Can Piecemeal Mucosectomy Completely Remove Barrett's Esophagus with High Grade Dysplasia or Adenocarcinoma?

Aim: Prospective evaluation of piecemeal mucosectomy using the cap method (EMR-c) in patients presenting with Barrett's esophagus and high grade dysplasia of superficial adenocarcinoma and aiming at complete removal of the neoplastic lesion and the intestinal metaplasia. Patients and Methods: Inclusion criteria: long or short Barrett's esophagus with high grade dysplasia or T1m N0 adenocarcinoma staged by radial or linear Pentax EUS scope (EG-3630-UR or EG-3830-UT) with the Hitachi EUB 6500 processor and 20MHz miniprobe. Resection was performed under general anesthesia, starting at the site of the tumour, after submucosal injection of 2-5 ml aliquots of saline for a total of 10-50 ml, than resecting the remaining Barrett's mucosa from anal to oral direction. Circonferential resection was avoided if the height of Barrett's metaplasia exceeded 1 cm. Oblique or straight transparent rigid cap was used and resection was completed if necessary by APC (0.6 L, 60 W) for residual bridging or short remaining tongs of metaplasia. Patients were discharged one or two days after mucosectomy under liquid diet and omeprazole 40 mg bid was started before treatment and continued for 8 weeks minimum. Results: 20 patients (mean age 68y, range 47-85, 3 women/17 men) were included with HGD in 15 and mucosal adenocarcinoma in 5. Circonferential length of Barrett's mucosa (C) was 19 mm (5-70) and highest limit (M) 26 mm (5-80). A total of 26 EMR-c sessions were performed (1.3; 1-5), removing 95 specimens (4.8; 1-13 per patient). Follow-up is now 13.3 months (3-38 months). Successful resection of HGD and adenocarcinoma was observed in all patients. Complete removal of intestinal metaplasia was observed in 65% of patients (13/20), with 2 patients still presenting low grade dysplasia. Remaining Barrett's mucosa was however limited to sections of < 5 mm in 6/7 patients. Complications occurred in 4 patients: 3 minor bleeding episodes during EMR treated by endoscopic hemostasis (APC or hemoclip) and 1 oesophageal stricture requiring endoscopic dilatation. Conclusions: Although EMR-C piecemeal resection is acceptable for treatment of intraepithelial or mucosal adenocarcinoma complicating Barrett's esophagus, it is only successful in 2/3 of patients when aiming at complete resection of intestinal metaplasia. Improvements in endoscopic techniques of esophageal mucosectomy and new appropriate devices to improve efficacy and safety are mandatory to obtain higher success rates.