Management of endoscopic submucosal dissection complications

Endoscopic submucosal dissection (ESD) is a new promising technique that allows endoscopic en bloc resection of premalignant and early malignant lesions in the gastrointestinal tract. In contrast to conventional endoscopic mucosal resection (EMR), lesions can be resected en bloc irrespective of their size. Clear advantages are an improvement in histopathological assessment of R0 resections and a lower risk of recurrence. Large series from Japan have shown significant improvement of en bloc resections after ESD compared with EMR in early gastric cancers [1], colonic lesions [2], and early esophageal neoplasms [3]. Guideline criteria for the resection of early gastric cancers in the pre-ESD era restricted the lesion size to 20 mm or less for conventional EMR [4]. New data on the risk of lymph node metastasis in early gastric cancer and the new ESD technique have allowed an extension of the resection criteria [5] [6]; for differentiated intramucosal cancers, the restriction on size could be lifted completely.

The introduction of ESD improved en bloc resection rates not only for large lesions but also for lesions smaller then 20 mm. Hoteya et al. recently confirmed this benefit even for lesions exceeding 5 mm in diameter [7]. We can summarize that ESD has revolutionized the endoscopic treatment of premalignancies and early malignancies in recent years. For early gastric cancers that fulfill the expanded resection criteria, ESD can be considered as the treatment of choice today.

ESD does have some disadvantages, however; it is technically difficult, time consuming, and requires a learning curve, especially outside Asia [8]. Compared with conventional EMR the complication rate is higher [9]. Bleeding and perforation are the major complications after ESD and are well known from other endoscopic resection techniques. The risk of intraprocedural bleeding is increased during ESD and has been reported in up to 22.6 % of gastric resections [9]. However, endoscopic treatment with electrocoagulation and hemoclipping is well established from other resection techniques and there is no difference in the management of bleeding with ESD, irrespective of whether bleeding is intraprocedural or delayed. Routine coagulation of visible vessels with a coagulation forceps may be helpful to prevent delayed bleeding after ESD [10]. Proton pump inhibitors are recommended after ESD in the upper gastrointestinal tract [11].

Large ESD series from Japan report perforation rates of about 5 % [2] [12] [13]. Perforation risk is even higher in the esophagus [3], the colon [14], and in the remnant stomach after distal gastrectomy [15].

If perforation is noted during ESD, immediate endoscopic closure should be the management of choice. In the case of tension pneumoperitoneum, percutaneous transabdominal air deflation must also be performed. Minami et al. treated 30 EMR perforations and 91 ESD perforations in the stomach endoscopically. The endoscopic closure techniques used were the ”single-closure method” using clips only or the ”omental-patch method” using the omentum as a patch and fixing it to the perforation margin for larger defects. In this study, endoscopic closure was successful in 98.3 %, and surgery could be avoided under antibiotic therapy and short-period fasting [13]. Smaller series have confirmed this conservative approach, with 100 % success rates after gastric ESD [12] and after ESD in different gastrointestinal organs [16]. In colonic ESD, however, the success rate may be lower. Taku et al. reported a closure rate by endoscopic clipping of only 56.6 % of ESD perforations in the colon [14]. To date there have been no reports of peritoneal dissemination and deterioration of the patient’s prognosis when perforation occurs during resection of an early cancer; however data are limited [17]. In a series from Japan, it was shown that the perforation rate in colonic ESD decreased significantly over time due to the rising experience of the endoscopist with increasing number of resections carried out. Additionally, the development of safer knives, such as the hook-knife, could further minimize the perforation risk [18].

Bleeding and perforation are the ”classical complications” of all endoscopic resection techniques. With the introduction of the ESD technique, which allows resection of large specimens and also circumferential resections, postinterventional stricture is increasingly observed as a ”new complication”, particularly after resections in the esophagus, at the gastroesophageal junction, and at the pylorus. Risk factors for strictures have not been clearly identified and treatment is not standardized.

In this issue of Endoscopy, Ono et al. report on 65 patients with superficial esophageal neoplasms resected with ESD (high-grade intraepithelial neoplasia and m2 cancers) [19]. Of the 65 patients, 11 (16.9 %) developed a stricture and were compared with the remaining 54 patients without strictures. Multivariate analysis revealed circumferential extension of the resected area of more than 75 % and histological invasion depth to the m2 level as risk factors for the development of a stricture. Additionally, for m2 cancers with a circumferential extension of less than 75 %, the circumferential diameter was shown to be another risk factor. A cut-off value of 30 mm showed a sensitivity of 100 % and a specificity of 54 % in the prediction of postinterventional stricture. All strictures were successfully treated by repeated balloon dilation. In conclusion the authors recommended preventive balloon dilation for defined subgroups after esophageal ESD (resections exceeding 75 % of the circumference regardless of the histology, and resections of m2 cancers with an extension of less than 75 % when the circumferential diameter exceeds 30 mm).

To date, ESD has been carried out predominantly in early gastric cancers. If the resection site is close to the cardia or to the pylorus, there is a risk of stricture development for gastric ESD. Coda et al. reported stricture rates of 17 % when the resection site included the gastroesophageal junction and 7 % for resections close to the pyloric ring. Risk factors were an extension of the mucosal defect of > 75 % of the circumference and a longitudinal extension of the defect of > 5 cm [20]. Although balloon dilation was effective and showed no complications in this series, Tsunada reported successful dilation in only two of five post-ESD stenoses in the gastric antrum. In one patient dilation was impossible, and two other patients underwent emergency surgery because of perforation related to the dilation [21].

Another treatment option for postinterventional strictures is endoscopic placement of stents. Saito et al. successfully placed biodegradable stents in two patients with esophageal strictures, which had developed 7 days and 4 weeks, respectively, after ESD of early squamous cell cancer. Mucosal defects had extended to seven-eights of the circumference in both lesions [22]. For cardiac or pyloric stenosis after ESD, stent placement has not been reported to date.

The progress of ESD in allowing en bloc resections of large lesions and even circumferential lesions is accompanied by an increasing knowledge of ESD complications and clear progress in their management. Technical improvements such as coagulation forceps have made endoscopic management of bleeding easier. The management of perforations has been revolutionized and has shifted from a surgical approach to the conservative endoscopic approach with increasing ESD experience in Japan. A new study from Japan provides new information on stricture development after esophageal ESD. Risk factors could be defined and preventive balloon dilation in subgroups was recommended. Although the study was retrospective and includes only a small number of strictures, the results are helpful and could provide a basis for prospective evaluation of stricture development and preventive treatment in high-risk patients. The best treatment of post-ESD strictures, and especially the potential role of biodegradable stents, is currently unknown. Prospective studies that compare stents with repeated dilations are needed, and patient selection could be based on the risk factors reported by Ono in this issue of Endoscopy [19].

As with every novel endoscopic technique, ESD shows new success but also shows new complications. The advantages of a new method can only be maintained if the associated complications are managed effectively. The ESD procedure, its success rate, and its complications must be compared with the therapeutic alternative of primary surgery; complications must show less morbidity and management of complications must be less invasive. We have reached these aims for the vast majority of ESD complications but further progress in technology and technique is on the way.

Competing interests: None

References

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