Esophagectomy after endoscopic submucosal dissection for esophageal carcinoma

Background: Endoscopic submucosal dissection (ESD) has been used to treat early stage esophageal cancer, but reports about additional esophagectomy after ESD and postoperative outcomes are lacking. Complete removal of cancer tissue together with lymph nodes was the advantage of esophagectomy; however, invasiveness, organ loss, postoperative complications, and worse postoperative quality of life were serious disadvantages. The purpose of this study was to find the clear indication of additional esophagectomy after ESD, and help the other patients avoid excessive surgery. Methods: We reviewed the clinicopathologic data and outcomes consecutive patients who had esophageal cancer confirmed by endoscopic biopsy and who were treated with ESD and subsequent esophagectomy between October 2011 and December 2016 in our department. The esophagectomy necessity following ESD was defined and the groups with necessity (+) vs. (−) were compared retrospectively. The esophagectomy necessity outcomes were retrospectively analyzed to judge whether the surgery option was correct. Results: Total 214 patients with esophageal and esophagogastric cancer have undergone ESD treatment in our center, of which 32 patients (23 men and 9 women; mean age, 60±8 years) ultimately required esophagectomy after ESD. All patients had complete resection (R0) from esophagectomy. Postoperative TNM staging included TisN0M0 (6 patients), T1aN0M0 (6 patients), T1bN0M0 (18 patients), T1bN1M0 (1 patient), and T2N3M0 (1 patient). Necessity of esophagectomy after ESD was associated with residual margin status. There was a significant difference in ESD specimen margin status between the esophagectomy necessity (+) vs. (−) groups (positive/negative margin: 8/3 vs. 2/9 patients; P=0.03). Esophagectomy should be delayed at least 30 days after ESD to enable resolution of esophageal edema (P=0.017) (206±68 vs. 163±56 mL, P=0.057). Median follow-up was 16.8 months (range, 11.2–54.5 months); 3 patients were lost to follow-up (9%) and 1 patient died of metastasis after esophagectomy. All other patients were alive with excellent postoperative disease-free survival. Conclusions: Indications for esophagectomy after ESD include ESD failure, cancer recurrence, esophageal rupture, esophageal stricture refractory to endoscopic dilation, and residual tumor at the ESD specimen margin. Stage T1b alone is not an indication for esophagectomy. According to our study, we recommend that esophagectomy should be delayed ≥30 dafter ESD unless urgent esophagectomy is indicated.