Endoscopic submucosal dissection for residual early gastric cancer after endoscopic submucosal dissection

Outcomes of repeated endoscopic submucosal dissection for superficial Esophageal squamous cell carcinoma on endoscopic resection scar

BACKGROUND

Endoscopic submucosal dissection (ESD) can be performed for superficial esophageal cancer. However, performing ESD for superficial esophageal cancer on a previous endoscopic resection scar may be difficult.

METHODS

We compared the outcomes between ESD for superficial esophageal cancers on previous endoscopic resection scar (group A) and that for naïve lesions (group B). The study included outcomes of ESD, cumulative incidence of local failure, and predictors of the occurrence of local failure in ESD patients with squamous cell carcinoma (SCC). The outcome variables evaluated were en bloc resection rates, procedure times, adverse events, and overall survival rates.

RESULTS

Overall, 220 lesions were extracted (groups A and B: 23 and 197 lesions, respectively). In groups A and B, the complete resection rates were 60.9 and 92.9% (P < 0.001), and the mean procedure times were 79 and 68 min (P = 0.15), respectively. The perforation rates in groups A and B were 4.3 and 1% (P = 0.28). The 1-year cumulative local failure rates were 22 and 1% (P < 0.001), respectively. In the multivariate Cox proportional hazards analysis, superficial esophageal SCC on a previous endoscopic resection scar was a strong predictor of local failure (hazard ratio = 21.95 [3.99-120.80], P < 0.001). The 3-year overall survival rates in groups A and B were 95 and 93% (P = 0.99), respectively.

CONCLUSIONS

Repeated ESD on scar is an option for treating superficial esophageal SCC with an acceptable rate of adverse events. Because of the low complete resection rate and high local failure compared with conventional ESD, strict endoscopic follow-up is required after repeated esophageal ESD.

Indications for Dental Floss Clip Traction During Gastric Endoscopic Submucosal Dissection by Less-Experienced Endoscopists

PURPOSE

Dental floss clip (DFC) traction-assisted endoscopic submucosal dissection (ESD) is widely performed owing to its simplicity. This study aimed to clarify the appropriate indications for the DFC traction method in early gastric cancer when ESD is performed by less-experienced endoscopists.

METHODS AND METHODS

We retrospectively analyzed 1,014 consecutive patients who had undergone gastric ESD performed by less-experienced endoscopists between January 2015 and December 2020. Gastric ESD was performed without DFC in all cases before December 2017 [DFC (-) group, 376 cases], and ESD was performed with DFC in all cases after January 2018 [DFC (+) group, 436 cases]. The procedure time and rates of en bloc resection, complete resection, and adverse events of the groups were compared.

RESULTS

The procedure time did not differ significantly between the 2 groups. However, when comparing lesions >20 mm, the procedure time in the DFC (+) group was significantly shorter than that in the DFC (-) group (95±46 vs. 75±31, P<0.01). The procedure time for lesions located in the greater curvature of the upper or middle stomach and lesions >20 mm located in the lesser curvature side of the stomach in the DFC (+) group was significantly shorter than that in the DFC (-) group.

CONCLUSIONS

The indications for DFC during gastric ESD by less-experienced endoscopists include lesions located in the greater curvature of the upper or middle stomach, and lesions >20 mm located in the lesser curvature of the stomach.

Magnetic ring-assisted endoscopic submucosal dissection for gastric lesions with submucosal fibrosis: A preliminary study in beagle model

BACKGROUND

During endoscopic submucosal dissection (ESD) for gastric lesions with fibrosis, appropriate traction could provide clear submucosal dissection visualization to improve safety and efficiency of procedures. Therefore, the aim of this study was to evaluate the feasibility of magnetic ring-assisted ESD (MRA-ESD) for gastric fibrotic lesions.

METHOD

In the eight healthy beagles, 2-3 mL of 50% glucose solution was injected into submucosal layer of the stomach to induce gastric fibrotic lesions. A week after submucosal injection, two endoscopists at different levels performed MRA-ESD or standard ESD (S-ESD) for gastric simulated lesions, respectively. The magnetic traction system consisted of external handheld magnet and internal magnetic ring. The feasibility and procedure outcomes of the magnetic traction system were mainly evaluated.

RESULTS

Forty-eight gastric simulated lesions with ulceration were confirmed to have submucosal fibrosis formation by preoperative endoscopic ultrasonography. The magnetic traction system could be easily established, only took 1.57 min, and allowed excellent submucosal visualization. The total procedure time was significantly shorter in the MRA-ESD group than in the S-ESD group for both endoscopists (mean: 46.83 vs. 25.09 min, p < 0.001), and this difference was accentuated in non-skilled endoscopist. There was significant difference between two groups in bleeding and perforation rates. Histological analysis showed the depth of resected specimens was a little deeper around the fibrotic portion in the S-ESD group (p < 0.001).

