Predictive Factors of Endoscopic Submucosal Dissection Procedure Time for Early Esophageal Cancer

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Predictive Factors of Endoscopic Submucosal Dissection Procedure Time for Early Esophageal Cancer

Endoscopic submucosal dissection (ESD) has emerged as a cornerstone technique for treating early esophageal cancer, offering precise removal of neoplastic lesions while preserving organ integrity. Despite its advantages, ESD remains technically challenging, with prolonged procedure times associated with complications such as perforation, bleeding, deep vein thrombosis, and post-operative pneumonia. This study aimed to identify factors influencing ESD operative time to optimize surgical planning, reduce risks, and improve clinical outcomes.

Study Design and Methodology

The retrospective analysis included 197 patients (201 lesions) diagnosed with early esophageal cancer treated via ESD. All procedures were performed by endoscopists with over 15 years of experience using standardized equipment. The procedural time was defined as the duration from initial peripheral lesion marking to complete tumor resection. Submucosal fibrosis, a key parameter, was identified endoscopically as whitish, muscle-like structures within the submucosal layer following glycerol mixture injection.

Data collection focused on tumor characteristics (size, macroscopic type, circumferential extension), intraoperative events (adhesion, perforation), and patient demographics. Tumor size was stratified as ≤2 cm, 2–4 cm, and ≥4 cm. Circumferential involvement was categorized as 3/4 of the esophageal lumen. Adhesion referred to fibrotic resistance encountered during dissection.

Statistical analyses included Pearson correlation for univariate assessment and multiple linear regression to identify independent predictors. A multivariate logistic regression further evaluated variables associated with prolonged ESD time (defined as >66.9 minutes, the median procedural duration).

Key Findings

Univariate Analysis

The median procedural time was 66.9 minutes (range: 10–190 minutes). Tumor size and circumferential extension demonstrated strong correlations with operative duration:

  • Tumor size: Lesions ≤2 cm required 41.0 ± 26.7 minutes, 2–4 cm took 64.9 ± 27.5 minutes, and ≥4 cm demanded 118.1 ± 39.3 minutes (P <0.001).
  • Circumferential extension: Involvement 3/4 with 137.3 ± 35.6 minutes (P <0.001).

Adhesion and perforation significantly prolonged ESD time:

  • Adhesion: Lesions with fibrosis required 107.6 ± 37.1 minutes vs. 62.4 ± 37.2 minutes for non-fibrotic cases (P <0.001).
  • Perforation: Cases complicated by perforation averaged 129.5 ± 45.6 minutes vs. 65.0 ± 37.8 minutes (P <0.001).

Macroscopic tumor type also influenced duration. Flat or slightly elevated lesions (0–IIa/IIb/IIc) required less time (50.4 ± 35.7 minutes) compared to combined-type lesions (111.7 ± 59.1 minutes; P = 0.001). Patient age, sex, tumor location, and depth of invasion (mucosal vs. submucosal) showed no significant associations.

Multivariate Analysis

Multiple regression confirmed three independent predictors of prolonged ESD time:

  1. Adhesion (P <0.001): Fibrotic tissue increased dissection difficulty, extending time by approximately 45 minutes.
  2. Circumferential extension >1/2 (P <0.001): Lesions involving over half the lumen required 30–60 additional minutes.
  3. Tumor size >2 cm (P <0.001): Larger lesions (2–4 cm) added 20–40 minutes, while those ≥4 cm nearly tripled baseline duration.

Perforation, though significantly linked to longer times in univariate analysis, was excluded as an independent factor in multivariable modeling, likely reflecting its sporadic occurrence (6 cases, 3%).

Clinical Implications

The findings underscore the importance of pre-procedural assessment to stratify ESD complexity. Key recommendations include:

  1. Operator Scheduling: Anticipated prolonged cases (e.g., large tumors, extensive circumferential involvement) should be assigned to senior endoscopists to minimize operative time and complications.
  2. Anesthetic Management: Longer procedures necessitate tailored sedation strategies to mitigate risks like CO₂ retention or aspiration.
  3. Complication Prevention: Prophylactic measures (e.g., anticoagulation for venous thrombosis, antibiotics for pneumonia) can be prioritized based on predicted duration.

Study Limitations

While offering novel insights, this analysis has limitations:

  1. Single-Center Design: Potential selection bias and limited generalizability.
  2. Sample Size: Small subgroups (e.g., perforation cases) reduced statistical power for rare events.
  3. Bleeding Documentation: Lack of standardized bleeding metrics precluded analysis of its impact on operative time.

Conclusion

This study identifies tumor size >2 cm, circumferential extension >1/2, and submucosal adhesion as critical determinants of ESD duration in early esophageal cancer. Preoperative evaluation of these factors enables optimized resource allocation, risk mitigation, and improved patient outcomes. Future multicenter studies with larger cohorts are warranted to validate these predictors and refine procedural guidelines.

doi.org/10.1097/CM9.0000000000001355

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