Endoscopic submucosal dissection/endoscopic mucosal resection guidelines for esophageal cancer

Clinical backgrounds and outcomes of patients with Barrett's esophageal adenocarcinoma treated via endoscopic submucosal dissection in Kyushu, Japan: A retrospective multicenter cohort study

Objectives

Most esophageal cancers in Japan are squamous cell carcinomas; however, there has been some concern regarding a recent increase in Barrett's esophageal adenocarcinoma (BEA). This study aimed to clarify the clinical characteristics and outcomes of patients treated via endoscopic submucosal dissection (ESD) in Kyushu, including changes over time.

Methods

This multicenter, retrospective, observational study was conducted among 21 institutes situated in Kyushu. Data from patients who underwent ESD for BEA or esophageal squamous cell carcinoma between January 2010 and December 2023 were extracted from the pathology database and reviewed.

Results

The total number of esophageal ESD cases increased from 2299 over the first 7 years to 4009 over the second seven. The incidence of BEA increased from 3.6% (86/2299) over the earlier period to 4.7% (197/4009; p = 0.034) over the latter. We analyzed data from 283 patients (287 lesions). Smaller tumor-sized lesions were detected over the latter period (14.2 ± 11.6 vs. 11.2 ± 9.5 cm2, p = 0.022), significantly reducing treatment times (122.1 ± 81.2 vs. 93.2 ± 53.3 min p < 0.001). The procedure was safe, with low incidence rates, over both the earlier and later periods (respectively), of perforation (0% vs. 1.0%), delayed bleeding (1.2% vs. 2.0%), and pneumonia (4.7% vs. 4.6%).

Conclusion

The proportion of esophageal ESD procedures to treat BEA has increased in Japan's Kyushu region. This procedure has a comparable safety profile to similar ESD procedures used to treat other conditions.

Esophageal ESD Training; Perspective of West vs. East

PURPOSE OF REVIEW: Esophageal cancer is one of the most common cancers in the world and carries a poor prognosis. While esophagectomy poses considerable mortality and morbidity risks, endoscopic resection can provide a safer and less invasive alternative. RECENT FINDINGS: Endoscopic resection therapy has allowed a less invasive approach with comparable outcomes to esophagectomy. EMR is considered safe and requires less intensive training, yet it does not offer complete histopathological assessment due to the nature of piecemeal resection for larger lesions. Alternatively, ESD offers an R0 resection, therefore allowing precise histopathological evaluation. Training in ESD is essential; however, a uniform training model has not been agreed upon. The Japanese apprenticeship training model has proven effective, with promising training outcomes from the Eastern experience. In the West, a comprehensive training model through a combination of apprenticeship with progressive exposure, including ex-vivo and live animal hands-on training, could be the optimal approach. Different methods of ESD training are currently available, all of which aim to provide the experience needed to perform safe ESD. Despite the differences in training styles between the East and the West, a modified apprenticeship model could potentially result in more effective and better training outcomes. The currently available technologies provide the environment to enhance ESD training.

Esophageal mucosal auto-transplantation versus acellular dermal matrix transplantation for preventing esophageal stenosis after endoscopic resection in patients with superficial esophageal mucosal lesions

BACKGROUND

Esophageal stricture is the principal complication associated with endoscopic resection (ER) in patients with superficial esophageal cancer (SEC), and medical intervention may be required to prevent esophageal stricture after ER. The aim of this study was to compare acellular dermal matrix (ADM) transplantation and esophageal mucosal autograft (EMA) transplantation in terms of efficacy in preventing esophageal stricture after ER for SEC.

METHODS

Between May 2017 and November 2022, 48 patients with SEC who underwent EMA or ADM after ER were enrolled in this study. The primary outcomes measured included esophageal stricture, refractory esophageal stricture, and the number of endoscopic dilations after esophageal stricture.

RESULTS

A total of 48 patients with SEC were enrolled in this study, 17 of whom underwent EMA after ER (EMA group) and 31 of whom underwent ADM after ER (ADM group). The median of total procedure duration and the median of transplantation duration in the ADM group was significantly shorter than that in the EMA group (Z = - 2.408, P = 0.016; Z = - 2.710, P = 0.006). During the follow-up, 4 patients developed refractory esophageal stricture in the EMA group and 1 developed refractory esophageal stricture in the ADM group. The rate of refractory esophageal stricture was lower in ADM group than in EMA group (3.2% vs. 23.5%, P = 0.047). In patients with > 3/4 circumferential range ER, the rate of refractory esophageal stricture was also lower in ADM group than in EMA group (4.0% vs. 25.0%, P = 0.067). Among the patients who developed esophageal stricture, the median number of endoscopic dilations in the ADM group was less than that in the EMA group (Z = 27.500; P = 0.040).

CONCLUSIONS

Compared with EMA, ADM provided several advantages, as it reduced the number of endoscopic dilations for patients with esophageal strictures and shortened the procedure duration for patients who underwent esophageal ESD.

Endoscopic background mucosal resurfacing to prevent metachronous recurrence of superficial esophageal squamous cell cancer after curative endoscopic submucosal dissection: randomized pilot study with 5-year follow-up (with video)

BACKGROUND AND AIMS

Metachronous recurrence frequently develops in patients with superficial esophageal squamous cell carcinomas (ESCCs) after curative endoscopic submucosal dissection (ESD), especially in those with multiple (>10) small Lugol-voiding lesions (LVLs) over the endoscopic background mucosa (ie, speckled pattern). We conducted a randomized controlled trial to investigate whether endoscopic radiofrequency ablation (RFA) for endoscopic background mucosal resurfacing (EBMR) can decrease the rate of metachronous neoplasia.

METHODS

Patients who received curative ESD and whose Lugol staining showed a speckled pattern over the background mucosa were randomly assigned in a 1:1 ratio to receive either RFA (EBMR group) or endoscopic surveillance alone (control group). EBMR with RFA was performed with a balloon device for circumferential ablation of the total esophageal mucosa 2 to 3 months after ESD. The primary outcome was the metachronous recurrence of squamous neoplasia during a 5-year follow-up period. Secondary outcomes were major adverse events.

RESULTS

Of 112 patients screened, 30 were randomized to receive EBMR (n = 15) or surveillance (n = 15). The mean procedure time of EBMR was 30.7 minutes (range, 25-40). One patient developed post-RFA stenosis, which resolved after 3 sessions of endoscopic dilation. EBMR reduced the risk of metachronous recurrence (0% in the EBMR group vs 53% in the control group, P = .001), with a number needed to treat of 1.9. Reversal of the Lugol-staining speckled pattern to only a few LVLs occurred in all patients and persisted for at least 5 years in the ablation group.

CONCLUSIONS

In this randomized trial of patients with multiple small LVLs over the endoscopic background after curative ESD, EBMR with balloon-type RFA is a promising and safe procedure for preventing metachronous recurrence over 5 years of follow-up. (Clinical trial registration number: NCT03183115.).

Exploring different techniques for endoscopic submucosal dissection of gastrointestinal lesions: a review of the literature

INTRODUCTION

Endoscopic submucosal dissection (ESD) has revolutionized the management of early gastrointestinal (GI) neoplasms by enabling en bloc resection with high R0 rates. Several modifications of conventional ESD (C-ESD) have been introduced, including pocket-creation (PCM-ESD), tunnel (T-ESD), traction-assisted (TA-ESD), and saline immersion therapeutic endoscopy (SITE-ESD) methods.

AREAS COVERED

A comprehensive literature search was conducted across main databases through February 2025 using keywords related to ESD, with studies selected based on their relevance. While no single technique has demonstrated superior efficacy and safety across different GI regions, a tailored and integrative approach to different techniques could enhance effectiveness. PCM-ESD and T-ESD are particularly advantageous circumferential lesions in the esophagus and rectum, whereas TA-ESD significantly reduces procedure time, particularly in colonic lesions. Moreover, PCM-ESD has demonstrated higher effectiveness for colorectal lesions compared to C-ESD. SITE-ESD has shown benefits in colorectal resections by improving trimming, submucosal space visualization and coagulation control.Advanced traction systems and resection tools has optimized ESD performance. However, selecting the most appropriate approach requires careful consideration of lesion characteristics (particularly fibrosis and location).

EXPERT OPINION

While conventional ESD remains the foundation, TA and SITE are expected to become the preferred approach in select GI regions during the following years.

