Clinical Case Summary

A 65-year old man visited our hospital for abdominal pain. Esophagogastroduodenoscopy showed an area of fainted redness in the right upper thoracic esophagus. Narrow band imaging (NBI) detected a demarcated area with brownish dots. Intrapapillary capillary loops (IPCL) implied that the carcinoma had not invaded the deep submucosa. The entire lesion showed no stains by 1% Lugol’s iodine solution. Therefore, endoscopic submucosal dissection (ESD) was conducted under general anesthesia with endotracheal intubation. Labeling, submucosal injection, mucosal incision were performed according to surgical protocols. During dissection, however, a depression was observed in the left of the cancer lesion. Submucosal and muscular defects appeared in the depression edge, which indicated a shallow pulsion diverticulum under the lesion. We proceeded cautiously the dissection to separate the submucosa from the adventitia. ESD was successfully completed without perforation. To prevent postoperative perforation, we placed a covered esophageal stent. Post-ESD CT showed mild mediastinal emphysema. No other adverse events were observed and the patient was discharged at five days after ESD. The esophageal stent was removed at one month after ESD without perforation, stenosis or bleeding. Histopathological examination showed a well-differentiated squamous cell carcinoma within the mucosa without lympho-vascular invasion, suggesting a low risk of recurrence without additional treatment. Esophageal cancer that involves diverticula is extremely rare. The thin wall of diverticulum is easily to be perforated, bringing a great challenge to endoscopic resection. The location of an esophageal diverticulum in the cancer lesion is critical to its outcome.In conclusion, we reported a rare case of a superficial esophageal cancer with an esophageal diverticulum, which was invisible before the ESD. The cancer was successfully removed by ESD with no perforation.

References

1. Watanabe S, Matsuda, K. Arima K, et.al. Detection of subclinical disorders of the hypopharynx and larynx by gastrointestinal endoscopy. Endoscopy. 1996; 28(3): 295-298.
2. Herbella, Fernando A M et al. Are idiopathic and Chagasic achalasia two different diseases? Digestive diseases and sciences vol. 49,3 (2004): 353-60.
3. Shinwa, T, Takashi T, Yoshiko O, et al. Esophageal diverticulum exposed during endoscopic submucosal dissection of superficial cancer. World J Gastroenterol. 2015 March 14;21(10):3121-3126.

Disclosure

All authors declare that there is no conflict of interest.

Introduction

Endoscopic submucosal dissection (ESD) is a challenging procedure for treating superficial pharyngeal cancer (SPC). While previous studies have utilized conventional endoscopes (CE), recent advancements in endoscopic equipment have made it possible to use ultra-thin endoscopes (UTE) for ESD. The purpose of this study was to evaluate the impact of using UTE on ESD for SPC.

Aims & Methods

A total of 97 lesions in 81 patients who underwent ESD for SPC between January 2021 and March 2023 were retrospectively analyzed. Patients who underwent ESD using UTE (1200N: Olympus, Tokyo Japan) were classified into the UESD group, while those who underwent ESD using CE (Q260J: Olympus, Tokyo Japan) were classified into the CESD group.

Results

Of the 81 patients, 24 underwent UESD for 30 lesions, while 57 underwent CESD for 67 lesions. In the UESD group, the mean age was 70 years, with 20 males and 4 females. The mean maximum lesion size and resection specimen size were 17.7 mm and 28.5 mm, respectively. The histologic depth was CIS/SEP 17/13. The average dissection time was 41.6 minutes, and the volume of local injection (glyceol) used was 4.2 ml. Traction was used in 28 cases. In the CESD group, the mean age was 70 years, with 52 males and 5 females. The mean maximum lesion size and resected specimen size were 18.4 mm and 29.2mm, respectively. The histologic CIS/SEP was 24/43. The mean dissection time was 32.3 minutes (p=0.099), and the volume of local injection used was 7.1 ml (p=0.002). Traction was used in all cases. Both groups had a 100% en bloc resection rate and zero treatment-related complications.