CONCLUSION

The magnetic ring-assisted ESD technique may be an effective and safe treatment for gastric fibrotic lesions and may shorten the endoscopic learning curve for non-skilled endoscopists.

Efficacy of the specialized scissor-type knife for gastric endoscopic submucosal dissection: a propensity score matched retrospective study

Background and study aims  Prevention of bleeding and perforation during gastric endoscopic submucosal dissection (ESD) is important. Scissor-type knives can accurately grasp and incise the targeted tissue using electrosurgical currents, thereby eliminating unexpected incisions. The SB Knife GX, a scissor-type knife specialized for gastric ESD, was released in June 2016 in Japan. The aim of the present study was to evaluate the efficacy and safety of gastric ESD using the SB Knife GX. Patients and methods  A total of 716 patients who underwent gastric ESD at Hiroshima University Hospital between July 2016 and December 2020 were retrospectively reviewed. From these, 671 patients underwent ESD using the IT Knife 2 (IT-2 group), while 45 underwent ESD using an SB Knife GX (SB-GX group). After propensity score matching, the procedure time, specimen size, en bloc and complete resection rates, and intraoperative bleeding, delayed bleeding, and perforation rates were evaluated. Results  No significant differences were observed in mean procedure time (SB-GX group: 115 ± 165 min; IT-2 group: 95 ± 61 min; P  = 0.82) and en bloc and complete resection rates between the two groups. Intraoperative bleeding rates were significantly lower in the SB-GX group than in the IT-2 group (18 % vs. 40 %; P  = 0.01), and there were no differences in delayed bleeding (4 % vs. 4 %) or perforation (0 % vs. 4 %) between the two groups. Conclusions  The SB Knife GX was proven to be useful for control of intraoperative bleeding during gastric ESD, although the procedure time tended to be longer.

Outcomes of endoscopic submucosal dissection in patients who develop metachronous superficial esophageal squamous cell carcinoma close to a post-endoscopic submucosal dissection scar

BACKGROUND

The presence of post-endoscopic submucosal dissection (ESD) scars renders complete metachronous superficial esophageal squamous cell carcinoma resection difficult. We aimed to identify the risk factors for incomplete resection of metachronous esophageal squamous cell carcinoma close to the post-ESD scar by ESD.

METHODS

We enrolled patients who developed post-ESD superficial esophageal squamous cell carcinoma at Hiroshima University Hospital between January 2006 and March 2020. We analyzed the outcomes and risk factors of incomplete resection between patients whose lesions were close to (close-to group) and away from (away-from group) the post-ESD scar.

RESULTS

We included 111 patients with 212 lesions. The close-to group had a significantly lower complete resection rate (88.6% [62/70] vs. 98.6% [69/70], p = 0.033), longer procedure time (80.2 ± 47.2 min vs. 60.4 ± 29.3 min, p < 0.01), higher proportion of lesions with severe fibrosis (72.9% [51/70] vs. 5.7% [4/70], p < 0.01), and higher intraoperative bleeding rate (78.6% [55/70] vs. 60.0% [42/70], p = 0.027) than the away-from group. There was no significant difference in the rate of local recurrence, muscle injury, perforation, and stenosis as well as the pathological tumor depth between the groups. Of the 92 lesions in the close-to group, the proportion of lesions located on the oral side of the post-ESD scar significantly affected the incidence of incomplete resection (91.7% [11/12] vs. 53.8% [43/80], p = 0.013).

CONCLUSIONS

Complete resection was more difficult for lesions located on the oral side of the post-ESD scar.

Repeat endoscopic submucosal dissection as salvage treatment for local recurrence of esophageal squamous cell carcinoma after initial endoscopic submucosal dissection

BACKGROUND AND AIMS

Local recurrence of esophageal squamous cell carcinoma (ESCC) after endoscopic resection does not have an established treatment. The efficacy and safety of repeat endoscopic submucosal dissection (ESD) for recurrent ESCC were determined in the study.

METHODS

Forty-three consecutive patients with 45 locally recurrent superficial ESCC lesions undergoing repeat ESD and 909 first ESD lesions for propensity score matching (PSM) at Zhongshan Hospital between January 2011 and January 2020 were retrospectively enrolled. After PSM (1:2), operation-related parameters were compared between repeat ESD and first ESD. In the repeat ESD group, the Kaplan-Meier method and log-rank tests were used for identification of risk factors for local recurrence after repeat ESD.

