Endoscopic submucosal dissection allows less-invasive curative resection for gastric tube cancer after esophagectomy - a case series

Long-Term Outcomes of the Treatment for Gastric Tube Cancer After Esophagectomy for Esophageal Cancer

BACKGROUND

The long-term outcomes of gastric tube cancer (GTC) are unclear. This study therefore aimed to clarify clinicopathologic features and the long-term outcomes of patients with GTC.

METHODS

The 25 patients who were diagnosed with GTC between April 2003 and December 2022 at our hospital were eligible for inclusion in this retrospective study, and this included 27 lesions. We retrospectively evaluated clinicopathologic factors based on hospital records.

RESULTS

In our cohort, 88% of incidences of GTC were located in the middle or lower gastric tube. As the treatment of GTC, we used endoscopic submucosal dissection, gastrectomy, chemoradiotherapy, chemotherapy, and best supportive care for 16 (59%), 6 (22%), 1 (4%), 1 (4%), and 3 (11%) lesions, respectively. Perforation after endoscopic submucosal dissection was observed in 6 of the 16 lesions. Partial gastric tube resection was performed for 3 patients and total gastric tube resection was performed for 3 patients. One patient who underwent total gastric tube resection died due to acute respiratory distress syndrome. In survival analysis, the 3-year overall survival rate was 52% and the 3-year disease-specific survival rate was 74%. Five patients (20%) died of aspiration pneumonia, 2 patients (8%) of another disease, and 1 patient (4%) of another type of cancer. According to multivariate analysis, independent prognostic factors for overall survival were cN status (HR, 18.021; P=0.004) and complication of aspiration pneumonia (HR, 8.373; P=0.004).

CONCLUSIONS

The occurrence of aspiration pneumonia and cN status were prognostic factors after the treatment for GTC. Assessment of dysphagia and surveillance after treatment for GTC are important to improve the prognosis.

Safety and Efficacy of Endoscopic Submucosal Dissection in the Management of Gastric Tube Cancers After Esophagectomy: A Systematic Review

Esophagectomy is the proposed standard of care for resectable primary esophageal cancers and recurrent lesions in the reconstructed gastric tube (GT); however, it carries significant morbidity and mortality. Endoscopic submucosal dissection (ESD) has established its role in the management of primary esophageal cancers with growing evidence of its safety in resecting recurrent primary lesions in GT. Our study aims to evaluate the safety and efficacy of ESD in the management of recurrent, localized primary esophageal cancers in GT. We searched PubMed, CENTRAL, EMBASE, Scopus, and clinical trial registries from inception to March 2023 for articles evaluating the safety and efficacy of ESD in the management of recurrent cancerous lesions in GT. Our primary outcome was the en bloc resection rate. Secondary outcomes were curative resection rate, complete resection rate, intra-procedural complication rate, post-procedure complication rate, and five-year survival rate. Seven studies with a total of 165 patients undergoing 192 ESDs were included in the review. The pooled en bloc resection rate was 92.5% (95% CI: 87.7-95.6), which was reported in all seven studies. Pooled complete resection rate was 78.9% (95% CI: 64.5-88.5) per three studies, pooled curative resection rate was 73.9% (95% CI: 63.5-82.2) per four studies, and pooled intra-procedural complication rate was 10.2% (95% CI: 1.5-46.3), which was reported in four studies. Only three studies reported a five-year survival rate that was 65.5% (95% CI: 56.0-73.9). ESD is safe and efficacious in the management of GT cancer after esophagectomy.

