Long-term outcomes of a primary complete endoscopic resection strategy for short-segment Barrett’s esophagus with high-grade dysplasia and/or early esophageal adenocarcinoma

      Background and Aims

      Complete endoscopic resection (CER) of Barrett’s esophagus (BE) with high-grade dysplasia (HGD) and early esophageal adenocarcinoma (EEA) is a comprehensive and precise staging tool and may produce a sustained treatment response, preventing metachronous disease. There are limited data on long-term clinical outcomes and the sustainability of dysplasia eradication after CER. We aimed to describe long-term outcomes of a primary CER strategy of BE with HGD/EEA.


      Patients with biopsy-proven HGD and EEA in short-segment BE (≤3 cm in circumferential length and ≤5 cm in maximal length) underwent staged CER by multiband mucosectomy or the cap method. The primary endpoint was remission of HGD or EEA (complete resection of HGD/EEA), dysplasia (complete resection of any dysplasia), and complete resection of intestinal metaplasia.


      Of 153 patients (126 HGD, 27 EEA; 83.7% male, median age of 66 years) considered suitable for CER, 138 met all inclusion criteria. CER was technically successful in all patients and was established after a median of 2 sessions. Covert synchronous EEA was found in 1 patient. At a mean follow-up of 40.7 months by intention-to-treat analysis, complete remission of HGD/EEA, dysplasia, and intestinal metaplasia was achieved in 98.5%, 89.1%, and 71.0%, respectively. In 47.1% of patients, CER changed the histological grade compared with pretreatment biopsies (28.1% downstaged and 19.0% upstaged). Esophageal dilation was performed in 36.8% in a mean of 2.5 sessions. At the end of follow-up, 96.4% of patients had no or minimal dysphagia and 90.6% of patients found CER an acceptable treatment.


      On long-term follow-up, a primary CER strategy was a highly effective, safe, and durable treatment for HGD and EEA. Despite the need for post-CER dilation in one-third of patients, the majority found it an acceptable treatment on long-term follow-up.


