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Cheema HI, Tharian B, Inamdar S, Garcia-Saenz-de-Sicilia M, Cengiz C. Recent advances in endoscopic management of gastric neoplasms. World J Gastrointest Endosc 2023; 15:319-337. [PMID: 37274561 PMCID: PMC10236974 DOI: 10.4253/wjge.v15.i5.319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 01/12/2023] [Accepted: 04/06/2023] [Indexed: 05/16/2023] Open
Abstract
The development and clinical application of new diagnostic endoscopic technologies such as endoscopic ultrasonography with biopsy, magnification endoscopy, and narrow-band imaging, more recently supplemented by artificial intelligence, have enabled wider recognition and detection of various gastric neoplasms including early gastric cancer (EGC) and subepithelial tumors, such as gastrointestinal stromal tumors and neuroendocrine tumors. Over the last decade, the evolution of novel advanced therapeutic endoscopic techniques, such as endoscopic mucosal resection, endoscopic submucosal dissection, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection, along with the advent of a broad array of endoscopic accessories, has provided a promising and yet less invasive strategy for treating gastric neoplasms with the advantage of a reduced need for gastric surgery. Thus, the management algorithms of various gastric tumors in a defined subset of the patient population at low risk of lymph node metastasis and amenable to endoscopic resection, may require revision considering upcoming data given the high success rate of en bloc resection by experienced endoscopists. Moreover, endoscopic surveillance protocols for precancerous gastric lesions will continue to be refined by systematic reviews and meta-analyses of further research. However, the lack of familiarity with subtle endoscopic changes associated with EGC, as well as longer procedural time, evolving resection techniques and tools, a steep learning curve of such high-risk procedures, and lack of coding are issues that do not appeal to many gastroenterologists in the field. This review summarizes recent advances in the endoscopic management of gastric neoplasms, with special emphasis on diagnostic and therapeutic methods and their future prospects.
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Affiliation(s)
- Hira Imad Cheema
- Department of Internal Medicine, Baptist Health Medical Center, Little Rock, AR 72205, United States
| | - Benjamin Tharian
- Department of Interventional Endoscopy/Gastroenterology, Bayfront Health, Digestive Health Institute, St. Petersberg, FL 33701, United States
| | - Sumant Inamdar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Mauricio Garcia-Saenz-de-Sicilia
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
| | - Cem Cengiz
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, AR 72205, United States
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, John L. McClellan Memorial Veterans Hospital, Little Rock, AR 72205, United States
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, TOBB University of Economics and Technology, Ankara 06510, Turkey
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Zandanell S, Gensluckner S, Wolkersdoerfer G, Berr F, Dienhart C, Gantschnigg A, Singhartinger F, Wagner A. Feasibility of Continuous Monitoring of Endoscopy Performance and Adverse Events: A Single-Center Experience. Cancers (Basel) 2023; 15:cancers15030725. [PMID: 36765682 PMCID: PMC9913416 DOI: 10.3390/cancers15030725] [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] [Received: 12/23/2022] [Revised: 01/19/2023] [Accepted: 01/22/2023] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We integrated a standardized questionnaire focusing on adverse events and performance measures in gastrointestinal endoscopy as a mandatory component of the electronical medical record. METHODS This retrospective study was conducted using prospectively collected data on quality parameters and adverse events (AEPM) for all diagnostic and therapeutic endoscopic procedures at our center between 2018 and 2020. RESULTS A total of 7532 consecutive endoscopic procedures were performed in 5035 patients. The proportion of high-risk examinations and high-risk patients was 20% and 23%, respectively. Severe adverse events (AEs, n = 21) occurred in 0.3% of procedures and significantly more often in patients with an ASA score > II (0.6%, p < 0.01). We observed no long-term morbidity after severe AEs. Mortality was 0.03% (n = 2). Following screening colonoscopy (n = 242), four endoscopists documented AEPM in more than 98% of the examinations. The cecal intubation rate was 97%, and the mean adenoma detection rate 60%. The quality of lavage was documented in 97% (rated as good in 70% and moderate in 24%). CONCLUSIONS The risk of adverse events is significantly increased in patients with an ASA score > II, which should be considered when choosing treatment methods and precautionary measures. Continuous recording of AEPM can be effectively integrated into the clinical reporting process, enabling analysis of the data and feedback to be provided to endoscopists.
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Affiliation(s)
- Stephan Zandanell
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Sophie Gensluckner
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Gernot Wolkersdoerfer
- Department of Internal Medicine, Rotthalmünster Hospital, 94094 Rotthalmünster, Germany
| | - Frieder Berr
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- Laboratory for Tumour Biology and Experimental Therapies (TREAT), Institute of Physiology and Pathophysiology, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Christiane Dienhart
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
| | - Antonia Gantschnigg
- Department of Surgery, University Clinics Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Franz Singhartinger
- Department of Surgery, University Clinics Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Andrej Wagner
- Department of Internal Medicine I, University Clinics Salzburg, Paracelsus Medical University, Müllner Hauptstrasse 48, 5020 Salzburg, Austria
- Correspondence: ; Tel.: +43-57255-57561
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Horie Y, Horiuchi Y, Ishiyama A, Tsuchida T, Yoshimizu S, Hirasawa T, Fujisaki J, Maetani I, Yoshio T. The effect of antithrombotic drug use on delayed bleeding with esophageal endoscopic resection. J Gastroenterol Hepatol 2022; 37:1792-1800. [PMID: 35844140 DOI: 10.1111/jgh.15944] [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: 03/17/2022] [Revised: 07/02/2022] [Accepted: 07/11/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Whether antithrombotic drugs increase the risk of post-esophageal endoscopic resection bleeding is unknown. This study examined the effect of antithrombotic drugs, aspirin, thienopyridine, direct oral anticoagulants (DOAC), and warfarin, on post-esophageal endoscopic resection bleeding. METHODS We enrolled 957 patients (1202 esophageal tumors) treated with endoscopic resection and classified them based on antithrombotic drug use as no use, aspirin, thienopyridine, DOAC, and warfarin. Patients using antiplatelet drugs (i.e. aspirin and thienopyridine) were further sub-classified based on their continued or discontinued use before endoscopic resection. The bleeding rates were compared between these groups to assess the effects of antithrombotic drug use and interruption of antiplatelet therapy on post-esophageal endoscopic resection bleeding. RESULTS The post-endoscopic resection bleeding rate was 0.3% (95% CI, 0.1-1) in the group without antithrombotic drug use, 4.5% (95% CI, 0.1-23) in the aspirin-continued group, 2.9% (95% CI, 0.1-15) in the aspirin-discontinued group, 0% (95% CI, 0-78) in the replaced thienopyridine with aspirin group, 0% (95% CI, 0-26) in the thienopyridine-discontinued group, 13% (95% CI, 1.6-38) in the DOAC group, and 0% (95% CI, 0-45) in the warfarin group. The post-endoscopic resection bleeding rate in the DOAC group was significantly higher than that in the group without antithrombotic drugs (P = 0.003). The post-endoscopic resection bleeding rates did not differ between the other groups. CONCLUSIONS Our results suggest that discontinuing aspirin is not necessary for esophageal endoscopic resection while we must be careful regarding DOAC.