Utility and Feasibility of Removing Surgical Staples from the Remnant Stomach or Gastric Conduit during Endoscopic Submucosal Dissection

Objective Endoscopic submucosal dissection (ESD) for gastric cancer in the remnant stomach poses some specific technical difficulties due to severe fibrosis and the presence of surgical staples. Therefore, we clarified the feasibility and safety of removing staples. Methods We retrospectively analyzed ESD outcomes of cases of gastric cancer in the remnant stomach. Materials This study reviewed 227 patients who underwent ESD for gastric cancer in the remnant stomach or gastric conduit. Patients were divided into those in whom resection extended to the anastomotic site or suture line (AS group; n=90) and those without such extension (non-AS group; n=137). The AS group was further divided into cases in which staples were removed (staple group; n=22) and those in which they were not (control group; n=68). Results The rates of specimen damage and curative resection and the duration and speed of the procedure were significantly worse in the AS group than the non-AS group. There were no significant differences between the staple group and the control group in the curative or complete resection rates, and no complications occurred in the staple group. In a propensity score-matched analysis, the rate of specimen damage was significantly lower in the staple group than in the control group (p=0.002), and the procedure speed tended to be faster (p=0.077). Conclusion Staple removal may improve the outcomes of ESD in patients with gastric cancer in the remnant stomach or gastric conduit by reducing the risk of specimen damage and increasing the procedure speed without complications.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Metachronous carcinoma of the gastric tube following tumour-associated oesophagectomy

INTRODUCTION

The prognosis of oesophageal carcinoma has improved during the last years. Thereby, the increasing survival has led to increasing occurrence of secondary gastric tube carcinoma (gastric conduit cancer, GTC) following oesophageal tumour resection.

MATERIAL AND PATIENTS

A literature review (EMBASE, PubMed), spanning the years 2000 to 2020, identified 342 patients worldwide with a GTC following tumour-related oesophagectomy, of which 306 patients could be included for further analysis.

RESULTS

The median age of 306 patients with GTC was 66.4 (39-80) years. 91.2% of patients (n = 279) were male. The median interval between oesophagectomy and GTC was 60.3 (4-236) months. 73.8% of patients (n = 226) were diagnosed as early cancer (EGC, T1) and 26.2% as advanced carcinoma (AGC, > T2; n = 80). Primary oesophagectomy was performed in 97.4% of patients (N = 298) for squamous cell carcinoma. AEG I carcinoma was present in only 5 patients (1.6%). In contrast, 99% (n = 303) of the GTC were found to be adenocarcinomas. One hundred eighty patients (58.8%) could be treated by endoscopic resection (ER). R0 resection was achieved in 82.8% (n = 149). The complication rate was 13.3% (n = 24) and the 30-day mortality 1.1% (n = 2) for ER. Eighty-three patients (27.1%) were treated surgically. These included 13 wedge resections, 25 partial resections and 45 total gastric graft resections with predominantly colon interposition. The R0 rate was 98.8% (n = 82). The postoperative morbidity was 24.1% (n = 20); the 90-day mortality was 6% (n = 5). In 43 patients (14%), palliative chemotherapy or radiotherapy or best supportive care took place. GTC diagnosed early in the EGC stage can be safely managed with ER. In cases of advanced GTC, surgical resection can be a potentially curative approach. Survival times of up to 120 months have been described after intervention for GTC.

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

Background/Aims

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

Methods

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

Results

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

Conclusions

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

Efficacy and safety of endoscopic submucosal dissection for gastric tube cancer: A multicenter retrospective study

BACKGROUND

Recent improvements in the prognosis of patients with esophageal cancer have led to the increased occurrence of gastric tube cancer (GTC) in the reconstructed gastric tube. However, there are few reports on the treatment results of endoscopic submucosal dissection (ESD) for GTC.

AIM

To evaluate the efficacy and safety of ESD for GTC after esophagectomy in a multicenter trial.

METHODS

We retrospectively investigated 48 GTC lesions in 38 consecutive patients with GTC in the reconstructed gastric tube after esophagectomy who had undergone ESD between January 2005 and December 2019 at 8 institutions participating in the Okayama Gut Study group. The clinical indications of ESD for early gastric cancer were similarly applied for GTC after esophagectomy. ESD specimens were evaluated in 2-mm slices according to the Japanese Classification of Gastric Carcinoma with curability assessments divided into curative and non-curative resection based on the Gastric Cancer Treatment Guidelines. Patient characteristics, treatment results, clinical course, and treatment outcomes were analyzed.

