Endoscopic Submucosal Tunnel Dissection And Endoscopic Submucosal Dissection For Large Superficial Esophageal Squamous Cell Neoplasm:Efficacy And Safety Study To Guide Future Practice

Background:Endoscopic submucosal dissection(ESD)is an established technique to resect superficial esophageal squamous cell neoplasms(SESCNs).However,ESD becomes time-consuming and challenging for large SESCNs that exceed one-third of the esophageal circumference and are greater than 2.0 cm in longitudinal-diameter for two reasons.For large SESCNs,rapid diffusion of the submucosal liquid cushion can occur after circumferential incision;additionally,the resected mucosa in large lesions may render the endoscopic view unclear.In 2013,single-tunnel endoscopic submucosal tunnel dissection(ESTD)technique for large SESCNs was introduced in a small case series;subsequently,to further reduce the dissection time and improve the endoscopic view of single-tunnel ESTD for circumferential SESCNs,double-tunnel ESTD was proposed.However,there are limited studies evaluating both ESD and ESTD for large SESCNs,and the advantage of double-tunnel ESTD over single-tunnel ESTD for circumferential SESCNs has not been confirmed.Thus,the purpose of this study is to fully verify the efficacy and safety of ESTD and ESD for large SESCNs in a relatively larger population,and compare the efficiency between single-and double-tunnel ESTD for treating circumferential lesions.Besides,we introduced a new method,autologous skin-grafting surgery(ASGS),for the prevention of esophageal stenosis after complete circular ESTD.Methods:There are three sections in this study,in the first section,we analyzed the data of 46 patients undergoing ESTD for large SESCNs between October 2011 and March 2016 in our center,and compared the outcomes between single-and double-tunnel ESTD for circumferential lesions.In the second section,we fully assessed the efficacy and safety of ESTD and ESD for large SESCNs,and compare the efficiency between these two techniques.In the third section,a case was reported to determine the feasibility of ASGS for the prevention of esophageal stenosis after complete circular ESTD.Results:In the first section,for all the 46 patients,the En bloc and RO resection rates were 95.7%and 82.6%,respectively.Perforation and cardiac mucosal laceration were detected at 2.2%(1/46)and 6.5%(3/46)of the procedures,respectively.Of the 18 patients with circumferential lesions,those who received a double-tunnel ESTD procedure(n=6)underwent faster dissection than those who had a single-tunnel ESTD procedure(n=12)(0.32 cm2/min vs.0.12 cm2/min,P<0.05).In the second section,all of the 150 patients were found to successfully undergo ESTD or ESD with 92.68 ±67.96(mean±SD)min.The En bloc resection and RO resection were achieved in 91.33%(137/150)and 86.00%(129/150)of the cases,respectively.A total of 13 patients(8.67%)were found to have intra-operative adverse events.Based on statistical analysis,ESTD was found to have a higher dissection speed compared with ESD.Moreover,a long operation time was found to be an independent risk factor for intra-operative adverse events.Besides,ASGS was preliminarily confirmed to be feasible for the prevention of esophageal stenosis after complete circular ESTD.Conclusion:ESTD and ESD both were found to be effective and safe treatment options for large SESCNs.ESTD appeared to improve operation efficacy,which was reflected in a higher dissection speed compared with ESD.Besides,double-tunnel ESTD appears to decrease operative time compared with single-tunnel ESTD for circumferential lesions.We also demonstrated that long operation time should be avoided as much as possible in order to reduce intra-operative adverse events.Moreover,ASGS seemed to be feasible for the prevention of esophageal stenosis after complete circular ESTD.