Innovations and brief communications

Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions

Authors

Mathieu Pioche1, 2, Laetitia Mais1, Olivier Guillaud1, Valérie Hervieu3, Jean-Christophe Saurin1, Thierry Ponchon1, 2, Vincent Lepilliez1

Institutions

1

Gastroenterology and Endoscopy Unit, Edouard Herriot Hospital, Hospices civils de Lyon, France Inserm U1032, LabTau, Lyon, France 3 Pathology Unit, Edouard Herriot Hospital, Hospices civils de Lyon, France 2

submitted 19. January 2013 accepted after revision 23. July 2013

Bibliography DOI http://dx.doi.org/ 10.1055/s-0033-1344855 Published online: 28.10.2013 Endoscopy 2013; 45: 1032– 1034 © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author Mathieu Pioche, MD Gastroenterology and Endoscopy unit, Pavillon H Edouard Herriot Hospital, Hospices civils de Lyon 5 place d’Arsonval 69437 Lyon Cédex France Fax: +33-47-2110146 [email protected]

Background and study aim: Endoscopic submucosal dissection (ESD) is recommended for en bloc R0 resection of superficial esophageal neoplasms larger than 20 mm, but is high risk and time-consuming. In the tunnel technique, incisions at the lower and upper lesion edges are joined by a submucosal tunnel and then lateral incisions are made. The mucosa is thereby easily separated from the muscular layer. We report our experience of esophageal tunnel ESD. Patients and methods: We retrospectively reviewed all consecutive esophageal tunnel ESDs performed at our unit between January 1 2010 and January 11 2013. Lesions were superficial esophageal neoplasms, UT1N0 at EUS.

Results: 11 patients underwent tunnel ESD (nine squamous cell carcinomas, two adenocarcinomas). Mean dissected surface area was 13.25 cm². Mean procedure duration was 76.7 minutes. All 11 resections were en bloc and 9 /11 were R0. Complications were one subcutaneous emphysema with spontaneous resolution, and stenosis in 4 /11 patients (36.4 %) with resolution after 1 – 5 dilations. Conclusion: Tunnel ESD of superficial esophageal neoplasms is an interesting option, seeming to be faster and more effective than standard ESD, without higher morbidity.

Introduction

to create a tunnel between the distal and proximal incisions. When the endoscope has reached the lower incision, and the distal end of the " Fig. 1), esophageal lumen has been visualized (● two lateral mucosal incisions are made, thus completing the procedure. The main advantage of the tunnel technique, in comparison with the standard procedure, is an easier separation of the mucosa from the muscular layer. This is because the liquid “lifting” agent that forms the mucosal cushion does not disappear so rapidly and because the mucosa between the lateral edges is stretched. We report our experience of esophageal ESD using the tunnel method.

!

Endoscopic submucosal dissection (ESD) is a recognized technique for the resection of esophageal superficial carcinomas larger than 20 mm as it allows en bloc R0 resection [1 – 3]. Nevertheless, it is considered to be a high risk and time-consuming method, which limits its widespread use. In the standard ESD procedure, a complete circumferential incision around the lesion is made before the submucosal dissection is begun. This circumferential incision is helpful in delineating the extent of dissection but tends to facilitate the diffusion of the ‘lifting’ fluid from the submucosa, thus reducing the duration of the submucosal cushioning. When evaluating a new waterjet system on living pigs, a physician from our unit (V.L.) performed esophageal ESD [4] using the tunnel technique as described in the peroral endoscopic myotomy (POEM) procedure in achalasia [5]. The ESD tunnel technique is carried out as follows: after creation of the submucosal cushion by injection of fluid in the usual way, incisions are made at the lower and upper edges of the lesion, and the submucosa under the lesion is then dissected in order

Patients and methods !

