Clinical outcomes of endoscopic submucosal dissection for early gastric cancer in remnant stomach or gastric tube

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.

Long-Term Outcomes of Endoscopic Submucosal Dissection for Early Remnant Gastric Cancer: A Retrospective Multicenter Study

INTRODUCTION

Favorable long-term outcomes of endoscopic submucosal dissection (ESD) for early remnant gastric cancer (ERGC) have been reported in single-center studies from advanced institutions. However, no studies have examined the long-term outcomes using a multicenter database. This study aimed to investigate the long-term outcomes of the aforementioned approach using a large multicenter database.

METHODS

This retrospective multicenter cohort study included 242 cases with 256 lesions that underwent ESD for ERGC between April 2009 and March 2019 across 12 centers. We investigated the long-term outcomes of these patients with the Kaplan-Meier method, and the relationship between curability, additional treatment, or hospital category, and the survival time was evaluated using the log-rank test.

RESULTS

During the median follow-up period of 48.4 months, the 5-year overall survival rate was 81.3%, and the 5-year gastric cancer-specific survival rate was 98.1%. The survival time of patients of endoscopic curability (eCura) C-2 without additional surgery was significantly shorter than the corresponding of patients of eCura A/B/C-1 and eCura C-2 with additional surgery. There was no significant difference in either overall survival or gastric cancer-specific survival rate between the high-volume and non-high-volume hospitals.

CONCLUSION

The gastric cancer-specific survival of ESD for ERGC using a multicenter database was favorable. ESD for ERGC is widely applicable regardless of the hospital case volume. Management in accordance with the latest guidelines will lead to long-term survival.

Appraisal of gastric stump carcinoma and current state of affairs

Gastric stump carcinoma, also known as remnant gastric carcinoma, is a malignancy arising in the remnant stomach following gastrectomy for a benign or malignant condition. Enterogastric reflux and preexisting risk factors in a patient with gastric cancer are the major contributors to the development of gastric stump carcinoma. The occurrence of gastric stump carcinoma is time-dependent and seen earlier in patients operated on for malignant rather than benign diseases. The tumor location is predominantly at the anastomotic site towards the stomach. However, it can occur anywhere in the remnant stomach. The pattern of lymph node involvement and the type of surgery required is distinctly different compared to primary gastric cancer. Gastric stump carcinoma is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. Recent advances in molecular profiling of gastric stump carcinoma have identified distinct molecular subtypes, thereby providing novel therapeutic targets. Also, reports of gastric stump carcinoma following pancreatoduodenectomy and bariatric surgery highlight the need for more research to standardize the diagnosis, staging, and treatment of these tumors. The present review aims to provide an overview of gastric stump carcinoma highlighting the differences in clinicopathological profile and management compared to primary gastric carcinoma.

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.

Endoscopic submucosal dissection for anastomotic lesions after colorectal surgery

BACKGROUND

Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging. We aimed to characterize the clinicopathologic characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the lower gastrointestinal tract.

METHOD

We retrospectively investigated 55 patients with anastomotic lesions of the lower gastrointestinal tract who underwent ESD from February 2008 to January 2021. The lesions involving one or both sides of anastomoses were classified into the unilaterally involving anastomosis (UIA) or straddling anastomosis (SA) group, respectively. We collected clinicopathological characteristics, procedure-related parameters and outcomes, and follow-up data and analyzed the impact of anastomotic involvement.

RESULTS

The mean age was 62.5 years, and the median procedure duration was 30 min. The rates of en bloc resection and R0 resection were 90.9% and 85.5%, respectively. Four patients (7.3%) experienced major adverse events (AEs). During a median follow-up of 66 months (range 14-169), seven patients had local recurrence, and six patients had metastases. The 5-year disease-free survival and overall survival rates were 82.4% and 90.7%, respectively. The 5-year disease -specific survival (DSS) rate was 93.3%. Compared with the UIA group, the SA group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and R0 resection, and shorter disease-free survival (all P < 0.05). However, rates of AEs did not differ significantly between the two groups.

CONCLUSIONS

The short-term and long-term outcomes of ESD for colorectal anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for lesions at the anastomoses.

Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos)

BACKGROUND

The impact of traction direction in traction-assisted gastric endoscopic submucosal dissection (ESD) has not been adequately investigated. A clip with line (CWL) is a classical single-directional traction device. In contrast, a spring and loop with clip (SLC; S-O clip) is a newly developed multidirectional traction device.

AIMS

To investigate the impact of traction direction in gastric ESD by comparing the procedure-related outcomes of CWL-assisted ESD (CWL-ESD) and SLC-assisted ESD (SLC-ESD).

METHODS

We retrospectively examined 140 patients with superficial gastric neoplasms who underwent SLC-ESD or CWL-ESD by a single ESD expert during November 2017-September 2020. The traction direction was classified based on the endoscopic finding in the following five categories: proximal, diagonally proximal, vertical, diagonally distal, and distal. In SLC-ESD, we set vertical traction, using the multidirectional traction function. Propensity score matching was conducted to compensate for the differences in lesion size, injection function of electrosurgical knife, ulcerative lesion, lesion location, and lesion position. The primary outcome was gastric ESD procedure time.

RESULTS

Propensity score matching created 42 pairs. The median gastric ESD procedure time in the SLC-ESD group was significantly shorter than that in the CWL-ESD group (28.3 min vs. 51.0 min, P = 0.022). All traction direction in the SLC-ESD group was vertical, while only 16.7% in the CWL-ESD group. En bloc resection was attained without perforation in all the patients in both groups.

CONCLUSION

Our findings suggest that SLC can provide vertical traction, which reduces the gastric ESD procedure time. Multidirectional traction devices can provide vertical traction in most cases of gastric ESD, unlike single-directional traction devices. Vertical traction may reduce the gastric ESD procedure time.

Endoscopic submucosal dissection for lesions involving the anastomosis after upper gastrointestinal surgery

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging due to severe fibrosis, deformity, staples, and limited space for procedure. We aimed to characterize the clinicopathological characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the upper gastrointestinal tract.

METHODS

We retrospectively investigated 43 patients with lesions involving the anastomoses of the upper GI tract who underwent ESD from April 2007 to February 2021. We collected clinicopathological characteristics, procedure‑related parameters and outcomes, and follow‑up data and analyzed the impact of anastomotic involvement.

RESULTS

The median duration from previous upper GI surgery was 60 months and the median procedure duration was 30 min. The rate of en bloc resection and en bloc with R0 resection was 90.7% and 81.4%, respectively. Two patients (4.7%) experienced major adverse events, including delayed bleeding and febrile episode. During a median follow-up of 80 months, 3 patients had local recurrence and 4 patients had metastases. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 89.6% and 95.1%, respectively. Compared with the unilaterally involving group, the straddling anastomosis group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and en bloc with R0 resection, and shorter DFS and OS (all P < 0.05). However, rates of adverse events did not differ significantly between the two groups.

CONCLUSIONS

The short‑ and long-term outcomes of ESD for upper GI anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for anastomotic lesions.

Feasibility, efficacy, and cautionary note of endoscopic resection for gastric tube cancer after esophagectomy

BACKGROUND

Gastric tube cancer (GTC), whose usual histology is adenocarcinoma, occurs frequently as a result of improved survival after esophagectomy. Whether endoscopic resection (ER) for GTC is safe and suitable and guidelines for treatment and follow-up remains unclear.

METHODS

Patients with GTC who underwent ER at Kanagawa Cancer Center Hospital between 1997 and 2020 were studied retrospectively to evaluate clinical characteristics and short- and long-term outcomes.

RESULTS

Twenty-two consecutive patients with 43 lesions were treated in 42 sessions of ER. Lesions were discovered at a median of 9.0 (0-21.8) years after esophageal surgery. Nine (40.9%) patients had multiple lesions at the time of the initial ER session. However, six (54.5%) of the 11 co-existing lesions were overlooked. The location of the middle third was an estimated risk factor for overlooking (p = 0.028). In endoscopic submucosal dissection (ESD) cases, the en bloc dissection rate was as high as 97.1%, and the rates of bleeding, perforation, and aspiration pneumonitis were 17.6%, 0%, and 2.9%, respectively. The bleeding rate was relatively higher than that in usual gastric ESD. Twelve patients (54.5%) experienced synchronous and/or metachronous multiple GTCs during their life span. Thirteen (61.9%) patients died during the median follow-up period of 5.9 (0.7-15.5) years. One patient (7.7%) died of GTC recurrence, 15.4 years after the initial non-curative ER date; 3 (23.1%) patients died of esophageal cancer recurrence, and 3 (23.1%) died of other organ malignancies. The 5-year overall survival rate was 85.0%, and the 5-year disease-specific survival rate was 100%.

