Useful strategies to prevent severe stricture after endoscopic submucosal dissection for superficial esophageal neoplasm

The minimal invasiveness of endoscopic submucosal dissection (ESD) prompted us to apply this technique to large-size early esophageal squamous cell carcinoma and Barrett’s adenocarcinoma, despite the limitations in the study population and surveillance duration. A post-ESD ulceration of greater than three-fourths of esophageal circumference was advocated as an important risk factor for refractory strictures that require several sessions of dilation therapy. Most of the preoperative conditions are asymptomatic, but dilatation treatment for dysphagia associated with the stricture has potential risks of severe complications and a worsening of quality of life. Possible mechanisms of dysphasia were demonstrated based on dysmotility and pathological abnormalities at the site: (1) delayed mucosal healing; (2) severe inflammation and disorganized fibrosis with abundant extracellular matrices in the submucosa; and (3) atrophy in the muscularis proper. However, reports on the administration of anti-scarring agents, preventive dilation therapies, and regenerative medicine demonstrated limited success in stricture prevention, and there were discrepancies in the study designs and protocols of these reports. The development and consequent long-term assessments of new prophylactic technologies on the promotion of wound healing and control of the inflammatory/tumor microenvironment will require collaboration among various research fields because of the limited accuracy of preoperative staging and high-risk of local recurrence.     

Risk factors of electrocoagulation syndrome after esophageal endoscopic submucosal dissection

AIM To investigate post endoscopic submucosal dissection electrocoagulation syndrome(PEECS) of the esophagus.METHODS We analyzed 55 consecutive cases with esophageal endoscopic submucosal dissection for superficial esophageal squamous neoplasms at a tertiary referral hospital in South Korea. Esophageal PEECS was defined as "mild" meeting one of the following criteria without any obvious perforation: fever(≥ 37.8 ℃), leukocytosis( 10800 cells/μl), or regional chest pain more than 5/10 points as rated on a numeric pain intensity scale. The grade of PEECS was determined as "severe" when meet two or more of above criteria.RESULTS We included 51 cases without obvious complications in the analysis. The incidence of mild and severe esophageal PEECS was 47.1% and 17.6%, respectively. Risk factor analysis revealed that resected area, procedure time, and muscle layer exposure were significantly associated with PEECS. In multivariate analysis, a resected area larger than 6.0 cm~2(OR = 4.995, 95%CI: 1.110-22.489, P = 0.036) and muscle layer exposure(OR = 5.661, 95%CI: 1.422-22.534, P = 0.014) were independent predictors of esophageal PEECS. All patients with PEECS had favorable outcomes with conservative management approaches, such as intravenous hydration or antibiotics.CONCLUSION Clinicians should consider the possibility of esophageal PEECS when the resected area exceeds 6.0 cm~2 or when the muscle layer exposure is noted.     

2020年日本食管癌内镜黏膜下剥离术和内镜黏膜切除术指南的解读：食管鳞癌部分

2020年日本胃肠内镜学会制定并发布了食管癌内镜黏膜下剥离术/内镜黏膜切除术指南。该指南基于已发表的大量临床研究证据,针对18个临床问题提出建议,问题涉及食管癌的术前诊断、内镜切除适应证、内镜切除方案、可治愈性评估以及术后监测5个方面,旨在解决实际工作中的问题并提高临床实践质量,主要内容包括食管鳞癌和食管腺癌2个部分,本文主要就食管鳞癌部分的指南内容进行解读。     

