Predictive risk factors of perforation in gastric endoscopic submucosal dissection for early gastric cancer: a large, multicenter study

Background

Although endoscopic submucosal dissection (ESD) is standard therapy for early gastric cancer, the complication rate is unsatisfactory, with perforation as the major complication during ESD. There have been several reports regarding the complications of ESD for gastric tumor especially perforation; however, little is known about the predictors for complications in patients undergoing ESD. The purpose of this retrospective study was to determine the risk factors for perforation in patients with early gastric cancer during ESD.

Methods

Between February 2003 and May 2010, we performed ESD for 1,289 lesions in 1,246 patients at six tertiary academic hospitals in Daegu, Kyungpook, Korea. Patient-related variables (age, sex, and underlying disease), endoscopic-related variables (indication of ESD, lesion size, location, type, and mucosal ulceration), procedure-related variables (operation time, complete resection, and invasion of submucosa/vessel/lymph node), and the pathologic diagnosis were evaluated as potential risk factors.

Results

The mean age of the patients was 64 years. The mean size of the endoscopic lesion was 19.4 mm. The overall en bloc resection rate was 93.3 %. Perforation (microperforation and macroperforation) was seen in 35 lesions. The location of the lesion (long axis: body/short axis: greater and lesser curvature) and piecemeal resection were associated with perforation (p = 0.01/0.047 and p = 0.049). Upon multivariate analysis, the location (body vs. antrum) of the lesion (odds ratio (OR) 2.636; 95 % confidence interval (CI) 1.319–5.267; p = 0.006) and piecemeal resection (OR 2.651; 95 % CI 1.056–6.656; p = 0.038) were significant predictive factors for perforation.

Conclusions

The result of this study demonstrated that the location of the lesion (body) and piecemeal resection were related to perforation during ESD.     

Feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body endoscopic submucosal dissection: a porcine model

Background

Total gastrectomy is performed for early gastric cancer in the upper body of the stomach because of the high complication rate of endoscopic submucosal dissection (ESD). The aims of the present animal study in pigs were to verify: (1) the feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body ESD; (2) the non-inferiority of single port laparoscopic lymph node dissection (LLND) compared with multiport LLND; and (3) the safety of 2-basin LLND (upper greater and lesser curvature).

Methods

We separated the pigs (~40 kg each) into two groups: conventional and experimental (n = 5 per group). We performed ESD in the fundus and upper body anterior wall (UBAW) via the trans-oral route and multiport LLND in the conventional group, and via the trans-umbilical route and single port LLND in the experimental group.

Results

The completion rates, tissue weights, and specimen diameters of both routes showed no statistical differences in either the fundus or the UBAW. The operative time was shorter with the trans-umbilical route than with the trans-oral route in both areas (p < 0.05). In LLND, there were no differences in surgical outcomes between the multiport and single port groups. Intraoperative perforation was seen in the trans-oral route group (n = 1). Delayed perforation was observed in 30 % of the ESD sites.

Conclusions

The trans-umbilical route is feasible and has lower complication rates than the trans-oral route in gastric upper body ESD. Additionally, single port LLND is not inferior to multiport LLND, and one-side-basin dissection is safer than two-side.     

The efficacy of single-dose postoperative intravenous dexamethasone for pain relief after endoscopic submucosal dissection for gastric neoplasm

Background

Endoscopic submucosal dissection (ESD) is the gold standard technique for en bloc resection of large superficial tumors in the upper and lower gastrointestinal tract. Little is known about the management of epigastric pain after ESD of gastric neoplasms. This study investigated the utility and safety of single-dose, perioperative, intravenous dexamethasone for epigastric pain relief following ESD.

Methods

The efficacy of intravenous dexamethasone 0.15 mg/kg (DEXA group) compared with saline-only placebo (placebo) for epigastric pain after ESD of early gastric neoplasms was assessed in a double-blinded, placebo-controlled trial. Patients completed a questionnaire about present pain intensity (PPI) and short-form McGill pain (SF-MP) categories for immediate and 6-, 12-, and 24-h postoperative periods. The primary outcome variable was PPI at 6 h following ESD. Secondary outcome variables included pain medication, SF-MP scores, complications, second-look endoscopic findings, and length of stay.