      BE (Barrett’s esophagus), CER (complete endoscopic resection), CI (confidence interval), EA (esophageal adenocarcinoma), EEA (early esophageal adenocarcinoma), ER (endoscopic resection), HGD (high-grade dysplasia), HR (hazard ratio), IM (intestinal metaplasia), IQR (interquartile range), RFA (radiofrequency ablation), SMC (submucosal carcinoma)
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        • Pohl H.
        • Sirovich B.
        • Welch H.G.
        Esophageal adenocarcinoma incidence: are we reaching the peak?.
        Cancer Epidemiol Biomarkers Prev. 2010; 19: 1468-1470
        • Rice T.W.
        Pro: esophagectomy is the treatment of choice for high-grade dysplasia in Barrett's esophagus.
        Am J Gastroenterol. 2006; 101: 2177-2179
        • Moss A.
        • Bourke M.J.
        • Hourigan L.F.
        • et al.
        Endoscopic resection for Barrett's high-grade dysplasia and early esophageal adenocarcinoma: an essential staging procedure with long-term therapeutic benefit.
        Am J Gastroenterol. 2010; 105: 1276-1283
        • Pech O.
        • May A.
        • Manner H.
        • et al.
        Long-term efficacy and safety of endoscopic resection for patients with mucosal adenocarcinoma of the esophagus.
        Gastroenterology. 2014; 146: 652-660.e1
        • Fitzgerald R.C.
        • di Pietro M.
        • Ragunath K.
        • et al.
        British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus.
        Gut. 2014; 63: 7-42
        • Spechler S.J.
        • Sharma P.
        • Souza R.F.
        • et al.
        American Gastroenterological Association technical review on the management of Barrett's esophagus.
        Gastroenterology. 2011; 140 (quiz e13): e18-e52
        • Lee J.K.
        • Cameron R.G.
        • Binmoeller K.F.
        • et al.
        Recurrence of subsquamous dysplasia and carcinoma after successful endoscopic and radiofrequency ablation therapy for dysplastic Barrett's esophagus.
        Endoscopy. 2013; 45: 571-574
        • Templeton A.
        • Bodnar A.
        • Gan S.I.
        • et al.
        Occurrence of invasive cancer after endoscopic treatment of Barrett's esophagus with high-grade dysplasia and intramucosal cancer in physiologically fit patients: time for a review of surveillance and treatment guidelines.
        Gastrointest Endosc. 2014; 79: 839-844
        • Titi M.
        • Overhiser A.
        • Ulusarac O.
        • et al.
        Development of subsquamous high-grade dysplasia and adenocarcinoma after successful radiofrequency ablation of Barrett's esophagus.
        Gastroenterology. 2012; 143: 564-566.e1
        • Chennat J.
        • Ross A.S.
        • Konda V.J.
        • et al.
        Advanced pathology under squamous epithelium on initial EMR specimens in patients with Barrett's esophagus and high-grade dysplasia or intramucosal carcinoma: implications for surveillance and endotherapy management.
        Gastrointest Endosc. 2009; 70: 417-421
        • Chung A.
        • Bourke M.J.
        • Hourigan L.F.
        • et al.
        Complete Barrett's excision by stepwise endoscopic resection in short-segment disease: long term outcomes and predictors of stricture.
        Endoscopy. 2011; 43: 1025-1032
        • Conio M.
        • Repici A.
        • Cestari R.
        • et al.
        Endoscopic mucosal resection for high-grade dysplasia and intramucosal carcinoma in Barrett's esophagus: an Italian experience.
        World J Gastroenterol. 2005; 11: 6650-6655
        • Pouw R.E.
        • Seewald S.
        • Gondrie J.J.
        • et al.
        Stepwise radical endoscopic resection for eradication of Barrett's oesophagus with early neoplasia in a cohort of 169 patients.
        Gut. 2010; 59: 1169-1177
        • Whiteman D.C.
        • Appleyard M.
        • Bahin F.F.
        • et al.
        Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma.
        J Gastroenterol Hepatol. 2015; 30: 804-820
      1. Update on the Paris classification of superficial neoplastic lesions in the digestive tract.
        Endoscopy. 2005; 37: 570-578
        • Sharma P.
        • Dent J.
        • Armstrong D.
        • et al.
        The development and validation of an endoscopic grading system for Barrett's esophagus: the Prague C & M criteria.
        Gastroenterology. 2006; 131: 1392-1399
        • Schlemper R.J.
        • Riddell R.H.
        • Kato Y.
        • et al.
        The Vienna classification of gastrointestinal epithelial neoplasia.
        Gut. 2000; 47: 251-255
        • Szegedi L.
        • Gal I.
        • Kosa I.
        • et al.
        Palliative treatment of esophageal carcinoma with self-expanding plastic stents: a report on 69 cases.
        Eur J Gastroenterol Hepatol. 2006; 18: 1197-1201
        • Merkow R.P.
        • Bilimoria K.Y.
        • Keswani R.N.
        • et al.
        Treatment trends, risk of lymph node metastasis, and outcomes for localized esophageal cancer.
        J Natl Cancer Inst. 2014; 106 (http://dx.doi.org/10.1093/jnci/dju133)
        • Nasr J.Y.
        • Schoen R.E.
        Prevalence of adenocarcinoma at esophagectomy for Barrett's esophagus with high grade dysplasia.
        J Gastrointest Oncol. 2011; 2: 34-38
        • Fujita H.
        • Sueyoshi S.
        • Yamana H.
        • et al.
        Optimum treatment strategy for superficial esophageal cancer: endoscopic mucosal resection versus radical esophagectomy.
        World J Surg. 2001; 25: 424-431
        • Luna R.A.
        • Gilbert E.
        • Hunter J.G.
        High-grade dysplasia and intramucosal adenocarcinoma in Barrett's esophagus: the role of esophagectomy in the era of endoscopic eradication therapy.
        Curr Opin Gastroenterol. 2012; 28: 362-369
        • Dunbar K.B.
        • Spechler S.J.
        The risk of lymph-node metastases in patients with high-grade dysplasia or intramucosal carcinoma in Barrett's esophagus: a systematic review.
        Am J Gastroenterol. 2012; 107 (quiz 863): 850-862
        • Griffin S.M.
        • Burt A.D.
        • Jennings N.A.
        Lymph node metastasis in early esophageal adenocarcinoma.
        Ann Surg. 2011; 254 (discussion 736-7): 731-736
