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Background: Postendoscopic submucosal dissection electrocoagulation syndrome (PEECS) is commonly observed after performing endoscopic submucosal dissection (ESD) for esophageal neoplasia. However, data on the incidence and risk factors for PEECS in the esophagus are lacking due to an unclear definition of PEECS and varied clinical settings. Therefore, we aimed to determine the risk factors for PEECS in patients undergoing ESD for esophageal neoplasia., Methods: We retrospectively reviewed data of relevant clinical and endoscopy-specific parameters from 202 consecutive patients with esophageal neoplasias (139 carcinomas and 63 dysplasias) who underwent ESD under general anesthesia. Esophageal PEECS was defined by satisfying at least two of the following criteria: fever ≥ 37.8 °C, leukocytosis ≥ 10,800/mm 3 , and localized chest pain ≥ 5/10 points as assessed on a numeric rating scale within 24 h after ESD. Significant factors associated with PEECS were determined by regression analysis., Results: PEECS was recorded in 98 of 202 (48.5%) patients. Patients with PEECS exhibited a larger tumor size (25.0 vs. 17.0 mm, P = 0.002), longer procedure (40.0 vs. 29.5 min, P = 0.021) and hemostasis times (5.0 vs. 3.5 min, P = 0.004), required greater submucosal injection volume (60.0 mL vs. 50.0 mL, P = 0.030), and had a lower rate of local steroid injection (4.1% vs. 12.5%, P = 0.029) than those without PEECS. Multivariate regression analysis revealed tumor size ≥ 17 mm (P = 0.047), procedure time ≥ 33 min (P = 0.027), and hemostasis time ≥ 5 min (P = 0.007) as risk factors for PEECS. In addition, local steroid injection was a significant negatively associated factor (P = 0.001)., Conclusions: Patients with a large tumor, prolonged procedure and hemostasis times are at a high risk of PEECS occurrence. Further, local steroid injection is a negatively associated factor., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background/aims: Although an association between achalasia and esophageal cancer has been reported, whether achalasia confers a substantial increase in mortality is unknown. Moreover, the causes of death related to achalasia have not been investigated. We performed this nationwide, population-based cohort study on achalasia because no such study has been performed since the introduction of high-resolution manometry in 2008., Methods: This study was performed using data extracted from the Korean National Health Insurance Service database, covering a 9-year period from 2009 to 2017. Control participants without a diagnostic code for achalasia were randomly selected and matched by sex and birth year at a case-to-control ratio of 1:4. Data on the cause of death from Statistics Korea were also analyzed., Results: The overall incidence of achalasia was 0.68 per 100,000 person-years, and the prevalence was 6.46 per 100,000 population. Patients with achalasia (n=3,063) had significantly higher adjusted hazard ratio (aHR) for esophageal cancer (aHR, 3.40; 95% confidence interval [CI], 1.25 to 9.22; p=0.017), pneumonia (aHR, 2.30; 95% CI, 1.89 to 2.81; p<0.001), aspiration pneumonia (aHR, 3.92; 95% CI, 2.38 to 6.48; p<0.001), and mortality (aHR, 1.68; 95% CI, 1.44 to 1.94; p<0.001). Esophageal cancer carried the highest mortality risk (aHR, 8.82; 95% CI, 2.35 to 33.16; p=0.001), while pneumonia had the highest non-cancer mortality risk (aHR, 2.28; 95% CI, 1.31 to 3.96; p=0.004)., Conclusions: In this nationwide study, achalasia was associated with increased risk of mortality. Esophageal cancer and pneumonia were the most common comorbidities and the major causes of death in patients with achalasia.

