Superficial Esophageal Lesions Research Articles

A novel strategy for performing endoscopic submucosal dissection for circumferential superficial esophageal neoplastic lesions with kissing traction.

A novel strategy for performing endoscopic submucosal dissection for circumferential superficial esophageal neoplastic lesions with kissing traction.

Implementation of esophageal endoscopic submucosal dissection in Spain: Results from the nationwide registry

Introduction and aimsThe outcomes of endoscopic submucosal dissection (ESD) in the esophagus have not been assessed in our country. Our primary aim was to analyze the effectiveness and safety of the technique. Material and methodsAnalysis of the prospectively maintained national registry of ESD. We included all superficial esophageal lesions removed by ESD in 17 hospitals (20 endoscopists) between January 2016 and December 2021. Subepithelial lesions were excluded. The primary outcome was curative resection. We conducted a survival analysis and used logistic regression analysis to assess predictors of non-curative resection. ResultsA total of 102 ESD were performed on 96 patients. The technical success rate was 100% and the percentage of en-bloc resection was 98%. The percentage of R0 and curative resection was 77.5% (n = 79; 95% CI: 68%–84%) and 63.7% (n = 65; 95% CI: 54%–72%), respectively. The most frequent histology was Barrett-related neoplasia (n = 55 [53.9%]). The main reason for non-curative resection was deep submucosal invasion (n = 25). The centers with a lower volume of ESD obtained worse results in terms of curative resection. The rate of perforation, delayed bleeding and post-procedural stenosis were 5%, 5% and 15.7%, respectively. No patient died or required surgery due to an adverse effect. After a median follow-up of 14 months, 20 patients (20.8%) underwent surgery and/or chemoradiotherapy, and 9 patients died (mortality 9.4%). ConclusionsIn Spain, esophageal ESD is curative in approximately two out of three patients, with an acceptable risk of adverse events.

A novel risk score model of esophageal stricture for patients undergoing endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) is a promising technique for superficial esophageal lesions. However, stricture is a frequent adverse complication. This study was performed to develop a precise and convenient score prediction model for esophageal strictures after ESD, and compare its efficacy with a previously published predictive model. This study enrolled clinical data of patients who underwent esophageal ESD for superficial esophageal lesions. Possible risk factors for esophageal stricture were identified by univariate and multivariate logistic regression analysis. Then we developed a prediction model according to the Framingham system for the first time and presented a convenient table containing the risk probability for each patient. In addition, we validated our score model and the previously published model in our center. A total of 838 patients were enrolled in this study and 6 variables, including age, surgery time, location of the lesion, circumference of the lesion, longitudinal resection length, and depth of infiltration were comprised in the score model. The total score ranged from 0 to 16 points and the risk probability was presented in one concise table for each patient. Areas under receiver-operator characteristic curves for the prediction model were 0.715 in derivation group and 0.804 in validation group. We designed and validated a prediction score model for esophageal stricture after ESD, which can be applied conveniently to stratify the stricture risk after esophageal ESD and may facilitate appropriate clinical decision-making for these patients.

Efficacy and safety of modified endoscopic submucosal tunnel dissection for superficial esophageal circumferential lesions.

To evaluate the efficacy and safety of intra-tunnel dissection using hemostatic forceps and needle-type device for patients with esophageal circumferential lesions (ECLs). Patients with ECLs were enrolled in the study and underwent endoscopic submucosal tunnel dissection (ESTD) or hemostatic forceps-based ESTD (ESFTD). All patients were divided into three subgroups according to longitudinal length of the lesions (LLLs): >8 cm, 4-8 cm and < 4 cm. The clinical data such as gender, age, length of lesions and operating time were collected. A total of 152 patients were included in this study and comprised 80 cases of ESFTD and 72 cases of ESTD. The procedure time was markedly shorter in the ESFTD group than in the ESTD group (P < 0.001). Moreover, ESFTD significantly increased the rate of complete resection and reduced specimen injury in LLLs >8 cm and 4-8 cm subgroup compared with ESTD (P < 0.001), but not in <4 cm subgroup (P > 0.05). The perforation and infection rate were similar in ESFTD and ESTD group (P > 0.05). However, ESFTD effectively decreased the muscular injury rate' the duration of chest pain and the time from endoscopic surgery to first occurrence of esophageal stenosis compared with ESTD group (P < 0.01). ESFTD has better efficacy and safety than ESTD in the treatment of ECLs, especially for large lesions. ESFTD could be recommended for patients with ECLs.

