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Giacobo Nunes F, Gomes ILC, De Moura DTH, Dominguez JEG, Fornari F, Ribeiro IB, Peixoto de Oliveira GH, de Figueiredo SMP, Bernardo WM, Hourneaux de Moura EG. Conventional Versus Traction-Assisted Endoscopic Submucosal Dissection for Esophageal, Gastric, and Colorectal Neoplasms: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Cureus 2024; 16:e55645. [PMID: 38586623 PMCID: PMC10996889 DOI: 10.7759/cureus.55645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2024] [Indexed: 04/09/2024] Open
Abstract
Endoscopic submucosal dissection (ESD) is increasingly being utilized for the resection of superficial gastrointestinal neoplasms. However, the long procedure time poses a technical challenge for conventional ESD (C-ESD). Traction-assisted ESD (T-ESD) was developed to facilitate the procedure by reducing its duration. This study compares the efficacy and safety of C-ESD versus T-ESD in the treatment of esophageal, gastric, and colorectal neoplasms. Nine randomized controlled trials (RCTs) were analyzed. Traction-assisted ESD exhibited shorter mean dissection times for the esophagus and colorectal regions and lower perforation rates in colorectal cases. No significant differences were observed in en bloc resection or bleeding rates. Traction-assisted ESD proves to be more efficient in mean procedure time for esophageal and colorectal cases and safer in perforation rates for colorectal cases, but similar rates are noted for en bloc resection or bleeding.
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Affiliation(s)
- Felipe Giacobo Nunes
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Igor Logetto Caetité Gomes
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | | | - Juan Eduardo G Dominguez
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Fernando Fornari
- Gastroenterology, Federal University of Fronteira Sul, Passo Fundo, BRA
| | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | | | | | - Wanderley Marques Bernardo
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Eduardo G Hourneaux de Moura
- Gastrointestinal Endoscopy, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
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Meng ZW, Bishay K, Vaska M, Ruan Y, Al-Haddad MA, Elhanafi SE, Qumseya BJ, Belletrutti PJ, Gill R, Debru E, Heitman SJ, Brenner DR, Forbes N. Endoscopic Submucosal Dissection Versus Surgery or Endoscopic Mucosal Resection for Metachronous Early Gastric Cancer: a Meta-analysis. J Gastrointest Surg 2023; 27:2628-2639. [PMID: 37752384 DOI: 10.1007/s11605-023-05840-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/26/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Resection options for early gastric cancer (EGC) include endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and surgery. In patients with metachronous EGC following previous resection, the optimal resection technique is not well elucidated. We conducted a systematic review and meta-analysis of studies comparing ESD to EMR, or ESD to surgery, in patients with metachronous EGC. METHODS We conducted an electronic search of studies reporting on outcomes and AEs following ESD versus either EMR or surgery for patients with metachronous EGC. Pooled odds ratios (OR) of included studies were obtained using DerSimonian and Laird random effects models. Funnel plots were produced and visually inspected for evidence of publication bias. The quality of the evidence was assessed using GRADE. RESULTS A total of 9367 abstracts were screened and 10 observational studies were included. The odds of complete resection were higher amongst patients undergoing ESD compared to EMR (OR 5.88, 95% confidence intervals, CI, 1.79-19.35), whereas the odds of complete resection were no different between ESD and surgery (OR 0.57, 95% CI 0.04-8.24). There were no differences in the odds of local recurrence with ESD versus surgery (OR 5.01, 95% CI 0.86-29.13). Post-procedural bleeding did not differ significantly between ESD and EMR (OR 0.70, 95% CI 0.16-3.00). There was no evidence of publication bias. DISCUSSION For metachronous EGC, ESD or surgery is preferred over EMR depending on local expertise and patient preferences, largely due to a higher risk of incomplete resection with EMR. REVIEW REGISTRATION PROSPERO CRD42021270445.
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Affiliation(s)
- Zhao Wu Meng
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, CWPH 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Kirles Bishay
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, CWPH 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Marcus Vaska
- Knowledge Resource Service, Alberta Health Services, Calgary, AB, Canada
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, AB, Canada
| | | | - Sherif E Elhanafi
- Department of Internal Medicine, Paul L Foster School of Medicine, Texas Tech University, El Paso, TX, USA
| | - Bashar J Qumseya
- Department of Gastroenterology, University of Florida, Gainesville, FL, USA
| | - Paul J Belletrutti
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, CWPH 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Richdeep Gill
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Estifanos Debru
- Department of Surgery, University of Calgary, Calgary, AB, Canada
| | - Steven J Heitman
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, CWPH 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Darren R Brenner
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cancer Epidemiology and Prevention Research, Cancer Control Alberta, Alberta Health Services, Calgary, AB, Canada
| | - Nauzer Forbes
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, CWPH 6D19, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, AB, Canada.
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3
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Al-Haddad MA, Elhanafi SE, Forbes N, Thosani NC, Draganov PV, Othman MO, Ceppa EP, Kaul V, Feely MM, Sahin I, Ruan Y, Sadeghirad B, Morgan RL, Buxbaum JL, Calderwood AH, Chalhoub JM, Coelho-Prabhu N, Desai M, Fujii-Lau LL, Kohli DR, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Storm AC, Thiruvengadam NR, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on endoscopic submucosal dissection for the management of early esophageal and gastric cancers: methodology and review of evidence. Gastrointest Endosc 2023; 98:285-305.e38. [PMID: 37498265 DOI: 10.1016/j.gie.2023.03.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/24/2023] [Indexed: 07/28/2023]
Abstract
This document from the American Society for Gastrointestinal Endoscopy (ASGE) provides a full description of the methodology used in the review of the evidence used to inform the final guidance outlined in the accompanying Summary and Recommendations document regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. This guideline used the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, the ASGE suggests surgical evaluation over endosic approaches.
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Affiliation(s)
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University Health Sciences Center, Paul Foster School of Medicine, El Paso, Texas, USA
| | - Nauzer Forbes
- Department of Medicine; Department of Community Health Sciences
| | - Nirav C Thosani
- Center for Interventional Gastroenterology (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | | | | | - Eugene P Ceppa
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Ilyas Sahin
- Division of Hematology and Oncology, Section of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - Yibing Ruan
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Cancer Epidemiology and Prevention Research, Cancer Care Alberta, Alberta Health Services, Calgary, Alberta, Canada
| | | | - Rebecca L Morgan
- Department of Health Research Methods, Evidence and Impact; Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada; School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Department of Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jean M Chalhoub
- Division of Gastroenterology and Hepatology, Department of Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Madhav Desai
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | | | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew C Storm
- Department of Gastroenterology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
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Forbes N, Elhanafi SE, Al-Haddad MA, Thosani NC, Draganov PV, Othman MO, Ceppa EP, Kaul V, Feely MM, Sahin I, Buxbaum JL, Calderwood AH, Chalhoub JM, Coelho-Prabhu N, Desai M, Fujii-Lau LL, Kohli DR, Kwon RS, Machicado JD, Marya NB, Pawa S, Ruan W, Sheth SG, Storm AC, Thiruvengadam NR, Qumseya BJ. American Society for Gastrointestinal Endoscopy guideline on endoscopic submucosal dissection for the management of early esophageal and gastric cancers: summary and recommendations. Gastrointest Endosc 2023; 98:271-284. [PMID: 37498266 DOI: 10.1016/j.gie.2023.03.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 03/23/2023] [Indexed: 07/28/2023]
Abstract
This clinical practice guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based summary and recommendations regarding the role of endoscopic submucosal dissection (ESD) in the management of early esophageal and gastric cancers. It is accompanied by the document subtitled "Methodology and Review of Evidence," which provides a detailed account of the methodology used for the evidence review. This guideline was developed using the Grading of Recommendations, Assessment, Development and Evaluation framework and specifically addresses the role of ESD versus EMR and/or surgery, where applicable, for the management of early esophageal squamous cell carcinoma (ESCC), esophageal adenocarcinoma (EAC), and gastric adenocarcinoma (GAC) and their corresponding precursor lesions. For ESCC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >15 mm, whereas in patients with similar lesions ≤15 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for such patients with ESCC, whenever possible. For EAC, the ASGE suggests ESD over EMR for patients with early-stage, well-differentiated, nonulcerated cancer >20 mm, whereas in patients with similar lesions measuring ≤20 mm, the ASGE suggests either ESD or EMR. For GAC, the ASGE suggests ESD over EMR for patients with early-stage, well- or moderately differentiated, nonulcerated intestinal type cancer measuring 20 to 30 mm, whereas for patients with similar lesions <20 mm, the ASGE suggests either ESD or EMR. The ASGE suggests against surgery for patients with such lesions measuring ≤30 mm, whereas for lesions that are poorly differentiated, regardless of size, we suggest surgical evaluation over endoscopic approaches.
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Affiliation(s)
- Nauzer Forbes
- Department of Medicine; Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Sherif E Elhanafi
- Division of Gastroenterology, Texas Tech University, Paul L. Foster School of Medicine, El Paso, Texas, USA
| | | | - Nirav C Thosani
- Center for Interventional Gastroenterology (iGUT), McGovern Medical School, UTHealth, Houston, Texas, USA
| | | | | | - Eugene P Ceppa
- Division of Surgical Oncology, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Ilyas Sahin
- Division of Hematology and Oncology, Section of Gastroenterology, University of Florida, Gainesville, Florida, USA
| | - James L Buxbaum
- Division of Gastrointestinal and Liver Diseases, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA
| | - Audrey H Calderwood
- Section of Gastroenterology and Hepatology, Department of Medicine, Geisel School of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Jean M Chalhoub
- Division of Gastroenterology and Hepatology, Department of Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York, USA
| | | | - Madhav Desai
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | | | - Divyanshoo R Kohli
- Pancreas and Liver Clinic, Providence Sacred Heart Medical Center, Spokane, Washington, USA
| | - Richard S Kwon
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jorge D Machicado
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Swati Pawa
- Department of Medicine, Section on Gastroenterology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Wenly Ruan
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Baylor College of Medicine, Texas Children's Hospital, Houston, Texas, USA
| | - Sunil G Sheth
- Division of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nikhil R Thiruvengadam
- Division of Gastroenterology and Hepatology, Loma Linda University, Loma Linda, California, USA
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Kouladouros K, Baral J. Transanal Endoscopic Microsurgical Submucosal Dissection for Recurrent Rectal Adenomas. Dig Dis 2022; 41:89-95. [PMID: 35203076 DOI: 10.1159/000523672] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 02/14/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND The local resection of recurrent rectal adenomas is a technically challenging task associated with increased local recurrence rate. Transanal endoscopic microsurgical submucosal dissection (TEM-ESD) uses traction to better expose the fibrotic submucosal layer, and therefore, is a valuable alternative for the treatment of such lesions. The aim of our study was to assess the feasibility and outcomes of TEM-ESD for the resection of recurrent rectal adenomas. METHODS We retrospectively analysed all TEM-ESD procedures performed in the Karlsruhe Municipal Hospital between 2012 and 2021 and isolated all cases of recurrent adenomas. Subsequently, we matched these cases 1:1 to TEM-ESD cases for primary rectal adenomas according to the size, localization, and histological type of the lesions and compared the outcomes between the two groups. RESULTS We identified 19 cases matching our criteria. The median diameter of the lesions was 25 mm and the median operating time 39 min. Macroscopic en bloc resection was achieved in 100% of the cases and histological complete en bloc resection in 78.9%. There was 1 case of conservatively treated postoperative bleeding. After a median follow-up period of 36 months, there was one local recurrence. After comparing those findings to the outcomes of TEM-ESD for primary rectal lesions, we found no significant differences on total operating time, complete en bloc resection rates, adverse events, and local recurrence. CONCLUSION TEM-ESD is a feasible therapeutic option for the resection of recurrent rectal adenomas, offering short operating times as well as high en bloc resection and low recurrence rates.
