 19 of these 23 patients. Three others had nondysplastic Barrett's esophagus and one patient had residual high-grade dysplasia and was treated further. All 23 in this group ultimately achieved remission after a mean of 23 months (range, 3–54 months).
A total of 21 other patients were still undergoing therapy when these results were presented at the ACG meeting. One patient died of unrelated causes.
The role of complete Barrett's esophagus eradication with endoscopic mucosal resection remains to be determined for patients with Barrett's esophagus who present with lymphatic invasion or superficial submucosal invasion, Dr. Chennat said.
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