Implementación de la disección endoscópica submucosa esofágica en España: resultados del registro nacional

Introduction and aimsThe outcomes of endoscopic submucosal dissection (ESD) in the esophagus have not been assessed in our country. Our primary aim was to analyze the effectiveness and safety of the technique. Material and methodsAnalysis of the prospectively maintained national registry of ESD. We included all superficial esophageal lesions removed by ESD in 17 hospitals (20 endoscopists) between January 2016 and December 2021. Subepithelial lesions were excluded. The primary outcome was curative resection. We conducted a survival analysis and used logistic regression analysis to assess predictors of non-curative resection. ResultsA total of 102 ESD were performed on 96 patients. The technical success rate was 100% and the percentage of en-bloc resection was 98%. The percentage of R0 and curative resection was 77.5% (n=79; 95%CI: 68%-84%) and 63.7% (n=65; 95%CI: 54%-72%), respectively. The most frequent histology was Barrett-related neoplasia (n=55 [53.9%]). The main reason for non-curative resection was deep submucosal invasion (n=25). The centers with a lower volume of ESD obtained worse results in terms of curative resection. The rate of perforation, delayed bleeding and post-procedural stenosis were 5%, 5% and 15.7%, respectively. No patient died or required surgery due to an adverse effect. After a median follow-up of 14months, 20patients (20.8%) underwent surgery and/or chemoradiotherapy, and 9 patients died (mortality 9.4%). ConclusionsIn Spain, esophageal ESD is curative in approximately two out of three patients, with an acceptable risk of adverse events.

Esophageal Mucosal Autograft for Preventing Stricture After Widespread Endoscopic Submucosal Dissection of Superficial Esophageal Lesions.

Although esophageal mucosal autograft prevents esophageal stricture after widespread endoscopic submucosal dissec- tion and has been reported as a new technique, it is relatively unproven in clinical practice. This prospective study was conducted to evaluate our experience using esophageal mucosal autograft to prevent strictures after widespread endoscopic submucosal dissection in patients with widespread superficial esophageal lesions. Between October 2017 and June 2018, 15 patients with widespread superficial esophageal lesions were consecutively treated with widespread endoscopic submucosal dissection and then underwent esophageal mucosal autograft. The main outcomes measured included esophageal epithelialization and esophageal stricture. The median longitudinal diameter of the widespread superficial esophageal lesions was 5.2 cm. All 15 patients were success- fully treated with widespread endoscopic submucosal dissection and esophageal mucosal autograft, and the median procedural time was 182 minutes. During follow-up (median, 23 months), esophageal epithelialization was found in 13 patients (86.7%), and 7 patients experienced esophageal stricture (46.7%). In those 7 patients, the esophageal strictures were successfully relieved after endoscopic bal- loon dilation or endoscopic radial incision. No complications related to endoscopic balloon dilation/endoscopic radial incision occurred. Additionally, local recurrence was found in 1 patient with poorly differentiated squamous cell carcinoma, and further surgical resection was performed. Esophageal mucosal autograft appears to be an efficient approach to reconstructing local esophageal epithelium and might have a potential role in preventing esophageal stricture after widespread endoscopic submucosal dissection. However, as a new technique, it needs more improvement to enhance its role in preventing esophageal stricture after widespread endoscopic submucosal dissection.

Muscular injury was identified the risk factor of post-operative stenosis after large area but non-circumferential esophageal endoscopic submucosal dissection

