Introduction

ESD is a standard treatment for Dysplasia or T1a esophageal cancers. However, severe stricture after circumferential ESD is a remaining major problem. Various managements have been reported, such as steroid injection, oral administration, and application of polyglycolic acid sheets, but none of them are sufficiently effective. Recently, the authors performed stepwise ESD in patients with circumferential esophageal cancers to prevent severe stricture after ESD.

Aims & Methods

The aim of this retrospective study is to clarify the usefulness of Stepwise ESD for preventing severe stricture after circumferential resection for esophageal tumor. Patients who underwent additional surgery due to the depth of SM2 or positive vascular invasion as a result of performing circumferential ESD were excluded from this study. Subjects were patients with circumferential esophageal tumors pathologically diagnosed as Vienna classification 4 or 5, who underwent ESD at Saku Hospital from 2006 to 2022. Sixteen and forty-six lesions were adenocarcinoma (EAC) and Squamous cell carcinoma (SCC), respectively. In the EAC group, the invasion depth was T1a in 9 cases and T1b in 1 case. In addition, the depth of invasion in the SCC group was T1a in 38 cases and T1b in 7 cases. The patients were divided into the En bloc (EB) group and the Stepwise (SW) group, and the background, number of endoscopic balloon dilatation (EBD), complications, etc. were examined for each group.

Results

Sixty-two patients, including 55 in the EB and 7 in the SW group, who required circumferential ESD, were entered into this study. There was no significant difference in age and gender between two groups.
Of the 55 patients in the EB group, 47 (85%) had severe stenosis and required EBD, but none in the SW group required EBD. The median number of EBDs was 5 (0-33) in the EB group and 0 (0-0) in the SW group.
And, the duration of ulcer healing in both groups were 137 (42-1028) days and 42 (30-120) days. The duration to healing of ESD ulcers was significantly shorter in the SW group (p<0.0001). The volume of TA injection were 50 (0-150) mg and 50 (0-100) mg, respectively. There was no significant difference (p=0.88).
The long axis mucosal defect lengths in the EB and SW groups were 8(5-15) cm and 6(3-9) cm, respectively. There was a significant difference between two groups (p=0.0004).
The diameters of the tumors were 59 (30-130) mm and 40 (36-64) mm, respectively. The length of resected specimen were 68 (29-150) mm and 56 (27-92) mm, respectively. There was a significant difference between two groups p=0.0004 and 0.0007.
Complications: There were no perforation and bleeding which needed blood transfusion. And, one patient in the EB group had a perforation during EBD, which could be cured with conservative treatment without surgery.

Conclusion

It has been reported that a circumference excision of 5 cm or more may cause severe stenosis. In this study, a median of 6 cm was performed even in the SW group, and stenosis could be prevented in all 7 cases. Therefore, Stepwise ESD may be a useful method to prevent post-ESD stricture in circumferential superficial esophageal tumors.

Introduction

Recently, ESD has become widespread, making it possible to safely remove large superficial esophageal cancers measuring 5 cm or more. However, severe stricture after circumferential ESD is a remaining major problem. Several treatment methods including local injection, oral administration of steroid, and stent insertion etc., have been reported. However, their effectiveness is insufficient.
We have reported the effectiveness of stepwise ESD to remove residual Barrett’s mucosa to prevent metachronous cancer in UEGW2023. And, we expanded the indication of Stepwise ESD for circumferential SCC.

Aims & Methods

The aim of this study is to clarify the usefulness of Stepwise ESD for preventing severe stricture after ESD for circumferential esophageal neoplasias. Subjects were patients with circumferential esophageal tumors, and underwent ESD at Saku Hospital from Jan. 2006 to Jan. 2024. Seventeen and fifty-one patients had adenocarcinoma (EAC) and Squamous cell carcinoma (SCC), respectively. The patients were divided into the En bloc (EB) group and the Stepwise (SW) group. In the EB group, a circumferential ESD was performed with or without triamcinolone injection. In the SW group, 2/3 of the circumference was resected in the first ESD, and 50-200 mg of TA was locally injected. And, the second ESD was performed 2-3 months later.