We retrospectively reviewed all consecutive esophageal tunnel ESD procedures done at our unit between 1 January 2010 and 1 January 2013. One experienced operator (V.L.) performed all these procedures. The patients presented with a superficial neoplasm of the esophagus, either adenocarcinoma

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Innovations and brief communications

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Table 1 Tunnel endoscopic submucosal dissection (ESD) procedures of large superficial neoplastic lesion in the esophagus in 11 patients: characteristics and outcomes. Number of patients

11

Tumor location, n (%) Upper third

0 (0 %)

Middle third

5 (45.5 %)

Lower third

6 (54.5 %)

Maximal diameter, mean, mm

49

Fig. 1 Tunnel endoscopic submucosal dissection (ESD) of large superficial neoplastic lesion in the esophagus. Endoscopic view of the tunnel after submucosal dissection with mucosal stretching. Thick arrow, the submucosal tunnel; red outline, lower edge of the tunnel; thin arrows, mucosal sides before final incisions.

or squamous cell carcinoma, categorized as UT1N0 on endoscopic ultrasound (EUS) examination. All lesions were found during routine upper gastrointestinal endoscopy and confirmed by biopsy. At staging examinations, including radial EUS and computed tomography (CT) scan, all patients were free of metastatic lymph nodes. No prior treatment was given before ESD. Before ESD procedures, the lesion margins were determined and marked after dedicated chromoendoscopy, using Lugol dye for squamous cell carcinoma (SCC) and acetic acid spraying for Barrett’s esophagus. For all patients we used standard high definition upper gastrointestinal scopes (GIF-H180; Olympus, Tokyo, Japan) with a transparent hood with (4 mm length, 3 mm hole, D201 – 11304; Olympus). Information collected and analyzed included lesion type, location, and size, and procedural details (knife used, solution injected, and duration). We also collected the histological data (en bloc or piecemeal resection, R0 laterally and in depth) and data on complications during or after the procedure including symptomatic stenosis with dysphagia. The specimen size, assessed at the time of histological analysis, was defined as the surface area when the lesion was pinned onto cork board. It was determined using the ellipse formula: Area [cm2] = (shortest length [cm]/2) × (longest length [cm]/2) × π. The duration of the procedure was defined as the time from commencement of marking around the lesion to the end of prophylactic hemostasis of the resected area. The speed of dissection (cm2/min) was defined as the specimen area (cm2) divided by duration (minutes). Follow-up was done at 3 months with a systematic endoscopy procedure. In accordance with French regulations, patients received complete information on the procedure prior to its performance and gave their oral consent.

100 %

3 (27.3 %)

75 %

1 (9.1 %)

50 %

3 (27.3 %)

33 %

3 (27.3 %)

25 %

1 (9.1 %)

Area, mean, mm 2

13.25

Duration of procedure, mean, min

76.7

Speed of dissection, mean, mm 2/min

16.9

En bloc resection

11 (100 %)

Tumor-free margins R0 resections, n (%)

9 (81.8 %)

Complications Immediate bleeding

0 (0 %)

Delayed bleeding

0 (0 %)

Perforation

0 (0 %)

Emphysema

1 (9.1 %)

Stenosis

4 (36.4 %)

Final pathological diagnosis, n (%) High grade dysplasia

0 (0 %)

Squamous cell carcinoma (SCC)

9 (81.8 %)

Adenocarcinoma

2 (18.2 %)

Vascular or lymphatic emboli, n (%)

0 (0 %)

Paris classification, n (%) IIa

1 (9.1 %)

IIb

7 (63.6 %)

IIa + IIb

3 (27.3 %)

Length of hospital stay, mean, days

5.5

Recurrence, n (%)

1 (9.1 %)

Results !

We retrospectively analyzed the records of 11 patients treated by the tunnel technique (nine men [81.8 %], two women; mean age 64.8 years, range 53.1 – 77). Histologically, two patients had adenocarcinomas on Barrett’s esophagus and nine had SCC. The mean lesion area was 13.25 cm² (range 4.45 cm² – 27.5 cm2). Resection was en bloc in all cases. The resection involved the entire circumference of the esophageal lumen (that is, circumferential extent 100 %) in three cases which were all complicated by stenosis. Paris classification, resection parameters, and pathological analysis, including tumor type, safety of margins, depth of carcinomatous invasion, and presence of vascular or lymphatic " Table 1. The R0 rate was 9/11 (81.8 %): emboli, are reported in ● two patients had squamous cancer tissue at the lesion margins, one in the lateral margin and the other in both lateral and deep margins. One patient with intramucosal microinvasive adenocarcinoma on Barrett’s esophagus had high grade dysplasia on the lateral margins but the adenocarcinoma was completely resected. The second patient with adenocarcinoma had intestinal metaplasia without dysplasia on the lateral margins. The mean procedure duration was 76.7 minutes (range 35 – 150 minutes). The average speed of dissection was 16.9 mm²/min (standard deviation [SD] 10.35). Concerning complications, one