Results

A total of 36 patients participated in the study. The mean 6-h PPI value was lower (p < 0.001) in the DEXA group (1.61 ± 0.21) than in the placebo group (2.66 ± 0.19). The total 6-h SF-MP score, especially the sensory domain, was higher (p = 0.054) in the placebo group (11.56 ± 0.75) than in the DEXA group (8.89 ± 0.75). Tramadol for epigastric pain relief was more frequent (p = 0.026) in the placebo group (44.4 %) than in the DEXA group (11.1 %). No differences were noted between groups in length of stay or complications, including acute or delayed bleeding. The distribution of artificial ulcer patterns at 48-h post-ESD as determined by second-look endoscopy was similar in both groups.

Conclusion

Single-dose perioperative intravenous dexamethasone after ESD effectively relieved epigastric pain 6 h postoperatively.     

Endoscopic submucosal dissection versus transanal endoscopic microsurgery for the treatment of early rectal cancer

Background

Endoscopic submucosal dissection (ESD) and transanal endoscopic microsurgery (TEM) are minimally invasive procedures that can be used to treat early rectal cancer.

Objective

The aim of this study was to compare clinical efficacy between ESD and TEM for the treatment of early rectal cancer.

Methods

Between July 2008 and August 2011, 24 patients with early rectal cancers were treated by ESD (11) or TEM (13) at the Cancer Institute of São Paulo University Medical School (São Paulo, Brazil). Data were analyzed retrospectively according to database and pathological reports, with respect to en bloc resection rate, local recurrence, complications, histological diagnosis, procedure time and length of hospital stay.

Results

En bloc resection rates with free margins were achieved in 81.8 % of patients in the ESD group and 84.6 % of patients in the TEM group (p = 0.40). Mean tumor size was 64.6 ± 57.9 mm in the ESD group and 43.9 ± 30.7 mm in the TEM group (p = 0.13). Two patients in the TEM group and one patient in the ESD group had a local recurrence. The mean procedure time was 133 ± 94.8 min in the ESD group and 150 ± 66.3 min in the TEM group (p = 0.69). Mean hospital stay was 3.8 ± 3.3 days in the ESD group and 4.08 ± 1.7 days in the TEM group (p = 0.81).

Limitations

This was a non-randomized clinical trial with a small sample size and selection bias in treatment options.

Conclusion

ESD and TEM are both safe and effective for the treatment of early rectal cancer.     

Sedation methods can determine performance of endoscopic submucosal dissection in patients with gastric neoplasia

Background

Although proper sedation is mandatory for endoscopic procedures such as endoscopic submucosal dissection (ESD), there is no research investigating the effects of sedation on ESD performance and complications. We aimed to evaluate the relationship among sedation methods, clinical outcomes, and complications after ESD for gastric neoplasia.

Methods

We retrospectively reviewed clinical data of 1,367 patients with 1,485 lesions who had undergone ESD for gastric adenoma or early gastric cancer at our tertiary teaching hospital in Seoul, Korea, between January 2008 and May 2011. Of these, 1,035 lesions in 958 patients were included in the intermittent midazolam/propofol injection by endoscopists (IMIE) group, and 450 lesions in 409 patients were included in the continuous propofol infusion with opioid administration by anesthesiologists (CPIA) group.

Results

En bloc resection and complete resection rates were higher in the CPIA group than in the IMIE group (CPIA vs. IMIE; en bloc resection, 99.8 and 95.0 %, P < 0.001; complete resection, 94.2 and 88.3 %, P < 0.001). Duration of procedure was shorter in the CPIA group than in the IMIE group (CPIA vs. IMIE; 48.2 ± 32.5 and 57.6 ± 41.3 min, P < 0.001). In multivariate analysis, sedation method was an independent factor associated with en bloc resection and complete resection. Additionally, sedation with CPIA was not a risk factor for bleeding (P = 0.403) or perforation (P = 0.474); however, aspiration pneumonia developed more frequently in patients sedated with CPIA (CPIA vs. IMIE, 4.4 and 1.5 %, P = 0.002).