Results

Totally sixty-eight patients were enrolled into this study. 55 patients underwent en bloc resection and 13 patients underwent stepwise ESD. There was no significant difference in age, gender and location between two groups.
The mean diameters of the tumor, length of resected specimen and long axis mucosal defect in the EB and the first Stepwise ESD were 59 (30-130) and 50 (36-90) mm (p=0.23), 68 (29-150) and 71 (50-100) mm (p=0.8264), and 8 (5-15) and 8 (3-9) cm (p=0.56), respectively. There was no significant difference. And, the mean duration of ulcer healing in both groups were 137 (42-1028) and 46 (32-120) days (p<0.0001). The duration of ulcer healing was significantly shorter in SW group.
In the EB group, 47 of 55 patients developed severe stenosis and underwent EBD, whereas only 1 of 13 patients in the SW group required EBD. The median number of EBDs in both groups were 5 (0-33) and 0 (0-5), respectively (<0.0001).

Conclusion

The number of EBDs in the SW group was significantly less than that in the EB group. And, there were no severe complications. Therefore, stepwise ESD is an excellent treatment method that can prevent severe stenosis after endoscopic resection of circumferential esophageal neoplasia.

Introduction

Twenty-five years have passed since the development of endoscopic submucosal dissection (ESD), and it has become widely used as the first-line treatment for early-stage esophageal and gastric cancers with low risk of lymph node metastasis. However, due to the anatomical complexity and technical difficulty, the application of ESD for hypopharyngeal cancer remains limited.

Aims & Methods

A total of 151 lesions in 106 patients with hypopharyngeal cancer who underwent ESD at the Department of Endoscopy, Saku Central Hospital Advanced Care Center from June 2006 to March 2025 were retrospectively reviewed to evaluate treatment outcomes. Cases of recurrence after chemoradiotherapy were excluded. ESD Procedure
All procedures were performed under general anesthesia with intubation. A hook knife J was used to perform circumferential incisions with the Autocut mode of the VIO 3000 or VIO 3. Submucosal dissection was carried out using Endocut I and spray coagulation. For traction and improved visualization, Clip line technique was used.

Results

The study included 116 patients (109 men, 7 women), with a mean age at diagnosis of 67.7 years (range: 40–92). Synchronous multiple pharyngeal cancers were found in 25 patients and metachronous in 13. A total of 156 lesions were resected: 10 by endoscopic mucosal resection (EMR) and 146 by ESD.
Tumor locations were as follows: oropharynx (7 lesions), hypopharynx (149 lesions), primarily in the piriform sinus (135) and posterior cricoid area (14). Of these, 6 extended to the epiglottis and 5 to the aryepiglottic fold.
Detailed Results

1. Tumor size: mean maximum diameter was 14.5 mm (range: 1–51; resection specimen size: 27.4 mm (5–90). Depth of invasion: EP in 92 lesions (59%) and SEP in 64 (41%). Mean invasion depth from the surface was 712 µm (range: 150–2600). Macroscopic types: 0-I (7), 0-IIa (53), 0-IIb (92), 0-IIc (4). Histology: squamous cell carcinoma (SCC) in 155 lesions, neurofibroma in 1. En bloc resection rate was 100%. Lateral margins: positive in 6, negative in 150. Deep margins: negative in all cases.
2. Adverse events: delayed bleeding (1), aspiration pneumonia (2), and stricture (1).
3. Local recurrence: observed in one SEP case with lymphatic involvement.
4. Pre-ESD metachronous cancers: esophagus: 42, stomach:17, colon:1.
5. Post-ESD metachronous cancers: esophagus:22, hypopharynx:13 and stomach:10.
6. Prognosis: Mean follow-up was 84.9 months (range: 5–222). There were 5 deaths from primary disease, 10 from other diseases, and 8 from other malignancies. All 5 primary disease-related deaths had ly1 and died due to lymph node, pulmonary, or hepatic metastases.
7. Among 11 cases with extension to the aryepiglottic fold or epiglottis, tracheostomy was performed in 8 and nasotracheal intubation in 2 cases.

Conclusion

ESD for hypopharyngeal cancer demonstrated a high rate of local control and was an effective treatment option. Even in cases with extension to the aryepiglottic fold or epiglottis, safe procedures were possible with tracheostomy. For cases with positive lympho-vascular involvement, the risk of lymph node and distant metastases warrants consideration of additional treatment. Metachronous multiple cancers in the hypopharynx, esophagus, and stomach occurred in 40% of patients, emphasizing the importance of postoperative surveillance.