Background: No definite guidelines for the management of small esophageal subepithelial tumors (SETs) have been established, because there are limited data and studies on their natural history. We aimed to assess the natural history and propose optimal management strategies for small esophageal SETs., Methods: Patients diagnosed as esophageal SETs ≤ 30 mm in size between 2003 and 2017 using endoscopic ultrasound (EUS) with a minimal follow-up of 3 months were enrolled, and their esophagogastroduodenoscopy (EGD) and EUS were retrospectively reviewed., Results: Of 275 esophageal SETs in 262 patients, the initial size was < 10 mm, 10-20 mm, and 20-30 mm in 104 (37.8%), 105 (38.2%), and 66 (24.0%) lesions, respectively. Only 22 (8.0%) SETs showed significant changes in size and/or echogenicity and/or morphology at a median of 40 months (range, 4-120 months). Tissues of 6 SETs showing interval changes were obtained using EUS-guided fine needle aspiration biopsy; 1 was identified as a gastrointestinal stromal tumor (GIST) and was surgically resected, while the other 5 were leiomyomas and were regularly observed. Eight SETs showing interval changes were resected surgically or endoscopically without pathological confirmation; 1 was a GIST, 2 were granular cell tumors, and the other 5 were leiomyomas., Conclusion: Regular follow-up with EGD or EUS may be necessary for esophageal SETs ≤ 30 mm in size considering that small portion of them has a possibility of malignant potential. When esophageal SETs ≤ 30 mm show significant interval changes, pathological confirmation may precede treatment to avoid unnecessary resection., Competing Interests: The authors have no potential conflicts of interest to disclose., (© 2022 The Korean Academy of Medical Sciences.)

Purpose: This study aimed to evaluate the real-world efficacy of immune checkpoint inhibitors (ICIs), and to identify clinicolaboratory factors to predict treatment outcomes in patients with advanced esophageal squamous cell carcinoma (ESCC) receiving ICIs., Materials and Methods: Sixty patients with metastatic or unresectable ESCC treated with nivolumab (n=48) or pembrolizumab (n=12) as ≥ second-line treatment between 2016 and 2019 at Asan Medical Center were included., Results: The median age of the patients was 68 years (range, 52 to 76 years), and 93.3% were male. Most patients had metastatic disease (81.7%) and had been previously treated with fluoropyrimidines, platinum, and taxane. In 53 patients with measurable disease, the overall response rate and disease control rate were 15.1% and 35.8%, respectively. With a median follow-up duration of 16.0 months, the median progression-free survival (PFS) and overall survival (OS) were 1.9 months (95% confidence interval [CI], 1.54 to 2.19) and 6.4 months (95% CI, 4.77 to 8.11), respectively. After multivariate analysis, recent use of antibiotics, low prognostic nutrition index (< 35.93), high Glasgow Prognosis Score (≥ 1) at baseline, and ≥ 1.4-fold increase in neutrophil-to-lymphocyte ratio after one cycle from baseline were significantly unfavorable factors for both PFS and OS. Younger age (< 65 years) was a significant factor for unfavorable PFS and hyponatremia (< 135 mmol/L) for unfavorable OS., Conclusion: The use of ICIs after the failure of chemotherapy showed comparable efficacy in patients with advanced ESCC in real practice; this may be associated with host immune-nutritional status, which could be predicted by clinical and routine laboratory factors.

Few studies have focused on preoperative nutritional status of esophageal cancer patients eligible for upfront surgery. We aimed to investigate the association of preoperative nutritional status with prognosis of patients who undergo upfront surgery for esophageal cancer. A total of 274 patients who underwent upfront surgery for esophageal squamous cell carcinoma between January 2012 and December 2016 were eligible. Preoperative nutritional status was evaluated using prognostic nutritional index (PNI) scoring system, nutritional risk screening 2002 (NRS 2002), and controlling nutritional status. The median age was 63 years (interquartile range, 58-70) and 94.7% of patients were male. The pathological stages were Stage I-74.5% (204/274), Stage II-20.4% (56/274), and Stage III-5.1% (14/274). Multivariate analysis revealed that advanced stage, a low PNI, and a high NRS 2002 were independent predictors of overall survival. During median follow-up period of 55 mo, overall survival rates were lower in the high NRS 2002 group ( P  < 0.001). A high NRS 2002 score was associated with frequent postoperative complications, especially pneumonia and anastomosis site leakage ( P  = 0.003). The poor preoperative nutritional status with a high NRS 2002 is associated with postoperative complications as well as poor overall survival in patients with upfront surgery for esophageal cancer.Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2022.2042573.