Conclusion

The use of UTE in ESD for SPC is a safe alternative to CE. The use of UTE resulted in a reduction in the amount of local injection required, and in some cases, traction was not necessary. However, the dissection time tended to be longer. From the surgeon's perspective, UTE made it easier to access the subepithelial layer and secure the dissected layer, with less interference from other devices, resulting in reduced stress during the procedure.

Introduction

Endoscopic submucosal dissection (ESD) has become a common treatment method for superficial esophageal cancer, allowing complete resection and accurate postoperative pathological evaluation, especially for relatively larger lesions^{1, 2}. However, resection of larger lesions, especially circumferential lesions, can be time-consuming and challenging. The resected tissue can obstruct the esophageal lumen, leading to limited working space and poor visibility, thereby increasing the risk of adverse events such as perforation and muscular injury³. In recent years, several auxiliary traction techniques have been emerged, including positional adjustment traction, hemostatic clip elastic band traction, snare traction, line traction, and magnet anchor traction, which significantly improve the visibility of the submucosal layer during dissection and enhance the efficiency of the procedure ^4-5. Among these techniques, snare traction allows bidirectional traction through "push and pull" maneuvers, offering flexibility and practicality in clinical practice. However, due to the difficulty and limited cases of circumferential esophageal ESD, there is currently no published literature demonstrating the advantages of snare traction-assisted ESD over traditional ESD techniques.

Aims & Methods

This study aims to investigate the efficacy and safety of snare traction assisted ESD for the management of circumferential superficial esophageal cancer. A total of 68 patients who underwent ESD for circumferential superficial esophageal cancer were included in this study. All the patients were divided into two groups based on whether the snare traction was used or not; the snare traction group (S-ESD, group n=35) and the control group (C-ESD, group n=33).

Results

There was no significant difference in the size of the resected area between the groups [21.98 (18.30, 27.00) cm² vs 24.00 (15.28, 30.72) cm², P=0.976]. The snare traction group had a shorter dissection time [92.00 (74.00, 121.00) min vs 110.00 (92.50, 137.00) min, P=0.017] and a faster resection speed [0.28±0.13 cm²/min vs 0.22±0.11cm²/min, P=0.040] compared to the control group. There were no statistically significant differences between the two groups in terms of hospital stay, cost, en bloc resection rate, R0 resection rate, curative resection rate，bleeding rate, perforation rate, stricture rate, and recurrence rate (P>0.05).

Conclusion

Snare traction-assisted ESD is a safe and efficient approach for the treatment of circumferential superficial esophageal cancer. Its advantages includes shorter procedure so the anesthesia requirement, clear operative filed view, improved mucosal dissection efficiency, simple, and easily accessible equipment.

References

1 Ishihara R, Arima M, Iizuka T et al. Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer. Dig Endosc. 2020; 32: 452-93.
2 Draganov PV, Wang AY, Othman MO, Fukami N. Aga institute clinical practice update: Endoscopic submucosal dissection in the united states. Clin Gastroenterol Hepatol. 2019; 17: 16-25.e1.
3 Zhang W, Zhai Y, Chai N et al. Endoscopic submucosal tunnel dissection and endoscopic submucosal dissection for large superficial esophageal squamous cell neoplasm: Efficacy and safety study to guide future practice. Surg Endosc. 2018; 32: 2814-21.
4 Fukami N. What we want for esd is a second hand! Traction method. Gastrointest Endosc. 2013; 78: 274-6.
5 Jin P, Yu Y, Fu KI, Yu DL, Li AQ, Sheng JQ. A new traction method with use of the snare as a "second hand" during endoscopic submucosal dissection. Endoscopy 2015; 47 Suppl 1 UCTN: E286-7.

Introduction

Endoscopic submucosal dissection is becoming the gold standard for the resection of superficial squamous cell carcinoma. It is unclear whether delaying esophgectomy after endoscopic submucosal dissection is better in terms of mortality and complications than primary esophgectomy in esophageal cancer patients. We compared the long-term outcomes and the complications between these two groups.

