Endoscopic submucosal tunnel dissection for large esophageal neoplastic lesions

• Introduction
• Case series
• Patients and lesions
• ESTD procedures
• Results
• Discussion
• References

Endoscopic submucosal dissection (ESD) has been widely used for resection of esophageal neoplastic lesions, but there are still technical challenges in treating large ones. Based on the development of tunneling technique, we report the first series in which the new technique of endoscopic submucosal tunnel dissection (ESTD) was used to remove large lesions in the esophagus. ESTD was attempted in five consecutive patients with esophageal lesions for which resection was indicated. In the operation, once the margin of the lesions had been marked, a submucosal tunnel was created by submucosal dissection from the oral incision to the anal incision. Bilateral resection was then performed to remove the lesion completely. The average length of the five lesions was 5.7 cm, and their extent as a proportion of the whole circumference of the lumen ranged from one third to four fifths. Operative time ranged from 50 minutes to 120 minutes (mean, 77 minutes). En bloc resection with negative lateral and basal margins was achieved in all lesions without complications.

Introduction

ESD has been proven to be safe and effective for the en bloc resection of esophageal neoplastic lesions in cases where removal is clinically indicated [1]. However, when the lesions are large, there are two problems in the standard ESD procedure. One is that the lifting effect of the submucosal injection is less obvious after the circumferential incision than before it. The other is that the endoscopic view is obstructed or reduced when the resection reaches the central portion, due to the confined space in the esophagus and contraction of the resected mucosa. Therefore, how to remove large lesions rapidly and safely according to the principles of en bloc resection remains a very challenging problem. Some methods and devices have been devised to facilitate visibility [2] [3], but they are not easy or convenient to use.

Recently, the tunnel technique has been introduced, and promising results have been shown in clinical studies and animal experiments [4] [5] [6] [7]. With this technique, a submucosal tunnel is created to provide working space for further endoscopic interventions, such as cutting the muscularis propria in the treatment of achalasia [4], removing gastrointestinal submucosal tumors [5], or even allowing access to the peritoneal and thoracic cavity for further interventions [6] [7]. Based on the principles of the tunnel technique and experience in its use in peroral endoscopic myotomy and ESD, a submucosal tunnel extending from the oral margin to the anal margin of esophageal lesions is established during ESD to improve efficacy. In the porcine model, the ESTD technique has been proven to be safe and effective for wide mucosal resection in the esophagus [8]. We report the preliminary results of ESTD in five patients at our hospital.

Case series

Patients and lesions

From October 2010 to February 2012, five consecutive patients with esophageal lesions underwent ESTD at our hospital. Written informed consent was obtained from all patients before the operation. Detailed clinicopathologic data are given in [Table 1].

Large lesions were defined as those more than 2 cm in length and with a circumferential extent of more than one third of the esophageal circumference, but not circular. The macroscopic types and the depth of invasion were classified according to the Paris endoscopic classification of superficial neoplastic lesions [9].

ESTD procedures

ESTD was performed with a single-accessory channel endoscope (GIF-Q260J; Olympus, Tokyo, Japan) with a transparent cap (D-201-11804; Olympus) attached to the front. Other equipment and accessories included a high-frequency generator (ICC-200; ERBE Elektromedizin, Tübingen, Germany), an argon plasma coagulation unit (APC 300; ERBE), injection needle (INJ1-A1; Medwork, Höchstadt, Germany), dual knife (KD-650Q; Olympus), insulated-tip (IT) knife (KD-611L; Olympus), hook knife (KD-620LR; Olympus), and hemostatic forceps (FD-410LR; Olympus). All the ESTD procedures were performed by a single operator. With patients under mechanically ventilated general anesthesia with electrocardiographic monitoring, magnification endoscopy with narrow band imaging and chromoendoscopy (using iodine) was used to determine the area of the lesions. Carbon dioxide insufflation was used during the procedure. The standard ESTD steps are shown in [Fig. 1]. During the procedure, endoscopic hemostasis was performed either with the knife itself or with a hemostatic forceps whenever active bleeding was noticed. After completion of ESTD, preventive coagulation was routinely performed for all visible vessels on the artificial ulcer using hemostatic forceps or argon plasma coagulation. For the lesion which extended around four fifths of the whole esophageal lumen, a fully covered retrievable metal stent was placed immediately after ESTD. Postoperative management was similar to that after standard ESD.

Results

Average lesion length was 5.7 cm and their extent as a proportion of the whole circumference of the lumen ranged between one third and four fifths ([Table 1]). Operating time ranged from 50 minutes to 120 minutes (mean, 77 minutes). En bloc resection was achieved in all lesions, with negative lateral and basal margins on pathology. During the procedure, a few shallow parts of the circular muscle were damaged in one case but required no special treatment. No patient presented with bleeding, perforation, or dysphagia after the operation. Biopsy samples collected at endoscopic follow-up showed no residual tumor or tumor recurrence, including in the patient with submucosal cancer.