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Affiliation(s)
- Yoshimasa Horie
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan.,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Yusuke Horiuchi
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Akiyoshi Ishiyama
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Tomohiro Tsuchida
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Shoichi Yoshimizu
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Toshiaki Hirasawa
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Junko Fujisaki
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
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Risk factors of major intraoperative bleeding and postoperative bleeding associated with endoscopic submucosal dissection for gastric neoplasms. Chin Med J (Engl) 2022; 135:309-316. [PMID: 34999611 PMCID: PMC8812675 DOI: 10.1097/cm9.0000000000001840] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Endoscopic resection bleeding (ERB) classification was proposed by the authors’ team to evaluate the severity of intraoperative bleeding (IB) during endoscopic submucosal dissection (ESD). This study aimed to evaluate the application of ERB classification and to analyze the risk factors of major IB (MIB) and postoperative bleeding (PB) associated with ESD for gastric neoplastic lesions. Methods: We retrospectively enrolled a total of 1334 patients who underwent ESD between November 2006 and September 2019 at The First Medical Center of Chinese People's Liberation Army General Hospital. All patients were divided into the non-MIB group (including ERB-0, ERB-controlled 1 [ERB-c1], and ERB-c2) and the MIB group (including ERB-c3 and ERB-uncontrolled [ERB-unc]) according to the ERB classification. Risk factors of major MIB and risk factors of PB were analyzed using a logistic regression model. Results: Among the 1334 patients, 773 (57.95%) had ERB-0, 477 (35.76%) had ERB-c1, 77 (5.77%) had ERB-c2, 7 (0.52%) had ERB-c3, and no patients had ERB-unc. The rate of PB in patients with IB classifications of ERB-0, ERB-c1, ERB-c2, and ERB-c3 were 2.20% (17/773), 3.35% (16/477), 9.09% (7/77), and 2/7, respectively. In multivariate analysis, proximal location (odds ratio [OR]: 1.488; 95% confidence interval [CI]: 1.045–3.645; P = 0.047) was the only significant risk factor of MIB. Chronic kidney disease (CKD) (OR: 7.844; 95% CI: 1.637–37.583; P = 0.010) and MIB (ERB-c3) (OR: 13.932; 95% CI: 2.585–74.794; P = 0.002) were independent risk factors of PB. Conclusions: Proximal location of lesions was a significant risk factor of MIB. Additionally, CKD and MIB (ERB-c3) were independent risk factors of PB. More attention should be paid to these high-risk patients for MIB and PB.
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Kim B, Kim BJ, Yoon HJ, Lee H, Park JY, Choi CH, Kim JG. Atypical Scar Patterns after Gastric Endoscopic Submucosal Dissection. THE KOREAN JOURNAL OF HELICOBACTER AND UPPER GASTROINTESTINAL RESEARCH 2021. [DOI: 10.7704/kjhugr.2020.0047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background/Aims: Endoscopic submucosal dissection (ESD) for gastric neoplasms is a widely performed procedure. Local recurrence is rare, but various post-ESD scars are encountered during follow-up endoscopy. Therefore, we investigated atypical scar patterns and evaluated the associated factors.Materials and Methods: Clinicopathologic and endoscopic reviews of gastric neoplasms treated with ESD from January 2009 to December 2015 were conducted. Atypical scar patterns were classified as irregular erythema, nodularity, or mucosal defect.Results: A total of 264 patients with 274 gastric neoplasms, including 201 adenomas and 73 early gastric cancers, were enrolled. The key endoscopic findings at the resection scar were defined on the basis of gross morphology as follows: irregular erythema, mucosal defect (erosion or ulcer), and nodularity. An irregular erythema scar pattern was associated with male sex, a nodularity scar pattern with smoking, and a mucosal defect scar pattern with infra-angle location (angle and antrum) and cancer. An irregular erythema with nodularity scar pattern was also associated with male sex. An irregular erythema with nodularity and mucosal defect scar pattern was associated with liver disease and chronic kidney disease.Conclusions: The atypical scar patterns after gastric ESD are associated with various clinicopathologic factors.
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Kolb JM, Hammad H. The Use of the Overstitch to Close Endoscopic Resection Defects. Gastrointest Endosc Clin N Am 2020; 30:163-171. [PMID: 31739962 PMCID: PMC7202237 DOI: 10.1016/j.giec.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic resection of luminal gastrointestinal neoplasia offers a minimally invasive, lower risk alternative that can be successful in the appropriate setting. Bleeding and perforation can occur with endoscopic mucosal resection and endoscopic submucosal dissection. Defect closure with conventional endoclips or modified technique using endoloops can decrease the risk of adverse events. The Overstitch (Apollo Endosurgery, Austin, TX) endoscopic suturing device is designed for tissue apposition and thus can effectively close a large resection defect. Herein we describe our technique. Our and other groups' initial experience with suturing for closure of the resection defect demonstrates high procedural success rates and safety.
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Chen Y, Wang M, Zhao L, Chen H, Liu L, Wang X, Fan Z. The retrospective comparison between submucosal tunneling endoscopic resection and endoscopic submucosal excavation for managing esophageal submucosal tumors originating from the muscularis propria layer. Surg Endosc 2019; 34:417-428. [PMID: 30972622 DOI: 10.1007/s00464-019-06785-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 04/04/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) were recently introduced to cure submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. This study aimed to compare clinical performance and safety of STER and ESE in treating esophageal SMTs originating from the MP layer. METHODS From January 2011 to December 2017, retrospective data collection and follow-up were applied for all STER or ESE cases with esophageal SMTs originating from the MP layer in our endoscopy center, including clinical characteristics, procedure success, efficacy, and adverse events. Subgroup analysis was further done based on tumor size and origin. RESULTS 90 STER and 77 ESE were enrolled in this study. There were no significant difference for patient characteristics, procedure performance, and complications for ESE and STER intervention (P > 0.05). STER was faster than ESE (3.90 mm2/min vs 2.82 mm2/min, P < 0.05). For large tumors (≥ 20 mm), both techniques had the similar performance (P > 0.05), while STER led to the shorter hospitalization (4.0d vs 7.0d, P < 0.05) and lower postoperative complication (16.3% vs 45.5%, P < 0.05). For small tumors (< 20 mm), STER achieved faster operation (STER vs ESE, 2.57 mm2/min vs 1.83 mm2/min, P < 0.05). Regardless of tumor origin, there were no significant difference for both techniques, but STER resulted in short hospitalization for SMTs from the deep MP layer (STER vs ESE, 5.0d vs 7.0d, P < 0.05). During the follow-up, 2 residual and 4 recurrence occurred in the STER group, as well as 1 residual and 2 recurrence in the ESE group. CONCLUSIONS Both STER and ESE were effective for treating esophageal SMTs originating from the MP layer. STER might be better due to its faster operation, less complications, and shorter hospitalization.
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Affiliation(s)
- Yingtong Chen
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Min Wang
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Lili Zhao
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
| | - He Chen
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Li Liu
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Xiang Wang
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
| | - Zhining Fan
- Digestive Endoscopy Department, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
- Department of General Surgery, The First Affiliated Hospital with Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China.
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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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So H, Yoo SH, Han S, Kim GU, Seo M, Hwang SW, Yang DH, Byeon JS. Efficacy of Precut Endoscopic Mucosal Resection for Treatment of Rectal Neuroendocrine Tumors. Clin Endosc 2017; 50:585-591. [PMID: 29020763 PMCID: PMC5719917 DOI: 10.5946/ce.2017.039] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 07/21/2017] [Accepted: 08/02/2017] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Endoscopic resection is the first-line treatment for rectal neuroendocrine tumors (NETs) measuring <1 cm and those between 1 and 2 cm in size. However, conventional endoscopic resection cannot achieve complete resection in all cases. We aimed to analyze clinical outcomes of precut endoscopic mucosal resection (EMR-P) used for the management of rectal NET.
Methods EMR-P was used to treat rectal NET in 72 patients at a single tertiary center between 2011 and 2015. Both, circumferential precutting and EMR were performed with the same snare device in all patients. Demographics, procedural details, and histopathological features were reviewed for all cases.
Results Mean size of the tumor measured endoscopically was 6.8±2.8 mm. En bloc and complete resection was achieved in 71 (98.6%) and 67 patients (93.1%), respectively. The mean time required for resection was 9.0±5.6 min. Immediate and delayed bleeding developed in six (8.3%) and 4 patients (5.6%), respectively. Immediate bleeding observed during EMR-P was associated with the risk of delayed bleeding.