Hydrogels in Endoscopic Submucosal Dissection for Gastrointestinal Cancers

Endoscopic Submucosal Dissection (ESD) has emerged as a pivotal technique for the minimally invasive treatment of early gastrointestinal cancers, offering benefits such as reduced trauma, lower complication rates, and cost-effectiveness. Despite its advantages, the selection of optimal biomaterials for submucosal injection poses significant challenges. Current materials used in clinical settings often suffer from rapid diffusion, requiring multiple injections and potentially causing localized inflammation. These issues underscore the importance of identifying more effective submucosal injection materials to minimize postoperative complications and enhance patient outcomes. Recent advancements have highlighted the potential of hydrogels in this context, favored for their ability to maintain mucosal elevation longer and support wound healing. This review comprehensively examines the development and application of hydrogels in ESD, focusing on their physicochemical properties, biocompatibility, and the clinical implications of their use. These issues discuss various formulations of hydrogels, their mechanisms of action, and comparative analyses with traditional materials. Furthermore, the review explores ongoing innovations and future perspectives in hydrogel research, aiming to catalyze further advancements in ESD techniques. STATEMENT OF SIGNIFICANCE: This review critically examines hydrogel technologies in endoscopic submucosal dissection for gastrointestinal cancers, highlighting their role in improving procedural outcomes and patient recovery. It explores hydrogels' ability to enhance mucosal elevation, reduce complications, and accelerate healing, offering insights into their transformative potential in medical treatments. The findings emphasize the development of innovative materials that could significantly advance clinical practices in gastrointestinal cancer management.

Sequential injection-electrocoagulation vs. traditional electrocoagulation haemostasis during endoscopic submucosal dissection: a randomized controlled trial

BACKGROUND

Electrocoagulation with an electrosurgical knife is the traditional approach to achieve haemostasis during endoscopic submucosal dissection (ESD), as bleeding may obscure the operative field and increase the risks of muscle injury and perforation.

AIMS

The aim of this study was to assess the efficacy and safety of the sequential injection-electrocoagulation procedure during ESD.

METHODS

In this randomized controlled trial, 69 patients undergoing upper gastrointestinal ESD were randomized to either the control group (traditional electrocoagulation) or the experimental group ("Sequential injection-electrocoagulation" method) from September 2023 to June 2024. Two endoscopists scored the visibility of each bleeding point from 1 (undetectable) to 4 (easily detectable).

RESULTS

The median time to haemostasis at each bleeding point was 17 (11-23) seconds in the experimental group and 22 (14.5-41) seconds in the control group (P < 0.001). The visibility scores were significantly higher in the experimental group than in the control group (3.24 ± 0.63 vs. 2.82 ± 0.57) (P < 0.001). Muscle injuries occurred more frequently in the control group (P = 0.003). Unfortunately, there was one case of perforation in the control group caused by haemostasis.

CONCLUSION

The sequential injection-electrocoagulation strategy shortened the time to hemostasis during ESD, improved the visibility of bleeding points, and minimized the risks of muscle injury and perforation.

Position statement of the World Endoscopy Organization: Role of endoscopy in screening, diagnosis, and treatment of esophageal superficial squamous neoplasiaia

Esophageal squamous cell carcinoma (ESCC) remains a significant global health challenge, being the sixth leading cause of cancer mortality with pronounced geographic variability. The incidence rates range from 125 per 100,000 in northern China to 1-1.5 per 100,000 in the United States, driven by environmental and lifestyle factors such as tobacco and alcohol use, dietary habits, and pollution. Major modifiable risk factors include tobacco and alcohol consumption, with a synergistic risk increase when combined. Nonmodifiable risk factors include previous diagnoses of head and neck squamous cell carcinoma (H&N SCC), achalasia, and prior radiotherapy. Prevention strategies must be tailored to specific regional burdens to efficiently allocate medical and financial resources. Gastrointestinal endoscopy is crucial in reducing ESCC burden through early detection and characterization of neoplastic changes, such as high-grade dysplasia. Early diagnosis significantly improves survival rates, while endoscopic resection of noninvasive dysplasia can prevent ESCC onset, reducing treatment burden for advanced disease. Postresection surveillance can detect high-risk metachronous lesions. Despite these benefits, endoscopic prevention faces challenges, including the lack of high-level evidence supporting its efficacy, opportunity costs, the need for specialized training and techniques, and the requirement for advanced technology investments. This Position Statement from the World Endoscopy Organization (WEO) aims to address these challenges, supplying recommendations for the exploitation of endoscopic resources regarding the possible role of screening, quality, and training for the detection, characterization, resection, and surveillance of ESCC.

Endoscopic ultrasound with submucosal saline injection improves the accuracy of T1a and T1b staging in superficial esophageal squamous cell carcinoma

Background

Endoscopic ultrasound (EUS) is important for diagnosing and staging esophageal cancer. However, substantial variability in the diagnostic and staging accuracy of EUS, especially in early-stage cancers, affects patients' treatment choices and quality of life.

Aims

To explore whether conventional endoscopic ultrasonography (EUS-C) combined with submucosal saline injection (EUS-SSI) improves diagnostic accuracy in preoperative T1a and T1b staging in superficial esophageal squamous cell carcinoma (SESCC).

Methods

Patients with SESCC first underwent EUS-C. Then, they received SSI and underwent a repeat EUS. The diagnostic accuracy of EUS-C and EUS-SSI was evaluated based on the final postoperative pathology results.

Results

A total of 92 patients with endoscopically diagnosed SESCC were included in the study. Postoperative pathology confirmed superficial SESCC in all patients (T1a stage, n = 77; T1b stage, n = 15). EUS-C correctly identified 54 of 77 patients with T1a cancer and nine of 15 patients with T1b cancer, whereas EUS-SSI identified 68 of 77 patients with T1a cancer and 10 of 15 patients with T1b cancer. EUS-SSI was more accurate than EUS-C in diagnosing T1a and T1b stage SESCC (84.8 and 68.5%, respectively).

Conclusion

EUS-SSI differentiates between T1a and T1b stages of superficial SESCC with better diagnostic accuracy than EUS-C, thereby reducing the rate of over-staging.

Chemotherapy May Influence Esophageal Lugol Chromoendoscopy Severity: A Retrospective Cohort Study and Literature Review

Lugol chromoendoscopy is widely used for screening esophageal squamous cell neoplasms (ESCNs) and evaluating dissection margins during endoscopic submucosal dissection (ESD). However, morphological variations may arise following treatment for synchronous cancers. This study aimed to assess the impact of chemotherapy on Lugol chromoendoscopy findings during both screening and ESD. From August 2009 to March 2024, ESCN patients undergoing esophageal ESD were enrolled. Lugol chromoendoscopy findings were analyzed based on four criteria: iodine staining, lesion size, margin assessment, and the pink-color sign. Findings from screening endoscopy and ESD were compared, and medical records were reviewed for chemotherapy and radiation data. A literature review was also conducted to explore the potential effects of chemotherapy on Lugol chromoendoscopy findings. Among the 162 patients in this ESD cohort, 32 (19.8%) demonstrated notable differences between initial and follow-up Lugol chromoendoscopy. Among them, 14 (43.8%) had undergone chemotherapy prior to ESD, while 26 received chemotherapy within 2 months before ESD. A significant proportion (53.8%) of chemotherapy-treated patients exhibited faded chromoendoscopy findings (p < 0.01), despite no esophageal radiation exposure. Literature review findings supported our observation that chemotherapy may reduce Lugol voiding lesions. These findings suggest that chemotherapy influences lesion size and morphology during Lugol chromoendoscopy, underscoring the importance of careful timing and interpretation in these patients.

Evaluating the discrepancies between evidence-based and community standard practices in the endoscopic examination of Barrett's esophagus: a nationwide survey in Japan

BACKGROUND

Barrett's esophagus (BE) is a known precursor of esophageal adenocarcinoma (EAC). EAC is comparatively rare in Japan compared to Western countries, where BE management guidelines have been well established based on robust evidence. This study evaluated for gaps between evidence-based medicine (EBM) and real-world clinical practice for BE management in Japan and examined endoscopist adherence to Japanese and Western guidelines.

METHODS

A nationwide survey consisting of 19 questions was conducted among Japanese endoscopists to assess their diagnostic and surveillance practices for BE. Descriptive statistics and multivariate logistic regression analysis were employed to interpret key data.

RESULTS

Responses from 804 endoscopists revealed significant differences between Western guidelines and Japanese practices. Local adherence to standardized inspection times was 7.6%, and 30.7% of endoscopists used the Prague classification. Biopsies for BE diagnosis and random biopsies following the Seattle protocol were rarely performed. For long-segment BE, 51.4% of respondents reported using magnifying endoscopy. Regarding ultra-short-segment BE (USSBE), opinions were divided on whether it should be diagnosed as BE and if patients should be informed of its diagnosis. Approximately 40% of respondents advocated annual surveillance for USSBE, with a general tendency to recommend closer follow-up regardless of BE length as compared with Western guidelines.

CONCLUSIONS

This survey highlighted several incongruities between EBM and real-world practices for BE, as well as differences between Western and Japanese approaches. Bridging these gaps will require generating more Japan-specific evidence, refining guidelines, and then promoting their dissemination to harmonize best BE practices with international standards and Japanese clinical settings.

Post-endoscopy esophageal squamous cell carcinoma with invasion of the muscularis mucosa or deeper detected in surveillance endoscopy after esophageal endoscopic resection

BACKGROUND

Surveillance endoscopy is recommended after endoscopic resection of esophageal squamous cell carcinomas (ESCCs). However, surveillance endoscopy sometimes detects advanced subsequent ESCCs with invasion of the muscularis mucosa (MM) or deeper. We aimed to clarify the clinicopathological features of these advanced subsequent ESCCs.

