Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions

AIM

To assess risk factors for bleeding after gastric endoscopic submucosal dissection (ESD) and to develop preventive measures.

METHODS

This retrospective study was performed in a tertiary referral center. A total of 328 patients underwent ESD for 398 gastric neoplasms between July 2007 and June 2009. The main outcome was association between post-ESD bleeding and the following: age; sex; comorbidities; daily use of medicine potentially related to gastric injury/bleeding; location, size, and histological depth of lesions; ulceration; experience of operator coagulating the ulcer floor, and duration of operation. We also determined the relationship between the location of post-ESD bleeding and risk factors for hemorrhage.

RESULTS

Univariate analysis revealed significant risk factors: tumor location [odds ratio (OR), 2.86; 95% CI: 1.21-6.79, P = 0.024], coagulator experience (OR, 4.29; 95% CI: 1.43-12.86, P = 0.009), and medicine potentially related to gastric injury/bleeding (OR, 2.80; 95% CI: 1.14-6.90, P = 0.039). Multivariate logistic regression analysis confirmed significant, independent risk factors: tumor in lower third of stomach (OR, 2.47; 95% CI: 1.02-5.96, P = 0.044), beginner coagulator (OR, 3.93; 95% CI: 1.29-11.9, P = 0.016), and medicine (OR, 2.76; 95% CI: 1.09-6.98, P = 0.032). We classified cases of post-ESD bleeding into two groups (bleeding at the ulcer margin vs bleeding at the center) and found that bleeding at the margin occurred more frequently with beginner coagulators compared with experts (OR, 16.00; 95% CI: 1.22-210.59, P = 0.040).

CONCLUSION

Beginner coagulators, tumor in the antrum, and medicines were significant risk factors for post-ESD bleeding. Bleeding at the ulcer margin frequently occurred with beginner operators.

Polyglycolic acid sheets and fibrin glue decrease the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms (with video)

BACKGROUND

The prevention of bleeding after endoscopic submucosal dissection (ESD) for gastric neoplasms is still an important problem.

OBJECTIVE

To investigate the efficacy and safety of a shielding method that uses polyglycolic acid (PGA) sheets and fibrin glue to prevent post-ESD bleeding in high-risk patients.

DESIGN

A nonrandomized trial with historical control subjects.

SETTING

A single academic hospital in Japan.

PATIENTS

From July 2013 to February 2014, 45 ESD-induced ulcers in 41 patients with a high risk of bleeding were enrolled in a study group. Forty-one consecutive ESD-induced ulcers in 37 control subjects with a high risk of bleeding were treated in 2013 before the first enrollment.

INTERVENTIONS

We placed PGA sheets on the mucosal defect and fixed with fibrin glue in the study group.

MAIN OUTCOME MEASUREMENTS

The post-ESD bleeding rate.

RESULTS

The post-ESD bleeding occurred at a rate of 6.7% in the study group (3/45 lesions) and 22.0% in the historical control group (9/41 lesions). There was a significant difference in the post-ESD bleeding rate between the 2 groups (P = .041).

LIMITATIONS

A nonrandomized trial with historical control subjects; a single-center analysis; small sample size.

CONCLUSIONS

The endoscopic tissue shielding method with PGA sheets and fibrin glue appears to be promising for the prevention of post-ESD bleeding. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000011058.).

Endoscopic tissue shielding method with polyglycolic acid sheets and fibrin glue to cover wounds after colorectal endoscopic submucosal dissection (with video)

BACKGROUND

Colorectal endoscopic submucosal dissection (ESD) has made it possible to resect large specimens in an en bloc fashion. However, this can lead to postoperative adverse events, such as perforation and bleeding. Prevention of adverse events after colorectal ESD is therefore an important goal.

OBJECTIVE

To evaluate the utility of a shielding method using polyglycolic acid (PGA) sheets and fibrin glue to manage ulcers after colorectal ESD.

DESIGN

Prospective, single-arm, pilot study.

SETTING

Single tertiary care center for colorectal ESD in Japan.

PATIENTS

Ten patients with 10 colorectal tumors scheduled for ESD were enrolled between September and November 2012.

INTERVENTIONS

Just after ESD, we placed PGA sheets on the mucosal defect with biopsy forceps. After the whole defect was covered, we sprayed fibrin glue through a special double-lumen spraying tube. We sprayed fibrinogen through 1 lumen and then thrombin through the other lumen.

MAIN OUTCOME MEASUREMENTS

Success rate, mean procedure time, and adverse events associated with the covering technique and the persistence of PGA sheets at follow-up colonoscopy.