Conclusions Both, the en bloc and complete resection rates of EMR-P in the treatment of rectal NETs using the same snare for precutting and EMR were noted to be high. The procedure was short and safe. EMR-P may be a good treatment choice for the management of rectal NETs.
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Affiliation(s)
- Hoonsub So
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su Hyun Yoo
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seungbong Han
- Department of Applied Statistics, Gachon University, Seongnam, Korea
| | - Gwang-Un Kim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Myeongsook Seo
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Wook Hwang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hoon Yang
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Sik Byeon
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Kim SJ, Choi CW, Kang DH, Kim HW, Park SB. Second-look endoscopy and factors associated with delayed bleeding after endoscopic submucosal dissection. World J Gastrointest Endosc 2016; 8:173-179. [PMID: 26862367 PMCID: PMC4734976 DOI: 10.4253/wjge.v8.i3.173] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Revised: 10/01/2015] [Accepted: 12/08/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD) is a widely used procedure as curative treatment for superficial gastric neoplasms, including early gastric cancer without lymph node metastasis. However, ESD requires advanced endoscopic skill and there is a major concern regarding complications from bleeding. So far, extensive efforts have been made to develop strategies to reduce post-ESD bleeding. Use of proton pump inhibitors and coagulating exposed vessels on the ulcer floor after ESD are strategies known to reduce the risk of delayed bleeding. Second-look endoscopy (SLE) is also carried out to reduce delayed bleeding following ESD in many institutions. However, the incidence of bleeding still remains around 5%, and further measures are needed to reduce delayed bleeding after gastric ESD. Recently, three randomized studies indicated that routine SLE was unnecessary. Although routine SLE may not be recommended for all patients after gastric ESD, SLE might be an important tool for the prevention of the delayed bleeding in selected high-risk patients. Thus, the identification of the risk factors, such as large size of resected specimen and treatment with multiple antiplatelet medications, may help to further guide clinicians in deciding whether to perform SLE. Studies carried out on larger cohorts are necessary to clarify the efficacy of SLE after ESD in the prevention of post-ESD bleeding in potentially high-risk patients.
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Iwatsuka K, Gotoda T, Kono S, Suzuki S, Yagi Kuwata N, Kusano C, Sugimoto K, Itoi T, Moriyasu F. Clinical Backgrounds and Outcomes of Elderly Japanese Patients with Gastrointestinal Bleeding. Intern Med 2016; 55:325-32. [PMID: 26875955 DOI: 10.2169/internalmedicine.55.5396] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVE Elderly gastrointestinal bleeding (GIB) patients sometimes cannot be discharged home. In some cases, they die after hemostasis, even following appropriate treatment. This study investigates the clinical backgrounds and outcomes of elderly Japanese GIB patients. METHODS The medical records of 185 patients (123 men, 62 women; mean age 68.2 years; range 10-99 years) with GIB symptoms who underwent esophagogastroduodenoscopy or colonoscopy to detect or treat the source of GIB were retrospectively reviewed. We compared the outcomes between patients ≤70 (n=85) and >70 (n=100) years. The clinical backgrounds of the patients who died or changed hospitals to undergo rehabilitation or receive palliative care were evaluated, as were the association of four factors with these poor outcomes: GIB (re-bleeding or uncontrolled bleeding), endoscopic procedure-related complications, exacerbation of the pre-existing comorbidity, and any complications that were not directly related to GIB. RESULTS Of the patients ≤70 and >70 years of age, three (3.5%) and 17 (17.0%), respectively, were transferred to another hospital (p=0.003). One (1.2%) and five (5.0%), respectively, died (p=0.144). All three patients ≤70 years old that changed hospitals did so because their comorbidities became worse. The reasons for changing hospitals in the 17 patients >70 years of age included exacerbation of a pre-existing comorbidity (41.1%, 7/17), other complications (35.4%, 6/17), GIB itself (17.6%, 3/17), and endoscopic procedure-related complications (5.9%, 1/17). CONCLUSION Although non-elderly and elderly GIB patients had similar mortality rates, many more elderly patients could not be discharged home for various reasons.
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Affiliation(s)
- Kunio Iwatsuka
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Japan
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Ono H, Yao K, Fujishiro M, Oda I, Nimura S, Yahagi N, Iishi H, Oka M, Ajioka Y, Ichinose M, Matsui T. Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer. Dig Endosc 2016; 28:3-15. [PMID: 26234303 DOI: 10.1111/den.12518] [Citation(s) in RCA: 370] [Impact Index Per Article: 46.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2014] [Accepted: 07/29/2015] [Indexed: 12/14/2022]
Abstract
In response to the rapid and wide acceptance and use of endoscopic treatments for early gastric cancer, the Japan Gastroenterological Endoscopy Society (JGES), in collaboration with the Japanese Gastric Cancer Association (JGCA), has produced 'Guidelines for ESD and EMR for Early Gastric Cancer', as a set of basic guidelines in accordance with the principles of evidence-based medicine. These Guidelines cover the present state of knowledge and are divided into the following seven categories: Indications, Preoperative diagnosis, Techniques, Evaluation of curability, Complications, Long-term postoperative surveillance, and Histology. Twenty-three statements were finally accepted as guidelines, and the majority of these were obtained from descriptive studies with lower evidence levels. A number of statements had to be created by consensus (the lowest evidence level), as evidence levels remain low for many specific areas in this field.
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Affiliation(s)
- Hiroyuki Ono
- Japan Gastroenterological Endoscopy Society, Tokyo.,Japanese Gastric Cancer Association, Kyoto, Japan
| | - Kenshi Yao
- Japan Gastroenterological Endoscopy Society, Tokyo.,Japanese Gastric Cancer Association, Kyoto, Japan
| | - Mitsuhiro Fujishiro
- Japan Gastroenterological Endoscopy Society, Tokyo.,Japanese Gastric Cancer Association, Kyoto, Japan
| | - Ichiro Oda
- Japan Gastroenterological Endoscopy Society, Tokyo.,Japanese Gastric Cancer Association, Kyoto, Japan
| | | | - Naohisa Yahagi
- Japan Gastroenterological Endoscopy Society, Tokyo.,Japanese Gastric Cancer Association, Kyoto, Japan
| | - Hiroyasu Iishi
- Japan Gastroenterological Endoscopy Society, Tokyo.,Japanese Gastric Cancer Association, Kyoto, Japan
| | - Masashi Oka
- Japan Gastroenterological Endoscopy Society, Tokyo.,Japanese Gastric Cancer Association, Kyoto, Japan
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Jung YS, Kim KO, Lee SH, Jang BI, Kim TN. Comparison on Oral versus Intravenous Proton Pump Inhibitors for Prevention of Bleeding after Endoscopic Submucosal Dissection of Gastric Lesions. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2016; 67:74-80. [DOI: 10.4166/kjg.2016.67.2.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Yeoun Su Jung
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Kyeong Ok Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Si Hyung Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Nyeun Kim
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Na S, Ahn JY, Choi KD, Kim MY, Lee JH, Choi KS, Kim DH, Song HJ, Lee GH, Jung HY, Kim JH. Delayed Bleeding Rate According to the Forrest Classification in Second-Look Endoscopy After Endoscopic Submucosal Dissection. Dig Dis Sci 2015; 60:3108-17. [PMID: 26003554 DOI: 10.1007/s10620-015-3693-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 04/29/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND AND AIM Forrest classification is a valid tool to predict rebleeding rate in peptic ulcer, not in post-endoscopic resection ulcer. We evaluated the delayed bleeding rate in Forrest classification II and III lesions when they were not treated in second-look endoscopy. METHODS Between July 2011 and February 2012, 706 lesions in 656 consecutive patients who underwent second-look endoscopy performed on the second day after endoscopic submucosal dissection (ESD) were prospectively investigated. Endoscopic findings were described according to Forrest classification, and late delayed bleeding was defined as bleeding from second-look endoscopy to 1 month. We evaluated the rate of late delayed bleeding in untreated Forrest classification II and III lesions during second-look endoscopy. RESULTS Among the 706 gastric tumors analyzed, late delayed bleeding after ESD occurred in 29 lesions (4.1%). At second-look endoscopy, Forrest I lesions (immediately treated by endoscopic hemostasis) were found in 63 cases [Ia, 8 lesions (1.1%); Ib, 55 lesions (7.8%)]; there was no further bleeding after discharge. Forrest II and III lesions (not treated in second-look endoscopy) were found in 643 cases [IIa, 62 lesions (8.8%); IIb, 119 lesions (16.9%); IIc, 460 lesions (65.2 %); III, 2 lesions (0.3%)]; and there was no significant difference in the late delayed bleeding rate between these groups [IIa, 2/62 (3.2%); IIb, 5/119 (4.2%); IIc and III, 22/462 (4.8%); P = 1.000]. CONCLUSIONS The rate of late delayed bleeding of post-ESD ulcers with non-bleeding visible vessels was not significantly different from that of ulcers with non-visible vessels ( http://cris.nih.go.kr , identifier KCT0000268).
