Endoscopic Submucosal Dissection of Superficial Esophageal Neoplasms Is Feasible and Not Riskier for Patients with Liver Cirrhosis

Esophageal squamous cell carcinoma complicated with varices successfully treated by endoscopic injection sclerotherapy and argon plasma coagulation: A case report

Treatment guidelines for esophageal squamous cell carcinoma (ESCC) with concomitant esophageal varices (EVs), which increase the risk of bleeding, are unavailable. A 66-year-old man with a history of total gastrectomy was admitted to the hospital owing to hematemesis. Emergency upper gastrointestinal endoscopy revealed variceal bleeding near the anastomosis between the esophagus and jejunum, and endoscopic clipping stopped the bleeding. Upper gastrointestinal endoscopy following hemostasis revealed four EVs and a two-thirds ESCC circumference. The ESCC depth was suspected to be up to the mucosa. The patient underwent intravariceal endoscopic injection sclerotherapy (EIS) for EVs, followed by paravariceal EIS. However, after these treatments, blood flow in the EVs just below the ESCC remained, and endoscopic resection of the ESCC was judged to be difficult to perform. Therefore, we prioritized EV treatment and performed a second EIS on the ESCC, followed by argon plasma coagulation (APC). APC was expected to not only solidify the EVs but also eliminate the ESCC existing in the mucosa. Finally, EVs and ESCC were treated by EIS and APC. EIS followed by APC may be useful for treating concurrent EVs and intramucosal ESCC in patients with liver cirrhosis when embolization of the EVs is ineffective.

Clinical outcomes of endoscopic submucosal dissection for superficial esophageal neoplasia in close proximity to esophageal varices: a multicenter international experience

BACKGROUND : There are limited data on the feasibility of endoscopic submucosal dissection (ESD) for superficial esophageal neoplasia (SEN) located at or adjacent to esophageal varices. We aimed to evaluate the outcomes of ESD in these patients.

METHODS

 This multicenter retrospective study included cirrhotic patients with a history of esophageal varices with SEN located at or adjacent to the esophageal varices who underwent ESD.

RESULTS

 23 patients with SEN (median lesion size 30 mm; 16 squamous cell neoplasia and seven Barrett's esophagus-related neoplasia) were included. The majority were Child-Pugh B (57 %) and had small esophageal varices (87 %). En bloc, R0, and curative resections were achieved in 22 (96 %), 21 (91 %), and 19 (83 %) of patients, respectively. Severe intraprocedural bleeding (n = 1) and delayed bleeding (n = 1) were successfully treated endoscopically. No delayed perforation, hepatic decompensation, or deaths were observed. During a median (interquartile range) follow-up of 36 (22-55) months, one case of local recurrence occurred after noncurative resection.

CONCLUSION

 ESD is feasible and effective for SEN located at or adjacent to esophageal varices in cirrhotic patients. Albeit, the majority of the esophageal varices in our study were small in size, when expertise is available, ESD should be considered as a viable option for such patients.

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

BACKGROUND

Liver cirrhosis and esophageal cancer share several risk factors, such as alcohol intake and excess weight. Endoscopic resection is the gold standard treatment for superficial tumors. Portal hypertension and coagulopathy may increase the bleeding risk in these patients. This study aimed to assess the safety and efficacy of endoscopic resection for early esophageal neoplasia in patients with cirrhosis or portal hypertension.

METHODS

This retrospective multicenter 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, including by endoscopic submucosal dissection in 101 cases (75 %). Most lesions (128/134, 96 %) were in patients with liver cirrhosis, with esophageal varices in 71 procedures. To prevent bleeding, 7 patients received a transjugular intrahepatic portosystemic shunt, 8 underwent endoscopic band ligation (EBL) before resection, 15 received vasoactive drugs, 8 received platelet transfusion, and 9 underwent EBL during the resection procedure. Rates of complete macroscopic resection, en bloc resection, and curative resection were 92 %, 86 %, and 63 %, respectively. Adverse events included 3 perforations, 8 delayed bleedings, 8 sepsis, 6 cirrhosis decompensations within 30 days, and 22 esophageal strictures; none required surgery. In univariate analysis, cap-assisted endoscopic mucosal resection was associated with delayed bleeding (P = 0.01).

CONCLUSIONS

In patients with liver cirrhosis or portal hypertension, endoscopic resection of early esophageal neoplasia appeared to be effective and should be considered in expert centers with choice of resection technique, following European Society of Gastrointestinal Endoscopy guidelines to avoid undertreatment.

