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BACKGROUND: Endoscopic submucosal dissection (ESD) of esophageal superficial neoplasm is associated with a high en bloc R0 resection rate and low recurrence. OBJECTIVE: We aim to compare the performance and clinical outcomes of ESD via ESD after circumferential incision (ESD-C) versus submucosal tunneling (ESD-T). METHODS: Single-center retrospective analysis of all consecutive patients who underwent ESD for superficial esophageal cancer, between 2009 and 2018. ESD-T was defined as the technique of making the mucosal incisions followed by submucosal tunneling in the oral to anal direction. ESD-C consisted of completing a circumferential incision followed by ESD. Main study outcomes included en bloc and R0 resection rates. Secondary outcomes included procedural characteristics, curative resection rate, local recurrence and adverse events. RESULTS: A total of 65 procedures (23 ESD-T and 42 ESD-C) were performed for ESCC (40; 61.5%) and BE-neoplasia (25; 38.5%). There were no statistically significant differences between patients who underwent ESD-T versus ESD-C in en bloc (91.3% vs 100%, P=0.12), R0 (65.2% vs 78.6%, P=0.24), curative resection rates (65.2% vs 73.8%, P=0.47) and mean procedure time (118.7 min with vs 102.4 min, P=0.35). Adverse events for ESD-T and ESD-C were as follows: bleeding (0 versus 2.4%; P=0.53), perforation (4.3% vs 0; P=0.61), esophageal stricture (8.7% versus 9.5%; P=0.31). Local recurrence was encountered in 8.7% after ESD-T and 2.4% after ESD-C (P=0.28) at a mean follow-up of 8 and 2.75 years, respectively (P=0.001). CONCLUSION: ESD-T and ESD-C appear to be equally effective with similar safety profiles for the management of superficial esophageal neoplasms. RESUMO CONTEXTO: A dissecção endoscópica submucosa (DES) no tratamento da neoplasia superficial do esôfago está associada a uma alta taxa de ressecção R0 em bloco e baixa taxa de recorrência. OBJETIVO: O objetivo deste estudo é comparar o desempenho e os resultados clínicos da DES com incisão circunferencial (DES-C) versus com DES com túnel submucoso (DES-TS). MÉTODOS: Estudo retrospectivo de banco de dados coletados prospectivamente de um centro especializado em DES, investigando pacientes consecutivos submetidos à DES por câncer de esôfago superficial, entre 2009 e 2018. DES-TS foi definida como a técnica de realizar primeiro incisões na mucosa seguida de tunelamento submucoso no sentido oral para anal. DES-C consistiu em completar uma incisão circunferencial seguida da dissecção submucosa. As principais variáveis do estudo incluíram taxas de ressecção em bloco e R0. Os resultados secundários incluíram características do procedimento, taxa de ressecção curativa, recorrência local e eventos adversos. RESULTADOS: Um total de 65 procedimentos (23 DES-TS e 42 DES-C) foram realizados para CCE de esôfago (40; 61,5%) e neoplasia associada ao EB (25; 38,5%). Não houve diferenças estatisticamente significativas entre os pacientes submetidos a DES-TS versus DES-C nas taxas de ressecção em bloco (91,3% vs 100%, P=0,12), R0 (65,2% vs 78,6%, P=0,24), taxas de ressecção curativa (65,2% vs 73,8%, P=0,47) e tempo médio do procedimento (118,7 min com vs 102,4 min, P=0,35). Os eventos adversos para DES-TS e DES-C foram os seguintes: sangramento (0 vs 2,4%; P=0,53), perfuração (4,3% vs 0; P=0,61), estenose esofágica (8,7% vs 9,5%; P=0,31). A recorrência local foi encontrada em 8,7% após DES-TS e 2,4% após DES-C (P=0,28) em um seguimento médio de 8 e 2,75 anos, respectivamente (P=0,001). CONCLUSÃO: DES-TS e DES-C demostram ser igualmente eficazes com perfil de segurança semelhante para o tratamento das neoplasias superficiais do esôfago.

Background and study aims Esophageal squamous cell carcinoma (ESCC) is the most common secondary tumor in patients with head and neck squamous cell cancer (HNSCC). Currently, endoscopic submucosal dissection (ESD) is the preferred approach to manage superficial ESCC, however, it remains to be elucidated whether patients with HNSCC and early ESCC managed by ESD have different outcomes. Patients and methods We retrospectively analyzed esophageal ESD for early ESCC from September 2009 to September 2017 and the following variables: demographics, tumor and specimen size, Paris classification, location, en bloc and R0 resection rates, overall survival (OS) and adverse events (AEs). To reduce selection bias, propensity score matching was applied to compare the results. Results Eighty-nine ESDs were performed in 81 consecutive patients (47 with HNSCC and 34 without HNSCC). Patients with HNSCC who developed superficial ESCC were found to be younger and to refer a more frequent history of alcohol ingestion and smoking. There was no difference in lesion size, number of lesions, procedure time, en bloc resection rate, R0 resection rate, local recurrence and adverse event rate between the two groups. The histological depth of invasion for patients with HNSCC was significantly shallower before (P = 0.016) and after (P = 0.047) matching. The overall survival rate was similar in both groups. Conclusions Patients with HNSCC have earlier detection of ESCC, probably due to endoscopic screening. Previous history of chemoradiation and surgery for HNSCC does not affect procedure time, AEs and OS.