RESULTS

As compared with propensity score-matched first ESD, rates of complete resection (86.7% vs 97.8%, P = .02) and curative resection (86.7% vs 96.7%, P = .06) were lower and procedure duration (54.8 ± 21.7 minutes vs 46.2 ± 20.6 minutes, P = .67) and hospital stay (4.3 ± 1.8 days vs 2.9 ± 1.4 days, P = .25) were longer in the repeat ESD group. The en-bloc resection rate (93.3% vs 98.8%, P > .11) remained comparable. Adverse events including bleeding (4.4% vs 0%, P = .11), perforation (.0% vs .0%, P > .99), and stricture (6.7% vs 2.2%, P = .33) presented with no difference. The 5-year overall survival rate and recurrence-free survival rate for repeat ESD was 100% and 86.0%, respectively. Multiplicity was significantly associated with recurrence after repeat ESD (P = .01).

CONCLUSIONS

Repeat esophageal ESD showed favorable short- and long-term outcomes and thus provides an alternative choice for recurrent superficial ESCC.

Long-term Outcomes of Additional Endoscopic Treatments for Patients with Positive Lateral Margins after Endoscopic Submucosal Dissection for Early Gastric Cancer

Background/Aims

It is uncertain whether additional endoscopic treatment may be chosen over surgery in patients with positive lateral margins (pLMs) as the only non-curative factor after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to compare the long-term outcomes of additional endoscopic treatments in such patients with those of surgery and elucidate the clinicopathological factors that could influence the treatment selection.

Methods

A total of 99 patients with 101 EGC lesions undergoing additional treatment after non-curative ESD with pLMs as the only non-curative factor were analyzed. Among them, 25 (27 lesions) underwent ESD, 29 (29 lesions) underwent argon plasma coagulation (APC), and 45 (45 lesions) underwent surgery. Clinicopathological characteristics and long-term outcomes were compared.

Results

Residual tumor was found in 73.6% of cases. The presence of multiple pLMs was associated with higher risk of residual tumor (p=0.046). During a median follow-up of 58.9 months, recurrent or residual lesions after additional ESD and APC were found in 4% (1/25) and 6.8% (2/29) of patients, respectively. However, all were completely cured with surgery or repeated ESD. There were no extragastric recurrences after additional endoscopic treatment. Lymph node metastasis was identified after additional surgery in one (2.2%) patient with an EGC showing histological heterogeneity.

Conclusions

Given the favorable long-term outcomes, additional ESD or APC may be an acceptable choice for patients with pLMs as the only non-curative factor after ESD for EGC. However, clincopathological characteristics such as multiple pLMs and histological heterogeneity should be considered in the treatment selection.

Repeated Endoscopic Submucosal Dissection for Esophageal Neoplasia Located Close to a Previous Endoscopic Submucosal Dissection Scar

INTRODUCTION:

Endoscopic submucosal dissection (ESD) could become a standard treatment for early stage esophageal neoplasia. Recurrence sometimes develops close to a previous ESD scar. These lesions are predictably difficult to treat with ESD because of severe fibrosis. We evaluated the clinical outcomes of ESD for esophageal neoplasia located close to a previous ESD scar.

METHODS:

This was a retrospective observational study in a single institution. A total of 549 consecutive patients with 927 esophageal lesions were treated with ESD. The primary outcomes were resectability and adverse events of esophageal neoplasia located close to previous ESD scars (ESD scar group) than in primary esophageal ESD (primary group). Furthermore, predictive factors of perforation were examined.

RESULTS:

A total of 545 primary and 29 ESD scars in consecutive patients were evaluated. En bloc and complete (R0) resection rates in the ESD scar group were lower than those in the primary group (79.3% vs 98.3%, P < 0.01 and 75.9% vs 93.4%, P < 0.01). Perforations occurred more frequently in the ESD scar group (10.3% vs 2.0%, P = 0.03). The ESD scar group was a predictive factor for perforation (odds ratio = 10.37, 95% confidence interval: 2.15–49.94, P = 0.004). There were similar results for inverse probability of treatment weighting methods (odds ratio = 6.78, 95% confidence interval: 1.40–32.98, P = 0.018).

DISCUSSION:

ESD for esophageal neoplasia located close to a previous ESD scar was difficult to completely resect and increased the likelihood of perforation but could be a treatment option.

Preceding endoscopic submucosal dissection in submucosal invasive gastric cancer patients does not impact clinical outcomes

Submucosal deep invasion of gastric cancer (T1b2; depth of submucosal invasion ≥ 500 μm) is a risk factor for lymph node metastasis and, thus, is one of the criteria for curative treatment. Our aim was to evaluate the specific influence of endoscopic submucosal dissection (ESD) on the prognosis of patients with T1b2 gastric cancer. This was a retrospective analysis of 248 consecutive patients, with 252 pT1b2 gastric cancer lesions, who underwent ESD prior to additional surgery (Group A, n = 101) or surgery only (Group B, n = 147). After propensity score-matching (for sex, age, tumor diameter and gross type), we compared pathological characteristics between the 2 groups and the prognosis over a follow-up period ≥ 60 months. Compared to Group B, patients in Group A were older, with a higher proportion of men. The proportion of depressed and undifferentiated type tumors was greater in Group B than A, with larger tumor size and depth of submucosal invasion as well. There was no incidence of local recurrence, but distant metastasis was identified in 5% of cases in Group A and 3% in Group B. After propensity score-matching, there were no difference in the 5-year overall survival rate between Group A and B (87.5% vs. 91.2%, respectively), nor in the 5-year disease-specific survival rate (96.3% vs. 96.4%, respectively). ESD prior to surgery for T1b2 gastric cancer did not adversely affect clinical outcomes after additional surgery.