Safety and efficacy of endoscopic submucosal dissection for superficial esophageal cancer with esophageal varices

BACKGROUND

Heavy drinking is associated with esophageal cancer and esophageal varices. However, there are limited reports of endoscopic resection for esophageal cancer with esophageal varices. In this multicenter study, we clarified the safety and efficacy of endoscopic submucosal dissection for superficial esophageal cancer with esophageal varices.

METHODS

In this multicenter, retrospective, observational study, patients underwent esophageal endoscopic submucosal dissection at 10 referral centers in Japan from January 2013 to December 2019. We analyzed characteristics including backgrounds and varices, treatment outcomes, and adverse events in cases with esophageal varices.

RESULTS

A total of 1708 patients were evaluated, 27 (1.6%) of whom had esophageal varices. In patients with esophageal varices, the en bloc resection rate and R0 resection rate were 100% and 77.8%, respectively. Patients with esophageal varices had longer procedure times than patients without esophageal varices (p = 0.015). There was no significant difference in adverse events. There was no significant difference in procedure time and number of adverse events between patients who underwent pretreatment and those who did not. There was no significant difference in these outcomes for patients with lesions on varices compared to those without. Child-Pugh classification and location of the lesions also did not affect these outcomes.

CONCLUSIONS

Esophageal cancer with esophageal varices could be treated endoscopically safely and effectively.

Endoscopic submucosal dissection for superficial esophageal squamous cell carcinoma in patients with cirrhosis and esophageal varices

Endoscopic submucosal dissection (ESD) has become the standard treatment for superficial esophageal squamous cell carcinoma (SESCC). However, the treatment strategy for SESCC complicated by esophageal varices (EVs) has not been established. We report two cases of SESCC in patients with alcoholic cirrhosis complicated by EVs who underwent ESD. Case 1 presented with EVs on the anal side of the SESCC, and endoscopic variceal ligation (EVL) was performed before ESD. After EVL, the SESCC was successfully treated by ESD without any adverse events. Case 2 presented EVs from the anal side of the SESCC to the submucosa just below the SESCC. Then, EVL and endoscopic injection sclerotherapy with polidocanol were performed before ESD. However, ESD was not completed because of severe bleeding by uncontrolled blood flow below and around the SESCC. Bleeding during ESD was controlled in case 1, but not in case 2.

Endoscopic treatment of early esophageal cancer with decompensated cirrhosis and successful prevention of postoperative stenosis: A case report

The management of gastrointestinal tumors with decompensated cirrhosis is extremely challenging. Patients often present with poor basic condition and coagulation function, and nutritional deficiency. Furthermore, postoperative recovery is difficult and so the majority of patients refuse surgery. The present study reports the case of a 73-year-old man with decompensated cirrhosis and early esophageal cancer. At the discretion of the patient and their family, a simultaneous approach was used to treat esophagogastric varices and perform a mucosal dissection of the early esophageal cancer via endoscopy. Post-surgery, multiple polyglycolic acid sheets were attached to the esophageal dissection wound. At >2 months post-surgery, an endoscopic re-examination of the patient showed that the esophageal mucosa had healed well, and there was no resistance detected via ordinary endoscopy. The main objective of the present study was to highlight the feasibility and safety of endoscopic treatment for patients with decompensated liver cirrhosis complicated with early esophageal cancer, and to provide a new treatment strategy for patients at high risk of esophageal stenosis after endoscopic mucosal dissection.

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

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.

Advanced Endoscopic Resection Techniques in Cirrhosis-A Systematic Review and Meta-Analysis of Outcomes

BACKGROUND/AIMS

While safety and effectiveness of advanced endoscopic resection techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) has been well established in general population, data regarding their utility in patients with cirrhosis is limited.

METHODS

We searched multiple databases from inception through July 2021 to identify studies that reported on outcomes of EMR and/or ESD in patients with cirrhosis. Meta-analysis was performed to determine pooled rates of immediate and delayed bleeding, perforation, death as well as rates of successful en bloc and R0 resection. Pooled relative risk (RR) was calculated for each outcome between patients with and without cirrhosis.

RESULTS

Ten studies with a total of 3244 patients were included in the final analysis. 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), respectively. Pooled rates of successful en bloc and R0 resection were 93% (CI 85.9-96.7) and 90.8% (CI 86.5-93.8), respectively. While incidence of immediate bleeding was higher in patients with cirrhosis, there was no statistically significant difference in any of the other outcomes between the patient groups.

