ENDOSCOPIC SUBMUCOSAL DISSECTION FOR UPPER GASTROINTESTINAL NEOPLASIA - LESSONS LEARNED FROM A HIGH VOLUME NORTH AMERICAN CENTER
Alex Chen, Michael Chen, Aya Siblini, Carmen L. Mueller, Jonathan Cools-Lartigue, Jonathan Spicer, Lorenzo E. Ferri*
McGill University, Montreal, QC, Canada
OBJECTIVES:Organ sparing endoscopic resection is an acceptable treatment strategy for superficial neoplastic lesions of the esophagus and stomach. Although Endoscopic Submucosal Dissection (ESD) has been shown to be more effective than EMR, adoption of this technique has lagged significantly in North America compared to Asia. We sought to report on our experience, one of the largest in the Western World, on ESD for upper GI neoplasia.
METHODS:A prospectively entered database of all patients undergoing endoscopic resection of esophageal and gastric neoplasia was queried for those received endoscopic submucosal dissection. Patients undergoing ESD from 2010-2018 were identified, and patient demographics, lesion characteristics and histology, procedural approach and variables, and post-operative outcomes were collected and reported.
RESULTS: Ninety-three consecutive ESD was identified from 2010-18. Most were male (71%) and median age was 72 (range: 38-90). Esophageal/EGJ ESD was performed in 45 and the rest were subcardia gastric (fundus = 5, body = 4, antrum = 33). Histology included invasive carcinoma (74%), high grade dysplasia (11%), LGD (7%), and benign (8%). Target lesion size was 20 (5-80) mm endoscopically. Slightly more than half were performed under general anesthesia in the operating theatre (51%), the rest under sedation in the endoscopy suite. Over the past 3 years most (58%) were performed under sedation in the endoscopy suite. En-bloc resection rates were 89%, 11% were done piecemeal. Average resected mucosal specimen was 36 (12-70) mm. Of the invasive malignancies, R0 was achieved in 67% (43/64), most R1 being at the deep margin. Tumour depth was T1a (41%), T1b (55%), and T2 (4%). 26% were either poorly differentiated or had LVI. Perforation occurred in 17%, all were managed with endoscopic clips. 92% of patients were admitted post-ESD, and the median length of stay was 1 (1-43) day. Post ESD complications (delayed perforation or bleeding) occurred in 4 (4%). Of the 56 patients with documented endoscopic follow up, 1 had recurrence.
CONCLUSION: Endoscopic Submucosal Dissection is a viable, effective, and safe option for superficial lesions of the stomach and esophagus. Efforts should be made to identify and address the barriers to adoption of this technique in North America.
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