Extending treatment criteria for Barrett's neoplasia: Results of a nationwide cohort of 138 endoscopic submucosal dissection procedures

Background The use of endoscopic submucosal dissection (ESD) is gradually expanding for treatment of neoplasia in Barrett s esophagus (BE). We aimed to report outcomes of all ESDs for BE neoplasia performed in the Netherlands. Methods Retrospective assessment of outcomes, using treatment and follow-up data from a joint database. Results 130/138 patients had complete ESDs, with 126/ 130 (97%) en bloc resections. Median (interquartile range (IQR)) procedure time was 121 minutes (90 180). Pathology findings were high grade dysplasia (HGD) (5 %) or esophageal adenocarcinoma (EAC) T1a (43 %) or T1b (52%; 19% sm1, 33%≤sm2). Among resections of HGD or T1a EAC lesions, 87% (95%CI 75% 92 %) were both en bloc and R0; the corresponding value for T1b EAC lesions was 49% (36% 60 %). Among R1 resections, 10/34 (29%) showed residual cancer, all detected at first endoscopic follow-up. The remaining 24 patients (71 %) showed no residual neoplasia. Six of these patients underwent surgery with no residual tumor; the remaining 18 underwent endoscopic follow-up during median 31 months with 1 local recurrence (annual recurrence rate 2 %). Among R0 resections, annual local recurrence rate during median 27 months was 0.5 %. Conclusion In expert hands, ESD allows safe removal of bulky intraluminal neoplasia and submucosal cancer. ESD of the latter showed R1 resection margins in 50%, yet only one third had persisting neoplasia at follow-up. To better stratify R1 patients with an indication for additional surgery, repeat endoscopy after healing of the ESD might be a helpful possible prognostic factor for residual cancer