Multicenter retrospective analysis of complications and risk factors in endoscopic resection for esophageal cancer across Japan.

Endoscopic resection (ER) is a minimally invasive treatment for esophageal cancer that sometimes causes complications. To understand the real-world incidence and risk factors for these complications, a nationwide survey was conducted across Japan. This retrospective multicenter study included patients who underwent ER for esophageal cancer from April 2017 to March 2018 (2017 complication analysis) and April 2021 to March 2022 (2021 complication analysis). The study assessed the complication rates and conducted risk factor analyses for endoscopic submucosal dissection (ESD) using data for these patients, with exclusions based on specific criteria to ensure data accuracy. In the 2021 complication analysis, there were two mortalities highly likely attributable (0.03%) to ER and one mortality possibly attributable (0.01%) to ER. Intraoperative perforation, delayed bleeding, and pneumonia occurred in 137 cases (1.8%), 44 cases (0.6%), and 130 cases (1.7%), respectively. In the multivariate analysis for complications after ESD, low ER volume of the facility was an independent risk factor for perforation, while lesion location in the cervical or upper thoracic esophagus was an independent factor for reduced risk of perforation. Age ≥ 80 years was a risk factor for pneumonia, while use of traction techniques was a factor for reduced risk of pneumonia. Lesions located in the middle thoracic esophagus had a lower risk of stricture, and the risk of stricture increased as the circumferential extent of the lesion increased. This large-scale study provided detailed insights into the complications associated with esophageal ER and identified significant risk factors.

Ishihara R ，Oyama T ，Takeuchi M ，Hirasawa D ，Kanetaka K ，Uesato M ，Tsuji Y ，Matsuura N ，Abe S ，Kadota T ，Yoshio T ，Tanaka T ，Urabe Y ，Suzuki Y ，Muto M ... -  《-》

Risk of stricture after endoscopic submucosal dissection in the cervical esophagus and efficacy of local steroid injection for stricture prevention (with video).

There is a high incidence of stricture after endoscopic submucosal dissection (ESD) for cervical esophageal cancer. We aimed to elucidate the risk factors for stricture and to evaluate the efficacy of steroid injection for stricture prevention in the cervical esophagus. We retrospectively analyzed 100 patients who underwent ESD for cervical esophageal cancer to (1) identify the factors associated with stricture among patients who did not receive steroid injection, and (2) compare the incidence of stricture between patients with and without steroid injection. Among 48 patients who did not receive steroid injection, there were significant differences in tumor size (P = .026), resection time (P = .028), and circumferential extent of the mucosal defect (P = .005) between patients with stricture (n = 5) and without stricture (n = 43). Compared with patients without steroid injection, patients with steroid injection had a significantly lower incidence of stricture when the post-ESD mucosal defect was <3/4 and ≥1/2 (40% versus 8%; P = .039). For the patients with a post-ESD mucosal defect of ≥3/4 (n = 13), local steroid injection was performed for all of them, and 6 (46%) developed stricture. Patients who underwent ≥1/2 circumferential resection were at high risk of cervical esophageal stricture. Steroid injection had a stricture prevention effect in patients with <3/4 and ≥1/2 circumferential resection, but seemed to be insufficient in preventing stricture in patients with ≥3/4 circumferential resection.

Ando Y ，Kato M ，Tani Y ，Okubo Y ，Asada Y ，Ueda T ，Kitagawa D ，Kizawa A ，Ninomiya T ，Tanabe G ，Fujimoto Y ，Mori H ，Yoshii S ，Shichijo S ，Kanesaka T ，Yamamoto S ，Higashino K ，Uedo N ，Michida T ，Ishihara R ... -  《-》

Endoscopic submucosal dissection for superficial esophageal cancer in the remnant esophagus after esophagectomy.

Treatment of esophageal cancer in the remnant esophagus after esophagectomy is highly invasive, therefore, early detection and minimally invasive treatment are considered necessary. Consequently, we aimed to clarify the safety and efficacy of endoscopic submucosal dissection (ESD) for residual esophageal cancer compared to that for esophageal cancer in a normal cervical esophagus. This study involved 47 patients with 59 residual esophageal cancers and 92 patients with 107 cervical esophageal cancers in normal esophagus who underwent ESD between January 2008 and December 2023. Their clinicopathological findings and long-term outcomes were retrospectively collected and evaluated. The median tumor diameter was 13 mm, and the median procedure time was 31 minutes in remnant esophagus group, with no significant difference between the two groups. No serious complications such as perforation, massive intraoperative bleeding, and pneumonia were observed in the remnant group, except for one case of postoperative bleeding. The rates of complete resection and disease specific survival were not significantly different between two groups, with complete resection rate of 86.4% and 5-year disease-specific survival rate of 95.7% in the remnant esophagus group. No local recurrence was observed during the median observation period of 43 months in the remnant esophagus group. ESD for superficial cancer of the remnant esophagus showed a high complete resection rate without serious complications and good local-regional control with no evidence of local recurrence. This indicates that ESD is a safe and useful treatment for superficial cancer of the remnant esophagus.

