Ralph Yeung

Clinical outcome in patients treated with endoscopic submucosal dissection for superficial Barrett's neoplasia.

BACKGROUND AND STUDY AIMS The role of endoscopic submucosal dissection (ESD) in Barretts neoplasia is ill-defined, although it might provide a higher curative resection rate and better histologic assessment than endoscopic mucosal resection (EMR). We aimed to assess efficacy, safety, and long-term results of ESD. PATIENTS AND METHODS A retrospective analysis was done of 75 consecutive patients with Barretts esophagus who underwent ESD between January 2007 and February 2014. ESD was performed for visible lesions that were multiple, larger than 15 mm, or poorly lifting, or suspected of submucosal infiltration. The primary end point was the rate of curative resection of carcinoma. RESULTS Median patient age was 68 years (interquartile range [IQR] 61 - 76), median follow-up was 20 months (IQR 8.5 - 37.5), and median maximum specimen diameter was 52.5 mm (IQR 43 - 71). En bloc resection rate was 90 % (66 /73), and rates of curative resection of carcinoma and high grade dysplasia/carcinoma were 85 % (47 /55) and 64 % (42 /66), respectively. G3 differentiation and invasion to greater than pT1m2 were observed in 25 % (14 /55) and 67 % (37 /55) of patients with adenocarcinoma, respectively. There were 5 early ( < 48 hours) adverse events (2 delayed hemorrhages and 3 perforations), all treated endoscopically. No ESD-specific death occurred. Esophageal strictures developed in 60 % of patients, all treated endoscopically. Additional treatment (median sessions 2 [IQR 2 - 3]) for residual Barretts esophagus were recommended to 62 % (42 /68). At latest follow-up, complete remission of neoplasia and intestinal metaplasia was found in 92 % (54 /59) and 73 % (43 /59) of patients, respectively. CONCLUSION ESD appears to be safe and effective, with a high rate of curative resection of carcinoma. ESD should be considered for patients with Barretts neoplasia at risk of incomplete resection or poor pathologic assessment with conventional EMR.

Comparative analysis of ESD versus EMR in a large European series of non-ampullary superficial duodenal tumors

Background and study aims  The choice of endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) in non-ampullary superficial duodenal tumors (NASDTs) is challenging and the benefits of ESD remain unclear. The aim was to comparatively analyze the feasibility, outcomes and safety of these techniques in these lesions. Patients and methods  This is an observational and retrospective study. All consecutive patients presenting with NASDTs who underwent EMR or ESD between 2005 and 2017 were included. The following main outcomes were comparatively evaluated: en-bloc and complete (R0) resection rates, and local recurrence. Secondary outcomes were perforation and delayed bleeding. Results  One hundred sixty-six tumors in 150 patients (age: 66 years, range: 31 – 83, 42.7 % males) were resected by ESD (n = 37) or EMR (n = 129) and included. The median procedure time (81 vs. 50 min, P  = 0.007) and tumor size (25 vs. 20 mm, P  = 0.01) were higher in the ESD group. The global malignancy rate was 50.3 %. There were no differences in en-bloc resection (29.7 % vs. 44.2 %, P  = 0.115), complete resection (19.4 % vs. 35.5 %, P  = 0.069), and local recurrence (14.7 % vs. 16.7 %, P  = 0.788) rates. Tumor size was associated with recurrence (28 vs. 20 mm, P  = 0.008), with a median follow-up of 6.5 months. Focal recurrence (n = 22, 13.3 %) was treated endoscopically in 86.4 %. En-bloc resection in the ESD group was comparable in large ( ≥ 20 mm) and small lesions (27.6 % vs. 37.5 %, P  = 0.587), while this outcome decreased significantly in large lesions resected by EMR (17.4 % vs. 75 %, P  < 0.001). Nine perforations were confirmed in 6 lesions (16.2 %) resected by ESD and 3 (2.3 %) by EMR ( P  = 0.001). Endoscopic therapy was successful in all but 1 patient (88.9 %) presenting with a delayed perforation. Conclusions  ESD may be an alternative to EMR and surgery in selected NASDTs, such as large duodenal tumors where EMR achieves low en-bloc resection rates and the local recurrence may be higher. However, this technique may have a higher risk of perforations.

ESD versus EMR in non-ampullary superficial duodenal tumors: a systematic review and meta-analysis

Background and study aims  Endoscopic submucosal dissection (ESD) has been developed as an option for treatment of esophageal, gastric and colorectal lesions. However, there is no consensus on the role of ESD in duodenal tumors. Methods  This systematic review and meta-analysis compared ESD and endoscopic mucosal resection (EMR) in sporadic non-ampullary superficial duodenal tumors (NASDTs), including local experience. We conducted a search in PubMed, Scopus and the Cochrane library up to August 2017 to identify studies that compared both techniques reporting at least one main outcome (en-bloc/complete resection, local recurrence). Pooled outcomes were calculated under fixed and random-effect models. Subgroup analyses were conducted. Results  A total of 753 patients presenting with 784 NASDTs (242 ESD, 542 EMR) in 14 studies were included. Tumor size (MD: 5.88, [CI95 %: 2.15, 9.62], P  = 0.002, I 2  = 79 %) and procedure time (MD: 65.65, [CI95 %: 40.39, 90.92], P  < 0.00001, I 2  = 88 %) were greater in the ESD group. En-bloc resection rate was significantly higher in Asian studies (OR: 2.16 [CI95 %: 1.15, 4.08], P  = 0.02, I 2 : 46 %). ESD provided a higher complete resection rate (OR: 1.63 [I95 %: 1.06, 2.50], P  = 0.03, I 2 : 59 %), but there was no risk difference in the risk of local recurrence (RD: – 0.03 [CI95 %: – 0.07, 0.01], P  = 0.15, I 2 : 0 %) or delayed bleeding. ESD was associated with an increased number of intraoperative perforations [RD: 0.12 (CI95 %: 0.04, 0.20), P  = 0.002, I 2 : 56 %] and emergency surgery for delayed perforations. The inclusion of eligible studies was limited to retrospective series with inequalities in comparative groups. Conclusions  Duodenal ESD for NASDTs may achieve higher en-bloc and complete resections at the expense of a greater perforation rate compared to EMR. The impact on local recurrence remains uncertain.