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Affiliation(s)
- Shin Na
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea.
| | - Mi-Young Kim
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Kwi-Sook Choi
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, Asan Medical Center, Asan Digestive Disease Research Institute, University of Ulsan College of Medicine, 388-1 Pungnap-2 dong, Songpa-gu, Seoul, 138-736, Korea
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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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16
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Choi CW, Kang DH, Kim HW, Hong JB, Park SB, Kim SJ, Cho M. High Dose Proton Pump Inhibitor Infusion Versus Bolus Injection for the Prevention of Bleeding After Endoscopic Submucosal Dissection: Prospective Randomized Controlled Study. Dig Dis Sci 2015; 60:2088-96. [PMID: 25821098 DOI: 10.1007/s10620-015-3560-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 01/22/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND A high dose of continuous intravenous infusion of proton pump inhibitor (PPI) is the standard treatment for peptic ulcer bleeding. The optimal dose for the prevention of bleeding after endoscopic submucosal dissection (ESD) is unclear. AIM The purpose of this study was to determine whether stronger acid suppression more effectively prevents bleeding and high risk ulcer stigma (HRS) after gastric ESD. METHODS A total of 273 patients who underwent ESD were randomly assigned to one of two treatment groups: the continuous infusion group and the bolus injection group. Second-look endoscopy was performed on the following day after ESD. The incidences and risk factors of HRS identified by second-look endoscopy and delayed bleeding were analyzed. RESULTS There were no differences in the incidences of HRS and delayed bleeding between two treatment groups. The incidence of HRS was 15.8 % (43/273) and the gross morphology (flat or depressed) was identified as a significant factor associated with HRS. The incidence of delayed bleeding was 8.4 % (23/273) and the gross morphology (flat) and the presence of submucosal invasive cancer were identified as the associated risk factors for delayed bleeding. CONCLUSION The incidences of delayed bleeding and HRS identified by second-look endoscopy were not affected by PPI infusion methods. Flat or depressed morphologic lesions and submucosal invasive cancer should be closely monitored.
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Affiliation(s)
- Cheol Woong Choi
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea
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Park SE, Kim DH, Jung HY, Lim H, Ahn JY, Choi KS, Lee JH, Choi KD, Song HJ, Lee GH, Kim JH, Han S. Risk factors and correlations of immediate, early delayed, and late delayed bleeding associated with endoscopic resection for gastric neoplasms. Surg Endosc 2015; 30:625-632. [PMID: 26091990 DOI: 10.1007/s00464-015-4250-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 05/19/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bleeding is a major complication following endoscopic resection (ER) of gastric mucosal lesions. We aimed to determine the risk factors for post-ER bleeding and their correlations according to the time elapsed since the procedure. METHODS We retrospectively enrolled 670 lesions in 610 patients who underwent ER between March 2009 and December 2010. We classified these lesions into three types in accordance with the bleeding time, i.e., immediate bleeding (IB), early delayed bleeding (EDB), and late delayed bleeding (LDB). We analyzed the risk factors for each bleeding type according to baseline patient characteristics, procedure-related factors, and correlations between the occurrence of each bleeding type. RESULTS There were 408 post-ER bleeding events in our study cohort: 302 IB events, 88 EDB events, and 18 LDB events. In multivariate analysis, a histologic finding of carcinoma and the resection time were significant predictors of IB (p < 0.001). Of the 302 IB events, 13.9% showed EDB. Additionally, LDB occurred in 2.4% of lesions with EDB and 4.6% of lesions without EDB. Similar to the IB group, of 368 lesions without IB, 12.5% showed EDB. In addition, LDB occurred in 2.2% of lesions with EDB and 1.2% of lesions without EDB. IB was associated with a higher risk of EDB (p < 0.001) and LDB (p < 0.001), whereas EDB was not related to an increased risk of LDB (p = 0.997). CONCLUSION IB significantly increases the risk of EDB and LDB, but EDB does not increase the risk of LDB. Histologically confirmed carcinoma or a prolonged time for resection increases the risk of post-ER IB. We recommend careful follow-up approaches following ER of a gastric mucosal lesion in high-risk patients to prevent a potentially critical occurrence of delayed bleeding.
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Affiliation(s)
- So-Eun Park
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea.
| | - Do Hoon Kim
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Hwoon-Yong Jung
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Hyun Lim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Ji Yong Ahn
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Kwi-Sook Choi
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Jeong Hoon Lee
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Kee Don Choi
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Ho June Song
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Gin Hyug Lee
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Jin-Ho Kim
- Department of Gastroenterology, Asan Digestive Disease Research Institute, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 138-736, Korea
| | - Seungbong Han
- Department of Applied Statistics, Gachon Univertisy, 1342 Seongnamdaero, Sujeong-gu, Seongnam-si, Gyeonggi-do, 461-701, Korea
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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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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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20
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Choi CW, Kim HW, Kang DH, Hong YM, Kim SJ, Park SB, Cho M, Kim DJ, Hong JB. Clinical outcomes of second-look endoscopy after gastric endoscopic submucosal dissection: predictive factors with high risks of bleeding. Surg Endosc 2014; 28:2213-20. [PMID: 24570014 DOI: 10.1007/s00464-014-3457-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2013] [Accepted: 01/22/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND A second-look endoscopy is routinely performed after endoscopic submucosal dissection (ESD) in many institutions, although the need is questionable. Additional hemostatic procedures might be necessary for the post-ESD ulcer with a high risk of bleeding. We investigated the predictive factors for post-ESD ulcers with a high risk of bleeding. METHODS Second-look endoscopy was performed on the day following ESD. The post-ESD ulcers were categorized into two risk groups according to the Forrest classification: high-risk ulcer stigma (type I and IIa) and low-risk ulcer stigma. We analyzed the risk factors associated with high-risk ulcer stigma and late delayed bleeding. RESULTS During the study period, 616 ESD procedures were performed. Second-look endoscopy revealed that the incidence of high-risk ulcer stigma post-ESD was 15.1%. Early and late delayed bleeding rates were 3.7 and 1.9%, respectively. Multivariate analysis revealed that submucosal fibrosis and nausea were significantly related to high-risk ulcer stigma after ESD. Multivariate analysis revealed that surface erosion, location of the lesion, and high-risk ulcer stigma identified by second-look endoscopy were significantly associated with late delayed bleeding. CONCLUSIONS The effective use of selective second-look endoscopy will help limit unnecessary procedures. Submucosal fibrosis and nausea were risk factors associated with high-risk ulcer stigma after ESD.
