Endoscopic submucosal dissection for early neoplastic lesions in the surgically altered stomach: a systematic review and meta-analysis

Surgical Management of Non-ulcer, Nonneoplastic Gastric Perforations

Gastric perforation is a core emergency disease treated by the general surgeon. The majority are caused by peptic ulcer disease and neoplasms; however, other etiologies, such as iatrogenic injury and gastric ischemia, are prevalent enough to merit separate attention. While the authors can extrapolate from our knowledge of the treatment of ulcer and neoplastic perforations when treating the lesser known causes, there are nuanced differences in how they approach it. The recognition and treatment of non-ulcer, nonneoplasm gastric perforation will be the focus of this article.

Current status of evaluation and treatment of early-stage remnant gastric cancer

Because of early diagnosis and improved prognosis, patients with gastric cancer are now surviving longer and remnant gastric cancer after gastrectomy is becoming more common. Remnant gastric cancer is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. In recent years, the development of endoscopic therapy has provided us with new therapeutic ideas. Although with some drawbacks, such as limited working space, gastric fibrosis and staples under the suture line, endoscopic management is still an effective treatment option with potential long-term survival advantage. For gastrectomy patients, endoscopic surveillance should also be recommended, for prompt surveillance and detection in the early remnant gastric cancer. This review aims to provide an overview of remnant gastric cancer, especially focusing on its pathogenesis as well as new advances in the diagnosis and endoscopic treatment of early-stage remnant gastric cancer.

Risk factors for intraoperative and delayed perforation related with gastric endoscopic submucosal dissection

BACKGROUND AND AIM

Perforation is one of the most important complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Several studies have examined risk factors for intraoperative and delayed perforations, but most were retrospective analyses with small numbers of patients.

METHODS

This study represents a secondary analysis of a Japanese multicenter prospective cohort study. We investigated the factors associated with each type of perforation using 9015 patients with 9975 EGCs undergoing ESD between July 2010 and June 2012.

RESULTS

Intraoperative perforation occurred in 198 patients (2.2%) with 203 lesions (2.0%), necessitating emergency surgery for four lesions (0.04% [2.0%, 4/203]). Delayed perforation occurred in another 37 patients (0.4%) with 42 lesions (0.4%), requiring emergency surgery for 12 lesions (0.12% [28.6%, 12/42]). Factors showing significant independent correlations with intraoperative perforation were upper or middle third of the stomach; remnant stomach or gastric tube; procedure time ≥100 min; tumor size >35 mm; body mass index (BMI) < 18.5 kg/m2; and ≥72 years. Factors showing significant independent correlations with delayed perforation were procedure time ≥60 min; BMI < 18.5 kg/m2; ≥75 years; ulceration; and tumor size >20 mm. Intraoperative perforation occurred most frequently at the greater curvature in the upper third of the stomach (7.9%), whereas delayed perforation occurred most frequently at the greater curvature in the middle third (1.2%).

CONCLUSION

This multicenter prospective cohort study clarified the risk and risk factors of intraoperative and delayed perforation related to ESD for EGCs, providing information to help endoscopists reduce perforation.

Underwater EMR in the reconstructed gastric conduit after esophagectomy

Video 1Three cases of underwater EMR for small gastric neoplasms in the reconstructed gastric conduit after esophagectomy.

Endoscopic Submucosal Dissection Versus Surgery or Endoscopic Mucosal Resection for Metachronous Early Gastric Cancer: a Meta-analysis

BACKGROUND

Resection options for early gastric cancer (EGC) include endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and surgery. In patients with metachronous EGC following previous resection, the optimal resection technique is not well elucidated. We conducted a systematic review and meta-analysis of studies comparing ESD to EMR, or ESD to surgery, in patients with metachronous EGC.

METHODS

We conducted an electronic search of studies reporting on outcomes and AEs following ESD versus either EMR or surgery for patients with metachronous EGC. Pooled odds ratios (OR) of included studies were obtained using DerSimonian and Laird random effects models. Funnel plots were produced and visually inspected for evidence of publication bias. The quality of the evidence was assessed using GRADE.