Clinical significance of endoscopic ultrasonography in diagnosing invasion depth of early gastric cancer prior to endoscopic submucosal dissection

BACKGROUND AND AIM

Endoscopic ultrasonography is a reliable diagnostic modality for determining indications of endoscopic submucosal dissection for early gastric cancer. We aimed to clarify the clinical significance of endoscopic ultrasonography in the invasion depth diagnosis of early gastric cancer.

METHODS

We retrospectively assessed 1598 consecutive patients with 2001 early gastric cancers who underwent EUS before ESD or surgery between October 2010 and April 2019 at our institution. Lesions were classified according to endoscopic ultrasonography-determined invasion depth as EUS-M/SM1 (lesions confined to sonographic layers 1 and 2 or lesions with changes in sonographic layer 3; depth, < 1 mm) and EUS-SM2 (lesions with changes in sonographic layer 3; depth, ≥ 1 mm). We evaluated the invasion depth determination accuracy of endoscopic ultrasonography and analyzed the clinicopathological features of misdiagnosed early gastric cancer cases.

RESULTS

The invasion depth determination accuracy was as follows: EUS-M/SM1: pathological T1a/T1b1 early gastric cancer, 97%; EUS-SM2: pathological T1b2 early gastric cancer, 79%. The accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 95%, 98%, 69%, 97%, and 79%, respectively. In EUS-M/SM1 early gastric cancer, tumor size of ≥ 15 mm, presence of ulceration, and undifferentiated histological type were significantly associated with endoscopic ultrasonography accuracy. In EUS-SM2 early gastric cancer, tumor size of ≥ 30 mm was significantly associated with endoscopic ultrasonography accuracy.

CONCLUSIONS

Endoscopic ultrasonography is a useful modality in accurately determining the invasion depth of early gastric cancer before endoscopic submucosal dissection.

Comparison Between Redo Endoscopic Treatment and Surgery in Patients with Locally Recurrent Gastric Neoplasms

BACKGROUND

Treatment of locally recurrent gastric neoplasms after endoscopic resection remains challenging. We investigated the efficacy and safety of treatment options for recurrent gastric neoplasms localized to the scar of previous endoscopic submucosal dissection (ESD).

METHODS

The clinicopathological characteristics and treatment outcomes of patients who underwent endoscopic treatment or surgery for recurrent gastric neoplasms between June 2010 and May 2017 were retrospectively reviewed.

RESULTS

Of the 92 patients included, 74 underwent endoscopic treatment (51 redo ESD, 23 argon plasma coagulation [APC] ablation) and 18 underwent surgery. The redo ESD procedure time was significantly longer than that of the primary ESD (31.0 versus 22.0 min, p = 0.018). Overall, adverse events occurred in 11 patients (12.0%), with the incidence being significantly higher in the surgery group (27.8% versus 8.1% in the endoscopic treatment group, p = 0.036). Local recurrence-free survival rates were 81.1% for the endoscopic treatment group (86.3% and 69.6% for redo ESD and APC groups, respectively) and 100% for the surgery group (log rank p = 0.033). Logistic regression analysis showed that tumor size > 12.5 mm (odds ratio [OR] 5.14, 95% confidence interval [CI] 1.25-26.9, p = 0.032) and tumors located in the upper two-thirds of the stomach (OR 4.43, 95% CI 1.27-16.8, p = 0.023) were associated with non-curative resection after redo ESD.

CONCLUSIONS

Endoscopic treatment could be an effective and safe alternative to surgery for selected patients with gastric neoplasms recurring at the scar of previous ESD. Especially, patients having small lesions located in the distal part of the stomach could be a good candidate for redo ESD.

Taking Warfarin with Heparin Replacement and Direct Oral Anticoagulant Is a Risk Factor for Bleeding after Endoscopic Submucosal Dissection for Early Gastric Cancer

BACKGROUND

Although bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) remains problematic, especially in patients taking anticoagulants, there are differing views on the ideal and optimal management for these patients. This study investigated the risk of bleeding after ESD in patients taking anticoagulants.