Background/aims: Data regarding the prognosis of early esophageal cancer are lacking. This study investigated the long-term outcomes and factors affecting the survival of patients with mucosal esophageal squamous cell carcinoma (T1aESCC)., Methods: We analyzed the clinical and tumor-specific parameters of 263 patients who received surgical resection (SR; n=63) or endoscopic resection (ER; n=200) for T1aESCC. Underlying comorbidities were scored using the Charlson comorbidity index (CCI). Overall survival (OS) was the primary outcome, and multivariate regression analysis was performed to predict factors for OS., Results: Of the study patients (age, 64.5±8.0 years), the CCI was 1.0±1.4 in the ER group and 0.6±0.9 in the SR group (p=0.107). The 5-year OS rate during follow-up (54.4±20.4 months) was 85.7% (ER group, 86.8%; SR group, 82.4%; p=0.631). The cumulative 5-year incidence of esophageal cancer recurrence was 10.5% in the ER group (vs 0% in the SR group). The overall mortality rate was 12.9% (ER group, 12.0%; SR group, 15.9%; p=0.399). The most common cause of mortality was second primary cancers in the ER group (75%) and organ dysfunction or postoperative complications in the SR group (70%). According to multivariate analysis, only CCI was significantly associated with OS (p<0.001). The 5-year OS rate in patients with a CCI >2 and in those with a CCI ≤2 was 60.2% and 88.2%, respectively (p<0.001). The treatment method (ER vs SR) was not a significant affecting factor (p=0.238)., Conclusions: The long-term prognosis of patients with T1aESCC was significantly associated with underlying comorbidities.

Objectives: Circumferential endoscopic submucosal dissection (ESD) for large lesions induces severe stricture, requiring subsequent treatment. We aimed to evaluate the efficacy of allogeneic epithelial cell sheet transplantation in preventing esophageal stricture after circumferential ESD in a porcine model., Materials and Methods: A total of 15 conventional pigs underwent a 4 cm long circumferential ESD in the mid-esophagus. Out of these animals, 11 were immediately subjected to allogeneic oral mucosal cell sheet transplantation at the resection site, whereas four pigs underwent circumferential ESD only. We performed upper endoscopy 1 and 2 weeks after ESD and assessed the degree of esophageal stricture and histologic characteristics., Results: Dysphagia scores and weight change ratios recorded 1 and 2 weeks after ESD did not differ between the two groups. The stricture rate 2 weeks after ESD was 100% in the control group and 90.9% in the cell sheet group ( p  = 1.000). The median mucosal constriction rates of the control and cell sheet groups were 73.5% (range 63.0-80.0%) and 53.8% (37.5-73.3%, p  = .018), respectively. With regard to microscopic measurements, the length of re-epithelialization was greater in the cell sheet group than in the control group (2,495 µm vs. 369 µm, p  = .008). Median fibrosis thickness and degree of muscle damage were not significantly different between groups., Conclusions: Although allogeneic epithelial cell sheet transplantation showed greater re-epithelialization and less mucosal constriction of post-ESD ulcers, it was not sufficiently effective in preventing post-ESD stricture.

As patients receiving definitive chemoradiotherapy (dCRT) for oesophageal squamous cell carcinoma (ESCC) are heterogeneous, we aimed to identify prognostic factors and failure patterns after dCRT. From 2006 to 2015, 327 patients who received dCRT for ESCC were reviewed. Treatment response to dCRT was evaluated based on EORTC-PET criteria with endoscopy and CT results. After dCRT, 296 patients (90.5%) achieved disease stabilisation, with 132 cases of complete response (CR) (40.4%), 158 of partial response (PR) (48.3%) and 6 of stable disease (SD) (1.8%); 31 patients (9.5%) had progressive disease (PD). Median overall survival (OS) from response evaluation was 24.0 months in the overall population. Post-treatment clinical response was the most significant prognostic factor for OS in the multivariate analysis (median OS, 65.0 months for CR, 17.3 months for PR, 4.4 months for SD and 4.0 months for PD; p < 0.0001). Median progression-free survival (PFS) in 296 patients who achieved disease stabilisation was 13.1 months, and only clinical response was a significant factor in the multivariate analysis. The median PFS of CR, PR and SD patients were 36.9, 9.2 and 2.8 months, respectively (p < 0.0001). The clinical response was also significantly associated with the predominant failure pattern (locoregional failure [81.6%] in the initial non-PD group vs. distant metastasis [87.1%] in the initial PD group [p < 0.0001]). In conclusion, definitive chemoradiotherapy-treated ESCC patients showed highly different prognoses after treatment especially according to the clinical response to chemoradiotherapy., (© 2021 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.)