Introduction

ESD is an excellent endoscopic treatment with high en-bloc and R0 resection rate. However, duodenal ESD is technically difficult. And, it has been reported that the perforation rate of duodenal ESD is higher than that of ESD of other organs.
Hybrid ESD, which involves circumferential incision followed by removal of the lesion using a snare, may shorten the operation time, but detailed studies have not been conducted.

Aims & Methods

The aim of this study was to compare the treatment outcomes of ESD and hybrid ESD for duodenal tumors.
The subjects were superficial duodenal tumors that were resected at Saku Central Hospital from Dec.2002 to Dec. 2023, and diagnosed as grade 3 or 4 according to the Vienna classification.
ESD and Hybrid ESD were performed for 16 and 148 patients. Gender (Male/Female), age and location (1^st, 2^nd, 3^rd) of both groups were 18/8, 106/42, 64 (39-84), 62 (37-84) and (4/18/4), 9/119/20, respectively. There was no significant difference.

Results

1. Paris classification 0-I/IIa/IIb/IIc were 2/17/1/6 and 3/6/0/84, respectively.
2. En-bloc resection rate was 100% (26/26) and 89% (131/148), respectively (p=0.07). R0 resection rate was 100% (26/26) and 82% (121/148), respectively (p=0.01).
3. Size of tumor and specimen were 20 (5-63) / 9(2-27) and 28 (17-66) / 16 (8-34) mm, respectively (P<0.001、P<0.001).
4. Duration of procedure was 95 (34-265) and 30 (8-34), respectively (P<0.001).
5. Complications: Perforation, delayed perforation and delayed bleeding were 0% and 2.7% (4/148), 3.8% (1/26) and 2% (3/148), 0% and 0.7% (1/148), respectively. There was no significant difference.
6. Local recurrence rate was 0%, 0.7% (1/148), and the only local recurrent case was treated by HOT biopsy.
Hybrid ESD was useful for shortening treatment duration, however the R0 rate were significantly lower. Recently, under water EMR has been applied to the duodenal lesions, and it seems necessary to conduct a comparative study of hybrid ESD and under water EMR in the future.

Conclusion

ESD has excellent R0 resection rate, however it is technically difficult and has long treatment duration. On the other hand, hybrid ESD shortens treatment times but has lower R0 resection rates. Therefore, the indication of hybrid ESD is limited. Further examination including under water EMR should be performed.

References

None

Introduction

The ulcers after duodenal endoscopic resection (ER) are exposed to bile and pancreatic juice, therefore delayed perforation and bleeding are major complications. The condition caused by perforation can become serious, requiring surgical treatment and even death.
As a preventive measure, the suture of the ulcer after ER has been reported to be effective. There are two main suture methods: endo clips and laparoscopic suturing.

Aims & Methods

The aim of this retrospective study is to investigate the outcome of Endoscopic submucosal dissection (ESD) and laparoscopic and endoscopic co-operative surgery (D-LECS) for superficial non-ampullary duodenal epithelial tumors (SNADETs). ESD ulcer was sutured with endo clips in ESD group, and with laparoscopic suture in D-LECS group.
One hundred seventy-eight patients with SNADETs who underwent ESD and 41 patients with SNADETs who underwent D-LECS from November 2002 to February 2025 were investigated outcome of procedure. The patient’s characteristics in ESD and D-LECS were as follows. male/female: 124/54 and 27/14, median age: 62 (37-86) and 67 (37-83) years old, location of the tumor (bulbs/2^nd/3rd portion): 15/139/24 and 0/32/9, major macroscopic type (0-I/0-IIa/0-IIb/0-IIc): 5/91/1/81 and 1/32/0/8. Only major macroscopic type was difference significantly between ESD and D-LECS (p=0.001). SM1 was defined as submucosal invasion of less than 500 μm, and SM2 was defined as deeper. R0 was defined as lateral and vertical margin negative, and lymph-vascular involvement negative. DLECS was selected when it was predicted that endo clips suture might be insufficient, or when the scope maneuverability was poor.

