Giovannini M, Bories E, Pesenti C, Moutardier V, Monges G, Danisi C, Lelong B, Delpero J R
Endoscopic Unit, Institut Paoli-Calmettes, 232 Boulevard St-Marguerite, 13273 Marseilles Cedex 9, France.
Endoscopy. 2004 Sep;36(9):782-7. doi: 10.1055/s-2004-825813.
Treatment by endoscopic mucosal resection (EMR) has been established for early lesions in Barrett's esophagus. However, the remaining Barrett's esophagus epithelium remains at risk of developing further lesions. The aim of this study was to evaluate the efficacy of circumferential endoscopic mucosectomy (circumferential EMR)s in removing not only the index lesion (high-grade intraepithelial neoplasia (HGIN) or mucosal cancer), but also the remaining Barrett's esophagus epithelium.
A total of 21 patients were included in the study (11 men, 10 women), who had Barrett's esophagus and either HGIN (n = 12) or mucosal cancer (n = 9). Of the patients, 17/21 were at high surgical risk and five had refused surgery. On the basis of preprocedure endosonography their lesions were classified as T1N0 (n = 19) or T0N0 (n = 2). The lesions and the Barrett's esophagus epithelium were removed by polypectomy after submucosal injection of 10-15 ml of saline; a double-channel endoscope was used in 15/21 cases. Circumferential EMR was performed in two sessions, the lesion and the surrounding half of the circumferential Barrett's esophagus mucosa being removed in the first session. In order to prevent the formation of esophageal stenosis, the second half of the Barrett's esophagus mucosa was resected 1 month later.
Complications occurred in 4/21 patients (19 %), consisting of bleeding which was successfully managed by endoscopic hemostasis in all cases. No strictures were observed during follow-up (mean duration 18 months) and endoscopic resection was considered complete in 18/21 patients (86 %). For three patients, histological examination showed incomplete removal of tumor: one of these underwent surgery; two received chemoradiotherapy, and showed no evidence of residual tumor at 18 months' and 24 months' follow-up, respectively. Two patients in whom resection was initially classified as complete later presented with local recurrence and were treated again by EMR. Barrett's esophagus mucosa was completely replaced by squamous cell epithelium in 15/20 patients (75 %).
Circumferential EMR is a noninvasive treatment of Barrett's esophagus with HGIN or mucosal cancer, with a low complication rate and good short-term clinical efficacy. Further studies should focus on long-term results and on technical improvements.
内镜黏膜切除术（EMR）已被确立用于治疗Barrett食管的早期病变。然而，剩余的Barrett食管上皮仍有发生进一步病变的风险。本研究的目的是评估环周内镜黏膜切除术（环周EMR）在切除不仅是索引病变（高级别上皮内瘤变（HGIN）或黏膜癌），而且还有剩余的Barrett食管上皮方面的疗效。
本研究共纳入21例患者（11例男性，10例女性），他们患有Barrett食管且伴有HGIN（n = 12）或黏膜癌（n = 9）。其中，17/21的患者手术风险高，5例拒绝手术。根据术前超声内镜检查，他们的病变被分类为T1N0（n = 19）或T0N0（n = 2）。在黏膜下注射10 - 15毫升生理盐水后，通过息肉切除术切除病变及Barrett食管上皮；21例中有15例使用了双通道内镜。环周EMR分两个阶段进行，第一阶段切除病变及环周Barrett食管黏膜的一半。为防止食管狭窄形成，1个月后切除Barrett食管黏膜的另一半。
21例患者中有4例（19%）发生并发症，均为出血，所有病例均通过内镜止血成功处理。随访期间（平均时长18个月）未观察到狭窄，21例患者中有18例（86%）的内镜切除被认为是完整的。3例患者的组织学检查显示肿瘤切除不完全：其中1例接受了手术；2例接受了放化疗，在18个月和24个月的随访中分别未发现残留肿瘤的证据。最初被分类为切除完整的2例患者后来出现局部复发，并再次接受EMR治疗。20例患者中有15例（75%）的Barrett食管黏膜被鳞状上皮完全替代。
环周EMR是一种治疗伴有HGIN或黏膜癌的Barrett食管的非侵入性方法，并发症发生率低，短期临床疗效良好。进一步的研究应聚焦于长期结果和技术改进。
