Clinical outcomes of endoscopic oblique aspiration mucosectomy for superficial esophageal cancer

BACKGROUND: EMR is now a widely accepted option for the treatment for superficial esophageal cancer (SEC). However, studies of medium-term to long-term outcomes are scarce. OBJECTIVE: To evaluate outcomes in patients with SEC who are undergoing medium-term to long-term follow-up after endoscopic oblique aspiration mucosectomy (EOAM). DESIGN: A single-center retrospective study. SETTING: Kitasato University East Hospital, Sagamihara, Kanagawa, Japan. PATIENTS AND INTERVENTIONS: From November 1999 to October 2005, 85 patients with SEC underwent EOAM. All tumors were macroscopically classified as the superficial type on the basis of preoperative endoscopic and EUS findings. Patients were followed-up, with an endoscopy every 6 months. MAIN OUTCOME MEASUREMENTS: Therapeutic efficacy, complications, and follow-up results. RESULTS: The rate of complete resection was 82.5% (70/85). In patients who underwent an incomplete resection, argon plasma coagulation and heat probe coagulation were, in addition, performed. The median longest diameter of the resected specimens was 25 mm. The median time required for a resection was 27 minutes. There was no perforation. Bleeding after an EOAM occurred in 1 patient (1.2%). Esophageal stenosis developed in 8 patients (9.4%). All strictures were managed by endoscopic balloon dilation, and symptoms improved. The median follow-up period after EMR was 36 months (range 6-72 months). Local recurrence occurred in 5 patients (5.9%); the nonrecurrence rate was 96.4% at 1 year, 95.0% at 2 years, and 93.4% at 3 years. As additional treatment, argon plasma coagulation was performed in 4 patients, and endoscopic mucosal dissection was conducted in 1 patient. CONCLUSIONS: EOAM is a safe, easy, and effective procedure for the treatment of SEC that can be completed within a short time. The rate of local recurrence is low on medium-term to long-term follow-up.     

Safety and curative ability of endoscopic submucosal dissection for superficial esophageal cancers at least 50 mm in diameter

Background and Aim: Limited data are available regarding the use of endoscopic submucosal dissection (ESD) for superficial esophageal cancers ≥50 mm in diameter. The aim of the present study was to investigate the safety and success of ESD for superficial esophageal cancers ≥50 mm. Methods: A total of 39 patients with superficial esophageal squamous cell carcinoma ≥50 mm were treated with ESD at Osaka Medical Center for Cancer and Cardiovascular Diseases between January 2004 and April 2011, and were analyzed in a retrospective study. Results: En bloc resection was achieved in all patients. One mediastinal emphysema without perforation occurred during the procedure. Stricture developed in 11 of 39 patients, requiring a median of five endoscopic balloon dilatation procedures. Thirty‐three clinical epithelial or lamina propria mucosal cancers were treated by ESD with curative intent, of which invasion into the muscularis mucosa or deeper was detected in seven and lymphovascular involvement in three. The en bloc resection rate was 100% with a tumor‐free margin achieved in 92% of lesions. The curative resection and complication rates during ESD were 70% and 2.5%, respectively. Conclusion: ESD achieved a high en bloc resection rate of 92% with a tumor‐free margin. Curative resection rate of ESD in patients with clinical epithelial or lamina propria mucosal cancers was not low at 70%. However, the risk of stricture must be taken into account when considering the use of ESD in lesions ≥50 mm.     

Risk factors of postoperative stricture after endoscopic submucosal dissection for superficial esophageal neoplasms: A meta-analysis

