Repeat endoscopic submucosal dissection for recurrent gastric cancers after endoscopic submucosal dissection

AIM: To clarify the safety and efficacy of repeat endoscopic submucosal dissection (re-ESD) for locally recurrent gastric cancers after ESD.METHODS: A retrospective evaluation was performed of the therapeutic efficacy, complications and follow-up results from ESD treatment for early gastric cancers in 521 consecutive patients with 616 lesions at St. Luke`s International Hospital between April 2004 and November 2012. In addition, tumor size, the size of resected specimens and the operation time were compared between re-ESD and initial ESD procedures. A flex knife was used as the primary surgical device and a hook knife was used in cases with severe fibrosis in the submucosal layer. Continuous variables were analyzed using the non-parametric Mann-Whitney U test and are expressed as medians (range). Categorical variables were analyzed using a Fisher’s exact test and are reported as proportions. Statistical significance was defined as a P-value less than 0.05.RESULTS: The number of cases in the re-ESD group and the initial ESD group were 5 and 611, respectively. The median time interval from the initial ESD to re-ESD was 14 (range, 4-44 mo). En bloc resection with free lateral and vertical margins was successfully performed in all re-ESD cases without any complications. No local or distant recurrence was observed during the median follow-up period of 48 (range, 11-56 mo). Tumor size was not significantly different between the re-ESD group and the initial ESD group (median 22 mm vs 11 mm, P = 0.09), although the size of resected specimens was significantly larger in the re-ESD group (median 47 mm vs 34 mm, P < 0.05). There was a non-significant increase observed in re-ESD operation time compared to initial ESD (median 202 min vs 67 min, respectively, P = 0.06).CONCLUSION: Despite the low patient number and short follow-up, the results suggest that re-ESD is a safe and effective endoscopic treatment for recurrent gastric cancer after ESD.     

Delayed perforation after endoscopic submucosal dissection for early gastric cancer: Clinical features and treatment

Perforation is an important procedural complication of endoscopic submucosal dissection (ESD) for early gastric cancer. Although the incidence of delayed perforation after ESD is low, extreme caution is necessary because many cases require surgical intervention. Among 1984 lesions of early gastric cancer treated in our hospital by ESD in 1588 patients from September 2002 through March 2015, delayed perforation developed in 4 patients (4 lesions, 0.25%). A diagnosis of delayed perforation requires prompt action, including surgical intervention when required.     

Outcome after endoscopic submucosal dissection for early gastric cancer in Korea

Endoscopic treatment,such as endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD),has been established as one of the treatment options for selected cases with early gastric cancer(EGC).Most studies on this topic have been carried out by researchers in Japan.Recently,the experience in EMR/ESD for EGC outside Japan is increasingly reported.In Korea,gastric cancer is the most common malignant disease,and the second leading cause of cancer death.Currently,EMR for EGC is widely performed i...     

Endoscopic submucosal dissection of early gastric cancer

Gastric cancer is the most common cancer worldwide. The proportion of early gastric cancer (EGC) cases at diagnosis has increased because of the use of mass screening endoscopy in older adults. Endoscopic mucosal resection has become the standard treatment for EGC in cases with standard indications because of its low risk of lymph node metastasis. A new endoscopic method, endoscopic submucosal dissection, has recently become available. This method allows en bloc resection without limitation of the size of the lesion. The goal of this article is to review the history and methods of endoscopic treatment with EGC, the conventional and extended indications, the therapeutic outcomes, and the complication rates.     

Mallory-Weiss tear during gastric endoscopic submucosal dissection

A 78-year-old woman was referred to our department for treatment of an early gastric cancer. Esophagogastroduodenoscopy (EGD) demonstrated a flat elevated lesion and a polypoid lesion on the greater curvature of the antrum. Histological analysis of, endoscopic biopsy samples taken from these lesions revealed an adenocarcinoma and a hyperplastic polyp, respectively. ESD was conducted for removal of the lesions. Carbon dioxide (CO2) in- stead of room air was used for insufflation, and the patient was adequately sedated without struggling or vomiting during the treatment. No significant bleeding from the lesion was observed during ESD, but fresh blood was identified endoscopically. Surprisingly, a Mallory- Weiss tear with active bleeding was detected on the lesser curvature of the gastric corpus. A total of eight hemoclips were applied for hemostasis. Both lesions were completely removed en bloc, and no bleeding or perforation developed after ESD. Histologically, the first lesion was apapillary carcinoma limited to the mucosal layer and without lymphovascular invasion or involvement of the surgical margins, while the second lesion was a benign hyperplastic polyp.     