CONCLUSIONS

ER is feasible for GTCs. However, the rate of bleeding was high in ESD cases. Life-long endoscopic screening of metachronous lesions is desirable. Care should be taken not to overlook lesions in the middle third of the gastric tube. Early detection of esophageal cancer recurrence and other organ malignancies may improve prognosis.

Endoscopic Submucosal Dissection in Patients with Early Gastric Cancer in the Remnant Stomach

Endoscopic submucosal dissection (ESD) in patients with early gastric cancers (EGCs) in the remnant stomach is technically difficult, owing to the limited space and fibrosis under the suture lines and anastomoses. Conversely, ESD for patients with EGCs in the remnant stomach is less invasive and provides better quality of life than completion total gastrectomy. To clarify the effectiveness and safety of ESD, we reviewed the medical records of patients with EGCs in the remnant stomach who underwent ESD between July 2006 and October 2020 at our institution. All identified patients were included in the analysis. Of 25 patients with 27 lesions, the en bloc and R0 resection rates were 88.9% and 85.2%, respectively. Neither perforation nor postoperative bleeding was observed. During a median follow-up period of 48 (range, 5–162) months, the 5-year overall survival rate was 71.0%, whereas the 5-year cause-specific survival rate was 100%. No obvious differences in the outcomes of procedures with suture line involvement and without suture line or anastomosis involvement were noted. In conclusion, ESD was effective and safe in patients with EGCs in the remnant stomach despite the suture line involvement.

Comparison of Endoscopic Submucosal Dissection and Radical Surgery for Early Gastric Cancer in Remnant Stomach

(1) Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the remnant stomach or gastric tube is not yet widespread and few studies have compared the short-term and long-term outcomes with radical surgery. (2) Methods: A total of 73 consecutive patients with EGC in the remnant stomach or gastric tube who underwent ESD or radical surgery between October 2009 and October 2020 were retrospectively analyzed in this study. Baseline characteristics, post-operative complications, quality of life (QOL), recurrence rate, overall survival (OS) and disease-free survival (DFS) were compared between the ESD and surgery groups. (3) Results: Among the 73 patients with EGC in the remnant stomach or gastric tube, 48 (65.8%) underwent ESD and 25 (34.2%) underwent surgery. The operation time (p = 0.000) and post-operative hospital stay (p = 0.002) of the ESD group were significantly shorter than those in the surgery group. The incidence of post-operative complications in the ESD group was significantly lower than that in surgery group (p = 0.001). The ESD group had significantly better functional scale scores and lower rates of fatigue, pain, appetite loss, financial difficulties, dysphagia, eating restrictions, hair loss, and poor body image than the surgery group. There was no significant difference in OS or DFS between the ESD and surgery groups (p = 0.124 and 0.344, respectively). (4) Conclusion: ESD can significantly shorten the operation time and hospital stay, reduce surgical complications, and provide better QOL for patients with EGC in the remnant stomach or gastric tube, and its long-term prognosis is no shorter than that of radical surgery.

The impact of sarcopenia on adverse events associated with gastric endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) is one of the main methods of treatments for early gastric cancer. Sarcopenia is a known risk factor for postoperative adverse events; however, the effect of sarcopenia on gastric ESD is unclear. We investigated the impact of sarcopenia on short-term prognosis after gastric ESD.

METHODS

This was a retrospective cohort study. We reviewed 832 patients who underwent gastric ESD between January 2015 and December 2019 and classified them into two groups: sarcopenia and non-sarcopenia groups. The curative resection rate, adverse events, and lengths of hospital stay were evaluated. We also evaluated risk factors associated with adverse events.

RESULTS

700 patients were analyzed (239 in the sarcopenia group and 461 in the non-sarcopenia group). The curative resection rates were similar in both groups. Common Terminology Criteria for Adverse Events (CTCAE) grade ≥ 2 (17% vs. 10%) were significantly more common, and the length of hospital stay was longer (8 vs. 7 days) in the sarcopenia group. Univariate analysis identified age ≥ 75 years, antithrombotic medication, history of gastric surgery, submucosal (SM) invasion, and sarcopenia as risk factors for CTCAE grade ≥ 2. Multivariate analysis showed that sarcopenia [odds ratio (OR) 1.79, 95% confidence interval (CI) 1.11-2.89, p = 0.016], history of gastric surgery (OR 9.32, 95% CI 1.97-44.05, p = 0.005), and SM invasion (OR 2.14, 95% CI 1.24-3.70, p = 0.006) were significant independent risk factors.

CONCLUSIONS

Sarcopenia significantly affected short-term prognosis and is a novel risk factor for gastric ESD.

Influence of hospital volume on bleeding after endoscopic submucosal dissection for early gastric cancer in Japan: a multicenter propensity score-matched analysis

BACKGROUND

Information on whether there is a relationship between hospital volume and bleeding after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is limited. This study aimed to compare the bleeding rates after ESD for EGC according to the hospital volume.

METHODS

Patients who underwent ESD for EGC at 33 institutions in Japan between November 2013 and October 2016 were included in this multicenter retrospective study. Hospital volume was categorized into three groups, based on the average annual number of ESD procedures: low- and medium-volume group (LMVG), high-volume group (HVG), and very high-volume group (VHVG). The bleeding rate after ESD for EGC was compared between the three hospital volume groups after propensity score matching.

RESULTS

A total of 10,320 patients, including 2797 patients in the LMVG, 4646 patients in the HVG, and 2877 patients in the VHVG, were identified. Propensity score matching yielded 2002 patients in each hospital volume group, with an improved balance of confounding variables between the three groups. The bleeding rates in the LMVG, HVG, and VHVG were 4.3%, 3.7%, and 4.9%, respectively, and no significant difference was noted between the three groups.

CONCLUSIONS

The bleeding rate after ESD for EGC did not differ between hospitals in Japan. The finding indicated that ESD for EGC is equally feasible across Japanese hospitals of different volumes regarding bleeding after ESD.

Clinicopathological Features of Remnant Gastric Cancer After Gastrectomy

BACKGROUND

Remnant gastric cancer (RGC) encompasses all cancers arising from the remnant stomach. Various studies have reported on RGC and its prognosis, but no consensus on its surgical treatment and postoperative management has been reached. Moreover, the correlation between the clinicopathological characteristics and long-term outcomes of RGC remains unclear. This study investigated the clinicopathological factors associated with the long-term survival of RGC patients.

METHODS

The medical records (March 1993-September 2020) of 104 RGC patients from Tokyo Medical University Hospital database were analyzed. Of these 104 patients, the medical records of 63 patients who underwent surgical curative resection were analyzed using R. Kaplan-Meier plots of cumulative incidence of RGC were made. Differences in survival rates were compared using the log-rank test. Prognostic factors were analyzed using multivariate Cox regression analysis (P < .05).

RESULTS

Of the 104 RGC patients, 63 underwent total remnant stomach excision. The median time from the first surgery to the total excision was 10 years. The 5-year survival rate of the 63 RGC patients was .55 ((95% CI); .417-.671). The clinicopathological factors that were significantly associated with the long-term outcome of the RGC patients were tumor diameter (≥3.5 cm), presence or absence of combined resection of multiple organs, tumor invasion (deeper than T2), TNM stage, and postoperative morbidity. The multivariate Cox regression analysis showed that tumor invasion depth was the only independent prognostic factor for RGC patients [HR (95% CI): 5.49 (2.629-11.5), P ≤ .005].

CONCLUSIONS

Among prognostic factors, tumor invasion depth was the only independent factor affecting RGC's long-term outcome.