Aims & Methods

Between 2003 and 2019, 191 patients underwent primary esophagectomy and 65 patients underwent ESD then delayed esophagectomy. In a matched group of 65 pairs, OS, DSS, and RFS were compared between the 2 groups. The overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS) and postoperative complications were compared between the propensity-matched groups.

Results

In a matched cohort, OS, DSS, and RFS were comparable between the 2 groups. Even though the overall survival of 6 years was 70% versus 80% (p value=0.041) in the primary esophgectomy versus ESD and consequent esophgectomy respectively, DSS was 25% versus 12.5% (p value=0.21). The RFS was 80% versus 98% with p value of 0.06. In terms of recurrence free survival, differentiation, and tumor size were independent factors. When comparing adverse events between two groups there were non 60 day mortality in both groups and significant difference in early complication in the primary surgery group compared to surgery after ESD group. (47.7% versus 15.4%, p=<0.001)

Conclusion

In management for the superficial esophageal cancer, delayed surgery may have advantage in terms of survival, recurrence-free survival and complications.

References

1. Global Burden of Disease Cancer Collaboration; Fitzmaurice C, Dicker D, et al. The global burden of cancer 2013. JAMA Oncol 2015;1:505-27.
2. Steffen T, Dietrich D, Schnider A, et al. Recurrence patterns and longterm results after induction chemotherapy, chemoradiotherapy, and curative surgery in patients with locally advanced esophageal cancer. Ann Surg. Epub 2017 Jul 24.
3. van Hagen P, Hulshof MC, van Lanschot JJ, et al. Preoperative chemoradiotherapy for esophageal or junctional cancer. N Engl J Med 2012;366:2074-84
4. Ra J, Paulson EC, Kucharczuk J, et al. Postoperative mortality after esophagectomy for cancer: development of a preoperative risk prediction model. Ann Surg Oncol 2008;15:1577-84.
5. Chang AC, Ji H, Birkmeyer NJ, et al. Outcomes after transhiatal and transthoracic esophagectomy for cancer. Ann Thorac Surg 2008;85: 424-9.
6. Connors RC, Reuben BC, Neumayer LA, et al. Comparing outcomes after transthoracic and transhiatal esophagectomy: a 5-year prospective cohort of 17,395 patients. J Am Coll Surg 2007;205:735-40.
7. Takahashi H, Arimura Y, Masao H, et al. Endoscopic submucosal dissection is superior to conventional endoscopic resection as a curative treatment for early squamous cell carcinoma of the esophagus (with video). Gastrointest Endosc 2010;72:255-64

Introduction

Endoscopic submucosal dissection (ESD) is now widely used to treat superficial esophageal squamous cell carcinoma (SESCC) that is preoperatively diagnosed as having a negligible risk of lymph node metastasis. SESCC sometimes experiences delays in ESD due to the patient's social background and the treatment of other synchronous cancers, but the effect of these delays has not been well established. In this study, we aimed to elucidate the relationship between the time from initial diagnosis to ESD and the curability in SESCC indicated for ESD.

Aims & Methods

The subjects were lesions diagnosed as SESCC with indication for ESD from January 2017 to December 2021 at our institution; the indication for ESD included lesions diagnosed endoscopically with a depth of cEP/LPM (cancer invading up to the mucosal epithelium and the lamina propia mucosa) or cMM/SM1 (cancer invading up to .2 mm into the submucosa) and confirmed via computed tomography to be absence of lymph nodes and distant metastasis. We compared the curability between lesions treated within three months after initial diagnosis (group A) and those treated after seven months from initial diagnosis (group B) in a retrospective analysis. Curative resection was defined as lesions that histologically confined within the muscularis mucosae, negative vertical margin (VM), with no lymphovascular invasion, while non-curative resection was defined as anything else. High-risk non-curative resection was defined as lesions that histologically reached SM2 (invasion depth into the submucosal layer >.2 mm) or with lymphovascular invasion or VM positive or unclear.

