THE “TUNNEL + CLIP” STRATEGY, A SAFE TECHNIQUE THAT FACILITATES OESOPHAGEAL ENDOSCOPIC SUBMUCOSAL DISSECTION: A FRENCH BI-CENTRIC PROSPECTIVE OBSERVATIONAL STUDY

Aims Endoscopic submucosal dissection (ESD) is the treatment of choice for superficial neoplasia of the oesophagus. ESD requires a high level of skill, being both technically challenging and time consuming. Therefore, ESD is often reserved for experts. A combination of the tunnel technique associated with clip + wire traction has been described as being able to optimize the performance of oesophageal ESD.

Methods Between January 2015 and August 2019 we performed a prospective two-centre case study of consecutive “tunnel + clip” oesophageal ESD. Three young operators (each of whom had performed fewer than 50 ESDs and fewer than five oesophageal ESDs) treated patients requiring ESD using the tunnel + clip method. This involves realization of a tunnel beneath the lesion, with constant traction being applied by a clip with a line connected to a metal forceps placed at the oral side of the tunnel.

Results Eighty-seven lesions (27 squamous cell carcinoma and 60 adenocarcinoma / high grade dysplasia on Barrett’s oesophagus) were consecutively resected. The rates of en bloc resection, R0, and curative resection were respectively 98.85% (86/87), 86.2% (75/87) and 75.86% (66/87). One perforation occurred (1.14%), treated medically (no surgery). Three post-procedure bleeding were noted (3.44%). The mean ESD velocity was 28,485 mm2/min for lesions of mean length 56.89 mm. The tunnel + clip approach greatly aided the procedure. No pathological damage caused by clipping was evident.

Conclusions The use of the tunnel + clip to perform oesophageal ESD is effective and safe even when performed by operators with low experience. It is the largest western series of oesophageal ESD showing R0 resection rate similar to that of Japanese experts [2], with a dissection speed rate even higher [3].The performances of this technique should encourage the development of oesophageal ESD in Western countries.