Usefulness of Magnifying Endoscopy with Narrow-Band Imaging for Diagnosing Mixed Poorly Differentiated Gastric Cancers

INTRODUCTION

Curative rates of endoscopic treatment for undifferentiated-type early gastric cancer (EGC), particularly mixed poorly differentiated adenocarcinoma (MIXED-POR), are lower than those of endoscopic treatment for the differentiated type. Magnifying endoscopy with narrow-band imaging (ME-NBI) is useful for diagnoses of the histological type. This study aimed to investigate the detection rates of MIXED-POR among undifferentiated-type EGCs using biopsy and ME-NBI in order to improve curative rates through endoscopic treatment.

METHODS

We analyzed 267 lesions initially subjected to endoscopic submucosal resection (ESD) and histologically diagnosed as undifferentiated-type EGCs between July 2005 and December 2016 at our hospital. We obtained written informed consent from all participants. Biopsy and ME-NBI findings were compared to distinguish pure signet ring cell carcinoma (PURE-SIG) and MIXED-POR. ME-NBI findings were divided into 2 categories depending on the presence of irregular vessels. Results of biopsy and ME-NBI (combination method) were also analyzed, and detection rates of MIXED-POR and PURE-SIG were evaluated in terms of sensitivity, specificity, and accuracy.

RESULTS

Overall, 114 lesions were analyzed. Fifty-eight lesions (50.9%) were identified as MIXED-POR. With biopsy, the detection rate of MIXED-POR was significantly lower than that of PURE-SIG (p < 0.0001). ME-NBI detected significantly more MIXED-POR with irregular vessels than PURE-SIG (p < 0.0001). The combination method could detect significantly more MIXED-POR than PURE-SIG (p < 0.0001). The sensitivity and accuracy for MIXED-POR diagnosis were significantly higher with the combination method than with biopsy alone (p < 0.0001).

DISCUSSION/CONCLUSION

Combining biopsy and ME-NBI improved the accuracy of pretreatment diagnosis before ESD in undifferentiated-type cancer.

Clinical Impact of Different Reconstruction Methods on Remnant Gastric Cancer at the Anastomotic Site after Distal Gastrectomy

Background/Aims

The anastomotic site after distal gastrectomy is the area most affected by duodenogastric reflux. Different reconstruction methods may affect the lesion characteristics and treatment outcomes of remnant gastric cancers at the anastomotic site. We retrospectively investigated the clinicopathologic and endoscopic submucosal dissection outcomes of remnant gastric cancers at the anastomotic site.

Methods

We recruited 34 consecutive patients who underwent endoscopic submucosal dissection for remnant gastric cancer at the anastomotic site after distal gastrectomy. Clinicopathology and treatment outcomes were compared between the Billroth II and non-Billroth II groups.

Results

The tumor size in the Billroth II group was significantly larger than that in the non-Billroth II group (22 vs. 19 mm; p=0.048). More severe gastritis was detected endoscopically in the Billroth II group (2 vs. 1.33; p=0.0075). Moreover, operation time was longer (238 vs. 121 min; p=0.004) and the frequency of bleeding episodes was higher (7.5 vs. 3.1; p=0.014) in the Billroth II group.

Conclusions

Compared to remnant gastric cancers in non-Billroth II patients, those in the Billroth II group had larger lesions with a background of severe remnant gastritis. Endoscopic submucosal dissection for remnant gastric cancers in Billroth II patients involved longer operative times and more frequent bleeding episodes than that in patients without Billroth II.

Internal traction method using a spring-and-loop with clip (S-O clip) allows countertraction in gastric endoscopic submucosal dissection

BACKGROUND

Insufficient countertraction and poor field of vision make endoscopic submucosal dissection (ESD) difficult. Internal traction method using a spring-and-loop with clip (SLC) allows sufficient traction in any direction and good field of vision. However, the attachment procedure is difficult and interference with the endoscope can occur in the retroflexed endoscopic position. We have developed a new use of SLC that simplifies the attachment procedure, eliminating interference with the endoscope. The aim of this study was to investigate the efficacy of SLC for gastric ESD.

METHODS

We retrospectively recruited 140 patients with gastric neoplasms who underwent ESD between November 2015 and October 2018 at our department. Among them, 51 patients treated using SLC-assisted ESD (SLC-ESD) and 89 patients treated using conventional ESD (C-ESD) were compared. Propensity score matching was performed to compensate for the differences in age, sex, lesion location, lesion position, specimen size, and ulcer findings. The primary outcome was ESD procedure time.

RESULTS

Propensity score matching generated 51 matched pairs. The procedure time in the SLC-ESD group was significantly shorter than that in the C-ESD group (median [interquartile], 40.0 [27.0-81.5] minutes versus 69.0 [46.5-113.5] minutes, P = 0.008). The mean SLC attachment time was 2.08 min. There were no significant differences in complete en bloc resection rate between SLC-ESD and C-ESD groups (100% versus 96.1%, P = 0.495). There were not perforation cases in either group.

CONCLUSIONS

SLC may offer an efficient method for gastric ESD, with a short attachment procedure time.

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.

Gastric endoscopic submucosal dissection: a systematic review and meta-analysis on risk factors for poor short-term outcomes

OBJECTIVE

Endoscopic submucosal dissection (ESD) is now established as the first option to manage early gastric neoplasms, but its efficacy may vary according to diverse factors. We aimed to systematically identify risk factors for poor short-term outcomes of gastric ESD with the purpose to improve patients' selection and management.

METHODS

Three online databases (MEDLINE, ISI Web of Knowledge and Scopus) were searched (last search on June 2018) for poor outcomes of gastric ESD (deep submucosal invasion, piecemeal/incomplete resection, noncurative resection and local recurrence).

RESULTS

One hundred five studies were included referring to 52.126 ESDs. Undifferentiated histology and upper location (vs lower) were associated with submucosal invasion [odds ratio (OR) = 2.42 [95% confidence interval (CI), 1.62-3.61] and OR = 3.20 (1.04-9.86), respectively] and deep submucosal invasion [OR = 2.98 (2.02-4.39) and OR = 2.35 (1.45-3.81), respectively]. Lesion size greater than 30 mm and ulceration were associated with piecemeal resection [OR = 2.78 (1.17-6.60) and OR = 2.76 (1.23, 6.20), respectively]. Lesion size greater than 30 mm, ulceration, upper location and fibrosis were risk factors for incomplete resection [OR = 3.83 (2.68-5.49), OR = 4.06 (1.62-10.16), OR = 3.71 (2.49-5.54) and OR = 4.46 (1.66-11.96), respectively]. A noncurative resection was more often observed for lesions located in the upper third of the stomach [OR = 1.49 (1.24-1.79)], depressed morphology [OR = 1.49 (1.04-2.12)] and those outside standard criteria [OR = 3.56 (2.31-5.48)]. Older age was significantly linked with local recurrence rates [OR = 3.08 (1.13-5.02)].

CONCLUSION

Several risk factors influence poor efficacy short-term outcomes of gastric ESD that may be used to inform both patients and health providers about the expected efficacy.

Short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the remnant stomach is a minimally invasive treatment. Few studies compared the technical difficulty of ESD involving the suture line and anastomosis, and information on long-term outcomes is insufficient. This study aimed to elucidate the short- and long-term outcomes of ESD for EGC in the remnant stomach.

METHODS

We investigated patients who underwent ESD for EGC in the remnant stomach between September 2002 and March 2016. Clinicopathological data were retrieved to assess en bloc resection rates, complications, and long-term outcomes including overall survival and cause-specific survival.

RESULTS

A total of 136 consecutive patients with 165 lesions resected by 157 ESD procedures were retrospectively evaluated. The en bloc resection rate was 95.5%. Complications included 16 intraoperative perforations (10.2%), 2 delayed perforations (1.3%), and 15 delayed bleeding (9.6%), which were successfully treated with endoscopy. The en bloc resection rate was significantly higher in the suture line group (100%) and the non-anastomosis or suture line group (98.8%) than in the anastomosis group (82.9%). However, the intraoperative perforation rate was significantly higher in the anastomosis group (31.4%) than in other groups. The 5-year overall and cause-specific survival rates were 88.4% and 97.6%, respectively, during a median follow-up period of 50.7 months (interquartile range 30.8-91.3).

CONCLUSIONS

The long-term outcomes of ESD for EGC in the remnant stomach were favorable. However, ESD involving the anastomosis was a technically demanding procedure due to the low en bloc resection rate and high perforation rate.