Results

The analysis included 177 patients with 249 lesions in group A and 61 patients with 74 lesions in group B, with no significant differences in gender, age and prior cancer. The median time from initial diagnosis to ESD in group A and B were 1 (interquartile range [IQR], 0-1) and 11 (IQR, 8-14) months, respectively. The rate of lesions treated with chemotherapy, radiation therapy or surgery for concurrent cancer within the period from initial diagnosis to ESD was significantly higher in group B (A vs. B: 4.4% vs 24.3%; p = 0.000). Median lesion size at initial diagnosis was significantly larger in group A (15mm (IQR, 10-25) vs. 10mm (IQR,8-20), p=0.03). The rate of lesions with cEP/LPM at initial diagnosis in group A and B were 83.1% and 93.2%, respectively.
The change in endoscopic tumor size at initial diagnosis and pathologic tumor size after ESD was significantly larger in group B (A vs. B: 1 mm (IQR,0-5) vs. 4 mm (IQR, 0-8), p=0.000), whereas there was no significant difference in the rate of non-curative and high-risk non-curative resection between the two groups for all lesions (A vs. B:16.9% vs. 12.2%; 6.8% vs. 8.5%). In cEP/LPM lesions at initial diagnosis (group A: 207, group B: 69), there was also no significant difference in the rate of non-curative and high-risk non-curative resection ( A vs. B: 8.2% vs. 5.8%; 6.8% vs. 5.8%). In cMM/SM1 lesions at initial diagnosis　(group A: 42, group B: 5), the rate of non-curative resection tended to be higher in group B (A vs. B: 59.5% vs 100%, p=0.143), and high-risk non-curative resection was significantly higher (A vs. B: 50% vs 100%, p=0.0429).

Conclusion

Our study suggested that delayed ESD did not significantly impact curability for cEP/LPM SESCC, whereas it reduced curability for cMM/SM1 lesions. ESD for SESCC can be delayed due to social factors and the management of other synchronous cancers; however, prompt treatment is important for cMM/SM1 lesions, while a delay might be acceptable for cEP/LPM lesions.

Introduction

Endoscopic submucosal dissection (ESD) is the preferred treatment for superficial esophageal squamous cell carcinoma (ESCC). However, curative resection is not always achievable for all patients¹. Currently, the curability criteria was inconsistent among different societies^2-3 and may be overly stringent for suggesting additional treatments⁴, which causes dilemmas in clinical decision-making and potential overtreatments in some low-risk cases.

Aims & Methods

The research aim was to develop and validate a risk scoring system to assess curability after ESD for superficial ESCC. This study was based on a nationwide cohort, the China Early Esophageal Cancer Cohort, and all patients were follow-up at least for 3 years. Patients with superficial ESCC undergoing ESD were included, and those with positive horizontal margin, adjuvant chemoradiotherapy, and metachronous esophegeal cance after ESD were excluded. The primary outcome was noncurative resection, defined as either (1) pathological confirmation of residual tumor or lymph node metastasis (LNM) after additional surgery, or (2) identification of local recurrence, LNM, or distant metastasis during follow-up. Data from South and North China were used to develop and validate the scoring system, respectively. Logistic regression analysis was used for model construction, and Kaplan-Meier survival estimates, the C-statistic, and decision curve analysis were employed for performance evaluation.

Results

A total of 1,273 patients with superficial ESCC were included, with 995 for model development and 278 for validation. Multivariable analysis identified 6 independent risk factors for noncurative resection: tumor size ≥30 mm, submucosa invasion, positive vertical margin, lymphatic invasion, vascular invasion, and poor differentiation. For the risk scoring system (ESCC-eCura), lymphatic invasion was assigned as 2 points, and others were assigned as 1 point. In the development cohort, the non-curative resection rates of the low- (≤1 point), intermediate- (2 to 3 points), and high-risk (≥4 points) groups was 4.5%, 16.3%, and 75.0%, respectively. The ESCC-eCura demonstrated a C-statistic of 0.75 (95% condifence interval [CI], 0.69 - 0.81). In the validation cohort, the C-statistic was 0.84 (95% CI, 0.73-0.95), and intermediate- or high-risk groups were significant predictors for subsequent recurrence (hazard ratio [HR] for intermediate-risk group 14.35, 95% CI 4.01-51.35, P<0.001; HR for high-risk group 28.16, 95% CI 4.90-161.83, P<0.001; all compared with the low-risk group). Decision curve analysis also showed acceptable clinical benefits and utility.

