Endoscopic Resection Strategy For Early Esophageal Cancer And Esophageal Submucosal Tumors With High Risk Of Bleeding

BackgroundEarly esophageal cancer and esophageal submucosal tumors(SMTs)are common esophageal diseases.With the popularization and development of the endoscopy,the detection rate of early esophageal cancer and esophageal SMTs has significantly improved.The treatment methods of early esophageal cancer and esophageal SMTs include traditional surgery,thoracoscopic surgery and endoscopic surgery.Endoscopic resection has gradually become the preferred method due to its minimal trauma,less complications and rapid recovery,such as endoscopic submucosal dissection(ESD)for the treatment of early esophageal cancer,endoscopic submucosal excavation(ESE)derived from ESD and endoscopic submucosal tunneling resection(STER)for SMTs.However,these techniques still have complications such as bleeding,perforation and pneumothorax.The risk of these complications may be higher in some special cases,such as early esophageal cancer with gastroesophageal varices and esophageal SMTs adjacent to large blood vessels(LBV).ObjectiveIn the retrospective study,we evaluated the safety and effectiveness of endoscopic treatment for esophageal diseases in some special circumstances.1.ESD for early esophageal cancer with gastroesophageal varices.2.ESE or STER for esophageal SMTs adjacent to LBV.Then we summarized the relevant treatment experience in the two cases.MethodsPart I:An retrospective analysis of patients who underwent ESD for early esophageal cancer or precancerous lesions at Qilu hospital of Shandong University from January 2017 to March 2022 was conducted.The patients were divided into varices groups and non-varices groups according to whether they combined with gastroesophageal varices.After propensity score matching(PSM),the incidence of en-bloc resection,complete resection,curative resection,and complications(bleeding,perforation,and esophageal stenosis)of the two groups were analyzed and compared.Part II:An retrospective analysis of patients with esophageal SMTs who received ESE or STER in Qilu hospital of Shandong University from January 2015 to March 2022 was conducted.According to whether the tumor adjacent to LBV,the patients were divided into the adjacent LBV group and non-adjacent LBV group.After PSM,the operation time,complete resection rate and incidence of complications(bleeding,chest pain,perforation and gas-related complications)of the two groups were analyzed and compared.Then The risk factors of esophageal SMTs adjacent to LBV,the influencing factors of endoscopic operation time and the selection strategy of ESE and STER were analyzed.ResultsPart I:A total of 322 patients were included in the study,including 12 patients combined with varices with 13 lesions and 310 patients without varices with 363 lesions.Five independent variables including gender,age,lesion location,lesion size and infiltration depth were used for PSM(varices group:non-varicose group=1:4).After PSM,Platelet count in varies group was significantly lower than that in non-varices group(98.2±44.3 × 10^g vs 225.1±59.6×10^9/L,P<0.001).The International normalized ratio of prothrombinase time(PT-INR)was significantly higher than that in the non-varices group(1.16(1.20-1.27)vs 0.99(0.95-1.03),P<0.001).There were no significant differences in the en-bloc resection rate,complete resection rate and curative resection rate between the two groups(P>0.05).In terms of complications,there were also no significant differences in the incidence of bleeding,perforation and esophageal stenosis(P>0.05).Part II:A total of 284 patients with esophageal SMTs were included in the study,including 82 SMTs adjacent to LBV and 202 SMTs non-adjacent to LBV.The tumors were larger(1.88±1.07 vs 1.23±0.76cm,P<0.001)and of deeper origin(65.9%vs 34.7%,P<0.001)in the adjacent LBV group.According to multi-factor binary logistics regression analysis,being located in the middle(OR=3.265,95%CI=1.424～7.482,P=0.005)and lower esophagus(OR=2.856,95%CI=1.276～6.392,P=0.011),large in size(OR=1.751,95%CI=1.242～2.468,P=0.001)and originating from the muscular propria(OR=2.146,95%CI=1.173～3.927,P=0.013)were the risk factors for SMTs adjacent to LBV.PSM was performed using six covariables including gender,age,tumor location,tumor size,depth of origin and endoscopist(adjacent LBV group:non-adjacent LBV group=1:1).After PSM,the operation time of the adjacent LBV group was significantly longer than that of the non-adjacent LBV group(72.0±52.0 vs 51.3±24.5 min,P=0.003).By multifactor linear regression analysis,tumor size and adjacent to LBV were significantly positively affected operation time.The resection rate of tumors in the adjacent LBV group was lower than in the other group,but the difference was not significant(91.8%vs 95.5%,P=0.494).There were also no significant differences in the incidence of complications including bleeding,chest pain,perforation and gas-related complications(P>0.05).For tumor adjacent to LBV,tumor size was significantly larger in patients treated with STER than in patients treated with ESE(2.30±1.01 vs 1.04±0.56,P<0.001)and originated from deeper location(87.3%vs 22.2%,P<0.001).The operation time of STER was longer than ESE(87.76±57.20 vs 59.33±46.80min,P=0.028).There were no significant differences between the two treatment methods in complete resection rate and the incidence of complications including bleeding,chest pain,perforation and gas-related complications(P>0.05).Conclusions1.ESD treatment is feasible for early esophageal cancer with gastroesophageal varices.Individualized treatment should be developed based on varices grade and location relationship between varices and lesions.2.Being located in the middle and lower esophagus,large in size and originating from the muscular propria are risk factors for esophageal SMTs adjacent to LBV.ESE and STER are safe and feasible for esophageal SMTs adjacent to LBV.However,the operation time of SMTs adjacent to LBV was significantly prolonged.3.When esophageal SMTs adjacent to LBV,ESE is just applicable when the tumor is small(diameter=1cm)and originating from superficial layer.For tumors with larger volume and deeper level of origin,STER should be selected,and the tumor should be removed in the appropriate position.