Clinical outcomes of endoscopic treatment for gastric epithelial neoplasm in remnant stomach after distal gastrectomy

BACKGROUNDS/AIM

We aimed to evaluate the feasibility of endoscopic treatment for gastric epithelial neoplasm in the remnant stomach after distal gastrectomy and compared the clinical outcomes by tumor location and endoscopic treatment modality.

METHODS

We reviewed the data of patients who underwent endoscopic treatment for gastric epithelial neoplasms in the remnant stomach after distal gastrectomy between January 1996 and August 2013. The treatments included endoscopic resection or argon plasma coagulation.

RESULTS

Herein, 107 patients (median age, 65.1 years; 92 men) encompassing 117 cases of gastric neoplasms in the remnant stomach after distal gastrectomy were endoscopically treated. Forty of these lesions were located at anastomotic sites; they were treated with endoscopic resection in 29 cases (72.5%) and argon plasma coagulation in 11 cases (27.5%). For 77 lesions located on the non-anastomotic site, endoscopic resection was performed in 68 cases (88.4%) and argon plasma coagulation was performed in nine cases (11.7%; p = 0.031). The mean endoscopic resection duration was significantly longer in the anastomotic site group than in the non-anastomotic site group (43.6 vs. 26.3 min, p = 0.018). Recurrence was observed in five (12.8%) patients in the former and in one (1.3%) in the latter (p = 0.015); all the patients were successfully retreated with endoscopic resection or APC.

CONCLUSIONS

Endoscopic treatment for gastric epithelial neoplasm in a remnant stomach after distal gastrectomy is effective and safe. However, closely monitoring for recurrence should be conducted, particularly when the tumor is located at the anastomotic site.

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

INTRODUCTION AND AIM

Endoscopic submucosal dissection (ESD) for early gastric cancer is highly effective and well established. Performing ESD in the surgically altered stomach (SAS) is challenging. The aim of this meta-analysis is to assess the safety and efficacy of ESD for patients with early neoplastic lesions occurring in the SAS with a subgroup analysis of lesions occurring on the suture line compared to non-suture line lesions and outcomes in the remnant stomach compared to the gastric tube.

METHODS

We performed a literature search of the PubMed, Embase, and CINAHL electronic databases from January 2000 to November 2017 for articles reporting the safety and efficacy of ESD in the surgically altered stomach. SAS was defined as the remnant stomach following gastrectomy and gastric tube following esophagectomy. Meta-analysis was performed using Review Manager version 5.3 software.

RESULTS

A total of 21 articles, with 903 lesions occurring in the remnant stomach or gastric tube, were included in this study. There was no significant difference between en bloc (RR 0.99, 95% CI 0.91-1.08), curative resection (RR 1.03, 95% CI 0.84-1.26), or bleeding rates (RR 1.40, 95% CI 0.18-10.72) between lesions in the remnant stomach and gastric tube. However, perforation was significantly higher in the gastric tube (RR 5.19, 95% 1.27-21.25). Suture line lesions had a significantly higher risk of perforation (RR 4.55, 95% CI 2.13-9.74).

CONCLUSION

ESD for early neoplastic lesions occurring in the SAS is a safe and efficacious with similar en bloc and curative resection rates compared to the anatomically normal stomach. ESD for lesions on the suture line or in the gastric tube is associated with an increased risk of perforation which can be managed endoscopically.

Clinical Outcomes and Adverse Events of Endoscopic Submucosal Dissection for Gastric Tube Cancer after Esophagectomy

Background and Aim

The clinical outcomes of endoscopic submucosal dissection (ESD) for gastric tube cancer (GTC) after esophagectomy remain unclear. The aim of this study was to evaluate the clinical outcomes and safety of ESD for GTC.

Patients and Methods

Twenty GTC lesions in 18 consecutive patients who underwent ESD between February 2008 and June 2018 were included in this retrospective study. The endpoints were the treatment outcomes of ESD (i.e., en bloc resection rate, complete en bloc resection rate, and curative resection rate), the adverse events following ESD, and the long-term outcomes.

Results

The en bloc resection rate was 100%, while the complete en bloc resection rate and curative resection rate were 80% each. Adverse events were observed in 16.7% (3/18) of patients: one postoperative bleeding, 1 intraoperative perforation that required emergency surgery, and 1 pyothorax that required chest drainage. The 1-, 3-, and 5-year overall survival rates were 100%, 70.9%, and 70.9%, respectively. Although local recurrence was detected in 1 case of noncurative resection, no GTC- or ESD-related deaths were observed.

Conclusion

ESD for GTC was feasible and acceptable to enable en bloc resection and to prevent cancer death. However, ESD for GTC should be performed more carefully than common gastric ESD because serious adverse events specific to the gastric tube may occur.

Poor expression of microRNA-135b results in the inhibition of cisplatin resistance and proliferation and induces the apoptosis of gastric cancer cells through MST1-mediated MAPK signaling pathway

Gastric cancer (GC) has been classified as the fourth leading cause of cancer-related deaths worldwide. Due to their ability to suppress the expression of target genes, microRNAs (miRNAs) are listed as one of the key elements involved in the formation and development of tumors. This study was therefore conducted to investigate the effects of microRNA-135b (miR-135b) on cisplatin [ cis-diamminedichloroplatinum (CDDP)] resistance of GC cells through the MAPK signaling pathway by targeting mammalian ste20-like kinase 1 (MST1). A microarray-based gene expression analysis was performed to screen the GC-related differentially expressed genes. The 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide assay was performed to determine the sensitivity of GC cells to CDDP. The bioinformatics database and dual luciferase reporter gene assay were used to check whether MST1 was a direct target gene of miR-135b. GC cell lines were prepared with high CDDP resistance, after which they were cultured and transfected respectively, followed by the administration of transfected cells into nude mice and subsequent treatment with CDDP in an attempt to identify the underlying mechanisms and functions of miR-135b in relation to MST1 in GC progression. The results were highly indicative of the crucial role played by MST1 in the development of GC and the sensitivity of GC to CDDP. miR-135b was found to regulate MST1, which in turn had an impact on the development of GC. MKN28 was observed to be most sensitive to CDDP, whereas MKN45 presented with the poorest sensitivity to CDDP. Furthermore, the down-regulation of miR-135b resulted in inactivation of the MAPK signaling pathway; increased the expression of MST1 and Bax; and decreased expression of p-p38MAPK, p-ERK1/2, P-glycoprotein, p38MAPK, ERK1/2, multidrug resistance protein 1, multidrug resistance-associated protein 1, lung resistance-related protein, and Bcl-2, thus inhibiting CDDP resistance of GC cells. The down-regulation of miR-135b also restrained cell proliferation and induced the apoptosis rate of GC cells. In summary, the results of this study showed that the down-regulation of miR-135b induced apoptosis, and it inhibited proliferation and CDDP resistance of GC cells by inactivating the MAPK signaling pathway and increasing the expression of MST1.-Zhou, J., Chen, Q. Poor expression of microRNA-135b results in the inhibition of cisplatin resistance and proliferation and induces the apoptosis of gastric cancer cells through MST1-mediated MAPK signaling pathway.

Propensity score-matching analysis to compare clinical outcomes of endoscopic submucosal dissection for early gastric cancer in the postoperative and non-operative stomachs

Background

Endoscopic submucosal dissection (ESD) of the postoperative stomach (ESD-P) for early gastric cancer (EGC) is considered a technically difficult procedure. However, it is difficult to compare the outcomes of ESD-P and ESD of the non-operative stomach (ESD-N) because their baseline characteristics are different. Therefore, we aimed to compare the technical outcomes of ESD-P with those of ESD-N using a propensity score-matching analysis to compensate for the differences.

Methods

The chart records of 1046 patients with EGC who were treated with ESD between January 2004 and July 2016 at Kitakyushu Municipal Medical Center in Japan were reviewed in this retrospective study. Multivariate analyses and propensity score-matching were performed for age, sex, lesion location, lesion size, tumor invasion, tumor size, ulcer (scar), and operator skill. The primary outcome was procedure time. Secondary outcomes were percentages of en bloc, complete, and curative resections, and percentages of adverse events, which were evaluated between the two groups.