Q法自牵引技术在大范围早期食管癌内镜 黏膜下剥离术中的应用研究（含视频）

目的初步报告Q法自牵引辅助内镜黏膜下剥离术(Q-ESD)应用于大范围早期食管癌(EEC)的临床效果。方法回顾性分析2015年1月至2018年12月间在福建省立医院接受ESD治疗的82例大范围EEC(单发病灶>1/2周径或纵径长度>5 cm)患者病例资料,按治疗方案不同分为传统ESD组(n=44)和Q-ESD组(n=38),比较两组操作面积、操作时间、操作速度、整块切除率、完整切除率、并发症情况。结果82例病灶均于内镜下成功整块切除。Q-ESD组和传统ESD组在操作面积[779.8(329.9~2552.5)mm^2比875.7(417.8~1914.8)mm^2,U=155,P=0.636]、操作时间[63(41~177)min比59(42~169)min,U=171,P=0.167]、完整切除率[94.7%(36/38)比93.2%(41/44),χ^2=0.086,P=0.769]方面比较差异无统计学意义。但Q-ESD组操作速度快[14.9(5.4~20.8)mm^2/min比9.0(5.0~19.5)mm^2/min,U=142,P=0.035],固有肌层损伤发生率低[7.9%(3/38)比27.3%(12/44),χ^2=5.123,P=0.023],术后狭窄发生率低[5.3%(2/38)比20.5%(9/44),χ^2=4.051,P=0.044]。除传统ESD组有1例穿孔外,未发生其他不良事件。结论Q-ESD是治疗大范围EEC安全有效的可选策略。     

Influence of endoscopic submucosal dissection on esophageal motility

AIM: To assess esophageal motility after esophageal endoscopic submucosal dissection (ESD). METHODS: Twelve patients (6 men and 6 women) aged 53-64 years (mean age, 58 years) who underwent regular examination 3-12 mo after esophageal ESD for neoplasms of the esophageal body were included in this study. The ESD procedure was performed under deep sedation using a combination of propofol and fentanyl, and involved a submucosal injection to lift the lesion and use of a dual-knife and an insulated-tip knife to create a circumferential incision around the lesion extending into the submucosa. Esophageal motility was examined using a high-resolution manometry system. Dysphagia was graded using a five-point scale according to the Mellow and Pinkas scoring system. Patient symptoms and the results of esophageal manometry were then analyzed. RESULTS: Of the 12 patients enrolled, 1 patient hadgrade 2 dysphagia, 1 patient had grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Ineffective esophageal motility was observed in 5 of 6 patients with above semi-circumference of resection extension. Of these 5 patients, 1 patient complained of grade 2 dysphagia (with esophageal stricture), one patient complained of grade 1 dysphagia, and 3 patients complained of sporadic dysphagia. Normal esophageal body manometry was observed in all 6 patients with below semi-circumference of resection extension. The 6 patients with normal esophageal motility did not complain of dysphagia. CONCLUSION: Extensive esophageal ESD may cause esophageal dysmotility in some patients, and might also have an influence on dysphagia although without esophageal stricture.     

Two traction methods that can facilitate esophageal endoscopic submucosal dissection

Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection(ESD) have been developed. Clip-with-line(CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial(CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD(CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed th...     

老年人食管内镜黏膜下剥离术后胃食管反流的初步评价

目的评估老年人的食管病变在进行内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）3个月后的胃食管反流情况。方法回顾性调查60岁及以上行食管ESD术后3个月及以上的患者烧心、反酸等症状的发生情况,用胃食管反流病症状量表进行评分。记录患者年龄、病变位置、大小和来源,分析软件SPSS17．0。结果共有144例患者完成了随访,其中男性86例,女性58例,中位年龄65岁（60—80岁）。食管病灶大小0．4-10cm,中位数2cm。病灶下缘距食管胃结合部0—21．5cm,25％和75％位数值分别为4．1cm和12．0cm,中位数值为8．0cm。有胃食管反流症状者40例（27．8％）,诊断为胃食管反流病者11例（7．6％）。女性较男性患者容易发生胃食管反流症状（P=0．028）,病灶下缘距离食管胃结合部〈2．0cm者较2．0cm以上的患者更容易发生胃食管反流病（P=0．011）。结论食管病变的ESD手术3个月后部分老年患者出现胃食管反流症状和食管炎,距离食管胃结合部2cm以内的病灶ESD术后患者可能容易发生胃食管反流病。     