METHODS

We enrolled 61 consecutive patients taking anticoagulants (anticoagulant group) and 968 patients taking no antithrombotic agents (non-antithrombotic group) treated with ESD for EGC between December 2010 and October 2016. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors.

RESULTS

Incidences of bleeding after ESD were significantly higher (14%; 11/76) in the anticoagulant group compared to the non-antithrombotic group (3%; 40/1,167). Moreover, bleeding after ESD was significantly more common in patients in the warfarin monotherapy group (14%; 5/37) and in the direct oral anticoagulant (DOAC) monotherapy group (22%; 4/18), compared to the non-antithrombotic group. Multivariate analysis revealed that dialysis, the use of anticoagulants, and an operation time ≥75 min were independent risk factors for bleeding after ESD.

CONCLUSIONS

Our data suggest that patients who take warfarin and receive heparin bridging, and those who take DOAC medication, are prone to bleeding after ESD for EGC.

Secondary endoscopic submucosal dissection for locally recurrent or incompletely resected gastric neoplasms

AIM

To investigate the feasibility and safety of secondary endoscopic submucosal dissection (ESD) for residual or locally recurrent gastric tumors.

METHODS

Between 2010 and 2017, 1623 consecutive patients underwent ESD for gastric neoplasms at a single tertiary referral center. Among these, 28 patients underwent secondary ESD for a residual or locally recurrent tumor. Our analysis compared clinicopathologic factors between primary ESD and secondary ESD groups.

RESULTS

The en bloc resection and curative rate of resection of secondary ESD were 92.9% and 89.3%, respectively. The average procedure time of secondary ESD was significantly longer than primary ESD (78.2 min vs 55.1 min, P = 0.004), and the adverse events rate was not significantly different but trended slightly higher in the secondary ESD group compared to the primary ESD group (10.7% vs 3.8%, P = 0.095). Patients who received secondary ESD had favorable outcomes without severe adverse events. During a mean follow-up period, no local recurrence occurred in patients who received secondary ESD.

CONCLUSION

Secondary ESD of residual or locally recurrent gastric tumors appears to be a feasible and curative treatment though it requires greater technical efficiency and longer procedure time.

The feasibility of colorectal endoscopic submucosal dissection for the treatment of residual or recurrent tumor localized in therapeutic scar tissue

BACKGROUND AND STUDY AIMS

 Endoscopic submucosal dissection (ESD) is used to treat superficial colorectal tumors. Previous studies have reported the efficacy of ESD for treating residual or local recurrent colorectal tumors. This study sought to evaluate the efficacy of ESD in treating these lesions and to assess factors that prevent successful ESD.

METHODS

 This retrospective study assessed 25 cases of residual or local recurrent lesions that were previously treated using EMR (18 lesions), TEM (5 lesions), ESD (1 lesion) or surgery (1 lesion), and 459 primary lesions treated using ESD between April 2008 and September 2015. Clinicopathological characteristics, treatment outcome and adverse events were compared between groups with or without scar tissue. Factors related to perforation and a prolonged treatment time, which indicate the likelihood of technical difficulties, were identified using multiple logistic regression analysis.

RESULTS

In residual or local recurrent lesions groups, patients experienced more perforations (32 % vs 4 %, P  < 0.001) and required a longer treatment time (117 min vs 61 min, P  < 0.001) compared with the primary lesions group. Both groups showed a similar curative resection rate. Emergency surgery was not needed in any case. Multiple logistic regression analysis indicated that tumor location and therapeutic scar tissue were high risk factors for perforation, and that large tumor size and therapeutic scar tissue were high risk factors for prolonged treatment time.

CONCLUSIONS

ESD for residual or local recurrent colorectal tumors is a technically challenging, but effective and minimally invasive treatment. When performed carefully with sufficient proficiency, it is a useful treatment option.

Management of early gastric cancer with positive horizontal or indeterminable margins after endoscopic submucosal dissection: multicenter survey

Background and study aims Positive horizontal margins in resected specimens are sometimes encountered after endoscopic submucosal dissection (ESD) for early gastric cancers, and appropriate treatment strategies for these cases are not established. The aim of this study was to evaluate current empirical treatments for patients with positive horizontal or indeterminable margins after ESD. Patients and methods We performed a multicenter survey and data from 14 hospitals were collected. The pooled proportions of positive horizontal or indeterminable margins and those of patients followed up without early intervention were calculated using a logistic-normal random-effects model. For calculating pooled estimates, subgroup analyses of high- and non-high-volume centers were conducted. Results A total of 11,796 ESD cases were enrolled and 229 patients (2 %) had positive horizontal or indeterminable margins. Ninety-eight cases were treated within 30 days of ESD and 131 cases were followed up without early treatments. Pooled estimates of positive margins in high- and non-high-volume centers were 1 % (95 % CI: 1 % - 2 %) and 2 % (95 % CI: 1 % - 4 %), respectively, and were not heterogeneous (P = 0.191). The proportion of patients followed up without early intervention ranged from 30 % to 100 %. The pooled estimate was 68 % (95 % CI: 50 % - 83 %). The pooled estimates of high- and non-high-volume centers were 65 % (95 % CI: 38 % - 85 %) and 72 % (95 % CI: 44 % - 89 %), respectively, and were not heterogeneous (P = 0.692). Conclusion There was insufficient consensus regarding treatment strategies used for early gastric cancer with positive horizontal or indeterminable margins after ESD. Further studies are required to establish a consensus.

