Endoscopic submucosal dissection with versus without traction for pathologically staged T1B esophageal cancer: a multicenter retrospective study

Background & Aims Positive vertical margins (VM) are common after endoscopic submucosal dissection (ESD) of T1b esophageal cancer (EC) and are associated with an increased risk of recurrence. Traction during ESD provides better exposure of the submucosa and may allow deeper dissection, potentially reducing the risk of positive VMs. We conducted a retrospective multicenter study to compare the proportion of resections with positive VMs in ESD performed with vs. without traction in pathologically staged T1b EC. Methods Patients who underwent ESD revealing T1b EC (squamous or adenocarcinoma) at 10 academic tertiary referral centers in the United States (n = 9) and Brazil (n = 1) were included. Demographic and clinical data were abstracted. ESD using either traction techniques (tunneling, pocket) or traction devices (clip line, traction wire) were classified as ESD with traction (Tr-ESD) and those without were classified as ESD without traction (cESD). The primary outcome was a negative VM. Multivariable logistic regression was used to assess associations with negative VM. Results 166 patients with pathologically staged T1b EC underwent Tr-ESD (n=63, 38%) or cESD (n=103, 62%). Baseline factors were comparable between both groups. On multivariable analysis, Tr-ESD was found to be independently associated with negative VM (OR 2.25, 95% CI 1.06, 4.91, P=0.037) and R0 resection (OR 2.83, 95% CI 1.33, 6.23 P=0.008). Conclusion ESD with traction seems to be associated with higher odds of negative VM than ESD without traction for pathologically staged T1b EC, and future well-conducted prospective studies are warranted to establish the findings of the current study.