Results

Forty-one patients were in the ESD-P group and 1005 patients were in the ESD-N group. Propensity score-matching created 41 matched pairs. According to the adjusted comparisons, ESD-P required a significantly longer procedure time (85 min vs 51 min, p < 0.001). Other treatment outcomes showed an en bloc resection rate of 100% for both groups (p = 1) and complete resection rates of 95.1 and 97.6% (p = 1), curative resection rates of 90.2 and 90.2% (p = 1), perforation during ESD rates of 2.4 and 0% (p = 1), and postprocedure bleeding rates of 2.4 and 2.4% (p = 1) for the ESD-P and ESD-N groups, respectively. For the ESD-P group, lesions on the suture line or anastomotic site were significantly associated with longer procedure times (p = 0.038).

Conclusions

ESD-P was a more time-consuming procedure than ESD-N. However, ESD-P and ESD-N achieved high rates of curative resection with a low rate of adverse events for the treatment of EGC. ESD could be selected as the treatment for EGC even in the postoperative stomach provided that careful attention is given to lesions on the suture line or anastomotic site.

Efficacy of Endoscopic Management for Early Remnant Gastric Cancer: Is Completion Gastrectomy Truly Necessary in Cases with Marginally Noncurative Histopathologic Features?

BACKGROUND

For patients with early primary gastric cancer, endoscopic management has become a standard of care. However, its efficacy for early remnant gastric cancer (ERGC) remains controversial and an invasive surgical procedure remains the primary choice of treatment.

METHODS

A multi-institutional database of ERGC cases was retrospectively reviewed. Efficacy of endoscopic resection was analyzed by reviewing the clinicopathologic features of patients who underwent endoscopic resection and comparing the long-term outcomes with those of surgical resection.

RESULTS

Of the 121 patients who were histopathologically diagnosed with ERGC after distal gastrectomy, 80 underwent endoscopic resection and 41 underwent completion gastrectomy (Group S). According to the histopathological criteria, 55 of the 80 endoscopic resection cases were classified as "curative resection" (Group E1) and the remaining 25 were classified as "noncurative resection" (Group E2). Tumor recurrence was observed only in three patients (12%) in Group E2, and no tumor recurrence was confirmed in Group S and Group E1. Multivariate analyses confirmed that completion gastrectomy [hazard ratio (HR), 6.2; 95% confidence interval (CI), 1.5-26.3] was associated with poor survival compared with endoscopic resection, and lymphovascular infiltration (HR 9.5; 95% CI 2.5-36.7) was correlated with tumor recurrence. Histopathological positive resection margin, tumor size, or deeper tumor invasion were not correlated with tumor recurrence after endoscopic resection.

CONCLUSIONS

Endoscopic management might be an effective treatment option for ERGC with potential long-term survival advantage over the completion gastrectomy even in cases with histopathological features, suggesting noncurative resection.

Endoscopic Submucosal Dissection of Gastric Epithelial Neoplasms after Partial Gastrectomy: A Single-Center Experience

Aims

To investigate the feasibility and safety of endoscopic submucosal dissection (ESD) of gastric epithelial neoplasms in the remnant stomach (GEN-RS) after various types of partial gastrectomy.

Methods

This study included 29 patients (31 lesions) who underwent ESD for GEN-RS between March 2006 and August 2016. Clinicopathologic data were retrieved retrospectively to assess the therapeutic ESD outcomes, including en bloc and complete resection rates and procedure-related adverse events.

Results

The en bloc, complete, and curative resection rates were 90%, 77%, and 71%, respectively. The types of previous gastrectomy, tumor size, macroscopic type, and tumor histology were not associated with incomplete resection. Only tumors involving the suture lines from the prior partial gastrectomy were significantly associated with incomplete resection. The procedure-related bleeding and perforation rates were 6% and 3%, respectively; none of the adverse events required surgical intervention. During a median follow-up period of 25 months (range, 6–58 months), there was no recurrence in any case.

Conclusions

ESD is a safe and feasible treatment for GEN-RS regardless of the previous gastrectomy type. However, the complete resection rate decreases for lesions involving the suture lines.

Long-term Survival of Patients With Endoscopic Submucosal Dissection for Remnant Gastric Cancers

PURPOSE

The aim of this study was to compare the oncologic results of endoscopic submucosal dissection (ESD) for early gastric cancers (EGC) in remnant stomachs (RS) with results of ESD for EGC in normal stomachs (NS).

METHODS

From 2002 to 2013, ESD was performed for 583 EGC lesions. ESD of the RS was performed for 34 lesions.

RESULTS

Two patients with EGC in the NS and 1 patient with EGC in the RS died from these gastric cancers. In all patients, the ESD treatments were considered outside of indications according to the pathologic results. The 5-year cause-specific survival rate was 99.5% for EGC patients with NS and 96.2% for EGC patients with RS. The 5-year overall survival rates were 88.4% for patients with NS and 58.4% for patients with RS.

CONCLUSIONS

On the basis of the favorable long-term oncologic outcomes, ESD for EGC in the RS can be considered feasible in clinical practice.

Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis

BACKGROUND AND AIMS

Postprocedural bleeding (PPB) is the most common adverse event associated with endoscopic resection. Several studies have tried to identify risk factors for PPB after gastric EMR and endoscopic submucosal dissection (ESD), with controversial results. This systematic review and meta-analysis aimed to identify significant risk factors for PPB after gastric EMR and ESD.

METHODS

Three online databases were searched. Pooled odds ratio (OR) was computed for each risk factor using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I(2).

RESULTS

Seventy-four articles were included. Pooled PPB rate was 5.1% (95% confidence interval, 4.5%-5.7%), which did not vary according to different study designs. Male sex (OR, 1.25), cardiopathy (OR, 1.54), antithrombotic drugs (OR, 1.63), cirrhosis (OR, 1.76), chronic kidney disease (OR, 3.38), tumor size > 20 mm (OR, 2.70), resected specimen size > 30 mm (OR, 2.85), localization in the lesser curvature (OR, 1.74), flat/depressed morphology (OR, 1.43), carcinoma histology (OR, 1.46), and ulceration (OR, 1.64) were identified as significant risk factors for PPB, whereas age, hypertension, submucosal invasion, fibrosis, and localization (upper, middle, or lower third) were not. Procedure duration > 60 minutes (OR, 2.05) and the use of histamine-2 receptor antagonists instead of proton pump inhibitors (OR, 2.13) were the procedural factors associated with PPB, whereas endoscopist experience and preprocedural proton pump inhibitors were not. Second-look endoscopy was not associated with decreased PPB (OR, 1.34; 95% confidence interval, .85-2.12).

CONCLUSIONS

Risk factors for PPB were identified that can help to guide management after gastric ESD, namely adjusting further management. Second-look endoscopy is not associated with decreased PPB.

Current status in remnant gastric cancer after distal gastrectomy

Remnant gastric cancer (RGC) and gastric stump cancer after distal gastrectomy (DG) are recognized as the same clinical entity. In this review, the current knowledges as well as the non-settled issues of RGC are presented. Duodenogastric reflux and denervation of the gastric mucosa are considered as the two main factors responsible for the development of RGC after benign disease. On the other hand, some precancerous circumstances which already have existed at the time of initial surgery, such as atrophic gastritis and intestinal metaplasia, are the main factors associated with RGC after gastric cancer. Although eradication of Helicobacter pylori (H. pylori) in remnant stomach is promising, it is still uncertain whether it can reduce the risk of carcinogenesis. Periodic endoscopic surveillance after DG was reported useful in detecting RGC at an early stage, which offers a chance to undergo minimally invasive endoscopic treatment or laparoscopic surgery and leads to an improved prognosis in RGC patients. Future challenges may be expected to elucidate the benefit of eradication of H. pylori in the remnant stomach if it could reduce the risk for RGC, to build an optimal endoscopic surveillance strategy after DG by stratifying the risk for development of RGC, and to develop a specific staging system for RGC for the standardization of the treatment by prospecting the prognosis.

Endoscopic Submucosal Dissection for Early Gastric Neoplasia Occurring in the Remnant Stomach after Distal Gastrectomy

Background/Aims:

Endoscopic submucosal dissection (ESD) for tumors occurring in the remnant stomach is technically difficult to perform because of limited working space and severe fibrosis and staples present around the suture line. We aimed to elucidate the feasibility and clinical outcomes of performing ESD for tumors in the remnant stomach.