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Circumferential extent of resection (estimated by endoscopist), n (%)

Innovations and brief communications

subcutaneous emphysema occurred without visible perforation at endoscopy or CT scan. There was no bleeding in this study. Symptomatic stenosis occurred in 4/11 patients (36.4 %) who received at least one balloon dilation (between 1 and 5 dilations). The median length of stay was 5.5 days. Different equipment was used at different study periods. Tools used were the Dual Knife (Olympus) (n = 7), the Nestis Enki 2 (Nestis, Lyon, France) (n = 3) and the Hybrid Knife T type (Erbe, Tuebingen, Germany) (n = 1). The solution used for the mucosal cushion was saline serum (n = 4), hydroxyethyl starch (Voluven; Fresenius Kabi, France) (n = 1) and glycerol mix (glycerol 10 %, fructose 5 %, saline serum 0.9 % [6]) (n = 6).

Discussion !

This descriptive study shows that the tunnel technique seems to be an optimal method for esophageal ESD that improves exposure of the submucosal and muscular planes. As the lateral edges of the mucosa remain intact during submucosal dissection, this increases mucosal stretching and also maintains mucosal lifting as the diffusion of injected fluids from the mucosal cushion is restricted. Stretching probably represents the main advantage, creating a large separation between the mucosal and muscular layers and making it easier to expose the cutting zone. The feasibility of this technique was also reported by Linghu et al., in five patients presenting with esophageal superficial tumor [7]. In our study, the mean procedure duration was 76.7 minutes for a 45 mm (range 27 – 80 mm) mean length of resected pieces. Considering the literature reports on standard esophageal procedures performed by experienced operators, Lee and colleagues described a mean duration of 92.7 minutes (SD 69) for 24 ESDs with a mean specimen size of 43.1 mm (8 – 80 mm) [8]. In western countries, procedures are slower, at 89 minutes for a mean size of 32 mm [9]; this can be explained by the lesser experience at western centers. The improved visualization of the dissecting zone seems to make the procedure faster. In our experience, ESD using the tunnel technique was effective, with R0 resection in 9/11 cases (81.8 %). According to Japanese results, in expert centers the rate of R0 resection using the standard technique is 78 % [10]. Concerning complications, the perforation rate was 0 % with the tunnel technique; there was only one subcutaneous emphysema, and this resolved spontaneously. There were no bleeding complications. There are several limitations of our study. The most important is the use of different knives, and moreover the use of a waterjet (Nestis, Erbe Jet) in 4/11 cases (36.4 %) as this could reduce the duration and the complication risk [6, 11, 12]. The use of different tools occurred because of the long period of observation in this retrospective cohort and the successive availability of new devices. Similarly, we used different solutions; the macromolecular solutions that provided longer-lasting and higher mucosal cushions made ESD easier [13 – 15].

To summarize, ESD using the tunnel method is an interesting option for the endoscopic management of superficial esophageal neoplasms. Compared with the standard technique, it is probably faster and equally effective in achieving R0 resections without engendering more complications. The technique could be crucial in optimizing ESD in the esophagus. Further prospective studies with standardized procedures are scheduled, to confirm these benefits and to better assess the effect on morbidity. Competing interests: None

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Pioche Mathieu et al. Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions … Endoscopy 2013; 45: 1032–1034

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Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions.

Endoscopic submucosal dissection (ESD) is recommended for en bloc R0 resection of superficial esophageal neoplasms larger than 20  mm, but is high ris...
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