CONCLUSIONS

Our study shows that performing EMR and ESD for gastrointestinal lesions in patients with cirrhosis is both safe and effective. The risks of procedural complications parallel those reported in general population.

Outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms in patients with liver cirrhosis

Background/Aims

The treatment of superficial esophageal neoplasms (SENs) in cirrhotic patients is challenging and rarely investigated. We evaluated the outcomes of endoscopic submucosal dissection (ESD) to determine the efficacy and safety of treating SENs in patients with liver cirrhosis.

Methods

The baseline characteristics and treatment outcomes of patients who underwent ESD for SENs between November 2005 and December 2017 were retrospectively reviewed.

Results

ESD was performed in 437 patients with 481 SENs, including 15 cirrhotic patients with 17 SENs. En bloc resection (88.2% vs. 97.0%) and curative resection (64.7% vs. 78.9%) rates were not different between the cirrhosis and non-cirrhosis groups (p=0.105 and p=0.224, respectively). Bleeding was more common in cirrhotic patients (p=0.054), and all cases were successfully controlled endoscopically. The median procedure and hospitalization duration did not differ between the groups. Overall survival was lower in cirrhotic patients (p=0.003), while disease-specific survival did not differ between the groups (p=0.85).

Conclusions

ESD could be a safe and effective treatment option for SENs in patients with cirrhosis. Detailed preprocedural assessments are needed, including determination of liver function, esophageal varix status, and remaining life expectancy, to identify patients who will obtain the greatest benefit.

Safety and efficacy of common endoscopic treatments in patients with decompensated liver cirrhosis

INTRODUCTION

The safety and efficacy have always been a concern, when patients with decompensated liver cirrhosis (DLC) receive endoscopic treatments.

METHODS

To evaluate the safety and efficacy of common endoscopic treatments including endoscopic resection (ER) and endoscopic retrograde cholangiopancreatography (ERCP) applying to patients with DLC, we performed a retrospective study finally including 81 patients receiving ER (43 endoscopic mucosal resection (EMR) and 38 endoscopic submucosal dissection (ESD)) and 131 patients treated by ERCP.

RESULTS

There were no significant differences in the rate of degeneration and invariability of Child-Pugh (CP) class and the overall rate of adverse events between two groups (93.8%/8.6% ER vs. 96.2%/15.3% ERCP). Both the degeneration rate of CP class (35.4%) and the rate of adverse events (27.1%) in subgroup CP class C of ERCP group were significantly higher (P=0). The rate of poor outcomes was higher in ERCP group (12.2%) than that in ER group (2.5%) (P=0.02). And subgroup CP class C of ERCP group had a higher poor outcome rate (27.1%) (P=0).

CONCLUSION

ER and ERCP could remove focal lesions or relieve symptoms induced by targeted diseases without significant changes of CP class. Significant benefits and risks coexisted in CP class C patients with DLC when receiving ERCP.

Polypectomy, Endoscopic Mucosal Resection, and Endoscopic Submucosal Dissection in the Cirrhotic Population

Endoscopic mucosal resection and dissection are advanced endoscopic procedures that have proven essential for resecting premalignant and early malignant lesions throughout the gastrointestinal tract. Over time, these procedures have proven to play a key role in avoiding more invasive surgical approaches and thus decrease overall mortality. However, the success of these procedures does come with a slightly increased risk of adverse events such as bleeding and perforation. In this article, we review the literature for reported adverse events, specifically in the cirrhotic population. This article also discusses experts' opinions on approaches taken to perform these procedures with acceptable risks.

cT1N0M0 Esophageal Squamous Cell Carcinoma Invades the Muscularis Mucosa or Submucosa: Comparison of the Results of Endoscopic Submucosal Dissection and Esophagectomy

Simple Summary

Esophagectomy has been the standard treatment for superficial esophageal squamous cell carcinoma (SESCC) that invades the muscularis mucosa or submucosa. This retrospective study aimed to assess the effects of endoscopic submucosal dissection (ESD) combined with selective adjuvant chemoradiotherapy on these SESCCs by comparing the results of esophagectomy. We found no significant differences in overall survival, disease-specific survival, and progression-free survival between the two groups. In the ESD group, the procedure time, overall complication rates, and length of hospital stay were significantly reduced, but the rate of metachronous tumor recurrence was significantly increased. Therefore, ESD combined with selective adjuvant chemoradiotherapy can be an alternative treatment to esophagectomy for SESCC invading the muscularis mucosa or submucosa.