RESULTS

The median age of patients was 71.5 years (range, 57-84years), and there were 34 men and 4 women. The median observation period after ESD was 884 d (range, 8-4040 d). The median procedure time was 81 min (range, 29-334 min), the en bloc resection rate was 91.7% (44/48), and the curative resection rate was 79% (38/48). Complications during ESD were seen in 4% (2/48) of case, and those after ESD were seen in 10% (5/48) of case. The survival rate at 5 years was 59.5%. During the observation period after ESD, 10 patients died of other diseases. Although there were differences in the procedure time between institutions, a multivariate analysis showed that tumor size was the only factor associated with prolonged procedure time.

CONCLUSION

ESD for GTC after esophagectomy was shown to be safe and effective.

Distal gastric tube resection with vascular preservation for gastric tube cancer: A case report and review of literature

BACKGROUND

Survival rates in patients with esophageal cancer undergoing esophagectomy have improved, but the prevalence of gastric tube cancer (GTC) has also increased. Total resection of the gastric tube with lymph node dissection is considered a radical treatment, but GTC surgery is more invasive and involves a higher risk of severe complications or death, particularly in elderly patients.

CASE SUMMARY

We report an elderly patient with early GTC that had invaded the duodenum who was successfully treated with resection of the distal gastric tube and Roux-en-Y (R-Y) reconstruction. The tumor was a type 0-IIc lesion with ulcer scars surrounding the pyloric ring. Endoscopic submucosal resection was not indicated because the primary lesion was submucosally invasive, was undifferentiated type, surrounded the pyloric ring, and had invaded the duodenum. Resection of distal gastric tube with R-Y reconstruction was safely performed, with preservation of the right gastroepiploic artery (RGEA) and right gastric artery (RGA).

CONCLUSION

Distal resection of the gastric tube with preservation of the RGEA and RGA is a good treatment option for elderly patients with cT1bN0 GTC in the lower part of the gastric tube.

Gastric tube cancer after esophagectomy for cancer: a systematic review

Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim of this study was to review literature and evaluate outcomes and possible treatment strategies for GTC. A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus, and the Cochrane Library Central Register of Controlled Trials. No restriction was set for the type of publication, number, age, or sex of the patients. The search was limited to articles in English. Characteristics of esophageal cancer (EC) and its treatment and GTC and its treatment were analyzed. A total of 28 studies were analyzed, 12 retrospective analyses and 16 case reports, involving 229 patients with 250 GTCs in total. The majority of ECs (88.2%) were squamous cell carcinomas. In 120 patients (52.4%) a posterior mediastinal reconstructive route was used when esophagectomy was performed. The mean interval between esophagectomy and diagnosis of GTC was 55.8 months, with a median interval of 56.8 months (4-236 months). One hundred and twenty-four GTCs (49.6%) were located in the lower part of the gastric tube. One hundred and forty patients were endoscopically treated. Eighty-five patients underwent surgery. Thirty-six total gastrectomies with lymphadenectomy with colon or jejunal interposition were performed. Forty-three subtotal gastrectomies and 6 wedge resections were performed. The main reported postoperative complications were anastomotic leak, vocal cord palsy, and respiratory failure. Twenty-five patients were treated with palliative chemotherapy. Three-year survival rates were 69.3% for endoscopically treated patients, 58.8% for surgically resected patients, and 4% for patients who underwent palliative treatment. The feasibility of endoscopic resections in patients diagnosed with superficial GTC has been reported. Surgical treatment represented the preferred treatment method in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. The development of GTC should be taken into consideration during the extended follow-up of patients undergoing esophagectomy for cancer. Total gastrectomy plus lymphadenectomy should be considered the preferred treatment modality in operable patients with locally invasive tumor, when endoscopy is contraindicated. Long-term yearly endoscopic follow-up is recommended.

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

INTRODUCTION AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy and safety of endoscopic resection for gastric tube cancer after surgical resection of esophageal squamous cell carcinoma

BACKGROUND

Gastric tube cancers (GTCs) are found frequently, even as the surgical outcomes of esophageal cancer improve. Diagnosing and treating early gastric tube cancer endoscopically has therefore become very important.

AIMS

This study aimed to evaluate the clinical characteristics and outcomes of endoscopic resection for GTC.

