Endoscopic submucosal dissection (ESD) for wide-spread ‘en bloc resection’ in the esophagus – preliminary experience of 10 ESD's in 9 patients

Introduction: ESD is an advanced endoscopic ‘free hand’ which can provide an ‘en bloc’ tissue specimen of the lesion plus surrunding ‘safety zone’. However, experience in the esophagus is limited so far.

Patients, Material & Method: From November 12, 2009 to November 3, 2010, 9 patients, ASA 1–4 were referred for ESD because of early cancer (n=6) or HG-IEN (n=2) in the distal esophagus (n=6) and gastro-esophageal junction (n=1; Siewert II). One patient had a symptomatic submucosal esophageal tumor. 2/7 had undergone unsuccessful or incomplete previous local EMR treatment for early cancer and Barrett's epithelium. All patients were inoperable or had refused primary surgical treatment. Mean age of patients was 63 years (42–82 y); 6 males, 1 female. Resection was carried out using a prograde HR double channel endoscope in 7 ESDs in combination with a 1 or 1.5mm ‘Flush Knife’ (Fujifilm Corp., Tokyo, Japan, 6 ESD) or 2mm ‘Dual Knife’ (Olympus Optical, Tokyo, Japan, 1 ESD). In 3 patients with 3 resections a slim HR video gastroscope and 1.8mm needle knife was applied. A roller pump was used to re-establish or sustain the submucosal fluid cushion after initial needle injection using HAES 6% as well as a 4 (-10mm) transparent cap. 9/10 procedures were carried out under propofol sedation, one in ITN.

Results: 5 circular ESD were performed in 5 patients. In 4 patients a 50–90% circumferential ESD was primarily carried out. Of the latter residual Barrett's epithelium was removed in 1 case by ESD again 4 months later. In 1 patient this was achieved by capEMR. In one patient with 90% initial ESD and R0 for a pT1a cancer residual linear Barrett's islands are still to be removed.

Follow-up: After a median follow-up of 180 days (4–324 days) all patients are alive and aside 1 (after 4 days) followed as out- patients. One patient with a pT1b cancer, resected R0 but L1 underwent secondary surgery after primary repeated refusal. One inoperable patient with basal R1 is free of local or distant tumor signs as are all other patients.

Temporary stricture formation developed in all patients with more than 50% circular ESD resection size and more than 10 weeks follow up (n=7) but could be managed in all cases conservatively by bouginage or balloon dilatation. In two cases with rapid stricture development bouginage frequency could be reduced by temporary placement of a self-expanding PU covered metal stent.

Conclusions: Esophageal ESD is technically feasible and can provide large ‘en bloc’ specimen allowing a thorough histo-pathologic evaluation. Secondary stricture formation can be managed conservatively but is currently the major drawback. It is currently subject of intense basic research and animal studies.