Department of Internal Medicine, Evangelisches Krankenhaus Düsseldorf, Düsseldorf, Germany.
Endoscopy. 2012 Dec;44(12):1105-13. doi: 10.1055/s-0032-1310155. Epub 2012 Sep 11.
Endoscopic submucosal dissection (ESD) of early gastrointestinal tumors has been shown to achieve complete resection rates superior to endoscopic mucosal resection (EMR), but at the cost of higher risk. The aim of this study was to prospectively assess the feasibility and oncological results of ESD in patients with neoplastic Barrett's esophagus in conjunction with subsequent radiofrequency ablation (RFA).
Patients with Barrett's esophagus who had visible lesions containing high grade intraepithelial neoplasia (HGIN) or mucosal adenocarcinoma (MAC) up to 3 cm in diameter were included in the study. ESD was performed using a new waterjet-assisted system (WESD) with a HybridKnife (Erbe Elektromedizin GmbH, Tübingen, Germany). Primary outcome was the rate of complete tumor resection. RFA of residual intestinal metaplasia was offered to all patients with at least two negative follow-up endoscopies.
Of 30 patients (m:f = 21:9; median age 60 years) with biopsy-proven MAC (n = 24) or HGIN (n = 6) with a median diameter of 2 cm, complete resection of the targeted area was achieved in 29 patients (96.7 %; 95 % confidence interval [CI] 82 % - 99 %); en bloc resection was achieved in 27 of these patients (90.0 %; 95 %CI 74 % - 97 %). Minor delayed bleedings occurred in two patients. One patient died due to a sudden cardiac death 7 days after an uneventful WESD. Specimen histology (n = 29) revealed no neoplasia in 3 patients, HGIN in 2, MAC in 21, and submucosal cancer in 3; complete resection was histologically confirmed in only 10 of the 26 patients with HGIN or adenocarcinoma (38.5 %; 95 %CI 22 % - 57 %). However, endoscopic follow-up (median 17 months) showed complete remission of neoplasia in 27 /28 (96.4 %; 95 %CI 81 % - 99 %) patients who underwent successful WESD and were alive at 30 days. One patient underwent EMR of residual tumor. All Barrett's tissue was eradicated by ESD alone in 15 cases and by additional RFA in 8 /10 cases (not done in three patients).
ESD of Barrett's neoplasia is feasible and safe, but does not achieve sufficient R0 resection rates to warrant its recommended use over piecemeal EMR. In combination with RFA it can achieve complete eradication of neoplastic and non-neoplastic Barrett's epithelium. The discrepancy between insufficient oncological resection and good medium-term results needs to be studied further.
内镜黏膜下剥离术（ESD）已被证明能够实现比内镜下黏膜切除术（EMR）更高的完全切除率，适用于早期胃肠道肿瘤，但风险也更高。本研究旨在前瞻性评估 ESD 联合后续射频消融（RFA）治疗伴有肿瘤的 Barrett 食管的可行性和肿瘤学结果。
本研究纳入了直径达 3cm 以内、可见病变包含高级别上皮内瘤变（HGIN）或黏膜腺癌（MAC）的 Barrett 食管患者。采用新型水刀辅助系统（WESD）联合 HybridKnife（Erbe Elektromedizin GmbH，德国图宾根）进行 ESD。主要结局是完全肿瘤切除率。所有至少两次阴性随访内镜的患者均接受 RFA 治疗残留的肠上皮化生。
30 例经活检证实 MAC（n=24）或 HGIN（n=6）的患者（男 21 例，女 9 例；中位年龄 60 岁）纳入本研究，其目标区域的完全切除率在 29 例患者中达到 96.7%（95%置信区间 82%-99%）；27 例患者实现整块切除（90.0%；95%置信区间 74%-97%）。2 例患者出现轻微延迟性出血。1 例患者在 WESD 后 7 天因心脏骤停意外死亡。29 例患者的标本组织学检查结果显示，3 例患者未见肿瘤，2 例患者为 HGIN，21 例患者为 MAC，3 例患者为黏膜下癌；仅 10 例 HGIN 或腺癌患者（38.5%；95%置信区间 22%-57%）经组织学证实完全切除。然而，内镜随访（中位随访时间 17 个月）显示，27/28（96.4%；95%置信区间 81%-99%）例成功进行 WESD 且在 30 天内存活的患者的肿瘤完全消退。1 例患者行残留肿瘤 EMR。15 例患者单独行 ESD 即可完全消除 Barrett 组织，8/10 例（3 例患者未进行）行 ESD+RFA 可完全消除 Barrett 组织。
ESD 治疗 Barrett 肿瘤是可行且安全的，但未能实现足够的 R0 切除率，因此不建议其用于 Barrett 肿瘤的治疗。联合 RFA 可以完全消除肿瘤性和非肿瘤性 Barrett 上皮。这种不理想的肿瘤学切除效果与良好的中期结果之间的差异需要进一步研究。