Abstract

Background: Endoscopic submucosal dissection (ESD) combined with selective adjuvant chemoradiotherapy may be a new treatment option for cT1N0M0 esophageal squamous cell carcinoma (ESCC) invading muscularis mucosa or submucosa (pT1a-M3/pT1b). We aim to report the effectiveness of this treatment by comparing the results of esophagectomy. Methods: This retrospective single-center study included 72 patients with pT1a-M3/pT1b ESCC who received ESD combined with selective adjuvant chemoradiotherapy (n = 40) and esophagectomy (n = 32). The main outcome comparison was overall survival (OS). The secondary outcomes were treatment-related events, including operation time, complication rate, and length of hospital stay. Disease-specific survival (DSS) and progression-free survival (PFS) were also evaluated. Results: There were no significant differences in the rates of OS, DSS, and PFS between the two groups (median follow-up time: 49.2 months vs. 50.9 months); these were also the same in the subgroup analysis of pT1b ESCC patients. In the ESD group, the procedure time, overall complication rates, and length of hospital stay were significantly reduced. However, the metachronous recurrence rate was significantly higher. In a multivariate analysis, tumor depth and R0 resection were the independent factors associated with OS. Conclusions: ESD combined with selective adjuvant chemoradiotherapy can be an alternative treatment to esophagectomy for cT1N0M0 ESCC invading muscularis mucosa or submucosa.

Pedunculated esophageal carcinoma endoscopically removed using SB knife Jr with detachable snare after neoadjuvant chemotherapy

An 82-year-old Japanese man with alcoholic liver cirrhosis was referred to our hospital for treatment of advanced esophageal cancer. A protruding tumor was endoscopically observed in the middle thoracic esophagus, and pathological findings of the biopsy specimens revealed a squamous cell carcinoma. The clinical tumor staging was stage II (T3N0M0). The patient received two courses of neoadjuvant chemotherapy with 5-fluorouracil and nedaplatin. After the treatments, computed tomography showed significant reductions in the size of the target tumor. However, radical esophagectomy was not performed because the patient refused major invasive treatments. Instead, endoscopic resection was performed using a combination of polypectomy and endoscopic submucosal resection (ESD). To prevent bleeding during endoscopic treatment, we applied a detachable snare to the base of the tumor and cut the stalk using by an SB knife Jr, without hemorrhage. The pathohistology of the resected specimen was positively showed cancer cells on the margin of the esophageal carcinoma stalk. At 4 weeks after the initial operation, an additional ESD was successfully performed, which pathologically led to radical removal. The patient survived for more than 18 months after beginning the initial treatment. We describe a successful treatment using endoscopic resection after chemotherapy for advanced esophageal cancer with high surgical treatment risks.

Adjuvant therapy for pT1a-m3/pT1b esophageal squamous cell carcinoma after endoscopic resection: Esophagectomy or chemoradiotherapy? A critical review

Endoscopic resection (ER) combined with adjuvant therapy appears to be a new treatment for esophageal squamous cell cancers (ESCC) invading to deep mucosa (pT1a-m3) or submucosa (pT1b). Adjuvant therapy can take the form of esophagectomy or chemoradiotherapy (CRT), but it is unclear which treatment is better. This review is to explore the outcomes of adjuvant therapy between esophagectomy and CRT for the treatment of pT1a-m3/pT1b ESCC after ER. Ten relevant studies with a total of 285 patients were included. The reported 5-year overall survival rates ranged between 90-100 % for ER-esophagectomy and 75-85 % for ER-CRT. ESCC with the invasion of ≥ sm2 combined with lymphovascular involvement was associated with a high-risk of relapse in patients receiving ER-CRT, but not in ER-esophagectomy. In conclusion, patients with a high-risk of relapse should be treated with ER-esophagectomy; ER-CRT may be used as an alternative treatment for patients with a nonhigh risk of relapse.

Barrett's adenocarcinoma with esophageal varices successfully treated by endoscopic submucosal dissection with direct varices coagulation

A 67-year-old Japanese man with alcoholic cirrhosis underwent esophagogastroduodenoscopy (EGD), which revealed a 15-mm elevated lesion on the esophagogastric junction (EGJ). Endoscopic findings suggested that the lesion was an intramucosal cancer present on the esophageal varices. The location of the lesion at EGJ caused difficulties in endoscopic injection sclerotherapy and endoscopic variceal ligation for esophageal varices before esophageal endoscopic submucosal dissection (ESD). Direct varices coagulation treatment was therefore selected during ESD. Coagulation of bared varices with hemostatic forceps after mucosal incision enabled performing ESD without serious bleeding. 2 months afterwards, the patient underwent EGD, with no esophageal varices or carcinoma recurrence. Direct varices coagulation was effective for ESD of Barrett adenocarcinoma with esophageal varices.