Conclusions

Sedation with CPIA can improve ESD performance.     

Is transnasal endoscope-assisted endoscopic submucosal dissection for gastric neoplasm useful in training beginners? A prospective randomized trial

Background

The main problem in performing endoscopic submucosal dissection (ESD) of gastric neoplasms is that it is technically difficult, especially for beginners.

Methods

A total of 51 patients were randomly assigned to undergo transnasal endoscope-assisted or routine ESD performed by two endoscopists inexperienced in ESD while supervised by one expert.

Results

Total procedure time (p = 0.330), complete resection rate (p = 0.977), and complication rate (p = 0.157) were similar for the patients who underwent transnasal endoscope-assisted and routine ESD, but bleeding control time was significantly longer in the transnasal endoscope-assisted ESD group (p = 0.002). Three and six patients in the transnasal endoscope-assisted and routine ESD groups, respectively, were “dropped out” during the procedures (p = 0.291). The endoscopists tended to regard the traction with the transnasal endoscope as more useful for large tumors (p = 0.062). Bleeding control in patients who underwent the transnasal endoscope-assisted ESD was significantly longer for patients with tumors located in the anterior wall, posterior wall, and lesser curvature of the stomach (p = 0.001).

Conclusion

Transnasal endoscope-assisted ESD does not result in improved outcomes when performed by beginners, except for some large tumors. The traction method used by beginners was not superior to proper supervision and advice by an expert during ESD and allowing the expert to perform the procedure when the risk of complications is high or the procedure is delayed.     

Safety and patient satisfaction of early diet after endoscopic submucosal dissection for gastric epithelial neoplasia: a prospective,randomized study

Background

Endoscopic submucosal dissection (ESD) is a standard treatment for gastric neoplasia limited to the mucosa without lymph node metastasis. However, there are neither standardized guidelines nor studies on the best time to start oral intake after ESD. The aim of this study was to compare patient satisfaction, safety, length of hospital stay, and economic feasibility between an early post-ESD diet and the conventional immediate fasting protocol.

Methods

A total of 130 patients with 156 gastric epithelial neoplasias who underwent ESD by a single expert endoscopist were consecutively and prospectively enrolled. Enrolled patients were randomized to an early diet group or a control group. The early diet group started meals as a clear liquid diet on day 0, and a soft diet and general diet in sequence on day 1. The fasting group was fasted for 2 days. Patients in both groups underwent second-look endoscopy within 2 days following ESD and follow-up endoscopy after 2 months.

Results

In the course of the study, ten patients were excluded. The total number of patients in the early diet group and control group was 63 and 57, respectively. Mean age was 62 years (±9.4). There were no significant differences in clinicopathologic conditions or endoscopic results such as procedure time or size of lesions between the two groups. There were no significant differences in abdominal pain score, rate of post-ESD bleeding or healing rate of ESD-induced ulcer between the two groups. However, the early diet protocol led to significantly higher patient satisfaction (p = 0.001), lower hospital costs (p < 0.001), and shorter hospital stay (p < 0.001) than the conventional fasting protocol.

Conclusions

An early post-ESD diet protocol provides higher patient satisfaction, is more cost effective, decreases hospital stay, and does not influence complication rates such as post-ESD bleeding, abdominal pain, or ulcer healing compared with the conventional fasting protocol.     

Outcomes and predictive factors of “not self-completion” in gastric endoscopic submucosal dissection for novice operators

Background

Endoscopic submucosal dissection (ESD) has become the standard endoscopic treatment for gastric neoplasms because of its safety and high rate of curability; however, it is not easy for novice operators to learn the technique of ESD. In this study, predictive factors of gastric neoplasms in which novices could not finish ESD by self-completion were evaluated.

Methods

Eighty consecutive ESD procedures performed by four novice operators were retrospectively analyzed. Standard ESD procedures were performed using an insulation-tipped (IT) knife under supervision. Self-completion rates, procedure time, and complete resection rates were evaluated, and predictive factors for “not self-completion” were assessed.

