World Congress of Gastroenterology

WCOG 2019


 
Endoscopic Submucosal Dissection with Tunneling Method versus Circumferential Incision for Treatment of Superficial Esophageal Cancer
Tarso Magno Leite Ribeiro 1 Vitor Arantes 2 Jonas Augusto Ramos 1 Roberto Gardone Guimarães 2

1- FEDERAL UNIVERSITY OF SãO JOãO DEL REI, BRAZIL
2- SCHOOL OF MEDICINE, FEDERAL UNIVERSITY OF MINAS GERAIS, BELO HORIZONTE, BRAZIL
 
Background/Aims:

Endoscopic submucosal dissection (ESD) is the best approach to treat esophageal superficial neoplastic lesions, enabling a higher rate of en bloc R0 resection and a lower recurrence rate. Esophageal ESD requires a long learning curve and still is restricted to tertiary centers. Esophageal ESD strategies include a tunneling method (TM) and the most traditional circumferential incision (CI). There are scarce reports in the West comparing clinical outcomes for existing ESD techniques. This study aimed to compare two esophageal ESD techniques: TM versus CI.

Materials and Methods:

Single-center retrospective review of prospectively collected endoscopic data of a specialized ESD center in Brazil, investigating consecutive patients that underwent esophageal ESD between October 2009 and December 2018. After placement of markings and submucosal injection, two different ESD strategies were assessed: TM -  first set the distal incision then proceed to oral incision followed by submucosal dissection in the oral-anal direction; CI – proceed a circumferential incision outside tumor borders followed by submucosal dissection. The following variables were assessed: demographic data, clinical-pathologic characteristics, procedure duration, en bloc resection rate, R0 resection rate, curative resection rate, local recurrence and adverse events.

Results:

A total of 65 procedures were carried out, 23 TM and 42 CI, with a mean follow-up of 8 years and 2.75 years respectively (p<0.001). Patient demographics and baseline characteristics are described in Table 1. Table 2 presents the clinical outcome of both ESD procedures. There was no statistically significant difference in terms of clinical outcome among ESD with TM versus CI: en bloc resection rate (91.3% vs 100%, p 0.122), R0 resection (65.2% vs 78.6% p 0.241), curative resection (65.2% vs 73.8%, p 0.466), average procedure time (118.7 min vs 102.4 min, p 0.351), local recurrence rate (8.7 vs 2.4, p 0.284), and procedure-related complications such as bleeding (0 vs 2.4%, p 0.53), perforation (8.7% vs 4.8%, p 0.610) and stricture (8.7% vs 9.5% p 0.310). Lesions were more superficial in patients that underwent ESD with CI (p<0.003).  There was no mortality related to the procedures.

Table 1. Baseline Characteristics

Characteristic

TM ESD

CI ESD

P value

Number of Patients

23

42

-

Gender

 

 

0,317****

   Male

19 (82,6%)

30 (71,4%)

 

   Female

4 (17,4%)

12 (28,6%)

 

Age (years) mean ± SD

64,6 ± 12,4

64,8 ± 9.8

0,947*

Tumor size (mm) ± SD

28,9 ± 12

35,8 ± 19.9

0,380***

Location of the tumor in the esophagus

 

 

0,165*

   Upper one-third

1 (4,3%)

6 (14,3%)

 

   Middle one-third

8 (34,8%)

20 (47,6%)

 

   Lower one-third

14 (60,9%)

16 (38,1%)

 

Paris Classification

 

 

0,773*

   Elevated 0-IIa

4 (17,4%)

12 (28,6%)

 

   Flat 0-IIb

15 (65,2%)

24 (57,1%)

 

   Depressed 0-IIc

3 (13%)

5 (11,9%)

 

   Mixed types

1 (4,3%)

1 (2,4%)

 

Luminal extent

 

 

0,147*

   <1/2

14 (60,9%)

15 (35,7%)

 

    ≥1/2

5 (21,7%)

16 (38,1%)

 

   >2/3

4 (17,4%)

11 (26,2%)

 

Lesion Type

 

 

0,129*

SCC

17 (73,9%)

23 (54,8%)

 

Dysplasia or adenocarcinoma associated with BE

6 (26,1%)

19 (45,2%)

 

SD: Standard deviation. * Chi square test. ** Fisher. ***Mann Whitney test. **** t-Student test. BE= Barretts Esophagus. SCC: Squamous Cell Carcinoma.

Table 2. ESD Outcomes

Characteristic

TM ESD

CI ESD

P value

Curative resection

15 (65,2%)

31 (73,8%)

0,466*

R0 Resection

15 (65,2%)

33 (78,6%)

0,241*

En bloc resection

21 (91,3%)

42 (100%)

0,122**

Procedure time (min)

118,7 ± 50,8

102,4 ± 40,4

0,351***

Recurrence

2 (8,7%)

1 (2,4%)

0,284**

Tumor invasion depth

 

 

0,003*

   Dysplasia/intraepithelial neoplasia (M1)

8 (34,8%)

20 (47,6%)

 

   Lamina propria mucosae (M2)

4 (17,4%)

1 (2,4%)

 

   Muscularis mucosae (M3)

5 (21,7%)

12 (28,6%)

 

   Submucosa (SM1)

4 (17,4%)

0

 

   Submucosa (SM2)

0

8 (19%)

 

   Submucosa (SM3 or deeper)

2 (8,7%)

1 (2,4%)

 

Procedure-related complications

 

 

 

      Bleeding

0

2 (4,8%)

0,536**

      Perforation

2 (8,7%)

2 (4,8%)

0,610**

      Pneumomediastinum

2 (8,7%)

0

0,122**

Stricture

2 (8,7%)

4 (9,5%)

0,310*

 * Chi square test. ** Fisher. ***Mann Whitney test. **** t-Student test. 

Conclusion:

ESD with TM or CI demonstrated to be equally safe, with low complication rate and zero mortality, presenting similar results in terms of clinical outcome for patients with superficial esophageal neoplastic lesions.

Keywords:

Endoscopic submucosal dissection, Esophageal cancer, Therapeutic endoscopy