Resection of early esophageal neoplasms: The pendulum swings from surgical to endoscopic management

Table 1 Summary of the history and role of all endoscopic therapies

Technique	History	Indications/role
EMR	EMR was introduced in Japan to treat early gastric cancer and its use in esophagus was first reported by Inoue in 1990[14]. EMR use determines local stage, degree of differentiation and lymphovascular invasion[15]	EMR is indicated to remove sessile, flat or discrete mucosal lesions < 2  cm in size and involving less than two-thirds of the circumference of esophageal wall[14] Focal EMR is removal of visible lesions only. Stepwise radical EMR is removal of entire Barrett’s segment in single or multiple sessions
ESD	ESD was introduced in 1988 in Japan to treat gastric cancer and subsequently, its use was extended to treat superficial esophageal cancer[17]	ESD is indicated for en-bloc resection of lesions irrespective of the size. ESD is a technically demanding and time consuming procedure
STER	STER was introduced in 2011 and is based on the principles of peroral endoscopic myotomy and ESD[21]	STER is used to resect submucosal tumors[21]. The advantage of STER is preservation of mucosal integrity that lowers adverse outcomes[23]
RFA	RFA was introduced in 2005 and is now a well-established modality for early esophageal cancer which utilizes high frequency alternating electrical current to generate thermal energy for ablation[25]	RFA is the standard of care in flat mucosal lesions[25]. In RFA, a circumferential catheter is used to ablate ≥ 3 cm Barrett’s segment or a focal catheter for shorter segments
PDT	PDT was one of the first techniques described for treatment of Barrett’s associated neoplasia	PDT is associated with many complications and is not commonly used in the United States any more
Cryotherapy	Cryotherapy was introduced in 1851 by James Arnott to freeze tumors[27]. The application of Cryotherapy was extended to the esophagus in 1997 using an endoscope	Cryotherapy circumvents the need for mucosal contact making ablation of an uneven or nodular surface feasible[27]. CbFAS uses cryogenic fluid and overcomes the challenges of unequal distribution and need for decompression tube
Hybrid-APC	APC was introduced in the early 1990s to perform thermal coagulation of tissue[25]. More recently, Hybrid APC in which a submucosal cushion is created before APC is being used[28]	Hybrid APC is indicated in Barrett’s esophagus up to 3-5 cm in length and the cushion controls the depth of ablation[28]

APC: Argon plasma coagulation; CbFAS: Cryoballoon focal ablation system; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; PDT: Photodynamic therapy; RFA: Radiofrequency ablation; STER: Submucosal tunneling endoscopic resection.

Table 2 Summary of the efficacy and complications of all endoscopic therapies

Technique	Efficacy	Complications
Focal EMR and ablation	CE in EAC: 96.3%[13] and ESCC: 90%[54]	Major bleeding: 1.4%[13] Perforation: 0.1% Strictures: 1.3%
Stepwise radical EMR	CE-N: 94.9%[42] CE-IM: 79.6%	Bleeding: 1.0%[16] Perforation: 1.0% Strictures: 49.7%
ESD	En-bloc resection rate in EAC: 92.9%[18] and ESCC: 90%-100%[55-57] Complete resection rate in EAC: 74.5%[18] Curative resection rate in EAC: 64.9%[18] and ESCC: 88%-97%[55-57]	Bleeding: 1.5%-1.8%[18,19] Perforation: 1.5%-4.6% Strictures: 6.5%-11.6%
STER	Complete Resection rates in SMTs: 100%[24] En-bloc resection rates in SMTs: 98.6%	Subcutaneous emphysema and pneumomediastinum: 14.8%[24] Pleural effusion: 16.9% Pneumoperitoneum: 6.8% Pneumothorax: 6.1% Mucosal injury: 5.6%
RFA	CE-D: 81%[44] CE-IM: 77.4%[44] CE in ESCC: 84%[61]	Strictures: 6%[25] Chest pain: 2% Bleeding: 1%
PDT	Discontinued in the United States	Photosensitivity reactions: 69%[25] Esophageal strictures: 36% Chest pain: 20%
Cryotherapy	CE-HGD: 98%[46] CE-D: 94% CE-IM: 82%	Abdominal pain: 19.3%[27] Dysphagia: 10.2% Sore throat: 9% Chest pain: 8% Strictures: 0-12.5%
Hybrid-APC	CE-IM:78%[28]	Strictures: 2%[28]

APC: Argon plasma coagulation; CE-D: Complete eradication of dysplasia; CE-HGD: Complete eradication of high grade dysplasia; CE-IM: Complete eradication of intestinal metaplasia; EAC: Esophageal adenocarcinoma; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; ESCC: Esophageal squamous cell carcinoma; PDT: Photodynamic therapy; RFA: Radiofrequency ablation; SMT: Submucosal tumors; STER: Submucosal tunneling endoscopic resection.