Endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: long-term follow-up in a Western center

Feasibility and predictors of same-day discharge following endoscopic submucosal dissection for early esophageal cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) is a common treatment for early esophageal cancer. Although ESD is considered safe, same-day discharge (SDD) is only feasible in selected patients. Therefore, identifying factors associated with the likelihood of SDD is crucial for optimizing patient selection and clinical management.

METHODS

We conducted a retrospective analysis of patients with early esophageal cancer treated with ESD between August 2020 and July 2024. Patients were divided into SDD and non-SDD groups. Preoperative clinical features were compared between the groups. Univariate and multivariate logistic regression analyses were performed to identify independent predictors associated with the feasibility of SDD.

RESULTS

Among 146 patients, 42 (28.8%) were discharged on the same day. Multivariate analysis identified larger lesion size (OR = 2.152, 95% CI: 2.037-2.280, p = 0.008), history of alcohol abuse (OR = 6.507, 95% CI: 3.169-11.211, p = 0.032), and tumor location in the upper esophagus (OR = 7.827, 95% CI: 5.481-14.547, p = 0.023) as significant factors negatively associated with SDD feasibility. Notably, larger lesions were associated with a lower likelihood of SDD.

CONCLUSION

Tumor size, upper esophageal location, and a history of alcohol abuse were identified as independent predictors associated with reduced feasibility of same-day discharge following ESD.

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.

Endoscopic resection of early esophageal neoplasia in patients with esophageal varices: a systematic review

Although endoscopic resection (ER) is recommended as first-choice treatment for early esophageal neoplasia, patients with esophageal varices are considered a high-risk group owing to an increased risk of bleeding. This systematic review aimed to evaluate the effectiveness and safety of ER in this specific patient category.We searched for studies reporting on clinical outcomes of ER in the presence of esophageal varices, irrespective of study design or follow-up time. End points included the incidence of prophylactic measures to reduce the risk of variceal hemorrhage, radical and curative resection rates, and adverse events.After screening 2371 studies, 42 studies (including our own unpublished cohort) with a total of 186 patients were included in this systematic review. Endoscopic band ligation (72/186; 39%) and endoscopic injection sclerotherapy (22/186; 12%) were the prophylactic measures most widely adopted to eradicate varices prior to ER. Other frequently described prophylactic measures included direct varix coagulation during ER (18/186; 10%) and the placement of a transjugular intrahepatic portosystemic shunt prior to ER (9/186; 5%). While the radical and curative resection rates were high (86% and 72%, respectively), the periprocedural and delayed bleeding risks were reported to be relatively low (6% and 3%, respectively). In all studies, no procedure-related mortality was observed.ER appeared to be a safe and effective treatment option in selected patients with concurrent early esophageal neoplasia and esophageal varices, provided that a tailored approach of adequate prophylactic measures to prevent bleeding is applied.

Long-Term Outcomes of Esophageal Squamous Neoplasia with Muscularis Mucosa Involvement after Endoscopic Submucosal Dissection

Ambiguity exists over treatment and surveillance strategies after endoscopic submucosal dissection (ESD) for esophageal squamous cell neoplasia (ESCN) with unfavorable histologic features. This study investigated the long-term outcomes of ESD in high-risk ESCN patients. We retrospectively included early ESCN patients treated with ESD at two medical centers in Taiwan between August 2010 and December 2023. Demographic, endoscopic and pathological data were collected. Among 146 patients (mean age 59.17 years) with 183 lesions, 73 (50%) had a history of head and neck cancer (HNC). En bloc and R0 resections were achieved in 100% and 95.6% of the lesions, respectively. The 5-year overall survival (OS), disease-specific survival (DSS) and local recurrence rates were 42.7%, 94.7% and 11%. R0 resections were significantly associated with recurrence in a univariate analysis (HR: 0.19, 95% CI: 0.06-0.66, p = 0.008). Alcohol abstinence was independently associated with lower recurrence (HR: 0.34, 95% CI: 0.16-0.73, p = 0.006). Patients with pT1a-MM (muscularis mucosa invasion) had comparable OS (p = 0.82), DSS (p = 0.617) and recurrence (p = 0.63) rates to those with pT1a-EP/LPM (epithelium/lamina propria invasion). The long-term outcomes of ESCN patients after ESD for expanded indications were satisfactory. ESD could be considered in selected ESCN patients involving the muscularis mucosa, notably among high-risk HNC patients.

Endoscopic submucosal dissection for early esophageal squamous cell carcinoma: long-term results from a Western cohort

BACKGROUND

Although endoscopic submucosal dissection (ESD) is established as first-choice treatment for early esophageal squamous cell carcinoma (ESCC) worldwide, most data are derived from Asian studies. We aimed to evaluate the long-term outcomes of ESD for patients with early ESCC in a Western cohort.

METHODS

In this retrospective cohort study, patients with early ESCC amenable to ESD were included from four tertiary referral hospitals in the Netherlands between 2012 and 2017. All ESD procedures were performed by experienced endoscopists, after which the decision for additional treatment was made on a per-patient basis. Outcomes were curative resection rate, ESCC-specific survival, and overall survival.

RESULTS

Of 68 included patients (mean age 69 years; 34 males), ESD was technically successful in 66 (97%; 95%CI 93%-100%), with curative resection achieved in 34/66 (52%; 95%CI 39%-64%). Among patients with noncurative resection, 15/32 (47%) underwent additional treatment, mainly esophagectomy (n = 10) or definitive chemoradiation therapy (n = 4). Endoscopic surveillance was preferred in 17/32 patients (53%), based on severe comorbidities or patient choice. Overall, 31/66 patients (47%) died during a median follow-up of 66 months; 8/31 (26%) were ESCC-related deaths. The 5-year overall and ESCC-specific survival probabilities were 62% (95%CI 52%-75%) and 86% (95%CI 77%-96%), respectively.

CONCLUSION

In this Western cohort with long-term follow-up, the effectiveness and safety of ESD for early ESCC was confirmed, although the rate of noncurative resections was substantial. Irrespective of curative status, the long-term prognosis of these patients was limited mainly due to competing mortality.

Endoscopic Submucosal Dissection for Esophageal Cancer: Current and Future

Endoscopic submucosal dissection (ESD) has been widely used to treat superficial esophageal cancer. The advantages of esophageal ESD include a high en bloc resection rate and accurate pathological diagnosis. It enables local resection of the primary tumor and accurate identification of the risk factors for lymph node metastasis, including depth, vascular invasion, and types of invasion. Even in cases with clinical T1b-SM cancer, ESD and additional treatment can achieve radical cure, depending on the risk of lymph node metastasis. Esophageal ESD will be increasingly vital in minimally invasive and effective esophageal cancer treatment. This article describes the current status and prospects of esophageal ESD.