Background The incidence of post-operative stenosis after esophageal Endoscopic Submucosal Dissection (ESD) ranks high. This study aimed to investigate the association between the degree of muscular injury and the incidence of post-operative stenosis. Research design This was a retrospective study of 133 patients with superficial esophageal lesions treated by non-circumferential ESD enrolled between January 2016 and May 2021 at two endoscopy centers. Demographic and clinical parameters were analyzed. A novel muscular injury classification system was proposed. Stenosis risk factors were identified using multivariate logistic regression. The association between the different degrees of muscular injury and the incidence of post-operative stenosis was investigated further by propensity score matching (PSM). Results There were 133 cases evaluated in this study, 33 of which developed stenosis. Multivariate analysis suggested lesions located in the upper 1/3 of the esophagus, resections >5/6 of the circumference, and muscular injury (Grade 3 or 4 according to our proposed classification) were risk factors for stenosis. Correlation analysis suggested a positive association between the degree of muscular injury and the incidence of post-operative stenosis (r = 0.408, p < .05). For PSM, 29 stenosis cases were matched and univariate analysis further corroborated that muscular injuries of grade 3 (OR = 6.429, 95%CI = 1.318–31.367, p = .021) or 4 (OR = 7, 95%CI = 1.068–45.901, p = .043) were risk factors for stenosis. Conclusion Grade 3–4 muscular injury was identified as a risk factor of post-operative stenosis.

Use of a convolutional neural network for classifying microvessels of superficial esophageal squamous cell carcinomas.

The morphological diagnosis of microvessels on the surface of superficial esophageal squamous cell carcinomas using magnifying endoscopy with narrow-band imaging is widely used in clinical practice. Nevertheless, inconsistency, even among experts, remains a problem. We constructed a convolutional neural network-based computer-aided diagnosis system to classify the microvessels of superficial esophageal squamous cell carcinomas and evaluated its diagnostic performance. In this retrospective study, a cropped magnifying endoscopy with narrow-band images from superficial esophageal squamous cell carcinoma lesions was used as the dataset. All images were assessed by three experts, and classified into three classes, Type B1, B2, and B3, based on the Japan Esophagus Society classification. The dataset was divided into training and validation datasets. A convolutional neural network model (ResNeXt-101) was trained and tuned with the training dataset. To evaluate diagnostic accuracy, the validation dataset was assessed by the computer-aided diagnosis system and eight endoscopists. In total, 1777 and 747 cropped images (total, 393 lesions) were included in the training and validation datasets, respectively. The diagnosis system took 20.3s to evaluate the 747 images in the validation dataset. The microvessel classification accuracy of the computer-aided diagnosis system was 84.2%, which was higher than the average of the eight endoscopists (77.8%, P<0.001). The area under the receiver operating characteristic curves for diagnosing Type B1, B2, and B3 vessels were 0.969, 0.948, and 0.973, respectively. The computer-aided diagnosis system showed remarkable performance in the classification of microvessels on superficial esophageal squamous cell carcinomas.

Efficacy and safety of endoscopic submucosal tunnel dissection vs endoscopic submucosal dissection for early superficial upper gastrointestinal precancerous lesions and tumors: A meta-analysis.

Endoscopic submucosal tunnel dissection (ESTD) is a new treatment for superficial upper gastrointestinal precancerous lesions and tumors. However, its safety and efficacy for treating these lesions is still uncertain. This meta-analysis aimed to compare the efficacy and safety of ESTD with those of endoscopic submucosal dissection (ESD) in treating early superficial upper gastrointestinal precancerous lesions and tumors. Electronic databases, including EMBASE, PubMed, Cochrane Library and the Web of Science, were systematically searched for articles published up to 1 April 2020. The primary outcomes were complete and en bloc resection rates of the lesions. The secondary outcomes included operation time, speed of dissection, complication and recurrence rates. The Newcastle-Ottawa quality assessment scale was used to evaluate the quality of the studies. Seven studies were included in the final meta-analysis. The complete and en bloc resection rates of early superficial esophageal lesions as well as the en bloc resection rate of early superficial gastric lesions were similar between the ESTD and ESD groups. Compared with the ESD group, the ESTD group had a higher en bloc resection rate for early superficial gastric lesions. A faster dissection speed was observed in both superficial esophageal and gastric lesions. In gastric lesions, the operation time of the ESTD group was shorter than that of the ESD group, while it did not differ for esophageal lesions. There were no obvious differences in bleeding and perforation rates between the groups. As an endoscopic technique for treating early superficial upper gastrointestinal lesions, ESTD is as safe as and more effective than ESD, especially for gastric lesions.

Efficacy of endoscopic submucosal tunnel dissection versus endoscopic submucosal dissection for superficial esophageal neoplastic lesions: a systematic review and meta-analysis.

