Thématique :
- Endoscopie/Imagerie
Originalité :
Très original
Solidité :
Très solide
Doit faire évoluer notre pratique :
Dans certains cas
Nom du veilleur :
Docteur Edouard Chabrun
Coup de coeur :
  2017 May;66(5):783-793.  
  doi: 10.1136/gutjnl-2015-310126.  
  A randomised trial of endoscopic submucosal dissection versus endoscopic mucosal resection for early Barrett's neoplasia  
  Terheggen G, Horn EM, Vieth M, Gabbert H, Enderle M, Neugebauer A, Schumacher B, Neuhaus H  



For endoscopic resection of early GI neoplasia, endoscopic submucosal dissection (ESD) achieves higher rates of complete resection (R0) than endoscopic mucosal resection (EMR). However, ESD is technically more difficult and evidence from randomised trial is missing.


We compared the efficacy and safety of ESD and EMR in patients with neoplastic Barrett's oesophagus (BO).


BO patients with a focal lesion of high-grade intraepithelial neoplasia (HGIN) or early adenocarcinoma (EAC) ≤3 cm were randomised to either ESD or EMR. Primary outcome was R0 resection; secondary outcomes were complete remission from neoplasia, recurrences and adverse events (AEs).


There were no significant differences in patient and lesion characteristics between the groups randomised to ESD (n=20) or EMR (n=20). Histology of the resected specimen showed HGIN or EAC in all but six cases. Although R0 resection defined as margins free of HGIN/EAC was achieved more frequently with ESD (10/17 vs 2/17, p=0.01), there was no difference in complete remission from neoplasia at 3 months (ESD 15/16 vs EMR 16/17, p=1.0). During a mean follow-up period of 23.1±6.4 months, recurrent EAC was observed in one case in the ESD group. Elective surgery was performed in four and three cases after ESD and EMR, respectively (p=1.0). Two severe AEs were recorded for ESD and none for EMR (p=0.49).


In terms of need for surgery, neoplasia remission and recurrence, ESD and EMR are both highly effective for endoscopic resection of early BO neoplasia. ESD achieves a higher R0 resection rate, but for most BO patients this bears little clinical relevance. ESD is, however, more time consuming and may cause severe AE.



Question posée
Essai comparant la résection muqueuse endoscopique (EMR) à la dissection sous-muqueuse endoscopique (ESD) pour l’œsophage de Barrett (OB) dégénéré en dysplasie de haut grade ou cancer superficiel de moins de 30mm.
Question posée
Etude prospective randomisée allemande comparant un groupe EMR (n=20) et un groupe ESD (n=20). La seule différence significative entre les 2 groupes était le taux de résection R0 en faveur de l’ESD, objectif primaire de l’étude. Il n’y avait pas différence significative pour les objectifs secondaires (taux de rémission complète, récidive et complications).

Cette étude originale montre une nouvelle fois les limites de l’ESD dans l’OB. La mucosectomie standard a encore une place certaine et l’ESD doit être proposée pour des larges lésions (> 30mm).