Results

The overall self-completion rate and en bloc plus R0 resection rate were 87.5% (70/80) and 95.7 % (67/70), respectively. In “not self-completion” cases (n = 10), the procedure time was longer and resected specimens were larger than those in self-completion cases (83.7 ± 47.3 min vs. 189.5 ± 106.8 min, p < 0.05; 641.2 ± 487.8 vs. 1,116 ± 480.4 mm², p < 0.01). Predictive factors of “not self-completion” were tumor location in the middle or upper third of the stomach or in the greater curvature and size of resected specimens larger than 900 mm². The self-completion rate of ESD was decreased in cases with more than two predictive factors.

Conclusions

For novice operators, tumor location and resected areas are predictive factors for failure to finish gastric ESD by self-completion. Selection of cancer lesions could be a key factor for effectiveness of ESD training.     

Laparoscopy-assisted pancreas- and spleen-preserving total gastrectomy for gastric cancer as compared with open total gastrectomy

Background

Laparoscopy-assisted total gastrectomy (LATG) is not widely used for the treatment of gastric cancer located in the upper or middle third of the stomach. To assess the safety and usefulness of LATG, we compared the outcomes of LATG with those of open total gastrectomy (OTG).

Methods

From July 2004 to July 2007, we performed pancreas- and spleen-preserving total gastrectomy with D1 + β or D2 lymph-node dissection and Roux-en-Y reconstruction in 74 patients with cancer located in the upper or middle third of the stomach. Of these patients, 30 underwent LATG (LATG group) and 44 underwent OTG (OTG group). Short-term outcomes were compared between the groups.

Results

Operation time was significantly longer in the LATG group than in the OTG group (313 min vs. 218 min, p < 0.001). Blood loss (134 g vs. 407 g, p < 0.001) and the rate of the use of analgesics (6.8 times vs. 11.8 times, p < 0.05) were significantly lower, and postoperative hospital stay was significantly shorter in the LATG group than in the OTG group (13.5 days vs. 18.2 days, p < 0.05). The LATG group had better hematologic and serum chemical profiles, including white-cell counts, C-reactive protein levels, total protein levels, and albumin levels, as well as lower rate of postoperative body-weight loss. The number of dissected lymph nodes (43.2 vs. 51.2, p = 0.098) and the rate of postoperative complications (20.0% vs. 27.3%, p = 0.287) were similar in the groups. However, major complications such as anastomotic leakage, abdominal abscess, and pancreatic leakage occurred in six patients (13.6%) in the OTG group, but in none of the patients in the LATG group.

Conclusions

LATG is associated with less severe complications and better postoperative quality of life than OTG. We believe that LATG is a safe, useful, and less invasive alternative for the treatment of gastric cancer located in the upper or middle third of the stomach.     

Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications

Background

Endoscopic submucosal dissection (ESD) is a well-established method for the treatment of gastrointestinal epithelial tumors. However, the treatment of gastric subepithelial tumors (SETs) that originate from the muscularis propria layer still depends primarily on surgical techniques. We evaluated the appropriate indications for ESD in the treatment of SETs that originate from the muscularis propria layer.

Methods

Thirty-five patients with gastric SETs that originate from the muscularis propria layer who underwent ESD were enrolled, and the charts were retrospectively reviewed to investigate the parameters predictive complete resection and complications.

Results

The mean age of the patients was 54.15 ± 9.3 years, and the male/female ratio was 2:3. Twenty-eight of the 35 SETs (85.7 %) were movable, and 15 (45.7 %) had a positive rolling sign. The most frequent location of the SETs was high body (n = 14). The most common pathological diagnoses were leiomyoma (60 %) and gastrointestinal stromal tumor (28.6 %). The complete resection rate was 74.3 %. A positive rolling sign (p = 0.022) and small tumor size (≤20 mm; p = 0.038) were significantly associated with complete resection. Two patients (6.1 %) developed perforations that required surgical treatment; their SMTs were neurogenic tumors with fixed lesion. Tumor mobility was significantly associated with perforation (p = 0.017).