To evaluate the effectiveness of endoscopic submucosal tunnel dissection (ESTD) and endoscopic submucosal dissection (ESD) in superficial esophageal neoplastic lesions (SENL). A comprehensive search for studies investigating the efficacy of ESTD and ESD for SENL was conducted to search for relevant studies through PubMed, Web of Science, Cochrane Library, SinoMed, CNKI, and Wanfang.Weighted pooled rates were calculated for en bloc resection rate, R0 resection rate, operation time, dissection area, dissection speed, and adverse events. The 95% confidence intervals (95%CI) for effect size were used to calculate the pooled value using the fixed- or random-effects model. A total of seventeen studies with 1161 patients were identified and included in the meta-analysis.The pooled analysis showed that ESTD had significantly higher en bloc resection (OR 3.98; 95% CI 1.74 to 9.12; p = 0.001) and R0 resection rates (OR 2.29; 95% CI 1.54 to 3.46; p < 0.001) than ESD.The operation time in the ESTD group was shorter than that in the ESD group (SMD = -0.57; 95% CI -0.95 to -0.19; p = 0.003). The dissection area of the ESTD group was larger than that in the ESD group (SMD = 0.49; 95% CI 0.16 to 0.83; p = 0.004), and the dissection speed is faster than that in the ESD group (SMD = 1.52; 95%CI 1.09 to 0.83; p < 0.001). There were no significant differences in esophageal stenosis (p = 0.94) between the two techniques. However, ESTD was superior to ESD in other adverse events (p < 0.05). ESTD has a significant advantage over ESD in the treatment of SENL. ESTD has significantly higher en bloc and R0 resection rates and reduced adverse events.

Sa1298 ENDOSCOPIC SUBMUCOSAL DISSECTION VERSUS ESOPHAGECTOMY FOR THE TREATMENT OF SUPERFICIAL ESOPHAGEAL LESIONS: A RETROSPECTIVE COMPARATIVE ANALYSIS

Dysplastic lesions associated with Barrett’s esophagus are commonly treated with endoscopic mucosal resection (EMR). Lesions refractory to EMR or with positive margins for intramucosal adenocarcinoma are commonly referred for esophagectomy. While typically curative, esophagectomy is associated with significant complications and morbidity. More recently, endoscopic submucosal dissection (ESD) has emerged as a recognized modality for dysplastic Barretts esophagus and non invasive adenocarcinoma, with high curative resection rates and low risks of complications. The aim of this study is to evaluate the comparative effectiveness of ESD versus esophagectomy for dysplastic Barrett’s esophageal lesions and non-invasive adenocarcinoma. This was a single-center retrospective study of adult patients that underwent ESD and surgical esophagectomy for the treatment of superficial esophageal lesions. Using the TNM staging classification, only T1aM0N0 lesions were included to ensure lesions were amenable to both treatment strategies. Baseline data was collected for age, gender, size of lesion, prior EMR, procedure times, and pathology. Cases with invasive cancers were excluded from the final analysis. Primary outcomes were procedure-associated adverse events and evidence of local recurrence. Secondary outcomes included adverse events and recurrence rates. Statistical analyses were performed using Student’s t-test or Fisher’s exact test with statistical significance defined as P<0.05. A total of 17 patients underwent ESD with 34 patients undergoing surgical esophagectomy at our institution. Baseline patient, lesion, and procedure characteristics are summarized in Table 1. Mean age, gender, and histologic pathology was not difference between ESD and esophagectomy. For ESD, en-bloc resection was achieved in 100% of patients with 4 (23.53%) patients having undergone previous resection attempts or treatment with radiofrequency ablation. A majority of patients in the esophagectomy group (71.88%) underwent minimally invasive Ivor Lewis procedures, with the other patients undergoing transhiatal (18.75%) or three-hole (9.38%) surgeries. Esophagectomy resulted in significantly longer hospitalization [8.58 ±6.25 vs 0.00 ±0.00; P<0.001] with more procedure-associated adverse events [61.76% vs 11.76%; P<0.001]. Post-procedure esophageal stricture formation was also higher for the esophagectomy group [41.18% vs 11.76%; P<0.050]. Both ESD and esophagectomy were curative with no cases of local recurrence in either group. In this retrospective study of dysplastic Barrett’s and T1aM0N0 esophageal lesions, ESD was associated with comparable curative resection rates to esophagectomy however with shorter length of hospital stay, fewer procedure related adverse events and less stricture formation.

