| Part 1 Multi-band mucosectomy Versus endoscopic submucosal disection for the treatment of early esophageal cancer and precancerous lesionsBackground and objectives:Esophageal squamous cell carcinoma (ESCC) is common in North Central China, and its incidence is among the highest, worldwide. Its pathogenesis involves a multistep process that evolves through grades of dysplasia to cancer. Each of these phases is characterized by an increased risk of eventual ESCC development. A follow-up study in patients over 13.5 years revealed that 25% of patients with mild dysplasia,50% of patients with moderate dysplasia, and 75% of patients with severe dysplasia developed cancer. Early detection and resection of cancerous lesions is essential for preventing metastatic disease of esophagus.EMR (endoscopic mucosal resection) and ESD(endoscopic submucosal disection) have become the mainstay for treating superficial neoplasms in the upper gastrointestinal (GI) tract. Due to continuous improvement, current EMR techniques allow the resection of mucosal lesions smaller than 2 cm; however, larger tumors remain challenging, especially for the esophagus. ESD allows en bloc resection regardless of tumor size and histology of the specimens. However, ESD is more time consuming than EMR, and is associated with higher rates of complications such as perforation or bleeding. Multi-band mucosectomy (MBM) is a technique that appears well-fitted for the resection of large mucosal areas without requiring submucosal injection, and a single snare can be used for the entire procedure. However, widespread implementation of MBM would require a head-to-head comparison of the efficacy and safety of these two approaches. To date, such comparisons are relatively scarce; prompting further efforts in this respect. So we decided to compare the efficacy and safety of endoscopic submucosal dissection (ESD) versus multi-band mucosectomy (MBM) for treating squamous intraepithelial neoplasia of the esophagus.Methods:A total of 78 patients with squamous intraepithelial neoplasia of the esophagus who received either ESD or MBM were included in this retrospective study. A fraction of patients underwent successful en bloc resection, in which complete resection of the neoplastic process was achieved during the procedure and the relative success of curative resection was calculated. Complications and local recurrence were compared between the two groups.Results:Overall, there was no statistical difference in the rate of complete resection between ESD and MBM (95.8% vs.93%, P>0.05). For tumors>15 mm in width, ESD produced a significantly higher en bloc resection rate (13/13 vs.13/29, P=0.002) and curative resection rate (12/13 vs.11/29, P=0.001) rate, compared to MBM. No significant difference was found between lesions<15 mm. MBM is associated with a significantly shorter procedure time compared to ESD (P<0.05). Major bleeding occurred in 1.85% and 16.7% of MBM and ESD procedures, respectively (P<0.05). Perforation rate for ESD (8.3%) was significantly higher than MBM (P<0.05). No significant difference was found between these two techniques with respect to the occurrence of postoperative esophageal strictures (P>0.05). There was no difference in the three-year local recurrence rate between the two groups (P>0.05).Conclusions:ESD appears to be superior to MBM with respect to the success of attempted en bloc resection and the number of curative resections achieved, while concomitantly showing a longer procedure time. However, MBM is associated with less perforation and bleeding, allows safe and easy piecemeal resections, and is associated with similar clinical success in ESD in follow-ups. Thus, larger randomized studies are needed to determine which endoscopic resection modality is far more superior over the other.Part 2:Comparison of Endoscopic Resection and Minimally Invasive Esophagectomy in Patients With Early Esophageal CancerBackground and objectives:The incidence of esophageal cancer has increased dramatically over the past decades. Traditional esophageal enucleation or esophagogastrectomy requires a laparotomy or thoracotomy, depending on the location of the tumor. And esophagectomy is a complex operation associated with significant morbidity and mortality.However, minimally invasive esophagectomy (MIE), which includes MIE techniques include both total laparoscopic/thoracoscopic THE or ILE and also hybrid procedures with at least one of the approaches being done via either laparoscopy or thoracoscopy, can reduce the rate of pulmonary infections, thus reducing the length of hospital stay. Because of these potential advantages, use of MIE is increasing. Several limitations to laparoscopic and thoracoscopic approaches for esophagectomy include instrumentation, the narrow field of the mediastinum, and the 2-dimensional view of conventional equipment. MIE is a complex procedure that requires a longer operative time but is associated with shorter hospital stays and a lower number of blood transfusions. Minimally invasive techniques for esophageal resection are feasible in terms of the completeness of resection and the extent of lymphadenectomy; however, these techniques have not insignificantly improved postoperative morbidity. Endoscopic resection (ER), including endoscopic mucosal resection and endoscopic submucosal dissection(ESD), has become the standard treatment for superficial neoplasms in the upper gastrointestinal (GI) tract. Endoscopic treatments are associated with excellent clinical results in terms of curative resection rate and overall survival, with fewer and generally less severe complications. ER may be a reasonable alternative for the treatment of early esophageal cancer, especially in patients with a higher surgical risk. To date, little information is available regarding the comparative efficacy of ER and MIE. Therefore, the aim of this study was to compare the clinical outcomes of ER and MIE for the treatment of early esophageal carcinoma.Materials and Methods:This study retrospectively analyzed a total of 99 consecutive patients with pathologically confirmed early esophageal cancer between December 2007 and 2011. ER was performed in 59 patients, whereas MIE was performed in 40 patients. We compared the 2 groups according to R0 resection rates, treatment-related complications, mean hospital stay, local recurrence rates, and 3-and 4-year overall survival.Results:No significant differences were found in the R0 resection rates between ER and MIE (94.9% vs.97.5%, P>0.05). The occurrence rate of minor complications in the ER group was significantly lower than that in the thoracoscopic esophagectomy group (11.8% vs.32.5%, P<0.05). The mean operative time in the ER group was 74+ 23 minutes, which was significantly shorter than that in the MIE group (298+46 min). The average length of hospital stay in the ER group was significantly shorter than that in the MIE group (P<0.001). No significant differences were observed in the local recurrence rates between the 2 groups(P>0.05). Similarly, no differences were foun or several patients in this study.Conclusions Endoscopic therapy is equal to the thoracoscopic esophagectomy in the treatment of early esophageal cancer with lower complication occurrence rate, shorter recovery time. and similar survival, but required multiple procedures in most patients. |
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