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Affiliation(s)
- Cheol Woong Choi
- Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea,
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Huang R, Pan Y, Hui N, Guo X, Zhang L, Wang X, Zhang R, Luo H, Zhou X, Tao Q, Liu Z, Wu K. Polysaccharide hemostatic system for hemostasis management in colorectal endoscopic mucosal resection. Dig Endosc 2014; 26:63-8. [PMID: 23551344 DOI: 10.1111/den.12054] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2012] [Accepted: 01/23/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND A new polysaccharide hemostatic system (EndoClot(TM) ) was recently developed for bleeding control in gastrointestinal tract endoscopy; however, its efficacy and safety is not yet well established in colorectal endoscopic mucosal resection (EMR). The aim of the present study was to observe the bleeding control effect after EMR in the colorectum. PATIENTS AND METHODS EndoClot(TM) was applied immediately to mucosal defects after resection whether or not there was post-resection bleeding. Bleeding was monitored post-procedurally by clinical findings including positive stool occult blood test and by second-look endoscopy. Hemostasis, rebleeding rates and treatment-related complications were observed. RESULTS In total, 82 patients were enrolled, totaling 181 lesions. Among them, 20 lesions in 18 cases showed bleeding immediately after the procedure. Among them, two lesions were treated by combined hot biopsy forceps, and complete hemostasis was achieved in all cases without surgery. It took 1.1 min (0.4-2.1) tocarry out hemostasis treatment. Rebleeding with positive stool test and colonoscopy recurred in three of 18 patients with immediate post-procedural bleeding. In patients without immediate post-procedural bleeding, three patients were confirmed with delayed bleeding. No major adverse events of treatment or procedure-related serious adverse events were reported during a 30-day follow up. Colonoscopy was done in selected patients at 30 days and full recovery of mucosal defect was achieved in all cases. CONCLUSION Polysaccharide hemostatic system effectively achieves hemostasis in controlling and preventing EMR-related bleeding with the advantage of simple application; thus it might be a useful alternative in treating bleeding endoscopically.
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Affiliation(s)
- Rui Huang
- Department of Gastroenterology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Rabbit gastric ulcer models: comparison and evaluation of acetic acid-induced ulcer and mucosectomy-induced ulcer. Lab Anim Res 2013; 29:96-102. [PMID: 23825482 PMCID: PMC3696630 DOI: 10.5625/lar.2013.29.2.96] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2013] [Revised: 05/27/2013] [Accepted: 05/28/2013] [Indexed: 01/01/2023] Open
Abstract
In this study, we examined rabbit gastric ulcer models that can serve as more clinically relevant models. Two types of ulcer model were studied: acetic acid-induced ulcers (AAU) and mucosal resection-induced ulcers (MRU). For AAU, rabbit gastric mucosa was exposed by median laparotomy and treated with bottled acetic acid. MRU was examined as a model for endoscopic mucosal resection (EMR). Normal saline was injected into the submucosal layer and the swollen mucosa was resected with scissors. Endoscopic mucosal resection (EMR) is frequently performed for treatment of early gastric cancers. This procedure inevitably leads to ulcers and bleeding. Bleeding control is the major concern in endoscopic mucosectomy, and some endoscopic hemostatic agents are currently under clinical and preclinical studies. MRU was developed as a model for these induced ulcers and the evaluation of the healing process. The clinical relevancy of those models was compared with that of rat models. Progressive healing was observed for 7 days based on histology. Rabbit models demonstrate round, deep ulcers with clear margins and well-defined healing stages that were difficult to define in rat models.
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Teshima T, Matsumoto H, Michishita M, Takahashi K, Koyama H. Multiple inflammatory gastric polyps treated by endoscopic polypectomy with argon plasma coagulation in a dog. J Small Anim Pract 2013; 54:265-8. [DOI: 10.1111/jsap.12032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- T. Teshima
- Division of Veterinary Internal Medicine, Department of Veterinary Science, Faculty of Veterinary Medicine; Nippon Veterinary and Life Science University; 1-7-1 Kyonan-cho, Musashino-shi Tokyo 180-8602 Japan
| | - H. Matsumoto
- Division of Veterinary Internal Medicine, Department of Veterinary Science, Faculty of Veterinary Medicine; Nippon Veterinary and Life Science University; 1-7-1 Kyonan-cho, Musashino-shi Tokyo 180-8602 Japan
| | - M. Michishita
- Division of Veterinary Pathology, Department of Veterinary Science, Faculty of Veterinary Medicine; Nippon Veterinary and Life Science University; 1-7-1 Kyonan-cho, Musashino-shi Tokyo 180-8602 Japan
| | - K. Takahashi
- Division of Veterinary Pathology, Department of Veterinary Science, Faculty of Veterinary Medicine; Nippon Veterinary and Life Science University; 1-7-1 Kyonan-cho, Musashino-shi Tokyo 180-8602 Japan
| | - H. Koyama
- Division of Veterinary Internal Medicine, Department of Veterinary Science, Faculty of Veterinary Medicine; Nippon Veterinary and Life Science University; 1-7-1 Kyonan-cho, Musashino-shi Tokyo 180-8602 Japan
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Tomita T, Kim Y, Yamasaki T, Okugawa T, Kondo T, Toyoshima F, Sakurai J, Tanaka J, Morita T, Oshima T, Fukui H, Hori K, Watari J, Matsumoto T, Miwa H. Prospective randomized controlled trial to compare the effects of omeprazole and famotidine in preventing delayed bleeding and promoting ulcer healing after endoscopic submucosal dissection. J Gastroenterol Hepatol 2012; 27:1441-6. [PMID: 22497427 DOI: 10.1111/j.1440-1746.2012.07144.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Proton pump inhibitors (PPIs) are generally used to prevent delayed bleeding after endoscopic submucosal dissection (ESD) and to heal the artificial ulcers. However, it remains controversial whether PPIs or histamine-2 receptor antagonists (H(2) RAs) are more effective in preventing delayed bleeding after ESD. We prospectively compared the effects of omeprazole and famotidine in preventing delayed bleeding and promoting artificial ulcer healing after ESD. METHODS A total of 158 patients (155 early gastric cancers and three adenomas) were randomly assigned to the PPI group (omeprazole 20 mg/day) or H(2) RA group (famotidine 40 mg/day) in a prospective randomized controlled trial. The primary end point was the incidence of hematemesis, melena, and/or a decrease in hemoglobin level of 2 g/dL or more requiring endoscopic hemostatic treatment. ESD-induced ulcer healing and changes in ulcer size were also compared at 6 weeks after ESD as a secondary end point. RESULTS Of the 158 patients, two were excluded from analysis because they had been treated with a PPI before the present study. Accordingly, data from 77 PPI and 79 H(2) RA subjects were included for analysis. Delayed bleeding after ESD occurred in 6.5% of subjects (PPI group) and in 6.3% (H(2) RA group); there was no significant difference between the two groups. Likewise, the two groups were not significantly different with respect to ulcer stage or ulcer size reduction rate. CONCLUSIONS Proton pump inhibitors are not superior to H(2) RAs for the prevention of delayed bleeding or the healing of artificially induced ulcers after ESD.
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Affiliation(s)
- Toshihiko Tomita
- Division of Upper Gastroenterology, Department of Internal Medicine, Hyogo College of Medicine, Hyogo, Japan
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Kim YS, Cho WY, Cho JY, Jin SY. Successful treatment of early gastric cancer adjacent to a fundal varix by endoscopic submucosal dissection and endoscopic cyanoacrylate therapy. Clin Endosc 2012; 45:169-73. [PMID: 22866260 PMCID: PMC3401623 DOI: 10.5946/ce.2012.45.2.169] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Revised: 02/14/2012] [Accepted: 03/12/2012] [Indexed: 12/15/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) was developed for the en bloc resection of large early gastrointestinal neoplasms. A disadvantage of ESD is its technical difficulty, which requires advanced skills and is associated with a higher rate of complications. Endoscopic variceal obturation (EVO) using cyanoacrylate has emerged as the initial treatment of choice for acute gastric variceal bleeding. This procedure achieves hemostasis in 90% of cases. A 52-year-old patient with Child A alcoholic liver cirrhosis presented with early gastric cancer in the cardia and type 1 isolated gastric varices in the fundus. The two lesions were so close together that treatment was not easy. The lesions were managed successfully with a combination of ESD and EVO using cyanoacrylate.