Methods:

Between December 2007 and January 2013, 18 patients underwent ESD for tumors (six adenomas and 12 differentiated-type early gastric cancers [EGCs]) occurring in the remnant stomach after distal gastrectomy. Clinicopathologic features and clinical outcomes after ESD were retrospectively analyzed.

Results:

Two-thirds of the lesions were located on the body, and half were located on the suture line. En bloc resection, R0 resection, and en bloc with R0 resection rates were 88.9%, 100%, and 88.9%, respectively. Curative resection rate for EGC was 91.7%. Perforation occurred in one patient (5.6%) and was successfully managed by endoscopic closure with metallic clips and conservative management. There was no significant bleeding after ESD. During a median follow-up of 47.5 months, no local, metachronous, or extragastric recurrence was seen for either EGC or adenoma lesions.

Conclusions:

ESD is a feasible and effective treatment modality and can be considered a primary intervention for early gastric neoplasia occurring in the remnant stomach.

Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos)

BACKGROUND AND AIMS

Although endoscopic submucosal dissection (ESD) is a significant advancement in therapeutic endoscopy, it is a complicated technique and requires considerable expertise. In this exploratory study, we evaluated the efficacy of a simple traction method that uses dental floss and a hemoclip (DFC) and was developed to overcome the technical difficulties of ESD.

METHODS

In total, 238 early gastric cancers treated by ESD between May 2012 and December 2014 at Tokyo Medical University were retrospectively reviewed. Lesions treated by conventional ESD (n = 185) and by ESD with DFC (ESD-DFC) (n = 53) were compared. Multivariable analyses and propensity score matching were used to compensate for the differences in age, sex, resected specimen size, lesion location, lesion position, presence of ulceration, and operator level. The procedure time, rate of en bloc and complete resection, and rates of adverse events were evaluated between the 2 groups.

RESULTS

Propensity score matching analysis created 43 matched pairs. Adjusted comparisons between ESD-DFC and conventional ESD showed similar treatment outcomes (en bloc resection rate: 97.7% vs 100%, P = .315; complete resection rate: 90.7% vs 95.3%, P = .397; perforation during ESD rate: 2.3% vs 2.3%, P = 1.000; post-ESD bleeding rate: 4.7% vs 4.7%, P = 1.000) but a significantly shorter procedure time for ESD-DFC (82.2 ± 79.5 minutes vs 118.2 ± 71.6 minutes, P = .002).

CONCLUSION

ESD-DFC facilitated rapid ESD with good visualization and traction while ensuring high curability and safety.

Clinical characteristics and management of gastric tube cancer with endoscopic submucosal dissection

AIM: To identify the characteristics of gastric tube cancer (GTC) and the complications associated with endoscopic submucosal dissection (ESD) for GTC.

METHODS: Between 2007 and 2012, 11 individuals with early gastric cancer in the reconstructed gastric tube after esophagectomy who underwent ESD in this hospital were studied. The characteristics of GTC were identified, and the complications of ESD for GTC were analyzed at three phases: preoperative, intraoperative, and postoperative.

RESULTS: A total of 11 consecutive patients with 11 GTCs were selected for this study. All cases underwent en bloc resections by ESD. The median procedure time was 142 min. The average GTC diameter was 26.1 mm, and the average size of the resected lesions was 45.5 mm. The histopathological diagnosis in all cases was a differentiated adenocarcinoma. In the preoperative phase, anastomotic strictures (5/11, 45%) and food residues (4/11, 36.4%) in the gastric tube were the main complications. In the intraoperative phase, bleeding was observed in 5 cases (45%). The postoperative complications observed were delayed bleeding in 2 cases (18.2%) and stenosis in one case (9.1%). The case with stenosis was successfully treated using endoscopic balloon dilatation.

CONCLUSION: Minor complications were frequently observed. However, all GTCs underwent en bloc resection with ESD without any serious complications. ESD is considered a useful treatment for GTC.

Efficacy and long-term outcome of pre-emptive endoscopic resection and surgery for multiple synchronous gastric cancers

BACKGROUND

In cases of synchronous gastric cancers (SGC) that include one for surgical indication and another for endoscopic resection (ER) in two different regions of the stomach, patients can avoid total gastrectomy and undergo subtotal gastrectomy following successful pre-emptive ER. The aim of this study was to evaluate the feasibility and efficacy of pre-emptive endoscopic resection and surgery (PRES) with curative intent for such SGCs.

METHODS

Between September 2002 and December 2012, 34 patients with SGCs (72 lesions) underwent PRES. Our institutional principals of PRES ensure the following: (1) treatment with curative intent, (2) multiple lesions indicated for ER and surgery, (3) evasion of TG following successful pre-emptive ER, (4) exclusion of type 4 and large type 3 (>80 mm) tumors, and (5) nonemergent cases such as hemorrhage, perforation, and obstruction. Clinicopathological characteristics and technical data were evaluated for all patients, and long-term outcomes were analyzed in patients who obtained curative ER and underwent subtotal gastrectomy.

RESULTS

Curative ER was obtained in 31 patients (91.1 %), and subtotal gastrectomy was performed a median of 44 days after ER. Final stages were as follows: stage I, 25 patients (80.6 %); stage II, four patients (12.9 %); stage III, one patient (3.2 %); and stage IV, one patient (3.2 %). The 5-year overall and cause-specific survival rates were 96.3 % (95 % confidence interval 89.4-100 %) and 100 %, respectively.

CONCLUSIONS

PRES was feasible and effective as the first treatment of choice for multiple SGCs. PRES enables minimally invasive surgery with promising oncological outcomes.

Efficacy of endoscopic submucosal dissection for cancer of the operated stomach

PURPOSE

Cancer can develop in the operated stomach after partial gastrectomy and in the reconstructed gastric tube after surgery for esophageal cancer. It is considered that endoscopic therapy is more safe and suitable for the early gastric cancer developed in such stomach than operation. We investigated the efficacy of endoscopic submucosal dissection (ESD) for cancer of the operated stomach.

METHODS

Subjects were 669 gastric cancer patients who underwent ESD: 22 patients (23 lesions) had surgically altered gastric anatomy, whereas 647 patients (727 lesions) had normal gastric anatomy. In the altered gastric anatomy group, 13 patients, 6 patients, and 3 patients had previously undergone distal gastrectomy, gastric tube reconstruction, and proximal gastrectomy, respectively. Rates of complete en bloc resection and curative resection were compared between the two groups. Influence of an anastomotic site and/or a suture line on ESD outcomes was examined in the altered gastric anatomy group.

RESULTS

The rate of complete en bloc resection by ESD was 82.6% (19/23 lesions) in the altered gastric anatomy group and 92.3% (671/727 lesions) in the normal gastric anatomy group. The rate of curative resection and incident rates of complications were not significantly different between the groups. In the altered gastric anatomy group, the rate of complete en bloc resection was significantly lower when a lesion had spread across an anastomotic site and/or a suture line (P = 0.0372). Furthermore, duration of ESD was significantly longer (P = 0.0276), and resection efficiency was significantly lower (13 mm(2)/min, P = 0.0283), when treating lesions with an anastomotic site and/or a suture line than when treating isolated lesions.

CONCLUSIONS

Outcome of ESD for cancer of the operated stomach compares with that in normal stomach anatomy. Anastomotic site/suture line within a lesion influenced the ESD procedure.

Efficacy of endoscopic submucosal dissection for cancer of the operated stomach

PURPOSE

Cancer can develop in the operated stomach after partial gastrectomy and in the reconstructed gastric tube after surgery for esophageal cancer. It is considered that endoscopic therapy is more safe and suitable for the early gastric cancer developed in such stomach than operation. We investigated the efficacy of endoscopic submucosal dissection (ESD) for cancer of the operated stomach.

METHODS

Subjects were 669 gastric cancer patients who underwent ESD: 22 patients (23 lesions) had surgically altered gastric anatomy, whereas 647 patients (727 lesions) had normal gastric anatomy. In the altered gastric anatomy group, 13 patients, 6 patients, and 3 patients had previously undergone distal gastrectomy, gastric tube reconstruction, and proximal gastrectomy, respectively. Rates of complete en bloc resection and curative resection were compared between the two groups. Influence of an anastomotic site and/or a suture line on ESD outcomes was examined in the altered gastric anatomy group.