Useful condition of chromoendoscopy with indigo carmine and acetic acid for identifying a demarcation line prior to endoscopic submucosal dissection for early gastric cancer

Background

Identifying a precise demarcation line (DL) is indispensable for pathological complete en bloc endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We evaluated the useful condition of chromoendoscopy with indigo carmine and acetic acid for marking dots around lesions before ESD for EGC.

Methods

We examined 98 consecutive patients with 109 intramucosal EGCs (mean diameter, 17.8 ± 12.4 mm; main histologic type, 96 intestinal and 13 diffuse) resected by en bloc ESD after chromoendoscopy with indigo carmine and acetic acid between December 2012 and February 2014. The DL was identified by this technique just before ESD (mean chromoendoscopy observation time, 71.6 s); subsequently, marking dots were placed around the EGC. EGCs were classified into two groups: useful for identifying the DL or useless. Clinicopathological characteristics and clinical outcomes were evaluated in each group.

Results

Forty-two of the 109 cases (38.5 %) were determined useful for chromoendoscopy with indigo carmine and acetic acid. Multivariate analysis with logistic regression showed that macroscopic type (protruded or flat elevated-type) and atrophic border (the oral side of tumor) were independently associated with the usefulness of chromoendoscopy using indigo carmine and acetic acid for identifying the DL of EGCs (P < 0.05). The histologically positive horizontal margin after ESD was 0 % (0/42) in useful cases, and 7.5 % (5/67) in useless cases.

Conclusions

Before ESD, chromoendoscopy with indigo carmine and acetic acid can be used for creating precise markings in protruded or flat elevated-type EGC or at the atrophic border on the oral side of EGCs.

Long-term prognosis after endoscopic submucosal dissection for early gastric cancer in super-elderly patients

BACKGROUND

No previous study has confirmed the safety of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the super-elderly patient population. The current study aimed to evaluate the validity of ESD for EGC in super-elderly patients aged ≥85 years with comorbidities.

METHODS

Our study group included 85 super-elderly patients (102 EGCs) who were diagnosed at Hiroshima University Hospital between April 2002 and October 2014. We evaluated the en bloc resection rates, R0 resection rates, complication rates, and prognosis in relation to the degree of comorbidities (group A-H, patients with high-risk comorbidities; group A-L, patients with low-risk comorbidities; group B, patients without comorbidities; and group C, patients followed without ESD).

RESULTS

The en bloc resection rates were 100, 96, and 100 % in groups A-H, A-L, and B, respectively. R0 resection rates were 94, 96, and 94 % in groups A-H, A-L, and B, respectively. There were no severe complications related to ESD. During the follow-up period, there was a significantly higher frequency of death in group A than in group B (p < 0.01), and there were no significant differences between groups A-H and A-L. However, there were no cases of death related to gastric cancer.

CONCLUSIONS

ESD was performed safely, and death related to gastric cancer was prevented in super-elderly patients with comorbidities, regardless of the degree of the disease. However, patients with comorbidities are at a high risk of poor prognosis.

Risk factors for local recurrence in patients with positive lateral resection margins after endoscopic submucosal dissection for early gastric cancer

BACKGROUND

With the widespread use of endoscopic submucosal dissection (ESD) in patients with early gastric cancer (EGC), the number of cases with incomplete resection due to positive lateral resection margins (LM+) is increasing. Local recurrence, which occurs frequently in LM+ cases, is an important issue. This study aimed to clarify the clinicopathological factors related to tumor recurrence in LM+ cases after ESD for EGC.

METHODS

From January 2005 to December 2012, a total of 1,083 patients with EGC underwent ESD at our hospital. Of these, cases with a pathological diagnosis of LM+ were included in this study. Patients with positive vertical resection margins, those who underwent surgical resection immediately or were followed up for less than 6 months after ESD, were excluded.