Background:As larger-sized superficial esophageal neoplasms became candidates for endoscopic submucosal dissection (ESD), post-ESD esophageal stricture has inevitably developed into a significant complication during long-term follow-up.Method:The PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, as well as China National Knowledge Infrastructure, the Wanfang Database, and the Chinese Biomedical Literature Database, were searched to identify all the appropriate studies published from January 2000 through October 2019. For risk factor assessment between postoperative stricture and control groups, pooled odds ratios (OR) and weighted mean differences (WMD) estimation was done. All meta-analytical procedures were conducted by using Stata version 15.1 software.Results:The results showed that 11 studies with 2248 patients (284 structure cases and 1964 controls) were eligible for this meta-analysis. Statistical results indicated 6 substantial risk factors: lesion characteristics involving the upper third of the esophagus (OR 1.51, [1.02–2.25]), macroscopic type of IIa/IIc (OR 2.76, [1.55–4.92]), tumor depth of invasion above m1 (OR 7.47, [3.31–16.86]), and m2 (OR 12.67, [4.00–40.10]), longitudinal length (WMD 13.75 mm, [7.76–19.74]), circumferential diameter (WMD 10.87 mm, [8.13–13.60]), and circumferential range >3/4 (OR 38.17, [9.94–146.52]). Each additional 10% of the circumferential range increased the risk of stricture by 149% (OR 9282.46, [978.14–88089.35]).Conclusions:Six risk factors were assessed to have a key role in the elevated risk levels of post-ESD esophageal stricture. The results can help doctors identify patients with increased risk and thus can guide management of the adequate period of surveillance after ESD and take available approaches of stricture prevention.     

Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer

Endoscopic submucosal dissection (ESD) has been utilized as an alternative treatment to endoscopic mucosal resection for superficial esophageal cancer. We aimed to evaluate the complications associated with esophageal ESD and elucidate predictive factors for post‐ESD stenosis. The study enrolled a total of 42 lesions of superficial esophageal cancer in 33 consecutive patients who underwent ESD in our department. We retrospectively reviewed ESD‐associated complications and comparatively analyzed regional and technical factors between cases with and without post‐ESD stenosis. The regional factors included location, endoscopic appearance, longitudinal and circumferential tumor sizes, depth of invasion, and lymphatic and vessel invasion. The technical factors included longitudinal and circumferential sizes of mucosal defects, muscle disclosure and cleavage, perforation, and en bloc resection. Esophageal stenosis was defined when a standard endoscope (9.8 mm in diameter) failed to pass through the stenosis. The results showed no cases of delayed bleeding, three cases of insidious perforation (7.1%), two cases of endoscopically confirmed perforation followed by mediastinitis (4.8%), and seven cases of esophageal stenosis (16.7%). Monovalent analysis indicated that the longitudinal and circumferential sizes of the tumor and mucosal defect were significant predictive factors for post‐ESD stenosis (P < 0.005). Receiver operating characteristic analysis showed the highest sensitivity and specificity for a circumferential mucosal defect size of more than 71% (100 and 97.1%, respectively), followed by a circumferential tumor size of more than 59% (85.7 and 97.1%, respectively). It is of note that the success rate of en bloc resection was 95.2%, and balloon dilatation was effective for clinical symptoms in all seven patients with post‐ESD stenosis. In conclusion, the most frequent complication with ESD was esophageal stenosis, for which the sizes of the tumor and mucosal defect were significant predictive factors. Although ESD enables large en bloc resection of esophageal cancer, practically, in cases with a lesion more than half of the circumference, great care must be taken because of the high risk of post‐ESD stenosis.     

内镜黏膜下剥离术治疗结直肠浅表性肿瘤性病变的术后随访

[目的]探讨结直肠浅表性肿瘤性病变行内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)后临床病理特征、术后并发症及非治愈性ESD的相关危险因素及追加手术的必要性.[方法]回顾性分析本院因结直肠浅表性肿瘤性病变行ESD治疗的383例患者的临床资料,分析其一般临床特点、病理特征及预...     

Clinical experience of esophageal perforation occurring with endoscopic submucosal dissection

Esophageal perforation occurring during or after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is a rare, but serious complication. However, reports of its characteristics, including endoscopic imaging and management, have not been fully detailed. To analyze and report the clinical presentation and management of esophageal perforations occurred during or after EMR/ESD. Four hundred seventy‐two esophageal neoplasms in 368 patients were treated (171 EMR; ESD 306) at Northern Yokohama Hospital from 2003 to 2012. Esophageal perforation occurred in a total of seven (1.9%) patients, all of whom were male and had undergone ESD. The etiology of perforation was: three (42.9%) intraoperative; three (42.9%) balloon dilatation for stricture prevention; one (14.2%) due to food bolus impaction. All cases were managed non‐operatively based on the comprehensive assessment of clinical severity, extent of the injury, and the time interval from perforation to treatment onset. Conservative management included (i) bed rest and continuous monitoring to determine the need for operative intervention; (ii) fasting and intravenous fluid infusion/ tube feeding; and (iii) intravenous antibiotics. All defects closed spontaneously, save one case where closure was achieved by endoscopic clipping. Surgery was not required. Conservative management for esophageal perforation during advanced endoscopic resection is may be possible when there is no delay in diagnosis or treatment. Decision‐making should be governed purely by multidisciplinary discussion.     