METHODS

This single-center retrospective study identified subsequent ESCCs detected during surveillance endoscopy. ESCCs that invaded the MM or deeper and were detected within 24 months after the previous endoscopy were defined as post-endoscopy esophageal advanced lesions (PEEALs), while the first ESCC detected in the patient was defined as the primary lesion. Study 1 compared the clinicopathological characteristics of PEEALs versus non-advanced lesions. Study 2 compared the endoscopic features of pT1a-MM PEEALs versus pT1a-MM primary lesions.

RESULTS

A total of 307 subsequent ESCCs were analyzed in Study 1. Of these, 20 were PEEALs and 287 were non-advanced lesions (pT1a-EP/LPM). The median intervals from the previous endoscopy for PEEALs and non-advanced lesions were 6.1 months and 6.7 months, respectively (P = 0.283). The morphological feature of marginal elevation was seen in 60% of PEEALs. In Study 2, 15 pT1a-MM PEEALs were compared with 149 pT1a-MM primary lesions. Compared with primary lesions, pT1a-MM PEEALs were smaller (median 10 mm vs. 30 mm, P < 0.001) and had a higher prevalence of marginal elevation morphology (53.3% vs. 10.1%, P < 0.001).

CONCLUSIONS

The specific feature of PEEALs was marginal elevation. Surveillance endoscopy with careful observation for these lesions is recommended after endoscopic resection of ESCCs.

Non-Curative Endoscopic Submucosal Dissection: Current Concepts, Pitfalls and Future Perspectives

Endoscopic submucosal dissection (ESD) is very effective for the treatment of digestive tract neoplasia. However, it is very demanding, with a long learning curve, and, therefore, a significant rate of non-curative resections is expected, considering lesion characteristics, location, and endoscopist experience. The management of patients after a non-curative ESD is not definitely established. It must consider patients' comorbidities and expected survival, as well as the morbidity and mortality of complementary treatments such as surgery, chemotherapy, or radiotherapy. On the other hand, there is a window of opportunity to offer those additional treatments to complete neoplastic treatment and give patients an oncological cure. This decision is sometimes difficult, since the diverse histological criteria that define a non-curative ESD do not have the same weight regarding residual risk and oncological progression. The prediction of residual lesion would be paramount to decide whether to refer patients to surgery; nowadays, this prediction is far from perfect, since most of the patients that undergo surgery due to a non-curative ESD do not have residual neoplasia in the surgical specimen. In this review, ESD curativeness and the management of non-curative ESDs performed for esophageal, gastric, and colorectal lesions will be addressed.

Impact of preceding treatment for head and neck squamous cell carcinoma on synchronous superficial esophageal squamous cell carcinoma

BACKGROUND

Patients with esophageal squamous cell carcinoma (ESCC) frequently develop synchronous head and neck squamous cell carcinoma (HNSCC). With advances in endoscopic technology and widespread screening of synchronous cancers, the detection of synchronous HNSCC and superficial ESCC (SESCC) is increasing. We aimed to evaluate the impact of preceding HNSCC treatment on synchronous SESCC.

METHODS

This single-center retrospective study enrolled patients with synchronous HNSCC and SESCC who were treated between January 2010 and December 2023. Tumor size and depth of SESCC before and after HNSCC treatment were evaluated. The factors associated with SESCC progression were investigated.

RESULTS

Of the 299 patients with synchronous HNSCC and SESCC, 134 who underwent preceding HNSCC treatment with follow-up esophagogastroduodenoscopy (EGD) for SESCC were evaluated. Chemoradiotherapy was the most common treatment for HNSCC (56.0%), followed by surgery (17.2%), radiotherapy (14.9%), local resection (7.5%), and chemotherapy (4.5%). The tumor size of SESCC increased after HNSCC treatment in 18 patients (13.4%). Multivariate analysis revealed that an EGD interval of ≥ 120 days was significantly associated with increased tumor size in SESCC (odds ratio, 6.64; 95% confidence interval, 1.91-23.1). Tumor regrowth was observed in 70.6% of SESCCs that shrank with HNSCC treatment, mostly within six months. Tumor depth aggravation was rare (2.2%), but progression to advanced ESCC was observed in two patients.

CONCLUSIONS

Timely endoscopic follow-up, preferably within 120 days, is crucial for managing synchronous SESCC after HNSCC treatment to prevent tumor progression. Tumor regrowth should be monitored when SESCC shrinks with HNSCC treatment.

Successful conservative management of delayed perforation following endoscopic submucosal dissection of the esophagus: A case report

Delayed perforation after esophageal endoscopic submucosal dissection is a rare complication that may result in severe outcomes. Here, we report a case of delayed perforation that was successfully managed with conservative treatment. A 72-year-old male with hypertensive renal failure and on maintenance hemodialysis underwent endoscopic submucosal dissection for a 2/3 circumferential superficial esophageal cancer in the middle thoracic esophagus, involving resection of 4/5 of the esophageal circumference. Locoregional steroid injections were administered after resection to prevent stenosis. No perforation occurred during the procedure; however, delayed perforation was identified on postoperative day 3. Endoscopy revealed necrosis and brittleness in a large area of the post-endoscopic submucosal dissection ulcer. The patient developed fever and mediastinal emphysema, and endoscopic attempts to close the perforation were unsuccessful. Conservative management-including fasting, antibiotics, and subsequent drainage-was initiated. The patient's condition improved with drainage tube placement, enteral nutrition, and antibiotic administration. A follow-up computed tomography scan on postoperative day 56 confirmed the resolution of mediastinal emphysema, and endoscopy revealed that the perforation healed with scarring. This case highlights that surgery may be avoided if appropriate treatment is initiated as early as possible, including drainage to prevent exposure to gastric and intestinal fluids, early initiation of enteral nutrition, rehabilitation to maintain strength, and blood transfusions as supportive care.

Feasibility of endoscopic submucosal dissection including papilla (with video)

OBJECTIVES

Endoscopic papillectomy (EP) is a low-invasive treatment for duodenal tumors including papilla. The limit of lesion size and local recurrence have been issues in EP. We developed endoscopic submucosal dissection (ESD) for the duodenal tumors including papilla (ESDIP: ESD including papilla) to overcome the problems. The aim of this study was to evaluate the feasibility of ESDIP.

METHODS

We included the patients who underwent ESDIP from August 2010 to January 2024 in this study. We evaluated the retrospective characteristics of patients and lesions, clinical results of ESDIP and of endoscopic retrograde cholangiopancreatography (ERCP) as prevention for delayed adverse events, and pathological findings. We also calculated the cumulative recurrence rate and overall survival rate at 12 months after ESDIP.

RESULTS

Fifty-four patients were included in this study. The mean lesion size was 39 mm. The third-quarter cases revealed a less than half-circumferential lesion, and the one case with a full-circumferential lesion. Resection was accomplished in 96% (n = 52), and also the en-bloc resection rate was 96%. Of the cases in accomplished resection, 98% of patients were intubated with a pancreaticobiliary drainage tube by ERCP. Intraprocedural perforation occurred in eight cases. Delayed bleeding occurred in 10 cases. Delayed perforation was seen only in one case. The incidence of post-ERCP pancreatitis was 25%. Cumulative local recurrence rate and the overall survival rate were 15% and 96%, respectively.

CONCLUSION

ESDIP may be feasible for duodenal tumors including papilla, and is a potential alternative option to avoid pancreaticoduodenectomy.

Impact of time from diagnosis to endoscopic submucosal dissection on curability in superficial esophageal squamous cell carcinoma

Objective

To investigate the time delay effect from initial diagnosis to endoscopic submucosal dissection on superficial esophageal squamous cell carcinoma curability, considering the preoperative invasion depth.

Methods

This study included superficial esophageal squamous cell carcinoma diagnosed as T1a-epithelial/lamina propria mucosa cancer (cEP/LPM; cancer invading up to the lamina propria mucosa) or cT1a-muscularis mucosa (MM)/T1b-submucosal cancer (cMM/SM1; cancer invading up to 200 µm into the submucosa) and treated using endoscopic submucosal dissection from January 2017 to December 2021. We compared curability in lesions treated within three months (early treatment group) versus those treated ≥7 months post-diagnosis (delayed treatment group). Curative resection criteria included lesions confined within the muscularis mucosae, with negative vertical margins, and with absence of lymphovascular invasion. Non-curative resection included all other cases.

Results

Among the 231 and 75 lesions in the early and delayed treatment groups, respectively, no significant difference was observed in non-curative resections for all lesions and cEP/LPM lesions (early: 194, delayed: 70). Conversely, the proportions were significantly higher in the delayed treatment group than in the early treatment group for cMM/SM1 lesions (early: 37, delayed: 5; p = 0.018).

Conclusions

This study suggests that delayed endoscopic submucosal dissection does not significantly affect cEP/LPM lesions curability but is associated with reduced cMM/SM1 lesions curability. Prompt treatment is important for cMM/SM1, whereas delayed treatment may be acceptable for cEP/LPM.