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Affiliation(s)
- Yeon Soo Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
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Lim JH, Kim SG, Kim JW, Choi YJ, Kwon J, Kim JY, Lee YB, Choi J, Im JP, Kim JS, Jung HC, Song IS. Do antiplatelets increase the risk of bleeding after endoscopic submucosal dissection of gastric neoplasms? Gastrointest Endosc 2012; 75:719-27. [PMID: 22317881 DOI: 10.1016/j.gie.2011.11.034] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2011] [Accepted: 11/30/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND It is rarely known whether antiplatelets increase the risk of bleeding after endoscopic submucosal dissection (ESD). OBJECTIVE To evaluate the effect of antiplatelets on post-ESD bleeding. DESIGN Retrospective study. SETTING Single, tertiary-care referral center. PATIENTS This study involved 1591 gastric neoplasms (815 adenomas and 776 early gastric cancers) in 1503 patients who had ESD between April 2005 and April 2010. INTERVENTION ESD. MAIN OUTCOME MEASUREMENTS Overt hematemesis/hematochezia, a drop of hemoglobin >2 g/dL from baseline, or requirement of endoscopic hemostasis, angiographic embolization, and/or transfusion. RESULTS Of 1591 subjects, 274 took antiplatelets, among whom 102 discontinued them for 7 days or more before ESD. Post-ESD bleeding occurred in 94 subjects including 20 from the continuation group, 6 from the withdrawal group, and 68 from the no-antiplatelet group. In univariate analysis, antiplatelets, early gastric cancer (EGC), comorbidity, and specimen diameter were related to post-ESD bleeding. In multivariate analysis, EGC (odds ratio [OR] 1.839; 95% confidence interval [CI], 1.168-2.896; P = .009), comorbidity (OR 2.246; 95% CI, 1.280-3.939; P = .005), and specimen diameter (OR 2.315; 95% CI, 1.282-4.180; P = .005) were independent risk factors of post-ESD bleeding, whereas antiplatelet usage was not (OR 1.596; 95% CI, 0.877-2.903; P = .126). In subgroup analysis, continuous antiplatelet usage was not found to be an independent risk factor of post-ESD bleeding in multivariate analysis (OR 2.027; P = .146). Among 102 subjects who discontinued antiplatelets, 1 developed an acute cerebral infarction (1.0%). LIMITATION A retrospective, single-center analysis. CONCLUSION In ESD for antiplatelet users, continuous administration was not found to have an independent significant association with bleeding.
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Affiliation(s)
- Joo Hyun Lim
- Department of Internal Medicine and Liver Research Institute, Seoul National University College of Medicine, Seoul, Korea
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Niimi K, Fujishiro M, Goto O, Kodashima S, Minatsuki C, Hirayama I, Mochizuki S, Ono S, Yamamichi N, Kakushima N, Ichinose M, Koike K. Prospective single-arm trial of two-week rabeprazole treatment for ulcer healing after gastric endoscopic submucosal dissection. Dig Endosc 2012; 24:110-6. [PMID: 22348835 DOI: 10.1111/j.1443-1661.2011.01178.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIM Endoscopic submucosal dissection (ESD) causes artificial ulcers, and there is no consensus regarding the degree of healing in ESD-induced ulcers or the optimal duration of proton pump inhibitor (PPI) treatment. The aim of the present study was to investigate the healing rates of post-ESD ulcers in response to the protective effect of 2-week PPI treatment. METHODS Between February 2007 and March 2010, 75 patients/75 lesions and 55 patients/55 lesions were enrolled as interim and per-protocol groups, respectively. All patients were prescribed rabeprazole (10 mg/day) orally for 16 days beginning on the day before ESD. Follow-up endoscopy was carried out 8 weeks after ESD to evaluate ulcer healing. The primary end-point was the healing rate of post-ESD ulcers at 8 weeks after ESD. Secondary end-points were the rate of post-ESD bleeding with emergency endoscopy and the rate of other severe adverse effects during the study period. RESULTS The transitional rate to scarring-stage ulcers was 80.0% (44/55). Location in the lesser curve and large resected size (>40 mm) were statistically significant predictors for delayed ulcer healing by univariate analysis and the latter was still significant by the multivariate analysis. Post-ESD bleeding occurred within 2 weeks in two cases (2.7%), but both cases were successfully managed with endoscopic hemostasis only. Severe adverse effects did not occur. CONCLUSIONS Two-week administration of PPI for post-ESD gastric ulcers may be sufficient to aid healing without increasing any adverse effects in cases where there are no possible deteriorating factors on ulcer healing, although large resection and/or resection in the lesser curve may result in delayed healing even after 8 weeks of ESD.
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Affiliation(s)
- Keiko Niimi
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Abstract
The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.
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Affiliation(s)
- Daniel Blero
- ISPPC, 1 Boulevard Zoé Drion, 6000 Charleroi, Belgium.
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Endoscopic submucosal dissection is an effective and safe therapy for early gastric neoplasms: a multicenter feasible study. J Clin Gastroenterol 2012; 46:124-9. [PMID: 21959325 DOI: 10.1097/mcg.0b013e31822f3988] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM The technique of endoscopic submucosal dissection (ESD) was introduced to obtain en bloc specimens of large early gastrointestinal neoplasms. The drawback of ESD is its technical difficulty and, consequently, its higher rate of complication. In this multicenter study, we investigated the therapeutic outcomes of ESD in consecutive patients. METHODS From January 2002 to December 2008, 485 early gastric neoplasms in 418 patients were consecutively treated by using ESD procedure performed by 6 endoscopists in 4 institutions in Tokyo. Demorgraphics, tumor location, therapeutic outcomes, and complication rates were analyzed. RESULTS The rates of en bloc resection, complete en bloc resection, submucosal invasion, and piecemeal resection were 93.6%, 85.4%, 10.9%, and 5.4%, respectively. In multivariate analysis, the en bloc resection rate was independently lower in lesions in upper portion than in lower portion (P<0.01), lower in larger lesions (>30 mm, P<0.05; 20 to 30 mm, P<0.05), and lower in lesions with a scar (P<0.01). Delayed bleeding occurrence was independently high in larger lesions (>30 mm, P<0.01; 20 to 29 mm, P<0.01) than in small lesions (<20 mm). Institution and endoscopists were not risk factors of en bloc resection and complications CONCLUSIONS ESD is an effective and safe therapy in the management of early gastric neoplasms when performed by well-trained endoscopists. Endoscopists should recognize the difficulty to perform ESD for en bloc resection of upper lesion, and the risk of delayed bleeding in cases of lesions >2 cm in size.