Dehiscence following successful endoscopic closure of gastric perforation during endoscopic submucosal dissection

Gastric perforation is one of the most serious complications that can occur during endoscopic submucosal dissection (ESD). In terms of the treatment of such perforations, we previously reported that perforations immediately observed and successfully closed with endoclips during endoscopic resection could be managed conservatively. We now report the first case in our medical facility of a gastric perforation during ESD that was ineffectively treated conservatively even after successful endoscopic closure. In December 2006, we performed ESD on a recurrent early gastric cancer in an 81-year-old man with a medical history of laparotomy for cholelithiasis. A perforation occurred during ESD that was immediately observed and successfully closed with endoclips so that ESD could be continued resulting in an en-bloc resection. Intensive conservative management was conducted following ESD, however, an endoscopic examination five days after ESD revealed dehiscence of the perforation requiring an emergency laparotomy.     

Second-look endoscopy and factors associated with delayed bleeding after endoscopic submucosal dissection

Endoscopic submucosal dissection(ESD) is a widely used procedure as curative treatment for superficial gastric neoplasms, including early gastric cancer without lymph node metastasis. However, ESD requires advanced endoscopic skill and there is a major concern regarding complications from bleeding. So far, extensive efforts have been made to develop strategies to reduce post-ESD bleeding. Use of proton pump inhibitors and coagulating exposed vessels on the ulcer floor after ESD are strategies known to reduce the risk of delayed bleeding. Second-look endoscopy(SLE) is also carried out to reduce delayed bleeding following ESD in many institutions. However, the incidence of bleeding still remains around 5%, and further measures are needed to reduce delayed bleeding after gastric ESD. Recently, three randomized studies indicated that routine SLE was unnecessary. Although routine SLE may not be recommended for all patients after gastric ESD, SLE might be an important tool for the prevention of the delayed bleeding in selected high-risk patients. Thus, the identification of the risk factors, such as large size of resected specimen and treatment with multiple antiplatelet medications, may help to further guide clinicians in deciding whether to perform SLE. Studies carried out on larger cohorts are necessary to clarify the efficacy of SLE after ESD in the prevention of post-ESD bleeding in potentially high-risk patients.     

Advanced endoscopic submucosal dissection with traction

Endoscopic submucosal dissection (ESD) has been established as a standard treatment for early stage gastric cancer (EGC) in Japan and has spread worldwide. ESD has been used not only for EGC but also for early esophageal and colonic cancers. However, ESD is as-sociated with several adverse events, such as bleeding and perforation, which requires more skill. Adequate tissue tension and clear visibility of the tissue to be dissected are important for effective and safe dissection. Many ESD methods using traction have been devel-oped, such as clip-with-line method, percutaneous trac-tion method, sinker-assisted method, magnetic anchor method, external forceps method, internal-traction method, double-channel-scope method, outerroute method, double-scope method, endoscopic-surgical-platform, and robot-assisted method. Each method has both advantages and disadvantages. Robotic endos-copy, enabling ESD with a traction method, will become more common due to advances in technology. In thenear future, simple, noninvasive, and effective ESD us-ing traction is expected to be developed and become established as a worldwide standard treatment for superficial gastrointestinal neoplasias.     

Current status of endoscopic submucosal dissection for the management of early gastric cancer: a Korean perspective

The early diagnosis of gastric cancer allows patients and physicians to pursue the option of endoscopic resection,which is significantly less invasive than conventional surgical resection.In Korea,the use of endoscopic submucosal dissection(ESD) has been increasing,and many reports on ESD have been published.In addition,Korean gastroenterologists from several hospitals performing ESD have conducted formal meetings to discuss useful information regarding ESD.Here,we discuss the Korean experience with ESD,inc...     

Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection

AIM: To identify the actual clinical management and associated factors of delayed perforation after gastric endoscopic submucosal dissection (ESD).METHODS: A total of 4943 early gastric cancer (EGC) patients underwent ESD at our hospital between January 1999 and June 2012. We retrospectively assessed the actual management of delayed perforation. In addition, to determine the factors associated with delayed perforation, after excluding 123 EGC patients with perforations that occurred during the ESD procedure, we analyzed the following clinicopathological factors among the remaining 4820 EGC patients by comparing the ESD cases with delayed perforation and the ESD cases without perforation: age, sex, chronological periods, clinical indications for ESD, status of the stomach, location, gastric circumference, tumor size, invasion depth, presence/absence of ulceration, histological type, type of resection, and procedure time.RESULTS: Delayed perforation occurred in 7 (0.1%) cases. The median time until the occurrence of delayed perforation was 11 h (range, 6-172 h). Three (43%) of the 7 cases required emergency surgery, while four were conservatively managed without surgical intervention. Among the 4 cases with conservative management, 2 were successfully managed endoscopically using the endoloop-endoclip technique. The median hospital stay was 18 d (range, 15-45 d). There were no delayed perforation-related deaths. Based on a multivariate analysis, gastric tube cases (OR = 11.0; 95%CI: 1.7-73.3; P = 0.013) were significantly associated with delayed perforation.CONCLUSION: Endoscopists must be aware of not only the identified factors associated with delayed perforation, but also how to treat this complication effectively and promptly.     

Clinical relevance of aberrant polypoid nodule scar after endoscopic submucosal dissection

AIM To describe a series of patients with aberrant polypoid nodule scar developed after gastric endoscopic submucosal dissection(ESD), and to discuss its pathogenesis and clinical management. METHODS We reviewed retrospectively the endoscopic database of two academic institutions located in Brazil and Japan and searched for all patients that underwent ESD to manage gastric neoplasms from 2003 to 2015. The criteria for admission in the study were:(1) successful en bloc ESD procedure with R0 and curative resection confirmed histologically;(2) postoperative endoscopic examination with identification of a polypoid nodule scar(PNS) at ESD scar;(3) biopsies of the PNS with hyperplastic or regenerative tissue, reviewed by two independent experienced gastrointestinal pathologists, one from each Institution. Data were examined for patient demographics, Helicobacter pylori status, precise neoplastic lesion location in the stomach, tumor size, histopathological assessment of the ESD specimen, and postoperative information including medical management, endoscopic and histological findings, and clinical outcome.RESULTS A total of 14 patients(10 men/4 women) fulfilled the inclusion criteria and were enrolled in this study. One center contributed with 8 cases out of 60 patients(13.3%) from 2008 to 2015. The second center contributed with 6 cases(1.7%) out of 343 patients from 2003 to 2015. Postoperative endoscopic follow-up revealed similar findings in all patients: A protruded polypoid appearing nodule situated in the center of the ESD scar surrounded by convergence of folds. Biopsies samples were taken from PNS, and histological assessment revealed in all cases regenerative and hyperplastic tissue, without recurrent tumor or dysplasia. Primary neoplastic lesions were located in the antrum in 13 patients and in the angle in one patient. PNS did not develop in any patient after ESD undertaken for tumors located in the corpus, fundus or cardia. All patients have been followed systematically on an annual basis and no malignant recurrence in the ESD scar has been identified(mean follow-up period: 45 mo).CONCLUSION PNS may occur after ESD for antral lesions and endoscopically look concerning, especially for the patient or the family doctor. However, as long as curative R0 resection was successfully achieved and histology demonstrates only regenerative and hyperplastic tissue, PNS should be viewed as a benign alteration that does not require any type of intervention, other than endoscopic surveillance.     

