Percutaneous transgastric traction-assisted esophageal endoscopic submucosal dissection: a randomized controlled trial in a porcine model

Comparable Data Between Double Endoscopic Intraluminal Operation and Conventional Endoscopic Submucosal Dissection for Esophageal Cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) of superficial esophageal cancer has been used increasingly as an alternative to surgery because it is minimally invasive and has a high rate of en bloc resection. We previously reported that the double endoscopic intraluminal operation (DEILO) is a useful technique for ESD of early esophageal cancers. In the current study, we showed comparable short-term data between DEILO and conventional ESD groups to demonstrate the further advanced use of DEILO.

METHODS

We studied 111 esophageal cancer patients with 111 lesions treated using endoscopic surgery between January 2010 and June 2016 at Gunma University Hospital. Of the patients, 51 underwent DEILO (DEILO group) and 60 underwent conventional ESD (ESD group). We compared the operable performance, complications, and pathological outcome between the ESD and DEILO groups.

RESULTS

There was no significant difference in operable performance. However, the DEILO group showed a significantly lower rate of mediastinal emphysema compared to the ESD group (p = 0.025). Overall, the DEILO group showed a lower complication rate compared to the ESD group, although there was no apparent significance.

CONCLUSION

To our knowledge, this is the first report comparing DEILO and conventional ESD for esophageal cancer. The results showed that DEILO is not inferior to conventional ESD. DEILO is an excellent endoscopic surgical method, although it has some limitations compared to conventional ESD.

Esophageal Endoscopic Submucosal Dissection Assisted by an Overtube with a Traction Forceps: An Animal Study

Esophageal endoscopic submucosal dissection (ESD) is technically difficult. To make it safer, we developed a novel method using overtube with a traction forceps (OTF) for countertraction during submucosal dissection. We conducted an ex vivo animal study and compared the clinical outcomes between OTF-ESD and conventional method (C-ESD). A total of 32 esophageal ESD procedures were performed by four beginner and expert endoscopists. After circumferential mucosal incision for the target lesion, structured as the isolated pig esophagus 3 cm long, either C-ESD or OTF-ESD was randomly selected for submucosal dissection. All the ESD procedures were completed as en bloc resections, while perforation only occurred in a beginner's C-ESD procedure. The dissection time for OTF-ESD was significantly shorter than that for C-ESD for both the beginner and expert endoscopists (22.8 ± 8.3 min versus 7.8 ± 4.5 min, P < 0.001, and 11.3 ± 4.4 min versus 5.9 ± 2.5 min, P = 0.01, resp.). The frequency and volume of the submucosal injections were significantly smaller for OTF-ESD than for C-ESD (1.3 ± 0.6 times versus 2.9 ± 1.5 times, P < 0.001, and 5.3 ± 2.8 mL versus 15.6 ± 7.3 mL, P < 0.001, resp.). Histologically, muscular injury was more common among the C-ESD procedures (80% versus 13%, P = 0.009). Our results indicated that the OTF-ESD technique is useful for the safe and easy completion of esophageal ESD.

Advanced endoscopic submucosal dissection with traction

Endoscopic submucosal dissection (ESD) has been established as a standard treatment for early stage gastric cancer (EGC) in Japan and has spread worldwide. ESD has been used not only for EGC but also for early esophageal and colonic cancers. However, ESD is associated with several adverse events, such as bleeding and perforation, which requires more skill. Adequate tissue tension and clear visibility of the tissue to be dissected are important for effective and safe dissection. Many ESD methods using traction have been developed, such as clip-with-line method, percutaneous traction method, sinker-assisted method, magnetic anchor method, external forceps method, internal-traction method, double-channel-scope method, outerroute method, double-scope method, endoscopic-surgical-platform, and robot-assisted method. Each method has both advantages and disadvantages. Robotic endoscopy, enabling ESD with a traction method, will become more common due to advances in technology. In the near future, simple, noninvasive, and effective ESD using traction is expected to be developed and become established as a worldwide standard treatment for superficial gastrointestinal neoplasias.