        • Wu J.
        • Pan Y.M.
        • Wang T.T.
        • et al.
        Endotherapy versus surgery for early neoplasia in Barrett's esophagus: a meta-analysis.
        Gastrointest Endosc. 2014; 79: 233-241.e2
        • Pech O.
        • Behrens A.
        • May A.
        • et al.
        Long-term results and risk factor analysis for recurrence after curative endoscopic therapy in 349 patients with high-grade intraepithelial neoplasia and mucosal adenocarcinoma in Barrett's oesophagus.
        Gut. 2008; 57: 1200-1206
        • Pech O.
        • Bollschweiler E.
        • Manner H.
        • et al.
        Comparison between endoscopic and surgical resection of mucosal esophageal adenocarcinoma in Barrett's esophagus at two high-volume centers.
        Ann Surg. 2011; 254: 67-72
        • Bedi A.O.
        • Kwon R.S.
        • Rubenstein J.H.
        • et al.
        A survey of expert follow-up practices after successful endoscopic eradication therapy for Barrett's esophagus with high-grade dysplasia and intramucosal adenocarcinoma.
        Gastrointest Endosc. 2013; 78: 696-701
        • Pouw R.E.
        • Wirths K.
        • Eisendrath P.
        • et al.
        Efficacy of radiofrequency ablation combined with endoscopic resection for Barrett's esophagus with early neoplasia.
        Clin Gastroenterol Hepatol. 2010; 8: 23-29
        • Larghi A.
        • Lightdale C.J.
        • Ross A.S.
        • et al.
        Long-term follow-up of complete Barrett's eradication endoscopic mucosal resection (CBE-EMR) for the treatment of high grade dysplasia and intramucosal carcinoma.
        Endoscopy. 2007; 39: 1086-1091
        • Konda V.J.
        • Gonzalez Haba Ruiz M.
        • Koons A.
        • et al.
        Complete endoscopic mucosal resection is effective and durable treatment for Barrett's-associated neoplasia.
        Clin Gastroenterol Hepatol. 2014; 12: 2002-2010.e2
        • Gupta M.
        • Iyer P.G.
        • Lutzke L.
        • et al.
        Recurrence of esophageal intestinal metaplasia after endoscopic mucosal resection and radiofrequency ablation of Barrett's esophagus: results from a US Multicenter Consortium.
        Gastroenterology. 2013; 145: 79-86.e1
        • Haidry R.J.
        • Dunn J.M.
        • Butt M.A.
        • et al.
        Radiofrequency ablation and endoscopic mucosal resection for dysplastic Barrett's esophagus and early esophageal adenocarcinoma: outcomes of the UK National Halo RFA Registry.
        Gastroenterology. 2013; 145: 87-95
        • Phoa K.N.
        • Pouw R.E.
        • van Vilsteren F.G.
        • et al.
        Remission of Barrett's esophagus with early neoplasia 5 years after radiofrequency ablation with endoscopic resection: a Netherlands cohort study.
        Gastroenterology. 2013; 145: 96-104
        • Kariyawasam V.C.
        • Bourke M.J.
        • Hourigan L.F.
        • et al.
        Circumferential location predicts the risk of high-grade dysplasia and early adenocarcinoma in short-segment Barrett's esophagus.
        Gastrointest Endosc. 2012; 75: 938-944
        • Anders M.
        • Bahr C.
        • El-Masry M.A.
        • et al.
        Long-term recurrence of neoplasia and Barrett's epithelium after complete endoscopic resection.
        Gut. 2014; 63: 1535-1543
        • Katada C.
        • Muto M.
        • Manabe T.
        • et al.
        Esophageal stenosis after endoscopic mucosal resection of superficial esophageal lesions.
        Gastrointest Endosc. 2003; 57: 165-169
        • Lewis J.J.
        • Rubenstein J.H.
        • Singal A.G.
        • et al.
        Factors associated with esophageal stricture formation after endoscopic mucosal resection for neoplastic Barrett's esophagus.
        Gastrointest Endosc. 2011; 74: 753-760
        • Gerke H.
        • Siddiqui J.
        • Nasr I.
        • et al.
        Efficacy and safety of EMR to completely remove Barrett's esophagus: experience in 41 patients.
        Gastrointest Endosc. 2011; 74: 761-771
        • van Vilsteren F.G.
        • Pouw R.E.
        • Seewald S.
        • et al.
        Stepwise radical endoscopic resection versus radiofrequency ablation for Barrett's oesophagus with high-grade dysplasia or early cancer: a multicentre randomised trial.
        Gut. 2011; 60: 765-773
        • Sato H.
        • Inoue H.
        • Kobayashi Y.
        • et al.
        Control of severe strictures after circumferential endoscopic submucosal dissection for esophageal carcinoma: oral steroid therapy with balloon dilation or balloon dilation alone.
        Gastrointest Endosc. 2013; 78: 250-257
        • Lee W.J.
        • Jung H.Y.
        • Kim do H.
        • et al.
        Intralesional steroid injection to prevent stricture after near-circumferential endosopic submucosal dissection for superficial esophageal cancer.
        Clin Endosc. 2013; 46: 643-646
        • Ezoe Y.
        • Muto M.
        • Horimatsu T.
        • et al.
        Efficacy of preventive endoscopic balloon dilation for esophageal stricture after endoscopic resection.
        J Clin Gastroenterol. 2011; 45: 222-227
        • Ohki T.
        • Yamato M.
        • Ota M.
        • et al.
        Prevention of esophageal stricture after endoscopic submucosal dissection using tissue-engineered cell sheets.
        Gastroenterology. 2012; 143 (e1-2): 582-588
        • Hashimoto S.
        • Kobayashi M.
        • Takeuchi M.
        • et al.
        The efficacy of endoscopic triamcinolone injection for the prevention of esophageal stricture after endoscopic submucosal dissection.
        Gastrointest Endosc. 2011; 74: 1389-1393
        • Barret M.
        • Pratico C.A.
        • Camus M.
        • et al.
        Amniotic membrane grafts for the prevention of esophageal stricture after circumferential endoscopic submucosal dissection.
        PLoS One. 2014; 9: e100236
        • Holt B.A.
        • Jayasekeran V.
        • Williams S.J.
        • et al.
        Early metal stent insertion fails to prevent stricturing after single-stage complete Barrett's excision for high-grade dysplasia and early cancer.
        Gastrointest Endosc. 2015; 81: 857-864