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ENDOSCOPIC SUBMUCOSAL DISSECTION AS AN ALTERNATIVE TO TRADITIONAL SURGERY FOR NEOPLASMS AND EARLY MALIGNANCIES OF THE ESOPHAGUS AND DUODENUM
MR Antillon, WP Pais, ML Miller, AA Diaz-Arias, G Hammoud, D Antillon, P Tiwari, JA Ibdah, JB Marshall
Division of Gastroenterology, University of Missouri, Columbia, MO, United States
BACKGROUND: Endoscopic submucosal dissection (ESD), a type of intralumenal endoscopic surgery, was recently developed in Japan for en-bloc removal of GI tumors as an alternative to conventional surgical removal. The technique employs an electrosurgical knife to dissect the submucosal layer beneath the lesion, and is capable of removing en-bloc much larger tumors than the older technique of endoscopic mucosal resection (EMR). Though initially done for gastric tumors, ESD has now been applied to lesions elsewhere in the gut. There is little published experience with ESD outside of Asia.
OBJECTIVE: Our purpose was to assess the effectiveness and safety of ESD for the removal of benign neoplasms and early cancers of the esophagus and duodenum.
METHODS: Retrospective analysis from chart audits of patients who underwent ESD of lesions from the esophagus and duodenum at our tertiary care university hospital in the U.S. over the period June 2006 to September 2007.
RESULTS: Our series of 16 patients included 11 benign duodenal neoplasms, 3 benign esophageal neoplasms, and 2 early esophageal cancers (by EUS criteria). All procedures were performed by one endoscopist (MRA). The electrosurgical knife used was the conventional (non-insulated tip) needle knife (CNK), which is readily available in the U.S. for ERCP. The 14 benign lesions ranged in size from 1-cm to 4-cm, with a mean of 2.5-cm. It was initially planned to remove the two smallest of these lesions by EMR, but this proved unsuccessful, prompting performance of ESD. The procedural success of ESD for the 14 benign cases was 100%, with successful en-bloc removal in 79% and free margins in 79%. The early esophageal cancers were 2-cm in size and 3-cm in size. Both did not have vertical free margins and required further surgery. The only complications for the 16 ESD cases were 2 duodenal perforations, both of which resolved with medical management. The mean hospital stay for the 16 duodenal and esophageal ESD cases was 1.3 days.
CONCLUSIONS: ESD, using a CNK, appears to be an effective and safe alternative to surgery for the removal of large benign duodenal and esophageal neoplasms. It was not able to curatively remove the two early stage esophageal cancers in our series.