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Affiliation(s)
- Konstantinos Kouladouros
- Central Interdisciplinary Endoscopy Department, Mannheim University Hospital, University of Heidelberg, Mannheim, Germany
| | - Jörg Baral
- Surgery Department, Karlsruhe Municipal Hospital, Karlsruhe, Germany
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Traction-assisted endoscopic submucosal dissection reduces procedure time and risk of serious adverse events: a systematic review and meta-analysis. Surg Endosc 2021; 36:1775-1788. [PMID: 33825013 DOI: 10.1007/s00464-021-08452-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS Conventional endoscopic submucosal dissection (C-ESD) is a technically demanding procedure with prolonged procedure times and higher risk of adverse events. To overcome the procedural difficulty of ESD, several traction-assisted techniques (T-ESD) have been developed to improve visualization of the submucosa in hopes to facilitate safe and effective dissection. The aim of this study was to conduct a meta-analysis that compares short-term outcomes (30-day) of T-ESD to C-ESD. METHODS Clinical studies published up to April 2020 comparing the efficacy and safety of T-ESD and C-ESD were identified using electronic bibliographic searches. Both randomized controlled trials and observational studies were included. Outcomes of interests were procedure time, rates of en bloc and R0 resection, and rates of adverse events. Fixed effect and random effect model were used to calculate pooled mean difference for continuous variables and risk differences (RDs) for categorical variables. RESULTS Twenty-three studies with 2574 patients were included in this meta-analysis, with a total of 2582 lesions (1292 T-ESD and 1290 C-ESD). Pooled estimates of T-ESD showed shorter procedure times (weighted mean difference = -20.35 min, 95% CI -27.51 to -13.19, p < 0.001), higher R0 resection rates (RD 0.04, 95% CI 0.01-0.06, p = 0.004) and lower perforation rates (RD -0.03, 95% CI -0.04 to -0.01, p = < 0.0001). No significant differences were seen in en bloc rates and bleeding risk between the two groups. CONCLUSIONS Traction-assisted ESD results in shorter procedure time, improved R0 resection rates and lower risk of perforation as compared to conventional ESD.
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Embaye KS, Zhang C, Ghebrehiwet MA, Wang Z, Zhang F, Liu L, Qin S, Qin L, Wang J, Wang X. Clinico-pathologic determinants of non-e-curative outcome following en-bloc endoscopic submucosal dissection in patients with early gastric neoplasia. BMC Cancer 2021; 21:92. [PMID: 33482761 PMCID: PMC7824923 DOI: 10.1186/s12885-020-07762-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 11/09/2020] [Indexed: 02/08/2023] Open
Abstract
Background Endoscopic submucosal dissection (ESD) is gaining enormous popularity in the treatment of early gastric cancers (EGCs) in many institutions across the world. However, appropriate selection of candidates for endoscopic resection is crucial to sufficiently mitigate non-e-curative (NEC) resection. This study aims at identifying the various clinico-pathologic factors that independently predict the NEC outcome and depth of submucosal invasion following ESD procedure in patients with EGC. Methods Multiple logistic regression analysis was applied to investigate factors that independently predict both non-curability phenomenon and the level of submucosal invasion in patients with early gastric neoplasia. Statistical Packages for the Social Sciences version 23 was used for analysis. Results A total of 153 patients (162 EGC lesions) underwent en-bloc ESD after which the rate of complete resection and non-e-curative outcome were 95% and 22.2%, correspondingly. Multivariate analysis depicted that tumor location in the upper two third of stomach (odds ratio [OR], 5.46; 95% confidence interval [95% CI], 1.65–18.12; p = 0.006), tumor size > 2 cm (OR, 7.63; 95% CI, 2.29–25.42; p = 0.001), histologically undifferentiated tumor (OR, 15.54; 95% CI, 1.65–146.22; p = 0.001), and tumors with 0-IIa/0-IIc or their mixed variants with predominant 0-IIa/0-IIc (OR, 9.77; 95% CI, 1.23–77.65; p = 0.031) were all independent predictors of NEC resection for early gastric tumors. Additionally, location in the upper two third of the stomach (OR, 8.88; 95% CI, 2.90–27.17; p < 0.001), ulcerated lesions (OR, 3.70; 95% CI, 1.15–11.90; p = 0.028), lesions with > 2 cm (OR, 2.94; 95% CI, 1.08–8.02; p = 0.036) and those with poor differentiation (OR, 6.51; 95% CI, 2.23–18.98; p = 0.001) were found to have significant association with submucosal invasion. Conclusions Tumors located in the upper two third of the stomach having a larger size (> 2 cm), poor histo-differentiation and a gross type of 0-IIa/0-IIc or their mixed variants with predominant 0-IIa/0-IIc were significantly associated with a risk of NEC after ESD procedure. Thus, early gastric tumors displaying these features need to be handled carefully during endoscopic resection. Our findings may shed light on the pre-procedural detection of clinicopathologic factors that determine non-e-curability in patients with EGC.
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Affiliation(s)
- Kidane Siele Embaye
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Orotta College of Medicine and Health Sciences, Asmara, Eritrea
| | - Chao Zhang
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Matiwos Araya Ghebrehiwet
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.,Orotta College of Medicine and Health Sciences, Asmara, Eritrea
| | - Zhihao Wang
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Fengdi Zhang
- Wuhan Third Hospital (Tongren Hospital of Wuhan University), Wuhan, 430060, China
| | - Liwei Liu
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Shenghui Qin
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Lingzhi Qin
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Jun Wang
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China
| | - Xi Wang
- Institute of Pathology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, China.
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Choi YK, Kim DH, Gong EJ, Na HK, Ahn JY, Jung KW, Lee JH, Choi KD, Song HJ, Jung HY, Yook JH, Kim BS. Comparison Between Redo Endoscopic Treatment and Surgery in Patients with Locally Recurrent Gastric Neoplasms. J Gastrointest Surg 2020; 24:1489-1498. [PMID: 31313143 DOI: 10.1007/s11605-019-04303-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 06/07/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Treatment of locally recurrent gastric neoplasms after endoscopic resection remains challenging. We investigated the efficacy and safety of treatment options for recurrent gastric neoplasms localized to the scar of previous endoscopic submucosal dissection (ESD). METHODS The clinicopathological characteristics and treatment outcomes of patients who underwent endoscopic treatment or surgery for recurrent gastric neoplasms between June 2010 and May 2017 were retrospectively reviewed. RESULTS Of the 92 patients included, 74 underwent endoscopic treatment (51 redo ESD, 23 argon plasma coagulation [APC] ablation) and 18 underwent surgery. The redo ESD procedure time was significantly longer than that of the primary ESD (31.0 versus 22.0 min, p = 0.018). Overall, adverse events occurred in 11 patients (12.0%), with the incidence being significantly higher in the surgery group (27.8% versus 8.1% in the endoscopic treatment group, p = 0.036). Local recurrence-free survival rates were 81.1% for the endoscopic treatment group (86.3% and 69.6% for redo ESD and APC groups, respectively) and 100% for the surgery group (log rank p = 0.033). Logistic regression analysis showed that tumor size > 12.5 mm (odds ratio [OR] 5.14, 95% confidence interval [CI] 1.25-26.9, p = 0.032) and tumors located in the upper two-thirds of the stomach (OR 4.43, 95% CI 1.27-16.8, p = 0.023) were associated with non-curative resection after redo ESD. CONCLUSIONS Endoscopic treatment could be an effective and safe alternative to surgery for selected patients with gastric neoplasms recurring at the scar of previous ESD. Especially, patients having small lesions located in the distal part of the stomach could be a good candidate for redo ESD.
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Affiliation(s)
- Young Kwon Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea.
| | - Eun Jeong Gong
- Department of Internal Medicine, Gangneung Asan Hospital, Gangneung, South Korea
| | - Hee Kyong Na
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Kee Wook Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, South Korea
| | - Jeong Hwan Yook
- Department of Surgery Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Byung Sik Kim
- Department of Surgery Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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9
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Tao M, Zhou X, Hu M, Pan J. Endoscopic submucosal dissection versus endoscopic mucosal resection for patients with early gastric cancer: a meta-analysis. BMJ Open 2019; 9:e025803. [PMID: 31874864 PMCID: PMC7008428 DOI: 10.1136/bmjopen-2018-025803] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES To investigate the treatment effects of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) for early gastric cancer (EGC). DESIGN Meta-analysis. METHODS We systematically searched three electronic databases, including PubMed, EmBase and the Cochrane library for studies published with inception to January 2018. The eligible studies should be evaluated for the efficacy and safety of ESD versus EMR for patients with EGC. The summary ORs and standard mean differences (SMDs) with 95% CIs were employed as effect estimates. Sensitivity analyses were conducted to evaluate the impact of single study on overall analysis. Subgroup analyses were performed for investigated outcomes to evaluate the treatment effects of ESD versus EMR for patients with EGC with specific subsets. RESULTS Eighteen studies, with a total of 6723 patients with EGC, were included in final analysis. The summary ORs indicated that patients with EGC who received ESD were associated with an increased incidence of en bloc resection (OR: 9.00; 95% CI: 6.66 to 12.17; p<0.001), complete resection (OR: 8.43; 95% CI: 5.04 to 14.09; p<0.001) and curative resection (OR: 2.92; 95% CI: 1.85 to 4.61; p<0.001) when compared with EMR. Furthermore, ESD was associated with lower risk of local recurrence (OR: 0.18; 95% CI: 0.09 to 0.34; p<0.001). In addition, there was no significant difference between ESD and EMR for the risk of bleeding (OR: 1.26; 95% CI: 0.88 to 1.80; p=0.203). Though, ESD was correlated with greater risk of perforation (OR: 2.55; 95% CI: 1.48 to 4.39; p=0.001), and longer operation time (SMD: 1.12; 95% CI: 0.13 to 2.10; p=0.026) as compared with EMR. Additionally, several different features observed in included studies and patients could bias the effectiveness of ESD versus EMR in patients with EGC. CONCLUSIONS ESD is superior than EMR for en bloc resection, complete resection, curative resection and local recurrence, while it increased perforation risk and longer operation time.
