Circumferential extension and histologic depth are the reliable risk factors for postoperative strictures. In combination with circumferential diameter, we can perform effective and appropriate preventive balloon dilatations after esophageal ESD.

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Endoscopic submucosal dissection (ESD) has gradually gained acceptance as one of the standard treatments for early esophageal cancer, as well as for early gastric cancer in Japan, but standardization of the knowledge is still incomplete. The final goal to perform ESD is not to resect the lesion in an en bloc fashion, but to save the patient from esophageal cancer-related death. Thus, the indications should be considered based on the entire patient, not just the target lesion itself, and pre-, peri-and postoperative management of the patient is also very important, as well as technical aspects of ESD. In terms of the techniques of ESD, owing to refinement of the procedural strategy, invention of the devices, and the learning curve, acceptable safety and favorable middle-term efficacy have been obtained. We believe that ESD will become a standard treatment for early esophageal cancer not only in Japan but also worldwide in the near future.

cancers in 302 patients by endoscopic resection. Among them, we identified 106 lesions that met our inclusion criteria: (1) lesions measuring 20 mm or more in diameter, (2) tumor invasion depth of m1-sm1 without lymphovascular involvement, (3) histologically proven squamous cell carcinoma, (4) no additional treatment immediately after ER, and (5) follow-up longer than 1 year, with more than two follow-up endoscopies. Patient factors, tumor factors and technical factors were classified into categories. Kaplan-Meier curves were constructed for the analysis of recurrence, and log-rank tests were used to evaluate the statistical significance of differences. In multivariate analysis, the independent factors were determined by Cox's regression hazard model using patient and tumor factors and treatment method. Results: The study included 57 lesions treated by EMR and 49 lesions treated by ESD. Median tumor size was 30 (20-70) mm. The en bloc resection rates of EMR and ESD were 17.5 % (10/57 lesions) and 93.9 % (46/49 lesions). At a median follow-up of 34 months (range 11-121 months), there were 12 (11.3%) local recurrences, one from ESD group and 11 from EMR group. There was no significant association between local recurrence and age (PZ0.27), gender (PZ0.17), multiple iodine-unstained lesions (PZ0.79), tumor size (PZ0.15), or circumferential spread of tumor (PZ0.054). However, the endoscopic resection method was significantly associated with local recurrence (PZ0.011). In multivariate analysis for local recurrence, endoscopic resection method was an only independent risk factor (hazard ratio, 12.9; 95% confidence interval, 1.6-104.3; PZ0.016). Conclusions: To minimize local recurrence, esophageal squamous cell carcinoma measuring 20 mm or more in diameter should be treated by ESD.

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