Short-term outcomes of multicenter prospective cohort study of gastric endoscopic resection: 'Real-world evidence' in Japan

Long-term outcomes of additional surgery vs. observation after noncurative endoscopic submucosal dissection for early gastric cancer and application value of the eCura scoring system: a propensity score-matched study

BACKGROUND

Endoscopic submucosal dissection (ESD) is increasingly used for treating early gastric cancer (EGC). Noncurative ESD often necessitates additional surgical intervention because of the high risk of lymph node metastasis (LNM), but the optimal post-ESD management remains controversial.

METHODS

This study collected data from patients with EGC who underwent noncurative ESD at Nanjing Drum Tower Hospital between January 2014 and December 2021. Patients were divided into surgical and observation groups and stratified by eCura scores into low (0-1), intermediate (2-4), and high-risk (5-7) categories. A 1:1 propensity score-matched analysis was performed between the 2 groups. Receiver operating characteristic analysis was used to assess the eCura score's ability to predict LNM. Survival outcomes, including overall survival (OS) and disease-specific survival (DSS), were compared between groups.

RESULTS

Among the 260 patients, 91 were included in each group. No significant differences in OS or DSS were observed between the groups overall or among low-risk and intermediate-risk patients. However, high-risk patients in the surgical group had significantly better 5-year OS rates than those in the observation group, whereas the difference in DSS was not statistically significant. The eCura score exhibited strong predictive accuracy for LNM (area under the curve, 0.835; sensitivity, 70%; specificity, 92%). The subgroup analysis suggested that postchemoradiotherapy and total gastrectomy might be associated with better prognosis, although the differences were not statistically significant.

CONCLUSION

The eCura scoring system seems to be a valuable tool for guiding post-ESD management. Treatment decisions should be based on the individual characteristics and clinical factors of each patient. For carefully selected patients who are not suitable candidates for surgery, ESD may be a viable alternative treatment option.

Comparative Analysis of Gastrectomy versus Endoscopic Therapy for T1b Gastric Cancer: Long-term Outcomes from a Population-based Propensity Score Matched Cohort Study

BACKGROUND

Endoscopic therapy is emerging as a viable treatment for early-stage gastric cancer, but its long-term survival benefits for T1b gastric cancer remain unclear. This study was aimed to investigate the efficacy of endoscopic therapy versus gastrectomy in T1bN0M0 gastric cancer.

METHODS

Patients with T1bN0M0 gastric cancer were identified, and demographic characteristics were compared between those undergoing endoscopic therapy and gastrectomy. Kaplan-Meier analysis and Cox regression models were utilized to assess clinical outcomes and prognostic factors. Propensity score matching (PSM) was employed to compare overall survival (OS) and disease-specific survival (DSS) between the two groups, with subgroup analysis identifying the beneficiary population.

RESULTS

Among 1519 patients with T1bN0M0 gastric cancer, endoscopic therapy utilization increased notably from 3.8% in 2010 to 19.0% in 2019. Overall, 159 underwent endoscopic therapy, while 1360 underwent gastrectomy. Patients opting for endoscopic therapy were tended to be older (61%), White race (76.1%), with lesions in the cardia/fundus region (67.9%), lower pathological grades (74.8%) and had tumors measuring 2cm or less (83%). Although patients undergoing gastrectomy were associated with longer OS compared to those undergoing endoscopic therapy, no significant difference was observed in DSS (P=0.381). After PSM, DSS remained similar between the two groups (P=0.703), with consistent results in subgroup analysis, except for lesions located in the middle of the stomach.

CONCLUSION

The utilization of endoscopic therapy for T1bN0M0 gastric cancer is on the rise, with comparable DSS outcomes to gastrectomy. This approach may offer a safe alternative for select high-risk surgical candidates and patients with low-risk cancers, aiming to reduce the need for unnecessary interventions.

External validation of the eCura system and comparison with the W-eCura score for predicting lymph node metastasis after non-curative endoscopic submucosal dissection for early gastric cancer: a multicenter retrospective cohort study

BACKGROUND

The eCura system is a widely used risk-scoring model for predicting lymph node metastasis (LNM) after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), but its external validation is limited. Recently, the W-eCura score, a modified version, was proposed. We aimed to validate the eCura system and compare its discriminatory performance with the W-eCura score.

METHODS

A multicenter retrospective study was conducted using data from 19 Japanese institutions. The patients who underwent ESD for EGC followed by gastrectomy with lymph node dissection were included. The predictive performance of the eCura system, including calibration and discrimination, was evaluated and its discrimination was compared with the W-eCura score.

RESULTS

Among 901 eligible patients, 65 cases (7.2%) showed LNM. The eCura system demonstrated good calibration, with a calibration-in-the-large of -0.008 (95% confidence interval [CI] -0.024-0.010), an observed-to-expected ratio of 0.905 (95% CI 0.707-1.121), and a calibration slope of 0.975 (95% CI 0.692-1.257). Discrimination was also good, with a C-statistic of 0.741 (95% CI 0.676-0.806). In patients evaluable for both systems, the C-statistics for the eCura system and W-eCura score were 0.745 (95% CI 0.675-0.816) and 0.750 (95% CI 0.684-0.817), respectively, showing no significant difference (P = 0.547).

CONCLUSIONS

The eCura system was validated as a reliable tool for predicting LNM following ESD in real-world clinical settings.

Recent Advances in Gastrointestinal Cancer Endoscopic Diagnosis and Treatment: Focusing on Older Adults

Recent advances in endoscopic equipment have improved the diagnosis of gastrointestinal tumors. Image-enhanced endoscopy, including narrow-band imaging, blue light imaging, and linked color imaging, has unified magnifying observation classification methods and significantly improved the qualitative and quantitative diagnostic performance of gastrointestinal epithelial tumors. Endoscopic submucosal dissection (ESD), a minimally invasive treatment for early-stage gastrointestinal cancer, is widely used. The aging population in Japan has been gradually increasing. Despite this, ESD has shown good outcomes in older adults. However, long-term prognostic analyses should take into account the high mortality rate from other illnesses. Prognostic indicators such as the Charlson Comorbidity Index (CCI) and the Prognostic Nutrition Index (PNI) should be used to determine whether ESD should be performed. Even in cases of noncurative resection, follow-up without additional surgical resection is an option if there are other comorbidities that affect the prognosis.

Evaluating the Need for Additional Surgery After Non-Curative Endoscopic Resection in Patients with Remnant Gastric Cancer

PURPOSE

Completion total gastrectomy is considered an additional treatment after non-curative endoscopic resection for remnant gastric cancer. However, its high invasiveness remains a concern. This study aimed to assess the necessity of additional surgery after non-curative endoscopic submucosal dissection in patients with remnant gastric cancer.

METHODS

This study included patients who underwent non-curative endoscopic submucosal dissection for remnant gastric cancer between September 2002 and January 2018. The eCura system was used to stratify the risk of lymph node metastasis into low, intermediate, or high. The overall survival, disease-specific survival, and long-term clinical course were analyzed.

RESULTS

Among the 46 patients analyzed, 15 underwent additional completion total gastrectomy, whereas 31 were only followed up. Within a median follow-up period of 62.5 months, the additional surgery and follow-up groups showed 5-year overall survival rates of 79.4% and 76.8% (P = 0.93) and disease-specific survival rates of 92.9% and 92.7% (P = 0.98). A total of 19 low-, 8 intermediate-, and 4 high-risk patients in the follow-up group achieved 5-year disease-specific survival rates of 100%, 100%, and 33.3%. Significant differences were observed in the disease-specific survival between the low- and high-risk patients (P < 0.001) and between the intermediate- and high-risk patients (P = 0.02).

CONCLUSION

Risk stratification using the eCura system allows for individualized treatment decisions, with follow-up being a viable option for low- and intermediate-risk patients and additional surgery recommended for high-risk patients after non-curative endoscopic submucosal dissection for remnant gastric cancer.

Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study

BACKGROUND/AIMS

The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM.

METHODS

This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis.

RESULTS

Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%).

CONCLUSIONS

ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

Spray and Forced Coagulation Mode Endoscopic Submucosal Dissection for Early Gastric Neoplasms: A Multicenter Randomized Controlled Trial

INTRODUCTION

Controlling intraoperative bleeding during endoscopic submucosal dissection (ESD) is essential to ensure the safety and reliability of the procedure. ESD in spray coagulation mode (SCM-ESD) is expected to ensure more effective bleeding control. The aim of this study was to investigate the superiority of SCM-ESD over conventional forced coagulation mode ESD (FCM-ESD) in hemostatic ability for treating early gastric neoplasms (EGNs).

METHODS

This multicenter randomized controlled trial (Spray-G Trial) was conducted at 5 Japanese institutions. Patients with intramucosal EGNs were enrolled and randomly assigned to either the SCM-ESD or FCM-ESD group. The primary outcome was ESD completion with an electrosurgical knife alone, that is, without the use of hemostatic forceps. The number and duration of hemostatic procedures using hemostatic forceps, procedure time, curability, and adverse events were also evaluated.

RESULTS

Each group included 65 patients. The rate of ESD completion without using hemostatic forceps was significantly higher for SCM-ESD than for FCM-ESD (83.1% vs 13.8%, P < 0.0001). SCM-ESD and FCM-ESD did not differ significantly in procedure time (48.3 minutes vs 56.0 minutes, P = 0.1071), R0 resection (100% vs 95.4%, P = 0.2442), and rate of adverse events (3.1% vs 6.2%, P = 0.6801).

DISCUSSION

SCM-ESD significantly improved ESD completion rates for intramucosal EGNs without using hemostatic forceps. SCM-ESD is a promising technique that may streamline ESD by eliminating the need to exchange devices and reducing costs (UMIN Clinical Trials Registry, Numbers: UMIN000047353).

Endoscopic closure using a dedicated device following gastric endoscopic submucosal dissection: Multicenter, prospective, observational pilot study

Background and study aims

Development of a simple, optimized closure method for mucosal defects left by gastric endoscopic submucosal dissection (ESD) is warranted. Herein, we developed a novel and dedicated closure device called FLEXLOOP and aimed to assess feasibility and safety of the closure using FLEXLOOP following gastric ESD.

Patients and methods

This multicenter, prospective, observational study enrolled patients clinically diagnosed with gastric neoplasms < 30 mm in size. Following gastric ESD, closure of the mucosal defect was performed using a FLEXLOOP with standard clips. The primary outcome was the complete closure rate. The secondary outcomes were procedure time, number of clips, sustained closure rate on second-look endoscopy on postoperative days (PODs) 5 to 7, and rate of post-ESD bleeding.

Results

Overall, 35 patients were included in this study. The median specimen size was 32 mm. The mucosal defect was completely closed in 31 patients (89%; 95% confidence interval, 73%-99%) and incompletely closed in four patients (11%). Median closure time was 11 minutes and median number of clips was 10. Second-look endoscopy performed on PODs 5 to 7 demonstrated sustained, partially sustained, and unsustained closures in seven (20%), 22 (63%), and six patients (17%), respectively. Post-ESD bleeding and complications related to FLEXLOOP were not observed.

Conclusions

Closure using FLEXLOOP is feasible and safe. Our technique using this new device can be an attractive option for more easily closing mucosal defects. However, further clinical research is warranted to confirm that this technique can prevent delayed complications.

Management Strategy of Non-curative ESD in Gastric Cancer: Curative Criteria, and the Critical Building Block for Determining Beyond It

Endoscopic submucosal dissection is performed in cases of early gastric cancer, where the risk of lymph node metastasis (LNM) is expected to be negligible, and 12%-21% of these patients are deemed to have undergone non-curative resections based on pathological criteria. In such cases, decisions regarding additional treatments must be made to maximize curability, depending on the anticipated LNM risk. Well-established risk factors for LNM include lymphatic invasion, vascular invasion, deep submucosal invasion, positive vertical margins, and larger tumor size. When pathological factors associated with a clear LNM risk, such as lymphatic or deep submucosal invasion, are present, additional gastrectomy with lymph node dissection should be considered. Conversely, in cases involving only a positive horizontal margin, additional endoscopic treatment may be an effective therapeutic option as opposed to gastrectomy because of the negligible risk of LNM despite the potential risk of residual tumors. Endoscopic resection is particularly advantageous for determining complete resection. In addition to pathological curability, patient-specific factors, such as age and comorbidities, must be considered. Several retrospective cohort studies have shown that the cause of mortality among patients placed only on observation without additional treatment after non-curative resection is generally related to underlying conditions irrelevant to gastric cancer. Thus, it is crucial to assess both GC-specific mortality and all-cause mortality to finalize treatment decisions that help minimize such mortality. Therefore, new treatment algorithms that integrate pathological curability with patient-specific factors must be developed.

Closure of gastric mucosal defects using the reopenable-clip over-the-line method to decrease the risk of bleeding after endoscopic submucosal dissection: a multicenter propensity score-matched case-control study (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer. However, post-ESD bleeding presents significant risks. Closing mucosal defects after ESD may reduce the incidence of post-ESD bleeding. Currently, no optimal closure method exists. Therefore, we invented clip-line closure using the reopenable-clip over-the-line method (ROLM) and evaluated its efficacy in preventing post-ESD bleeding.

METHODS

We retrospectively reviewed data from patients who underwent gastric ESD between January 2012 and March 2024. Patients were categorized into 2 groups: the nonclosure group (mucosal defect remained unclosed) and the ROLM group (defect was closed using ROLM). Baseline characteristics of patients, distribution of bleeding risk factors, and incidence and timing of post-ESD bleeding were compared between the groups. Propensity score matching was used to minimize potential bias.

RESULTS

After propensity score matching, 162 ESDs were performed for 168 lesions in the nonclosure group, whereas 160 ESDs were performed for 168 lesions in the ROLM group. The mean long diameter of the mucosal defects, procedure time for ROLM, and number of clips required for ROLM were 45.9 mm, 35.6 minutes, and 33.2, respectively. All mucosal defects resulting from the ESD were fully closed using ROLM. The post-ESD bleeding rate in the ROLM group was significantly lower (1.8%; 3 of 168 lesions) than in the nonclosure group (7.7%; 13 of 168 lesions; P = .02).

CONCLUSIONS

ROLM is feasible for mucosal defect closure after gastric ESD and effectively prevents post-ESD bleeding in high-risk patients, addressing a significant gap in existing methods.

Effectiveness and safety of newly introduced endoscopic submucosal dissection in a Western center: a real-life study

OBJECTIVES

Endoscopic submucosal dissection (ESD) is a minimally invasive technique for the resection of superficial gastrointestinal lesions, providing high rates of 'en bloc' and R0 resection. East-West differences in ESD quality indicators have been reported. This study aims to assess feasibility, effectiveness, and safety of ESD for the treatment of superficial gastrointestinal (GI) lesions in a Western cohort.

METHODS

Consecutive patients undergoing ESD at one Italian endoscopic referral center from September 2018 to March 2020 were included in this prospective study. Primary outcomes were technical success, R0 resection rate, curative resection rate, and adverse events (AEs).

RESULTS

In total 111 patients (111 lesions) undergoing ESD were included. Anatomic site of the lesions was rectum in 56.8%, colon in 13.5%, stomach in 24.3%, and esophagus in 5.4% of cases, respectively. For upper GI procedures, technical success was 100%, and R0 and curative resection rates were 84.8% and 78.8%, respectively. For colorectal procedures, technical success was 98.7%, R0 and curative resection rates were 88.5% and 84.6%, respectively. Major AEs were reported in 12 cases (10.8%).

CONCLUSION

The introduction of ESD in a Tertiary Center is feasible, effective, and safe, and should be taken into consideration for the treatment of superficial GI lesions requiring 'en bloc' resection.

