A randomized prospective trial in 74 patients comparing the ER

A randomized prospective trial in 74 patients comparing the ERcap technique and multi-band mucosectomy technique for
piecemeal endoscopic resection in Barrett esophagus
R.E. Pouw1, L. Alvarez Herrero1,2, F.G. van Vilsteren1, F.J.W. ten Kate3, B.E.
Schenk4, E.J. Schoon5, F.T.M. Peters6, R. Bisschops7, B.L. Weusten2, J.J. Bergman1
Dept. of Gastroenterology, Academic Medical Center, Amsterdam, Netherlands
Dept. of Gastroenterology, St. Antonius Ziekenhuis, Nieuwegein, Netherlands
Dept. of Pathology, Academic Medical Center, Amsterdam, Netherlands
Dept. of Gastroenterology, Isala Clinics, Zwolle, Netherlands
Dept. of Gastroenterology, Catharina Ziekenhuis, Eindhoven, Netherlands
Dept. of Gastroenterology, University Medical Center, Groningen, Netherlands
Dept. of Gastroenterology, University Hospital Leuven, Leuven, Belgium
Endoscopic resection (ER) is an important modality to treat high-grade
dysplasia (HGD) or early cancer (EC) in Barrett esophagus (BE). The most
widely used ER technique, the ER-cap technique, requires submucosal lifting
and prelooping of a snare in a cap making it technically demanding and
laborious for piecemeal ER, and a new snare is needed for every resection.
The newer multi-band mucosectomy (MBM) technique does not require
submucosal lifting or prelooping of a snare and one snare can be used for
multiple resections.
Aim was to prospectively compare ER-cap and MBM for piecemeal ER in BE.
Patients scheduled for piecemeal ER of biopsy-proven HGD/EC in BE,
without suspicion on submucosal invasion on endoscopy and EUS, were
included. After delineation of the target area patients were randomized to ERcap (16.1mm hard oblique, Olympus) or MBM (Duette, Cook Medical).
Assessment criteria were: number of resections/procedure; procedure time;
complications; maximum diameter and thickness of specimens; costs of
74 pts (57M, median 70yrs, median BE 5cm) were randomized: 35 MBM vs
39 ER-cap. Procedure time (34 vs 50min, p=0.03) and costs (€240 vs €322,
p=0.001) were significantly less with MBM vs ER-cap. MBM resulted in
smaller specimens than ER-cap (17 vs 20mm, p<0.001). Maximum thickness
of resected specimens and submucosa of specimens obtained with MBM vs
ER-cap was 1.9 vs 2.0mm (p=ns) and 0.8 vs 1.0mm (p=ns), respectively.
There were three severe complications: 3 perforations in the ER-cap group,
all treated endoscopically.
Conclusions: This randomized trial shows that piecemeal ER with MBM is
faster and cheaper than with ER-cap and may be associated with fewer
complications. MBM results in statistically significantly smaller sized
specimens, but the clinical relevance of this may be limited since the depth of
resection did not differ. MBM may thus be preferable for piecemeal ER of flattype HGD/EC with a low risk of submucosal invasion.