RESULTS

The rate of complete en bloc resection by ESD was 82.6% (19/23 lesions) in the altered gastric anatomy group and 92.3% (671/727 lesions) in the normal gastric anatomy group. The rate of curative resection and incident rates of complications were not significantly different between the groups. In the altered gastric anatomy group, the rate of complete en bloc resection was significantly lower when a lesion had spread across an anastomotic site and/or a suture line (P = 0.0372). Furthermore, duration of ESD was significantly longer (P = 0.0276), and resection efficiency was significantly lower (13 mm(2)/min, P = 0.0283), when treating lesions with an anastomotic site and/or a suture line than when treating isolated lesions.

CONCLUSIONS

Outcome of ESD for cancer of the operated stomach compares with that in normal stomach anatomy. Anastomotic site/suture line within a lesion influenced the ESD procedure.

Endoscopic submucosal dissection of colorectal neoplasia located on the suture line of anastomosis

Although endoscopic submucosal dissection (ESD) can remove gastrointestinal neoplasia even with severe fibrosis into the submucosa, the safety and efficacy of ESD for colorectal neoplasia (CRN) located on the suture line of anastomosis (SLA) has not been assessed. The aim of this study was to evaluate the feasibility of ESD for CRN located on the SLA, performed by a highly skilled endoscopist. Three consecutive patients with CRN located on the SLA were treated with ESD. In all cases, ESD was safely performed without any adverse events. The median tumor size of the resected CRN was 30 mm (range 12-75 mm) and the median procedure time was 150 min (range 50-150 min). Curative resection was achieved in two cases without local recurrence during a 12-month observation period. In one case, the CRN were resected in an almost en bloc fashion, but a decision was made to spare the edge of the CRN that was directly on the SLA in order to avoid delayed perforation, and this edge was instead removed with hemostatic forceps. Although the surveillance colonoscopy revealed a small residual neoplasia, it was curatively treated by endoscopically. In all cases, ESD managed to avoid the need for repetitive surgery. This case series suggests the feasibility of ESD performed by a highly skilled endoscopist as a curative treatment for the CRN located on the SLA.

Endoscopic submucosal dissection for early gastric cancer in anastomosis site after distal gastrectomy

BACKGROUND

Detection of early gastric cancer (EGC) in the remnant stomach is increasing because of follow-up endoscopic surveillance programs. Endoscopic treatment appears to be desirable for EGC in the remnant stomach because it is less invasive than surgical resection.

METHODS

In this retrospective study, to evaluate the feasibility of endoscopic submucosal dissection (ESD) for EGC in an anastomotic site, treatment results of ESD for EGC in an anastomotic site and in remnant stomach not involving an anastomotic site were compared. In total, 11 EGC lesions of anastomotic sites in 11 patients and 22 EGC lesions of remnant stomach not involving an anastomotic site in 21 patients were treated by ESD.

RESULTS

All lesions were successfully treated by en bloc resection. There were three patients with perforations in the anastomotic site group. Although resected specimen size and tumor size were larger in the anastomotic site group than in the non-anastomotic site group (P < 0.01), the procedure duration was far longer in the anastomotic site group than in the non-anastomotic site group (P < 0.01). The speed of the procedure was faster in the non-anastomotic site group than in the anastomotic site group (P < 0.05).

CONCLUSIONS

Although ESD for EGC in an anastomotic site is a time-consuming procedure and requires advanced techniques compared with ESD for EGC not involving an anastomotic site, a high en bloc resection rate was achieved. ESD by endoscopists with sufficient experience appears to be a feasible treatment for EGC in an anastomotic site.

Can we apply the same indication of endoscopic submucosal dissection for primary gastric cancer to remnant gastric cancer?

BACKGROUND

Currently, remnant gastric cancer (RGC) is uncommon compared with gastric stump cancer, but early detection of gastric cancer and improved postsurgical survival will lead to increased incidence of RGC. Therefore, the indication of endoscopic submucosal dissection (ESD) for RGC is now required, but there have been no reports about this because of the lack of information for RGC.

METHODS

A retrospective review was conducted on 105 patients who underwent completion total gastrectomy (CTG) and 5 patients who underwent ESD for RGC between January 1998 and December 2010 at Yonsei University Hospital.

RESULTS

Forty-one (39 %) of 105 patients were diagnosed with early RGC. Among these patients, 6 had an absolute indication for ESD, whereas 11 met expanded criteria for ESD. In these patients, there was no association between the severity of the former gastric cancer and the current RGC. Also, none of these 17 patients had LN metastasis after CTG, and only 1 (2.4 %) of 41 early RGC patients had LN metastasis. Median operative time was 216 min for CTG and median hospital stay was 8 days. There were two major and five minor complications. One splenectomy was performed because of injury that occurred during CTG.

CONCLUSIONS

Applying the indication of ESD for primary gastric cancer to RGC would be possible, and it could be an alternative treatment option for selected patients with RGC.

Gastric stump cancer after distal gastrectomy for benign disease: clinicopathological features and surgical outcomes

PURPOSE

The purpose of the present study was to analyze clinicopathologic features and long-term prognosis of gastric stump cancer (GSC) arising in the remnant stomach 5 years or later after partial gastrectomy for benign disease.

METHODS

We reviewed the results of 176 patients resected with curative intent for GSC at 8 Italian centers belonging to the Italian Research Group for Gastric Cancer (GIRCG). The median (range) follow-up time for surviving patients was 71.2 (6-207) months.

RESULTS

One hundred forty-six patients were men, the mean age at the time of diagnosis was 69.2 years, and the great majority (167 cases) underwent Billroth II reconstruction. R0 resection was achieved in 158 (90 %) patients, and in 94 (53 %) lymph node dissection was ≥D2. Postoperative mortality and complication rates were 6.2 and 43.2 %, respectively. T1 tumor was diagnosed in 45 (25 %) cases. Lymph node metastases were evident in 86 patients (49 %). Thirteen patients had involvement of the jejunal mesentery nodes (pJN+); five cases were T2-T3 and eight cases were T4. Overall 5-year survival rate was 53.1 %. Five-year survival rates were 68.1, 37.8, and 33.1 % for pT1, pT2-3, and pT4 tumors, respectively (P = 0.001). Five-year survival rate was 56.5 % for node-negative tumors (pN0), 32.3 % for tumors with nodal metastases without involvement of jejunal mesentery nodes (pN+), and 17.1 % for tumors with involvement of jejunal mesentery nodes (pJN+) (P = 0.002).

CONCLUSIONS

Our study suggests that an aggressive surgical approach can achieve a satisfactory outcome in GSC.

Endoscopic submucosal dissection for gastric tube cancer after esophagectomy

BACKGROUND

Recent improvements in the survival of patients after esophagectomy have led to an increasing occurrence of gastric tube cancer (GTC). Removal of the reconstructed gastric tube, however, can lead to high morbidity and mortality.

OBJECTIVE

To assess the feasibility and effectiveness of endoscopic submucosal dissection (ESD) for GTC.

DESIGN

Retrospective study.

SETTING

National Cancer Center Hospital, Tokyo, Japan.

PATIENTS

We investigated patients with GTC after esophagectomy undergoing ESD from 1998 to 2011.

INTERVENTION ESD MAIN OUTCOME MEASUREMENTS

Patient characteristics, endoscopic findings, technical results, histopathology including curability and Helicobacter pylori gastritis, and long-term outcomes.

RESULTS

There were 51 consecutive patients with 79 lesions including 38 lesions (48%) meeting the absolute indication, 31 (39%) satisfying the expanded indications, and 10 (13%) falling outside such indications. The median procedure time was 90 minutes. There were 73 en bloc resections (92%), 59 en bloc resections with tumor-free margins (R0 resections, 75%), and 51 curative resections (65%) based on the Japanese Gastric Cancer Association criteria. Fifty patients (98%) were assessed as H pylori gastritis positive. Adverse events included 3 perforations (3.8%) during ESD and 2 delayed perforations (2.5%) without any emergency surgery and 3 delayed bleeding (3.8%). Local recurrence was detected in 4 patients (7.8%), and metachronous GTCs were identified in 18 patients (35%). Five patients (10%) died of GTC including 3 metachronous lesions. The 5-year overall survival rate was 68.4%, and the disease-specific survival rate was 86.7% with 100% for curative and 72.7% for non-curative patients during a median follow-up period of 3.8 years (range, 0-12.1 years).

