Optimal Endoluminal Treatment of Barrett's Esophagus: Integrating Novel Strategies into Clinical Practice

Raf Bisschops

Disclosures

Expert Rev Gastroenterol Hepatol. 2010;4(3):319-333. 

In This Article

Endoscopic Resection

Different Resection Techniques

Several techniques can be used for ER in the esophagus. These include a lift and snare technique, Cap-ER (Figure 2), MBM (Figure 3), the Euroligator technique or the ESD.

Figure 2.

The multiband mucosectomy technique. Example of an endoscopic resection using the multiband mucosectomy technique. (A) One of the possible devices that can be used is a prefabricated hard straight cap with six rubber bands in place. This causes a decreased visibility (see Figure 3A for contrast). Through the cap, the demarcated target lesion is visible. (B) Situation after firing a first rubber band, which is visible at 11 o'clock. The rubber band creates a pseudopolyp. (C) Resection with a standard polypectomy snare. (D) Situation after four resections showing a mucosal defect from 12 to 6 o'clock at the dorsal side of the esophagus.

Figure 3.

The endoscopic resection Cap technique. Example of an endoscopic resection with the Cap technique. (A) A transparent, hard, standard oblique cap is placed on the tip of the endoscope. (B) Placement of the snare in the distal rim of the Cap at a site different from the target lesion. (C) The lesion is subsequently sucked into the Cap to create a pseudopolyp. (D) After closure of the snare, inspection of the resection plane should be performed to rule out bleeding or perforation. The resection plane is visible at the 6 o'clock position with a view onto the deep submucosa and muscularis.

As demonstrated in the next paragraph, results of endoscopic mucosal resections are excellent considering oncological outcome and procedural safety. It is unlikely that these can be improved by a technically more challenging ESD. First, adenocarcinoma of the esophagus is a Western disease where endoscopists do not have the opportunity to learn the skills to perform ESD, as in Japan. Indeed, the stomach is the place to start performing ESD for gastric cancer and in Western countries this is still a rare disease. Second, the cost of equipment and procedural time for ESD are significantly higher in comparison to endoscopic mucosal resection.[201]

The most commonly used techniques for ER are the Cap-ER and MBM technique. The first involves the attachment of a hard or a flexible large caliber cap at the tip of the endoscope,[8] and a preshaped snare fits into a rim at the distal end of this cap. After submucosal lifting, which is necessary to assess the lifting sign and create a safety cushion to prevent perforation, the target lesion is sucked into the cap. After closure of the snare a pseudopolyp is created that can be resected with conventional electrocauterization. The MBM technique consists of a prefabricated kit of a cap with six prefixed rubber bands, comparable to devices used for ligation of esophageal varices. The Euroligator is a device developed in-house by the Wiesbaden group that works according to the same principle. The target lesion is sucked into the cap and subsequently a rubber band is released to create a pseudopolyp. When a piecemeal resection is performed, a single standard polypectomy snare can be used for all resections; this is in contrast to the Cap-ER technique where very often a snare can only be used once owing to deformation after resection. Additionally, no submucosal lifting is required since the rubber bands are not strong enough to retain any muscularis propriae that might have been sucked into the cap. One recent ongoing study by Pouw et al. compared the use of MBM and Cap-ER techniques. To date, in 45 patients (22 ER-Cap) the MBM technique was shown to be faster and cheaper. ER-Cap was associated with two perforations whereas no perforation occurred in the MBM group. However, since the diameter of the specimens after MBM were smaller and less deep, it is probably advisable to use the Cap-ER technique in lesions carrying a higher risk of submucosal invasion (more elevated and nodular lesions).[202]

Results of ER of High-grade Intraepithelial Neoplasia & Early Cancer in Barrett's Esophagus

The use of endoluminal therapy for early esophageal adenocarcinoma is further supported by its excellent long-term outcome, which is comparable to the outcome of surgical series for T1a lesions. An overview of the outcome of different studies using ER for HGIN and early cancer is given in Table 1. The most extensive experience with ER comes from the Wiesbaden group.[7] Of the 349 patients treated with endoluminal therapy, 82% had a mucosal adenocarcinoma. The majority of the patients (80%) were treated by ER, whereas 55 patients received PDT and two patients received APC. Only 13 patients were treated with a combination therapy of ER and PDT. Complete response was achieved in 96.6% of patients, with endoscopic therapy failing in 3.7% of the patients who subsequently underwent esophagectomy. The calculated 5-year survival was 84% and mortality was due to concomitant disease. Additionally, there were no cancer-related deaths during the follow-up. However, metachronous lesions occurred in 21.5% of the patients. Therefore, meticulous follow-up after ER is necessary in order to be able to re-treat most patients by endoluminal therapy. Using this approach in the study resulted in long-term eradication in 95% of cases. The risk factors for recurrent disease are listed in Box 2..

Until recently there was still concern about the oncological outcome of endoluminal therapy in esophageal adenocarcinoma in comparison to the gold standard of surgery. There are no prospective head-to-head randomized trials to address this issue; however, some recent retrospective studies comparing esophagectomy with a combination of different endoscopic treatment options have addressed this issue. These studies indicate that both modalities are equally effective in treating early Barrett's neoplasia with regard to oncological outcome and survival. In a first study by Schembre et al., there was no mortality in the surgery group but the sample size was very small.[68] Prasad et al. compared the long-term follow-up of 132 patients treated with ER and 46 who underwent surgery.[69] There was no difference in the 5-year survival rate between the surgically or endoscopically treated group. In the cohort treated with ER there was, however, a significant decrease in cancer-free survival; the incidence of recurrent carcinoma was 5.5/100 person-years versus 0.56/100 person-years in the surgically treated group.

Recently, it has also been suggested that the indication for endoluminal therapy can be extended to lesions with only superficial submucosal infiltration.[70,71] The authors defined a low-risk submucosal lesion as infiltrating only the superficial submucosa (sm1), with a macroscopic type 0–I or 0–II appearance, without infiltrations of the lymphatic or blood vessels and being histologically well-to-moderately differentiated. In 18 out of 19 patients complete remission was achieved and after a mean follow-up of 62 months, and no cancer-related deaths have been reported.[70] After careful analysis of surgical resection specimens,[6] the Amsterdam group has already adapted the criteria for ER for a longer time,[8–11,202] showing similar results. Since these data come from centers with a high level of expertise in endoluminal treatment of early esophageal neoplasia, it is not certain if they can be extrapolated to any first-line endoscopy unit throughout the world.

The safety of the ER procedure in all series is excellent and only a small risk of perforation, post-procedural bleeding and stenosis exist. Perforation has been reported in 1–2.6% of the patients, but seems to decrease with more experience (Table 1).[7–25] Development of stenosis is highly dependent on the circumferential extent of the resection. Resections limited to 50% of the circumference rarely cause a significant stenosis.

Taking the safety and efficacy into account, endoluminal therapy with ER has become the treatment of choice for early Barrett's neoplasia in well-selected patients. The oncological safety of this change in therapeutic approach has now been confirmed by long-term follow-up data in different centers, both in endoscopically treated patients and in retrospective series comparing surgery and endoluminal therapy. Therefore, endoscopic therapy for early Barrett's neoplasia is not only indicated in patients with high surgical risk, but certainly also in younger patients who might benefit most from a life without the morbidity associated with esophagectomy.

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