Usefulness of clip traction in the early phase of esophageal endoscopic submucosal dissection

Background: The usefulness of clip traction in endoscopic submucosal dissection (ESD) for early esophageal carcinoma was investigated. Methods: A total of 87 patients who underwent ESD for esophageal squamous cell carcinoma were included in the study. The hook knife method was used for ESD. Twenty patients underwent ESD without clip traction (non‐clip group) and 67 underwent procedures in which clip traction was used (clip group). A clip with a string was attached to the oral edge of the lesion after mucosal incision in the clip group. Results: ESD was successful in all cases. Wide exposure of the submucosal tissue below the lesion was obtained by applying tension to the clip traction. The duration of ESD was shorter in the clip group, and there was a significant difference in duration between the non‐clip and clip groups. There were no complications of ESD in the clip group, but muscle layer injury occurred in three patients in the non‐clip group. Conclusion: Clip traction shortens operating time and is safer in esophageal ESD. Clip traction is recommended as a useful auxiliary procedure.     

Endoscopic submucosal dissection vs endoscopic mucosal resection for superficial esophageal cancer

AIM:To investigate the effectiveness of endoscopic submucosal dissection(ESD)and endoscopic mucosal resection(EMR)in treating superficial esophageal cancer(SEC).METHODS:Studies investigating the safety and efficacy of ESD and EMR for SEC were searched from the databases of Pubmed,Web of Science,EMBASE and the Cochrane Library.Primary end points included the en bloc resection rate and the curative resection rate.Secondary end points included operative time,rates of perforation,postoperative esophageal stricture,bleeding and local recurrence.The random-effect model and the fixed-effect model were used for statistical analysis.RESULTS:Eight studies were identified and included in the meta-analysis.As shown by the pooled analysis,ESD had significantly higher en bloc and curative resection rates than EMR.Local recurrence rate in the ESD group was remarkably lower than that in the EMR group.However,operative time and perforation rate for ESD were significantly higher than those for EMR.As for the rate of postoperative esophageal stricture and procedure-related bleeding,no significant difference was found between the two techniques.CONCLUSION:ESD seems superior to EMR in the treatment of SEC as evidenced by significantly higher en bloc and curative resection rates and by obviously lower local recurrence rate.     

Endoscopic submucosal dissection for superficial esophageal neoplasms using the stag beetle knife

Endoscopic submucosal dissection (ESD) is an accepted standard treatment for early gastric cancer but is not widely used in the esophagus because of technical difficulties. To increase the safety of esophageal ESD, we used a scissors‐type device called the stag beetle (SB) knife. The aim of this study was to determine the efficacy and safety of ESD using the SB knife. We performed a single‐center retrospective, uncontrolled trial. A total of 38 lesions were excised by ESD from 35 consecutive patients who were retrospectively divided into the following two groups according to the type of knife used to perform ESD: the hook knife (hook group) was used in 20 patients (21 lesions), and the SB knife (SB group) was used in 15 patients (17 lesions). We evaluated and compared the operative time, lesion size, en bloc resection rate, pathological margins free rate, and complication rate in both groups. The operative time was shorter in the SB group (median 70.0 minutes [interquartile range, 47.5–87.0]) than in the hook group (92.0 minutes [interquartile range, 63.0–114.0]) (P = 0.019), and the rate of complications in the SB group was 0% compared with 45.0% in the hook group (P = 0.004). However, the lesion size, en bloc resection rate, and pathological margins free rate did not differ significantly between the two groups. In conclusion, ESD using the SB knife was safer than that using a conventional knife for superficial esophageal neoplasms.     

