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Introduction:
Endoscopic resection as an organ sparing option in the management of early cancers of the foregut is becoming increasingly accepted. In North America, endoscopic mucosal resection (EMR) is the technique primarily employed. However lesions greater than 1 cm frequently require piecemeal resection with EMR, resulting in a high rate of local recurrence. Endoscopic Submucosal Dissection (ESD) allows for the en-bloc removal of larger tumors, however there is very limited data of this procedure in North America. We present our experience as one of the only centers in North America routinely performing ESD for neoplasia of the foregut.
Methods:
A prospectively maintained database of all patients with early neoplasia of the foregut managed in a busy North American centre was reviewed for patients undergoing ESD. Patient characteristics, endoscopic/post-endoscopy outcomes, pathologic features, and oncologic outcomes were captured. Data presented as median(range).
Results:
From 5/2009-11/2012 twenty patients (74 (38-85)yrs: 16M/4F) underwent ESD for neoplasia in the gastric antrum (10), body (2), cardia (6), or esophagus (2). General anesthesia was performed in the majority (19/20) and endoscopy time was 75 (30-330) minutes. The first 5 cases were longer than the last 15 (235(132-330) vs 75 (30-240) minutes). Median lesion size was 2.25 (0.6-5) cm and most underwent en-bloc resection (18/20). Perforation occurred in 3 patients, which was repaired by endoscopy (2) or by laparoscopy (1). Bleeding requiring repeat endoscopy occurred in 1 pt. Length of stay was 2 (1-7) days, there were no re-admissions. Final pathology revealed invasive cancer in 13 (ADC=9, SCC=3, NET=1: T1a=9, T1b=3, T2=1)) and adenoma with dysplasia in 7. Complete resection (R0) was achieved in 18/20, the 2 incomplete resection cases underwent laparoscopic resection. There is no evidence of recurrence at 5 (1-41) months follow-up.
Conclusions: Although technically challenging, endoscopic submucosal dissection for neoplastic lesions of the upper GI tract is effective, feasible, and can be safely applied in a North American setting.