Photodynamic Therapy for Gastrointestinal Cancer.

The clinical application of photodynamic therapy (PDT) for gastrointestinal (GI) neoplastic lesions has been developed with appreciation for the great efforts and kind support of Dr. Tom Dougherty and his followers' contributions. There are several published studies on clinical PDT in the field of GI oncology. Esophageal cancer was one of the first clinical indications for PDT that was approved as an endoscopic procedure in both the United States and Japan. PDT was initially used as a palliative local treatment for patients with obstructive esophageal cancer. PDT is also indicated for eradicative therapy for dysplastic Barret's esophagus, which is the precursor state of esophageal adenocarcinoma, with the support of level one evidence. In Japan, PDT was approved as a curative treatment for superficial esophageal carcinoma lesions, which are difficult to treat with endoscopic resection. Further, PDT using second-generation photosensitizers is approved for early local failure after radiotherapy, for which treatment with other modalities is difficult. PDT has also been assessed in other GI cancers, including gastric cancer, biliary cancer and pancreatic cancer. In this review, we overview the history and state of PDT for GI cancer.

Irregularly branched microvessels as visualized by magnifying endoscopy: a reliable marker for predicting deep submucosal invasion of superficial esophageal squamous cell carcinoma.

Background and study aims Magnifying endoscopy with narrow-band imaging (M-NBI) is reported to be useful in diagnosing invasion depth of superficial esophageal squamous cell carcinoma (SCC), but accurate diagnosis of deep submucosal invasion (SM2) has remained difficult. However, we discovered that irregularly branched microvessels observed with M-NBI are detected in SM2 cancers with high prevalence. Thus, this retrospective study aimed to investigate the diagnostic performance of irregularly branched microvessels as visualized by M-NBI for predicting SM2 cancers. Patients and methods Patients with superficial esophageal SCC lesions that were endoscopically or surgically resected at our hospital between September 2005 and December 2014 were included. Endoscopic findings by M-NBI of these lesions were presented to an experienced endoscopist who was unaware of the histopathological diagnosis and who then judged whether irregularly branched microvessels were present. Using the invasion depth according to postoperative histopathological diagnosis as the gold standard, we determined the diagnostic performance of the presence of irregularly branched microvessels as an indicator for SM2 cancers. Results A total of 302 superficial esophageal SCC lesions (228 patients) were included in the analysis. When irregularly branched microvessels were used as an indicator of SM2 cancers, the diagnostic accuracy was 94.0 % (95 % confidence interval [CI]: 91.1–96.1 %), sensitivity was 79.4 % (95 % CI: 66.6–88.4 %), specificity was 95.9 % (95 % CI: 94.3–97.0 %), positive predictive value was 71.1 % (95 % CI: 59.6–79.1 %), and negative predictive value was 97.3 % (95% CI: 95.7–98.5 %). Conclusions Irregularly branched microvessels may be a reliable M-NBI indicator for the diagnosis of cancers with deep submucosal invasion.

Efficacy and safety of endoscopic submucosal tunnel dissection for superficial esophageal neoplastic lesions: a systematic review and meta-analysis

BackgroundPresently, endoscopic submucosal tunnel dissection (ESTD) has been a novel therapy for superficial esophageal neoplastic lesions (SENL), especially for circumferential neoplastic lesions. A number of studies have reported the clinical application of ESTD with promising outcomes. Therefore, we conducted a systematic review and meta-analysis to evaluated the efficacy and safety of ESTD for SENL .MethodsFrom 2013 to November 2018, Pubmed, Embase and Cochrane databases were searched to determine studies reporting ESTD treatment of SENL. Weighted pooled rates (WPR) were calculated for en bloc resection, R0 resection and complication of ESTD. Risk ratios (RR) were calculated and pooled to compare the clinical outcomes of ESTD with ESD for SENL.ResultsA total of 9 studies involving 494 patients with 518 esophageal neoplastic lesions were included in our study. WPR for en bloc resection and R0 resection of ESTD was 97.0% (95% CI: 94.7–98.3%) and 84.1% (95% CI: 80.5–87.1%), respectively. WPR for complication was 40.0% (95% CI: 25.8–56.1%). Two studies with 265 patients compared the performance of ESTD with ESD. Pooled RR for en bloc resection and R0 resection was 1.04 (95% CI: 0.95–1.14, P = 0.42) and 1.01 (95% CI: 0.93–1.10, P = 0.73), respectively. Pooled RR for complication was 0.68 (95% CI: 0.46–1.01, P = 0.05).ConclusionOur study showed that ESTD is effective for treating SENL with high en bloc resection rate and R0 resection rate, but accompanying by a relatively high complications.