磁锚定技术辅助内镜黏膜下剥离术治疗早期食管癌的实验研究

目的 探讨磁锚定技术辅助内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗早期食管癌的可行性。方法 以6个比格(Beagle)犬离体食管为实验对象,利用自行设计加工的磁锚定装置(锚定磁体和靶磁体),对假定的食管病变黏膜实施ESD。评价手术操作的可行性及便捷性。结果 成功完成6个犬离体食管的ESD。调整锚定磁体位置可灵活控制靶磁体对黏膜的牵拉方向和牵拉力,充分显露黏膜剥离面,并提供组织张力,确保病变黏膜顺利切除。整个过程操作流畅,靶磁体留置方便,术中未出现靶磁体滑脱及黏膜撕伤。结论 磁锚定技术可有效地对病变黏膜进行牵拉,用于ESD进行早期食管癌的治疗安全可行,能够极大地改善内镜下操作体验。     

浅表食管鳞状细胞癌内镜黏膜下剥离术后追加治疗的疗效分析

目的:评价浅表食管鳞状细胞癌行内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）术后追加治疗（放化疗或外科手术治疗）的疗效。方法:2014年7月—2019年4月,在东南大学附属中大医院接受食管鳞状细胞癌ESD治疗,病理证实肿瘤浸润至黏膜肌层或黏膜下层的97例病例纳入回顾性分析,...     

内镜黏膜下隧道法剥离术治疗早期食管癌伴黏膜下层纤维化的临床观察

目的评价内镜黏膜下隧道法剥离术（endoscopic submucosal tunnel dissection,ESTD）治疗早期食管癌伴黏膜下层纤维化的效果和安全性。方法2015年6月—2018年2月间,在江苏省苏北人民医院消化内科采用ESTD或内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗,术后病理证实病灶＜1/3食管管周,且伴有黏膜下层纤维化的早期食管癌病例87例纳入回顾性分析,按纤维化程度分成轻度纤维化60例（ESTD 31例、ESD 29例）和重度纤维化27例（ESTD 16例、ESD 11例）,比较同一纤维化程度时两种手术方式的剥离速度、整块切除率、完全切除率,以及出血、肌层损伤、穿孔、颈部皮下气肿和术后狭窄的发生率。结果对于伴有轻度黏膜下层纤维化的早期食管癌患者,ESTD的整块切除率[96.8%（30/31）比82.8%（24/29）,P＜0.05]和完全切除率[96.8%（30/31）比75.9%（22/29）,P＜0.05]明显高于ESD,固有肌层损伤发生率明显低于ESD[6.5%（2/31）比17.2%（5/29）,P＜0.05],剥离速度、术中出血发生率、穿孔发生率、术后狭窄发生率与ESD比较差异均无统计学意义（P均＞0.05）,两种手术方式均无术后迟发性出血和颈部皮下气肿发生。对于伴有重度黏膜下层纤维化的早期食管癌患者,ESTD的剥离速度快于ESD[（12.3±2.8）mm2/min比（7.1±3.2）mm2/min],整块切除率、完全切除率、术后狭窄发生率与ESD相近,术中出血发生率[12.5%（2/16）比54.5%（6/11）]、固有肌层损伤发生率[18.8%（3/16）比54.5%（6/11）]、穿孔发生率[6.3%（1/16）比27.3%（3/11）]、颈部皮下气肿发生率[6.3%（1/16）比27.3%（3/11）]低于ESD,两种手术方式均无术后迟发性出血发生。术后12个月2例行ESD和1例行ESTD患者局部复发,术后24个月1例行ESTD患者发生异时癌。结论ESTD能安全、有效切除伴有黏膜下层纤维化的早期食管癌。对于伴有轻度黏膜下层纤维化者,ESTD的优势主要体现在治疗效果方面;对于伴有重度黏膜下层纤维化者,ESTD的优势主要体现在治疗安全性方面。     

Effect of polyglycolic acid sheet plus esophageal stent placement in preventing esophageal stricture after endoscopic submucosal dissection in patients with earlystage esophageal cancer: A randomized,controlled trial