Suzuki Y ，Kikuchi D ，Nakamura S ，Iizuka T ，Ochiai Y ，Hayasaka J ，Ueno M ，Udagawa H ，Hoteya S ... -  《-》

Characteristics of cases for which esophageal endoscopic submucosal dissection under general anesthesia is recommended.

Esophageal endoscopic submucosal dissection (ESD) performed under general anesthesia can potentially provide more stable treatment in difficult cases than that under sedation. We evaluated the clinical characteristics and outcomes of ESD performed under general anesthesia compared with those under propofol sedation and discussed the cases in which general anesthesia is recommended. In total, 292 lesions in 265 consecutive patients undergoing esophageal ESD at Yamaguchi University Hospital from 2013 to 2023 were included in this retrospective study. ESD was performed under general anesthesia for 92 lesions in 81 patients and under propofol sedation for 200 lesions in 184 patients. Tumor long-axis diameter was larger (39.8 ± 14.4 mm vs. 32.4 ± 9.9 mm, p < 0.01) and dissection speed was faster (10.5 ± 5.9 mm2/min vs. 7.5 ± 4.2 mm2/min, p < 0.01) in the general anesthesia group versus the sedation group. In the sedation group, a treatment history of pharyngeal cancer was significantly associated with a slower dissection speed (p = 0.037). The sedation group showed higher frequencies of hypoxemia (0% vs 9.8%, p < 0.01), interruption due to body movement (0% vs 13%, p < 0.01), and acute adverse events (21.7% vs 33.5%, p = 0.05). A treatment history of pharyngeal cancer was shown to be the significant factor contributing to acute adverse events (p = 0.018). Esophageal ESD under general anesthesia can be a treatment option in patients with difficulty in performing stable procedures with propofol sedation. Especially in patients with a treatment history of pharyngeal cancer in whom ESD is more difficult to be performed and who are at higher risk for acute adverse events, general anesthesia can be considered.

Goto A ，Hamabe K ，Ito S ，Hashimoto S ，Nishikawa J ，Takami T ... -  《-》

Safety and efficacy of endoscopic submucosal dissection with gel immersion technique for superficial esophageal neoplasms.

Gel immersion (GI) endoscopy provides a good visual field in endoscopic submucosal dissection (ESD); however, its clinical outcomes are poorly understood. This study aimed to compare the treatment outcomes between esophageal gel immersion endoscopic submucosal dissection (GI-ESD) and conventional ESD (C-ESD) to determine the safety and efficacy of GI-ESD. The data of 71 consecutive patients who underwent esophageal ESD between April 2021 and March 2023 at a Japanese tertiary center were retrospectively reviewed. GI was achieved using an additional irrigation tube. The treatment outcomes between the GI-ESD and C-ESD groups were compared using inverse probability of treatment weighting (IPTW) to control for confounding factors. A total of 75 superficial esophageal epithelial neoplasms (41 in the C-ESD and 34 in the GI-ESD groups) were treated using ESD. The mean procedure time in the GI-ESD group was significantly shorter than that in the C-ESD group (59.2 ± 36.2 vs 85.3 ± 45.7 min, P = 0.008). After IPTW adjustment, the mean procedural times were 62.6 ± 36.6 and 82.9 ± 41.7 min in the GI-ESD and C-ESD groups, respectively (P = 0.037), and the incidence rate of muscle layer damage was 4.2% in the GI-ESD group and 30.6% in the C-ESD group (P = 0.001). In the multivariate analysis, specimen size ≥ 30 mm (odds ratio [OR]: 9.44, 95% confidence interval [CI]: 2.46-36.30, P = 0.001) was positively correlated with longer procedural time (≥ 90 min), whereas GI-ESD (OR: 0.19, 95%CI: 0.05-0.68, P = 0.011) showed a negative association. Esophageal GI-ESD may be useful in terms of safety and time efficiency. The GI technique could be an option for esophageal ESD.

Iwatsubo T ，Hakoda A ，Sugawara N ，Sasaki S ，Nakajima N ，Mori Y ，Tanaka H ，Ota K ，Takeuchi T ，Nishikawa H ... -  《-》