Endoscopic submucosal tunnel dissection for superficial esophageal neoplastic lesions: a meta-analysis.

The emerging endoscopic submucosal tunnel dissection (ESTD) is becoming an alternative method for superficial esophageal neoplastic lesions. This study aimed to evaluate the effectiveness and feasibility of ESTD for superficial esophageal neoplastic lesions. A comprehensive literature review was conducted to search relevant studies through PubMed, EMBASE, Cochrane Library, and Web of Science before 1 December 2018. Studies relating to ESTD for superficial esophageal neoplastic lesions were included. Rates of effectiveness (en bloc resection rate, R0 resection rate, and curative resection rate), rates of feasibility (muscular damage rate, perforation rate, postprocedural bleeding rate, and emphysema rate), and rates of follow-up (recurrence rate and stricture rate) were pooled and analyzed. Forest plots were constructed based on the random-effects model. Sensitivity analyses were also performed if significant heterogeneity existed. Six studies including 414 patients and 436 superficial esophageal neoplastic lesions that underwent ESTD were available for analysis. The pooled estimates of en bloc resection rate, R0 resection rate, and curative resection rate were 98% (95% CI 95.8-99.0%), 87.0% (95% CI 78.2-92.5%), and 87.6% (95% CI 67.4-96.0%), respectively. The pooled outcomes of muscular damage rate, perforation rate, postprocedural bleeding rate and emphysema rate were 19.1% (95% CI 9.8-33.8%), 2.2% (95% CI 1.1-4.1%), 1.6% (95% CI 0.7-3.5%), and 12.2% (95% CI 4.3-29.9%), respectively. Finally, the pooled results of recurrence and stricture were 4.7% (0.9-20.5%) and 20.9% (11.3-35.2%), respectively. ESTD appears to be an effective and feasible approach for treating superficial esophageal neoplastic lesions. However, future research is needed for new and comprehensive methods to decrease the stricture rate after ESTD.

1065 ENDOSCOPIC SUBMUCOSAL TUNNEL DISSECTION (ESTD) FOR 17-CM SUPERFICIAL SPREADING ESOPHAGEAL CANCER AND POLYGLYCOLIC ACID (PGA) COATED STENT

Endoscopic submucosal tunnel dissection (ESTD) is generally indicated to superficial esophageal neoplastic lesions less than one-third of the esophageal circumference due to the concerns of esophageal stricture. Fully-covered self-expandable stent and steroid injection have been conventional preventive methods for esophageal stricture. Recently, an esophageal stent coated with polyglycolic acid (PGA) sheet is emerging for the promising options to prevent the esophageal stricture. Here, we report the unusual case of a 17 cm-long and 360-degree circumferential ESTD for esophageal cancer and PGA sheet-coated esophageal stents placement to prevent the esophageal stricture.

Endoscopic Submucosal Single- or Multi-tunnel Dissection for Near-Circumferential and Circumferential Superficial Esophageal Neoplastic Lesions.