Risk factors and a nomogram for predicting local recurrence in adult patients with early gastric cancer after endoscopic submucosal dissection

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is an effective treatment method for early gastric cancers. The aim of this study was to evaluate the risk factors of recurrence for patients with early gastric cancer after ESD and construct a nomogram for predicting recurrence.

METHODS

A retrospective observational study was conducted on patients with early gastric cancer who underwent ESD at Beijing Friendship Hospital between 2013 and 2018. The risk factors of gastric cancer recurrence after ESD were analyzed by univariate and multivariate Cox regression.

RESULTS

A total of 238 patients with a median follow-up period of 70.5-month were enrolled in the study. Risk factors for recurrence included diabetes (HR = 3.68), alcohol consumption history (HR = 5.73), complications (HR = 5.22), lymphatic invasion (HR = 13.09) and multiple lesions (HR = 4.34). The analysis of the receiver operating characteristic curve, calibration curve, and model consistency index demonstrates that the graphical representation exhibits a good predictive capability.

CONCLUSIONS

Based on identified risk factors, this study developed the first nomogram with high accuracy to predict the recurrence of early gastric cancer after ESD. This model offers valuable guidance to clinicians for identifying high-risk patient groups and planning more intensive follow-up strategies.

Over-the-scope clip closure with dual thin grasping forceps after gastric endoscopic submucosal dissection

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Noninferiority of additional gastrectomy after endoscopic submucosal dissection compared with surgery alone on long-term prognosis: a propensity score matching analysis

BACKGROUND

Patients in whom endoscopic submucosal dissection (ESD) has resulted in noncurative resection need further surgical treatment. However, the oncologic outcome of additional gastrectomy after ESD compared with surgery alone remains unclear.

METHODS

The clinical data of 778 patients who underwent gastrectomy for early gastric cancer (EGC) from January 2008 to December 2019 in Ishikawa Prefectural Central Hospital were retrospectively analyzed. Of these 778 patients, 187 underwent additional gastrectomy after ESD [ESD (+) group] and 591 underwent surgery alone [ESD (-) group]. We compared the overall survival and disease-free survival between the ESD (+) and ESD (-) groups, using propensity score matching (PSM) to adjust for baseline characteristics. We also assessed early postoperative outcomes.

RESULTS

After PSM based on sex (male or female), age, tumor diameter, tumor gross type, and operative procedure, each group comprised 144 patients with no significant differences in clinical background characteristics. After matching, the 5-year overall survival rate in the ESD (+) and ESD (-) group was 90.9% and 87.8%, respectively, with no significant difference (P = .470). In addition, there was no significant difference in the disease-free survival rate (97.6% vs 95.8%, respectively; P = .504). The postoperative complication rate was similar in both groups.

CONCLUSION

Additional gastrectomy for patients in whom ESD resulted in noncurative resection did not adversely affect the long-term prognosis. Additional gastrectomy after ESD is oncologically acceptable for EGC.

Local recurrence after endoscopic submucosal dissection of gastric neoplastic lesions: special attention should be given also to safety margins

INTRODUCTION

The incidence of local recurrence following gastric endoscopic submucosal dissection (ESD) remains a clinical concern. We aimed to evaluate the impact of narrow safety margin (< 1 mm) on the recurrence rate.

METHODS

A retrospective cohort study was conducted across two centers. Cases of R0-ESD with subsequent recurrence were compared to matched controls in a 1:2 ratio in a case-cohort analysis.

RESULTS

Over a median period of 25 months (IQR 14-43), a recurrence rate of 3% (95%CI 1.7-4.3) was observed, predominantly (13/21) following R0 resections with favourable histology. Endoscopic retreatment was feasible in 18 of 21 recurrences. The proportion of R0-cases where the safety margin in both horizontal (HM) and vertical (VM) margin exceeded 1 mm was similarly distributed in the recurrence and non-recurrence group, representing nearly 20% of cases. However, cases with HM less than 1 mm, despite VM greater than 1 mm, nearly doubled in the recurrence group (7.7% vs. 3.9%), and tripled when both margins were under 1 mm (23.1% vs. 7.7%). Despite this trend, statistical significance was not achieved (p = 0.05). In the overall cohort, the only independent risk factor significantly associated with local recurrence was the presence of residual tumor at the HM (HM1) or not assessable HM (HMx) (OR 16.5 (95%CI 4.4-61.7), and OR 11.7 (95%CI 1.1-124.1), respectively).

CONCLUSIONS

While not common or typically challenging to manage, recurrence post-ESD warrants attention and justifies rigorous post-procedural surveillance, especially in patients with HM1, HMx, and probably also in those with R0 resections but narrow safety margin.

Potential for expanding indications and curability criteria of endoscopic resection for early gastric cancer in elderly patients: results from a Japanese multicenter prospective cohort study

BACKGROUND AND AIMS

Evidence for endoscopic resection (ER) in elderly patients with early gastric cancer (EGC) is limited. We assessed its clinical outcomes and explored new indications and curability criteria.

METHODS

We analyzed data from a Japanese multicenter, prospective cohort study. Patients aged ≥75 years with EGC treated with ER were included. We classified eCuraC-2 (corresponding to noncurative ER, defined in the Japanese gastric cancer treatment guidelines) into elderly-high (>10% estimated metastatic risk) and elderly-low (EL-L) (≤10% estimated metastatic risk).

RESULTS

In total, 3371 patients with 3821 EGCs were included; endoscopic submucosal dissection was the prominent treatment choice. Among them, 3586 lesions met the guidelines' ER indications, and 235 did not. The proportions of en bloc and R0 resections and perforations were 98.9%, 94.4%, and 0.8%, respectively, in EGCs within the indications. In EGCs beyond the indications, they were 99.5%, 85.4%, and 5.9%, respectively, for lesions diagnosed as ≤3 cm and 96.0%, 64.0%, and 18.0%, respectively, for those >3 cm. Curative ER and EL-L were observed in 83.6% and 6.2% of lesions within the indications, respectively, and in 44.2% and 16.8% of lesions <3 cm beyond the indications, respectively. The 5-year cumulative gastric cancer death rates after curative ER and elderly-high were 0.3% (95% confidence interval [CI], 0.2-0.6) and 3.5% (95% CI, 2.0-5.7), respectively. After EL-L, the rate was 0.9% (95% CI, 0.2-3.5) even without subsequent treatment.

CONCLUSIONS

The usefulness of endoscopic submucosal dissection for elderly EGC patients was confirmed by their clinical outcomes. Lesions of ≤3 cm and EL-L emerged as new ER indication and curability criteria, respectively. (Clinical trial registration number: UMIN000005871.).

Upper gastrointestinal endoscopic submucosal dissection using an ultrathin endoscope: a retrospective, single-center evaluation

BACKGROUND

Recent studies have reported the therapeutic use of endoscopic submucosal dissection (ESD) using an ultrathin endoscope for targeting pharyngeal and distal side lesions in the stenosis or as a less invasive treatment via the nasal route. However, the effectiveness and safety of these treatments remain undetermined. Therefore, this study aimed to review treatment outcomes and discuss the advantages and precautions of the treatments based on our experience.

METHODS

This study included 13 patients with 14 lesions who underwent 14 sessions of upper gastrointestinal ESD using an ultrathin endoscope between December 2021 and August 2023. The outcome measures included lesion background, en bloc resection rate, en bloc complete resection rates, and incidence of adverse events (including post-operative bleeding, intraoperative perforation, and delayed perforation).

RESULTS

The lesions in the esophagus, stomach, and duodenum were eight, three, and three, respectively, and the median length (range) of each located lesion was 16.5 (6-26), 17 (9-36), and 10 (4-16) mm, respectively. En bloc resection and en bloc complete resection rates were 100 and 92.9%, respectively. The only adverse event was an intraoperative perforation observed during duodenal ESD, resulting from the assistant's inadvertent expansion of the SOUTEN at the final dissection stage.