AIM To assess the effect of polyglycolic acid(PGA) plus stent placement compared with stent placement alone in the prevention of post-endoscopic submucosal dissection(ESD) esophageal stricture in early-stage esophageal cancer(EC) patients. METHODS Seventy EC patients undergoing ESD were enrolled in this randomized, controlled study. Patients were allocated randomly at a 1:1 ratio into two groups as follows:(1) PGA plus stent group(PGA sheet-coated stent placement was performed); and(2) Stent group(only stent placement was performed). This study was registered on http://www.chictr.org.cn(No. chictrinr-16008709). RESULTS The occurrence rate of esophageal stricture in the PGA plus stent group was 20.5%(n = 7), which was lower than that in the stent group(46.9%, n = 15)(P = 0.024). The mean value of esophageal stricture time was 59.6 ± 16.1 d and 70.7 ± 28.6 d in the PGA plus stent group and stent group(P = 0.174), respectively. Times of balloon dilatation in the PGA plus stent group were less than those in the stent group [4(2-5) vs 6(1-14), P = 0.007]. The length(P = 0.080) and diameter(P = 0.061) of esophageal strictures were numerically decreased in the PGA plus stent group, whereas no difference in location(P = 0.232) between the two groups was found. Multivariate logistic analysis suggested that PGA plus stent placement(P = 0.026) was an independent predictive factor for a lower risk of esophageal stricture, while location in the middle third(P = 0.034) and circumferential range = 1/1(P = 0.028) could independently predict a higher risk of esophageal stricture in EC patients after ESD. CONCLUSION PGA plus stent placement is more effective in preventing post-ESD esophageal stricture compared with stent placement alone in EC patients with earlystage disease.     

Short term results of endoscopic submucosal dissection in superficial esophageal squamous cell neoplasms

AIM: To evaluate the efficacy of endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms.METHODS: Between July 2007 and March 2009, 27 consecutive superficial esophageal squamous cell neoplasms in 25 enrolled patients were treated by endoscopic submucosal dissection. The therapeutic efficacy, complications, and follow-up results were assessed.RESULTS: The mean size of the lesions was 21 ± 13 mm (range 2-55 mm); the mean size of the resection specimens was 32 ± 12 mm (range 10-70 mm). The en block resection rate was 100% (27/27), and en block resection with tumor-free lateral/basal margins was 88.9% (24/27). Perforation occurred in 1 patient who was managed by conservative medical treatments. None of the patients developed local recurrence or distant metastasis in the follow-up period.CONCLUSION: Endoscopic submucosal dissection is applicable to superficial esophageal squamous cell neoplasms with promising results.     

Endoscopic submucosal dissection for superficial esophageal neoplasms

Endoscopic submucosal dissection(ESD) is currently accepted as the major treatment modality for superficial neoplasms in the gastrointestinal tract including the esophagus.An important advantage of ESD is its effectiveness in resecting lesions regardless of their size and severity of fibrosis.Based on excellent outcomes for esophageal neoplasms with a small likelihood of lymph node metastasis,the number of ESD candidates has increased.On the other hand,ESD still requires highly skilled endoscopists due to technical difficulties.To avoid unnecessary complications including perforation and postoperative stricture,the indications for ESD require careful consideration and a full understanding of this modality.This article,in the highlight topic series,provides detailed information on the indication,procedure,outcome,complications and their prevention in ESD of superficial esophageal neoplasms.     

Endoscopic submucosal dissection for superficial esophageal squamous cell neoplasms

Endoscopic resection is an effective treatment for noninvasive esophageal squamous cell neoplasms(ESCNs).Endoscopic mucosal resection(EMR)has been developed for small localized ESCNs as an alternative to surgical therapy because it shows similar effectiveness and is less invasive than esophagectomy.However,EMR is limited in resection size and therefore piecemeal resection is performed for large lesions,resulting in an imprecise histological evaluation and a high frequency of local recurrence.Endoscopic submucosal dissection(ESD)has been developed in Japan as one of the standard endoscopic resection techniques for ESCNs.ESD enables esophageal lesions,regardless of their size,to be removed en bloc and thus has a lower local recurrence rate than EMR.The development of new devices and the establishment of optimal strategies for esophageal ESD have resulted in fewer complications such as perforation than expected.However,esophageal stricture after ESD may occur when the resected area is larger than three-quarters of the esophageal lumen or particularly when it encompasses the entire circumference;such a stricture requires multiple sessions of endoscopic balloon dilatation.Recently,oral prednisolone has been reported to be useful in preventing post-ESD stricture.In addition,a combination of chemoradiotherapy(CRT)and ESD might be an alternative therapy for submucosal esophageal cancer that has a risk of lymph node metastasis because esophagectomy is extremely invasive;CRT has a higher local recurrence rate than esophagectomy but is less invasive.ESD is likely to play a central role in the treatment of superficial esophageal squamous cell neoplasms in the future.     