METHODS

We analyzed 29 patients (33 lesions) with metachronous GTC who underwent endoscopic resection from April 2005 to August 2016 and evaluated their clinical characteristics and the short-term outcomes of endoscopic resection.

RESULTS

All of the cases were identified by periodic examinations. The lesions were found a median of 6.5 years after surgery (range 9 months-19 years), with six lesions found more than 10 years later. Among the total of 33 lesions, 28 resulted in curative resections (85%), and five were non-curative resections because of lymphovascular invasion, submucosal deep invasion, histological type, and size. None had received additional treatment or had a local recurrence thus far. Regarding the complications, delayed perforation occurred in a case (3%) and precordial skin burn occurred in four cases (12%).

CONCLUSION

The safety and efficacy of endoscopic resection for gastric tube cancer were evaluated. Additionally, it is important to continue annual endoscopy even 5 years or more after esophageal surgery.

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

Background and Aim

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

Patients and Methods

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

Results

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

Conclusion

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

Clinical characteristics and management of gastric tube cancer after esophagectomy

BACKGROUND

Gastric cancer is the second most common malignancy, overlapping with thoracic esophageal cancer (TEC). Among them, metachronous gastric tube cancers after TEC surgery have been increasing. The aims of this study were to examine the clinicopathological factors and treatment outcomes of gastric tube cancer (GTC) after TEC surgery.

METHODS

Thirty-three GTCs in 30 cases after TEC treated between 1997 and 2016 were investigated retrospectively.

RESULTS

Most cases were males. The median interval from TEC surgery to GTC occurrence was 57 (6.5-107.5) months. Almost 2/3 lesions occurred in the lower third of the gastric tube (21/33); 29 lesions (in 26 cases) were superficial cancers, and 4 lesions were advanced cancers. Twenty-two lesions of superficial cancer were differentiated type, and the remaining seven lesions were undifferentiated type. Treatment for superficial cancer had previously been performed with partial gastric tube resection (10 lesions), and the number of cases undergoing endoscopic submucosal dissection (ESD) had increased recently (19 lesions). Most cases with superficial cancer survived without relapse. Four lesions of advanced cancer were found after a relatively long interval following TEC surgery. Most lesions of advanced cancer were scirrhous, undifferentiated type, and they died due to GTC.

CONCLUSION

GTCs may occur late in the postoperative course following TEC surgery. If they are discovered at an early stage, these lesions can be cured with ESD. Long-term periodic endoscopic examinations after TEC surgery are important.

Endoscopic submucosal dissection to relieve a flexure of the gastric conduit after esophagectomy

Background and study aims  A 70-year-old-man underwent an esophagectomy and posterior mediastinal reconstruction for esophageal cancer that was curatively resected. Although the patient was allowed to eat after surgery, he repeatedly vomited after drinking water or eating meals and required continuous hospitalization. An upper gastrointestinal series and endoscopic examination revealed an obstruction due to the flexure of the gastric conduit, which was repeatedly treated with endoscopic balloon dilation. Endoscopic balloon dilation was completely ineffective, however, because the obstruction was not due to a small lumen diameter, but rather to severe flexure. We hypothesized that the power of contraction provided by ulcer scar formation after mucosal resection could straighten the flexure, and thus removed a piece of the mucosa 8 cm in diameter on the oral side of the flexure by endoscopic submucosal dissection (ESD) 4 months after the esophagectomy. Endoscopic examination on post-ESD Day 10 revealed that the gastric conduit flexure was straightened due to ulcer scarring, and obstruction at the flexure opened over time. Meals were restarted and the patient could eat without vomiting. He was discharged from the hospital 5 weeks after ESD. This is the first case report of obstruction due to flexure of the gastric conduit after esophagectomy that was successfully treated with mucosectomy using ESD. Mucosectomy using ESD may be an effective treatment option for obstruction due to flexure of the gastric conduit after esophagectomy.