Recent Advances in Gastrointestinal Cancer Endoscopic Diagnosis and Treatment: Focusing on Older Adults

Recent advances in endoscopic equipment have improved the diagnosis of gastrointestinal tumors. Image-enhanced endoscopy, including narrow-band imaging, blue light imaging, and linked color imaging, has unified magnifying observation classification methods and significantly improved the qualitative and quantitative diagnostic performance of gastrointestinal epithelial tumors. Endoscopic submucosal dissection (ESD), a minimally invasive treatment for early-stage gastrointestinal cancer, is widely used. The aging population in Japan has been gradually increasing. Despite this, ESD has shown good outcomes in older adults. However, long-term prognostic analyses should take into account the high mortality rate from other illnesses. Prognostic indicators such as the Charlson Comorbidity Index (CCI) and the Prognostic Nutrition Index (PNI) should be used to determine whether ESD should be performed. Even in cases of noncurative resection, follow-up without additional surgical resection is an option if there are other comorbidities that affect the prognosis.

Establishing and popularizing a standard pathological diagnostic model of endoscopic submucosal dissection specimens in China

BACKGROUND

Endoscopic submucosal dissection (ESD) is a standardized therapeutic approach for early carcinoma of the digestive tracts. In this regard, the process of histopathological diagnosis requires standardization. However, the uneven development of healthcare in China, especially in eastern and western China, creates challenges for sharing a standardized diagnostic process.

AIM

To optimize the process of ESD specimen sampling, embedding and slide production, and to provide complete and accurate pathological reports.

METHODS

We established a practical process of specimen sampling, created standardized reporting templates, and trained pathologists from neighboring hospitals and those in the western region. A training effectiveness survey was conducted, and the collected data were assessed by the corresponding percentages.

RESULTS

A total of 111 valid feedback forms have been received, among which 58% of the participants obtained photographs during specimen collection, whereas the percentage increased to 79% after training. Only 58% and 62% of the respondents ensured the mucosal tissue strips were flat and their order remained unchanged; after training, these two proportions increased to 95% and 92%, respectively. Approximately half the participants measured the depth of the submucosal infiltration, which significantly increased to 95% after training. The percentage of pathologists who did not evaluate lymphovascular invasion effectively reduced. Only 22% of the participants had fixed clinic-pathological meetings before training, which increased to 49% after training. The number of participants who had a thorough understanding of endoscopic diagnosis also significantly increased.

CONCLUSION

There have been significant improvements in the process of specimen collection, section quality, and pathology reporting in trained hospitals. Therefore, our study provides valuable insights for others facing similar challenges.

Stricture prevention after circumferential endoscopic submucosal dissection of the esophagus: Proactive vs reactive strategies

In this editorial, we explored currently available strategies for reducing the occurrence of esophageal strictures following circumferential endoscopic submucosal dissection. This manuscript provided a comprehensive overview of the various strategies including recent insights from Wang et al. To this end, stenosis-related symptoms such as dysphagia and vomiting can severely affect a patient's quality of life. Therefore, we assess the efficacy of both reactive and proactive measures, ranging from traditional approaches like endoscopic balloon dilation and steroid administration to more advanced techniques, including tissue engineering and polyglycolic acid sheet placement. However, no single treatment has shown high efficacy, particularly for resections involving the entire circumference. Despite these shortcomings, the combination of different strategies may improve patient outcomes, although further large-scale studies are needed for validation.

Long-term Outcomes of Endoscopic Radiofrequency Ablation versus Endoscopic Submucosal Dissection for Widespread Superficial Esophageal Squamous Cell Neoplasia

Background/Aims

Endoscopic radiofrequency ablation (ERFA) is a treatment option for superficial esophageal squamous cell neoplasia (ESCN), with a relatively low risk of stenosis; however, the long-term outcomes remain unclear. We aimed to compare the long-term outcomes of patients with widespread superficial ESCN who underwent endoscopic submucosal dissection (ESD) or ERFA.

Methods

We retrospectively analyzed the clinical data of patients with superficial ESCN who underwent ESD or ERFA between January 2015 and December 2021. The primary outcome measure was recurrence-free survival.

Results

Ninety-two and 33 patients with superficial ESCN underwent ESD and ERFA, respectively. The en bloc, R0, and curative resection rates for ESD were 100.0%, 90.2%, and 76.1%, respectively. At 12 months, the complete response rate was comparable between the two groups (94.6% vs 90.9%, p=0.748). During a median follow-up of 66 months, recurrence-free survival was significantly longer in the ESD group than in the ERFA group (p=0.004), while no significant differences in overall survival (p=0.845) and disease-specific survival (p=0.494) were observed. Preoperative diagnosis of intramucosal cancer (adjusted hazard ratio, 5.55; vs high-grade intraepithelial neoplasia) was an independent predictor of recurrence. Significantly fewer patients in the ERFA group experienced stenosis compare to ESD group (15.2% vs 38.0%, p=0.016).

Conclusions

The risk of recurrence was higher for ERFA than ESD for ESCN but overall survival was not affected. The risk of esophageal stenosis was significantly lower for patients who underwent ERFA.

Safety and Effectiveness of Electroacupuncture During Colon Endoscopic Submucosal Dissection: A Randomized Controlled Trial

Background

Endoscopic treatment of early colon neoplasms has evolved as a valid and less traumatic alternative to surgical resection. It can usually be performed with sedation on an outpatient basis. The present study was performed to determine the safety and effectiveness of electroacupuncture (EA) versus propofol sedation during endoscopic submucosal dissection (ESD) for early colon neoplasm.

Methods

A total of 150 adult outpatients undergoing ESD were selected and divided into the EA combined with propofol group (EP group), remifentanil combined with propofol group (RP group), and propofol group (SP group), with 50 patients in each group. All patients received standard sedation with propofol. Acupuncture was performed before intravenous propofol injection in the EP group. A density wave of 1-3 mA, 2/100 hz current was administered for 20 min before the induction of anesthesia. The effectiveness of sedation was measured by satisfaction levels, and pain and sedation scores were measured by questionnaires. Respiratory and hemodynamic complications were monitored and compared as indices of safety.

Results

Demographic data were comparable among the three groups. The total dose of propofol and the percentage of body movement in the EP group were lower than in the SP and RP groups (P<0.01). The incidence of hypotension and bradycardia in the SP and RP groups was higher than in the EP group. Patients who received the EA intervention showed a significant reduction in hypoxemia. The endoscopists felt that the procedure was more favorable in the EP group, but, there was no significant difference of patient satisfaction scores among three groups.

Conclusion

Sedation with EA is effective and safe for patients undergoing ESD, and could improve the satisfaction levels of patients and gastroendoscopists.

The Endoscopic Management of Anastomotic Strictures After Esophagogastric Surgery: A Comprehensive Review of Emerging Approaches Beyond Endoscopic Dilation

Anastomotic strictures are a common complication following esophagogastric surgery, with prevalence varying depending on the type of surgery and anatomical site. These strictures can lead to debilitating symptoms such as dysphagia, pain, and malabsorption, significantly impacting patients' quality of life. Endoscopic treatment of anastomotic strictures has established a role as the first-line strategy in this setting instead of revision surgery, offering benefits in terms of lower morbidity. Various endoscopic methods are available for anastomotic stricture management, including balloon dilation, stent placement, the new lumen-apposing metal stent, and endoscopic incision techniques. However, there is currently no strong evidence and established guidelines for the optimal treatment strategy. Available data suggest that endoscopic treatments, when performed in tertiary referral centers, can provide favorable outcomes in terms of symptom relief and reduced need for rescue surgical intervention. Nonetheless, challenges remain regarding the management of recurrent strictures and procedural complications, underscoring the need for a personalized, multidisciplinary approach to optimize clinical outcomes. This review aims to provide an updated overview of endoscopic techniques and available evidence with a focus on the most recent technologies, supporting clinicians in effectively managing anastomotic strictures in complex clinical settings.

Prophylactic endoscopic vacuum therapy for stricture prevention after wide-field endoscopic submucosal dissection of superficial esophageal cancer

BACKGROUND AND AIMS

Esophageal stricture is a severe adverse event after wide-field endoscopic submucosal dissection (ESD) of superficial esophageal carcinoma. This study evaluated the efficacy and safety of combining endoscopic vacuum therapy (EVT) and a budesonide orodispersible tablet (BOT) in preventing post-ESD strictures.

METHODS

This prospective case series included patients with superficial esophageal squamous cell carcinoma and adenocarcinoma who had wide-field ESD (≥75% circumference, resection length ≥50 mm). After ESD, EVT was applied immediately followed by 8 weeks of BOTs. The main outcome measurement was the incidence of post-ESD stricture.

RESULTS

Eleven patients underwent ESD. Of these, 81.8% had 75% to 99% circumference resected and 18.2% had a circumferential resection. EVT remained in situ for a mean of 3.5 days. No esophageal strictures were observed by the final follow-up, and no major adverse events occurred related to EVT or the BOT.

CONCLUSIONS

The prophylactic combination of EVT and BOT is a novel and promising strategy for reducing post-ESD strictures.