RESULTS

All 10 tumors were successfully resected. Mean tumor size was 39.7 ± 15.2 mm. All mucosal defects were successfully covered with PGA sheets. Mean procedure time was 18.7 ± 15.9 minutes. No procedure-related adverse events occurred. Upon colonoscopy 9 to 12 days after ESD, the PGA sheets were still fixed on the whole defect in 8 patients.

LIMITATIONS

Small sample size.

CONCLUSIONS

Our technique, which uses PGA sheets and fibrin glue, appears to shield mucosal defects, and it may be effective in reducing postoperative adverse events.

An effective training system for endoscopic submucosal dissection of gastric neoplasm

BACKGROUND AND STUDY AIMS

A standard training system for endoscopic submucosal dissection (ESD) remains to be established. In this study, we evaluated the validity of our training program for gastric ESD.

PATIENTS AND METHODS

Four trainees performed gastric ESD for a total of 117 lesions in 107 patients (27 to 30 consecutive lesions per trainee) at a tertiary referral center during 2 years in the training program. Trainees, who already had the fundamental skills and knowledge needed for ESD, each assisted at 40 gastric ESD procedures, then in 20 cases applied post-ESD coagulation (PEC) to gastric mucosal defects; they then began to perform ESD, starting with gastric antral lesions. Treatment outcomes, including mean procedure time, and rates of en bloc resection, en bloc plus R0 resections, complications, and self-completion, were evaluated, for the initial 15 and subsequent 12 to 15 cases.

RESULTS

Overall rates of en bloc resection and en bloc plus R0 resection were as high as 100 % and 96.6 %, respectively. Regarding complications, seven cases of delayed hemorrhage (6.0 %) and three cases of perforation (2.6 %) occurred; all complications were solved endoscopically. The most frequent reason for operator change was lack of submucosal dissection skill. The self-completion rate was more than 80 % even in the early period, and did not increase for later cases.

CONCLUSIONS

Our training system enabled novice operators to perform gastric ESD without a decline in clinical outcomes. Key features of this training are prior intensive learning and actual ESD during the learning period under expert supervision.

Magnifying endoscopy with narrow-band imaging helps determine the management of gastric adenomas

BACKGROUND

There are no clear clinical criteria for the management of gastric lesions diagnosed as adenomas (Vienna classification category 3) by pre-treatment biopsy. In the present study, we examined the feasibility of magnifying endoscopy with narrow-band imaging (ME-NBI) in discriminating early gastric cancers (Vienna classification category 4 or 5) from adenomas in lesions diagnosed as adenomas by pre-treatment biopsy.

METHODS

This was a single-center cross-sectional retrospective study at a tertiary referral center. One hundred thirty-seven consecutive cases of gastric lesions diagnosed as adenomas in pre-treatment forceps biopsy were examined with conventional non-magnifying endoscopy under white light, non-magnifying chromoendoscopy, and ME-NBI. We investigated the association between the final pathological diagnoses (carcinoma or adenoma) and the following factors: lesion size (mm), color (red or white), macroscopic type (depressed or others), presence of ulceration, and positive ME-NBI finding. The presence of an irregular microvascular pattern or an irregular microsurface pattern with a demarcation line between the lesion and the surrounding area was regarded as a positive ME-NBI finding.

RESULTS

Lesion size was significantly larger in carcinomas than adenomas (P = 0.005). Depressed lesion (P = 0.011), red color (P < 0.001), and positive ME-NBI finding (P < 0.001) were significant predictive factors for carcinoma. Multivariate logistic regression confirmed that red color (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.26-7.34, P = 0.14) and a positive ME-NBI finding (OR 13.68, 95% CI 5.69-32.88, P < 0.001) were independent predictive factors for carcinomas. A positive ME-NBI finding was the strongest predictive factor.

CONCLUSIONS

ME-NBI is useful in planning the management of lesions diagnosed as adenomas by pre-treatment forceps biopsy.

Antithrombotic drug does not affect the positive predictive value of an immunochemical fecal occult blood test

BACKGROUND AND AIM

Antithrombotic drugs may affect the diagnostic performance of immunochemical fecal occult blood test (iFOBT) for colorectal cancer (CRC) screening. The aim of the present study was to assess the effect of antithrombotic drugs on the diagnostic performance of iFOBT.

METHODS

We analyzed 1016 patients who underwent colonoscopy for positive iFOBT. Patients were classified as follows: patients who had advanced neoplasms detected and those who did not; patients who had cancers detected and those who did not; patients who had any neoplasms detected and those who did not. We compared the following factors between two paired groups: sex, age, endoscopists' experience, and antithrombotic drug usage.