Discussion

In these five cases, the operative time for en bloc resection of large lesions in the esophagus was greatly reduced. The mean operative time for ESTD in the five cases was 77 minutes. The following factors may play a role in submucosal dissection in the ESTD procedure: (i) As the endoscope moves forward, the transparent cap attached to the endoscope tip can have the effect of blunt dissection. (ii) CO₂ insufflation can increase the distance between the mucosa and the muscularis propria, contributing to blunt dissection and working as a gas cushion. (iii) Submucosal injection solutions are mainly retained in the submucosal layer, reducing the amount of injection required and increasing the efficiency and safety of dissection. The operative view is clear and the speed of the operation improves accordingly.

The use of the tunnel technique in ESD for large esophageal lesions changes the standard procedure of ESD from marking – injection – circumferential incision – dissection to marking – injection – anal incision – oral incision – tunnel creation – bilateral resection. During the ESTD procedure, the anal incision was made before the tunnel creation. The anal incision can serve as the endpoint of the tunnel so that the submucosa will not be dissected immoderately. In addition, the anal incision can prevent abundant gas from overaccumulating during the creation of the tunnel, which might result in excessive mucosal separation. In the five cases presented, there was no postoperative bleeding or perforation. Another common complication after esophageal ESD, postoperative esophageal stricture, is similar in ESTD to what is seen after ESD. In the present series, one patient whose lesion extended to four fifths of the whole esophageal lumen had a fully covered retrievable metal stent placed immediately after ESTD to prevent esophageal stricture. No patient presented any stricture at follow-up. Thus, ESTD is a safe technique.

One new problem in the operation of ESTD, however, is how to keep the extent of the bilateral resection moderate. In the standard ESD procedure, the resection is based on the submucosal injection. Due to lack of fluid cushion, in one of our ESTD procedures a few shallow parts of circular muscle were damaged in the bilateral resection from the esophageal lumen. Dissection from the side of the tunnel to the esophageal lumen may avoid such damage to the muscles, and suitable new accessories may also help to solve this problem.

In conclusion, this preliminary study has shown that the ESTD technique is feasible and appears to be effective and safe. This needs to be further confirmed by larger, comparative studies.

Competing interests: None.

• References

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Corresponding author

• References

• 1 Inoue H, Minami H, Kaga M et al. Endoscopic mucosal resection and endoscopic submucosal dissection for esophageal dysplasia and carcinoma. Gastrointest Endosc Clin N Am 2010; 20: 25-34
  CrossrefPubMedSearch in Google Scholar
• 2 Tsao SK, Toyonaga T, Morita Y et al. Modified fishing-line traction system in endoscopic submucosal dissection of large esophageal tumors. Endoscopy 2011; 43: E119
  Thieme ConnectPubMedSearch in Google Scholar
• 3 Matsumoto K, Nagahara A, Sakamoto N et al. A new traction device for facilitating endoscopic submucosal dissection (ESD) for early gastric cancer: the “medical ring”. Endoscopy 2011; 43: E67-E68
  Thieme ConnectPubMedSearch in Google Scholar
• 4 Inoue H, Minami H, Kobayashi Y et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
  Thieme ConnectPubMedSearch in Google Scholar
• 5 Gong W, Xiong Y, Zhi F et al. Preliminary experience of endoscopic submucosal tunnel dissection for upper gastrointestinal submucosal tumors. Endoscopy 2012; 44: 231-235
  Thieme ConnectPubMedSearch in Google Scholar
• 6 Sumiyama K, Gostout CJ, Rajan E et al. Pilot study of transesophageal endoscopic epicardial coagulation by submucosal endoscopy with the mucosal flap safety valve technique (with videos). Gastrointest Endosc 2008; 67: 497-501
  CrossrefPubMedSearch in Google Scholar
• 7 Yoshizumi F, Yasuda K, Kawaguchi K et al. Submucosal tunneling using endoscopic submucosal dissection for peritoneal access and closure in natural orifice transluminal endoscopic surgery: a porcine survival study. Endoscopy 2009; 41: 707-711
  Thieme ConnectPubMedSearch in Google Scholar
• 8 Linghu EQ, Yang J, Zhang YC et al. Endoscopic submucosal dissection through tunnel for esophageal lesions with diameter more than 2.5cm in pigs. Chin J Laparo Surg (Electronic Edition) 2011; 4: 394-396
  PubMedSearch in Google Scholar
• 9 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002. Gastrointest Endosc 2003; 58: 3-43
  CrossrefPubMedSearch in Google Scholar