Long-Term Prognostic Factors for Patients Aged 80 and Older With Superficial Esophageal Squamous Cell Carcinoma Undergoing Endoscopic Submucosal Dissection

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is an acceptable treatment for superficial esophageal squamous cell carcinoma (ESCC) even in elderly patients. However, studies on the prognostic factors in very elderly patients are limited. Therefore, we aimed to explore the prognostic factors affecting overall survival (OS) in patients aged ≥ 80 with superficial ESCC who underwent ESD.

METHODS

This study included 155 patients aged ≥ 80 who underwent ESD for superficial ESCC. Clinicopathological findings and long-term outcomes were examined. The prognostic nutritional index (PNI) and geriatric nutritional index (GNRI) were used to assess pre-treatment nutritional status.

RESULTS

Twenty-nine patients (18.7%) were aged ≥ 85. Thirty-five (22.6%) and 61 (39.4%) patients had a GNRI < 92 and PNI < 45, respectively. Metastatic relapse was observed in five cases, four (80%) of which resulted in death due to the primary disease. The median OS of all patients was 86 months. Although factors specifically associated with disease-specific survival were not identified, GNRI, PNI, comorbidity, and physical status were associated with OS. In multivariate analysis, age ≥ 85 years (p = 0.03), GNRI (p < 0.01), and PNI (p < 0.01) remained factors associated with OS. Patients aged ≥ 85 with either GNRI ≥ 92 or PNI ≥ 45 had a median OS of 106 months, whereas those aged ≥ 85 with GNRI < 92 had a median OS of 12 months.

CONCLUSIONS

GNRI and PNI are important indicators for assessing the suitability of ESD in elderly patients aged ≥ 80. These indices can help predict OS and guide clinical decision-making for this patient population.

[Endoscopic Diagnosis and Treatment of Early Mucosal Neoplasms in the Oesophagus]

Endoscopy is the gold standard for diagnosis of oesophageal cancer and its precursor lesions. Besides this, endoscopic treatment of these precursor lesions and early oesophageal cancer has been well evaluated and established. This includes dysplastic lesions associated with Barrett's oesophagus and early adenocarcinoma, as well as early squamous cell cancer of the oesophagus. The role of endoscopy for diagnosis and treatment of these lesions is summarised.

Prevention strategies of esophageal stenosis after endoscopic resection for superficial esophageal cancer: a Bayesian network meta-analysis

INTRODUCTION

What interventions effectively prevent postoperative stenosis following endoscopic resection (ER) of superficial esophageal cancer? This study aimed to identify effective interventions or combinations through a systematic review and network meta-analysis.

METHODS

Six databases were systematically searched for eligible studies up to 30 April 2023, on interventions to prevent esophageal stenosis post-ER. Odds ratios (ORs) evaluated stenosis rate (primary outcome) and complications (secondary outcome), while mean differences (MD) evaluated endoscopic balloon dilatation (EBD) sessions post-stenosis.

RESULTS

Twenty-three studies involving 1271 patients and 11 different interventions were included. Eight interventions were effective in preventing post-ER stenosis: oral hydrocortisone sodium succinate and aluminum phosphate gel (OHA) (OR: 0.02, 95% credible interval [CrI]: 0.00-0.11), polyglycolic acid (PGA) + ST (OR: 0.02, 95% CrI: 0.00-0.23), oral tranilast (OT) + preemptive endoscopic balloon dilatation (PEBD) (OR: 0.08, 95% CrI: 0.01-0.77), botulinum toxin (BT) (OR: 0.10, 95% CrI: 0.03-0.32), ST (OR: 0.08, 95% CrI: 0.01-0.67), oral steroid (OS) (OR: 0.11, 95% CrI: 0.05-0.28), endoscopic triamcinolone injection (ETI) + OS (OR: 0.17, 95% CrI: 0.07-0.42), and ETI (OR: 0.18, 95% CrI: 0.11-0.30). Five interventions significantly reduced EBD sessions: PGA + ST (MD: -5.78, 95% CrI: -11.04 to -1.21), ETI + OS (MD: -3.27, 95% CrI: -5.37 to -0.72), OS (MD: -6.18, 95% CrI: -9.43 to -3.38), ETI (MD: -3.81, 95% CrI: -5.74 to -1.99), and BT (MD: -2.16, 95% CrI: -4.12 to -0.40). None of the interventions significantly increased complications.

CONCLUSIONS

This study confirmed the efficacy of OS, ETI, and ETI + OS and verified five other interventions (OHA, PGA + ST, OT + PEBD, BT, and ST) in preventing stenosis. Notably, PGA + ST and BT also reduced the number of EBD sessions.

Development of Deep Learning-Based Virtual Lugol Chromoendoscopy for Superficial Esophageal Squamous Cell Carcinoma

BACKGROUND

Lugol chromoendoscopy has been shown to increase the sensitivity of detection of esophageal squamous cell carcinoma (ESCC). We aimed to develop a deep learning-based virtual lugol chromoendoscopy (V-LCE) method.

METHODS

We developed still V-LCE images for superficial ESCC using a cycle-consistent generative adversarial network (CycleGAN). Six endoscopists graded the detection and margins of ESCCs using white-light endoscopy (WLE), real lugol chromoendoscopy (R-LCE), and V-LCE on a five-point scale ranging from 1 (poor) to 5 (excellent). We also calculated and compared the color differences between cancerous and non-cancerous areas using WLE, R-LCE, and V-LCE.

RESULTS

Scores for the detection and margins were significantly higher with R-LCE than V-LCE (detection, 4.7 vs. 3.8, respectively; p < 0.001; margins, 4.3 vs. 3.0, respectively; p < 0.001). There were nonsignificant trends towards higher scores with V-LCE than WLE (detection, 3.8 vs. 3.3, respectively; p = 0.089; margins, 3.0 vs. 2.7, respectively; p = 0.130). Color differences were significantly greater with V-LCE than WLE (p < 0.001) and with R-LCE than V-LCE (p < 0.001) (39.6 with R-LCE, 29.6 with V-LCE, and 18.3 with WLE).

CONCLUSIONS

Our V-LCE has a middle performance between R-LCE and WLE in terms of lesion detection, margin, and color difference. It suggests that V-LCE potentially improves the endoscopic diagnosis of superficial ESCC.

Deep learning detected histological differences between invasive and non-invasive areas of early esophageal cancer

The depth of invasion plays a critical role in predicting the prognosis of early esophageal cancer, but the reasons behind invasion and the changes occurring in invasive areas are still not well understood. This study aimed to explore the morphological differences between invasive and non-invasive areas in early esophageal cancer specimens that have undergone endoscopic submucosal dissection (ESD), using artificial intelligence (AI) to shed light on the underlying mechanisms. In this study, data from 75 patients with esophageal squamous cell carcinoma (ESCC) were analyzed and endoscopic assessments were conducted to determine submucosal (SM) invasion. An AI model, specifically a Clustering-constrained Attention Multiple Instance Learning model (CLAM), was developed to predict the depth of cancer by training on surface histological images taken from both invasive and non-invasive regions. The AI model highlighted specific image portions, or patches, which were further examined to identify morphological differences between the two types of areas. The 256-pixel AI model demonstrated an average area under the receiver operating characteristic curve (AUC) value of 0.869 and an accuracy (ACC) of 0.788. The analysis of the AI-identified patches revealed that regions with invasion (SM) exhibited greater vascularity compared with non-invasive regions (epithelial). The invasive patches were characterized by a significant increase in the number and size of blood vessels, as well as a higher count of red blood cells (all with p-values <0.001). In conclusion, this study demonstrated that AI could identify critical differences in surface histopathology between non-invasive and invasive regions, particularly highlighting a higher number and larger size of blood vessels in invasive areas.

More efficient endoscopic submucosal dissection with deep endotracheal intubation for superficial cervical esophageal carcinoma: a dual-center, prospective, randomized controlled study

BACKGROUND AND AIMS

Deep endotracheal intubation (DET) has been proposed to improve cervical esophageal endoscopic submucosal dissection (ESD) because of the limited space and visibility. We aimed to evaluate the efficacy and safety of DET.

METHODS

In the current dual-center trial, patients were randomized into DET or conventional endotracheal intubation (CET) groups. Complete resection rate, operation time, and adverse events were measured and compared.

RESULTS

Fifty-nine patients (60 lesions) were assigned to the groups, showing comparable baseline characteristics. The complete resection rates were similarly high in both groups. However, DET significantly reduced ESD operation time (52.2 minutes vs 71.1 minutes, P < .001) and postoperative pain scores (3.1 vs 4.7, P < .01). Severe stenosis occurred more frequently in the CET patients (20% vs 0%, P = .035). No significant differences were observed in other adverse events.

CONCLUSIONS

DET can overcome technical challenges to improve therapeutic efficiency and safety. (Clinical trial registration number: NCT06420258.).