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Affiliation(s)
- Maogen Tao
- Department of Gastroenterology, Lanxi People's Hospital, Lanxi, China
| | - Xiaobo Zhou
- Department of Gastroenterology, Lanxi People's Hospital, Lanxi, China
| | - Meiqing Hu
- Department of Gastroenterology, Lanxi People's Hospital, Lanxi, China
| | - Jun Pan
- Department of Gastroenterology, Lanxi People's Hospital, Lanxi, China
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10
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The optimal timing of additional surgery after non-curative endoscopic resection to treat early gastric cancer: long-term follow-up study. Sci Rep 2019; 9:18331. [PMID: 31797969 PMCID: PMC6892792 DOI: 10.1038/s41598-019-54778-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 11/19/2019] [Indexed: 12/14/2022] Open
Abstract
Patients with early gastric cancer (EGC) who undergo non-curative endoscopic resection (ER) require additional surgery. The aim of the study was to validate surgical and oncological outcomes according to the timing of additional surgery after non-curative endoscopic resection. We retrospectively analyzed long-term follow-up data on the 302 patients enrolled between January 2007 and December 2014. We validated our earlier suggestion that the optimal time interval from non-curative ER to additional surgery was 29 days. All patients were divided into two groups by reference to time intervals from ER to additional surgery of ≤29days (n = 133; group A) and >29 days (n = 169; group B). The median follow-up duration was 41.98 ± 21.23 months. As in our previous study, group B exhibited better surgical outcomes. A total of 10 patients developed locoregional or distant recurrences during the follow-up period, but no significant difference was evident between the two groups. Interestingly, the survival rate was better in group B. Group B (>29 days) exhibited better surgical and oncological outcomes. Thus, additional gastrectomy after non-curative ER should be delayed for 1 month to ensure optimal surgical and oncological outcomes.
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11
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Catalano F, Mengardo V, Trecca A, Tomezzoli A, Rodella L, Cerofolini A, Verlato G, de Manzoni G. The impact of experience on short- and long-term outcomes on gastric ESD: a western series. Updates Surg 2019; 71:359-365. [DOI: 10.1007/s13304-019-00628-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 01/28/2019] [Indexed: 12/18/2022]
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12
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Yamamoto S, Nishimura N, Mizuno M, Shimodate Y, Doi A, Mouri H, Matsueda K, Yamamoto H. Endoscopic Submucosal Dissection for Gastric-phenotype Adenoma on the Surface of Gastric Gastrointestinal Stromal Tumor. Intern Med 2019; 58:201-205. [PMID: 30210112 PMCID: PMC6378170 DOI: 10.2169/internalmedicine.1122-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
We herein report a rare case of a gastric adenoma overlying a gastrointestinal stromal tumor (GIST) that was removed by endoscopic submucosal dissection (ESD). A 78-year-old woman was referred to our hospital. Esophagogastroduodenoscopy revealed an elevated lesion of 15 mm in diameter overlying a submucosal mass in the gastric cardia. ESD was performed for the epithelial neoplasm, and biopsy specimens were obtained directly from the exposed surface of the submucosal tumor. The epithelial tumor was a tubular adenoma with focal severe atypia and a gastric phenotype. Biopsy specimens revealed a GIST, which was resected by laparoscopic intragastric surgery afterward.
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Affiliation(s)
- Shumpei Yamamoto
- Department of Gastroenterology, Kurashiki Central Hospital, Japan
| | | | - Motowo Mizuno
- Department of Gastroenterology, Kurashiki Central Hospital, Japan
| | - Yuichi Shimodate
- Department of Gastroenterology, Kurashiki Central Hospital, Japan
| | - Akira Doi
- Department of Gastroenterology, Kurashiki Central Hospital, Japan
| | - Hirokazu Mouri
- Department of Gastroenterology, Kurashiki Central Hospital, Japan
| | | | - Hiroshi Yamamoto
- Department of Gastroenterology, Kurashiki Central Hospital, Japan
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13
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Reggiani Bonetti L, Manta R, Manno M, Conigliaro R, Missale G, Bassotti G, Villanacci V. Optimal processing of ESD specimens to avoid pathological artifacts. Tech Coloproctol 2018; 22:857-866. [PMID: 30560321 DOI: 10.1007/s10151-018-1887-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 11/19/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND En bloc endoscopic submucosal dissection (ESD) has been recently introduced as a treatment for precancerous/neoplastic gastrointestinal conditions. The aim of the present study was histological assessment of en bloc ESD specimens. METHODS Fifty-three ESD specimens were positioned over a cellulose acetate support (40 specimens; 12 from the upper gastrointestinal tract and 28 from the lower gastrointestinal tract) or pinned with nails on polystyrene or cork (13 specimens; 7 from the upper gastrointestinal tract and 6 from the lower gastrointestinal tract). We cut consecutive 2 mm-thick sections stained with hematoxylin and eosin. From the first and the last sections, we obtained a second slide, after a 180° rotation and re-embedding. The quality of ESD samples was scored as inadequate, suboptimal and adequate, based on the amount of crushing, shearing and stretching artifacts that were scored from 0 (absent) to 2 (diffuse or maximum). From the sum of these we obtained a global artifact score (GAS). RESULTS Removed lesions were: adenocarcinoma (5 cases), neuroendocrine tumor (NET) G1 (1 case), premalignant conditions, including adenomatous polyps (41 cases) and hyperplastic lesions (6 cases). A positive deep surgical margin was found in 8/53 cases (15%): high- and low-grade dysplastic glands were detected in 5 cases, low-grade adenocarcinoma in 2, and NET cells in 1. Dysplastic glands were detected in the lateral surgical margins of 12 ESD specimens (23%). Among the ESD specimens positioned on the cellulose acetate support, apart from the modifications due to electrocoagulation, 2 (5%) showed shearing modifications. In the group of ESD specimens fixed with nails, 5 (38%) showed shearing, 10 (77%) crushing artifacts, 11 (85%) stretching and 11 (85%) multiple holes caused by the nails. On the basis of these data all histological specimens from ESD on cellulose acetate were adequate (GAS 0-1).However, in the group of ESD fixed with nails, 1 was adequate (GAS 0), 11 suboptimal (GAS 2-5) and 1 inadequate (GAS 6). CONCLUSIONS Specific devices including cellulose support and adequate sampling blocks can be helpful to perform accurate histological assessment of ESD specimens after en bloc ESD for precancerous/neoplastic gastrointestinal lesions, with complete analysis of the status of the margins and the entirely en bloc evaluation of the lesion.
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Affiliation(s)
- L Reggiani Bonetti
- Institute of Pathology of Modena Az., Ospedaliero-Universitaria Policlinico di Modena, Modena, Italy. .,Department of Diagnostic Medicine and Public Health, University of Modena and Reggio Emilia Section of Pathology, Via del Pozzo 71, 41100, Modena, Italy.
| | - R Manta
- Endoscopy Unit Ospedale Baggiovara, (NOCSAE), Baggiovara, Italy
| | - M Manno
- Digestive Endoscopy Unit, Carpi Hospital, Modena, Italy
| | - R Conigliaro
- Endoscopy Unit Ospedale Baggiovara, (NOCSAE), Baggiovara, Italy
| | - G Missale
- Endoscopy Unit Spedali Civili, Brescia, Italy
| | - G Bassotti
- Gastroenterology and Hepatology Section, Department of Medicine, University of Perugia School of Medicine, Perugia, Italy
| | - V Villanacci
- Institute of Pathology Spedali Civili, Brescia, Italy
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14
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Pittayanon R, Martel M, Barkun A. Role of mucoprotective agents in endoscopic submucosal dissection-derived ulcers: A systematic review. J Gastroenterol Hepatol 2018; 33:1948-1955. [PMID: 29870582 DOI: 10.1111/jgh.14305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Revised: 05/21/2018] [Accepted: 05/27/2018] [Indexed: 12/09/2022]
Abstract
BACKGROUND Currently, it is still unclear whether adding a mucoprotective agent to a proton pump inhibitor (PPI) results in better outcomes compared with using a PPI alone in patients with post-gastric endoscopic submucosal dissection (ESD) ulcers. This study aimed to examine the efficacy of PPI alone versus combination treatment in healing of post-gastric ESD ulcers, as well as on delayed bleeding and amount of blood transfused. METHODS A systematic search of MEDLINE, EMBASE, Cochrane, and ISI Web of knowledge databases, up until May 2017, for randomized trials comparing PPI alone versus PPI plus a mucoprotective drug in achieving ulcer healing in patients undergoing gastric ESD was performed. The primary outcome is scarring stage on endoscopic assessment at 4 or 8 weeks after gastric ESD. RESULTS From an initial 3071 citations, eight articles (n = 953 lesions from 934 patients) were analyzed. Patients receiving combination treatment achieved a scarring stage significantly more often than those on a PPIs alone at 4 or 8 weeks after ESD, (risk ratio = 1.36, 95% CI; 1.06-1.75). No study reported amount of blood transfused. There were no significant between treatment-group differences in terms of delayed bleeding (risk ratio = 0.58, 95% CI; 0.17-1.99). Neither location of ulcer nor Helicobacter pylori infection was related to ulcer scarring stage. CONCLUSION The limited evidences suggested combination treatment may be more effective in accelerating the process of ulcer healing in patients undergoing gastric ESD than the use of PPI alone, but does not appear to alter delayed bleeding risk.