LIMITATION

Single-center retrospective study.

CONCLUSIONS

ESD for GTC was feasible and effective for curative patients; however, long-term outcomes for non-curative patients were less satisfactory.

Endoscopic submucosal dissection for early gastric cancer in cases preoperatively contraindicated for endoscopic treatment

BACKGROUND AND STUDY AIMS

Endoscopic submucosal dissection (ESD) is an optimal treatment for early gastric cancer (EGC) with negligible risk of lymph node metastasis; however, ESD is sometimes performed to treat lesions preoperatively contraindicated for the procedure due to various reasons. Here we aim to evaluate the treatment outcomes of ESD for lesions that were preoperatively contraindicated for ESD.

PATIENTS AND METHODS

Clinicopathological data of 104 EGC lesions in 104 patients were reviewed retrospectively. The demographic characteristics of patients, reasons for ESD, treatment results, complications, and outcomes were assessed.

RESULTS

The major reasons for undergoing ESD included advanced age, desire to undergo ESD, and the existence of comorbidities. En-bloc and complete resection rates were 97 and 71%, respectively. Perforation and postoperative bleeding rates were 13 and 9%, respectively. Resection was beyond the expanded Japanese criteria for endoscopic treatment of EGC in 87 patients (84%), 41 (47%) of whom underwent additional therapy, including subsequent gastrectomy (29 patients) and photodynamic therapy (12 patients). The median follow-up period was 47 months, during which seven patients died from recurrent disease. The 5-year overall and disease-specific survival rates were 70 and 91.5%, respectively.

CONCLUSIONS

ESD is a technically demanding procedure for lesions preoperatively contraindicated for endoscopic resection. The curative resection rate was low, but the 5-year disease-specific survival rate of 91.5% was favourable. In experienced hands, ESD may be a treatment option for patients not suitable for radical surgery, and the relevant risk of complications must be considered before treatment.

Gastric conduit cancer after oesophagectomy for oesophageal cancer: incidence and clinical implications

OBJECTIVES

Gastric conduit cancer (GCC), which is a carcinoma that arises in the gastric conduit after oesophagectomy, often negatively affects long-term survivors of oesophageal cancer. The aim of this study was to evaluate the incidence and clinical implications of GCC.

METHODS

We reviewed data for 863 patients who underwent an oesophagectomy and a reconstruction of the gastric conduit from 1993 to 2011 for oesophageal cancer.

RESULTS

A total of 18 cases of GCC in 18 patients were identified. Cumulative incidence rates of GCC were 2.4% at 5 years and 5.7% at 10 years. The median interval between oesophagectomy and detection of gastric tube cancer was 5.0 years (range, 1-16 years). Ten patients were incidentally diagnosed with GCC under periodic endoscopy. All cases of gastric tube cancer were adenocarcinoma and 12 cases were located at the antrum of the gastric conduit. For GCC treatment, endoscopic submucosal dissection was performed in 6 patients, total gastric conduit gastrectomy with colon interposition in 3 patients and chemotherapy in 6 patients. Five patients received conservative treatment alone. The 5-year survival rate of all patients was 22.2%. The 3-year survival rates of the patients who underwent endoscopic resection, total gastrectomy with colon interposition or chemotherapy or conservative treatment were 100, 50, and 9.1%, respectively (P = 0.003).

CONCLUSIONS

Patients had a constant risk of GCC occurrence after oesophagectomy for oesophageal cancer. Endoscopic or surgical resection for early GCC showed favourable outcomes compared with chemotherapy or conservative treatment for advanced GCC. A regular and long-term follow-up, including detailed endoscopy, is essential for the early detection of GCC in patients who underwent oesophagectomy for oesophageal cancer.

Highlights of international digestive endoscopy network 2013

Rapid advances in the technology of gastrointestinal endoscopy as well as the evolution of science have made it necessary for us to continue update in either various endoscopic techniques or state of art lectures relevant to endoscopy. International Digestive Endoscopy Network (IDEN) 2013 was held in conjunction with Korea-Japan Joint Symposium on Gastrointestinal Endoscopy (KJSGE) during June 8 to 9, 2013 at Seoul, Korea. Two days of impressive scientific program dealt with a wide variety of basic concerns from upper gastrointestine (GI), lower GI, pancreaticobiliary endoscopy to advanced knowledge including endoscopic submucosal dissection forum. IDEN seems to be an excellent opportunity to exchange advanced information of the latest issues on endoscopy with experts from around the world. In this special issue of Clinical Endoscopy, we prepared state of art review articles from contributing authors and the current highlights will skillfully deal with very hot spots of each KJSGE, upper GI, lower GI, and pancreaticobiliary sessions by associated editors of Clinical Endoscopy.

Endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) after surgical gastrectomy is a technically difficult procedure because of the limited working space in the remnant stomach as well as the presence of severe gastric fibrosis and staples under the suture line.

OBJECTIVE

We evaluated clinical results including long-term outcomes to determine the feasibility and effectiveness of ESD for EGC in the remnant stomach of patients after gastrectomy.

DESIGN

Retrospective study.

SETTING

National Cancer Center Hospital, Tokyo, Japan.

PATIENTS

We investigated patients undergoing ESD for EGC in the remnant stomach from 1997 to 2011.

INTERVENTION ESD MAIN OUTCOME MEASUREMENTS

We examined the patient characteristics, endoscopic findings, technical results, adverse events, and histopathologic results including curability and evaluations of Helicobacter pylori gastritis in addition to the rates of local recurrence, metachronous gastric cancer, overall survival, and cause-specific survival.

RESULTS

A total of 128 consecutive patients with 139 lesions had previously undergone 87 distal (68%), 25 proximal (19.5%) and 16 pylorus-preserving gastrectomies (12.5%). The median period from the original gastrectomy to the subsequent ESD for EGC in the remnant stomach was 5.7 years (range 0.6-51 years), the median tumor size was 13 mm (range 1-60 mm), and the median procedure time was 60 minutes (range 15-310 minutes). There were 131 en bloc resections (94%), with curative resections achieved for 109 lesions (78%); 22 lesions (16%) resulted in non-curative resections, and 8 lesions (6%) had only a horizontal margin positive or had inconclusive results. A total of 118 patients (92%) were assessed as H pylori gastritis-positive, with 7 patients (5%) negative. Adverse events included 2 cases of delayed bleeding (1.4%) and 2 perforations (1.4%), with 1 patient requiring emergency surgery. The 5-year overall and cause-specific survival rates were 87.3% and 100%, respectively, during a median follow-up period of 4.5 years (range 0-13.7 years), with no deaths from EGC in the remnant stomach.

LIMITATIONS

Single-center, retrospective study.

CONCLUSION

ESD for EGC in the remnant stomach of patients after gastrectomy was a feasible and effective therapeutic method and should become the standard treatment in such cases, based on the favorable long-term outcomes.

Metachronous adenoma on ileorectal anastomosis suture line and submucosal deep invasive cancer suspected of rapid growth in rectal remnant following long-term interval after curative surgery for advanced colon cancer

There is general agreement as to the value of postoperative surveillance and the effectiveness of colonoscopy in the early detection of metachronous colorectal lesions. In the present case, a 56-year-old woman with no family history of colon cancer underwent surveillance colonoscopy in which a metachronous flat adenoma was detected following an interval of 23 years after a colectomy and 20 years subsequent to treatment for uterine cancer. A second metachronous flat lesion histopathologically determined to be a submucosal (sm) deep invasive cancer with lymphovascular involvement was detected 12 months later. This second metachronous lesion was suspected of having developed rapidly in the rectal remnant accounting for its sm deep invasion. The findings of this case suggest colonoscopy surveillance guidelines proposed for individuals at high risk should be evaluated based on cancer history and an analysis of possible mismatch repair gene mutations. In addition, the first metachronous lesion was located directly on the suture line of the anastomosis. Endoscopic submucosal dissection (ESD) was indicated despite severe fibrosis into the sm layer. This case also demonstrates the successful use of improved ESD instruments, sm injection agents and technique refinements in the treatment of a technically difficult lesion with a high risk of complications.