RESULTS

A total of 55 LM+ cases after ESD for EGC were enrolled. Incorrect delineation of a lesion that extended pathologically beyond the ESD marking dots was the main cause of LM+. Local recurrence was found in 20 (36.4 %) patients (median follow-up period, 23 months). Local recurrence rates related to LM+ length were as follows: 7/29 (24.1 %) in 2 mm, 6/16 (37.5 %) in 4 mm, 1/3 (33.3 %) in 6 mm, 4/5 (80 %) in 8 mm, and 2/2 (100 %) in ≥ 10 mm. In multivariate analysis, tumor size > 2 cm (OR 4.48, 95 % CI 1.18-16.99, p = 0.027), and LM+ length > 6 mm (OR 7.65, 95 % CI 1.15-50.70, p = 0.035) were independent risk factors for tumor recurrence.

CONCLUSION

To decrease the risk of LM+, it is highly important to accurately delineate the lateral margins during ESD; when the final histopathological result is LM+, cases with LM+ length >6 mm or tumor size > 2 cm should be considered for additional surgical resection or re-ESD because of a high risk of tumor recurrence.

Risk factors and management of positive horizontal margin in early gastric cancer resected by en bloc endoscopic submucosal dissection

BACKGROUND

Although endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), there is no consensus regarding the management of positive horizontal margin (HM) despite en bloc ESD. The aim of the current study was to identify the risk factors and optimal management of positive HM in EGCs resected by en bloc ESD.

METHODS

A total of 890 consecutive patients with 1,053 intramucosal EGCs resected by en bloc ESD between April 2005 and June 2011. Clinicopathological data were retrieved retrospectively to assess the positive HM rate, local recurrence rate, risk factors for positive HM, and outcomes of treatment for local recurrent tumor. Positive HM was defined as a margin with direct tumor invasion (type A), the presence of cancerous cells on either end of 2-mm-thick cut sections (type B), or an unclear tumor margin resulting from crush or burn damage (type C).

RESULTS

The positive HM rate was 2.0% (21/1,053). The local recurrence rate was 0.3% (3/1,053). All local recurrent tumors were intramucosal carcinomas, and were resected curatively by re-ESD. Multivariate analysis with logistic regression showed tumor location in the upper third of the stomach and lesions not matching the absolute indication to be independent risk factors for positive HM.

CONCLUSION

The risk factors for HM positivity in cases of EGC resected by en bloc ESD are tumor location in the upper third of the stomach and dissatisfaction of the absolute indication for curative ESD.

Clinical outcomes of early gastric cancer with lymphovascular invasion or positive vertical resection margin after endoscopic submucosal dissection

BACKGROUND

In early gastric cancer (EGC) cases with lymphovascular invasion or positive vertical margins after endoscopic submucosal dissection (ESD), additional radical gastrectomy is performed on principle. However, an additional surgery is often difficult to consider if the surgical approach itself is challenging or the patient refuses surgery. In such cases, only close surveillance is performed without additional surgical procedures. This study aimed to examine the difference in clinical prognosis of EGC cases with lymphovascular invasion or positive vertical margins after ESD either with or without surgery.

METHODS

We retrospectively studied 83 patients with lymphovascular invasion or positive vertical margins after ESD from July 2005 to November 2013.

RESULTS

Of the 83 patients, 45 (54.2%) underwent radical additional gastrectomy (surgical group) and 38 (45.8%) were under close surveillance without surgical or endoscopic treatments (close surveillance group.) The cancer-free survival period was 78.3 ± 3.4 months in the surgical group and 64.5 ± 4.6 months in the close surveillance group. The recurrence rates did not significantly differ between the 2 groups, at 7.9% in the surgical group and 6.7% in the non-surgical group.

CONCLUSIONS

Close surveillance may be suggested as an option for EGC patients for whom a surgical approach is difficult, who exhibit a positive vertical margin after ESD, and who have no lymphovascular or deep submucosa invasion after ESD.

Secondary endoscopic submucosal dissection for residual or recurrent tumors after gastric endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) is a widely accepted technique for the management of gastric tumors. However, residual or recurrent tumors can occur after ESD; currently, there is no adequate management strategy for these tumors. Thus, the aim of the present study was to establish a strategy of secondary ESD (sESD) for cases with positive lateral margins (LM+), which cause post-ESD residual or recurrent tumors.

METHODS

Fifty-three lesions that were subjected to ESD were diagnosed as LM+ with suspected local residual tumor. The short- and long-term outcomes of early sESD (performed shortly after the initial ESD in LM+ cases to prevent local recurrence) were retrospectively compared with those of late sESD (performed after the detection of recurrent tumors).

RESULTS

Of the 53 LM+ cases, the local residual positive rate was 38.5 % (10/26) in those undergoing early sESD or additional surgery and the local recurrence rate was 29.6 % (8/27) in those that were not treated. Thus, the overall incidence of residual or recurrent tumors in LM+ cases was 34.0 % (18/53). Both early and late sESD had favorable outcomes with no severe complications: 100 % of early sESD resections were curative, compared with 86.7 % of late sESD resections, over the course of a mean (±SD) observation period of 50.8 ± 16.7 months. The performance of early sESD was significantly greater than that of late sESD (in terms of dissection speed).