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Affiliation(s)
- Rapat Pittayanon
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Canada.,Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital the Thai Red Cross, Bangkok, Thailand
| | - Myriam Martel
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Canada
| | - Alan Barkun
- Division of Gastroenterology, McGill University and the McGill University Health Centre, Montreal, Canada
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15
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Jung DH, Youn YH, Kim JH, Park JJ, Park H. Secondary endoscopic submucosal dissection for locally recurrent or incompletely resected gastric neoplasms. World J Gastroenterol 2018; 24:3776-3785. [PMID: 30197483 PMCID: PMC6127657 DOI: 10.3748/wjg.v24.i33.3776] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Revised: 07/31/2018] [Accepted: 08/01/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the feasibility and safety of secondary endoscopic submucosal dissection (ESD) for residual or locally recurrent gastric tumors.
METHODS Between 2010 and 2017, 1623 consecutive patients underwent ESD for gastric neoplasms at a single tertiary referral center. Among these, 28 patients underwent secondary ESD for a residual or locally recurrent tumor. Our analysis compared clinicopathologic factors between primary ESD and secondary ESD groups.
RESULTS The en bloc resection and curative rate of resection of secondary ESD were 92.9% and 89.3%, respectively. The average procedure time of secondary ESD was significantly longer than primary ESD (78.2 min vs 55.1 min, P = 0.004), and the adverse events rate was not significantly different but trended slightly higher in the secondary ESD group compared to the primary ESD group (10.7% vs 3.8%, P = 0.095). Patients who received secondary ESD had favorable outcomes without severe adverse events. During a mean follow-up period, no local recurrence occurred in patients who received secondary ESD.
CONCLUSION Secondary ESD of residual or locally recurrent gastric tumors appears to be a feasible and curative treatment though it requires greater technical efficiency and longer procedure time.
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Affiliation(s)
- Da Hyun Jung
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
| | - Young Hoon Youn
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
| | - Jie-Hyun Kim
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
| | - Jae Jun Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
| | - Hyojin Park
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 06273, South Korea
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16
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Zhao Y, Wang C. Long-Term Clinical Efficacy and Perioperative Safety of Endoscopic Submucosal Dissection versus Endoscopic Mucosal Resection for Early Gastric Cancer: An Updated Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:3152346. [PMID: 29568748 PMCID: PMC5820679 DOI: 10.1155/2018/3152346] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/10/2017] [Indexed: 02/07/2023]
Abstract
BACKGROUND To systematically evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) for early gastric cancer (EGC). METHODS We searched the databases of PubMed, Web of Science, EMBASE, and the Cochrane Library from January 2000 to April 2017 and included studies that compared the outcomes of ESD with EMR for EGC. These eligible studies that met the inclusion criteria were screened out and were assessed by two independent investigators. RESULT In total, 18 retrospective cohort studies were eligible for analysis. Our results indicated that ESD is more beneficial than EMR in increasing the complete resection rate and en bloc resection rate and decreasing the local recurrence rate. However, ESD prolonged operative time and increased incidence of gastric perforation than EMR. No differences were found in postoperative bleeding rate between the two approaches. CONCLUSION Compared with EMR, ESD offers higher complete resection rate, higher en bloc resection rate, and lower local recurrence rate but has prolonged operative time and increased incidence of gastric perfusion. There is no statistical difference in the rate of postoperative bleeding between the two groups. However, the above conclusion needs further verification by well-designed, randomized trials with larger samples and long follow-up periods.
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Affiliation(s)
- Yajie Zhao
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
| | - Chengfeng Wang
- Department of Pancreatic and Gastric Surgery, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100021, China
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17
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Jung Y. Management of gastrointestinal tract perforations. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii170016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Yunho Jung
- Division of Gastroenterology, Department of Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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18
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Ngamruengphong S, Abe S, Oda I. Endoscopic Management of Early Gastric Adenocarcinoma and Preinvasive Gastric Lesions. Surg Clin North Am 2017; 97:371-385. [PMID: 28325192 DOI: 10.1016/j.suc.2016.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Early gastric cancer (ECG) can be difficult to diagnose endoscopically. Endoscopists should be familiar with subtle changes and endoscopic features of EGC. Chromoendoscopy and image-enhanced endoscopy improve diagnostic accuracy and facilitate endoscopic resection. Endoscopic submucosal dissection is a preferred endoscopic technique for resection of EGC and offers a comparable overall survival to surgical resection. Endoscopic management of benign gastric epithelial polyps (fundic gland polyps, hyperplastic polyps, and gastric adenoma) depends on patient symptomatology, patient's comorbidities (eg, familial syndromes), lesions' characteristics, and risk of malignant transformation. This article provides an overview of endoscopic management of EGC and common premalignant gastric lesions.
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Affiliation(s)
- Saowanee Ngamruengphong
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Johns Hopkins Medical Institutions, 4940 Eastern Avenue, A Building, 5th Floor, Baltimore, MD 21224, USA.
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | - Ichiro Oda
- Endoscopy Division, National Cancer Center Hospital, 5-1-1, Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
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19
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Postoperative bleeding after gastric endoscopic submucosal dissection in patients receiving antithrombotic therapy. Gastric Cancer 2017; 20:207-214. [PMID: 26754296 DOI: 10.1007/s10120-015-0588-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Accepted: 12/21/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS It is controversial whether antithrombotic therapy increases the risk of bleeding after endoscopic submucosal dissection (ESD). The aim of this study was to evaluate the effects of antithrombotic therapy on gastric ESD. METHODS Patients who underwent gastric ESD at Toranomon Hospital between April 2005 and July 2014 were enrolled. The risk of post-ESD bleeding was evaluated by multivariate logistic regression analysis. RESULTS Of 1781 patients enrolled, 253 were taking an antithrombotic; 186 discontinued taking a single antithrombotic (n = 150) or multiple antithrombotics (n = 36) before ESD, whereas 15 continued taking a single antiplatelet agent and another 52 switched to heparin alternative therapy during the peri-ESD period. Post-ESD bleeding occurred in 101 patients (5.7 %): 68 patients (3.8 %) who did not take an antithrombotic, 11 patients (7.3 %) who discontinued taking a single antithrombotic, six patients (16.7 %) who discontinued taking multiple antithrombotics, one patient (6.7 %) who continued taking a single antiplatelet agent, and 15 patients (28.8 %) who switched to heparin therapy. In multivariate analysis, heparin alternative therapy [odds ratio (OR) 10.04, 95 % confidence interval (CI) 4.35-23.16], discontinuation of the use of multiple antithrombotics before ESD (OR 5.44, 95 % CI 2.00-14.79), tumor location in the lower third of the stomach (OR 2.17, 95 % CI: 1.32-3.58), and a long procedure time (100 min or greater; OR 2.00, 95 % CI 1.25-3.20) were independent risk factors for post-ESD bleeding. Among 52 subjects who switched to heparin therapy, one developed acute renal infarction and one developed cerebral bleeding. CONCLUSIONS Because heparin alternative therapy significantly increases the risk of post-ESD bleeding and may not decrease the risk of thromboembolic events, other options should be considered for patients receiving anticoagulation therapy.
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20
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Pimentel-Nunes P, Libânio D, Dinis-Ribeiro M. Evaluation and Management of Gastric Superficial Neoplastic Lesions. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2016; 24:8-21. [PMID: 28848776 PMCID: PMC5553389 DOI: 10.1159/000450870] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 07/03/2016] [Indexed: 12/14/2022]
Abstract
Gastric cancer is one of the most common and lethal cancers in the world. In Portugal, it is a major health problem presenting one of the highest incidence rates among European countries. In most Western countries, gastric cancer is generally diagnosed in advanced stages. Nevertheless, with the widespread use of upper endoscopy, gastric superficial neoplastic lesions are being increasingly recognized and diagnosed. However, there are no clear recommendations regarding who should be screened for its presence and only recently guidelines concerning the evaluation and management of these lesions were published. In this review, we summarize the current scientific evidence regarding diagnosis and management of gastric superficial neoplastic lesions. Topics like screening, diagnosis, endoscopic evaluation, management, treatment, pathologic evaluation and follow-up of patients with these lesions are covered and areas of future research are discussed. Whenever possible, evidence-based recommendations are made, and on the other cases expert opinion is presented.
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Affiliation(s)
- Pedro Pimentel-Nunes
- Department of Gastroenterology, Portuguese Oncology Institute, Porto, Portugal.,Department of Physiology, Faculty of Medicine, University of Porto, Porto, Portugal.,CINTESIS/Department of Biostatistics and Medical Informatics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Diogo Libânio
- Department of Gastroenterology, Portuguese Oncology Institute, Porto, Portugal.,CINTESIS/Department of Biostatistics and Medical Informatics, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Mário Dinis-Ribeiro
- Department of Gastroenterology, Portuguese Oncology Institute, Porto, Portugal.,CINTESIS/Department of Biostatistics and Medical Informatics, Faculty of Medicine, University of Porto, Porto, Portugal
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21
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Li Y, Wu JH, Meng Y, Zhang Q, Gong W, Liu SD. New devices and techniques for endoscopic closure of gastrointestinal perforations. World J Gastroenterol 2016; 22:7453-7462. [PMID: 27672268 PMCID: PMC5011661 DOI: 10.3748/wjg.v22.i33.7453] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 05/30/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Gastrointestinal perforations, which need to be managed quickly, are associated with high morbidity and mortality. Treatments used to close these perforations range from surgery to endoscopic therapy. Nowadays, with the development of new devices and techniques, endoscopic therapy is becoming more popular. However, there are different indications and clinical efficacies between different methods, because of the diverse properties of endoscopic devices and techniques. Successful management also depends on other factors, such as the precise location of the perforation, its size and the length of time between the occurrence and diagnosis. In this study, we performed a comprehensive review of various devices and introduced the different techniques that are considered effective to treat gastrointestinal perforations. In addition, we focused on the different methods used to achieve successful closure, based on the literature and our clinical experiences.
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22
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Li H, Huo ZB, Chen SB, Li H, Wu DC, Zhai TS, Xiao QH, Wang SX, Zhang LL. Feasibility study on expanded indication for endoscopic submucosal dissection of intramucosal poorly differentiated early gastric cancer. World J Gastroenterol 2016; 22:6736-6741. [PMID: 27547016 PMCID: PMC4970474 DOI: 10.3748/wjg.v22.i29.6736] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Revised: 05/20/2016] [Accepted: 06/28/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify clinicopathological factors predictive of lymph node metastasis (LNM) in intramucosal poorly differentiated early gastric cancer (EGC), and further to expand the possibility of using endoscopic submucosal dissection (ESD) for the treatment of intramucosal poorly differentiated EGC.
