Clinical study of endoscopic submucosal tunnel dissection on treatment of early esophageal cancer with submucosal fibrosis / 中华消化内镜杂志

ABSTRACT

Objective:To evaluate the efficiency and safety of endoscopic submucosal tunnel dissection (ESTD) on treatment of early esophageal cancer with submucosal fibrosis.Methods:In the Department of Gastroenterology of Northern Jiangsu People′s Hospital from June 2015 to Feburary 2018, data of 87 patients undergoing ESTD or endoscopic submucosal dissection (ESD) for early esophageal cancer or precancerous lesion were collected with inclusion criteria of cancer size less than 1/3 circumference with submucosal fibrosis, which was confirmed by pathology. According to the degree of submucosal fibrosis, 60 patients had mild fibrosis (31 underwent ESTD and 29 underwent ESD), and 27 patients had severe fibrosis (16 underwent ESTD and 11 underwent ESD). The dissection speed, en bloc resection rate, complete resection rate, and the complications (including bleeding, muscularis injury, perforation, neck subcutaneous emphysema and esophageal stenosis) were compared between the two methods of dissection in the groups with same degree of submucosal fibrosis.Results:For patients with mild submucosal fibrosis, ESTD had a higher en bloc resection rate (96.8%, 30/31) and complete resection rate (96.8%, 30/31), and lower muscularis injury rate (6.5%, 2/31) than those of ESD [82.8% (24/29), 75.9% (22/29), and 17.2% (5/29), respectively, all P<0.05]. There was no difference in the dissection speed, incidence of intraoperative bleeding, perforation and postoperative esophageal stenosis between the two methods (all P>0.05), and no postoperative delayed bleeding or neck subcutaneous emphysema occurred. For patients with severe submucosal fibrosis, ESTD had a higher dissection speed (12.3±2.8 mm 2/min), and lower incidence of intraoperative bleeding (12.5%, 2/16), muscularis injury (18.8%, 3/16), perforation (6.3%, 1/16) and neck subcutaneous emphysema (6.3%, 1/16) than those of ESD [7.1±3.2 mm 2/min, 54.5% (6/11), 54.5% (6/11), 27.3% (3/11), and 27.3% (3/11)]. There was no difference in en bloc resection rate, complete resection rate, and the incidence of postoperative esophageal stenosis between the two methods, and no postoperative delayed bleeding occurred. Cancer recurred locally in 2 patients undergoing ESD and 1 patient undergoing ESTD at 12 months after the operation, and 1 patient undergoing ESTD developed metachronous cancer at 24 months after the operation. Conclusion:ESTD is safe and effective for endoscopic management of early esophageal cancer or precancerous lesion with submucosal fibrosis. Compared with standard ESD, the advantage of ESTD is more efficient for patients with mild submucosal fibrosis, and is safer for patients with severe submucosal fibrosis.