Effect of Esophageal Endoscopic Submucosal Dissection on Motility and Symptoms: A Prospective Study

Abstract

Background: Endoscopic submucosal dissection (ESD) of esophageal tumors can cause stenosis, yet the effect of esophageal ESD on motility remains unclarified. This study aimed to compare esophageal motility and symptoms, before and after ESD, using high-resolution manometry (HRM) and symptom scoring.

Methods: Twenty-eight patients with 35 cT1a cancers were prospectively enrolled between December 2014 and February 2016. Pre- and post-ESD symptom score and HRM were recorded. Based on circumferential resection (CR), patients were divided into group A (n = 17, <2/3 CR) or B (n = 11, 2/3 CR or greater). HRM parameters evaluated were distal contractile integral (DCI), contractile front velocity (CFV), intrabolus pressure, integrated relaxation pressure, distal latency, and peristaltic breaks.

Results: Symptom scores worsened after ESD in 8/11 patients in group B, and 0/17 patients in group A. There was no significant difference in any HRM parameter after ESD in the whole study group but mean DCI tended to increase (p = 0.07). In group B, DCI increased significantly after ESD (p = 0.04), and CFV tended to decrease after ESD (p = 0.08).

Conclusions: DCI tended to increase after esophageal ESD. ESD affected the symptom score and esophageal motility in cases with 2/3 CR or greater. This trial is registered with UMIN000015829.

Figure 1

Endoscopic findings in a case of endoscopic submucosal dissection (patient number 20) 0-llb, more than 2/3 circumferential lesion. (a) Chromoendoscopy with iodine staining (with marking around the lesion). (b) Artificial ulcer after 4/5 circumferential resection. (c) Artificial ulcer scar with mild stenosis 8 weeks after endoscopic submucosal dissection.

Figure 2

Schedule of symptom scoring, high-resolution manometry (HRM), and endoscopic submucosal dissection (ESD). The patients were interviewed to determine the symptom scores (dysphagia score and Eckardt score) and HRM was performed before ESD. Eight weeks after ESD, the artificial ulcer scar was confirmed endoscopically; the interview to determine the symptom scores and HRM were performed on a separate date to avoid any influence from air insufflation and insertion of the endoscope.

Figure 3

High-resolution manometry (HRM) system. HRM was performed using (a) a Starlet system (Star Medical Inc., Tokyo, Japan) with (b) a catheter (Unisensor AG, Attikon, Switzerland). There were sensor monitors every 1 cm.

Figure 4

Study outline. Of 42 enrolled patients, 28 patients with 35 lesions were analyzed (group A: n = 17, group B: n = 11). Eight patients had a post-ESD increase in symptom score; all of these patients were in group B. ESD: esophageal submucosal dissection, cT1b: clinical T1b, HRM: high-resolution manometry, CR: circumferential resection.

Figure 5

Representative case from group A in which no change was found after endoscopic submucosal dissection (ESD). Patient number 11 is a typical case from group A (less than 2/3 circumferential resection). Symptom score and distal contractile index (DCI) were not increased after ESD. Red arrows indicate physiological contractions: the first, second, and third pressure trough, respectively.

Figure 6

Representative case from group B in which there were changes after endoscopic submucosal dissection (ESD). Patient number 25 is a typical case from group B (more than 2/3 circumferential resection). Symptom score and distal contractile index (DCI) were increased after ESD compared with before ESD. The yellow arrow indicates the resected region (29–32 cm from the incisor column). DCI increased significantly in the resected region.