Endoscopic resection of early esophageal tumors in patients with cirrhosis or portal hypertension: a multicenter observational study

Abstract

Background: Liver cirrhosis and esophageal cancer share several risk factors, such as alcohol intake and overweight. Endoscopic resection is the gold standard treatment for superficial tumors. Portal hypertension and coagulopathy may increase the bleeding risk in these patients. This study aims to assess the safety and efficacy of endoscopic resection for early esophageal neoplasia in patients with cirrhosis or portal hypertension. Methods: This retrospective multicentric international study included consecutive patients with cirrhosis or portal hypertension who underwent endoscopic resection in the esophagus from January 2005 to March 2021. Results: 134 lesions in 112 patients were treated, in 101 (77%) cases by endoscopic submucosal dissection. Most patients (128/134 cases, 96%) had liver cirrhosis, with esophageal varices in 71 procedures. To prevent bleeding, 7 patients underwent a transjugular intrahepatic portosystemic shunt, 8 had endoscopic band ligation (EBL) before resection, 15 received vasoactive drugs, 8 a platelet transfusion and 9 underwent EBL during the resection procedure. The complete macroscopic resection rate, en-bloc resection rate and curative resection rate were 92%, 86%, and 63%, respectively. Three perforations, 8 delayed bleedings, 8 sepsis, 6 cirrhosis decompensations within 30 days and 22 esophageal strictures occurred. No adverse event required surgery. In univariate analyses, cap-assisted endoscopic mucosal resection was associated with more delayed bleeding (p=0.01). Conclusions: In case of liver cirrhosis or portal hypertension, endoscopic resection of early esophageal neoplasia in patients appears to be effective and should be considered in expert centres with choice of resection technique following ESGE guidelines without undertreatment.

Endoscopic Submucosal Dissection for Treatment of Early-Stage Cancer or Precancerous Lesion of the Upper Gastrointestinal Tract in Patients with Liver Cirrhosis

“…A systematic review and meta-analysis revealed that pooled rates of immediate & delayed bleeding, perforation, and death during EMR and/or ESD in patients with cirrhosis were 9.5% (CI 4.0-21.1), 6.6% (CI 4.2-10.3), 2.1% (CI 1.1-3.9) and 0.6% (CI 0.2-1.7), with only immediate bleeding rate higher than that in general population [22]. A multicenter observational study enrolled 134 early esophageal tumor lesions in 112 patients with liver cirrhosis reported 3(2.7%) perforations, 8 (7.1%) delayed bleedings, 8 (7.1%) sepsis, 6 (5.4%) cirrhosis decompensations within 30 days and 22 (19.6%) esophageal strictures [15]. A systematic review enrolling 68 gastric ESD patients reported a total of 8 (13.1%) post-ESD bleeding and 1 (1.6%) perforation [23].…”

“…As for the management strategy of GOV, no consensus was reached. Either endoscopic or interventional therapy is acceptable for patients with early cancer of precancerous lesion far from GOV, While some researchers recommend against endoscopic treatment as it may induce submucosal fibrosis which will increase the technical difficulty of subsequent ESD [28,29], therefore transjugular intrahepatic portosystemic shunt (TIPS) or balloon-occluded retrograde transvenous obliteration were used to prevent variceal bleeding [15,[30][31][32]. Endoscopic radiofrequency ablation and laparoscopic-endoscopic cooperative surgery have also been reported for management of such patients [33,34].…”

“…Patients with liver cirrhosis are considered as high-risk candidates for invasive treatments including ESD due to the tendency to bleed and the vulnerability of tissues [10]. Although several studies have reported the safety and efficacy of ESD or related techniques in these population [11][12][13][14][15], many concerns have not been solved satisfactorily, for example, the proper perioperative management, how to deal with co-exiting esophagogastric varices, the minimum requirement of platelet account, etc. In the present study, we retrospectively collected and analyzed the clinical data of patients with co-exiting early esophageal/gastric cancer or precancerous lesions and liver cirrhosis, to explore the safety and efficacy of ESD in these population, as well as to explore the proper perioperative management.…”

Endoscopic Submucosal Dissection for Treatment of Early-Stage Cancer or Precancerous Lesion in the Upper Gastrointestinal Tract in Patients with Liver Cirrhosis

“…[12]. Although several studies have demonstrated that endoscopic treatments including ESD are safe and effective in this population [13][14][15][16][17][18][19][20], many concerns have not been solved satisfactorily or sometimes their conclusion was contradictory. Kim et al [14] found that liver cirrhosis was associated with a higher rate of cancer recurrence, while Choe et al [13] failed to demonstrate the difference regarding cancer recurrence rate, but they found the overall mortality rate was higher in the liver cirrhosis group.…”

“…Kim et al [14] found that liver cirrhosis was associated with a higher rate of cancer recurrence, while Choe et al [13] failed to demonstrate the difference regarding cancer recurrence rate, but they found the overall mortality rate was higher in the liver cirrhosis group. Two recent studies have demonstrated that the presence of gastroesophageal varices (GOV) does not compromise the safety and efficacy of endoscopic resection [17,21]; however, the management of coexisting GOV remains debatable. What is more, no consensus was reached on many other concerns such as proper perioperative management, the minimum requirement of platelet (PLT) count, etc.…”