METHODS: Data for 81 surgically treated patients with intramucosal poorly differentiated EGC were collected, and the association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Several clinicopathologic factors were investigated to identify predictive factors for lymph nodes metastasis, including gender, age, family history of gastric cancer, number of tumors, tumor location, ulceration, tumor size, macroscopic type, lymphatic vessel involvement, and signet-ring-cell component.
RESULTS: Tumor size (OR = 7.273, 95%CI: 1.246-29.918, P = 0.042), lymphatic vessel involvement (OR = 42.219, 95%CI: 1.923-97.052, P = 0.018) and signet-ring-cell component (OR = 17.513, 95%CI: 1.647-77.469, P = 0.034) that were significantly associated with LNM by univariate analysis, were found to be significant and independent risk factors for LNM by multivariate analysis. However, gender, age, family history of gastric cancer, number, location, ulceration and macroscopic type of tumor were found not to be associated with LNM. Of these 81 patients diagnosed with intramucosal poorly differentiated EGC, 7 (8.6%) had LNM. The LNM rates were 9.1%, 22.2% and 57.1%, respectively, in cases with one, two and three of the risk factors. There was no LNM in 54 patients without the three risk clinicopathological factors.
CONCLUSION: Tumor size, lymphatic vessel involvement and signet-ring-cell component are independently associated with the presence of LNM in intramucosal poorly differentiated EGC. Thus, these three risk factors may be used as a simple criterion to expand the possibility of using ESD for the treatment of intramucosal poorly differentiated EGC.
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Na HK, Choi KD, Ahn JY, Lee JH, Kim DH, Song HJ, Lee GH, Jung HY, Kim JH. Endoscopic prediction of recurrence in patients with early gastric cancer after margin-negative endoscopic resection. J Gastroenterol Hepatol 2016; 31:1284-90. [PMID: 26820101 DOI: 10.1111/jgh.13301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/20/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIM Although follow-up endoscopy is routinely performed after endoscopic resection (ER) for early gastric cancer (EGC), it remains unclear whether resection scar biopsies should also be taken. This study sought to predict local recurrence at the ER scar on the basis of endoscopic criteria after margin-negative EGC resection and to determine the necessity of taking scar biopsies. METHODS All consecutive patients with EGC who underwent margin-negative ER in June 1995 to December 2011 and developed recurrence at the scar were identified. Each case was matched by four controls with EGC and margin-negative ER but without local recurrence for age, sex, and en-bloc resectability (en-bloc vs. piecemeal resection). Endoscopic data were reviewed by consensus of two endoscopists. Key endoscopic criteria were gross morphology (evenly elevated, unevenly elevated, and flat), hyperemic change, mucosal defect, and spontaneous bleeding. RESULTS Of 3037 cases, which underwent margin-negative ER, 22 developed local recurrence (mean age, 63.8 years; 72.9% male). En-bloc resection was achieved in 20 of the 22 (90.9%). Flat endoscopic morphology without hyperemic changes predicted non-recurrence at the scar with a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 95.5%, 68.2%, 2.6%, 99.94%, and 73.6%, respectively. For patients who underwent en-bloc resection for differentiated EGC, these values were 100%, 71.4%, 3.0%, 100%, and 75.8%, respectively. CONCLUSIONS Routine follow-up biopsies may be unnecessary when follow-up endoscopy reveals flat mucosa without hyperemic changes at the scar, especially for en-bloc resected and differentiated EGCs.
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Affiliation(s)
- Hee Kyong Na
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Kee Don Choi
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Ho June Song
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Korea
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Suzuki S, Gotoda T, Kobayashi Y, Kono S, Iwatsuka K, Yagi-Kuwata N, Kusano C, Fukuzawa M, Moriyasu F. Usefulness of a traction method using dental floss and a hemoclip for gastric endoscopic submucosal dissection: a propensity score matching analysis (with videos). Gastrointest Endosc 2016; 83:337-46. [PMID: 26320698 DOI: 10.1016/j.gie.2015.07.014] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Although endoscopic submucosal dissection (ESD) is a significant advancement in therapeutic endoscopy, it is a complicated technique and requires considerable expertise. In this exploratory study, we evaluated the efficacy of a simple traction method that uses dental floss and a hemoclip (DFC) and was developed to overcome the technical difficulties of ESD. METHODS In total, 238 early gastric cancers treated by ESD between May 2012 and December 2014 at Tokyo Medical University were retrospectively reviewed. Lesions treated by conventional ESD (n = 185) and by ESD with DFC (ESD-DFC) (n = 53) were compared. Multivariable analyses and propensity score matching were used to compensate for the differences in age, sex, resected specimen size, lesion location, lesion position, presence of ulceration, and operator level. The procedure time, rate of en bloc and complete resection, and rates of adverse events were evaluated between the 2 groups. RESULTS Propensity score matching analysis created 43 matched pairs. Adjusted comparisons between ESD-DFC and conventional ESD showed similar treatment outcomes (en bloc resection rate: 97.7% vs 100%, P = .315; complete resection rate: 90.7% vs 95.3%, P = .397; perforation during ESD rate: 2.3% vs 2.3%, P = 1.000; post-ESD bleeding rate: 4.7% vs 4.7%, P = 1.000) but a significantly shorter procedure time for ESD-DFC (82.2 ± 79.5 minutes vs 118.2 ± 71.6 minutes, P = .002). CONCLUSION ESD-DFC facilitated rapid ESD with good visualization and traction while ensuring high curability and safety.
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Affiliation(s)
- Sho Suzuki
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Yoshiyuki Kobayashi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Shin Kono
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Kunio Iwatsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naoko Yagi-Kuwata
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Chika Kusano
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | | | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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25
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Toyokawa T, Ohira M, Tanaka H, Minamino H, Sakurai K, Nagami Y, Kubo N, Yamamoto A, Sano K, Muguruma K, Tominaga K, Nebiki H, Yamashita Y, Arakawa T, Hirakawa K. Optimal management for patients not meeting the inclusion criteria after endoscopic submucosal dissection for gastric cancer. Surg Endosc 2015; 30:2404-14. [PMID: 26463497 DOI: 10.1007/s00464-015-4491-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 08/01/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND The necessity of additional gastrectomy for patients not meeting the inclusion criteria after endoscopic submu cosal dissection (ESD) is controversial. The aim of this study was to elucidate the risk factors for lymph node metastasis (LNM) and residual cancer (RC) in patients not meeting the inclusion criteria after ESD and to determine additional treatment strategies. METHODS Of 1443 gastric cancer patients who underwent ESD between 2004 and 2013, 167 patients diagnosed as having a lesion not meeting the inclusion criteria after ESD were retrospectively analyzed. Of the 167 cases, 100 cases underwent additional gastrectomy, and 67 cases were observed without surgery. RESULTS Overall, 9.0 % (9/100) and 9.0 % (9/100) of patients not meeting the inclusion criteria after ESD presented with LNM and RC, respectively, but neither was observed in 83 patients (83.0 %). Multivariate analysis revealed that lymphovascular involvement (LVI) (OR 38.38; 95 % CI 1.94-761.43, p = 0.017) and undifferentiated type (OR 45.58; 95 % CI 2.88-720.94, p = 0.007) were independent risk factors for LNM, and positive horizontal margin was an independent risk factor for RC (OR 9.48; 95 % CI 1.72-52.13, p = 0.010). In differentiated types without LVI, no cases had LNM (0/38) in the additional gastrectomy group, and there was no lymph node or distant recurrence (0/39) in the observation group. CONCLUSIONS Additional treatment is necessary for patients with LVI, undifferentiated type, and positive horizontal margin. Careful follow-up may be acceptable for patients with the differentiated type without LVI, especially for the elderly or patients with severe comorbidities.
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Affiliation(s)
- Takahiro Toyokawa
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masaichi Ohira
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Hiroaki Tanaka
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hiroaki Minamino
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Katsunobu Sakurai
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Naoshi Kubo
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Atsushi Yamamoto
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Koji Sano
- Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan
| | - Kazuya Muguruma
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kazunari Tominaga
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Hiroko Nebiki
- Department of Gastroenterology, Osaka City General Hospital, Osaka, Japan
| | - Yoshito Yamashita
- Department of Gastroenterological Surgery, Osaka City General Hospital, Osaka, Japan
| | - Tetsuo Arakawa
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kosei Hirakawa
- Department of Surgical Oncology, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno-ku, Osaka, 545-8585, Japan
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26
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Li H, Chen L, Huo Z, Xi H, Cui J, Zhao X. Defining a Subgroup Treatable for Laparoscopic and Endoscopic Cooperative Surgery in Undifferentiated Early Gastric Cancer: the Role of Lymph Node Metastasis. J Gastrointest Surg 2015. [PMID: 26224040 DOI: 10.1007/s11605-015-2897-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recently, the use of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) and the development of laparoscopic and endoscopic cooperative surgery (LECS) have enabled either the preservation of the stomach or the minimization of the extent of partial resection. ESD has recently been practiced on a differentiated type of EGC. However, there is no clear evidence for endoscopic treatments of undifferentiated EGC. The purposes of this study are to investigate predictive factors of lymph node metastasis (LNM) in undifferentiated EGC and expand the possibility of using LECS for the treatment of undifferentiated EGC. METHODS Data from 116 patients with undifferentiated EGC and surgically treated were collected, and the association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios (OR) with 95 % confidence interval (95 % CI) were calculated. RESULTS The tumor size (OR = 11.748, 95 % CI 2.034-62.213, P = 0.008), depth of invasion (OR = 13.928, 95 % CI 1.971-92.434, P = 0.016), and lymphatic vessel involvement (OR = 11.522, 95 % CI 2.645-59.172, P = 0.021) that were significantly associated with LNM by univariate analysis were found to be significant and independent risk factors for LNM by multivariate analysis. The LNM rate was 5.9 % (4/68) and 29.2 % (14/48) with intramucosal and submucosal undifferentiated EGC, respectively. LNM was observed in 66.7 % (2/3) of patients with both risk factors (tumor larger than or equal to 2.0 cm and the presence of lymphatic vessel involvement (LVI)), but in none of 36 patients without the two risk factors in intramucosal undifferentiated EGC. The 5-year survival rates were 88.9, 72.4, and 33.3 %, respectively, in cases with none, one, and two of the risk factors, respectively, in intramucosal undifferentiated EGC (P < 0.05). CONCLUSIONS ESD alone may be a sufficient treatment for intramucosal undifferentiated EGC if the tumor is less than 2.0 cm in size and when LVI is absent upon postoperative histological examination. LECS is feasible and safe for patients with undifferentiated EGC.
