Endoscopic mucosal resection of Barrett’s oesophagus
containing dysplasia or intramucosal cancer
S Seewald, T L Ang, N Soehendra
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Postgrad Med J 2007;83:367–372. doi: 10.1136/pgmj.2006.054841
Barrett’s oesophagus is premalignant. Oesophagectomy is
traditionally regarded as the standard treatment option in the
presence of high grade intraepithelial neoplasia or
intramucosal cancer. However, oesophagectomy is associated
with high rates of mortality and morbidity. Endoscopic ablative
therapies are limited by the lack of tissue for histological
assessment, and the ablation may be incomplete. Endoscopic
mucosal resection is an alternative to surgery in the
management of high grade intraepithelial neoplasia and
intramucosal cancer. It is less invasive than surgery and, unlike
ablative treatments, provides tissue for histological assessment.
This review will cover the indications, techniques and results of
endoscopic mucosal resection.
premalignant, with oesophageal adenocarcinoma
occurring at an overall incidence rate of 0.4–0.5%
per year.4It progresses through stages of dysplasia
to cancer. Patients without dysplasia and those
with low grade intraepithelial neoplasia (LGIN)
have low rates of disease progression. In the
presence of high grade intraepithelial neoplasia
(HGIN), disease may progress at rates .10% per
Surveillance endoscopy for Barrett’s oesopha-
gus—with the aim of detecting HGIN or early
cancer in order to facilitate earlier therapeutic
American College of Gastroenterology, with the
time interval of endoscopy being dependent on the
presence and severity of dysplasia. In the absence
of dysplasia, follow up endoscopy is performed at 3
years. When there is LGIN, endoscopy is performed
yearly. If focal HGIN is present, endoscopy is
repeated at 3-monthly intervals, but in the
presence of multifocal HGIN or intramucosal
cancer (IMC), intervention is required.7
Oesophagectomy is traditionally regarded as the
standard treatment option in the presence of HGIN
or cancer. It is a definitive treatment which
removes all neoplastic epithelia. This is important
because of the limitation of endoscopic biopsy,
which may not detect other foci of HGIN or IMC.
In a series of patients who underwent oeso-
phagectomy for HGIN detected by endoscopy,
surgery revealed invasive cancer in 30–40% of
cases which was missed preoperatively.8However,
See end of article for
Dr Stefan Seewald,
Medical Center Hamburg-
52, 20246 Hamburg,
Received 30 October 2006
Accepted 12 January 2007
arrett’s oesophagus is a sequel of gastro-
oesophageal reflux disease (GORD) and may
be present in 5–15% of GORD patients in the
Barrett’s oesophagus is
oesophagectomy is also associated with the highest
rates of procedure related mortality and long term
morbidity. Mortality rates ranging from 2.5–20.3%
have been reported, and 30–50% of patients may
develop serious postoperative complications such
as pneumonia, anastomotic leaks and myocardial
infarction.9In addition, there have been reports of
patients whose preoperative biopsy specimens
showed IMC that was not seen in the surgical
specimens.10There is thus a need for a less invasive
alternative treatment strategy.
Endoscopic ablative therapies such as argon
plasma coagulation (APC) and photodynamic
therapy (PDT) have been proposed as less invasive
alternatives to oesophagectomy, but are clearly not
optimal. These therapies are limited by the lack of
tissue for histological assessment, which is crucial
for determining treatment adequacy, and the
possibility that the ablation may be incomplete,
with remnant Barrett’s mucosa post treatment;
this persistent Barrett’s oesophagus will remain at
risk for progression to adenocarcinoma.9In a
multicentre randomised study which compared
PDT using porfimer sodium, combined with
omeprazole, versus omeprazole alone, it was
shown that although PDT was superior to ome-
prazole alone, complete ablation of HGIN was
achieved in only 77% of cases, while complete
ablation of Barrett’s oesophagus was achieved in
only 52%. In addition, oesophageal adenocarci-
noma still occurred in 13% of cases in the treated
group; strictures also occurred in 36% of cases.11
Poor results were also obtained when 5-aminole-
vulinic acid-PDT was used to treat patients with
residual HGIN and IMC after endoscopic mucosal
resection, with failure of PDT in 25% of cases, and
recurrence of HGIN in 27% of successfully treated
cases on follow up.12APC has been used to ablate
Barrett’s oesophagus with HGIN and IMC as well,
but the failure rate was 20%.13In a study of
patients with Barrett’s oesophagus (both without
dysplasia as well as with LGIN) treated with APC
and acid suppression, a relapse rate of 62% over a
median period of 36 months was reported. In
addition, 5% of patients progressed to adenocarci-
noma during this period.14
Abbreviations: APC, argon plasma coagulation; EMR,
endoscopic mucosal resection; EMRC, cap assistant
endoscopic mucosal resection; EMRL, endoscopic mucosal
resection with ligation; EST, endoscopic submucosal
dissection; EUS, endoscopic ultrasound; GORD, gastro-
oesophageal reflux disease; HGIN, high grade
intraepithelial neoplasia; IMC, intramucosal cancer; LGIN,
low grade intraepithelial neoplasia; PDT, photodynamic
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(A) F (B) F (C) F (D) T;
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372 Seewald, Ang, Soehendra