超声内镜联合EMR或ESD在食管表浅隆起性病变诊断和治疗中的作用

目的：探讨超声内镜（EUS）联合内镜下黏膜切除术（EMR）或内镜下黏膜剥离术（ESD）在食管表浅隆起性病变诊断和治疗中的价值。方法对35例经EUS检查拟诊为食管表浅隆起性病变患者进行EMR或ESD治疗的病例资料进行回顾性研究,分析病变部位的EUS图像、病理诊断结果及随访治疗效果。结果35例中21例经EMR治疗,14例经ESD治疗。经病理组织学检查确诊为早期食管癌9例,重度不典型增生5例,良性间质瘤3例,腺瘤性息肉4例,非腺瘤性息肉6例,平滑肌瘤8例。经EUS及病理证实病变均起源于黏膜层、黏膜肌层和黏膜下层。34例分别于术后1、3、6月复查EUS随访,术后1个月后伤口均完全愈合,无出血、食管狭窄及局部复发现象发生。结论联合应用EUS和EMR或ESD技术,不仅可以提高食管表浅隆起性病变早期的确诊率,而且是一种微创、有效、安全、快速的治疗措施。     

体外自助式扩张球囊预防食管大面积病变内镜黏膜下剥离术后狭窄的长期疗效分析

目的 评估体外自助式扩张球囊预防食管大面积病变内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）后食管狭窄的长期有效性和安全性。方法 前瞻性纳入2018年1月—2019年12月在解放军总医院第一医学中心行ESD且术后黏膜缺损≥5/6食管环周、长度30～100 mm的早期食管癌或癌前病变患者,术后使用体外自助式扩张球囊预防食管狭窄。ESD术后食管黏膜缺损分为2级:1级为≥5/6环周但未累及全环周;2级累及全环周。观察术后狭窄发生率,狭窄出现时间,内镜下球囊扩张（endoscopic balloon dilations,EBD）或放射状切开（radial incision and cuttings,RIC）治疗狭窄的次数,以及其他不良事件发生率。结果 共27例患者纳入研究,随访14～38个月,其中术后黏膜缺损范围1级的患者3例,2级24例。术后黏膜缺损长度（73.7±18.4）mm,球囊放置时间（92.0±20.0）d;总狭窄发生率为18.5%（5/27）,其中术后黏膜缺损2级的患者狭窄发生率为16.7%（4/24）。球囊取出到发生狭窄的中位时间为17 d,其中2例狭窄患者分别进行了3次EBD治疗,其余3例患者分别接受了2次、1次和2次RIC治疗。所有患者在佩戴球囊过程中未出现穿孔和迟发性出血。结论 对于ESD术后黏膜缺损≥5/6食管环周且长度≤100 mm的食管大面积病变患者,体外自助式扩张球囊是一种安全有效的预防术后狭窄的方法。     

Role of endoscopic therapy in early esophageal cancer

Esophageal carcinoma is a highly lethal cancer associated with high morbidity and mortality. Esophageal squamous cell carcinoma and esophageal adenocarcinoma are the two distinct histological types. There has been significant progress in endoscopic diagnosis and treatment of early stages of cancer using resection and ablation techniques, as shown in several trials in the recent past. Earlier detection of esophageal cancer and advances in treatment modalities have lead to improvement in the 5-year survival from 5% to about 20% in the past decade. Endoscopic eradication therapy is the preferred modality of treatment in cancer limited to mucosal layer of the esophagus as there is very low risk of lymph node metastasis, leading to high cure rates, low risk of recurrence and with few adverse effects. The most common adverse events seen are strictures, bleeding and rarely perforation which can be endoscopically managed. In patients with recurrent advanced disease or invasive tumor, esophagectomy with lymph node dissection remains the mainstay of treatment. There is debate on post-endoscopic surveillance with some studies suggesting closer follow up with upper endoscopy every 6 mo for the first 1-2 years and then annually for the 3 years while others recommending the appropriate action only if symptoms or other abnormalities develop. Overall, the field of endoscopic therapy is still evolving and focus should be placed on careful patient selection using a multidisciplinary approach.     