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Affiliation(s)
- Hua Li
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.,Department of Surgical Oncology, Affiliated Xing Tai People Hospital of Hebei Medial University, Xingtai, 054001, Hebei Province, China
| | - Lin Chen
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China.
| | - Zhibin Huo
- Department of Surgical Oncology, Affiliated Xing Tai People Hospital of Hebei Medial University, Xingtai, 054001, Hebei Province, China
| | - Hongqing Xi
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Jianxin Cui
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
| | - Xudong Zhao
- Department of General Surgery, Chinese People's Liberation Army General Hospital, Beijing, 100853, China
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27
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Hwang JH, Konda V, Abu Dayyeh BK, Chauhan SS, Enestvedt BK, Fujii-Lau LL, Komanduri S, Maple JT, Murad FM, Pannala R, Thosani NC, Banerjee S. Endoscopic mucosal resection. Gastrointest Endosc 2015; 82:215-26. [PMID: 26077453 DOI: 10.1016/j.gie.2015.05.001] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/01/2015] [Indexed: 02/06/2023]
Abstract
EMR has become an established therapeutic option for premalignant and early-stage GI malignancies, particularly in the esophagus and colon. EMR can also aid in the diagnosis and therapy of subepithelial lesions localized to the muscularis mucosa or submucosa. Several dedicated EMR devices are available to facilitate these procedures. Adverse event rates, particularly bleeding and perforation, are higher after EMR relative to other basic endoscopic interventions but lower than adverse event rates for ESD. Endoscopists performing EMR should be knowledgeable and skilled in managing potential adverse events resulting from EMR.
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28
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Zhang Y, Huang L, Li L, Ji F. Endoscopic submucosal dissection for early gastric neoplasms in elderly patients. J Laparoendosc Adv Surg Tech A 2015; 24:391-8. [PMID: 24914925 DOI: 10.1089/lap.2013.0572] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To retrospectively evaluate the safety and feasibility of endoscopic submucosal dissection (ESD) for the treatment of early gastric cancer (EGC) in elderly patients ≥75 years of age. PATIENTS AND METHODS One hundred seventy-one patients (187 lesions) treated with ESD from January 2010 to September 2013 were enrolled in our study. Subjects were classified into two groups: elderly (age ≥75 years) or non-elderly (age <75 years). Clinicopathological characteristics, resectability, curability, complications, rates of local recurrence, and residual disease were evaluated. Association of clinicopathological characteristics of the lesions with immediate bleeding was analyzed. RESULTS No significant differences in clinical characteristics were observed. The incidences of comorbidity were significantly different between the elderly group and the non-elderly group (P<.001). Of the elderly patients, 54.3% had two or more underlying diseases compared with 18.4% of the non-elderly patients (P<.001). Of the 98.0% of elderly patients and 97.1% of younger patients who received en bloc resection, curative resection reached 94.1% and 96.3%, respectively. Immediate bleeding occurred in 15.2% of the elderly group and 4.8% of the non-elderly group (P=.044). Operation time differed significantly (P=.039). No apparent discrepancy was observed in perforation and delayed bleeding. The differences in the invasion depth were considered between the two groups (P=.001). Logistic regression analysis revealed that the rate of immediate bleeding was associated with invasion depth (P=.003). There were no differences in the follow-up period and rates of local recurrence and residual disease. CONCLUSIONS ESD is safe and feasible for elderly patients in the era of a graying population. Higher risk of immediate bleeding and longer operation time should be concerned.
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Affiliation(s)
- Yan Zhang
- 1 Department of Gastroenterology, The First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou, China
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29
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Cho JY. Is the Endoscopic Grasp-and-Traction Device Useful for Endoscopic Submucosal Dissection in Treating Early Gastric Cancer? Clin Endosc 2015; 48:181-2. [PMID: 26064814 PMCID: PMC4461658 DOI: 10.5946/ce.2015.48.3.181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 04/25/2015] [Accepted: 04/25/2015] [Indexed: 11/21/2022] Open
Affiliation(s)
- Joo Young Cho
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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30
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Rahmi G, Tanaka S, Ohara Y, Ishida T, Yoshizaki T, Morita Y, Toyonaga T, Azuma T. Efficacy of endoscopic submucosal dissection for residual or recurrent superficial colorectal tumors after endoscopic mucosal resection. J Dig Dis 2015; 16:14-21. [PMID: 25366265 DOI: 10.1111/1751-2980.12207] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Superficial colorectal tumors can be treated effectively by endoscopic submucosal dissection (ESD). Few data are available on using ESD for residual or recurrent tumors after the first endoscopic resection. This study aimed to evaluate the efficacy of ESD for these lesions. METHODS In all, 28 patients with residual or recurrent superficial colorectal tumors were referred to the Kobe University Hospital for ESD. The therapeutic outcomes and the possible factors predictive of procedure difficulties for ESD were analyzed. RESULTS In total, 27 (96.4%) patients were successfully treated using ESD. There was no related immediate complication. One patient had a delayed perforation which was then treated surgically. En bloc R0 resection was possible in all the patients and curative resection in 26 patients (92.9%). One invasive cancer was treated surgically. More than one previous endoscopic resection was the only significant predictive factor for the difficulty in performing ESD. None of the patients experienced recurrence during a follow-up of 22 months (range 3-41 months). CONCLUSIONS The use of ESD allowed a high rate of en bloc resection for residual or locally recurrent colorectal tumors. Furthermore, these lesions should be treated by ESD as a first-line treatment.
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Affiliation(s)
- Gabriel Rahmi
- Department of Hepatogastroenterology and Digestive Endoscopy, Université Paris Descartes, Georges Pompidou European Hospital, Paris, France
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Gotoda T, Kusano C, Moriyasu F. Future perspective of gastric cancer endotherapy. ANNALS OF TRANSLATIONAL MEDICINE 2014; 2:25. [PMID: 25333001 DOI: 10.3978/j.issn.2305-5839.2014.03.03] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/08/2014] [Accepted: 03/11/2014] [Indexed: 12/15/2022]
Abstract
Endoscopic resection of early gastric cancer (EGC) has proven safety and efficacy, and is the established standard of care in Japan. In the past decade, it is increasingly established worldwide. The endoscopic submucosal dissection (ESD) is superior to endoscopic mucosal resection (EMR) technique as it is designed to provide adequate staging and long-term curative therapy-based on the en bloc R0 specimen irrespective of the size and/or location of the tumor coupled with the reliable pathological specimen. However, ESD is still requiring skilled and experienced endoscopist to perform because of complex procedures, higher complication and causing long-time consuming. The learning and application of these relatively complex endoscopic techniques for EGC has been shown across the world. Thus, a standardized ESD training system is urgently needed to disseminate safe and effective ESD technique to practices with limited ESD experience. In recent years, several innovations providing solutions to easier and safer performance of ESD have emerged. Those increase control of surgical effectors manipulating the target tissue, and enhance performance in complex surgical tasks. Very recently, the use of the laparoscopic and endoscopic cooperative surgery (LECS) procedure is indicated for EGC that would be difficult to treat with ESD. As an ultimate gastric cancer endotherapy with a reasonable surgical time, LECS might be promising method at this stage. The indications for LECS for EGC could be expanded in the future, which could result in increasingly successful gastric cancer treatment.
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Affiliation(s)
- Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Chika Kusano
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Fuminori Moriyasu
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
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32
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Hoteya S, Iizuka T, Kikuchi D, Mitani T, Matsui A, Ogawa O, Furuhata T, Yamashta S, Yamada A, Kaise M, Yahagi N. Secondary endoscopic submucosal dissection for residual or recurrent tumors after gastric endoscopic submucosal dissection. Gastric Cancer 2014; 17:697-702. [PMID: 24310295 DOI: 10.1007/s10120-013-0325-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 11/24/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is a widely accepted technique for the management of gastric tumors. However, residual or recurrent tumors can occur after ESD; currently, there is no adequate management strategy for these tumors. Thus, the aim of the present study was to establish a strategy of secondary ESD (sESD) for cases with positive lateral margins (LM+), which cause post-ESD residual or recurrent tumors. METHODS Fifty-three lesions that were subjected to ESD were diagnosed as LM+ with suspected local residual tumor. The short- and long-term outcomes of early sESD (performed shortly after the initial ESD in LM+ cases to prevent local recurrence) were retrospectively compared with those of late sESD (performed after the detection of recurrent tumors). RESULTS Of the 53 LM+ cases, the local residual positive rate was 38.5 % (10/26) in those undergoing early sESD or additional surgery and the local recurrence rate was 29.6 % (8/27) in those that were not treated. Thus, the overall incidence of residual or recurrent tumors in LM+ cases was 34.0 % (18/53). Both early and late sESD had favorable outcomes with no severe complications: 100 % of early sESD resections were curative, compared with 86.7 % of late sESD resections, over the course of a mean (±SD) observation period of 50.8 ± 16.7 months. The performance of early sESD was significantly greater than that of late sESD (in terms of dissection speed). CONCLUSIONS Early sESD is more reliable than late sESD as a therapeutic strategy for salvaging residual tumors and for preventing recurrence. However, if a tumor has already recurred, late sESD remains useful.
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Affiliation(s)
- Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo, 105-8470, Japan,
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Training the next generation of Western endoscopists in endoscopic submucosal dissection. Gastrointest Endosc 2014; 80:680-683. [PMID: 25220512 DOI: 10.1016/j.gie.2014.07.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Accepted: 07/03/2014] [Indexed: 02/07/2023]
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34
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Long-term clinical outcomes of endoscopic resection for early gastric cancer. Surg Endosc 2014; 29:1223-30. [PMID: 25159644 DOI: 10.1007/s00464-014-3800-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 08/04/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND We aimed to evaluate long-term clinical outcomes of endoscopic resection for early gastric cancer (EGC). PATIENTS AND METHODS From 2005 through 2011, 961 patients with EGC were treated with endoscopic submucosal dissection (ESD). Patients were grouped as standard and expanded criteria, while those who did not meet the expanded criteria were regarded as the group beyond the expanded criteria. Complete resection rate and the long-term clinical outcomes were compared among the three groups. RESULTS Complete resection rate was significantly higher in the standard group than in expanded and beyond the expanded group; 96.1% for standard, 92.5% for expanded, 55.5% for beyond the expanded indication group. During a mean follow-up of 42 months, local tumor recurrence developed more frequently in beyond the expanded group (7.8%) than in the standard and expanded group (1.8%). Metachronous cancer incidence (6.5%) did not differ significantly between the three groups. Two-thirds of recurred or metachronous tumors were treated with additional ESD. Lymph node metastasis developed in 0.6%. Five-year overall survival rate was 94.8% (96.6% for standard, 94.2% for expanded, 84.4% for beyond expanded, P < 0.001) and disease-free survival rate was 99.1% (100, 99.3, 92.8%, respectively, P < 0.001). CONCLUSIONS Endoscopic resection for EGC showed favorable long-term clinical outcomes in the patients within the standard and expanded criteria, whereas less favorable clinical outcomes in the patients beyond the expanded criteria.