Endoscopic submucosal dissection vs endoscopic mucosal resection for early gastric cancer: A meta-analysis

AIM: To compare endoscopic submucosal dissection(ESD) and endoscopic mucosal resection(EMR) for early gastric cancer(EGC).METHODS: Computerized bibliographic search was performed on PubMed/Medline, Embase, Google Schol-ar and Cochrane library databases. Quality of each included study was assessed according to current Co-chrane guidelines. Primary endpoints were en bloc re-section rate and histologically complete resection rate. Secondary endpoints were length of procedure, post-treatment bleeding, post-procedural perforation and re-currence rate. Comparisons between the two treatment groups across all the included studies were performed by using Mantel-Haenszel test for fixed-effects mod-els(in case of low heterogeneity) or DerSimonian and Laird test for random-effects models(in case of high heterogeneity).RESULTS: Ten retrospective studies(8 full text and 2 abstracts) were included in the meta-analysis. Overall data on 4328 lesions, 1916 in the ESD and 2412 in the EMR group were pooled and analyzed. The mean operation time was longer for ESD than for EMR(stan-dardized mean difference 1.73, 95%CI: 0.52-2.95, P =0.005) and the "en bloc " and histological complete re-section rates were significantly higher in the ESD group [OR = 9.69(95%CI: 7.74-12.13), P 0.001 and OR = 5.66,(95%CI: 2.92-10.96), P 0.001, respectively]. As a consequence of its greater radicality, ESD provided lower recurrence rate [OR = 0.09,(95%CI: 0.05-0.17), P 0.001]. Among complications, perforation rate was significantly higher after ESD [OR = 4.67,(95%CI, 2.77-7.87), P 0.001] whereas the bleeding incidences did not differ between the two techniques [OR = 1.49(0.6-3.71), P = 0.39].CONCLUSION: In the endoscopic therapy of EGC, ESD showed a superior efficacy but higher complication rate with respect to EMR.     

How to establish endoscopic submucosal dissection in Western countries

Endoscopic submucosal dissection(ESD) has been invented in Japan to provide resection for cure of early cancer in the gastrointestinal tract. Professional level of ESD requires excellent staging of early neoplasias with image enhanced endoscopy(IEE) to make correct indications for ESD,and high skills in endoscopic electrosurgical dissection. In Japan,endodiagnostic and endosurgical excellence spread through personal tutoring of skilled endoscopists by the inventors and experts in IEE and ESD. To translocate this expertise to other continents must overcome two fundamental obstacles:(1) inadequate expectations as to the complexity of IEE and ESD; and(2) lack of suitable lesions and master-mentors for ESD trainees. Leading endoscopic mucosal resection-proficient endoscopists must pioneer themselves through the long learning curve to proficient ESD experts. Major referral centers for ESD must arise in Western countries on comparable professional level as in Japan. In the second stage,the upcoming Western experts must commit themselves to teach skilled endoscopists from other referral centers,in order to spread ESD in Western countries. Respect for patients with early gastrointestinal cancer asks for best efforts to learn endoscopic categorization of early neoplasias and skills for ESD based on sustained cooperation with the masters in Japan. The strategy is discussed here.     

Fatal submucosal invasive gastric adenosquamous carcinoma detected at surveillance after gastric endoscopic submucosal dissection

An 80-year-old man was under annual surveillance esophagogastroduodenoscopy after endoscopic submucosal dissection(ESD) for early gastric cancer(EGC).Two years after the initial ESD, a 0-Ⅱc type metachronous EGC lesion, 8 mm in size, without an ulcer scar, was found in the gastric antrum.The estimated tumor depth was up to the mucosa, and biopsy revealed well and poorly differentiated adenocarcinoma.ESD was performed for this lesion and en bloc resection with negative margins was achieved.Histopathological examination revealed an adenosquamous carcinoma 8 mm in size invading the deep submucosal layer(1600 μm), with lymphovascular invasion, consistent with the diagnosis of non-curative resection.Additional gastrectomy was recommended for this patient; however, two months after the ESD, preoperative computed tomography revealed multiple liver metastases, and the patient was considered as an unsuitable candidate for surgical resection.Systemic chemotherapy was therefore started; however, the patient died of gastric cancer 27 mo after the second ESD.Early gastric adenosquamous carcinoma localized to the mucosa and submucosa is extremely rare and its clinical behavior is not well known.The present report is very significant in that it underscores the distinct possibility of gastric adenosquamous carcinoma being very aggressive and fatal even when detected at an early cancer.     