RESULTS

A total of 9367 abstracts were screened and 10 observational studies were included. The odds of complete resection were higher amongst patients undergoing ESD compared to EMR (OR 5.88, 95% confidence intervals, CI, 1.79-19.35), whereas the odds of complete resection were no different between ESD and surgery (OR 0.57, 95% CI 0.04-8.24). There were no differences in the odds of local recurrence with ESD versus surgery (OR 5.01, 95% CI 0.86-29.13). Post-procedural bleeding did not differ significantly between ESD and EMR (OR 0.70, 95% CI 0.16-3.00). There was no evidence of publication bias.

DISCUSSION

For metachronous EGC, ESD or surgery is preferred over EMR depending on local expertise and patient preferences, largely due to a higher risk of incomplete resection with EMR.

REVIEW REGISTRATION

PROSPERO CRD42021270445.

Safety and Efficacy of Endoscopic Submucosal Dissection in the Management of Gastric Tube Cancers After Esophagectomy: A Systematic Review

Esophagectomy is the proposed standard of care for resectable primary esophageal cancers and recurrent lesions in the reconstructed gastric tube (GT); however, it carries significant morbidity and mortality. Endoscopic submucosal dissection (ESD) has established its role in the management of primary esophageal cancers with growing evidence of its safety in resecting recurrent primary lesions in GT. Our study aims to evaluate the safety and efficacy of ESD in the management of recurrent, localized primary esophageal cancers in GT. We searched PubMed, CENTRAL, EMBASE, Scopus, and clinical trial registries from inception to March 2023 for articles evaluating the safety and efficacy of ESD in the management of recurrent cancerous lesions in GT. Our primary outcome was the en bloc resection rate. Secondary outcomes were curative resection rate, complete resection rate, intra-procedural complication rate, post-procedure complication rate, and five-year survival rate. Seven studies with a total of 165 patients undergoing 192 ESDs were included in the review. The pooled en bloc resection rate was 92.5% (95% CI: 87.7-95.6), which was reported in all seven studies. Pooled complete resection rate was 78.9% (95% CI: 64.5-88.5) per three studies, pooled curative resection rate was 73.9% (95% CI: 63.5-82.2) per four studies, and pooled intra-procedural complication rate was 10.2% (95% CI: 1.5-46.3), which was reported in four studies. Only three studies reported a five-year survival rate that was 65.5% (95% CI: 56.0-73.9). ESD is safe and efficacious in the management of GT cancer after esophagectomy.

Surgical treatment of gastric stump carcinoma after Whipple procedure: A case report

RATIONALE

Gastric stump carcinoma (GSC) is very exceptional and little known after Whipple procedure, and its diagnosis and treatment are extremely difficult to handle.

PATIENT CONCERNS

The patient, a 68-year-old man, visited our hospital's General surgery outpatient clinic complaining of upper abdominal pain that had been bothering him for half a month. The endoscopy revealed lesions in the stomach residual, and the pathological results suggested adenocarcinoma. The patient underwent Whipple procedure for periampullary adenocarcinoma in the 4th year ago.

DIAGNOSES

The final diagnosis was gastric adenocarcinoma and its pathological stage was Ⅱ A (T3N0M0).

INTERVENTIONS

The patient underwent stump gastrectomy and end-to-side esophagojejunostomy (Roux-en-Y reconstruction).

OUTCOMES

The operation went smoothly and the patient recovered well with only mild bloating and nausea, and the symptoms completely disappeared during the hospital stay.

LESSONS

The development of GSC several years after Whipple procedure is uncommon. This is the first case from China that has received international attention. Early diagnosis is crucial. Surgery is considered to be the most effective treatment for GSC after Whipple procedure if long-term survival is possible and surgical risks are controllable.