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Muraki Y, Enomoto S, Iguchi M, Fujishiro M, Yahagi N, Ichinose M. Management of bleeding and artificial gastric ulcers associated with endoscopic submucosal dissection. World J Gastrointest Endosc 2012; 4:1-8. [PMID: 22267977 PMCID: PMC3262173 DOI: 10.4253/wjge.v4.i1.1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Revised: 11/06/2011] [Accepted: 01/12/2012] [Indexed: 02/05/2023] Open
Abstract
Endoscopic submucosal dissection (ESD), an endoscopic procedure for the treatment of gastric epithelial neoplasia without lymph node metastases, spread rapidly, primarily in Japan, starting in the late 1990s. ESD enables en bloc resection of lesions that are difficult to resect using conventional endoscopic mucosal resection (EMR). However, in comparison to EMR, ESD requires a high level of endoscopic competence and a longer resection time. Thus, ESD is associated with a higher risk of adverse events, including intraoperative and postoperative bleeding and gastrointestinal perforation. In particular, because of a higher incidence of intraoperative bleeding with mucosal incision and submucosal dissection, which are distinctive endoscopic procedures in ESD, a strategy for endoscopic hemostasis, mainly by thermo-coagulation hemostasis using hemostatic forceps, is important. In addition, because of iatrogenic artificial ulcers that always form after ESD, endoscopic hemostasis and appropriate pharmacotherapy during the healing process are essential.
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Affiliation(s)
- Yosuke Muraki
- Yosuke Muraki, Shotaro Enomoto, Mikitaka Iguchi, Masao Ichinose, Second Department of Internal Medicine, Wakayama Medical University, Wakayama-city, Wakayama 641-0012, Japan
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Higashiyama M, Oka S, Tanaka S, Sanomura Y, Imagawa H, Shishido T, Yoshida S, Chayama K. Risk factors for bleeding after endoscopic submucosal dissection of gastric epithelial neoplasm. Dig Endosc 2011; 23:290-5. [PMID: 21951088 DOI: 10.1111/j.1443-1661.2011.01151.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Although endoscopic submucosal dissection (ESD) is standard therapy in Japan for gastric epithelial neoplasm, the complication rate is unsatisfactory, with postoperative bleeding as the major complication. The aim of the present study was to determine risk factors for post-ESD bleeding in patients with gastric epithelial neoplasm. PATIENTS AND METHODS The study included 764 patients in whom 924 gastric epithelial neoplasms were resected endoscopically between June 2005 and December 2009: the period during which preventative coagulation for all exposed vessels on the artificial ulcer with hemostatic forceps upon completion of ESD was performed routinely. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors. RESULTS The post-ESD bleeding rate was 3.0%. Dialysis (vs no dialysis, P = 0.034), operation time ≥75 min (vs <75 min, P = 0.012) and poor control of bleeding during ESD (vs good control, P = 0.014) were significantly related to post-ESD bleeding. Poor control of bleeding during ESD (vs good control; P = 0.04) and operation time ≥75 min (vs <75 min; P = 0.012) were significantly related to bleeding after second-look endoscopy. CONCLUSIONS Patients at high risk for post-ESD bleeding in gastric epithelial neoplasm were those undergoing dialysis, those in whom operation time was ≥75 min, and those in whom bleeding during ESD was poorly controlled. The latter two are risk factors for bleeding even after second-look endoscopy.
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Affiliation(s)
- Makoto Higashiyama
- Department of Medicine and Molecular Science, Division of Frontier Medical Science, Programs for Biomedical Research, Graduate School of Biomedical Sciences, Hiroshima University, Hiroshima, Japan
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Romagnuolo J, Cotton PB, Eisen G, Vargo J, Petersen BT. Identifying and reporting risk factors for adverse events in endoscopy. Part II: noncardiopulmonary events. Gastrointest Endosc 2011; 73:586-97. [PMID: 21353858 DOI: 10.1016/j.gie.2010.11.023] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Accepted: 11/16/2010] [Indexed: 02/08/2023]
Affiliation(s)
- Joseph Romagnuolo
- Medical University of South Carolina, Charleston, South Carolina 29425, USA
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Immediate bleeding during endoscopic submucosal dissection: a predictor of delayed bleeding? Gastrointest Endosc 2011; 73:413-4; author reply 414-5. [PMID: 21295659 DOI: 10.1016/j.gie.2010.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Accepted: 05/24/2010] [Indexed: 02/08/2023]
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Kwon YL, Kim ES, Lee KI, Kim YJ, Park CW, Kim YJ, Seo HJ, Cho KB, Park KS, Jang BK, Chung WJ, Hwang JS. Endoscopic treatments of gastric mucosal lesions are not riskier in patients with chronic renal failure or liver cirrhosis. Surg Endosc 2010; 25:1994-9. [PMID: 21136091 DOI: 10.1007/s00464-010-1500-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 10/22/2010] [Indexed: 02/06/2023]
Abstract
BACKGROUND Little is known about the feasibility of endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) for patients with chronic renal failure (CRF) or liver cirrhosis (LC). This study aimed to assess the safety, efficacy, and clinical outcomes of EMR or ESD in patients with CRF or LC compared to those in patients without. METHODS Between February 2003 and November 2009, a total of 1016 gastric neoplastic lesions in 928 patients were treated by using EMR or ESD. Among them, 18 patients had LC and 17 patients had CRF. Their medical records were reviewed retrospectively. En bloc resection rate, histological complete resection rate, operation time, and complications were compared between patients with CRF or LC and those without (control group). RESULTS Baseline characteristics were not significantly different between the CRF, LC, and control groups except for a high rate of comorbidities in the CRF group and prolonged prothrombin time in the LC group. Operation time and therapeutic outcomes such as en bloc and complete resection rates did not differ significantly between the groups. Immediate bleeding tended to occur more frequently in the CRF+LC group than in controls (47.5 vs. 33.9%, p=0.077). There was no significant difference in the incidence of perforation between the CRF, LC, and control groups. The hospital stay was longer in the CRF+LC group than in the control group (6.4±3.53 vs. 4.9±3.15 days, p=0.012). CONCLUSIONS EMR and ESD for the treatment of early gastric neoplasia may be equally effective and tolerable in the CRF or the LC group compared to the control group, although patients with CRF or LC might need the longer admission period than the control group.
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Affiliation(s)
- Young Lan Kwon
- Department of Internal Medicine, Institute of Gastroenterology and Hepatology, Keimyung University School of Medicine, 194 Dong San-dong, Jung-gu, Daegu, 700-712, South Korea
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Matsushita M, Mori S, Tahashi Y, Uchida K, Nishio A, Okazaki K. The site of delayed bleeding suggests the cause of bleeding after endoscopic submucosal dissection. Scand J Gastroenterol 2010; 45:1127-8. [PMID: 20443747 DOI: 10.3109/00365521.2010.483742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Tsuji Y, Ohata K, Ito T, Chiba H, Ohya T, Gunji T, Matsuhashi N. Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions. World J Gastroenterol 2010; 16:2913-7. [PMID: 20556838 PMCID: PMC2887588 DOI: 10.3748/wjg.v16.i23.2913] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To assess risk factors for bleeding after gastric endoscopic submucosal dissection (ESD) and to develop preventive measures.
METHODS: This retrospective study was performed in a tertiary referral center. A total of 328 patients underwent ESD for 398 gastric neoplasms between July 2007 and June 2009. The main outcome was association between post-ESD bleeding and the following: age; sex; comorbidities; daily use of medicine potentially related to gastric injury/bleeding; location, size, and histological depth of lesions; ulceration; experience of operator coagulating the ulcer floor, and duration of operation. We also determined the relationship between the location of post-ESD bleeding and risk factors for hemorrhage.
RESULTS: Univariate analysis revealed significant risk factors: tumor location [odds ratio (OR), 2.86; 95% CI: 1.21-6.79, P = 0.024], coagulator experience (OR, 4.29; 95% CI: 1.43-12.86, P = 0.009), and medicine potentially related to gastric injury/bleeding (OR, 2.80; 95% CI: 1.14-6.90, P = 0.039). Multivariate logistic regression analysis confirmed significant, independent risk factors: tumor in lower third of stomach (OR, 2.47; 95% CI: 1.02-5.96, P = 0.044), beginner coagulator (OR, 3.93; 95% CI: 1.29-11.9, P = 0.016), and medicine (OR, 2.76; 95% CI: 1.09-6.98, P = 0.032). We classified cases of post-ESD bleeding into two groups (bleeding at the ulcer margin vs bleeding at the center) and found that bleeding at the margin occurred more frequently with beginner coagulators compared with experts (OR, 16.00; 95% CI: 1.22-210.59, P = 0.040).
