Prospective Evaluation of a Standardized Approach to Improve Procedure Speed in Esophageal Endoscopic Submucosal Dissection

Background and Aims

Endoscopic submucosal dissection (ESD) of esophageal lesions is limited by the lengthy procedure time, technique's complexity, and need for specialized training. We propose a standardized esophageal ESD technique that takes advantage of specimen self-retraction to improve visualization and procedure speed by starting the margins’ incision at the anal side, followed by the laterals and the proximal.

Methods

This was a prospective clinical trial of all consecutive patients who underwent a standardized esophageal ESD of esophageal lesions at a single tertiary referral center between December 2016 and January 2021. The primary outcome was the entire procedure speed calculated as centimeters squared per hour. Secondary outcomes included the rates of en bloc resection, R0 resection, and adverse events. Linear regression analysis was conducted to test the association between the entire procedure speed and tumor location, number of knives used, year of procedure, and pathology results.

Results

Thirty-two patients prospectively enrolled in our study. The mean patient age was 65 ± 10.9 years. The mean specimen surface area was 17.9 ± 12.7 cm². The mean entire procedure speed was 11 ± 5.9 cm²/h. The mean total procedure time was 93.5 ± 31 minutes. The entire procedure speed was significantly faster with procedures performed over the last 3 years (+5.86 cm²/h; P = 0.003) or Barrett's esophagus (+7.77 cm²/h; P = 0.001). En-bloc and R0 resection rates were 100% and 68.8%, respectively. There were only 2 early bleeding events (6.3%) and 4 stricture formations (12.5%). All adverse events were successfully managed endoscopically.

Conclusion

Our standardized esophageal ESD technique offered our operator a remarkable entire procedure speed with continuous annual improvement and an acceptable safety profile. Future controlled multicenter studies are warranted to confirm the results’ generalizability and help promote wider adoption of esophageal ESD (ClinicalTrials.gov identifier: NCT04547881).