Endoscopic submucosal tunnel dissection for early esophageal squamous cell carcinoma in patients with cirrhosis: A propensity score analysis

Abstract

BACKGROUND Although early esophageal squamous cell carcinoma (EESCC) with cirrhosis is a relatively rare clinical phenomenon, the management of EESCC in cirrhotic patients continues to be a challenge. AIM To evaluate the feasibility, safety, efficacy and long-term survival outcomes of endoscopic submucosal tunnel dissection (ESTD) for treating EESCC in patients with cirrhosis. METHODS This was a single-center retrospective cohort study. We examined 590 EESCC patients who underwent ESTD between July 14, 2014, and May 26, 2021, from a large-scale tertiary hospital. After excluding 25 patients with unclear lesion areas or pathological results, the remaining 565 patients were matched at a ratio of 1:3 by using propensity score matching. A total of 25 EESCC patients with comorbid liver cirrhosis and 75 matched EESCC patients were ultimately included in the analysis. Parametric and nonparametric statistical methods were used to compare the differences between the two groups. The Kaplan–Meier method was used to create survival curves, and differences in survival curves were compared by the log-rank test. RESULTS Among 25 patients with liver cirrhosis and 75 matched noncirrhotic patients, there were no significant differences in intraoperative bleeding (P = 0.234) , 30-d post-ESTD bleeding ( P = 0.099 ), disease-specific survival ( P = 0.075), or recurrence-free survival ( P = 0.8196) . The mean hospitalization time and costs were significantly longer ( P = 0.007) and higher ( P = 0.023) in the cirrhosis group than in the noncirrhosis group. The overall survival rate was significantly lower in the cirrhosis group ( P = 0.001). CONCLUSION ESTD is technically feasible, safe, and effective for patients with EESCC and liver cirrhosis. EESCC patients with Child-Pugh A disease seem to be good candidates for ESTD.

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

“…However, little is known about the incidence of early esophageal/gastric cancer in patients with liver cirrhosis. Zhu et al [14] reported a proportion of 4.24% (25/565) patients had comorbid liver cirrhosis in patients with early esophageal cancer who underwent endoscopic submucosal tunnel dissection. In our study, 0.94% of patients had comorbid liver cirrhosis among patients with early esophageal cancer/precancerous lesions who received ESD.…”

“…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 intraoperative bleeding, Zhu et al [14] reported a rate of 48% (12/25) during endoscopic submucosal tunnel dissection for early esophageal carcinoma in patients with liver cirrhosis, and Kwon et al [24] reported 47% during endoscopic resection of gastric mucosal lesions in patients with chronic renal failure and liver cirrhosis. In the present study, intraoperative bleeding was found in 50% (4/8) patients, which is similar to the above reports.…”

“…Platelet were infused preoperatively in patients with platelet account of less than 50x10^9/L, frensh frozen plasma were infused for patients with coagulation dysfunction (mainly impaired INR), and albumin were infused for patients with blood albumin <30g/L. Intraoperative bleeding was recorded as the necessity of endoscopic hemostasis during ESD [14]. Postoperative bleeding was defined as any of the following: apparent hematemesis or melena, unstable vital signs, and a >2 g/dL decrease in hemoglobin concentration after ESD.…”

“…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.…”