Results

1. Median procedure time was 36 (7-245) in ESD and 351 (202-673) minutes in D-LECS, respectively(p<0.001). Median diameter of resected specimen was 17 (8-66) and 38 (17-70) mm(p<0.001). Median diameter of resected specimen and tumor was 10 (2-63) and 27 (14-52) mm(p<0.001). Intramucosal tumor (Vienna classification category 3 to 5.1) /T1bSM (category 5.2): 176/2 and 37/4 (p=0.01).
2. The en bloc resection was 90% (161/178) and 95% (39/41), respectively (p=0.53). R0 resection rate was 85% (151/178) and 88% (36/41) (p=0.62).
3. The rate of complete suture for ESD ulcer was 92% (164/178) in ESD group and 100% in D-LECS group, respectively (p=0.07). The details in D-LECS are as follows: 27% (11/41) of laparoscopic suture alone and 73% (30/41) of laparoscopic and endo clips suture.　
4. Complications: intraoperative perforation was 2% (4/178) and 10% (4/41) (p=0.04). Intraoperative bleeding requiring blood transfusion was 0% and 0%. Delayed perforation was 1% (2/178) and 0% (p=1.00). Delayed bleeding was 2% (4/178) and 0% (p=1.00).
Discussion:
1. The DLECS group treated larger cases and had more intraoperative perforations, but no delayed perforation or bleeding was observed.
2. Laparoscopic suture of the pancreatic side was not possible, but complete suture was achieved in all cases by adding a clip from the luminal side endoscopically.
3. Even after complete suture by ESD, delayed perforation can still occur. Therefore, if abdominal pain occurs, a CT scan should be performed immediately.　And if perforation is suspected, laparoscopic re-suture should be considered immediately.

Conclusion

DLECS for large SNADETs has similar outcome of ESD, and is an effective treatment. DLECS should be considered when complete suture with a clip is predicted to be difficult or when the scope maneuverability was poor.

References

None

Introduction

The standard treatment for T1b esophagogastric junctional adenocarcinoma (EGJAC) is surgery. However, surgery is highly invasive especially for elderly patients. Endoscopic submucosal dissection (ESD) is an alternative treatment of T1b cancer for such patients. However, the outcome and long-term prognosis of T1b EGJAC treated by ESD is unknown.

Aims & Methods

The aim of this study is to investigate the outcome and prognosis of T1b EGJAC treated by ESD.
Fifty lesions in 49 patients with pT1b EGJAC who underwent ESD from January 2000 to September 2019 were investigated the outcome and prognosis. The patients were divided into pT1bSM1 (n=30) and pT1bSM2 (n=20).
The patient characteristics were as follows. Male/female: 28/2, 18/2, median age: 69, 75 years old, macroscopic type (protuberance/depression): 5/25, 6/14, main histology (well differentiated (diff.)/ mixed poorly diff.): 22/8, 9/11, median diameter of resected specimen: 45, 39mm, median diameter of tumors: 22, 19mm, median follow-up period: 53, 64months, respectively. There was significant difference in only main histology (p=0.04).
EGJAC was defined as Siewert II, with T1bSM1 for ≤500 μm and T1bSM2 for >501 μm. R0 was defined as lateral and vertical margin negative, and lymph-vascular involvement negative. According to Japanese guidelines, additional treatment was recommended for all T1bSM2 cases and for SM1 lymph duct (ly)-positive and poorly diff. cases.

Results

1. Outcome of ESD
The en bloc resection rate is 100% for both T1bSM1 and T1bSM2. The R0 rate was 100% for T1bSM1 and 95% (19/20) for T1bSM2. Intraoperative perforation rate was 2% (1/50), delayed bleeding rate was 2% (1/50), and delayed perforation rate was 0%. Stenosis rate was 10% (5/50), and all of such complications were treated by endoscopy without surgery.
2. Long-term prognosis
A) T1bSM1 (n = 30)
a) One case (3%) was ly-positive. Additional surgical resection was performed, and lymph node metastasis (LNM) was observed. The patient is alive without recurrence.
b) Twenty-nine cases were ly/vascular (v) negative, and followed up without additional treatment (AT). Nineteen in 29 cases are alive without recurrence, and 10 in 29 cases died by other diseases.
c) Local recurrence rate was 0%, LNM rate was 3% (1/30), and distant metastasis (DM) rate was 0%.
B) T1bSM2 (n=20)
a) Six cases (30%) were ly and/or v positive. Additional surgical resection was performed in 3 cases, and no LNM was observed in any of the cases. Of the other 3 cases, 1 patient underwent only radiotherapy. LNM was found 14 months later, and chemotherapy was added, but treatment-related death occurred. One of the two cases who did not undergo AT had DM and multiple liver metastases 61 months after ESD, and died of the original disease despite of chemotherapy. Another patient died of other diseases.
b) Nine in 14 cases of ly/v negative underwent additional surgical resection, and no LNM was observed in any of the cases. 7 cases are alive without recurrence, and 2 cases died of other diseases. Four in 5 cases who did not undergo AT are alive without recurrence, and 1 patient died from other diseases.
c) R1 rate was 5% (1/20), local recurrence rate was 0%, LNM rate was 5% (1/20), DM rate was 5% (1/20), and mortality by primary cancer was 5% (1/20).