Introdução: A dissecção endoscópica submucosa (ESD) é a abordagem de escolha para o tratamento de lesões neoplásicas superficiais do esôfago, permitindo maior taxa de ressecção em bloco e menor recorrência local. A ESD esofágica requer uma longa curva de aprendizado e ainda é restrita a centros terciários. As estratégias de ESD incluem a dissecção endoscópica com túnel submucoso (ESD-TD) e a dissecção endoscópica de submucosa convencional com incisão circunferencial (ESD-C). Existem escassos relatos no Ocidente comparando resultados clínicos de técnicas de ESD. Objetivo: comparar a performance e os resultados clínicos das técnicas de ESD-TD versus ESD-C. Métodos: Estudo retrospectivo de banco de dados coletados prospectivamente de um centro especializado em ESD, investigando pacientes consecutivos com neoplasia superficial de esôfago tipo carcinoma de células escamosas e adenocarcinoma associado ao Esôfago de Barrett (EB), operados entre outubro de 2009 e dezembro de 2018. Após marcação das margens e a injeção submucosa, duas estratégias diferentes de dissecção foram avaliadas: ESD-TD – primeiro realizada incisão anal, seguida da incisão oral e confecção de túnel submucoso na direção oral-anal; ESD-C – incisão circunferencial, seguida de dissecção submucosa. Foram avaliadas as seguintes variáveis: dados demográficos, características clínico-patológicas, duração do procedimento, taxa de ressecção em bloco, taxa de ressecção R0, taxa de ressecção curativa, recorrência local e eventos adversos. Resultados: Foram realizados 65 procedimentos, 23 ESTD e 42 ESDC, com seguimento médio de 8 e 2,75 anos, respectivamente (p0,05). Não houve diferença estatisticamente significante entre ESD-TD versus ESD-C nos seguintes desfechos: taxa de ressecção em bloco (91,3% vs 100%, p=0,122), ressecção R0 (65,2% vs 78,6% p=0,241), ressecção curativa (65,2% 73,8%, p=0,466), tempo médio do procedimento (118,7 min vs 102,4 min, p 0,351), taxa de recorrência local (8,7 vs 2,4, p 0,284), profundidade de invasão (p=0,745) e complicações relacionadas ao procedimento, como sangramento (0 vs 2,4%, p 0,53), perfuração (4,3% vs 0%, p=0,610), estenose (8,7% vs 9,5% p=0,310). Não houve mortalidade relacionada aos procedimentos. Conclusão: ESD-TD e ESD-C demonstraram ser igualmente seguras e efetivas, com baixas taxas de complicações e mortalidade zero, apresentando resultados clínicos semelhantes para pacientes com lesões neoplásicas superficiais do esôfago. Introduction: Endoscopic submucosal dissection (ESD) is the best approach for treatment of esophageal superficial neoplastic lesions, achieving a high rate of en bloc R0 ressection and low recurrence rate. Esophageal ESD requires a long learning curve and it is still restricted to tertiary centers. ESD strategy in the esophagus includes endoscopic submucosal tunnel dissection (ESD-TD) and the most traditional endoscopic submucosal dissection with circumferential incision (ESD-C). There are scarce reports in the West comparing clinical outcomes for existing ESD techniques. Objective: To compare the performance and clinical outcomes of ESD-TD and ESD-C. Methods: Single-center retrospective review of prospectively collected endoscopic data of a specialized ESD center in Brazil, investigating consecutive patients that underwent esophageal ESD for early squamous cells carcinoma and Barrett’s neoplasia, between October 2009 and December 2018. After placement of markings and submucosal injection, two different ESD strategies were assessed: ESD-TD - first set the anal incision then proceed to oral incision followed by submucosal dissection and tunnel making in the oral-anal direction; ESD-C – proceed a circumferential incision outside tumor borders followed by submucosal dissection. The following variables were assessed: demographic data, clinical-pathologic characteristics, procedure duration, en bloc resection rate, R0 resection rate, curative resection rate, local recurrence and adverse events. Results: A total of 65 procedures were carried out, 23 ESD-TD and 42 ESD-C, with a mean follow-up of 8 years and 2.75 years respectively (p=0.001). The demographic characteristics of patients and pathological data of the lesions were similar in both groups (p>0,05). There was no statistically significant difference in terms of clinical outcome among ESD-TD versus ESDC: en bloc resection rate (91.3% vs 100%, p=0.122), R0 resection rate (65.2% vs 78.6% p=0.241), curative resection rate (65.2% vs 73.8%, p=0.466), mean procedure time (118.7 min vs 102.4 min, p=0.351), local recurrence rate (8.7 vs 2.4, p=0.284), and procedure-related complications such as bleeding (0 vs 2.4%, p=0.53), perforation (4.3% vs 0%, p=0.610) and esophageal stricture (8.7% vs 9.5% p=0.310). There was no mortality related to the procedures. Conclusion: ESD-TD and ESD-C demonstrated to be equally safe, with low complication rate and zero mortality, presenting similar results in terms of clinical outcome for patients with superficial esophageal neoplastic lesions.