Complex early Barrett's neoplasia at 3 Western centers:  European Barrett's Endoscopic Submucosal Dissection Trial (E-BEST)

Background and Aims Endoscopic submucosal dissection (ESD) is an effective technique to resect early Barrett's neoplasia and has advantages over conventional EMR in that it enables en-bloc resection and accurate histopathologic analysis of cancer resection margins. However, its long learning curve and higher adverse event rate have tempered its uptake in the West. We aimed to analyze the safety and efficacy of ESD when used to resect complex Barrett's neoplasia. The primary endpoint was the en-bloc and R0 resection rate. Methods This was a retrospective analysis of 143 ESDs for Barrett's neoplasia performed in 3 tertiary referral centers from 2008 to 2016. Results The mean lesion size was 31.1 mm (range, 5-90) and median follow-up time 21.6 months (interquartile range, 11.0-32.6). In total, 24.5% of lesions (35/143) were scarred after previous endoscopic resection, surgery, or radiotherapy. The en-bloc resection rate was 90.8% and R0 resection rate 79% in this series. The overall adverse event rate was 3.5% (1.4% bleeding, 0% perforation, and 2.1% stricture formation). The expanded curative resection rate was 65.8%, reflecting the R0 resection rate and proportion of cases with more advanced disease. Submucosal cancer was identified as a significant factor affecting the R0 resection rate. Conclusion We demonstrated the feasibility and safety of ESD in the West for resection of complex Barrett's neoplasia including large, nodular, or scarred lesions. This is a safe and effective technique with a low adverse event rate when performed by an experienced operator. The en-bloc resection rate reached a plateau once 30 procedures had been performed.