Conclusions

The ESD method appears to be relatively safe for use in the complete resection of SETs that originate from the muscularis propria layer. Small tumor size (≤20 mm) and a positive rolling sign are appropriate indications for ESD.     

Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a single-center experience

Background

In Korea, endoscopic submucosal dissection (ESD) has been widely accepted for the treatment of early gastric cancers (EGCs). However, the understanding of the long-term clinical outcome of ESD for EGC remains insufficient. Therefore, the aim of the present study was to assess the long-term clinical outcome and efficacy of ESD for the treatment of EGCs, including the clinical application of the expanded criteria for ESD.

Methods

From January 2006 to December 2010, a total of 515 patients with 522 EGCs were treated by ESD in our hospital; study enrollment was based on the expanded criteria. Comparisons of resectability (en bloc or piecemeal resection), curability (curative or non-curative), and complications (bleeding and perforation) between the standard and expanded groups were assessed. Thereafter, 336 patients with 342 EGCs were finally included in a long-term analysis of local tumor recurrence, development of synchronous and metachronous cancers, and overall and disease-specific survival rates.

Results

En bloc and curative resection rates of 96.7 % and 88.3 %, respectively, were achieved. The curative resection rate was significantly lower in the expanded group than in the standard group (82.1 % vs. 91.5 %, p = 0.001). During a median follow-up of 24 months, the local tumor recurrence rate was also higher in the expanded group than in the standard group (7.0 % vs. 1.8 %, p = 0.025). Local recurrence was more frequent in lesions with non-curative resection than in those with curative resection (20.0 % vs. 1.3 %, p < 0.001). The 5-year overall and disease-specific survival rates were 88 % and 100 %, respectively; the difference between the standard and expanded groups was not significant (p = 0.834).

Conclusions

ESD appears to be a feasible and effective method for treating EGCs, based on the standard and expanded criteria. Close follow-up surveillance, after ESD, should be standard for all patients.     

Factors related to the curability of early gastric cancer with endoscopic submucosal dissection

Background

Endoscopic submucosal dissection (ESD) yields substantially high rates for curative resection of early gastric cancer (EGC). It is suggested that larger, ulcerative, or upper EGCs may prevent successful ESD. A detailed analysis of factors associated with the curability of ESD was performed.

Methods

Endoscopic submucosal dissection was performed for patients with EGC that fulfilled the expanded criteria, which specified mucosal cancer without ulcer findings irrespective of tumor size, mucosal cancer with ulcers 3 cm in diameter or smaller, and minute submucosal invasive cancer 3 cm or smaller. Resectability (en bloc or by piecemeal resection), curability (curative or non-curative), and complications were assessed, and logistic regression analysis was used to analyze the related factors.

Results

Ulcerative EGCs showed a significantly higher risk associated with ESD on multivariate analysis. When the risk factors (tumor size, location, and ulcer findings) were combined, the larger EGCs (>30 mm) located in the upper third or ulcerative tumors located in the upper and middle portion of the stomach were at significantly higher risk of non-curative resection. Such lesions also were associated with increased risk of procedure-related perforation.

Conclusions

When risk factors including positive ulcer findings and larger size and upper location of tumors are combined, ESD should be performed more carefully.     

Retrospective study of endoscopic submucosal tunnel dissection (ESTD) for surgical resection of esophageal leiomyoma

Background

Esophageal leiomyoma is benign and often asymptomatic, but if the tumor is too large or obstructive, it should be resected. The aim of this study was to compare a novel approach, endoscopic submucosal tunnel dissection (ESTD), with a more established method, endoscopic submucosal dissection (ESD).

Methods

This was a retrospective study of 39 patients in Chongqing Xinqiao Hospital, China, undergoing resection for leiomyoma >2 cm in diameter, or 1.5–2.0 cm in diameter with symptoms of obstructive dysphagia. Epidemiological data, presenting symptoms, diagnostic investigations, tumor location, histopathological findings, and safety and efficacy of surgical resection were analyzed.

