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Endoscopic mucosal resection (EMR) has clearly emerged as the best nonsurgical option for patients with Barrett esophagus (BE) with high-grade dysplasia (HGD) or early adenocarcinoma (EAC). Although considered a relatively safe intervention, the limited data available on complication rates are wide-ranging.
In the current retrospective cohort study, researchers further investigated the risks for complications during EMR for BE. In 681 patients (83% men; mean age, 70 years) who underwent EMR, pathology results indicated HGD in 63%, EAC in 19%, low-grade dysplasia in 14%, and no BE or no dysplastic BE in 5%. Ninety-nine percent of patients were treated by a single skilled endoscopist (without trainee participation) at one U.S. center. Resection techniques used were cap and snare (77%), Duette band and snare (18%), and variceal band ligation device and snare (5%).
Significant bleeding complications (defined as hemoglobin drop >2 mg/dL, therapeutic intervention, transfusion, or hospitalization for postprocedure bleeding) occurred in 1.2% of patients. In one patient, surgery was required to oversew a bleeding lesion. Stricture complications (marked by dysphagia requiring dilation) occurred in 1%; all were successfully resolved with dilation. No perforations occurred. In univariate analysis, no predictors of bleeding or stricture complications were identified. The complication rates were similar in the first and second halves of the study period.
Tomizawa Y et al. Safety of endoscopic mucosal resection for Barrett's esophagus. Am J Gastroenterol 2013 Sep; 108:1440. (http://dx.doi.org/10.1038/ajg.2013.187)
Comment
This is the largest series to date on the assessment of endoscopic mucosal resection for Barrett esophagus. The absence of a learning-curve effect is likely attributable to the remarkably low number of complications occurring under the care of the expert endoscopist. This high level of skill and the rigorous protocol used in EMR in this study limit the generalizability of results. Nonetheless, referral of patients with BE with high-grade dysplasia or early adenocarcinoma to specialty centers should be the preferred first-line therapy, even in patients with high morbidity or advanced age.