Aim: The number of elderly patients with superficial esophageal neoplasms has steadily increased, but few studies have focused on the clinical outcomes of esophageal endoscopic submucosal dissection in these patients. Therefore, the aim of our study was to investigate the feasibility and safety of endoscopic submucosal dissection among elderly patients with superficial esophageal neoplasms., Methods: Patients who underwent endoscopic submucosal dissection for superficial esophageal neoplasms between December 2005 and December 2017 were eligible. The patients were divided into two groups according to age: Not-old (<75 years, n = 369) and Old (≥75 years, n = 44). Clinical features and treatment outcomes were retrospectively investigated by reviewing medical records., Results: In total, 413 patients with 459 lesions were enrolled in to this study. Comorbidities, except for a previous history of malignancy, were not significantly different between the two groups. Procedure-related characteristics and the rate of adverse events were similar in the two groups. During a median follow-up period of 33.4 months, the overall survival rate was lower in the Old group (P = 0.046), and the cumulative recurrence rate did not differ significantly between the two groups (P = 0.334)., Conclusion: Based on these favorable outcomes, endoscopic submucosal dissection is as feasible and effective for the treatment of superficial esophageal neoplasms among elderly patients as it is among non-elderly patients. Geriatr Gerontol Int 2020; 20: 430-435., (© 2020 Japan Geriatrics Society.)

Objectives: This study aimed to investigate the efficacy of prophylactic steroid administration in preventing post-endoscopic submucosal dissection (ESD) esophageal stricture and to determine risk factors for these strictures., Methods: Patients who underwent ESD for superficial esophageal neoplasms with a mucosal defect affecting >75% of the esophageal circumference between January 2011 and August 2016 were eligible. Patients were classified into three groups, including ESD-alone group (n = 22), oral steroid group (n = 25) and intralesional steroid injection group (n = 6). Univariate and multivariate logistic regression analyses were performed to evaluate the risk factors for esophageal stricture., Results: The stricture rate was 50.0%, 20.0% and 33.3% in the ESD-alone group, oral steroid group and steroid injection group, respectively. Patients treated with steroids had a significantly lower stricture rate than the ESD-alone group (22.6% vs 50.0%, P = 0.046). Additionally, oral steroid group had a significantly lower stricture rate than the ESD-alone group (P = 0.037). Multivariate analysis revealed that the extent of the circumferential mucosal defect was a significant risk factor for post-ESD strictures (odds ratio [OR] 13.015, 95% confidence interval [CI] 2.257-76.077, P = 0.004). The administration of steroids (OR 0.108, 95% CI 0.020-0.578, P = 0.009), specifically oral steroids (OR 0.109, 95% CI 0.019-0.622, P = 0.013), was associated with prevention of post-ESD strictures., Conclusion: Oral steroid prophylaxis appears to be a safe and effective treatment in preventing post-ESD stricture and improving patients' quality of life., (© 2019 Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.)

Background: Malignant dysphagia can result in poor nutritional status with severe weight loss. Rapid relief from dysphagia can be achieved with esophageal self-expanding metal stents (SEMSs), a minimally invasive method. In this study, we evaluated the usefulness of SEMSs for malignant dysphagia., Methods: Between 2012 and 2015, 119 patients with malignant dysphagia underwent esophageal SEMS insertion with endoscopic assistance. Their demographics and clinical outcomes were collected. Factors associated with stent-related complications and patient survival were evaluated. All data were retrospectively analyzed., Results: The mean age of the 119 patients was 64.9 ± 11.6 years, and 25 (21%) were female. Seventy-five patients (63.0%) had squamous carcinoma, majority of which were located in the lower thoracic esophagus (n = 42), followed by middle thoracic esophagus (n = 19) and upper esophagus (n = 10). Eighty patients (67.2%) underwent SEMS insertion at diagnosis. Technical and clinical success rates were 99.2 and 89.9%, respectively. Complications occurred in 47 patients (39.5%); the most common complication was migration (36.3%), followed by pain and obstruction. The median stent patency time was 145 days (95% confidence interval 55.19-234.81 days). Gastric cancer (odds ratio 3.51, 95% confidence interval 1.21-10.15; p = 0.021) and a 20-mm-wide stent (odds ratio 2.922, 95% confidence interval 1.237-6.904; p = 0.015) were risk factors for complications., Conclusions: SEMSs are effective in palliation of malignant dysphagia. However, stent-related complications should be borne in mind, particularly in patients with gastric cancer with esophageal invasion and with larger width stents.