CONCLUSION

Our results demonstrate that ESD with an ultrathin endoscope effectively reaches lesions in difficult locations and enables treatment within a small working space. Therefore, ESD using an ultrathin endoscope is a treatment option for lesions located distally to gastrointestinal stenosis, highly fibrotic lesions, and duodenal tumors.

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.

Development of a novel multipoint traction device for gastric and colorectal endoscopic submucosal dissection and evaluation of its efficacy and safety

BACKGROUND

Proper traction allows safer and easier endoscopic submucosal dissection; however, single-point traction may not be sufficient. In this study we assessed the safety, efficacy, and feasibility of our newly developed multipoint traction device.

METHODS

During an ex vivo study using a Konjac training model, two experts and two trainees resected 80 mock lesions of 20-mm diameter by performing endoscopic submucosal dissection with and without multipoint traction. The primary outcome was the success rate of the procedure involving traction. The secondary outcomes were the submucosal dissection time, dissection speed, and perforation during endoscopic submucosal dissection. During the in vivo study, to clarify the initial clinical outcomes, we used data from the electronic medical record of patients at our institution who underwent gastric and colorectal endoscopic submucosal dissection, which was performed by experts with our newly developed multipoint traction device, from March to December 2022.

RESULTS

The ex vivo study indicated that all traction procedures were successful. Higher resection speeds were observed with endoscopic submucosal dissection with traction than without traction (P < 0.001). Perforations were not observed. During the first in vivo clinical study, traction was feasible during 20 gastric and colorectal endoscopic submucosal dissection procedures. No adverse events occurred.

CONCLUSIONS

Our multitraction device can increase the submucosal dissection speed and simplify endoscopic submucosal dissection techniques, thus safely reducing technical challenges. The application of this device for endoscopic submucosal dissection could lead to safer and more efficient procedures. Clinical registration UMIN Clinical Trials Registry, Japan (registration number UMIN000053384).

Endoscopic Resection of Malignancies in the Upper GI Tract: A Clinical Algorithm

Background

Malignancies in the upper gastrointestinal tract are amenable to endoscopic resection at an early stage. Achieving a curative resection is the most stringent quality criterion, but post-resection risk assessment and aftercare are also part of a comprehensive quality program.

Summary

Various factors influence the achievement of curative resection. These include endoscopic assessment prior to resection using chromoendoscopy and HD technology. If resectability is possible, it is particularly important to delineate the lateral resection margins as precisely as possible before resection. Furthermore, the correct choice of resection technique depending on the lesion must be taken into account. Endoscopic submucosal dissection is the standard for esophageal squamous cell carcinoma and gastric carcinoma. In Western countries, it is becoming increasingly popular to treat Barrett's neoplasia over 2 cm in size and/or with suspected submucosal infiltration with en bloc resection instead of piece meal resection. After resection, risk assessment based on the histopathological resection determines the patient's individual risk of lymph node metastases, particularly in the case of high-risk lesions. This is categorized according to the current literature.

Key Messages

This review presents clinical algorithms for endoscopic resection of esophageal SCC, Barrett's neoplasia, and gastric neoplasia. The algorithms include the pre-resection assessment of the lesion and the resection margins, the adequate resection technique for the respective lesion, as well as the post-resection risk assessment with an evidence-based recommendation for follow-up therapy and surveillance.

Endoscopic Features of Synchronous Multiple Early Gastric Cancers: Findings from a Nationwide Cohort

INTRODUCTION

We investigated the factors associated with synchronous multiple early gastric cancers and determined their localization.

METHODS

We analyzed 8,191 patients who underwent endoscopic submucosal dissection for early gastric cancers at 33 hospitals in Japan from November 2013 to October 2016. Background factors were compared between single-lesion (n = 7,221) and synchronous multi-lesion cases (n = 970) using univariate and multivariate analyses. We extracted cases with two synchronous lesions (n = 832) and evaluated their localization.

RESULTS

Significant independent risk factors for synchronous multiple early gastric cancer were older age (≥75 years old) (odds ratio [OR] = 1.257), male sex (OR = 1.385), severe mucosal atrophy (OR = 1.400), tumor localization in the middle (OR = 1.362) or lower region (OR = 1.404), and submucosal invasion (OR = 1.528 [SM1], 1.488 [SM2]). Depressed macroscopic type (OR = 0.679) and pure undifferentiated histology OR = 0.334) were more common in single early gastric cancers. When one lesion was in the upper region, the other was more frequently located in the lesser curvature of the middle region. When one lesion was in the middle region, the other was more frequently located in the middle region or the lesser curvature of the lower region. When one lesion was in the lower region, the other was more frequently located in the lesser curvature of the middle region or the lower region.

CONCLUSION

Factors associated with synchronous multiple early gastric cancer included older age, male sex, severe mucosal atrophy, tumor localization in the middle or lower region, and tumor submucosal invasion. Our findings provide useful information regarding specific areas that should be examined carefully when one lesion is detected.

Diagnostic performance of deep-learning-based virtual chromoendoscopy in gastric neoplasms

BACKGROUNDS

Cycle-consistent generative adversarial network (CycleGAN) is a deep neural network model that performs image-to-image translations. We generated virtual indigo carmine (IC) chromoendoscopy images of gastric neoplasms using CycleGAN and compared their diagnostic performance with that of white light endoscopy (WLE).

METHODS

WLE and IC images of 176 patients with gastric neoplasms who underwent endoscopic resection were obtained. We used 1,633 images (911 WLE and 722 IC) of 146 cases in the training dataset to develop virtual IC images using CycleGAN. The remaining 30 WLE images were translated into 30 virtual IC images using the trained CycleGAN and used for validation. The lesion borders were evaluated by 118 endoscopists from 22 institutions using the 60 paired virtual IC and WLE images. The lesion area concordance rate and successful whole-lesion diagnosis were compared.

RESULTS

The lesion area concordance rate based on the pathological diagnosis in virtual IC was lower than in WLE (44.1% vs. 48.5%, p < 0.01). The successful whole-lesion diagnosis was higher in the virtual IC than in WLE images; however, the difference was insignificant (28.2% vs. 26.4%, p = 0.11). Conversely, subgroup analyses revealed a significantly higher diagnosis in virtual IC than in WLE for depressed morphology (41.9% vs. 36.9%, p = 0.02), differentiated histology (27.6% vs. 24.8%, p = 0.02), smaller lesion size (42.3% vs. 38.3%, p = 0.01), and assessed by expert endoscopists (27.3% vs. 23.6%, p = 0.03).

CONCLUSIONS

The diagnostic ability of virtual IC was higher for some lesions, but not completely superior to that of WLE. Adjustments are required to improve the imaging system's performance.

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer

BACKGROUND

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer.

METHODS

This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG.

RESULTS

This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations.

CONCLUSIONS

This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

Using a novel hemostatic peptide solution to prevent bleeding after endoscopic submucosal dissection of a gastric tumor

BACKGROUND

Endoscopic mucosal dissection has become the standard treatment for early gastric cancer. However, post-endoscopic submucosal dissection (ESD) ulcer occurs in 4.4% of patients. This study hypothesized whether applying PuraStat, a novel hemostatic peptide solution, prevents post-ESD bleeding.

AIM

To investigate the preventive potential of PuraStat, a hemostatic formulation, against bleeding in post-ESD gastric ulcers.

METHODS

Between May 2022 and March 2023, 101 patients (Group P) underwent ESD for gastric diseases at our hospital and received PuraStat (2 mL) for post-ESD ulcers. We retrospectively compared this group with a control group (Group C) comprising 297 patients who underwent ESD for gastric diseases at our hospital between April 2017 and March 2021. P values < 0.05 on two-sided tests indicated significance.