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35
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[Endolifter, a new tool for safe and rapid submucosal endoscopic dissection]. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014; 79:161-5. [PMID: 25028055 DOI: 10.1016/j.rgmx.2014.05.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2013] [Accepted: 05/21/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The effectiveness of endoscopic submucosal dissection (ESD) is similar to that of surgery in the treatment of early lesions. The technique requires a high level of technical skill. Training on biologic models and the mastering of accessories facilitate ESD. AIMS The aim was to evaluate the usefulness of the Endolifter in facilitating tissue exposure during ESD in an in vivo porcine model performed at the experimental surgery laboratory of the School of Medicine at the Universidad de São Paulo in Brazil. MATERIAL AND METHOD A study with an experimental design employing an in vivo porcine model was conducted on 5 Yorkshire pigs weighing 20-25kg. ESDs were performed using the Endolifter. Mucosal layer dissection was carried out with a dual knife and IT knife and all the endoscopic procedures were performed by a single expert endoscopist. RESULTS A total of 25 ESDs were performed, with a technical success rate of 100%. The mean dissection time was 12.34min (range: 10.40-14.50 min) and the mean lesion size was 2.7cm (range: 2.3-3.2cm). There were no episodes of bleeding or perforations during the procedures. CONCLUSIONS The Endolifter enables rapid and effective ESDs to be carried out. It is an applicable and easy-to-use device that can be manipulated by a single operator.
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Sato-Uemura R, Christiano-Sakai M, Duarte-Jordão R, Guimarães-Horneaux de Moura E, Velázquez-Aviña J, Sobrino-Cossío S, Sakai P. Endolifter, a new tool for safe and rapid submucosal endoscopic dissection. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014. [DOI: 10.1016/j.rgmxen.2014.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Gotoda T, Ho KY, Soetikno R, Kaltenbach T, Draganov P. Gastric ESD: current status and future directions of devices and training. Gastrointest Endosc Clin N Am 2014; 24:213-33. [PMID: 24679233 DOI: 10.1016/j.giec.2013.11.009] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic mucosal resection (EMR) of early gastric cancer, which has been proved to be safe and effective and is the established standard of care in Japan, has become increasingly established worldwide in the past decade. Endoscopic submucosal dissection (ESD) is superior to EMR, as it is designed to provide precise pathologic staging and long-term curative therapy based on an en bloc R0 specimen irrespective of the size and/or location of the tumor. However, ESD requires highly skilled and experienced endoscopists. The introduction of ESD to the Western world necessitates collaborations between Eastern and Western endoscopists, pathologists, and surgeons.
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Affiliation(s)
- Takuji Gotoda
- Department of Gastroenterology and Hepatology, Tokyo Medical University, 6-7-1, Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan.
| | - Khek-Yu Ho
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Level 10, NUHS Tower Block, 1E Kent Ridge Road, Singapore 119228
| | - Roy Soetikno
- Department of Gastroenterology and Hepatology, Veterans Affairs Palo Alto, Stanford University, 3801 Miranda Avenue, GI-111, Palo Alto, CA 94304, USA
| | - Tonya Kaltenbach
- Department of Gastroenterology and Hepatology, Veterans Affairs Palo Alto, Stanford University, 3801 Miranda Avenue, GI-111, Palo Alto, CA 94304, USA
| | - Peter Draganov
- Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1600 SW Archer Road, Room HD 602, PO Box 100214, Gainesville, FL 32610, USA
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Shim JH, Song KY, Jeon HM, Park CH, Jacks LM, Gonen M, Shah MA, Brennan MF, Coit DG, Strong VE. Is gastric cancer different in Korea and the United States? Impact of tumor location on prognosis. Ann Surg Oncol 2014; 21:2332-9. [PMID: 24599411 DOI: 10.1245/s10434-014-3608-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Indexed: 12/15/2022]
Abstract
PURPOSE To compare the characteristics and prognoses of gastric cancers by tumor location in Korean and U.S. subjects after curative-intent (R0) resection for gastric cancer (GC). METHODS Data were collected for all patients who had undergone R0 resection at one U.S. institution (n = 567) and one South Korean institution (n = 1,620). Patients with gastroesophageal junction tumors or neoadjuvant therapy were excluded. Patient, surgical, and pathologic variables were compared by tumor location. Factors associated with disease-specific survival (DSS) were determined via multivariate analysis. RESULTS In the Korean cohort, significantly more upper third GC (UTG) patients had undifferentiated, diffuse type, and advanced stage cancers compared to lower third GC (LTG) and middle third GC (MTG) patients. In the U.S. cohort, however, T stage was relatively evenly distributed among UTG, MTG, and LTG patients. The independent predictors of DSS in the Korean cohort were T stage, tumor size, retrieved and positive lymph node counts, and age, but in the U.S. cohort, the only independent predictors were T stage and positive lymph node count. Tumor size significantly affected DSS of Korean UTG patients but not U.S. UTG patients. CONCLUSIONS There were significant differences in tumor characteristics by tumor location within and between both national cohorts. On the basis of these findings, further study to investigate the biological difference between the two countries is needed.
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Affiliation(s)
- Jung Ho Shim
- Department of Surgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
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Clinicopathologic factors and outcomes of histologic discrepancy between differentiated and undifferentiated types after endoscopic resection of early gastric cancer. Surg Endosc 2014; 28:2097-105. [PMID: 24488356 DOI: 10.1007/s00464-014-3441-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 01/12/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Histologic discrepancies among specimens obtained by forceps biopsy and endoscopic resection (ER) between the differentiated and undifferentiated types often occur in early gastric cancer (EGC). This study aimed to evaluate the predictive clinicopathologic characteristics and clinical implications of histologic discrepancies in EGC. METHODS From August 2005 to March 2012, 596 lesions from 579 patients underwent ER for EGC. The lesions studied were diagnosed as the differentiated histologic type from forceps biopsy specimens. The lesions were grouped according to the occurrence of histologic discrepancy between the differentiated and undifferentiated types in specimens obtained by ER as concordant (n = 570) or discordant (n = 26). The main outcome measures were en bloc resection, complete resection, and curative resection rates. RESULTS The histologic discrepancy rate was 4.4% among the studied lesions. Larger size, lesion location in the mid third of the stomach, easy friability, exudates, and submucosal invasion shown on endoscopic ultrasound were significantly related to histologic discrepancy in the univariate analysis. In the multivariate analysis, lesion location in the mid third of the stomach [odds ratio (OR) 5.34, 95% confidence interval (CI) 1.59-19.13] and easy friability (OR 29.26, 95% CI 2.30 to >999.9) were significant factors associated with histologic discrepancy. The complete resection and curative resection rates were significantly lower and the additional operation rates after ER were significantly higher in the discordant group. CONCLUSIONS The EGCs with histologic discrepancy between the differentiated and undifferentiated types changed the therapeutic outcomes of ER. Easily friable lesions located in the mid third of the stomach carry a significant risk for histologic discrepancy in undifferentiated histology when ER of EGCs is performed.
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Ohnita K, Isomoto H, Shikuwa S, Yajima H, Minami H, Matsushima K, Akazawa Y, Yamaguchi N, Fukuda E, Nishiyama H, Takeshima F, Nakao K. Early and long-term outcomes of endoscopic submucosal dissection for early gastric cancer in a large patient series. Exp Ther Med 2014; 7:594-598. [PMID: 24520251 PMCID: PMC3919913 DOI: 10.3892/etm.2014.1488] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Accepted: 12/31/2013] [Indexed: 12/12/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) enables the curative resection of early gastric cancer (EGC); however, little information is available on the long-term outcomes of ESD. This study was conducted to clarify the clinical outcomes of a large number of patients with EGC who underwent ESD. The early outcomes were assessed in 1,209 patients and the long-term outcomes were assessed in 300 patients at a follow-up >5 years after the ESD procedure. The overall survival rates were compared between indication and expanded-indication groups, and between the patients who did or did not undergo additional surgery in an out-of-indication group. Overall survival rates were also compared among different age groups. In total, 617 lesions were classed as the indication group, 507 as the expanded-indication group and 208 as the out-of-indication group. Curative resection rates were 96.6% and 91.5% in the indication and expanded-indication groups, respectively. In terms of the long-term outcomes, 20 of the 146 patients in the indication group, 15 of the 105 patients in the expanded-indication group and one of the 23 patients who underwent additional surgery in the out-of-indication group succumbed due to causes other than gastric cancer. Among the 26 patients who did not undergo additional surgery in the out-of-indication group, 10 mortalities occurred, including one due to gastric cancer. The five-year survival rates were not significantly different between the indication and expanded-indication groups. In the out-of-indication group, the five-year survival rate for the patients who did not undergo additional surgery (65.0%) was significantly lower than that for those who did undergo additional surgery (100%) (P<0.01). The five-year survival rate of patients aged >80 years (67.1%) was significantly lower than that of the younger patients (<60 years, 91.6%; sixties, 93.0%; seventies, 84.5%) (P<0.0001). In conclusion, although expanded-indication of ESD for EGC is appropriate, comorbidities require consideration in elderly patients.
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Affiliation(s)
- Ken Ohnita
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Hajime Isomoto
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Saburo Shikuwa
- Sankokai Miyazaki Hospital, Isahaya-shi, Nagasaki 854-0066, Japan
| | - Hiroyuki Yajima
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Kayoko Matsushima
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Yuko Akazawa
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Naoyuki Yamaguchi
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Eiichiro Fukuda
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Hitoshi Nishiyama
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Fuminao Takeshima
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki-shi, Nagasaki 852-8501, Japan
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Raju GS. Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks. Dig Endosc 2014; 26 Suppl 1:95-104. [PMID: 24373001 DOI: 10.1111/den.12191] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023]
Abstract
Development of endoscopic devices to close perforations has certainly revolutionized endoscopy. Immediate closure of perforations eliminates the need for surgery, which allows us to push the limits of endoscopic surgery from the mucosal plane to deep submucosal layers and eventually transmurally. The present article focuses on endoscopic closure devices, closure techniques, followed by a review of animal and clinical studies on endoscopic closure of perforations.