Utility and Feasibility of Removing Surgical Staples from the Remnant Stomach or Gastric Conduit during Endoscopic Submucosal Dissection

Objective Endoscopic submucosal dissection (ESD) for gastric cancer in the remnant stomach poses some specific technical difficulties due to severe fibrosis and the presence of surgical staples. Therefore, we clarified the feasibility and safety of removing staples. Methods We retrospectively analyzed ESD outcomes of cases of gastric cancer in the remnant stomach. Materials This study reviewed 227 patients who underwent ESD for gastric cancer in the remnant stomach or gastric conduit. Patients were divided into those in whom resection extended to the anastomotic site or suture line (AS group; n=90) and those without such extension (non-AS group; n=137). The AS group was further divided into cases in which staples were removed (staple group; n=22) and those in which they were not (control group; n=68). Results The rates of specimen damage and curative resection and the duration and speed of the procedure were significantly worse in the AS group than the non-AS group. There were no significant differences between the staple group and the control group in the curative or complete resection rates, and no complications occurred in the staple group. In a propensity score-matched analysis, the rate of specimen damage was significantly lower in the staple group than in the control group (p=0.002), and the procedure speed tended to be faster (p=0.077). Conclusion Staple removal may improve the outcomes of ESD in patients with gastric cancer in the remnant stomach or gastric conduit by reducing the risk of specimen damage and increasing the procedure speed without complications.

The efficient of application of a fine magnetic traction system simplifies colorectal endoscopic submucosal dissection: A porcine study

BACKGROUND

Sometimes it is difficult to maintain good visualization of the submucosal layer during colorectal endoscopic submucosal dissection (ESD). This study aimed to evaluate the feasibility and efficacy of a novel traction method, the fine magnetic traction system (FMTS), in colorectal ESD.

METHODS

ESD was performed 10, 15, or 30 cm from the anus in the colorectums of 10 Bama miniature pigs with or without FMTS. The circumcision and dissection per unit time (cm2/min), en bloc resection, perforation and bleeding rates, size and integrity of the specimen and submucosal injection times were analysed.

RESULTS

A total of 60 ESD procedures were performed with or without FMTS assistance. The en bloc resection rates were 100% at 10 and 15 cm from the anus in both the control group (conventional ESD) and the FMTS group. However, at 30 cm from the anus, these rates were only 10% and 70% (p = 0.006). The resection speeds (control vs. FMTS) at the 10, 15, and 30 cm points were 0.35 ± 0.07 cm2/min vs. 0.39 ± 0.19 cm2/min (p = 0.56), 0.30 ± 0.09 cm2/min vs. 0.38 ± 0.02 cm2/min (p = 0.04), and 0.11 cm2/min vs. 0.26 ± 0.10 cm2/min, respectively.

CONCLUSIONS

The FMTS provides effective counter-traction and efficiently reduces the risks and difficulties of difficult colonic ESD in the porcine model.

Endoscopic submucosal dissection for superficial gastric neoplasias in two referral hospitals in Brazil: Can the Japanese and South Korean results be equaled?

INTRODUCTION AND AIMS

Endoscopic submucosal dissection (ESD) in the treatment of superficial neoplasias of the gastrointestinal tract is currently one of the greatest advances in therapeutic endoscopy. Due to its high technical complexity, it is not yet a routine procedure in Latin America. The aim of the present study was to present the experience in Brazil with ESD in superficial gastric neoplasias, based on training received from Japanese experts.

MATERIALS AND METHODS

A retrospective study was conducted, in which information was prospectively collected from a database that included all patients that underwent ESD due to superficial gastric neoplasias at two endoscopy referral centers in Brazil, within the time frame of June 2008 to June 2019. En bloc, complete, and curative resection rates were calculated, along with the local recurrence rate and adverse events.

RESULTS

A total of 103 ESDs for superficial gastric neoplasias were performed during the study period. Eighty of those patients (77.6%) presented with early malignant gastric neoplasias or premalignant lesions (adenocarcinoma: 52.5%, high-grade dysplasia: 27.5%, low-grade dysplasia: 16.3%, and neuroendocrine tumors: 3.8%). Overall en bloc and complete resection rates for the superficial gastric neoplasias were 96.3% and 92.5%, respectively, whereas the curative resection rate based on expanded criteria was 76%.

CONCLUSIONS

ESD for the treatment of superficial gastric neoplasias is a safe and effective therapeutic modality in Latin America, with results similar to those shown in the most representative Japanese studies.