RESULTS

Post-ESD bleeding occurred in 6 (5.9%) (95%CI: 2.8–12.4) and 20 (6.7%) (95%CI: 4.4–10.2) patients in Groups P and C, respectively, with no significant between-group difference. The relative risk was 1.01 (95%CI: 0.95–1.07). The lesser curvature or anterior wall was the bleeding site in all 6 patients who experienced postoperative bleeding in Group P. In multivariate analysis, the odds ratios for resection diameter ≥ 50 mm and oral anticoagulant use were 6.63 (95%CI: 2.52–14.47; P = 0.0001) and 4.04 (1.26–0.69; P = 0.0164), respectively. The adjusted odds ratio of post-ESD bleeding and PuraStat was 1.28 (95%CI: 0.28–2.15).

CONCLUSION

PuraStat application is not associated with post-ESD bleeding. However, the study suggests that gravitational forces may affect the effectiveness of applied PuraStat.

Potential of Direct Oral Anticoagulant in Bleeding After Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

BACKGROUND AND AIMS

An increasing number of patients are undergoing gastric endoscopic submucosal dissection (ESD) with active prescriptions of direct oral anticoagulants (DOACs). Only a few reports have described the effects of DOAC intake on postoperative bleeding. We aimed to investigate the bleeding risk associated with DOACs after gastric ESD.

METHODS

Clinical studies published up to April 2022 showing bleeding rates after gastric ESD in patients taking DOACs were identified using electronic searches. The primary outcome was the rate of bleeding after gastric ESD in patients receiving DOACs compared to those not receiving antithrombotic therapy. In this meta-analysis, odds ratios (ORs) were calculated and pooled using a random effects model. The secondary outcome was the difference in the bleeding rate between patients treated with DOACs and those treated with warfarin and antiplatelet drugs.

RESULTS

Seven studies were included in this meta-analysis. The pooled analysis showed that DOACs had a higher bleeding rate than non-thrombotic therapy (17.0% vs. 3.4%; OR 5.72; 95% confidence interval [CI], 4.33-7.54; I2 = 0%). The bleeding risk associated with DOAC administration was similar to that associated with warfarin (17.0% vs. 20.0%; OR 0.83; 95% CI 0.59-1.18; I2 = 0%), whereas it was higher than that associated with antiplatelet administration (16.9% vs. 11.0%; OR 1.63; 95% CI 1.14-2.34; I2 = 8%).

CONCLUSIONS

This meta-analysis reveals that the bleeding risk of DOACs is higher than that of non-antithrombotics and antiplatelets, whereas it is comparable to that of warfarin. Gastric ESD in patients on anticoagulants requires careful postoperative management.

Characteristics and Risk Factors of Delayed Perforation in Endoscopic Submucosal Dissection for Early Gastric Cancer

(1) Background: Delayed perforation after gastric endoscopic submucosal dissection (ESD) for early gastric cancer is a relatively uncommon and serious complication that sometimes requires emergency surgery. This study aimed to determine the clinicopathological features, risk factors, and appropriate management strategies for delayed perforation. (2) Methods: This study included 735 patients with 791 lesions who underwent ESD for early gastric cancer at a single institution between July 2009 and June 2019. We retrospectively compared the clinical features of patients with and without delayed perforations. (3) Results: The incidence of delayed perforations was 0.91%. The identified risk factors included a postoperative stomach condition and histopathological ulceration. A comparison between delayed and intraoperative perforations revealed a postoperative stomach condition as a characteristic risk factor for delayed perforation. Patients with delayed perforation who avoided emergency surgery tended to exhibit an earlier onset of symptoms such as abdominal pain and fever. No peritoneal seeding following delayed perforation was observed for any patient. (4) Conclusions: A postoperative stomach condition and histopathological ulceration were risk factors for delayed perforation. Delayed perforation is a significant complication that requires careful monitoring after gastric ESD for early gastric cancer, particularly in patients with postoperative gastric conditions.

Curative criteria for endoscopic treatment of gastric cancer

Endoscopic treatment, particularly endoscopic submucosal dissection, has become the primary treatment for early gastric cancer. A comprehensive optical assessment, including white light endoscopy, image-enhanced endoscopy, and magnification, are the cornerstones for clinical staging and determining the resectability of lesions. This paper discusses factors that influence the indication for endoscopic resection and the likelihood of achieving a curative resection. Our review stresses the critical need for interpreting the histopathological report in accordance with clinical guidelines and the imperative of tailoring decisions based on the patients' and lesions' characteristics and preferences. Moreover, we offer guidance on managing complex scenarios, such as those involving non-curative resection. Finally, we identify future research avenues, including the role of artificial intelligence in estimating the depth of invasion and the urgent need to refine predictive scores for lymph node metastasis and metachronous lesions.

Lesion size affects the risk of technical difficulty in gastric endoscopic submucosal dissection

Current evidence shows an inter-country inconsistency in the effect of lesion size on the technical difficulty of gastric endoscopic submucosal dissection (ESD). We aimed to evaluate the specific correlation and quantify the ensuing risks. This retrospective study consisted of 405 ESD cases with gastric single lesion from April 2015 to April 2023. The correlation and risk prediction of lesion size with technical difficulty was explored to provide further clinical evidence. An additive generalized model and recursive algorithm were used to describe the non-linear association, and a linear two-piece regression was constructed to analyze the inflection point. Subgroup analysis and interaction were used to explore intergroup characteristics. Overall, difficult cases had larger lesion sizes, and the more significant the increase, the higher the risk of technical difficulty. In the full model, after adjusting for all covariates, each 1 mm, 3 mm, 5 mm, 7 mm, and one standard increase in lesion size increased the risk of technical difficulty by 8%, 26%, 42%, 72%, and 125%, respectively. There is a nonlinear positive correlation between lesion size and risk of technical difficulty, and the premeditated inflection point was 40 (mm) via two-piecewise linear regression and recursive algorithm. Subgroup analysis showed a stronger correlation between lesion size and difficult ESD in the upper site and submucosal fibrosis groups. Available evidence suggests that lesion size as a risk signal nonlinearly increases the technical difficulty of gastric ESD procedure, especially in cases of upper site and submucosal fibrosis, which deserves further investigation.

Delayed Perforation Occurring after Gastric Endoscopic Submucosal Dissection: Clinical Features and Management Strategy

Background/Aims

Delayed perforation is a rare but serious adverse event of gastric endoscopic submucosal dissection (ESD). The aim of this study was to clarify the clinical features and appropriate management strategy of patients with delayed perforation.

Methods

Among 11,531 patients who underwent gastric ESD, the clinical features and outcomes of patients who experienced delayed perforation were retrospectively reviewed and compared with those of the control group.

Results

Delayed perforation occurred in 15 of 11,531 patients (0.13%). The patients with delayed perforation were significantly older than those without delayed perforation (p=0.027). The median time to diagnosis of delayed perforation was 28.8 hours (range, 14 to 71 hours). All 15 patients with delayed perforation complained of severe abdominal pain after gastric ESD and underwent subsequent chest X-rays (CXRs) for evaluation. In subsequent CXR, free air was found in 12 patients (80%). For three (20%) patients without free air in CXR, delayed perforation was finally diagnosed by computed tomography. Leukocytosis was significantly less frequent in the patients without free air in CXR (p=0.022). A perforation hole smaller than 1 cm in size was more frequently observed in the six patients who underwent successful non-surgical treatments than in the nine patients who underwent surgery (p<0.001). There was no mortality related to delayed perforation.

Conclusions

One-fifth of the patients with delayed perforation did not show free air in CXR and exhibited less leukocytosis than those with free air. Non-surgical treatments including endoscopic closure might be considered as an initial treatment modality for delayed perforation smaller than 1 cm.

