Endoscopic resection of early esophageal neoplasia in patients with esophageal varices: a systematic review.

Background: Although endoscopic resection (ER) is recommended as first-choice treatment for early esophageal neoplasia, patients with esophageal varices are considered a high-risk group owing to an increased risk of bleeding. This systematic review aimed to evaluate the effectiveness and safety of ER in this specific patient category. Methods: We searched for studies reporting on clinical outcomes of ER in the presence of esophageal varices, irrespective of study design or follow-up time. End points included the incidence of prophylactic measures to reduce the risk of variceal hemorrhage, radical and curative resection rates, and adverse events. Results: After screening 2371 studies, 42 studies (including our own unpublished cohort) with a total of 186 patients were included in this systematic review. Endoscopic band ligation (72/186; 39%) and endoscopic injection sclerotherapy (22/186; 12%) were the prophylactic measures most widely adopted to eradicate varices prior to ER. Other frequently described prophylactic measures included direct varix coagulation during ER (18/186; 10%) and the placement of a transjugular intrahepatic portosystemic shunt prior to ER (9/186; 5%). While the radical and curative resection rates were high (86% and 72%, respectively), the periprocedural and delayed bleeding risks were reported to be relatively low (6% and 3%, respectively). In all studies, no procedure-related mortality was observed. Conclusions: ER appeared to be a safe and effective treatment option in selected patients with concurrent early esophageal neoplasia and esophageal varices, provided that a tailored approach of adequate prophylactic measures to prevent bleeding is applied.