Early Esophageal Squamous Cell Carcinoma on Varix Treated With Endoscopic Submucosal Dissection After Variceal Banding

Endoscopic submucosal dissection (ESD) is known as a representative therapy for the early esophageal carcinoma, but an underlying varix is an obstacle to perform ESD. Patients with alcoholic cirrhosis may develop esophageal varix and esophageal squamous cell carcinoma at the same time. We report a case of early esophageal squamous cell carcinoma just above the esophageal varix. We performed the combination therapy of variceal banding and ESD. The number of reports about the combination therapy and optimal time to perform variceal banding before ESD is not sufficient.

Novel endoscopic treatment strategy for early esophageal cancer in cirrhotic patients with esophageal varices

The safety and efficacy of endoscopic submucosal dissection (ESD) and radiofrequency ablation for early esophageal cancer (EEC) in cirrhotic patients has not been thoroughly investigated to date. The present study aimed to establish a standard treatment strategy for EEC in cirrhotic patients with esophageal varices. Six cirrhotic patients with early flat-type EECs (high-grade intraepithelial neoplasia) on or adjacent to esophageal varices were enrolled. Esophageal varix ligation (EVL) or transjugular intrahepatic portosystemic shunt (TIPS) were used for the initial management of esophageal varices. Follow-up endoscopy was performed two months following the initial procedure. The mean longitudinal length of the lesions was 4.3 cm (range, 2-6 cm). The average procedure time was 72.8 min (range, 34-135 min) and the average longitudinal length of the resected specimens was 45.6 mm (range, 30-90 mm). One case had a tumor-positive lateral margin with lymphovascular infiltration. Both complete and curative resection rates were 80% (4/5 lesions). Large intraoperative bleeding was detected in patients undergoing EVL compared with TIPS prior to the ESD procedure. No severe complications or mortality-associated events, including massive postoperative bleeding, perforation or hepatic failure, were observed. No recurrence and metastasis were observed during the follow-up period. The current study suggested a novel treatment strategy for EECs complicated by esophageal varices in cirrhosis with good treatment results, no neoplastic progression and an acceptable adverse event profile.

Can we perform esophagectomy for esophageal cancer patients with concomitant liver cirrhosis? A comprehensive systematic review and meta-analysis

Liver cirrhosis is sometimes encountered in esophageal cancer patients intended for surgery. However, the impact of liver cirrhosis on patients with surgically treated esophageal cancer remains unclear. Therefore, we conducted the first meta-analysis focusing on current topic. We comprehensively searched relevant studies in Pubmed, Embase, and Web of Science on September 3, 2018. Data for analysis included both short-term (including morbidity and mortality rates) and long-term (5-year survival rate) outcomes. Our meta-analysis was conducted by using the STATA 12.0 package. We finally included a total of six cohort studies involving a total of 1426 patients (161 cirrhotic patients and 1265 noncirrhotic patients). Meta-analysis showed that cirrhotic patients had a significantly higher morbidity rate (risk ratio (RR) = 1.226; 95% Confidence interval (CI) = [1.043, 1.442]; P = 0.014) than noncirrhotic patients. For specific complications, cirrhotic patients had a significantly higher rate of pulmonary complications (RR = 2.354; 95%CI = [1.376, 4.026]; P = 0.002) and pleural effusion (RR = 2.414; 95%CI = [1.482, 3.613]; P < 0.001) than noncirrhotic patients and there was a trend toward a higher rate of anastomotic leak (RR = 1.759; 95%CI = [0.945, 3.274]; P = 0.075) in cirrhotic patients. Moreover, cirrhotic patients also had a significantly higher mortality rate (RR = 2.529; 95%CI = [1.480, 4.324]; P = 0.001) than noncirrhotic patients. Cirrhotic patients tended to yield a lower 5-year survival rate than those noncirrhotic patients after surgical resection of esophageal cancer (RR = 0.715; 95%CI = [0.492, 1.039]; P = 0.079). In conclusion, liver cirrhosis was significantly correlated with high morbidity and mortality rates. However, there was no sufficient evidence of unfavorable survival in cirrhotic patients. Esophagectomy can be performed for certain esophageal cancer patients with concomitant liver cirrhosis with acceptable operative risks, providing that careful preoperative evaluation and patient selection have been achieved.