Predictive Role of Endoscopic Surveillance after Total Gastrectomy with R0 Resection for Gastric Cancer

BACKGROUND

Endoscopic surveillance after total gastrectomy (TG) for gastric cancer is routinely performed to detect tumor recurrence and postoperative adverse events. However, the reports on the clinical benefits of endoscopic surveillance are ambiguous. We investigated the clinical benefit of endoscopic surveillance after TG for gastric cancer.

METHODS

We analyzed 848 patients who underwent TG with R0 resection for gastric cancer between 2011 and 2012 (380 early gastric cancer and 468 advanced gastric cancer) and underwent regular postoperative surveillance with endoscopy and abdominopelvic computed tomography (CT) with contrast.

RESULTS

Median follow-up periods were 58 months for both endoscopy (range, 3-96) and abdominopelvic CT (range, 1-96). Tumor recurrence occurred in 167 patients (19.7%), of whom seven (4.2%) were locoregional recurrences in the peri-anastomotic area (n = 5) or regional gastric lymph nodes (n = 2). Whereas the peri-anastomotic recurrences were detected by both endoscopy and abdominopelvic CT, regional lymph node recurrences were only detected by abdominopelvic CT. Out of the 23 events of postoperative adverse events, the majority (87%) were detected by radiologic examinations; three events of benign strictures in the anastomotic site were detected only by endoscopy.

CONCLUSION

Endoscopic surveillance did not have a significant role in detecting locoregional tumor recurrence and postoperative adverse events after TG with R0 resection for gastric cancer. Routine endoscopic surveillance after TG may be considered optional and performed according to the capacities of each clinical setting.

Safety and efficacy of endoscopic submucosal dissection for metachronous early cancer or precancerous lesions emerging at the anastomotic site after curative surgical resection of colorectal cancer

Background

The incidence of metachronous early cancer or precancerous lesions (MECPL) emerging at the anastomotic site (AS) after curative surgical resection of colorectal cancer (CRC) is so low that few study have been conducted to explore the clinical characteristics, diagnosis and treatment of these lesions. Endoscopic submucosal dissection (ESD) is technically difficult for these lesions because of the presence of severe fibrosis and AS. The aim of this study was to explore the safety and efficacy of ESD for MECPL emerging at the AS after curative surgical resection of CRC.

Methods

The data used in the analysis were retrospectively collected from CICAMS in Beijing China between January 2013 and May 2019 and from all the patients who underwent ESD for MECPL emerging at the AS after curative surgical resection of CRC. The rates of en bloc resection (ER), complete resection (CR), curative resection (CuR) and incidence of complications were analyzed by SPSS software.

Results

A total of 11 patients were included. The rates of ER, CR and CuR were 63.6%, 54.5% and 54.5%, respectively. No additional surgery was performed, and no recurrences were found. Bleeding occurred in only one case and there was no perforation after the operation.

Conclusions

Overall, ESD is safe and effective in the treatment of MECPL emerging at the AS after curative surgical resection of CRC. Especially for patients with anastomotic recurrence close to anal margin, this method can avoid the risks of reoperation and improve the rate of anal preservation.

Current controversies in treating remnant gastric cancer: Are minimally invasive approaches feasible?

The incidence of remnant gastric cancer (RGC) is still increasing. Minimally invasive approaches including endoscopic resection, laparoscopic and robotic approaches, and function-preserving gastrectomy have been utilized as curative treatment methods for primary gastric cancer. However, adhesions and anatomical alterations due to previous gastrectomy make the use of minimally invasive approaches complicated and difficult for RGC. Application of these approaches for the treatment of RGC is still controversial. Endoscopic submucosal dissection is a favorable alternative therapy for the resection of early gastric cancer that occurs in the remnant stomach and can prevent unnecessary complications. The majority of retrospective studies have shown that endoscopic submucosal dissection is an effective and oncologically safe treatment modality for RGC. Subtotal gastrectomy could serve as a function-preserving gastrectomy for patients with early RGC and improve postoperative late-phase function. However, there are only two studies that demonstrate the feasibility and oncological efficacy of subtotal gastrectomy for RGC. The non-randomized controlled trials showed that compared to open gastrectomy, laparoscopic gastrectomy for RGC led to better short-term outcomes and similar oncologic results. Because of the rarity of RGC, future multicenter studies are required to determine the indications of minimally invasive treatment for RGC.