Conclusion

LNM and DM were not observed in the T1bSM1, ly0 group, however LNM and DM were observed in the T1bSM1,ly1 or T1bSM2 groups. Therefore, the current Japanese ESD criteria is appropriate. 　
The R0 resection rate for T1bSM2 was excellent at 95%, and local recurrence was 0%. ESD could be alternative treatment for patients with comorbidity.

References

None

Introduction

Esophageal stricture after endoscopic submucosal dissection (ESD) remains a significant clinical challenge, particularly when the post-ESD mucosal defect involves ≥75% of the esophageal circumference. Various preventive strategies, including local or systemic corticosteroids, have been explored to mitigate this risk, but their efficacy is often limited by incomplete drug coverage, suboptimal timing of administration, or considerable side effects. This study aimed to investigate a new prophylactic strategy to prevent post-ESD esophageal strictures in cases of large circumferential mucosal defects.

Aims & Methods

This was a prospective single-arm trial conducted at a large regional medical center in Southwest China. Patients were considered eligible if they met all of the following criteria: (1) early esophageal cancer confirmed by postoperative pathology; (2) an ESD-induced mucosal defect involving ≥75% of the esophageal circumference; (3) no evidence of local or distant metastasis; and (4) no contraindications to corticosteroid therapy. All eligible patients received a combined steroid regimen to prevent stricture formation. Specifically, the first triamcinolone injection was administered intraoperatively immediately after complete lesion resection. Using a 23G endoscopic needle, triamcinolone (8 mg/mL) was injected submucosally at multiple points around the resection bed, spaced approximately 1 cm apart in four quadrants (0.5-1 mL per site; total of 20-40 injections). The second injection, following the same protocol, was given on postoperative day 4. Oral prednisone was started on day 5 post-ESD at 30 mg/day for 2 weeks, then reduced to 25 mg/day for the next 2 weeks, followed by a taper of 5 mg per week until discontinuation at 8 weeks. Clinically significant stricture was defined by both an inability to pass a standard 9.9 mm endoscope and a dysphagia severity of Stooler grade ≥3. Scheduled follow-up endoscopies at 3, 6, 12, and 24 months were performed to assess stricture formation and detect any residual or recurrent disease. Dysphagia symptoms were also assessed via telephone interviews at 2, 4, 6, 8, 12, and 24 months using the Stooler grading.

Results

Between September 2024 and March 2025, ten patients meeting the inclusion criteria (6 women and 4 men; mean age 67.5 years) were enrolled and treated with the combined steroid regimen. Six patients had full circumferential mucosal defects after ESD, while the remaining four had near-circumferential defects ranging from approximately five-sixths to eight-ninths of the esophageal circumference. The median longitudinal length of the post-ESD mucosal defects was 7.5 cm (range 4-12 cm), and the median resected area was 3375 mm² (range 1500-5250 mm²). No procedure-related complications were observed within 30 days post-ESD. Over a median follow-up period of 5 months (range 2-7 months), only one patient (10%) developed an esophageal stricture. This stricture was successfully managed with a single endoscopic dilation at 2 months after ESD. All other patients exhibited good mucosal healing and remained free of significant strictures throughout the follow-up.

Conclusion

This combined approach of intraoperative and postoperative local steroid injections coupled with a short-term oral corticosteroid taper appears to be a safe and preliminarily effective strategy for preventing esophageal strictures after ESD when large circumferential mucosal defects are present. Further validation in large-scale, multicenter randomized controlled trials is warranted to confirm its efficacy and safety.