Comparison of hemostatic ability between spray coagulation and forced coagulation modes in endoscopic submucosal dissection in patients with early gastric neoplasms: a study protocol for multicenter randomized controlled trial (Spray-G trial)

BACKGROUND

Endoscopic submucosal dissection (ESD) is the standard treatment for early gastric neoplasms (EGN). Controlling intraoperative bleeding is crucial for ensuring safe and reliable procedures. ESD using the spray coagulation mode (SCM-ESD) has been developed to control bleeding more effectively than ESD using the conventional forced coagulation mode (FCM-ESD). This study aims to compare the hemostatic efficacies of SCM-ESD and FCM-ESD.

METHODS

This multicenter, prospective, parallel, randomized, open-label superiority trial will be conducted in five Japanese institutions. Patients with a preoperative diagnosis of intramucosal EGC will be randomized to undergo either SCM-ESD or FCM-ESD. The primary outcome measure is the completion of ESD with an electrosurgical knife alone, without the use of hemostatic forceps. Secondary outcomes include the number and duration of hemostasis using hemostatic forceps, procedure time, curability, and safety. A total of 130 patients will be enrolled in this study.

DISCUSSION

This trial will provide evidence on the hemostatic efficacy of SCM-ESD compared with FCM-ESD in patients with intramucosal EGN, potentially improving the safety and reliability of ESD procedures.

TRIAL REGISTRATION

The trial has been registered at the University Hospital Medical Information Network Clinical Trials Registration (UMIN-CTR) as UMIN000040518. The reception number is R000054009.

Decision to perform additional surgery after non-curative endoscopic submucosal dissection for gastric cancer based on the risk of lymph node metastasis: a long-term follow-up study

BACKGROUND

Radical surgery after non-curative endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) may be excessive, since only 5-10% of patients have lymph node metastasis (LNM). This study investigated the suitability of the eCura system for determining the need for radical surgery after non-curative ESD.

METHODS

We retrospectively investigated 343 patients who underwent non-curative ESD for EGC from 2006 to 2021 at a tertiary hospital in Korea. These patients were divided into surgery (n = 191) and observation (n = 152) groups based on whether they underwent additional surgery post-ESD. Each group was further classified into low-risk (eCura score 0-1), intermediate-risk (eCura score 2-4) and high-risk (eCura score 5-7). All patients were regularly followed-up at least annually after the initial treatment. The cumulative overall and recurrence-free survival rates were calculated for each category and compared between the surgery and observation groups.

RESULTS

No significant differences in overall survival were found between the surgery and observation groups in low-risk (p = 0.168) and intermediate-risk patients (p = 0.306); however, high-risk patients had better 5-year overall survival rate in the surgery group than in the follow-up group (95.2% vs. 71.4%, p < 0.001). The 5-year recurrence-free survival rate was higher in the surgery group than in the observation group for low-risk (100% vs. 84.3%; p = 0.034), intermediate-risk (96.1% vs. 88.4%; p = 0.081) and high-risk patients (100% vs. 83.3%; p = 0.023).

CONCLUSIONS

Follow-up without additional surgery after non-curative ESD can be a reasonable option for low-risk and even intermediate-risk patients according to the eCura system. However, surgery is warranted for eCura high-risk patients.

Metachronous lesions after gastric endoscopic submucosal dissection: first assessment of the FAMISH prediction score

BACKGROUND

Surveillance after gastric endoscopic submucosal dissection (ESD) is recommended for all patients owing to the persistent risk of metachronous gastric lesions (MGLs). We developed and validated a prediction score to estimate MGL risk after ESD for early neoplastic gastric lesions, to define an individualized and cost-saving approach.

METHODS

Clinical predictors and a risk score were derived from meta-analysis data. A retrospective, single-center, cohort study including patients with ≥ 3 years of standardized surveillance after ESD was conducted for score validation. Predictive accuracy of the score by the area under the receiver operating characteristic curve (AUC) was assessed and cumulative probabilities of MGL were estimated.

RESULTS

The risk score (0-9 points) included six clinical predictors (scored 0-3): positive family history of gastric cancer, older age, male sex, corpus intestinal metaplasia, synchronous gastric lesions, and persistent Helicobacter pylori infection (FAMISH). The study population included 263 patients. The MGL rate was 16 %. The score diagnostic accuracy for predicting MGL at 3 years' follow-up, measured by the AUC, was 0.704 (95 %CI 0.603-0.806). At 3 years and a cutoff < 2, the score achieved maximal sensitivity and negative predictive value; 15 % of patients could be assigned to a low-risk group, in which the progression to MGL was significantly lower than for the high-risk group (P = 0.04).

CONCLUSION

The FAMISH score might be a useful tool to accurately identify patients with low-to-intermediate risk for MGL at 3 years of follow-up who could have surveillance intervals extended to reduce the burden of care.

Predictors of long-term outcomes of endoscopic submucosal dissection of early gastric neoplasia in the West: a multicenter study

BACKGROUND

This study aimed to determine long-term outcomes of gastric endoscopic submucosal dissection (ESD) in Western settings based on the latest Japanese indication criteria, and to examine predictors of outcomes and complications.

METHODS

Data were collected from consecutive patients undergoing gastric ESD at four participating centers from 2009 to 2021. Retrospective analysis using logistic regression and survival analysis was performed.

RESULTS

415 patients were included (mean age 71.7 years; 56.4 % male). Absolute indication criteria (2018 guideline) were met in 75.3 % of patients. Median follow-up was 52 months. Post-resection histology was adenocarcinoma, high grade dysplasia, and low grade dysplasia in 49.9 %, 22.7 %, and 17.1 %, respectively. Perforation, early and delayed bleeding occurred in 2.4 %, 4.3 %, and 3.4 %, respectively. Rates of en bloc and R0 resection, and recurrence on first endoscopic follow-up were 94.7 %, 83.4 %, and 2.7 %, respectively. Relative indication (2018 guideline) for ESD was associated with R1 outcome (P = 0.02). Distal location (P = 0.002) and increased procedure time (P = 0.04) were associated with bleeding, and scarring (P = 0.009) and increased procedure duration (P = 0.003) were associated with perforation. Recurrence-free survival at 2 and 5 years was 94 % and 83 %, respectively.

CONCLUSION

This is the largest Western multicenter cohort and suggests that gastric ESD is safe and effective in the Western setting. A quarter of patients fell outside the new absolute indications for ESD, suggesting that Western practice involves more advanced lesions. We identified the predictors of complications, which should help to inform future Western practice and research.

Predictive Factors for the Outcome of Unsupervised Endoscopic Submucosal Dissection During the Initial Learning Curve with Prevalence-Based Indication

BACKGROUND

For an adequate educational strategy of ESD in non-Asian settings with prevalence-based indication it is essential to define adequate lesions, suitable for the beginner without on-site expert-supervision.

AIMS

We analyzed possible predictors for outcome parameters of effectiveness and safety during the initial learning curve.

METHODS

The first 120 ESDs of four operators (n = 480), performed between 2007 and 2020 in four tertiary hospitals, were enrolled. Uni-/multivariable regression analysis was done with sex, age, pretreated lesion, lesion size, organ, and organ-based localization as possible independent predictors for en bloc resection (EBR), complication, and resection speed.

RESULTS

Rates of EBR, complication, and resection speed were 84.5%, 14.2%, and 6.20 (± 4.45) cm2/h. Independent predictors for EBR were pretreated lesion (OR 0.27 [0.13-0.57], p < 0.001) and non-colonic ESD (OR 2.29 [1.26-4.17] (rectum)/5.72 [2.36-13.89] (stomach)/7.80 [2.60-23.42] (esophagus), p < 0.001), for complication pretreated lesion (OR 3.04 [1.46-6.34], p < 0.001) and lesion size (OR 1.02 [1.004-1.04], p = 0.012) and for resection speed pretreated lesion (RC - 3.10 [- 4.39 to - 1.81], p < 0.001), lesion size (RC 0.13 [0.11-0.16], p < 0.001) and male patient (RC - 1.11 [- 1.85 to - 0.37], p < 0.001). We found no significant difference in the incidence of technically unsuccessful resections in esophageal (1/84), gastric (3/113), rectal (7/181), and colonic (3/101) ESDs (p = 0.76). Technical failure was mainly caused by complication and fibrosis/pretreatment.

