Barrett's esophagus: The advocacy for ESD

Endoscopic submucosal dissection (ESD) is now an approved technique for removal of superficial tumors in the upper and lower gastrointestinal tract. The European Society of Gastrointestinal Endoscopy (ESGE) recommends ESD as the first treatment for superficial SCC and for early gastric cancer [1]. In Barrett’s cancer, however, ESD’s role and indications are still debated by “pro” and “con” experts, very often with the assumption that ESD is driven by a “mode” effect. Why are some European experts so reluctant to accept ESD as part of the armamentarium for Barrett’s neoplasia? The main reasons seem to be the high success rates and safety of endoscopic mucosal resection (EMR), which have to be balanced against the technical difficulties and the risks of ESD for esophageal lesions [2]. Some experts even question the conceptual advantage of ESD over EMR, namely the ability to perform an enbloc resection for lesions of any size, in Barrett’s neoplasia. Indeed Barrett’s cancer often arises in a field of dysplastic Barrett’s epithelium, therefore, the lateral margins very often still harbor dysplasia. R0 resection rates in Barrett’s, even with ESD, are therefore lower than in other superficial tumors [3]. This leads to the concept of R0 for cancer, for severe dysplasia and for dysplasia in recent guidelines. In spite of initial technical advantages, ESD does not seem to offer clinical advantages over EMR in terms of need for surgery, neoplasia remission, and early recurrence rates. Therefore, in Barrett’s-related neoplasia, the additional value of en-bloc resection by means of ESD may possibly not counterbalance the downside of ESD in terms of perforation risk [4,5]. The study published in this issue by Coman et al. reports on a prospective cohort including 36 patients in whom ESD was indicated for suspicion of superficial submucosal invasion, positive lateral margin after EMR, and nodularity with HGD that could not be removed en-bloc with EMR. En bloc, R0, and curative resection rates were 100%, 81%, and 69%, respectively. Intramucosal EAC was found in 13 patients (36%), and submucosal invasion in 13 patients (36%) [6]. Adverse events occurred in 8 patients (22%), including bleeding in 1 patient, which was treated with endoscopy, and esophageal strictures in 7 patients, which were successfully managed with dilatations. The authors also comment that, contrary to accepted algorithms in the East, performing ESD in Barrett’s esophagus did not require extensive prior experience with ESD in the stomach. Hence, they support the belief that similarly high en-bloc and R0 resection rates can be achieved with initial introduction of the ESD program in Western centers. These data are comparable to those from 2 recent series published in Endoscopy. In a series of 87 patients with Barrett’s neoplasia, Probst et al. showed en-bloc resection rates of 95.4% and R0 resection rates of 83.9% [7]. The curative resection rate was 72.4% and endoluminal recurrence was observed in 2.4% of patients (8% with Barrett’s >M3, 0% in Barrett’s ≤M3. Complications included strictures (11.7%) and bleeding (0.9%), but no perforation. Disease-specific survival was 97.7% (EAC), and overall survival was 96.6% over a mean follow-up periods of 24.3 months and 38.0 months, respectively. Chevaux et al., in a series of 75 patients, reported an en-bloc resection rate of 90% and a rate of curative resection of carcinoma as high as 85% [8]. Western data now show results similar to those in Japanese series reporting en-bloc and curative resection rates of 100% and 84%, respectively, with no recurrent or metastatic carcinoma detected during a mean follow-up period of 33 months [9,10].