A reliable nomogram model for predicting esophageal stricture after endoscopic submucosal dissection

Currently, endoscopic submucosal dissection (ESD) has gradually become the diagnosis and treatment of choice for initial esophageal cancer. However, the formation of esophageal stricture after ESD is one of its important complications. In this paper, we intend to identify the risk factors of esophageal stricture to develop a nomogram model to predict the risk of esophageal stricture and validate this model.A total, 159 patients were included in this study, including 21 patients with esophageal stenosis. Multivariate analysis showed that age greater than 60 years, high neutrophil-to-lymphocyte ratio, the extent of esophageal mucosal defect greater than 1/2, and postoperative pathological type of early esophageal squamous cell carcinoma were independent risk factors for predicting esophageal stricture. We constructed a nomogram model to predict esophageal stenosis by these 4 independent predictors.The prediction performance of the model was verified by the area under the receiver operating characteristic curve, the area under the receiver operating characteristic curve of the model was 0.889, and the sensitivity and specificity were 80.00% and 91.28%, respectively, indicating that the prediction performance of the model was good; The calibration curve constructed by internal cross-validation suggested that the predicted results of the nomogram agreed well with the actual observed values.The nomogram model has a high accuracy for predicting esophageal stricture after esophageal ESD and is extremely important to reduce or avoid the occurrence of esophageal stricture. But it needs more external and prospective validation.     

内镜黏膜下剥离术治疗胃肠间质瘤的疗效分析

[目的]探讨内镜黏膜下剥离术(endoscopic submucosal dissection,ESD)治疗胃肠间质瘤(gastrointestinal stromal tumors,GIST)的疗效。[方法]回顾性分析运用ESD治疗的27例GIST患者的临床资料。[结果]27例均为单发肿瘤,直径为5~30(16±8)mm,其中位于胃底部13例,胃体8例,胃窦部3例,贲门部2例,直肠1例。27例均内镜下成功完成手术,手术时间为35~180(75±43.6)min,术中出血量较少,平均(10±8.2)ml,4例术中出现穿孔,其中1例主动穿孔行内镜下胃壁全层切除术,均予金属夹成功夹闭。术后病理提示26例为GIST,1例为平滑肌瘤。术后随访6~24个月,所有患者未见肿瘤复发及转移。[结论]ESD治疗GIST是安全、有效的。     

Impact of endoscopic submucosal dissection for the therapeutic strategy of large colorectal tumors

Background and Aims: The change of therapeutic strategy for large colorectal tumors after the introduction of endoscopic submucosal dissection (ESD) has not yet been clarified. The aim of this study was to estimate the impact of ESD as an initial treatment strategy. Methods: A questionnaire was administered to nine expert panelists in colorectal ESD. The questionnaire used retrospective data from consecutive case series. Forty‐seven cases of early colorectal tumors (≥ 20 mm) were included. Endoscopic growth types were 25 laterally‐spreading tumors (LST) of granular type (G), 15 LST of non‐granular types (NG), and seven protruded types. Pathological diagnoses included 15 adenomas (Ad), 18 intramucosal cancers (M), three submucosally‐shallow invasive cancers (< 1000 µm) (SMs), and 11 submucosally‐deep invasive cancers (≥ 1000 µm) (SMd). The expert panelists completed questionnaires about recommended initial treatment under suppositions of before and after the introduction of ESD. Over‐surgery was defined as surgery for Ad, M, and SMs. Non‐curative endoscopic resection (ER) was defined as ER for SMd. Results: After the introduction of ESD, the reduction in the over‐surgery rate was estimated at 10.8% for Ad, M, and SMs, and the increase in the non‐curative ER rate was estimated at 27.2% for SMd. By endoscopic growth type, the reduction of over‐surgery rates for LST–NG, LST–G, and protruded type was 15.5%, 10.5%, and 2.2%, respectively. Conclusions: The endoscopists changed their therapeutic strategy for large colorectal tumors to reduce over‐surgery, especially in LST–NG, demonstrating the impact of ESD.     

超声内镜结合内镜黏膜下剥离术对直肠类癌的临床疗效观察

[目的]探讨超声内镜(EUS)结合内镜黏膜下剥离术(ESD)治疗直肠类癌的效果及价值。[方法]对EUS检查发现来源于黏膜下层、无固有肌层受累、无淋巴结转移、直径≤1.5cm、考虑为直肠类癌的21例直肠黏膜隆起病灶行ESD治疗。ESD后6个月、12个月及24个月行EUS随访。[结果]21例均成功完成ESD,瘤体完整剥离,基底及边缘无残留;术中均无穿孔,术后创面少量出血5例,经内科治疗后痊愈;术后病检确诊为类癌,随访6~24个月,无一例病变残留和复发。[结论]EUS结合ESD治疗直径≤1.5cm、未侵犯固有肌层的直肠类癌安全有效,可避免不必要的外科手术。