CONCLUSIONS

Early sESD is more reliable than late sESD as a therapeutic strategy for salvaging residual tumors and for preventing recurrence. However, if a tumor has already recurred, late sESD remains useful.

Characteristics of metachronous gastric tumors after endoscopic submucosal dissection for gastric intraepithelial neoplasms

Background. Recently, endoscopic submucosal dissection (ESD) has become a standard treatment method for early gastric cancer and concurrent stomach preservation. However, metachronous recurrences have become a major problem. We evaluated the incidence and clinicopathologic features of and examined the risk factors for metachronous gastric tumors. Methods. A total of 357 patients who underwent ESD for gastric tumors (245 early gastric cancers and 112 adenomas) and were followed up for more than 12 months without recurrence within the first 12 months were enrolled. We investigated the incidence and clinicopathologic features of metachronous tumors after ESD. We also analyzed the potential risk factors for metachronous tumors using the Kaplan-Meier method and Cox's proportional hazards model. Results. The annual incidence of metachronous tumors after ESD was 2.4%. The median period until discovery after initial ESD was 26.0 months, and the median observation period was 52.6 months. Male patients developed metachronous tumors more frequently (P = 0.04), and the hazard ratio of female to male patients was 0.36 (95% confidence interval: 0.11–0.89). Conclusions. Patients with a previous history of gastric tumors have a high risk of subsequent gastric tumor development and male patients should be carefully followed up after ESD for gastric tumor.

Continued use of low-dose aspirin does not increase the risk of bleeding during or after endoscopic submucosal dissection for early gastric cancer

BACKGROUND

Although recent guidelines for endoscopic submucosal dissection (ESD) as treatment for early gastric cancer (EGC) recommend noninterruption of low-dose aspirin (LDA) perioperatively, this strategy is controversial. It was our practice to interrupt LDA therapy 5-7 days before to ESD until December 2010, when we instituted the new guidelines and performed ESD without interrupting LDA therapy. Our purpose in this study was to confirm the validity of noninterrupted use of LDA in patients undergoing ESD for EGC.

METHODS

We studied 78 consecutive patients with 94 EGCs who were routinely taking LDA and were treated by ESD at Hiroshima University Hospital between April 2005 and June 2012. The patients were of two groups: those in whom LDA was interrupted perioperatively (53 patients with 66 EGCs) and those in whom LDA was continued perioperatively (25 patients with 28 EGCs).

RESULTS

The complete resection rate was 92.4 % (61/66) in the LDA-interrupted group and 100 % (28/28) in the LDA-continued group. Incidences of poor bleeding control during the procedure and bleeding after procedure were 10.6 % (7/66) and 4.8 % (3/66), respectively, in the LDA-interrupted group and 7.1 % (2/28) and 3.6 % (1/28) in the LDA-continued group. Two patients in the interrupted-LDA group suffered cerebrovascular infarction before ESD, and 2 patients in this group suffered acute myocardial infarction after ESD.

CONCLUSIONS

Our data suggest that continued use of LDA does not increase the risk of bleeding during or after ESD for EGC and does decrease the risk of ischemic events.

Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in patients with chronic kidney disease

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for early gastric cancer (EGC), and the number of ESD performed for EGC in patients with chronic kidney disease (CKD) is increasing. Although patients undergoing hemodialysis tend to bleed and are at high risk for cardiovascular disease, the effectiveness and safety of ESD for EGC in patients with CKD in particular have not been established. The aim of this study was to evaluate the effectiveness and potential adverse effects of ESD for EGC in patients with CKD undergoing hemodialysis.

METHODS

Sixty-three consecutive CKD patients in whom 79 EGCs were treated by ESD between October 2004 and January 2012; 15 of the 63 patients were hemodialysis patients. Complete en bloc resection rate and ESD-related complications in hemodialysis patients versus non-hemodialysis patients were evaluated.

RESULTS

The complete en bloc resection rate was 100% (15/15) in the hemodialysis patients and 87.5% (56/64) in the non-hemodialysis patients, respectively. The post-ESD bleeding rate was 33% (5/15) and 9% (6/64), respectively (P < 0.05). Perforation occurred only in non-hemodialysis patients; the incidence was 5% (3/64). Two ESD-related deaths occurred among hemodialysis patients (13%, 2/15); femoral artery infarction triggered post-ESD bleeding in one of these two patients, and alveolar hemorrhage occurred in the other.

CONCLUSION

Hemodialysis poses a risk of post-ESD bleeding. We must understand this risk and provide countermeasures for post-ESD bleeding in hemodialysis patients.