Artificial intelligence in endoscopic diagnosis of esophageal squamous cell carcinoma and precancerous lesions

Esophageal squamous cell carcinoma (ESCC) poses a significant global health challenge, necessitating early detection, timely diagnosis, and prompt treatment to improve patient outcomes. Endoscopic examination plays a pivotal role in this regard. However, despite the availability of various endoscopic techniques, certain limitations can result in missed or misdiagnosed ESCCs. Currently, artificial intelligence (AI)-assisted endoscopic diagnosis has made significant strides in addressing these limitations and improving the diagnosis of ESCC and precancerous lesions. In this review, we provide an overview of the current state of AI applications for endoscopic diagnosis of ESCC and precancerous lesions in aspects including lesion characterization, margin delineation, invasion depth estimation, and microvascular subtype classification. Furthermore, we offer insights into the future direction of this field, highlighting potential advancements that can lead to more accurate diagnoses and ultimately better prognoses for patients.

Effectiveness of glucocorticoids in preventing esophageal stricture and predictors of stricture after esophageal ESD: 5 years of experience in a single medical center

Background

Esophageal stricture is one of the major complications after endoscopic submucosal dissection (ESD) of the esophagus. However, even with steroid prophylaxis, stenosis still occurs in up to 45% of patients. Accordingly, the aim of this study was to evaluate the efficacy and safety of steroid therapy in preventing esophageal strictures after ESD, as well as to assess the predictors of esophageal strictures after the application of steroids.

Methods

Between February 2018 and March 2023, 207 patients who underwent esophageal ESD at Southeast University Affiliated Zhongda Hospital were retrospectively enrolled. We evaluated stenosis rate, number of endoscopic dilations after ESD, the interval between the first endoscopic dilatation after ESD and explored risk factors for strictures after steroid prophylaxis.

Results

In the control group, the oral steroids group, and the combined group, the stenosis rates were 83/87 (95.4%), 44/53 (83.0%), and 56/67 (83.6%), respectively; the number of endoscopic dilations were 3.43 (±2.22), 2.34 (±2.17), and 1.52 (±1.25), respectively; the time intervals between first endoscopic dilation and ESD procedure were 38.36 (±6.87), 68.18 (±9.49), and 96.82 (±8.41) days, respectively; all these indicators were significantly better in the oral and combined groups than in the control group (p < 0.05). Multivariate analysis identified lesion circumference ≥ 5/6th and submucosal injection of solution were two independent factors on esophageal stricture formation (p < 0.05).

Conclusion

Steroid prophylaxis is effective and safe in preventing esophageal stenosis. Moreover, lesion circumference and submucosal injection of sodium hyaluronate were two independent factors on esophageal stricture formation even with steroids administration.

Learning curve for endoscopic submucosal dissection in early gastric neoplasm using a multibending endoscope

Background

Endoscopic submucosal dissection (ESD) is a representative treatment modality for early gastric neoplasms. However, the learning curve for beginners performing ESD using a multibending endoscope has not been introduced.

Objective

This study aimed to evaluate the learning curves of operators undergoing intensive training using a multibending endoscope.

Design

This was a retrospective single center study.

Methods

We retrospectively analyzed data of over 1500 consecutive gastric ESDs performed by two operators using a multibending endoscope. A change-point analysis with 50 cases of moving average speeds was used to determine the new target resection speed. Cumulative sum (CUSUM) analysis was used to identify the cases required for proficiency in ESD. Risk-adjusted CUSUM (RA-CUSUM) analysis was performed for each operator after adjusting for confounding factors influencing the resection speed.

Results

In total, 1491 cases were enrolled, with early gastric cancer accounting for 43.2% (n = 644). Overall, the en bloc resection, R0 resection, and curability rates were 97.7%, 96.0%, and 92.3%, respectively. The mean resection speed was 19.8 cm2/h. Because both operators surpassed the commonly used benchmark resection speed of 9 cm2/h in the first 50-case block, we established a new target benchmark of 17.9 cm2/h in the change-point analysis. CUSUM analysis indicated that performing 166 cases overall was required to achieve the benchmark, with the 2 operators needing 153 and 69 cases to meet this target speed after RA-CUSUM analysis.

Conclusion

Using a multibending endoscope for gastric ESD can help beginners achieve safe and excellent outcomes. These findings will serve as a useful guide for beginners attempting to use a multibending endoscope.

Comparative study on different endoscopic submucosal dissection techniques for the treatment of superficial esophageal cancer and precancerous lesions

BACKGROUND

This study aims to compare the effectiveness and safety of traditional endoscopic submucosal dissection (ESD), endoscopic submucosal tunneling dissection (ESTD), and endoscopic submucosal dissection with C-shaped incision (ESD-C) in the treatment of superficial esophageal cancer and precancerous lesions, providing reference and guidance for the treatment of esophageal cancer.

METHODS

A retrospective analysis was conducted on the clinical data of patients who underwent ESD (n = 96), ESTD (n = 103), and ESD-C (n = 98) for superficial esophageal cancer or precancerous lesions between January 2017 and December 2022. Through comparative analysis, the effectiveness and safety of the three surgical methods were evaluated, and the risk factors for postoperative esophageal stricture were explored.

RESULTS

In terms of total operative time and dissection time, the ESD group > ESTD group > ESD-C group; in terms of dissection speed, the ESD group < ESTD group < ESD-C group; in terms of dissection area, the ESD group < ESTD group and ESD-C group; and in terms of wound treatment time, the ESD group > ESTD group and ESD-C group. In terms of surgical outcomes, the en bloc resection rate was 100% in all three groups, with complete resection rates of 86.84%, 90.79%, and 88.16% in the ESD, ESTD, and ESD-C groups, respectively. The risk factors for postoperative esophageal stricture included dissection area, circumferential proportion of the lesion, and injury to the muscularis propria.

CONCLUSION

Among the three surgical approaches, ESD-C demonstrated superior performance in operative time, resection speed, and procedural efficiency. Increased circumferential involvement of the lesion, larger resection area, and greater injury to the muscularis propria were associated with a heightened risk of postoperative esophageal stricture.

Adipose stem cells prevent esophageal strictures after extensive endoscopic submucosal dissection - experimental research

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a pivotal technique for excision of early-stage esophageal tumors. However, its primary complication, postoperative esophageal stricture, is a significant challenge owing to the absence of effective preventive measures. Adipose-derived stem cells (ADSCs) have emerged as a promising treatment modality to address this concern. In this study, we aimed to investigate, for the first time, the efficacy of allogenic ADSC injections in preventing esophageal stenosis after ESD.

METHODS

We administered allogeneic ADSC injections (same-species but different individual) to a porcine model of ESD as a way to observe the role of ADSC in preventing esophageal stricture. We also co-cultured rats' ADSCs with rats' esophageal fibroblasts and esophageal mucosal epithelial cells to investigate the mechanism.

RESULTS

ADSCs notably facilitated epithelial-mesenchymal transition of epithelial cells. Furthermore, ADSC-conditioned medium exhibited a substantial inhibitory effect on fibroblast proliferation and migration, which was mediated by the transforming growth factor-beta pathway.

CONCLUSIONS

Our findings underscore the potential of ADSC injections as a promising therapeutic intervention to enhance recovery and prevent post-ESD complications.

Comprehensive pathological evaluation of risk factors for metastasis after endoscopic resection of superficial esophageal squamous cell carcinoma

BACKGROUND

Esophageal cancer is a major cause of cancer mortality worldwide. Endoscopic resection (ER) is a curative treatment for esophageal squamous cell carcinoma (ESCC). Predicting risk of metastasis is crucial for post-ER management. In this study, we aimed to identify predictors of metastasis by examining endoscopically resected specimens.

METHODS

The cohort of this retrospective multicenter study comprised 422 patients who had undergone ER for ESCC from 1994 to 2017. Inclusion required a histological diagnosis of pT1a-muscularis mucosa or pT1b-submucosa (SM) cancer. Central pathological review comprehensively evaluated depth of invasion, lymphovascular invasion (LVI), droplet infiltration (DI), infiltrative growth pattern, histological differentiation, intraductal and intraglandular involvement, solitary nest, resected margin, and other factors. Logistic regression was used to identify predictors of metastasis.

RESULTS

Metastases were identified in 103 patients. Univariate analysis identified LVI, depth of invasion, and DI as significant predictive factors. Multivariate analysis identified LVI, depth of invasion pT1b-SM2 (odds ratio 2.72) and indeterminate (positive vertical margin) (odds ratio 3.63) compared with the reference category of pT1b-SM1 as independent predictors of metastasis. Conversely, there were no significant associations between metastasis and lesion size, differentiation, cytological atypia, or infiltration pattern. Subgroup analysis showed that both the number and layer of LVI were associated with metastasis risk. In addition, four or more foci of DI was an independent predictor of LVI.

CONCLUSIONS

LVI and depth of invasion were significant predictors of metastasis in ESCC. Detailed pathological evaluation and standardized criteria are essential for accurately assessing risk of metastasis and guiding post-ER treatment strategies.

Efficacy and safety of neoadjuvant immunotherapy combined with chemotherapy for stage II-IVa esophageal cancer: a network meta-analysis

OBJECTIVE

The objective of this study was to evaluate the clinical efficacy and safety of neoadjuvant immunochemotherapy in the treatment of locally advanced, resectable esophageal cancer.

METHODS

Literature published before November 2023 on the clinical efficacy and safety of neoadjuvant immunotherapy in resectable esophageal squamous cell carcinoma was searched in CNKI, VIP, Wanfang, Chinese Biomedical Literature, PubMed, Embase, Cochrane, and the Web of Science. A meta-analysis was conducted using Stata 17.0.