Results

Mean tumor sizes in the ESTD (n = 18; mean age = 36.7 ± 6.3 years) and ESD (n = 21; age = 41.0 ± 4.4 years) groups were 3.3 ± 0.7 and 3.0 ± 0.4 cm, respectively. The male:female ratio was 25:14, with a distribution of lesions among the lower, middle, and upper esophagus of 22:14:3. Operating time was significantly shorter (p < 0.05) for ESTD (67.5 ± 9.5 min) than for ESD (87.2 ± 7.7 min), while incision healing was faster (p < 0.05) for ESTD (14.7 ± 2.5 days) than for ESD (57.9 ± 7.5 days). Hospital stay was also shorter (p < 0.05) for ESTD (2.3 ± 0.5 days) than for ESD (5.7 ± 1.0 days). Bleeding was the only complication with ESTD (3/18 patients), with no significant difference in the incidence of complications between groups. ESTD was rapidly learned by surgeons.

Conclusion

ESTD is a safe and effective treatment for esophageal leiomyoma, with advantages over ESD.     

Clinical outcome of endoscopic submucosal dissection versus endoscopic mucosal resection of large colorectal tumors as determined by curative resection

Background and Aims

Endoscopic submucosal dissection (ESD) has recently been applied to the treatment of superficial colorectal cancer. Clinical outcomes compared with conventional endoscopic mucosal resection (EMR) have not been determined so our aim was to compare the effectiveness of ESD with conventional EMR for colorectal tumors ≥20 mm.

Methods

This was a retrospective case-controlled study performed at the National Cancer Center Hospital in Tokyo, Japan involving 373 colorectal tumors ≥20 mm determined histologically to be curative resections. Data acquisition was from a prospectively completed database. We evaluated histology, tumor size, procedure time, en bloc resection rate, recurrence rate, and associated complications for both the ESD and EMR groups.

Results

A total of 145 colorectal tumors were treated by ESD and another 228 were treated by EMR. ESD was associated with a longer procedure time (108 ± 71 min/29 ± 25 min; p < 0.0001), higher en bloc resection rate (84%/33%; p < 0.0001) and larger resected specimens (37 ± 14 mm/28 ± 8 mm; p = 0.0006), but involved a similar percentage of cancers (69%/66%; p = NS). There were three (2%) recurrences in the ESD group and 33 (14%) in the EMR group requiring additional EMR (p < 0.0001). The perforation rate was 6.2% (9) in the ESD group and 1.3% (3) in the EMR group (p = NS) with delayed bleeding occurring in 1.4% (2) and 3.1% (7) of the procedures (p = NS), respectively, as all complications were effectively treated endoscopically.

Conclusions

Despite its longer procedure time and higher perforation rate, ESD resulted in higher en bloc resection and curative rates compared with EMR and all ESD perforations were successfully managed by conservative endoscopic treatment.     

Centralisation of upper-GI cancer services: is the hub quicker than the spoke?

Background

The aim of this study was to assess whether patients diagnosed with oesophageal or gastric cancer at a local district general hospital (the “spoke”) have a similar temporal pathway through the decision-making and treatment process compared to those patients presenting at the centralised, tertiary hospital (the “hub”).

Methods

Between April 2010 and April 2011, patients with a new diagnosis of oesophagogastric cancer from both hub and spoke hospitals were analysed. Data regarding diagnosis, time from diagnosis to multidisciplinary meeting (MDM) discussion, and time from MDM decision to first treatment were all recorded. Statistical analysis was performed using parametric two-tailed t test to assess significance.

Results

There was a statistically significant increase in the time from diagnosis to MDM discussion at the spoke hospital compared to the hub (13.3 days vs. 25.67 days; p = 0.001). However, time to first treatment (surgery, palliative therapy, neoadjuvant therapy, or best supportive care) was significantly increased in the hub hospital compared to the spoke (43.4 days vs. 25.5 days; p = 0.023).

Conclusions

Notwithstanding its limitations, this study is the first of its kind to show that there is a disparity in the management pathways of patients who first present to a regional hospital rather than the tertiary centre. Patients at the spoke hospital have a longer lead time into the MDM but nonoperative treatment appears to be delivered more quickly locally.     

