Long-term Efficacy Of Endoscopic Therapy For Early Esophageal Cancer And Risk Factors For Postoperative Esophageal Stricture

Part I Long-term Outcomes of Endoscopic Piecemeal Mucosal Resection for Superficial Esophageal Carcinoma and Precancerous LesionsBackground:Endoscopic treatment has been an alternative treatment for esophageal cancer limited to the mucosa and superficial submucosa,which can get similar outcomes compared with esophagectomy.Nowadays most of the studies related to endoscopic mucosal resection(EMR)and multiband mucosectomy(MBM)focus on security and effectiveness,and rare of them are associated with long-term outcomes.The aim of the study was to explore the long-term outcomes of endoscopic piecemeal mucosal resection for superficial esophageal carcinoma and precancerous lesions.Methods:From March 1 2001 to May 31 2017,371 patients with 416 lesions who were diagnosed with superficial esophageal carcinoma or high-grade intraepithelial neoplasia and underwent endoscopic mucosal resection(EMR)or endoscopic multi-band mucosal resection(MBM)were retrospectively enrolled in this study.Long-term recurrence free survival rate(RFS)was analyzed and the effects of risk factors such as submucosal invasion,poorly differentiation,vascular invasion and positive vertical margin to the long-term outcomes were also analyzed.The difference of the effect between the surgical treatment and adjuvant radiotherapy to the long-term outcomes were compared.Results:There was no statistically significant difference of surgical complication rate between the two groups of EMR and MBM.During the follow-up period,there were 9 cases of lymph node metastasis and 8 cases of distant metastasis.The 5-year RFS was 93.9%and 10-year RFS was estimated RFS was 87.8%,respectively.There was no statistically significant difference of long-term outcomes between the two groups of EMR and MBM.Local recurrence was found in 2 cases in each group and were curative treated by endoscopic submucosal dissection.Heterogeneous multiple primary esophageal cancer was diagnosed in 5 and 3 cases for the EMR and MBM group,of whom 5 was curative treated with endoscopic resection and 3 were diagnosed with advanced esophageal cancer in which 2 patients were dead.Lymph node metastasis(LNM)was found in 5 cases in the EMR group and 4 cases in the MBM group.of whom 6 patients were passed away.Distant metastasis was found in 5 cases in the EMR group and 4 cases in the MBM group,of whom 5 patients were passed away.There were 83 patients combined with risk factors which included submucosal invasion,poorly differentiation,vascular invasion and positive vertical margin,of whom 8 patients were diagnosed with LNM and 8 patients with distant metastasis.The 5-year RFS of patients with 1,2,and 3 risk factors were 93.6%,82.2%,and 25.0%,and the difference was statistically significant(p<0.001).When the submucosal invasion or poorly differentiation was the only risk factor,the rates of lymph node or distant metastasis were merely 14.2%(3/21)and 8.6%(3/35),When the vascular invasion was positive,the rate of lymph node or distant metastasis was 36.3%.There was no significant difference between the patients underwent additional surgical treatment and adjuvant radiotherapy.Lymph nodes were the most frequent metastatic sites in the patients underwent esophagectomy and distant sites were the most frequent metastatic sites in the patients underwent adjuvant radiotherapy.Conclusions:EMR and MBM were both safe and feasible procedures for superficial esophageal carcinoma and precancerous lesions.Additional treatments are not necessary for the patients in whom the submucosal invasion or poorly differentiation was the only risk factor.Additional treatments should be used in patients with no less than 2 risk factors,vascular invasion or positive vertical margin.Additional treatments should be selected according to the variety of risk factors to get better long-term outcomes and quality of lives.Part ? Risk Factors for Esophageal Refractory Stenosis after Endoscopic Submucosal Dissection of Superficial Esophageal NeoplasmsBackground:This study aimed to clarify risk factors for postoperative esophageal stenosis and refractory stenosis after ESD involving>3/4 of the circumferential extension.Methods:Two hundred two lesions in 186 patients undergoing ESD of>3/4 of the total circumference between July 2013 and December 2017 were divided into two groups:a stenosis group(n=108)and non-stenosis group(n=78).The 108 patients with postoperative stenosis were divided into two subgroups according to sessions of endoscopic balloon dilatation(EBD):a refractory stenosis group(n=69,?6 EBD sessions)and non-refractory stenosis group(n=39,?5 EBD sessions).Clinical factors including age,sex,longitudinal diameter of the lesions and mucosal defect,lesion location,circumferential extent and invasion depth were compared between the two groups.Results:The longitudinal diameter of the lesions and specimens,circumferential extent and the ratio of muscular layer damage was significantly larger in the stenosis group and refractory group(p<0.05).The ratio of refractory stenosis was significantly higher in cervical-esophageal lesions than in lesions of the upper-thoracic esophagus,middle-thoracic esophagus and lower-thoracic esophagus(p=0.006).Conclusions:Our findings suggest that the longitudinal diameter of lesions and specimens,the circumferential extent of esophageal ESD,and muscular layer damage were closely associated with postoperative esophageal stenosis and refractory stenosis.Furthermore,patients with cervical or upper-thoracic esophageal lesions had a higher risk of refractory esophageal stenosis after ESD.