| BackgroundEsophageal cancer is a deadly disease, ranking sixth among all cancers in mortality, and the eighth leading cause of cancer death. Esophageal cancer is one of common malignant tumors in China. Despite considerable advancement of therapeutic strategies, the mortality rate of esophageal cancer remains high. Early esophageal cancer generally no symptoms, At the moment, doctors usually only discover them by accident when endoscopy. The overall 5-year survival rate of early esophageal cancer is around 90%, but less than 10% for advanced patients. Surgery is commonly accepted as a standard treatment for resectable cancers but the prognosis remains unsatisfactory, because most patients were diagnosed at late stage and with high lymph node metastasis. Therefore, early discovery, diagnosis and treatment are necessary to elevate survival rates and quality of life for those patients.The two major histologic types of esophageal cancers are squamous cell carcinomas and adenocarcinomas. Over 90% of the patients are histologically proven to be squamous cell carcinoma patients and in more than 40% of the patients it occurs in the middle third of the thoracic esophagus. The abnormalities of esophageal squamous epithelium included in the order from normal, mild, moderate to severe atypical hyperplasia and squamous carcinoma. The atypical hyperplasia means the adult cell morphology, size changes and the neoplastic cells show pleomorphism, with hyperchromatic nuclei. In the tubal gut, the term "indefinite for dysplasia (intraepithelial neoplasia)" is used instead of "atypical" to describe lesions that raise concerns for, but not diagnostic of, neoplasia.Early esophageal cancer refers to cancer within bound the esophageal submucosa, not involving the muscle layer, Endoscopic approachs in diagnosing early esophageal cancer and precancerous lesions include chromoendoscopy, endoscopic ultrasonography, narrow-band imaging, magnifying endoscope and confocal laser endoscopy. They select reasonable endoscopic therapy or surgical resection, according to lesion characteristics of intramucosal cancer and submucosal cancer in endoscopy and metastasis with the lymph node and the vessel or not.Esophageal cancer is one of the most malignant cancers worldwide. In the past, for larger early esophageal cancer, surgery was performed to remove them, however, it’s either large surgical trauma or difficult to indentify. A large amount of data showed that patients with ml or m2 lesions are good candidates for endoscopy resection because there was no case of lymph node metastasis in ml and m2. With the improvement of endoscopic diagnosis and the widespread application of endoscopic ultrasonography (EUS), esophageal cancer could be detected and the depth of invasion diagnosis more accurate. Then early esophageal cancer resected in endoscopy becomes possible. Endoscopic submucosal dissection (ESD) is a recognized technique for the resection of esophageal superficial carcinomas larger than 20mm as it allows en bloc R0 resection. Nevertheless, Its high risk and time-consuming limits its widespread use. In recent years, endoscopic submucosal tunneling dissection (ESTD) has emerged as a new technique for resecting early esophageal cancer for its low perforation. Endoscopic submucosal tunnel dissection (ESTD) was first introduced by Linghu as a new strategy for rapid resection of early esophageal cancer. However, for large early esophageal cancer, endoscopic submucosal single-tunneling dissection is time-consuming and the resected mucosal always blocked the tunnel, then endoscopy submucosal multi-tunneling dissection (ESMTD) appeared. In this study, we evaluate the safety and efficacy of endoscopic submucosal multi-tunnel dissection in 15 larger early esophageal cancers. To investigated the safety and efficacy of endoscopic submucosal multi-tunnel dissection for the larger early esophageal cancer lesions.ObjectTo evaluated the safety and efficacy and its complications of submucosal multi-tunnel dissection in treating large early esophageal cancers. To analyze the key techniques of the ESMTD could reduce the operating difficulty and shorten the operating time. To investigate the efficacy of endoscopic water balloon dilatation for patients with esophagostenosisPatients and methods1. patients15 patients with early esophageal cancer that larger than 3 cm in diameter or 1/2 circumferential were detected by endoscopy and EUS in our endoscopy center from December 2012 to June 2015. ESMTD was applied to remove those cancers. The all lesions were successfully resected and definitely diagnosed by pathology, and the therapeutic effect and safety were followed-up. One experienced operator performed all these procedures. All