Differences in histopathological evaluation of standard lymph node dissections result in differences in nodal count but not in survival

Objective

To analyse whether the reported differences in nodal yield at pelvic lymph node dissection (PLND) for bladder cancer, between two hospitals, are reflected in the survival rates.

Patients and methods

We assessed follow-up data of all 174 patients (mean age: 62.7, median follow-up: 3 years) who underwent PLND between 1 January 2007 and 31 December 2009 at two different hospitals. PLND was performed according to a standardized template by the same urologists for comparable bladder cancer patients. Mean number of reported lymph nodes was 16 at hospital A versus 28 at hospital B. We compared the overall survival (OS), disease-specific survival (DSS) and recurrence-free survival (RFS) between both cohorts and performed a multivariate analysis.

Results

The cumulative probability for 2-year OS, DSS and RFS for hospital A are 61, 64 and 54 %, versus 58, 58 and 53 % for hospital B, respectively. Kaplan–Meier survival curves did not reveal statistically significant differences between both groups (OS: p log-rank = 0.75, DSS: p log-rank = 0.56, and RFS: p log-rank = 0.80). Also after adjustment for pT stage and neoadjuvant chemotherapy, survival was not significantly different between hospital A and hospital B.

Conclusion

Despite differences in lymph node yield in PLND specimens, this study reveals no significant differences in survival outcomes between both hospitals. Standardized histopathological methods should be agreed upon by pathologists before integrating nodal yield and subsequent lymph node density as indicators of the quality of surgery and as prognostic factors.     

Surgical volume and quality of care for esophageal resection: do high-volume hospitals have fewer complications?

BACKGROUND: Previous studies have shown that high-volume hospitals (HVHs) have lower mortality rates than low-volume hospitals (LVHs). However, little is known regarding the relationship of morbidity to hospital volume. The objective of the current study was to investigate the relative incidence of postoperative complications after esophageal resection at HVHs and LVHs. METHODS: All patients discharged from a nonfederal, acute-care hospital in Maryland after esophageal resection from 1994 to 1998 were included (n = 366). Rates of 10 postoperative complications were compared at HVHs and LVHs. Risk-adjusted analyses were performed using multiple logistic regression. RESULTS: High-volume hospitals had a mortality rate of 2.5% compared with 15.4% at LVHs (p < 0.001), with a case-mixed adjusted odds ratio (OR) of death equal to 5.7 (95% confidence interval [CI], 2.0 to 16; p < 0.001). Low-volume hospitals had a profound increase in the risk of several complications after adjusting for case-mix: renal failure (OR, 19; 95% CI, 1.9 to 178; p = 0.01), pulmonary failure (OR, 4.8; 95% CI, 1.6 to 14; p = 0.002), septicemia (OR, 4.0; 95% CI, 1.1 to 15; p = 0.04), reintubation (OR, 2.9; 95% CI, 1.4 to 6.1; p = 0.004), surgical complications (OR, 3.3; 95% CI, 1.6 to 6.9; p = 0.001), and aspiration (OR, 1.8; 95% CI, 1.0 to 3.3; p = 0.04). CONCLUSIONS: Patients undergoing esophageal resection at LVHs were at a markedly increased risk of postoperative complications and death. Pulmonary complications are particularly prevalent at LVHs and contribute to the death of patients having surgery at those centers.     

Clinical outcomes for patients with perforations during endoscopic submucosal dissection of laterally spreading tumors of the colorectum

Background

Endoscopic submucosal dissection (ESD) for colorectal neoplasms is not widely performed because of the high risk of perforation. Perforations are divided into macroperforations and microperforations. Currently, there is a limited amount of clinical data on the outcome of patients with these types of perforations during colonic ESD. The aim of this study was to investigate the clinical outcome of patients who sustained colon perforations during ESD. We also compared the clinical outcome of patients with microperforations and those with macroperforations.

Methods

This study enrolled 101 patients with colorectal laterally spreading tumors (LST) who underwent ESD. We retrospectively reviewed their medical records, including patient demographic data and the clinical, endoscopic, and pathologic features. In the cases where perforation had occurred, the course of hospital treatment was analyzed. All ESD-related perforations were divided into macroperforations and microperforations. A macroperforation was defined as a gross perforation that occurred during an ESD procedure and a microperforation was defined by free air visible on X-rays after the procedure.

