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A 64-year-old woman initially underwent endoscopy for reflux symptoms and was found to have C7M8 Barrett’s esophagus with biopsies demonstrating high-grade dysplasia. She was referred to a tertiary esophageal center, which performed endoscopic mucosa resection.
Pathology results revealed M3 intramucosal carcinoma. Radiofrequency ablation of the remaining Barrett’s was attempted, with only a partial response. Further endoscopic mucosal resection and biopsy specimens demonstrated low-grade dysplasia.
Referral was made to thoracic surgery for esophagectomy, which the patient declined. Surveillance endoscopy was resumed, and 2 years later low-grade dysplasia was detected again. The patient was referred to our esophageal center.
Endoscopy demonstrated C1M8 Barrett’s with areas of low- and high-grade dysplasia (Fig. 1; and Video 1, available online at www.VideoGIE.org). Considering the previous failed radiofrequency ablation, there was suspicion of buried Barrett’s in the neosquamous area between the distal and proximal Barrett’s. After an extensive discussion regarding treatment options, risks, and benefits, circumferential endoscopic submucosal dissection (ESD) was planned with a gastric distal margin and normal squamous tissue as the proximal margin to ensure R0 resection of Barrett’s and dysplasia.
Figure 1Macroscopic white light and magnifying optical enhancement view of Barrett’s segment pre– and postendoscopic submucosal dissection. A, Distal Barrett’s esophagus. B, Mid-Barrett’s with neosquamous tissue. C, Proximal Barrett’s with insert. D-F, Magnification with 415- and 540-nm wavelength optical enhancement demonstrating low-grade dysplasia (D, E) and high-grade dysplasia (F).
ESD was uncomplicated, and the entire segment was removed en bloc (Fig. 2). Pathology demonstrated scattered low-grade dysplasia, foci of high-grade dysplasia proximally, and buried Barrett’s centrally. The patient was discharged home 24 hours after ESD on a liquid/pureed diet.
Figure 2Postendoscopic submucosal dissection (ESD) endoscopic view and pathology results. A, Retroflexed view of the distal ESD defect. B, Mid ESD defect. C, Proximal ESD defect. D, Gross pathology with 10-mL syringe placed within lumen of specimen, inked on submucosal surface (left), and lesion after being slit open and pinned (right). E, Buried Barrett’s in the area of prior radiofrequency ablation. F, High-grade dysplasia in proximal segment of Barrett’s esophagus.
This is a case of a patient with refractory dysplastic Barrett’s who underwent complete circumferential endoscopic submucosal dissection with R0 resection of Barrett’s, buried Barrett’s, and dysplasia. This case demonstrates the feasibility of complete circumferential ESD as an organ-preserving technique in the management of complex dysplastic Barrett’s.
Article info
Publication history
Published online: August 10, 2020
Footnotes
If you would like to chat with an author of this article, you may contact Dr Bechara at [email protected]
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