RESULTS

The cumulative ranked probability results indicated that Camrelizumab + TN had the highest probability of achieving pCR, Camrelizumab + TP of achieving MPR, and Sintilimab + TP of achieving DCR and ORR. Camrelizumab + TP also had the highest probability of achieving an R0 resection rate. In terms of adverse events and postoperative complications, Pembrolizumab + TN had the highest likelihood of inducing myelosuppression and rash. Toripalimab + TP had the highest probability of inducing vomiting, while traditional chemotherapy alone had the highest likelihood of inducing postoperative cardiac adverse events.

CONCLUSION

Neoadjuvant immunotherapy combined with chemotherapy has demonstrated superior clinical efficacy and safety compared to chemotherapy alone. The regimen of Camrelizumab + TP showed significant advantages in pCR, MPR, DCR, and R0 resection rates, particularly excelling in MPR and R0 resection rates. However, it was associated with a higher incidence of rash compared to chemotherapy alone and the Toripalimab + TP regimen. Neoadjuvant immunotherapy, when combined with chemotherapy, has been shown to reduce the occurrence of postoperative cardiac adverse events. Among the various treatment options, Sintilimab + TP exhibited the most favorable outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Protocol Number: CRD42024623160.

Measures to prevent esophageal stenosis are necessary after endoscopic submucosal dissection for early esophageal cancer lesions with a circumferential ratio of 75%-99%: a retrospective case analysis

PURPOSE

Endoscopic submucosal dissection (ESD) is currently one of the most curative treatments for early esophageal cancer. We conducted a retrospective case analysis to identify the characteristics of early esophageal cancer that indicate esophageal stenosis prevention measures. Our aim was to provide a reference for clinical decision-making.

METHODS

Six hundred and fifty-four patients with early esophageal cancer treated with ESD were admitted to our hospital between January 2011 and December 2018.Clinical information such as patients' demographic characteristics, lesion features, preventive measures if any, and complications of esophageal stenosis after ESD were collected from the hospital information system. The data were statistically analysed by SPSS software (version 23.0).

RESULTS

1. Seventy-nine patients with early esophageal cancer suffered from esophageal stenosis after ESD. The median time from undergoing ESD to the first occurrence of stenosis was 27 (17-43) days. Specifically, among the 79 cases, 47 of them experienced stenosis within one month after ESD, and 23 cases experienced stenosis between 1 and 2 months after ESD, and 9 cases experienced stenosis more than 2 months after the operation.2. Taking preventive measures significantly reduced overall esophageal stenosis incidence in patients with early esophageal cancer with lesion circumferential ratio of 75%-99% (P < 0.05).3. Among patients with early esophageal cancer with 75%-99% circumferential proportion of lesions, the risk of esophageal stenosis within 2 months without prevention measures was 2.617(95% CI, 1.057-6.479) times higher than that with prevention measures.

CONCLUSION

It is necessary to take measures to prevent esophageal stenosis after ESD for early esophageal cancer lesions with a circumferential ratio of 75%-99%.

Application of failure model and effect analysis in nursing care for patients who have undergone endoscopic sub-mucosal dissection

OBJECTIVE

The objective of this study is to investigate the effect after the application of Failure Model and Effect Analysis (FMEA) in nursing care for patients who have undergone endoscopic submucosal dissection (ESD).

METHODS

A cohort of 40 patients who underwent ESD between July and September 2023 were selected as the control group, while 42 patients who underwent ESD between October 2023 and June 2024 after implementing FMEA were selected as the observation group. A multidisciplinary team was established based on the FMEA model to analyze and create a nursing flowchart. The 3 primary processes and 13 sub-processes were thoroughly analyzed and assessed to identify potential failure models, possible causes of failure, and consequences for each sub-process. Risk Priority Numbers (RPNs) were calculated to determine priority failure models, including medication and item preparation, specimen collection, equipment/instrument/accessory preparation, and nursing coordination. Corresponding improvement measures were formulated and implemented followed by a subsequent analysis of the effects.

RESULTS

After implementing the improvement measures, there was a significant decrease in RPNs in the observation group when compared with the control group. A statistical significance was observed in context of medication and item preparation (P < 0.001), specimen collection (P < 0.001), equipment/instrument/accessory preparation (P < 0.001), and nursing coordination (P < 0.001).

CONCLUSION

The application of the FMEA model can effectively facilitate early nursing interventions for identified risks in patient who have undergone ESD. By instituting suitable corrective measures for aspects deemed high-risk, this approach significantly diminishes surgical nursing hazards, enhances the quality of nursing care, and guarantees patient safety.

Characteristics and Risk Factors for Postoperative Bleeding Following Endoscopic Resection of Esophageal Squamous Neoplasms

BACKGROUND

Reports on postoperative bleeding after esophageal endoscopic resection are limited.

AIMS

This study aimed to identify the clinical characteristics and risk factors for postoperative bleeding following endoscopic resection of esophageal neoplasms.

METHODS

This single-center, retrospective study included consecutive patients who underwent endoscopic resection for esophageal squamous cell carcinoma or squamous intraepithelial neoplasm between January 2018 and December 2022. We investigated the incidence, timing, severity, and risk factors for postoperative bleeding.

RESULTS

Of 1288 patients, 1062 (82%) underwent endoscopic submucosal dissection, and 226 (18%) underwent endoscopic mucosal resection. Postoperative bleeding occurred in seven (0.5%) patients (95% confidence interval [CI] 0.2-1.1%; median postoperative day 8 [range, 4-17 days]). In these seven patients, hemoglobin concentration decreased by a median of 3.0 g/dL (range, 1.6-6.8 g/dL). Antithrombotic agent use, resection wound circumference, and specimen size were significantly associated with postoperative bleeding (P < 0.001, P = 0.002, and P = 0.024, respectively). Among 43 patients who received direct oral anticoagulants (DOACs), postoperative bleeding occurred in four (9%) patients (95% CI 2.6-22.1%). DOACs were significantly associated with postoperative bleeding even after propensity score matching (4/40 [10%] vs. 0/80 [0%], respectively; P = 0.011).

CONCLUSIONS

The overall bleeding rate following esophageal endoscopic resection was 0.5%, with a delayed onset, leading to anemia. DOACs emerged as the most significant risk factor for postoperative bleeding.

Safety and efficacy of endoscopic submucosal dissection with gel immersion technique for superficial esophageal neoplasms

BACKGROUND AND AIM

Gel immersion (GI) endoscopy provides a good visual field in endoscopic submucosal dissection (ESD); however, its clinical outcomes are poorly understood. This study aimed to compare the treatment outcomes between esophageal gel immersion endoscopic submucosal dissection (GI-ESD) and conventional ESD (C-ESD) to determine the safety and efficacy of GI-ESD.

METHODS

The data of 71 consecutive patients who underwent esophageal ESD between April 2021 and March 2023 at a Japanese tertiary center were retrospectively reviewed. GI was achieved using an additional irrigation tube. The treatment outcomes between the GI-ESD and C-ESD groups were compared using inverse probability of treatment weighting (IPTW) to control for confounding factors.

RESULTS

A total of 75 superficial esophageal epithelial neoplasms (41 in the C-ESD and 34 in the GI-ESD groups) were treated using ESD. The mean procedure time in the GI-ESD group was significantly shorter than that in the C-ESD group (59.2 ± 36.2 vs 85.3 ± 45.7 min, P = 0.008). After IPTW adjustment, the mean procedural times were 62.6 ± 36.6 and 82.9 ± 41.7 min in the GI-ESD and C-ESD groups, respectively (P = 0.037), and the incidence rate of muscle layer damage was 4.2% in the GI-ESD group and 30.6% in the C-ESD group (P = 0.001). In the multivariate analysis, specimen size ≥ 30 mm (odds ratio [OR]: 9.44, 95% confidence interval [CI]: 2.46-36.30, P = 0.001) was positively correlated with longer procedural time (≥ 90 min), whereas GI-ESD (OR: 0.19, 95%CI: 0.05-0.68, P = 0.011) showed a negative association.

CONCLUSIONS

Esophageal GI-ESD may be useful in terms of safety and time efficiency. The GI technique could be an option for esophageal ESD.

Outcomes of endoscopic submucosal dissection versus esophagectomy for poorly differentiated superficial esophageal squamous cell carcinoma: A 10-year cohort study

BACKGROUNDS

The efficacy of endoscopic submucosal dissection (ESD) to treat poorly differentiated superficial esophageal squamous cell carcinoma (SESCC) is unclear.

AIMS

To exploring the efficacy and prognosis of ESD treatment poorly differentiated SESCC compared with esophagectomy.

METHODS

A retrospective cohort study was conducted, the data of poorly differentiated SESCC patients who received ESD or esophagectomy from Jan 2011 to Jan 2021 were analyzed. Overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), and procedure-related variables were compared between ESD and esophagectomy group.

