The Efficacy And Safety Of Endoscopic Submucosal Dissection For Superficial Esophageal Cancer With Large Circumferential Lesion

Background and Objective:With the development of endoscopic technology,endoscopic submucosal dissection(ESD)has become one of the standard treatments of early esophageal cancer.Because of the particularity of esophageal structure,postoperative strictures will develop particularly frequently when the resection involves greater than 3/4 of the esophageal circumference and endoscopic balloon dilations are required to be performed consistently,which decrease the patient's quality of life and thus limite the application of ESD technology used in large circumferential superficial esophageal carcinoma.Currently,few reports have been reported on the treatment of ESD in patients with large circumferential superficial esophageal carcinoma with relatively large number of cases.So we conducted a retrospective study to evaluate the efficacy and safety of ESD for 43 cases of large circumferential superficial esophageal carcinoma and to discuss the prevention of local injection of triamcinolone on esophageal strictures after ESD.Methods:A total of 43 patients with superficial esophageal carcinoma who were treated with ESD at the Endoscopy Center of Zhejiang Cancer Hospital from Jan 2013 to Jun 2017 were retrospectively analyzed,all of which with the lesions resection involve more than 3/4 of the circumference and pathologically proven less than 200?m in submucosal invasion depth.The characteristics of the patients,the ESD procedure variables,the rates of en bloc resection,and the major complications were evaluated.Patients who underwent endoscopic local injections were compared with patients without any other therapy after ESD,the outcomes were reliably followed up to evaluate the prevention of endoscopic local injections on esophageal strictures.The primary outcome was the incidence of stricture formation.The secondary outcome was the number of balloon dilatation procedures required to resolve the stricture formation.Results:A total of 43 patients with superficial esophageal carcinoma were treated with ESD procedure,including 32 men and 11 women,and the age was from 47 to 79 years old(average 65.9±7.6).There are 6 lesions located in upper esophagus,32 lesions in middle and other 5 lesions in lower.The extent of the lesions as a proportion of the whole circumference of the esophageal lumen contains 3 cases of complete circumference and the other 40 cases of non-complete circumference that resection more than 3/4,and endoscopic local injections of triamcinolone were conducted in 16 cases to treat the esophageal strictures.The longitudinal diameter of the lesions was 4?12 cm(average 5.5±1.6cm).All of these lesions were resected by ESD successfully.The en bloc resection rate was 100%(43/43).The procedure time was 45?280 min(average 109.5±47.3 min).According to the pathology results,2 lesions were proved to be low grade epithelial neoplasia,9 lesions to be high grade epithelial neoplasia and 32 lesions to be early esophageal cancer(9 were situ cancer,8 were lamina propria mucosal cancer,11 were muscularis mucosa cancer,4 were submucosa cancer).Overall,the complete resection rate was 79.1%(34/43),which with tumor-free horizontal and vertical margins(RO).The diagnostic accuracy of narrow band imaging combined with magnification endoscopy(NBI-ME)for the infiltration depth was 90.1%(39/43).The results showed no case of delayed bleeding,one case of perforation(1/43,2.9%),4 cases of mediastinal emphysema(4/43,5.9%)and 23 cases with obvious chest pain after operation(23/43,53.5%).These patients were successfully managed by medical conservative treatment.A total of 23 cases of esophageal stenosis occurred in this study,with an overall stenosis rate of 53.5%(23/43).The incidence of stricture formation decreased from 74.1%(20/27)without triamcinolone injection to 18.8%(3/16)with triamcinolone injection(p<0.01).The mean number of balloon dilatation procedures required also decreased from 8.7(1?17)to 3.7(2?5)times(p<0.05).All patients were followed up for more than 15 months as required,and no residual or recurrent cases were detected.Conclusion:1.ESD enables a high en bloc resection which can provide sufficient pathological information and achieve a high curative resection with controllable complication and low recurrence rate of residual.So ESD is a safe and effective endoscopic treatment for large circumferential superficial esophageal carcinoma.2.Esophageal stenosis is the most common complication for large circumferential superficial esophageal carcinoma after ESD.Endoscopic balloon dilation is an effective postoperative treatment.Local injection of triamcinolone after esophageal ESD can effectively prevent the occurrence of esophageal stenosis and significantly reduce the number of endoscopic balloon dilation treatment.