CONCLUSION

During the initial learning curve of an unsupervised ESD program with prevalence-based indication, pretreated lesions and colonic ESDs should be avoided. In contrast, lesion size and organ-based localizations have less predictive value for the outcome.

Clinical and endoscopic features of metachronous gastric cancer with possible lymph node metastasis after endoscopic submucosal dissection and Helicobacter pylori eradication

BACKGROUND

Several studies have reported the metachronous gastric cancers (MGCs) with possible lymph node metastasis (LNM) after endoscopic submucosal dissection (ESD) and Helicobacter pylori (H. pylori) eradication in which a curative ESD had not been achieved. There have been no published reports of evaluations of the features of patients with MGC with possible LNM after ESD and H. pylori eradication.

METHODS

We identified 264 patients with 369 MGCs after H. pylori eradication among the 4354 patients with 5059 early gastric cancers (EGCs) who underwent ESD between 1999 and 2017 and divided them into two groups: patients with MGCs with possible LNM (Group I) and patients with MGCs undergone curative ESD (Group II). We retrospectively compared the features of patients with MGCs and patients with EGCs at index ESD in the two groups.

RESULT

Group I consisted of 20 patients with 21 MGCs, and Group II consisted of 244 patients with 348 MGCs. Group I lesions were significantly more common in the posterior wall than in the lesser curvature (odds ratio [OR] = 3.97; 95% confidence intervals [CI] 1.20-13.10). Development of Group I was significantly more common in patients with a body mass index (BMI) < 19.0 kg/m2 than in patients with a BMI ≥ 19.0 kg/m2 at index ESD (OR = 4.44; 95% CI 1.30-15.20).

CONCLUSIONS

During surveillance endoscopy after gastric ESD and H. pylori eradication, the posterior wall should be carefully examined to detect MGCs early. Lower BMI may be associated with the development of MGCs with possible LNM.

Hybrid and Conventional Endoscopic Submucosal Dissection for Early Gastric Neoplasms: A Multi-Center Randomized Controlled Trial

BACKGROUND & AIMS

Hybrid endoscopic submucosal dissection (H-ESD), which incorporates endoscopic submucosal dissection (ESD) with endoscopic mucosal resection, has been developed to make ESD technically easier. This study aimed to determine if H-ESD is superior to conventional ESD (C-ESD) for small early gastric neoplasms (EGNs).

METHODS

We conducted a multi-center, prospective, open-label, randomized controlled trial to compare the treatment outcomes of H-ESD and C-ESD (Hybrid-G Trial). Patients with differentiated type intramucosal EGN ≤20 mm in diameter and without ulceration were randomly assigned (1:1) to groups that underwent H-ESD or C-ESD. A single multi-functional snare, SOUTEN (ST1850-20, Kaneka, Medix, Tokyo, Japan), was used for H-ESD. The primary outcome was procedure time. Secondary outcomes included mucosal incision time, time and speed of submucosal dissection, curability, and endoscopic procedural adverse events.

RESULTS

A total of 39 and 40 patients underwent H-ESD and C-ESD, respectively. The procedure time of H-ESD was significantly shorter than that of C-ESD (33.16 min vs 62.46 min; H-ESD/C-ESD ratio: 0.53; 95% confidence interval, 0.41-0.69; P < .0001). There was no significant difference in mucosal incision time between the 2 groups; the time and speed of submucosal dissection of H-ESD were significantly shorter than those of C-ESD. No difference was observed between the 2 groups in other outcomes.

CONCLUSIONS

H-ESD has significantly shorter procedure time than C-ESD, with high and comparable curability and safety for both H-ESD and C-ESD. H-ESD can be a good option for the endoscopic treatment of small EGNs. (UMIN Clinical Trials Registry, Numbers: UMIN000041244).

Endoscopic Resection of Early Gastric Cancer and Pre-Malignant Gastric Lesions

Early gastric cancer comprises gastric malignancies that are confined to the mucosa or submucosa, irrespective of lymph node metastasis. Endoscopic resection is currently pivotal for the management of such early lesions, and it is the recommended treatment for tumors presenting a very low risk of lymph node metastasis. In general, these lesions consist of two groups of differentiated mucosal adenocarcinomas: non-ulcerated lesions (regardless of their size) and small ulcerated lesions. Endoscopic submucosal dissection is the technique of choice in most cases. This procedure has high rates of complete histological resection while maintaining gastric anatomy and its functions, resulting in fewer adverse events than surgery and having a lesser impact on patient-reported quality of life. Nonetheless, approximately 20% of resected lesions do not fulfill curative criteria and demand further treatment, highlighting the importance of patient selection. Additionally, the preservation of the stomach results in a moderate risk of metachronous lesions, which underlines the need for surveillance. We review the current evidence regarding the endoscopic treatment of early gastric cancer, including the short-and long-term results and management after resection.

Hybrid Dry Powders for Rapid Sealing of Gastric Perforations under an Endoscope

Effective wound sealing is key to prevent postoperative complications arising from gastric endoscopic submucosal dissection (ESD). Accurate delivery of the adhesive to wet and dynamic tissues and rapid action of the adhesive onsite should be considered for endoscopic operation. A hybrid dry powder (HDP) strategy, characterized by decoupling of powder gelation and tissue adhesion, for rapid sealing of wet tissues is presented. HDPs carrying oppositely charged polyelectrolytes become a hydrogel layer over the target tissue by absorbing the surrounding water and forming strong electrostatic interactions between heterogeneous components. Strong adhesion is realized through hydrogen bonding between the adhesive component, poly(acrylic acid), and the tissue. Wet tissue adhesion can be achieved in a few seconds (adhesion strength of ∼30 kPa to porcine skin). Notably, the HDP-assembled hydrogel can maintain a low swelling rate and resist degradation in acidic aqueous environments (pH 1). Furthermore, HDPs can be delivered to target tissues by spraying via an endoscope. The results of in vivo experiments indicate that healing of gastric ESD perforations by sealing with the powder-assembled hydrogel is as effective as that by sealing with clips. This strategy is expected to facilitate the development of fast-acting hydrogel-based adhesives for endoscopic operation.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants

Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection (ESD) for early-stage gastrointestinal tumors. The rate of post-ESD bleeding for gastric cancer is higher (around 5%-8%) than that for esophagus, duodenum and colon cancer (around 2%-4%). Although investigations into the risk factors for post-ESD bleeding have identified several procedure-, lesion-, physician- and patient-related factors, use of antithrombotic drugs, especially anticoagulants [direct oral anticoagulants (DOACs) and warfarin], is thought to be the biggest risk factor for post-ESD bleeding. In fact, the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%, which is higher than that in patients not receiving anticoagulants. However, because clinical guidelines for management of ESD in patients receiving DOACs differ among countries, it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice. Given that the pharmacokinetics (e.g., plasma DOAC level at both trough and Tmax) and pharmacodynamics (e.g., anti-factor Xa activity) of DOACs are related to risk of major bleeding, plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.

Association between perioperative management of antiplatelet agents and risk of post-endoscopic submucosal dissection bleeding in early gastric cancer: analysis of a nationwide multicenter study

BACKGROUND AND AIMS

Data are lacking regarding post-endoscopic submucosal dissection (ESD) bleeding in patients with early gastric cancer (EGC) who take antiplatelet agents (APAs), particularly in those taking thienopyridine and cilostazol. We aimed to clarify the association between the status of APA medication and post-ESD bleeding risk.

METHODS

This study is a secondary analysis using data from a recently conducted nationwide multicenter study in Japan. We retrospectively reviewed patients treated with APAs or on no antithrombotic therapy recruited from 33 institutions who underwent ESD for EGC between November 2013 and October 2016. The primary outcome of this study was the relationship between the rate of post-ESD bleeding and the status of each APA medication.