Conclusion

This ESCC-eCura scoring system can predict non-curative resection after ESD for superficial ESCC, which offers a practical tool for individualized management. Additiomal treatments should be recommended for patients in ESCC-eCura intermediate- or high-risk groups, while follow-up may be acceptable for the low-risk group.

References

1.Jiang, H., et al., Risk and Pathological Factors of Recurrence after Endoscopic Resection for Superficial Esophageal Squamous Cell Carcinoma: A Systematic Review and Meta-analysis. Gastrointest Endosc, 2024.
2. Kitagawa, Y., et al., Esophageal cancer practice guidelines 2022 edited by the Japan esophageal society: part 1. Esophagus, 2023. 20(3): p. 343-372.
3. Pimentel-Nunes, P., et al., Endoscopic submucosal dissection for superficial gastrointestinal lesions: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022. Endoscopy, 2022. 54(6): p. 591-622.
4.Liu, Z., et al., Additional Esophagectomy Following Noncurative Endoscopic Resection for Early Esophageal Squamous Cell Carcinoma: A Multicenter Retrospective Study. Ann Surg Oncol, 2021. 28(12): p. 7149-7159.

Disclosure

Nothing to disclose.

Introduction

Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) with esophageal varices (EVs) is one of the most challenging endoscopic procedures due to the high risk of bleeding and fibrosis caused by prior treatment of varices. However, due to the small number of such cases, the clinical outcomes of ESD for ESCC with EVs have been reported in only a limited number of cases at single centers^​1-3.

Aims & Methods

We conducted a multicenter, retrospective, cohort study to clarify the safety and efficacy of ESD for ESCC with EVs.Eleven institutions in the Tohoku region of Japan participated in this multicenter, collaborative, retrospective study. We performed endoscopic resection for 3619 patients with esophageal carcinoma at the participating institutions during the period from January 2010 to April 2022. Among those, 30 patients who underwent ESD for ESCC with EVs were recruited for the present study.
Rates of en bloc resection and R0 resection, procedure time and adverse events were evaluated as indicators of the feasibility and safety of ESD. Additional treatment, recurrence and metastasis of the lesions were evaluated as indicators of the long-term efficacy of ESD.

Results

Portal hypertension was caused by cirrhosis, of which alcohol was the most common cause. En bloc resection was achieved in 93.3% and R0 resection in 80.0% of the patients. The median procedure time was 92 minutes. Adverse events included a case of uncontrolled intraoperative bleeding leading to discontinuation of ESD and a case of esophageal stricture due to extensive resection. During the follow-up period of a median for 42 months, a patient with local recurrence and another patient with liver metastasis were observed. One patient died of liver failure after receiving chemoradiotherapy as an additional treatment after ESD. No patient died of ESCC.

Conclusion

This multicenter, retrospective cohort study demonstrated the safety and efficacy of ESD for ESCC with EVs. Further studies are needed to establish appropriate treatment methods for EVs before ESD and additional treatments for patients with insufficient ESD.

References

1. Sawaguchi M, Jin M, Matsuhashi T, et al. The feasibility of endoscopic submucosal dissection for superficial esophageal cancer in patients with cirrhosis (with video). Gastrointest Endosc 2014;79:681-5.
2. Choi YK, Noh JH, Kim DH, et al. Outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms in patients with liver cirrhosis. Clin Endosc 2022;55:381-9.
3. Zhang S, Liu YD, Chai NL, et al. Endoscopic submucosal dissection for early cancers or precancerous lesions of the upper gastrointestinal tract in cirrhotic patients with esophagogastric varices: Ten-year experience from a large tertiary center in China. Gastrointest Endosc 2023 Online ahead of print.

Disclosure

The authors declare that they have no conflicts of interest.