Endoscopic transgastric drainage of a gastric wall abscess after endoscopic submucosal dissection

A 63-year-old woman was referred to our hospital for further examination because of an incidental finding of early gastric cancer.Endoscopic submucosal dissection(ESD)was successfully performed for complete resection of the tumor.On the first post-ESD day,the patient suddenly complained of abdominal pain after an episode of vomiting.Abdominal computed tomography(CT)showed delayed perforation after ESD.The patient was conservatively treated with an intravenous proton pump inhibitor and antibiotics.On the fifth post-ESD day,CT revealed a gastric wall abscess in the gastric body.Gastroscopy revealed a gastric fistula at the edge of the post-ESD ulcer,and pus was found flowing into the stomach.An intradrainage stent and an extradrainage nasocystic catheter were successfully inserted into the abscess for endoscopic transgastric drainage.After the procedure,the clinical symptoms and laboratory test results improved quickly.Two months later,a follow-up CT scan showed no collection of pus.Consequently,the intradrainage stent was removed.Although the gastric wall abscess recurred 2 wk after stent removal,it recovered soon after endoscopic transgastric drainage.Finally,after stent removal and oral antibiotic treatment for 1 mo,no recurrence of the gastric wall abscess was found.     

内镜黏膜下剥离术治疗早期胃癌40例临床分析

目的比较内镜黏膜下剥离术与外科手术治疗早期胃癌的临床疗效。方法回顾性分析2010年4月到2015年3月,在我院接受治疗的80例早期胃癌患者的临床资料,根据治疗方式的不同分为ESD组和外科手术组。对两组患者的病灶切除率、手术时间、住院时间、医疗费用、以及术后并发症等进行比较。结果ESD组和外科手术组,病灶治愈性切除率均为100%,两组比较无统计学差异(P＞0.05)。ESD组与外科手术组比较,平均手术时间缩短(89.3vs 215.4 min,P＜0.05),平均住院时间缩短(10.5 vs 22.5 d,P＜0.05),平均医疗费用减少(1.79 vs 5.93万元,P＜0.05)。ESD组术后并发胃食管反流1例,感染1例(肺部感染),狭窄1例,出血1例,总发生率10.0%(4/40)；外科手术组术后并发胃食管反流7例,感染5例(肺部感染1例,创口感染4例),狭窄2例,出血6例,总发生率50.0%(20/40),术后并发症发生率明显高于ESD组。结论内镜黏膜下剥离术治疗早期胃癌疗效确切,而且具有手术和住院时间短,医疗费用少,术后并发症发生率低等特点。     

Additional laparoscopic gastrectomy after noncurative endoscopic submucosal dissection for early gastric cancer: A single-center experience

BACKGROUND The necessity of additional gastrectomy for early gastric cancer (EGC) patients who do not meet curative criteria after endoscopic submucosal dissection (ESD) is controversial. AIM To examine the clinicopathologic characteristics of patients who underwent additional laparoscopic gastrectomy after ESD and to determine the appropriate strategy for treating those after noncurative ESD. METHODS We retrospectively studied 45 patients with EGC who underwent additional laparoscopic gastrectomy after noncurative ESD from January 2013 to January 2019 at the Cancer Hospital of the Chinese Academy of Medical Sciences. We analyzed the patients’ clinicopathological data and identified the predictors of residual cancer (RC) and lymph node metastasis (LNM). RESULTS Surgical specimens showed RC in ten (22.2%) patients and LNM in five (11.1%).Multivariate analysis revealed that positive horizontal margin [odds ratio (OR)=13.393, 95% confidence interval (CI): 1.435-125, P=0.023] and neural invasion (OR=14.714, 95%CI: 1.087-199, P=0.043) were independent risk factors for RC. Undifferentiated type was an independent risk factor for LNM (OR=12.000, 95%CI: 1.197-120, P=0.035). Tumors in all patients with LNM showed submucosal invasion more than 500 μm. Postoperative complications after additional laparoscopic gastrectomy occurred in five (11.1%) patients, and no deaths occurred among patients with complications. CONCLUSION Gastrectomy is necessary not only for patients who have a positive margin after ESD, but also for cases with neural invasion, undifferentiated type, and submucosal invasion more than 500 μm. Laparoscopic gastrectomy is a safe, minimally invasive, and feasible procedure for additional surgery after noncurative ESD. However, further studies are needed to apply these results to clinical practice.     