RESULTS

A total of 9736 patients were included in the analysis. Among 665 aspirin users, the continuation group was significantly associated with post-ESD bleeding (odds ratio [OR], 2.79; 95% confidence interval [CI], 1.77-4.37). Among 227 thienopyridine users, the aspirin or cilostazol replacement group was not significantly associated with post-ESD bleeding (OR, 1.85; 95% CI, .72-4.78). Among 158 cilostazol users, there was no significant association with post-ESD bleeding, irrespective of medication status. The rate of post-ESD bleeding was approximately 10% to 20% irrespective of the status of APA administration among dual-antiplatelet therapy users. No patients experienced thromboembolic events in this study.

CONCLUSIONS

Replacement of thienopyridine with aspirin or cilostazol may be acceptable for minimizing both the risk of post-ESD bleeding and thromboembolism in patients with EGC. In patients on cilostazol monotherapy undergoing ESD, continuation of therapy may be acceptable.

Prediction model of 3-year survival after endoscopic submucosal dissection for early gastric cancer in elderly patients aged ≥ 85 years: EGC-2 model

PURPOSE

Little is known about the prognostic factors for survival after endoscopic submucosal dissection (ESD) in elderly patients with early gastric cancer (EGC). The aim of this study is to determine prognostic factors and a prediction model of 3-year survival after ESD for EGC in patients aged ≥ 85 years.

METHODS

We retrospectively evaluated the clinical outcomes of 740 patients with EGC aged ≥ 85 years, who were treated by ESD at 30 institutions in Japan. Overall survival (OS) and disease-specific survival (DSS) were calculated with the Kaplan-Meier method. Prediction models for 3-year OS after ESD were estimated using the Cox proportional hazards model based on Uno's C-statistics.

RESULTS

During the follow-up period, 309 patients died of any cause and 10 patients died of gastric cancer. OS and DSS after 3 years were 82.7% and 99.2%, respectively. No significant differences in OS were found among curability categories. The Cox proportional hazards model revealed the geriatric nutritional risk index (GNRI) and the Charlson comorbidity index (CCI) to be predictors of 3-year survival. We established a final model (EGC-2 model) expressed by GNRI - (2.2×CCI) with a cutoff value of 96. The overall survival rate was significantly lower in the model value < 96 group than in the model value ≥ 96 group (P < 0.001).

CONCLUSIONS

The prediction model using GNRI and CCI will be useful to support decision-making for the treatment of EGC in elderly patients aged ≥ 85 years.

Perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection: successful conservative treatment without perforation closure: a case report

BACKGROUND

Perigastric abscess caused by delayed perforation after endoscopic submucosal dissection is a very rare complication. In principle, delayed perforation after endoscopic submucosal dissection is treated surgically. Herein, we report a case of perigastric abscess caused by delayed perforation after gastric endoscopic submucosal dissection that was treated conservatively, without perforation closure, and in which the patient was discharged from hospital in a short period.

CASE PRESENTATION

A-74-year-old Asian man was diagnosed with having early gastric cancer on follow-up endoscopy and was admitted to our hospital for endoscopic resection. Endoscopic submucosal dissection was performed without intraoperative complications. On postoperative day 2, the patient complained of a slight abdominal pain localized to the epigastric region and a small amount of melena. A computed tomography scan revealed the presence of free air in the peritoneal cavity, and a little fluid collection abutting the dorsal area of the stomach. An endoscopy examination showed a deep ulcer with the accumulation of pus, suggesting a perforation in the post-endoscopic submucosal dissection ulcer. We diagnosed a perigastric abscess, caused by delayed perforation after endoscopic submucosal dissection, and opted for conservative treatment, leaving the perforation site open to allow spontaneous drainage from the abscess into the stomach. A follow-up computed tomography scan revealed an encapsuled and localized perigastric abscess on postoperative day 5, and the disappearance of the free air and the regression of the perigastric abscess on postoperative day 7. A follow-up endoscopy examination on postoperative day 7 showed the closure of the perforation. Finally, surgery was avoided, and the patient was discharged on postoperative day 14, after a relatively short hospital stay.

CONCLUSION

Regarding the treatment of perigastric abscess, caused by delayed perforation after endoscopic submucosal dissection, leaving the perforation site open to allow spontaneous drainage may shorten the conservative treatment period.

Suturing techniques with endoscopic clips and special devices after endoscopic resection

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.

Long-term Survival After Endoscopic Resection For Gastric Cancer: Real-world Evidence From a Multicenter Prospective Cohort

BACKGROUND & AIMS

We aimed to clarify the long-term outcomes of endoscopic resection (ER) for early gastric cancers (EGCs) based on pathological curability in a multicenter prospective cohort study.

METHODS

We analyzed the long-term outcomes of 9054 patients with 10,021 EGCs undergoing ER between July 2010 and June 2012. Primary endpoint was the 5-year overall survival (OS). The hazard ratio for all-cause mortality was calculated using the Cox proportional hazards model. We also compared the 5-year OS with the expected one calculated for the surgically resected patients with EGC. If the lower limit of the 95% confidence interval (CI) of the 5-year OS exceeded the expected 5-year OS minus a margin of 5% (threshold 5-year OS), ER was considered to be effective. Pathological curability was categorized into en bloc resection, negative margins, and negative lymphovascular invasion: differentiated-type, pT1a, ulcer negative, ≤2 cm (Category A1); differentiated-type, pT1a, ulcer negative, >2 cm or ulcer positive, ≤3 cm (Category A2); undifferentiated-type, pT1a, ulcer negative, ≤2 cm (Category A3); differentiated-type, pT1b (SM1), ≤3 cm (Category B); or noncurative resections (Category C).

RESULTS

Overall, the 5-year OS was 89.0% (95% CI, 88.3%-89.6%). In a multivariate analysis, no significant differences were observed when the hazard ratio of Categories A2, A3, and B were compared with that of A1. In all the pathological curability categories, the lower limit of the 95% CI for the 5-year OS exceeded the threshold 5-year OS.

CONCLUSION

ER can be recommended as a standard treatment for patients with EGCs fulfilling Category A2, A3, and B, as well as A1 (UMIN Clinical Trial Registry, UMIN000005871).

Treatment strategy after noncurative endoscopic resection for early gastric cancers in patients aged ≥ 85 years: a multicenter retrospective study in a highly aged area of Japan

BACKGROUND

The guidelines recommend additional gastrectomy after noncurative endoscopic resection for early gastric cancers (EGCs). However, no additional treatment might be acceptable in some patients aged ≥ 85 years. We aimed to identify this patient group using the data in a highly aged area.

METHODS

We enrolled patients aged ≥ 85 years after noncurative endoscopic resection for EGCs at 30 institutions of the Tohoku district in Japan between 2002 and 2017. Treatment selection and prognosis after noncurative endoscopic resection were investigated. Fourteen candidates were evaluated using the Cox model to identify risk factors for poor overall survival (OS) in patients with no additional treatment.

RESULTS

Of 1065 patients aged ≥ 85 years, 143 underwent noncurative endoscopic resection. Despite the guidelines' recommendation, 88.8% of them underwent no additional treatment. The 5-year OS rates in those with additional gastrectomy and those with no additional treatment were 63.1 and 65.2%, respectively. Multivariate analysis showed independent risk factors for poor OS in patients with no additional treatment were the high-risk category in the eCura system (hazard ratio [HR], 2.91), Charlson comorbidity index (CCI) ≥ 3 (HR, 2.78), and male (HR, 2.04). In patients with no additional treatment, nongastric cancer-specific survival was low (69.0% in 5 years), whereas disease-specific survival rates were very high in the low- and intermediate-risk categories of the eCura system (100.0 and 97.1%, respectively, in 5 years).

CONCLUSIONS

No additional treatment may be acceptable in the low- and intermediate-risk categories of the eCura system in patients aged ≥ 85 years with noncurative endoscopic resection for EGCs.