Factors Related to Difficulty in Endoscopic Submucosal Dissection for Superficial Esophageal Cancer

Abstract

Introduction: Endoscopic submucosal dissection (ESD) for superficial esophageal cancer is technically challenging, and research on predictive factors related to the difficulty in the procedure is limited. This study aimed to investigate the factors predicting the difficulty in esophageal ESD. Methods: This retrospective study analyzed 303 lesions treated at our institution between April 2005 and June 2021. The following 13 factors were evaluated: sex, age, tumor location, tumor localization, macroscopic type, tumor size, tumor circumference, preoperative diagnosis of histological type, preoperative diagnosis of invasion depth, previous radiotherapy for esophageal cancer, metachronous lesion located close to post ESD scar, operator’s skill, and use of a clip-and-thread traction method. Difficult esophageal ESD cases were defined as those requiring long procedure time (> 120 min). Results: Fifty-one lesions (16.8%) met the defined criterion for difficult cases of esophageal ESD. Logistic regression analysis identified tumor size larger than 30 mm (odds ratio 9.17, 95% confidence interval: 4.27–19.69, P < 0.001) and tumor circumference more than half that of the esophagus (odds ratio 2.53, 95% confidence interval: 1.15–5.54, P = 0.021) as independent predictive factors related to difficulty in esophageal ESD. Discussion/Conclusion: Tumor size larger than 30 mm and tumor circumference more than half that of the esophagus can predict difficulty in performing esophageal ESD. This knowledge can provide useful information for developing ESD strategies and selecting a suitable operator on a case-by-case basis to achieve favorable clinical outcomes.

Assessment of predictive factors associated with the technical difficulty of endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma: Japanese multicenter retrospective study

“…Difficult lesions were defined as lesions with: (i) a long procedure time (≥120 min); (ii) development of perforation during ESD; (iii) piecemeal resection; or (iv) discontinued ESD based on previous reports 10–13,18,19 . Procedure time was defined as the time from the start of mucosal injection to the end of resection.…”

“…Difficult lesions were defined as lesions with: (i) a long procedure time (≥120 min); (ii) development of perforation during ESD; (iii) piecemeal resection; or (iv) discontinued ESD based on previous reports. [10][11][12][13]18,19 Procedure time was defined as the time from the start of mucosal injection to the end of resection. Perforation was diagnosed as follows: (i) endoscopic observation of a perforation site; or (ii) the presence of free air detected by radiography or computed tomography.…”

“…18,19 Therefore, the definitions in this study were based on these previous reports. [10][11][12][13]18,19 However, it was difficult to explain why cases with antiplatelet discontinuation were identified as difficult factors and those with continuation were not. With the recent increase in the kinds of antiplatelet drugs and the use of dual antiplatelet drugs, prospective studies will be needed to determine whether they can be continued in esophageal ESD.…”

“…Several studies have investigated the factors associated with the technical difficulty of esophageal ESD. [10][11][12][13] These studies indicated lesion length ≥30 mm, circumference >1/2, lower esophagus, left wall, and previous chemoradiotherapy (CRT) as factors associated with the technical difficulty of esophageal ESD. However, these studies were single-center retrospective studies and included patients with no history of esophageal cancer treatment, such as surgery or ER.…”

“…Moreover, it has been applied to varied lesions, including circumferential lesions, near or recurrent lesions after endoscopic treatment, lesions with a history of radiotherapy (RT), and special locations such as near the diverticula and anastomotic sites. Several studies have investigated the factors associated with the technical difficulty of esophageal ESD 10–13 . These studies indicated lesion length ≥30 mm, circumference >1/2, lower esophagus, left wall, and previous chemoradiotherapy (CRT) as factors associated with the technical difficulty of esophageal ESD.…”