GIE Associate Editor Seiichiro Abe, MD, PhD, FASGE, FJGES, highlights this article from the May issue: “Endoscopic submucosal dissection with versus without traction for pathologically staged T1B esophageal cancer: a multicenter retrospective study” by Abel Joseph, MD, et al.

Guidelines recommend staging endoscopic resection for a visible neoplastic lesion in Barrett’s esophagus and noncircumferential esophageal squamous cell carcinoma clinically diagnosed with the deepest invasion to m3 to sm1. Endoscopic submucosal dissection (ESD) offers a high en bloc resection rate leading to detailed histologic evaluation.

However, positive vertical margins (VMs) are common after esophageal ESD of T1b esophageal cancer and associated with an increased risk of local recurrence.

Traction-assisted esophageal ESD provides better exposure of the submucosa. A randomized controlled trial from Japan (Yoshida et al, 2020) showed that traction-assisted esophageal ESD significantly shortened the ESD procedure time and tended to reduce the risk of perforation compared with traditional ESD without traction. It may allow for deeper submucosal dissection, potentially reducing the risk of positive VMs.

Joseph et al conducted a multicenter retrospective study to compare the proportion of resections with positive VMs in ESD performed with versus without traction in pathologically staged T1b esophageal cancer. This study confirmed that EUS was inaccurate in staging T1b. On the multivariable analysis, traction-assisted ESD was found to be independently associated with negative VMs and R0 resection. (See graphical abstract.)

Traction-assisted esophageal ESD reduces the risk of positive VMs, which can lead to high-quality histologic assessment and appropriate treatment decisions in patients with pathologically T1b esophageal cancer, especially those with superficial submucosal invasion (sm1, ≤500 μm for adenocarcinoma and ≤200 μm for squamous cell carcinoma).

Although additional esophagectomy is the standard of care, traction-assisted esophageal ESD can potentially reduce the risk of local recurrence and provide a minimally invasive alternative treatment option for poor surgical candidates.

Graphical Abstract

Read the full article online.

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