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Affiliation(s)
- Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, USA
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Teoh AYB, Chiu PWY. Collaboration between laparoscopic surgery and endoscopic resection: an evidence-based review. Dig Endosc 2014; 26 Suppl 1:12-9. [PMID: 24188505 DOI: 10.1111/den.12193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Accepted: 09/18/2013] [Indexed: 02/08/2023]
Abstract
Developments in endoscopy and laparoscopy have made monumental changes to the way gastrointestinal diseases are being managed. Many diseases that were traditionally managed by open surgical resection could now be treated by endoscopy alone. However, there are still instances where endoscopic treatment alone is inadequate for disease control and laparoscopic surgery is required. In addition, the collaboration between laparoscopic surgery and endoscopic submucosal dissection or other endoscopic resectional techniques represents a new frontier for further research. The present manuscript aims to discuss the complementary role of laparoscopic surgery to endoscopic resection in the traditional context and also its future development.
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Affiliation(s)
- Anthony Yuen Bun Teoh
- CUHK Jockey Club Minimally Invasive Surgical Skills Center and Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
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Safety and patient satisfaction of early diet after endoscopic submucosal dissection for gastric epithelial neoplasia: a prospective, randomized study. Surg Endosc 2013; 28:1321-9. [DOI: 10.1007/s00464-013-3336-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 11/10/2013] [Indexed: 12/16/2022]
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Kim MJ, Kim JH, Lee YC, Kim JW, Choi SH, Hyung WJ, Noh SH, Youn YH, Park H, Lee SI. Is there an optimal surgery time after endoscopic resection in early gastric cancer? Ann Surg Oncol 2013; 21:232-9. [PMID: 24100960 DOI: 10.1245/s10434-013-3299-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND The patients with early gastric cancer who have undergone incomplete endoscopic resection (ER) generally need additional surgery because of the possibility of lymph node metastasis. The aim of study was to evaluate the optimal time interval from ER to additive surgery by evaluating the effect of time interval on the surgical and oncological outcomes. METHODS We analyzed 154 patients who underwent additive gastrectomy after incomplete ER at Severance and Gangnam Severance Hospitals. The time interval point, at which operative time and estimated intraoperative blood loss (EBL) of the earlier operation group and the later operation group showed the greatest disparities, was evaluated. The patients were divided into 2 groups according to the time interval point, as the earlier operation group (group A) and the later operation group (group B). We retrospectively evaluated the clinicopathological characteristics and surgical and oncological outcomes. RESULTS The greatest difference between operative time and EBL was in the groups who underwent operation before and after 29 days. Of the 154 patients, 78 were in group A (≤29 days) and 76 in group B (>29 days). There were no differences in the clinicopathological characteristics and oncological outcomes except for tumor size. The operative time and EBL were significantly longer and more in group A compared with group B. CONCLUSIONS The time interval between ER and additive surgery is associated with surgical outcomes. Additive surgery at about 1 month after ER may be optimal for better surgical outcomes without affecting the oncological outcomes.
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Affiliation(s)
- Moo Jung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Koh R, Hirasawa K, Yahara S, Oka H, Sugimori K, Morimoto M, Numata K, Kokawa A, Sasaki T, Nozawa A, Taguri M, Morita S, Maeda S, Tanaka K. Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms. Gastrointest Endosc 2013; 78:476-83. [PMID: 23622974 DOI: 10.1016/j.gie.2013.03.008] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 03/06/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND The discontinuation of antithrombotic drugs is recommended during endoscopic submucosal dissection (ESD) for gastric neoplasms; however, controversy remains as to whether antithrombotic drugs are risk factors for postoperative bleeding. OBJECTIVE To determine the risk factors for post-ESD bleeding. DESIGN Single-institution, retrospective review. SETTING University hospital. PATIENTS From June 2000 to December 2010, we treated 1192 gastric neoplasms in 1032 consecutive patients. INTERVENTION The ESD procedures were performed by using the standard techniques. Antithrombotic drug therapy was principally interrupted preoperatively and was restarted when hemostasis was confirmed by second-look endoscopy. MAIN OUTCOME MEASUREMENTS Risk factors for postoperative bleeding after ESD (early, delayed, and overall [combined] occurrence of bleeding during the first 5 postoperative days or thereafter) were analyzed by using logistic regression analysis. RESULTS Among 1166 ESD-induced ulcer lesions, overall postoperative bleeding was evident in 62 lesions (5.3%); early and delayed bleeding occurred in 30 and 32 lesions (2.6% and 2.7%), respectively. Based on a multivariate analysis, a specimen size of >40 mm was the sole independent risk factor for overall bleeding. Moreover, oral antithrombotic drug therapy was selected as independent risk factor for delayed but not early bleeding, according to the multivariate analysis. The delayed bleeding rate in patients who had a specimen size of >40 mm and who used antithrombotic drugs was 11.6%. LIMITATIONS Retrospective design and single-site data collection. CONCLUSION Interruption of antithrombotic drug therapy may be adequate for preventing early post-ESD bleeding; however, reinitiating antithrombotic drug therapy is a significant independent risk factor for delayed post-ESD bleeding.
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Affiliation(s)
- Ryonho Koh
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
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Coman RM, Gotoda T, Draganov PV. Training in endoscopic submucosal dissection. World J Gastrointest Endosc 2013; 5:369-378. [PMID: 23951392 PMCID: PMC3742702 DOI: 10.4253/wjge.v5.i8.369] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Revised: 04/26/2013] [Accepted: 06/19/2013] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient’s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee’s background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.
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Abstract
Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient's quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee's background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.
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Affiliation(s)
- Roxana M Coman
- Roxana M Coman, Peter V Draganov, Division of Gastroenterology, Hepatology and Nutrition, University of Florida, Gainesville, Gainesville, FL 32610, United States
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Outcome of endoscopic submucosal dissection for gastric neoplasm in relationship to endoscopic classification of submucosal fibrosis. Gastric Cancer 2013; 16:404-10. [PMID: 23053827 DOI: 10.1007/s10120-012-0203-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2012] [Accepted: 09/23/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Whether submucosal fibrosis is related to ulceration and affects the outcome of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unknown. This study aimed to determine ESD outcome in relationship to degree of submucosal fibrosis of gastric epithelial neoplasms and to identify factors predictive of submucosal fibrosis. METHODS Eight hundred ninety-one patients with 1,027 gastric epithelial neoplasms were treated by ESD from April 2005 to January 2011. Complete en bloc resection and perforation rates in relationship to degree of submucosal fibrosis (F0, no fibrosis; F1; mild fibrosis; F2, severe fibrosis) were determined during ESD, as well as degree of concordance between endoscopically observed ulceration and pathologically determined ulceration and pathological fibrosis stained with Masson's trichrome. RESULTS The complete en bloc resection rate was significantly low and the perforation rate was high for F2 versus F0/F1 tumors. Ulceration, tumor size ≥30 mm, and depressed histological type were independent risk factors for severe (F2) fibrosis. No fibrosis (F0) was observed in 77% (732/951) of endoscopically negative ulceration cases, whereas fibrosis was observed in 100% (76/76) of endoscopically positive cases. Masson trichrome staining was weak in 97% (710/732) of F0, moderate in 85% (181/214) of F1, and strong in 100% (81/81) of F2 cases. CONCLUSIONS Histopathological type of submucosal fibrosis predicts outcome of ESD for EGC. Endoscopic indications of F2 submucosal fibrosis are ulceration, tumor ≥30 mm, and macroscopic depression.
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Choi MK, Kim GH, Park DY, Song GA, Kim DU, Ryu DY, Lee BE, Cheong JH, Cho M. Long-term outcomes of endoscopic submucosal dissection for early gastric cancer: a single-center experience. Surg Endosc 2013; 27:4250-8. [PMID: 23765426 DOI: 10.1007/s00464-013-3030-4] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2013] [Accepted: 05/10/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND In Korea, endoscopic submucosal dissection (ESD) has been widely accepted for the treatment of early gastric cancers (EGCs). However, the understanding of the long-term clinical outcome of ESD for EGC remains insufficient. Therefore, the aim of the present study was to assess the long-term clinical outcome and efficacy of ESD for the treatment of EGCs, including the clinical application of the expanded criteria for ESD. METHODS From January 2006 to December 2010, a total of 515 patients with 522 EGCs were treated by ESD in our hospital; study enrollment was based on the expanded criteria. Comparisons of resectability (en bloc or piecemeal resection), curability (curative or non-curative), and complications (bleeding and perforation) between the standard and expanded groups were assessed. Thereafter, 336 patients with 342 EGCs were finally included in a long-term analysis of local tumor recurrence, development of synchronous and metachronous cancers, and overall and disease-specific survival rates. RESULTS En bloc and curative resection rates of 96.7 % and 88.3 %, respectively, were achieved. The curative resection rate was significantly lower in the expanded group than in the standard group (82.1 % vs. 91.5 %, p = 0.001). During a median follow-up of 24 months, the local tumor recurrence rate was also higher in the expanded group than in the standard group (7.0 % vs. 1.8 %, p = 0.025). Local recurrence was more frequent in lesions with non-curative resection than in those with curative resection (20.0 % vs. 1.3 %, p < 0.001). The 5-year overall and disease-specific survival rates were 88 % and 100 %, respectively; the difference between the standard and expanded groups was not significant (p = 0.834). CONCLUSIONS ESD appears to be a feasible and effective method for treating EGCs, based on the standard and expanded criteria. Close follow-up surveillance, after ESD, should be standard for all patients.
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Affiliation(s)
- Mun Ki Choi
- Department of Internal Medicine, Pusan National University School of Medicine, 1-10, Ami-dong, Seo-gu, Busan, 602-739, Korea,
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Uedo N, Yao K, Ishihara R. Screening and treating intermediate lesions to prevent gastric cancer. Gastroenterol Clin North Am 2013; 42:317-35. [PMID: 23639643 DOI: 10.1016/j.gtc.2013.01.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Early gastric cancer is defined as adenocarcinoma confined to the mucosa or submucosa irrespective of lymph node involvement. In Japan, mucosal high-grade neoplasia is diagnosed as intramucosal early gastric cancer. Some early gastric cancers progress to advanced gastric cancer after several years of follow-up. Image-enhanced endoscopy (chromoendoscopy), narrow-band imaging, and magnifying endoscopy increase the diagnostic yield in characterizing early gastric cancer. Endoscopic resection of intramucosal early gastric cancer with endoscopic mucosal resection or endoscopic submucosal dissection is currently performed in East Asian countries to prevent the development of advanced gastric cancer and preserve patients' quality of life after treatment.
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Affiliation(s)
- Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan.
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