Predictors of postoperative stricture after esophageal endoscopic submucosal dissection for superficial squamous cell neoplasms

Background and study aims: Although endoscopic submucosal dissection (ESD) is becoming accepted as an established treatment for superficial esophageal squamous cell neoplasms, the risks for developing postoperative stricture have not been elucidated.

Patients and methods: This was a retrospective study at a single institution. From January 2002 to October 2008, 65 patients with high-grade intraepithelial neoplasms (HGINs) or m2 carcinomas treated by ESD were enrolled. Predictors of postoperative stricture were investigated by comparing results from 11 patients who developed strictures with those from 54 patients who did not .

Results: Significant differences between the two groups were observed in longitudinal diameter (45.0 ± 15.9 mm vs. 31.5 ± 13.6 mm) and circumferential diameter (37.2 ± 8.6 mm vs. 26.8 ± 9.7 mm) of the resected specimens, and the proportion of extension to the whole circumference of the lumen (< 1 / 2/ > 1 / 2/ > 3 / 4 : 2 / 4 / 5 vs. 40 / 13 / 1), histologic depth (HGIN/m2 : 2 / 9 vs. 41 / 13), and procedure time (85.6 ± 42.8 minutes vs. 53.3 ± 30.1 minutes). Multivariate analysis revealed that circumferential extension of > 3 / 4 (odds ration [OR]: 44.2; 95 % confidence interval [CI]: 4.4 – 443.6) and histologic depth to m2 (OR: 14.2; 95 %CI: 2.7 – 74.2) are reliable risk factors. Subanalysis for each category by combinations of these risk factors revealed that patients with lesions in > 3 / 4 of the circumferential area were associated with a high rate of postoperative stricture. By contrast, patients with HGIN lesions in < 3 / 4 extension have no probability of postoperative strictures. Additionally, subanalysis of patients with m2 lesions in < 3 / 4 circumferential extension revealed that circumferential diameter can be a reliable predictor for postoperative stricture.

Conclusions: Circumferential extension and histologic depth are the reliable risk factors for postoperative strictures. In combination with circumferential diameter, we can perform effective and appropriate preventive balloon dilatations after esophageal ESD.

References

• 1 Ohkuwa M, Hosokawa K, Boku N. et al . New endoscopic treatment for intramucosal gastric tumors using an insulated-tip diathermic knife.  Endoscopy. 2001;  33 221-226
• 2 Yamamoto H, Kawata H, Sunada K. et al . Success rate of curative endoscopic mucosal resection with circumferential mucosal incision assisted by submucosal injection of sodium hyaluronate.  Gastrointest Endosc. 2002;  56 507-512
• 3 Yahagi N, Fujishiro M, Kakushima N. et al . Endoscopic submucosal dissection for early gastric cancer using the tip of an electrosurgical snare (thin type).  Dig Endosc. 2004;  16 34-38
• 4 Oyama T, Tomori A, Hotta K. et al . Endoscopic submucosal dissection of early esophageal cancer.  Clin Gastroenterol Hepatol. 2005;  3 67-70
• 5 Fujishiro M, Yahagi N, Kakushima N. et al . Endoscopic submucosal dissection of esophageal squamous cell neoplasms.  Clin Gastroenterol Hepatol. 2006;  4 688-694
• 6 Ono S, Kodashima S, Fujishiro M. et al . Clinical outcomes of endoscopic submucosal dissection for esophageal squamous cell carcinoma (in Japanese).  Stomach Intestine. 2009;  44 (in press)
• 7 Kato H, Tachimori Y, Watanabe H. et al . Superficial esophageal carcinoma. Surgical treatment and the results.  Cancer. 1990;  66 2319-2323
• 8 Kato H, Tachimori Y, Mizobuchi S. et al . Cervical, mediastinal, and abdominal lymph node dissection (three-field dissection) for superficial carcinoma of the thoracic esophagus.  Cancer. 1993;  72 2879-2882
• 9 Roth J A, Putnam Jr. J B. Surgery for cancer of the esophagus.  Semin Oncol. 1994;  21 453-461
• 10 Katada C, Muto M, Manabe T. et al . Local recurrence of squamous-cell carcinoma of the esophagus after EMR.  Gastrointest Endosc. 2005;  61 219-225
• 11 Shimura T, Sasaki M, Kataoka H. et al . Advantages of endoscopic submucosal dissection over conventional endoscopic mucosal resection.  J Gastroenterol Hepatol. 2007;  22 821-826
• 12 Mandard A M, Tourneux J, Gignoux M. et al . In situ carcinoma of the esophagus. Macroscopic study with particular reference to the Lugol test.  Endoscopy. 1980;  12 51-57
• 13 Yoshida T, Inoue H, Usui S. et al . Narrow-band imaging system with magnifying endoscopy for superficial esophageal lesions.  Gastrointest Endosc. 2004;  59 288-295
• 14 The Paris endoscopic classification of superficial neoplastic lesions: esophagus, stomach, and colon: November 30 to December 1, 2002.  Gastrointest Endosc. 2003;  58 3-43
• 15 Schlemper R J, Riddell R H, Kato Y. et al . The Vienna classification of gastrointestinal epithelial neoplasia.  Gut. 2000;  47 251-255
• 16 Giovannini M, Bories E, Pesenti C. et al . Circumferential endoscopic mucosal resection in Barrett"s esophagus with high-grade intraepithelial neoplasia or mucosal cancer. Preliminary results in 21 patients.  Endoscopy. 2004;  36 782-787
• 17 Lambert R. Treatment of esophagogastric tumors.  Endoscopy. 2003;  35 118-126