RESULTS

95 patients underwent ESD, while 86 underwent esophagectomy. No significant differences were found between the two groups in OS (P = 0.587), DSS (P = 0.172), and RFS (P = 0.111). Oncologic outcomes were also similar between the two groups in propensity score-matched analysis. For T1a ESCC, the rates of R0 resection, LVI or nodal metastasis and additional therapy were similar between ESD and esophagectomy groups. But for T1b ESCC, the rates of positive resection margin and additional therapy were significantly higher in ESD group than those in esophagectomy group.

CONCLUSIONS

ESD is a minimally invasive procedure that has comparable oncologic outcomes with esophagectomy for treatment poorly differentiated T1a ESCC. However, ESD is not suitable for poorly differentiated T1b ESCC, additional surgery or radiochemotherapy should be required.

Characteristics of multiple esophageal squamous cell carcinomas detected in the surveillance after endoscopic resection

BACKGROUND AND STUDY AIM

Endoscopic resection (ER) of esophageal squamous cell carcinoma (ESCC) is an organ-preserving treatment; however, heterochronic carcinomas are often encountered. Most patients are treated using ER; however, for some, this is inadequate and requires additional treatment. We sought to identify the characteristics and frequency of lesions at high risk of metastasis during surveillance based on Lugol-voiding lesion (LVL) grading and esophagogastroduodenoscopy (EGD) intervals.

METHODS

Of the 1301 patients who underwent ER, 956 underwent surveillance EGD at our hospital for at least 1 year (median, 59 months). We analyzed identified multiple ESCCs to reveal the characteristic of high-metastasis-risk lesions, which was defined ESCC with submucosal or lymphovascular invasion.

RESULTS

In the 956 patients, 444 multiple ESCCs were identified in 216 patients and the cumulative incidence of multiple ESCCs was 15.4% and 22.9% at 3 and 5 years, respectively, while for high-risk lesions, it was 1.0% and 1.8%. The risk factors for high-metastasis-risk lesions were being female (odds ratio (OR):5.58, 95% confidence interval (CI):1.96-15.9), lesions located in the cervical/upper thoracic esophagus (OR: 4.81, 95% CI:1.80-12.8), and the presence of submucosal tumor (SMT)-like marginal elevation (OR:65.4, 95% CI:11.0-390). No significant differences in the frequency of high-risk lesions were found based on LVL grade at any EGD intervals.

CONCLUSION

During endoscopic surveillance, attention should be given to the cervical/upper thoracic esophagus and lesions with SMT-like marginal elevation. The frequency of high-metastasis-risk lesions was not different by LVL grade or EGD intervals.

Characteristics of cases for which esophageal endoscopic submucosal dissection under general anesthesia is recommended

BACKGROUND/AIMS

Esophageal endoscopic submucosal dissection (ESD) performed under general anesthesia can potentially provide more stable treatment in difficult cases than that under sedation. We evaluated the clinical characteristics and outcomes of ESD performed under general anesthesia compared with those under propofol sedation and discussed the cases in which general anesthesia is recommended.

PATIENTS AND METHODS

In total, 292 lesions in 265 consecutive patients undergoing esophageal ESD at Yamaguchi University Hospital from 2013 to 2023 were included in this retrospective study.

RESULTS

ESD was performed under general anesthesia for 92 lesions in 81 patients and under propofol sedation for 200 lesions in 184 patients. Tumor long-axis diameter was larger (39.8 ± 14.4 mm vs. 32.4 ± 9.9 mm, p < 0.01) and dissection speed was faster (10.5 ± 5.9 mm2/min vs. 7.5 ± 4.2 mm2/min, p < 0.01) in the general anesthesia group versus the sedation group. In the sedation group, a treatment history of pharyngeal cancer was significantly associated with a slower dissection speed (p = 0.037). The sedation group showed higher frequencies of hypoxemia (0% vs 9.8%, p < 0.01), interruption due to body movement (0% vs 13%, p < 0.01), and acute adverse events (21.7% vs 33.5%, p = 0.05). A treatment history of pharyngeal cancer was shown to be the significant factor contributing to acute adverse events (p = 0.018).

CONCLUSION

Esophageal ESD under general anesthesia can be a treatment option in patients with difficulty in performing stable procedures with propofol sedation. Especially in patients with a treatment history of pharyngeal cancer in whom ESD is more difficult to be performed and who are at higher risk for acute adverse events, general anesthesia can be considered.

International Validation of a Novel PEACE Scale to Improve the Quality of Upper Gastrointestinal Mucosal Inspection During Endoscopy

INTRODUCTION

The performance of a high quality esophagogastroduodenoscopy (EGD) is dependent on the mucosal cleanliness. Recently, the Polprep: Effective Assessment of Cleanliness in EGD (PEACE) scale was created to assess the degree of mucosal cleanliness during EGD. The aim of this study was to validate this scoring system in a cohort of international endoscopists.

METHODS

In total, 39 EGD videos, with different degrees of mucosal cleanliness were retrieved from a previously conducted prospective trial. All experts rated the cleanliness of the mucosa on each video using the PEACE scale. To evaluate agreement of all scores (0-3), intraclass correlation coefficient 2.1 was used. The agreement on adequate (scores 2 and 3) and inadequate (scores 0 and 1) cleanliness was assessed using kappa values.

RESULTS

Videos evaluating esophagus, stomach, and duodenum cleanliness were reviewed by 16 endoscopists. The PEACE scores demonstrated good agreement (intraclass correlation coefficient 0.82, 95% CI 0.75-0.89), especially for esophagus (0.84; 95% CI 0.71-0.95) and stomach (0.81; 95% CI 0.69-0.91), while agreement was moderate for the duodenum (0.69; 95% CI 0.51-0.87). The agreement was similar between Eastern (0.86; 95% CI 0.79-0.92) and Western experts (0.80; 95% CI 0.72-0.88). Similarly, agreement regarding adequate cleanliness was comparable between Eastern (0.70; 95% CI 0.55-0.85) and Western (0.74; 95% CI 0.64-0.84) endoscopists being overall 0.75 (95% CI 0.65-0.85).

DISCUSSION

The PEACE scoring system is a simple and reliable scale to assess the cleanliness during EGD. The score is now validated among international experts with high concordance, justifying its use in clinical practice.

Effectiveness of Triamcinolone Injections in Preventing Scar Deformity following Endoscopic Submucosal Dissection for Pharyngeal Cancer

Introduction

Endoscopic submucosal dissection (ESD) is an effective treatment for superficial pharyngeal cancer. However, pharyngeal deformity caused by postoperative ulcer contraction is a major concern and can result in a poor quality of life. While local steroid injections have been shown to prevent strictures after ESD for esophageal cancer, their effectiveness in preventing deformities following ESD for pharyngeal cancer remains unclear.

Case Presentation

A 60-year-old woman with superficial pharyngeal cancer in the left pyriform sinus underwent ESD. After ESD, 80 mg of triamcinolone acetonide was injected into the ulcer bed to prevent scar contracture. The patient experienced mild pharyngeal pain, which resolved within a few days. Histopathological examination confirmed the lesion was well-differentiated SCC, with negative resection margins and no lymphovascular invasion. Follow-up endoscopy at 6 weeks showed granulation tissue in the surgical wound, which completely healed without pharyngeal deformity by 14 weeks post-ESD.

Conclusion

This case demonstrated that the injection of triamcinolone in an ulcer that developed after ESD may be an effective method of preventing pharyngeal deformity caused by scar contracture.

Comparison of outcomes between surgery and chemoradiotherapy after endoscopic resection for pT1a-MM with lymphovascular invasion or pT1b esophageal squamous cell carcinoma: Japanese multicenter propensity score-matched study

BACKGROUND

Lymphovascular invasion (LVI) or pT1b is noncurative after endoscopic resection (ER) for esophageal squamous cell carcinoma (ESCC), and therefore surgery or chemoradiotherapy (CRT) is recommended. However, there has been debate regarding which treatment has better outcomes and whether individual risks should be considered.

METHODS

This was a multicenter, retrospective study conducted at 65 hospitals in Japan. The inclusion criteria were patients with ESCC who underwent ER between January 2006 and December 2015, with pT1a-muscularis mucosa (MM) with LVI or pT1b, with negative vertical margins, cN0M0, and who underwent surgery or CRT. A 1:1 propensity score-matched analysis was performed between two groups. The primary and secondary end points were overall survival (OS) and relapse-free survival (RFS). OS and RFS were also compared between two subgroups: low risk (pT1a-MM with LVI and pT1b without LVI) and high risk (pT1b with LVI) for metastatic recurrence.

RESULTS

Among 472 patients, 160 patients were selected from each group. The OS and RFS did not differ between surgery and CRT groups (hazard ratio, 0.887; P = .635 and hazard ratio, 1.036; P = .876, respectively). Subgroup analysis showed that CRT had a better prognosis in the low-risk group, and conversely, surgery had a better prognosis in the high-risk group. But these were not significant. The high-risk CRT group had a significant worse prognosis than the low-risk CRT group.

CONCLUSIONS

In patients with noncurative ER for ESCC, surgery and CRT showed no difference in long-term outcomes. Indications for CRT in the high-risk group need further investigation because of poor prognosis.