lesions were found during routine upper gastrointestinal endoscopy and confirmed by biopsy, there were all larger early esophageal cancer, UT1N0 at EUS. At staging examinations, including radial EUS and computed tomography (CT) scan, all patients were free of metastatic lymph nodes. Every patient signed written informed consent, and had been told possible procedure-related benefits and risks (including possible complications and corresponding managements).2. Procedure of submucosal multi-tunnel endoscopic dissectionAll procedures were carried out under tracheal intubation and propofol anesthesia. No prior treatment was given before the procedures. A transparent cap was attached to the front of the endoscope. CO2 insufflation was achieved by using a CO2 insufflator. Before ESMTD procedures, the lesion margins were determined and marked after dedicated chromoendoscopy, using 3% Lugol dye. The procedure was performed as following steps:Build the submucosal tunnel:a complete circumferential incision around the lesion 0.5cm is made. Confirmed the location of all the lesions and selected two or three proper direction of tunnel to make. For the first tunnel, a mucosal incision was made using the triangle knife at the normal esophageal mucosa at the anal point. The lesion and potential location of the submucosal tunnel were injected with a mixture (100ml normal saline,2ml indigo carmine and 1ml epinephrine), a fluid cushion was created. The first mucosal incision was made using the hook knife at the esophageal mucosa at the entry point. A submucosal longitudinal tunnel was then created using the hook knife or hybrid knife between the mucosal and muscular layers. With the help of cap and injected, separated mucosa from muscular layer preliminarily at tunnel entrance and then pushed the end of the endoscope into the entrance to go on separating the two layers until the mucosal incision at the anal point. In our study, the 15 early esophageal cancer were all larger than 3.0cm in diameter, a 2cm longitudinal mucosal incision was not enough for them, then another one or two same submucosal tunnel would be made, Finally, the narrow borders between two tunnels were easily resected, which allowed for complete removal of the lesion. Endoscopic resection of the esophageal cancer was performed using the IT knife. After all the tunnels became into a big one, two sides of the tunnel were resected 0.5cm out from the tag line. When the lesion was completely resected, it was removed with a snare or forceps. All visible blood vessels were coagulated with hot biopsy forceps or by argon plasma coagulation.ResultsFifteen consecutive patients were included in this study. The mean age of the patients was (60.3±6.6) years (median 60.3-year, range 51-69 years)and the male: female ratio was 2:1 (10/5). During the operations,7 lesions were found located in superficial ml layer,8 in m2. Endoscopic submucosal multi-tunnel dissection method was performed successfully in all of the 15 patients. En bloc resection was achieved in all 15patients while the margins of 13 resected specimens were negative, R0 resection was 86.7%(13/15), and surgical operation were added to the 2 patients. The median size (the largest diameter) of all the resected lesions was (4.2±0.9) cm (range 3.0-6.0 cm). The pathological results showed that there were 9 middle-differentiated squamous cell carcinomas, and 6 high-differentiated squamous cell carcinomas. The median procedure time was (94.7±252.9) min (range50-270min). None bleeding and perforation occurred during operation and postoperation. During the follow-up period of 15 months (median, range 6-36 months),7 patient have esophagostenosis. The esophageal balloon dilations were performed in the 7 patients with the double-balloon catheters. No residual or recurrent lesion was found during the follow-up period.ConclusionsTo summarize, endoscopic submucosal multi-tunnel dissection method is a safe and efficient technique for treating large early esophageal cancer, and is an interesting option for the endoscopic management of superficial esophageal neoplasms. Compared with the single-tunnel procedure, the multi-tunneling procedure made it easier to dissect the esophageal mucosa and offered significant improvements in the endoscopic view and the ease of submucosal lifting. Grasping the key techniques of the operation could reduce the operating difficulty and shorten the operating time. Endoscopic balloon dilatation is a safe and effective method for the treatment of esophageal stenosis. However, further prospective studies with standardized procedures are scheduled, to confirm these benefits and to better assess the effect on morbidity. |
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