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

Aims

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

Methods

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

Results

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

Conclusions

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

Precordial skin burns after endoscopic submucosal dissection for gastric tube cancer

BACKGROUND AND AIM

Endoscopic submucosal dissection (ESD) is useful as a minimally invasive treatment option for early gastric cancer. ESD is also used in the management of postoperative remnant gastric cancers in the stomach and gastric tube cancers. Perforation and delayed bleeding have been the main complications of ESD reported in the management of gastric tube cancer. However, in the current literature, there is no description of precordial skin burns caused by electrical coagulation.

METHODS

While we treated 22 patients with gastric tube cancers by ESD from 2005 to 2014, we experienced five skin burns in four patients after ESD. We retrospectively analyzed clinical characteristics of precordial skin burn as a complication of ESD.

RESULTS

All skin burns occurred in patients reconstructed using a presternal route, whose incidence of precordial skin burn was 55.6%. In all cases, lesions were located in the upper or middle third of gastric tubes irrespective of their direction. Skin burn developed on postoperative day (POD) 1 or POD 2, taking 4-7 days to heal and was accompanied by high fever in 60% of cases.

CONCLUSION

The present study suggests that when carrying out ESD for gastric tube cancer using the presternal route, it is necessary to consider the occurrence of a precordial skin burn as a possible complication.

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

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

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic submucosal dissection for gastric tube cancer after esophagectomy

BACKGROUND

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

OBJECTIVE

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

DESIGN

Retrospective study.

SETTING

National Cancer Center Hospital, Tokyo, Japan.

PATIENTS

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

INTERVENTION ESD MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

LIMITATION

Single-center retrospective study.

CONCLUSIONS

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

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic submucosal dissection and surgical treatment for gastrointestinal cancer

Endoscopic submucosal dissection (ESD) is widely used in Japan as a minimally invasive treatment for early gastric cancer. The application of ESD has expanded to the esophagus and colorectum. The indication criteria for endoscopic resection (ER) are established for each organ in Japan. Additional treatment, including surgery with lymph node dissection, is recommended when pathological examinations of resected specimens do not meet the criteria. Repeat ER for locally recurrent gastrointestinal tumors may be difficult because of submucosal fibrosis, and surgical resection is required in these cases. However, ESD enables complete resection in 82%-100% of locally recurrent tumors. Transanal endoscopic microsurgery (TEM) is a well-developed surgical procedure for the local excision of rectal tumors. ESD may be superior to TEM alone for superficial rectal tumors. Perforation is a major complication of ESD, and it is traditionally treated using salvage laparotomy. However, immediate endoscopic closure followed by adequate intensive treatment may avoid the need for surgical treatment for perforations that occur during ESD. A second primary tumor in the remnant stomach after gastrectomy or a tumor in the reconstructed organ after esophageal resection has traditionally required surgical treatment because of the technical difficulty of ER. However, ESD enables complete resection in 74%-92% of these lesions. Trials of a combination of ESD and laparoscopic surgery for the resection of gastric submucosal tumors or the performance of sentinel lymph node biopsy after ESD have been reported, but the latter procedure requires a careful evaluation of its clinical feasibility.

Endoscopic mucosal resection and endoscopic submucosal dissection in esophageal and gastric cancers

PURPOSE OF REVIEW

To summarize the literature to date on endoscopic mucosal removal techniques as applied to the upper gastrointestinal tract, predominantly the stomach and esophagus. This is an area that has rapidly advanced in terms of new procedures and techniques with a large body of outcomes that support their use.

RECENT FINDINGS

The resection techniques can be divided into two forms, mucosal resection and submucosal dissection. Mucosal resection is typically done with cap techniques and is more suitable for removable of neoplastic lesions that are less than 1.5 cm in size. Submucosal dissection techniques are more difficult, associated with increased complications, and typically reserved for lesions greater than 1.5 cm and less than 3 cm in size. Ideal lesions for mucosal resection are generally flat and are located in areas easily accessible by the endoscope.

SUMMARY

Endoscopic tissue removal methods are capable of removing neoplastic lesions en bloc in the upper gastrointestinal tract. These techniques fulfill cancer treatment guidelines by having histological confirmation of total removal of neoplastic lesions with assessment of the margins of resections. Long-term clinical outcomes of these techniques are emerging and seem promising in terms of disease-free and overall survival.