Endoscopic submucosal tunnel dissection salvage technique for ulcerative early gastric cancer

Endoscopic submucosal dissection is an effective treatment modality for early gastric cancer (EGC), though the submucosal fibrosis found in ulcerative EGC is an obstacle for successful treatment. This report presents two cases of ulcerative EGC in two males, 73- and 80-year-old, with severe fibrosis. As endoscopic ultrasonography suggested that the EGCs had invaded the submucosal layer, the endoscopic submucosal tunnel dissection salvage technique was utilized for complete resection of the lesions. Although surgical gastrectomy was originally scheduled, the two patients had severe coronary heart disease, and surgeries were refused because of the risks associated with their heart conditions. The endoscopic submucosal tunnel dissection salvage technique procedures described in these cases were performed under conscious sedation, and were completed within 30 min. The complete en bloc resection of EGC using endoscopic submucosal tunnel dissection salvage technique was possible with a free resection margin, and no other complications were noted during the procedure. This is the first known report concerning the use of the endoscopic submucosal tunnel dissection salvage technique salvage technique for treatment of ulcerative EGC. We demonstrate that endoscopic submucosal tunnel dissection salvage technique it is a feasible method showing several advantages over endoscopic submucosal dissection for cases of EGC with fibrosis.     

Endoscopic predictive factors associated with local recurrence after gastric endoscopic submucosal dissection

Objective: Endoscopic submucosal dissection (ESD) has been accepted as the treatment of choice for gastric epithelial neoplasia. Endoscopic characteristics of the primary lesion and post-ESD scars may be informative to predict the possibility of local recurrence.

Methods: Between November 2008 and July 2015, a retrospective study was conducted in a single-tertiary referral hospital. Consecutive patients who underwent ESD for early gastric cancer (EGC) or high-grade dysplasia were analyzed to evaluate the incidence of local recurrence and associated endoscopic characteristics.

Results: A total of 639 lesions were analyzed. The rates of en-bloc and complete resection were 98.1% and 95.5%, respectively. A total of 15 local recurrent lesions were found (2.3%). The endoscopic findings of primary lesions associated with local recurrence were a lesion size ≥20?mm (odds ratio, OR, 4.408; 95% confidence interval, CI, 1.369–14.186, p?=?.013) and incomplete endoscopic resection (OR 17.059, 95% CI 4.887–59.551, p?Conclusion: Lesions with larger size (≥ 20?mm) and incompletely resected lesions had higher risk of local recurrence. Endoscopic forceps biopsy is unnecessary for even-flat ESD scar without erythematous changes.     

Feasibility of same-day discharge following endoscopic submucosal dissection for esophageal or gastric early cancer

BACKGROUNDEndoscopic submucosal dissection (ESD) is an established technique for the treatment of early gastrointestinal neoplasia. Generally, multi-day (M-D) admission is required for patients undergoing ESD due to potential complications.AIMTo evaluate the feasibility of a same-day (S-D) discharge strategy for ESD of the esophagus or stomach.METHODSThe data of patients who underwent esophageal or gastric ESD were retrospectively collected from January 2018 to December 2021 at Peking University Cancer Hospital. The propensity score matching (PSM) method was applied to balance the unevenly distributed patient baseline characteristics between the S-D and M-D groups. Intraoperative and postoperative parameters were compared between the matched groups.RESULTSAmong the 479 patients reviewed, 470 patients, including 91 in the S-D group and 379 in the M-D group, fulfilled the inclusion and exclusion criteria. Following PSM, 78 patients in each group were paired using the 1:1 nearest available score match algorithm. No significant difference was found between groups with respect to intraoperative and postprocedural major adverse events (AEs). Tumor size, complete resection rate, and procedural duration were comparable between the groups. The S-D group demonstrated a significantly shorter length of hospital stay (P < 0.001) and lower overall medical expenses (P < 0.001) compared with the M-D group.CONCLUSIONThe S-D discharge strategy may be feasible and effective for esophagogastric ESD, and the procedural-related AEs can be managed successfully.