Trimodal imaging-assisted endoscopic mucosal resection of early Barrett's neoplasia

T Thomas, R Singh, K Ragunath
Surgical Endoscopy 2009, 23 (7): 1609-13

BACKGROUND: Chromoendoscopy is traditionally used to identify inconspicuous Barrett's neoplasia and mark the boundaries before endoscopic mucosal resection (EMR). Trimodal imaging endoscopy is useful in identifying early neoplasia in Barrett's esophagus. The purpose of this study was to determine the efficacy (lateral and deep margin clearance) of trimodal imaging endoscopy-assisted EMR in early Barrett's neoplasia in a tertiary referral setting.

METHODS: The entire Barrett's segment was visualized by high-resolution endoscopy followed by autofluorescence imaging, and suspicious areas were identified. Narrow band imaging and magnification was used to confirm the suspicious areas. The outer boundary of the lesion was then marked using the tip of a snare diathermy and EMR was performed using multiband mucosectomy technique by a single operator (KR).

RESULTS: Sixteen patients were included: 13 patients had high-grade intraepithelial neoplasia (HGIN); 3 patients had intramucosal carcinoma (IMC); (8 males, median age, 69.5 (range, 50-77) years with Barrett's esophagus (interquartile range (IQR), 2-5 cm; median length, 3 cm). All lesions were successfully identified, using trimodal imaging endoscopy. Overall EMR was complete in 14 of 16 (81.2%) patients with early Barrett's neoplasia. Four of 16 patients (18%; all with pre-EMR HGIN) were considered to have incomplete EMR (deep margins involved), but operative histology showed only Barrett's metaplasia in 2 (histological false positive) and IMC in 1. Thus, overall 14 of 16 (87.5%) patients had complete EMR of the original lesions. In patients who did not undergo esophagectomy, there was no disease recurrence on endoscopic biopsies at a mean follow-up of 8 (IQR, 6-12) months. Three of the 16 patients (18.75%) with post-EMR bleeding were successfully treated with APC/hemoclips.

CONCLUSIONS: Trimodal imaging endoscopy is a feasible alternative to chromoendoscopy to identify inconspicuous neoplasia and assist EMR of early neoplasia in Barrett's esophagus.

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