How to establish endoscopic submucosal dissection in Western countries

Endoscopic submucosal dissection(ESD) has been invented in Japan to provide resection for cure of early cancer in the gastrointestinal tract. Professional level of ESD requires excellent staging of early neoplasias with image enhanced endoscopy(IEE) to make correct indications for ESD,and high skills in endoscopic electrosurgical dissection. In Japan,endodiagnostic and endosurgical excellence spread through personal tutoring of skilled endoscopists by the inventors and experts in IEE and ESD. To translocate this expertise to other continents must overcome two fundamental obstacles:(1) inadequate expectations as to the complexity of IEE and ESD; and(2) lack of suitable lesions and master-mentors for ESD trainees. Leading endoscopic mucosal resection-proficient endoscopists must pioneer themselves through the long learning curve to proficient ESD experts. Major referral centers for ESD must arise in Western countries on comparable professional level as in Japan. In the second stage,the upcoming Western experts must commit themselves to teach skilled endoscopists from other referral centers,in order to spread ESD in Western countries. Respect for patients with early gastrointestinal cancer asks for best efforts to learn endoscopic categorization of early neoplasias and skills for ESD based on sustained cooperation with the masters in Japan. The strategy is discussed here.     

单中心早期胃癌内镜下治疗10年回顾性研究

目的：探讨早期胃癌内镜下治疗的疗效、安全性及其影响因素。 方法：回顾性分析2006年1月至2015年12月于北京协和医院消化内镜中心拟诊早期胃癌、接受内镜下治疗并证实的病例186例次,根据内镜下治疗适应证分组,统计治愈性切除率及并发症的发生率,分析其影响因素。统计随访事件的发生情况。 结果：研究期间,接受内镜下切除的早期胃癌共186例次,绝对适应证组治愈性切除率86.9%（73/84）,扩大适应证组61.7%（50/81）,非适应证组33.3%（7/21）,不同适应证组治愈性切除率有显著差异（P<0.01）。多因素分析显示,胃下1/3、无溃疡、直径≤2cm、无黏连、分化型癌均为治愈性切除的独立预测因素。病理分化程度改变或浸润深度升级是完全切除的扩大适应证病变无法达到治愈性切除的主要原因。出血及穿孔的发生率分别为4.8%（9/186）、3.8%（7/186）。胃下1/3、无黏连、整块切除的病变穿孔发生率低,差异有统计学意义。成功随访154例患者,中位随访时间22.3个月。治愈性切除者同时癌及异时癌的发生率分别为7.5%、0.9%。 结论：早期胃癌内镜下治疗的绝对适应证患者其治愈性切除率高;而扩大适应证者采取内镜下治疗需慎重。术前应进行细致的内镜评估,尤其是辨别未分化成分及垂直浸润深度。内镜治疗后应密切随访以早期发现同时癌及异时癌     

磁锚定辅助牵引技术在食管早癌内镜黏膜下剥离术中应用的初步研究

目的目前,内镜黏膜下剥离术(ESD)已经成为消化道表浅癌的标准治疗方式,但对于食管病变,由于操作空间较为狭小,往往导致技术难度较大,手术耗时较长。本文报道了磁锚定牵引ESD治疗食管病变的初步结果。 方法2020年4月至2020年6月,共计5例食管浅表癌患者于解放军总医院第一医学中心接受磁锚定牵引ESD,前瞻性收集患者相关信息。 结果对于接受磁锚定牵引ESD的5例患者,整块切除率及完整切除率均为100%,R0切除率为80%,未见术中出血、术中穿孔、术后出血、术后穿孔等并发症发生。 结论初步研究结果证实,磁锚定牵引ESD治疗食管病变是安全可行的,但仍需进一步大样本的研究印证上述观点,并同时评估其长期有效性。