Endoscopic resection of early esophageal neoplasia can safely be performed in patients with esophageal varices

Aims Although endoscopic resection (ER) is recommended as first-choice treatment for early esophageal neoplasia, patients with esophageal varices are considered a high risk group due to an increased bleeding risk. However, since most of these patients are precluded from major esophageal surgery due to portal hypertension, endoscopic therapy may be the only treatment option in these patients. This retrospective, multicenter study aimed to evaluate the efficacy and safety of endoscopic therapy of early esophageal neoplasia in this specific patient category.

Methods Patients with esophageal varices who underwent ER for early esophageal neoplasia were included in three Dutch tertiary centers between January 2014 and December 2022. Patients were identified by systematically screening endoscopy databases in each participating site. All ER procedures were performed by dedicated endoscopists and prophylactic measures to reduce the risk of variceal hemorrhage were initiated at the discretion of the endoscopist. Outcomes included the incidence of prophylactic measures, histologically radical and curative resection rate, adverse events and procedure-related mortality.

Results Twenty-one patients (21 male; median age 69; 16 Child Pugh A liver cirrhosis) were included of which the majority was diagnosed with Barrett’s neoplasia (15/21; 71%), while the remaining cases had esophageal squamous cell carcinoma (3/21; 14%) or cardia neoplasia (3/21; 14%). In 16/21 (76%) patients, the esophageal varices were small (i.e.<5mm) and prophylactic measures mainly consisted of octreotide administration (5/16; 31%) and/or direct varix coagulation during resection (9/16; 56%). In one patient (1/21; 5%), the lesion was located on top of a large varix (i.e.≥5mm) after which the decision was made to ligate the lesion without subsequent snaring. Endoscopic rubber band ligation prior to ER was applied in one patient with large varices (1/21; 5%), while periprocedural prophylactic ligation was performed in one patient (1/21; 5%) with small varices distal from the lesion. A transjugular intrahepatic portosystemic shunt was placed prior to ER in two patients (2/21; 10%), either due to the large size of the varices (n=1) or the large extent of the neoplastic lesion in combination with small varices (n=1). Histologically radical resection was achieved in 18/21 (86% [95% CI 67-100%]) and the curative resection rate was 14/21 (67% [95% CI 43-86%]). While no procedure-related mortality was observed, adverse events were seen in 4/21 (19% [95% CI 5%-38%]) patients. Only one patient (1/21; 5% [95% CI 0%-14%]) with small varices experienced postprocedural bleeding which resolved after octreotide administration. Other adverse events included stricture (n=1), laceration (n=1) and aspiration pneumonia (n=1).

Conclusions ER appears to be a safe and effective option in selected patients with concurrent early esophageal neoplasia and esophageal varices, provided that a tailored approach of adequate prophylactic measures is applied to prevent bleeding.

Publication History

Article published online:
15 April 2024