This study reports the outcomes of endoscopic submucosal single-tunnel dissection or endoscopic submucosal multi-tunnel dissection for the treatment of esophageal neoplastic lesions of at least three-quarters of the esophageal circumference, including circumferential superficial esophageal neoplastic lesions. From July 2014 to February 2018, a total of 124 lesions underwent endoscopic submucosal tunnel dissection at our hospital. One to four submucosal tunnels were created in the oral to anal direction. Of the 124 lesions, there were 83 noncomplete circumferential lesions and 41 circumferential lesions. Endoscopic submucosal single-tunnel dissection was performed in 54 patients, two-tunnel dissection in 43 patients, three-tunnel dissection in 19 patients, and four-tunnel dissection in 8 patients. The mean dissection speed was 22.8 ± 12.7 mm2/min. En bloc dissection was achieved in all lesions, and the R0 resection rate was 70.2 percent. No matter how large the lesion area was, there were no significant differences in the dissection speed and the R0 resection rate when lesions were at least three-quarters of the esophageal circumference. Esophageal stricture was observed in 54 patients and was relieved by placement of a retrievable metal stent or by endoscopic water balloon dilation. No recurrence was noted after 19.1 ± 12.4 months of follow-up. Our large sample size study showed that endoscopic submucosal tunnel dissection showed effectiveness and safety for the treatment of large superficial esophageal neoplastic lesions at least three-quarters of the esophageal circumference, including circumferential superficial esophageal neoplastic lesions.

POEM and Submucosal Tunneling.

Submucosal endoscopy has introduced new and important aspects into gastrointestinal endoscopic therapeutics by opening the way to interventions even outside of the GI tract. At present, innovative techniques for submucosal endoscopy in different esophageal diseases include peroral endoscopic myotomy (POEM) for idiopathic achalasia and related motility disorders, submucosal tunneling endoscopic resection (STER) for submucosal tumors arising from the muscularis propria, and endoscopic submucosal tunneling dissection (ESTD) for superficial esophageal neoplastic lesions. POEM for achalasia-still a rare disease-is currently evaluated in comparison to endoscopic and surgical standard therapies, while this procedure enabling a long thoracic myotomy might constitute an advantage over the laparoscopic approach in treatments of spastic esophageal diseases. Removal of smaller submucosal esophageal tumors may appear tempting, but the clinical indications are limited by the facts that the vast majority of such smaller tumors are asymptomatic and benign.For all these innovative and technically demanding techniques, learning curves have to be taken into account, not only with regard to technical competence but also to clinical assessment, ranging from proper indication and patient selection to the management of (potential) complications and logistics/back-up. Although preliminary results from high-skilled endoscopic centers have been very encouraging, long-term data as well as prospective randomized controlled trials are needed to validate the efficacy and safety of the modalities.

The intrapapillary capillary loop (IPCL) changes in superficial esophageal lesions.

The aims of this study were to investigate intrapapillary capillary loops (IPCLs) of superficial esophageal lesions changes in different types classified by the Japan Esophageal Society classification. The calibers, areas, and densities of IPCLs were detected in 34 cases of esophageal lesions using immunohistochemical analysis. Statistically significant differences in calibers, areas, and densities of IPCLs were observed between type A, type B1/B2, and type B3 area (P < 0.001). In conclusion, the results of this observation showed the Japan Esophageal Society classification of IPCL would help endoscopists to diagnose the type and the invasion depth of lesion in esophagus, and decide the treatment strategy.

Endoscopic submucosal multi-tunnel dissection for circumferential superficial esophageal neoplastic lesions (with videos)

Endoscopic submucosal tunnel dissection (ESTD) has been used for dissection of large esophageal neoplastic lesions, but there are still some technical problems in treating circumferential superficial esophageal neoplastic lesions. This study aimed to assess the efficacy and safety of endoscopic submucosal multi-tunnel dissection (ESMTD) for circumferential superficial esophageal neoplastic lesions in selected patients followed up for 1 to 12 months. From July 2014 to February 2015, the first series of 7 consecutive patients with circumferential superficial esophageal neoplastic lesions underwent ESMTD at our endoscopic center. The macroscopic types were classified according to the Paris endoscopic classification of superficial neoplastic lesions. The average length of lesions was 6.1 cm in 7 selected patients. The operative time ranged from 69 to 169 minutes (mean 121 minutes). En bloc dissection with negative basal margins was achieved in all lesions without serious intraoperative adverse events. Esophageal stricture was observed in all patients 1 to 3 months after the operation and was relieved after a retrievable metal stent was placed or esophageal water balloon dilatation was performed; however, one patient died of cerebral infarction 2 months after ESMTD. ESMTD is feasible, safe, and effective for the treatment of circumferential superficial esophageal neoplastic lesions in select patients.