Results

Of the 101 enrolled patients, 9 (8.9 %) developed perforations. The most common tumor morphology was nongranular-type LST (5 of 9 cases, 55.6 %) based on endoscopic examination. Five patients had microperforations and four had macroperforations. All macroperforations were closed primarily by endoclips during ESD. The endoscopic characteristics did not differ between the groups. However, the length of hospital stay and the mean duration of NPO and antibiotic treatments were longer for microperforation patients. All patients had conservative nonsurgical management such as fasting, intravenous antibiotics, and nasogastric tube drainage.

Conclusions

The clinical complications for microperforation patients were worse than those for macroperforation patients. However, the clinical prognoses of patients with perforations that occur during colonic ESD are favorable.     

Argon plasma coagulation is safe and effective for treating smaller gastric lesions with low-grade dysplasia: a comparison with endoscopic submucosal dissection

Background and aims

The best therapeutic modality has not been established for gastric low-grade adenomas or dysplasia (LGD), which can progress to invasive carcinoma despite a low risk. This study aims to investigate the clinical efficacy, safety, and local recurrence after argon plasma coagulation (APC) treatment of gastric LGD compared with endoscopic submucosal dissection (ESD).

Patients and methods

A total of 320 patients with gastric LGD ≤2.0 cm treated with APC or ESD between 2004 and 2011 were retrospectively analyzed. We compared local recurrence rate, complication rate, procedure time, and admission to hospital between APC and ESD groups.

Results

Of the 320 patients, 116 patients were treated with APC and 204 with ESD. During follow-up, local recurrence was more common in the APC group (3.8 %, 4/106) than the ESD group (0.5 %, 1/188; log-rank test P = 0.036). However, all patients with local recurrence (n = 5) were treated by additional APC, and followed up without further recurrences. ESD was complicated by two perforations (1.0 %, 2/204) compared with no perforations in the APC group (0 %, 0/116). Bleeding complications were not different between the APC (1.7 %, 2/116) and ESD (2.0 %, 4/204) groups. Procedure time was shorter in the APC (7.8 ± 5.1 min) than the ESD (53.1 ± 38.1 min) group (P < 0.001). The proportion of hospitalization was less in the APC group (31.0 %, 36/116) than the ESD group (100.0 %, 204/204) (P < 0.001).

Conclusions

APC can be a good treatment option for patients with LGD ≤2.0 cm.     

A propensity score–matched case–control comparative study of laparoscopic and open extended (D2) lymph node dissection for distal gastric carcinoma

Background

Technical proficiency at laparoscopic D2 lymph node dissection (LND) is essential for extending the use of laparoscopic surgery beyond the treatment of early gastric cancer (EGC). The aim of this study was to evaluate the technical and oncological feasibility of laparoscopic distal gastrectomy (LDG) with D2 LND for distal gastric cancer.

Methods

Of 922 patients who underwent open or LDG with D2 LND for gastric carcinoma, 133 treated by LDG and 133 treated by open distal gastrectomy (ODG) were selected using the propensity score matching method. The short-term surgical outcomes and long-term survivals of these matched groups were compared.

Results

The two study groups were well matched with respect to age, sex, body mass index, comorbidity, ASA score, abdominal operation history, and tumor stage. The LDG group had a significantly longer mean operating time (227 vs. 161 min, p < 0.001) but showed significantly less intraoperative blood loss (149 vs. 189 ml, p = 0.007). Total numbers of collected lymph nodes were similar in the two groups. Postoperatively, no significant intergroup differences were found for hospital stay, morbidity, or mortality. Furthermore, overall survivals were similar in the two groups (p = 0.621). Multivariate analysis showed that male gender, age ≥70 years, and intraoperative blood loss of ≥200 ml were independent risk factors of postoperative morbidity.

Conclusions

Laparoscopic D2 LND for distal gastric cancer is technically safe and feasible compared with ODG. A prospective randomized trial is warranted to evaluate long-term oncological outcomes in advanced gastric carcinoma.