Background/aims: Endoscopic submucosal dissection (ESD) of a superficial esophageal neoplasm (SEN) is a technically difficult procedure. We investigated the clinical outcomes of ESD to determine its feasibility and effectiveness for the treatment of SEN., Methods: Patients who underwent ESD for SEN between August 2005 and June 2014 were eligible for this study. The clinical features of patients and tumors, histopathologic characteristics, adverse events, results of endoscopic resection, and survival were investigated., Results: ESD was performed in 225 patients with 261 lesions, including 70 cases (26.8%) of dysplasias and 191 cases (73.2%) of squamous cell carcinomas. The median age was 65 years (range, 44 to 86), and the male to female ratio was 21.5:1. Median tumor size was 37 mm (range, 5 to 85) and median procedure time was 45 minutes (range, 9 to 160). En bloc resection was performed in 245 of 261 lesions (93.9%), with complete resection in 234 lesions (89.7%) and curative resection in 201 lesions (77.0%). Adverse events occurred in 33 cases (12.6%), including bleeding (1.5%), perforation (4.6%), and stricture (6.5%). During a median follow-up period of 35.0 months (interquartile range, 18 to 62), none of the patients showed local recurrence. The 5-year overall and disease-specific survival rates were 89.7% and 100%, respectively., Conclusions: ESD is a feasible and effective procedure for the treatment of SEN based on our 10-year experience, which showed favorable outcomes., Competing Interests: No potential conflict of interest relevant to this article was reported.

Background/aims: The efficacy of surveillance for esopha-geal squamous cell neoplasia (ESCN) in patients with head and neck squamous cell carcinoma (HNSCC) remains contro-versial. Our study aimed to provide clinical data concerning the necessity of surveillance for detecting early ESCN in pa-tients with HNSCC., Methods: We retrospectively reviewed the data from 714 patients who were pathologically confirmed as having HNSCC (n=236 oral cavity cancers, 137 oropha-ryngeal cancers, 87 hypopharyngeal cancers, and 254 la-ryngeal cancers)., Results: Of 714 patients, during a median follow-up of 31 months, 48 ESCNs (37 synchronous and 11 metachronous) were detected in 36 patients (5%). Fifteen synchronous lesions (40.3%) were early ESCN, whereas nine metachronous lesions (81.8%) were early ESCN. The 3-year survival rates of HNSCC only and HNSCC combined with ESCN were 71.2% and 48.2%, respectively (p<0.001). Among 36 patients with ESCN, the 3-year survival rates for early and advanced ESCN were 77.7% and 21.7%, respec-tively (p=0.01). In the multivariate analysis, alcohol consump-tion and hypopharyngeal cancer were significant factors associated with the development of ESCN., Conclusions: HN-SCC patients with early ESCN were similar in prognosis with patients without ESCN, in contrast to patients with advanced ESCN. Therefore, surveillance for the early detection of ESCN in patients with HNSCC, especially in alcohol drinkers and those with hypopharyngeal cancer, is warranted. (Gut Liver, 2015;9159-166).

Objectives: To evaluate the clinical efficacy and safety of self-expandable metallic stent (SEMS) placement for malignant oesophageal strictures and their relationship with stent designs., Methods: Seven generations of SEMS were used to treat 645 consecutive patients with oesophageal strictures. Logistic regression models were constructed to identify predictive factors associated with complications., Results: Stent placement was technically successful in 641 of 645 patients (99.4%). The clinical success rate was 95.5%. There were 260 (40.3%) complications after stent placement. Due to complications, 68 stents were removed; 66 of 68 stents (97.1%) were removed successfully. Stainless steel (SS) stents (odds ratio [OR] 4.18; 95% confidence interval [CI] 2.10, 8.32) and radiation therapy (RT) before stent placement (OR 4.23; CI 2.02, 8.83) were significantly associated with severe pain. Flared ends (OR 9.63; CI 3.38, 27.43), stricture length <6 cm (OR 2.01; CI 1.13, 3.60), and a stent diameter <18 mm (OR 3.00; CI 1.32, 6.84) were predictive factors of stent migration. Polyurethane membranes were associated with more frequent tumour ingrowth than polytetrafluoroethylene (PTFE) membranes (P = 0.002)., Conclusions: Despite the relatively high complication rate, retrievable self-expandable PTFE-covered nitinol stents equipped with a head and a tail appeared to be an effective treatment for malignant oesophageal strictures.