RESULTS

A total of 139 patients were taking antithrombotic drugs (13.7%). Advanced neoplasms, cancers, and any neoplasms were detected in 196 (19.3%), 59 (5.8%), and 490 (48.2%)patients, respectively. There were no higher detection rates in the antithrombotic drug (-) group than in the (+) group (advanced neoplasms: 19.3% vs 19.4%, P=1.000; cancers: 5.8% vs 5.8%, P=1.000; any neoplasms: 48.4% vs 47.5%, P=0.856). Multivariate logistic regression analysis revealed that none of aspirin, warfarin, or other antithrombotic drugs was a significant factor for advanced neoplasms (95% CI 0.350-1.216, P=0.179; 95% CI 0.421-1.899, P=0.772; 95% CI 0.323-1.810, P=0.764, respectively). As to cancers and any neoplasms, no antithrombotic drug also proved to be a significant factor.

CONCLUSION

The present study demonstrated that the positive predictive value of iFOBT was not affected by ongoing antithrombotic therapy.

Risk for lymph node metastasis in Epstein-Barr virus-associated gastric carcinoma with submucosal invasion

OBJECTIVES

Epstein-Barr virus-associated gastric cancer (EBVGC) has been reported to be associated with a low risk for lymph node metastasis (LNM). However, the curative criteria for endoscopic submucosal dissection (ESD) for submucosal EBVGC (pT1b-EBVGC) remain unclear. Our study aimed to investigate the risk factors for LNM in pT1b-EBVGC.

METHODS

This was a retrospective multicenter study at five institutes in Japan. We reviewed medical records and extracted all pT1b-EBVGC cases that met the following criteria: (i) histologically proven submucosal gastric cancer; (ii) surgical or endoscopic resection between January 2000 and December 2016; and (iii) presence of Epstein-Barr virus (EBV) in tumor cells verified by EBV-encoded small RNA in situ hybridization (EBER-ISH). The association between clinicopathological factors and LNM were assessed using multivariable logistic regression analysis.

RESULTS

A total of 185 pT1b-EBVGC cases were included in the analysis. LNM was found in nine cases (4.9%). Multivariable logistic regression analysis demonstrated that lymphatic invasion (OR 9.1; 95% CI 2.1-46.1) and submucosal invasion ≥4000 μm (OR 9.2; 95% CI 1.3-110.3) were significant risk factors for LNM. When we focused on pT1b-EBVGC without lymphatic invasion and with submucosal invasion <2000 μm, the rate of LNM was 0% (0/96, 95% CI 0-3.8%).

CONCLUSIONS

Our findings indicated that lymphatic invasion and submucosal invasion ≥4000 μm were significant risk factors for LNM. ESD could be an appropriate option for pT1b-EBVGC without lymphatic invasion and with submucosal invasion <2000 μm.

Desirable training of endoscopic submucosal dissection: further spread worldwide

Endoscopic submucosal dissection (ESD) is an excellent treatment because of its high curative resection rate and low local recurrence rate. However, its technical difficulty prevents from its permeation worldwide. For further permeation of ESD, the establishment of an appropriate training system is essential. In Japan, trainee endoscopists who have had prerequisites for ESD, that is to say, basic knowledge and skills, start ESD in accordance with a stepwise training system under close supervision by experts. The trainers select an appropriate lesion in human for each step of developments in ESD techniques. In Western countries there are few ESD experts at present, so an ex vivo animal model training must play a major role in the training system. It is desirable that these training systems should be constructed by some authorized organizations such as Japan Gastroenterological Endoscopy Society (JGES).

Preventive measures against stricture after esophageal endoscopic submucosal dissection: Halfway through the journey to the best method

This Editorial refers to the article by J. Tang, p 608‐615 of this issue.

Traction-assisted esophageal endoscopic submucosal dissection for treatment of squamous cell carcinoma involving a diverticulum

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[Diagnosis of small bowel carcinoma by capsule endoscopy]

Now in Japan, the use of capsule endoscopy for small bowel is approved only for the diagnosis of obscure gastrointestinal bleeding. Since the small bowel is anatomically difficult to approach, and small bowel carcinomas are often asymptomatic at early stages, they were usually diagnosed only after symptoms such as intestinal stenosis have developed. The advent of capsule endoscopy, however, enabled us to diagnose small bowel carcinoma at an early stage. However, we must be careful of the risk of capsule retention. The combination of capsule endoscopy, double balloon endoscopy, and traditional examination modalities including radiography or computed tomography will make it possible to diagnose and treat small bowel carcinoma at an early stage, and further progress is expected in this field.