Ligation-assisted endoscopic submucosal resection following the unroofing technique for esophageal lesions

Abstract

For the treatment method of esophageal subepithelial lesions originating from the muscularis propria, conventional endoscopic resection techniques are time-consuming and lack efficacy for small subepithelial lesions originating from the muscularis propria. Lu et al presented an exploration of the effectiveness and safety of ligation-assisted endoscopic submucosal resection, aiming to provide a minimally invasive method for treatment. We discussed and analyzed this study from the aspects of sample screening, clinical pathological characteristics, case-control analysis, and follow-up data.

Key Words: Endoscopic submucosal resection; Ligation; Esophagus; Subepithelial lesions; Muscularis propria

Core Tip: The study presents an exploration of the effectiveness and safety of ligation-assisted endoscopic submucosal resection following the unroofing technique for small esophageal subepithelial lesions originating from the muscularis propria. The research aims to contribute to the field by providing insights into a less invasive approach to treating small esophageal subepithelial lesions originating from the muscularis propria.

TO THE EDITOR

I would like to share my ideas on the publication “Ligation-assisted endoscopic submucosal resection following unroofing technique for small esophageal subepithelial lesions originating from the muscularis propria”[1]. Lu et al[1] included 17 patients diagnosed with esophageal subepithelial lesions originating from the muscularis propria (SEL-MPs) in their study, exploring and analyzing the effectiveness and safety of ligation-assisted endoscopic submucosal resection (ESMR-L) following unroofing technique for small esophageal SEL-MPs. We deeply appreciate their rigorous efforts and valuable contributions to this study and also offer some constructive suggestions.

First, the inclusion and exclusion criteria. We noticed that the article did not mention in detail the exclusion criteria and specific case numbers. Invasive treatment for malignant tumors, surgical contraindications, pregnant women, and patients with organ failure may lead to bias in results. These biases do not apply to ordinary patients, which may bring inappropriate limitations to the discussion and expansion of results. Detailed, comprehensive, and scientific inclusion and exclusion criteria will ensure the scientific nature of data analysis results and discussions, reducing bias[2].

Second, clinical pathological characteristics. Compared with traditional surgery, endoscopic treatment enters the natural body cavity and has the advantage of minimal trauma[3]. It is recommended to add coagulation function, platelet count, serum albumin, and liver function tests into the listed clinical pathological characteristics of patients. This will eliminate interference from diseases such as poor coagulation function on surgical complications, thereby increasing the accuracy of experimental results.

Third, case-control analysis. The article only analyzed patients who underwent ESMR-L following unroofing technique at the Endoscopy Center of Shenzhen People’s Hospital, and there were no cases of bleeding, perforation, or recurrence. In the discussion section, the authors cited research results from Lu et al[4], suggesting that the ESMR-L technique offers a shorter treatment time compared to traditional surgery. However, there are differences in quality control standards among different centers, and the time span is too long. The conclusions drawn from comparisons inevitably produce bias. It is recommended to conduct case-control analysis in a single research center or multiple centers with identical quality control standards so as to increase the accuracy of the results.

Fourth, increase the description of follow-up data. The article only lists two data items, namely follow-up time and recurrence. Moreover, the difference in follow-up times is quite large, which may lead to the missing of follow-up results. ESMR-L following unroofing technique does not guarantee complete removal of the lesion[5]. It is recommended to include gastroscopy and pathology results from follow-up examinations, narrow the gap in follow-up time for different patients, and increase patient descriptions of discomfort symptoms. Analyzing and discussing the above results will bring more in-depth insights into the therapeutic effect of ESMR-L following unroofing technique.

In summary, the study by Lu et al[1] has made significant progress in our treatment of small esophageal SEL-MPs. My suggestion is just to further improve an already good study. We eagerly await more insightful insights from the authors in the future.