Clin Endosc.  2023 Sep;56(5):613-622. 10.5946/ce.2022.245.

Management of esophageal neoplasms by endoscopic submucosal dissection: experience over 100 consecutive procedures

• Ramos JA
• Morita Y
• Toyonaga T
• Carvalho D
• Pedrosa MS
• Arantes VN

• KMID: 2546140
• DOI: http://doi.org/10.5946/ce.2022.245

Abstract

Background/Aims
Endoscopic submucosal dissection (ESD) is currently considered the first-line treatment for the eradication of superficial neoplasms of the esophagus in Eastern countries. However, in the West, particularly in Latin America, the experience with esophageal ESD is still limited because of the high technical complexity required for its execution. This study aimed to present the results of the clinical application of ESD to manage superficial esophageal neoplasms in a Latin American center in over 100 consecutive cases.
Methods
This retrospective study included consecutive patients who underwent endoscopic ESD for superficial esophageal neoplasms between 2009 and 2022. The following clinical outcomes were assessed: en bloc, complete, and curative resection rates, local recurrence, adverse events, and procedure-related mortality.
Results
Esophageal ESD was performed mainly for squamous cell carcinoma (66.6%), high-grade intraepithelial neoplasia (17.1%), and adenocarcinoma (11.4%). En bloc and complete resection rates were 96.2% and 81.0%, respectively. The curative resection rate was 64.8%. Adverse events occurred in six cases (5.7%). Endoscopic follow-up was performed for an average period of 29.7 months.
Conclusions
ESD performed by trained operators is feasible, safe, and clinically effective for managing superficial neoplastic lesions of the esophagus in Latin America.

Keyword

Early esophageal cancer; Endoscopic submucosal dissection; Superficial esophageal neoplasms

Figure

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  Fig. 1. Outline of the selection process. IPCL, intrapapillary capillary loop; M1, intramucosal M1; M2, intramucosal M2; M3, intramucosal M3; SM1, superficial submucosa; SM2, deep submucosa; ESD, endoscopic submucosal dissection; EUS, endoscopic ultrasonography; CT, computed tomography; PET, positron emission tomography; CRT, chemoradiotherapy. N+ is locoregional lymphatic metastasis.

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  Fig. 2. An illustrative case of esophageal endoscopic submucosal dissection (ESD). (A) A slightly depressed, erythematous lesion (type 0-IIc) was observed in the distal esophagus in white-light view. (B) Lugol chromoendoscopy demonstrating lesion extension. The biopsy findings were consistent with those of squamous cell cancer. (C) Narrow band imaging (NBI) view revealing a slightly depressed neoplasm with clear margins and a good indication for endoscopic resection. (D) Markings were placed. (E) After submucosal injection of sodium hyaluronate, oral incision was started. (F) After circumferential incision and submucosal dissection, a flap was created toward the gravity side. (G) ESD was performed in the oral to anal direction. A clear view of the submucosal space was noted for trimming. (H) ESD was successfully accomplished with a final defect occupying 50% of the circumference and 6 cm in longitudinal extension. (I) A 60-mm specimen was fixed for histological assessment. The NBI view showing all the markings inside the specimen. (J) Closed-view NBI demonstrating a mixed B1 microvascular pattern with minimal avascular areas. (K) Lugol chromoendoscopy of the specimen revealing a tumor with free margins. Histology revealed squamous cell carcinoma with lamina propria invasion (M2), free margins, and no lymph/vascular invasion. ESD was considered curative, and endoscopic follow-up was recommended.

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