CONCLUSION: Beginner coagulators, tumor in the antrum, and medicines were significant risk factors for post-ESD bleeding. Bleeding at the ulcer margin frequently occurred with beginner operators.
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Risk factors for complications of endoscopic submucosal dissection in gastric tumors: analysis of 478 lesions. J Gastroenterol 2010; 45:30-6. [PMID: 19760133 DOI: 10.1007/s00535-009-0137-4] [Citation(s) in RCA: 119] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2009] [Accepted: 08/31/2009] [Indexed: 02/06/2023]
Abstract
PURPOSE Endoscopic submucosal dissection (ESD) technique has facilitated en bloc removal of widely spread lesions from the stomach. This retrospective study aimed to determine factors associated with serious complications of ESD. METHODS Between December 2001 and March 2007, we have performed ESD for 478 lesions in 436 patients. We experienced 39 patients with post-operative bleeding and 17 patients with perforation. Risk factors of patients who received ESD in gastric mucosal tumors for complications were evaluated, focusing on resected size, location, scar lesions, operation time, and experience of endoscopists. We evaluated the patients' background characteristics including sex, age, body mass index (kg/m(2)), drug history of anticoagulant, and underlying diseases including cerebrovascular disorder, ischemic heart disease, liver dysfunction, renal dysfunction, hyperuricemia, hypertension and diabetes mellitus. RESULTS Multivariate analysis indicated a risk factor for perforation was long operation time. Multivariate analysis indicated a significant risk factor for post-operative bleeding was size of the resected tumor. CONCLUSIONS This study indicated risk factors for serious complications of ESD. Large resected tumor size was a risk factor for post-operative bleeding, while long operation time was a risk factor for perforation. Information regarding operation risk factors should be useful for planning strategies for ESD.
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Jang JS, Choi SR, Graham DY, Kwon HC, Kim MC, Jeong JS, Won JJ, Han SY, Noh MH, Lee JH, Lee SW, Baek YH, Kim MJ, Jeong DS, Kim SK. Risk factors for immediate and delayed bleeding associated with endoscopic submucosal dissection of gastric neoplastic lesions. Scand J Gastroenterol 2010; 44:1370-6. [PMID: 19891589 DOI: 10.3109/00365520903194609] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE. Endoscopic submucosal dissection (ESD) of gastric neoplasia has been reported to have a higher bleeding rate than conventional endoscopic mucosal resection (EMR). The aim of this study was to identify the risk factors for bleeding associated with ESD. MATERIAL AND METHODS. The records of consecutive patients who underwent ESD for gastric adenoma/early gastric cancer were reviewed. Potential risk factors included patient age, lesion size, gross findings, location, and histology of the tumor. The primary end-point was the incidence of immediate or delayed bleeding related to ESD. RESULTS. A total of 144 patients were studied; bleeding occurred in 32 cases (22.2%) with immediate bleeding in 29 cases. Delayed bleeding (3 cases) occurred at day 2 (2 patients) and at day 7 in 1 patient. In all cases of immediate bleeding, immediate hemostatic therapy was successful. The histology of tumor was the only factor that was statistically significantly associated with bleeding (adjusted hazard ratio 6.770, 95% confidence interval 1.830-25.048, p=0.004). CONCLUSIONS. The only factor that correlated with an increased risk of bleeding with ESD was the presence of gastric malignancy. We found no factor that would, prospectively, be amenable to prevention of bleeding.
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Affiliation(s)
- Jin Seok Jang
- Department of Internal Medicine, Dong-A Medical Center, University College of Medicine, Busan, Korea
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Tappin SW, Brissot H. Endoscopic excision of a gastric polyp causing intermittent pyloric obstruction in a dog. Vet Rec 2009; 165:379-80. [DOI: 10.1136/vr.165.13.379] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- S. W. Tappin
- Dick White Referrals, The Six Mile Bottom Veterinary Specialist Centre; Station Farm, London Road Six Mile Bottom Suffolk CB8 0UH
| | - H. Brissot
- Dick White Referrals, The Six Mile Bottom Veterinary Specialist Centre; Station Farm, London Road Six Mile Bottom Suffolk CB8 0UH
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Abstract
Platelet transfusion therapy is the standard of care for thrombocytopenic patients with hemato-oncological disorders and bone marrow failure states due to intensive chemoradiotherapy. Guidelines to lower triggers for prophylactic and therapeutic transfusions are being developed based on better levels of evidence. The optimum transfusion dose, the choice of platelet concentrate and transfusion interval pose a challenge to balance scientific advances with cost-effective strategies. Platelet refractoriness requires "matched" platelets and is a difficult to treat phenomenon. Pathogen inactivation is a crucial issue in view of susceptibility of platelet concentrates to bacterial contamination. This article reviews the current developments and challenges in optimizing platelet transfusion therapy.
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Affiliation(s)
- Neelam Marwaha
- Department of Transfusion Medicine, PGIMER, Chandigarh, India.
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Gotoda T. Endoscopic resection for premalignant and malignant lesions of the gastrointestinal tract from the esophagus to the colon. Gastrointest Endosc Clin N Am 2008; 18:435-50, viii. [PMID: 18674695 DOI: 10.1016/j.giec.2008.05.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The endoscopic mucosal resection and endoscopic submucosal dissection techniques, if performed with the right indications and with expertise, should be considered even in the West as elective treatment modalities for early gastrointestinal neoplasia. Because the experience is still limited, more should be done to strengthen the performance capacity and foster cooperation among skilled endoscopists.
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Affiliation(s)
- Takuji Gotoda
- Endoscopy Division, Department of Endoscopy, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, Japan.
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Predictors of immediate bleeding during endoscopic submucosal dissection in gastric lesions. Surg Endosc 2008; 23:1974-9. [PMID: 18553202 DOI: 10.1007/s00464-008-9988-7] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Revised: 04/02/2008] [Accepted: 05/03/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although there have been several reports regarding complications, especially immediate bleeding, of endoscopic mucosal resection for a gastric neoplasm, little is known about the predictors of complications of endoscopic submucosal dissection (ESD). Thus, this study was performed to evaluate the predictive factors for immediate bleeding during ESD procedures. METHODS We analyzed 167 patients with 167 gastric lesions from June 2006 to June 2007. Patient-related variables (age, gender, history of aspirin or anti-platelet agents, triple therapy for H. pylori, and use of a proton pump inhibitor), endoscopic variables (lesion size, location, type, and mucosal ulceration), procedure-related variables (procedure time and volume of submucosal injection), and the pathology diagnosis were evaluated as potential risk factors. RESULTS The mean age of the patients was 62 years. The mean size of the lesions was 15 mm. The overall en bloc resection rate was 98.2%. Immediate bleeding occurred in 20 out of 167 patients. Delayed bleeding was seen in only three patients within 24 h after the procedure. Older age and the location of the lesions (antrum) were associated with a lower frequency of bleeding (p = 0.006 and p = 0.007, respectively). On multivariate analysis, an older age (OR 0.931, 95% CI 0.88-0.98) and the location of the lesion (antrum; OR 0.254, 95% CI 0.09-0.69) were significant predictive factors for a successful ESD without bleeding. CONCLUSION The results of this study demonstrated that age and lesion location were related to the ESD procedure outcome.
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Choi KD, Jung HY, Lee GH, Oh TH, Jo JY, Song HJ, Hong SS, Kim JH. Application of metal hemoclips for closure of endoscopic mucosal resection-induced ulcers of the stomach to prevent delayed bleeding. Surg Endosc 2008; 22:1882-6. [PMID: 18270775 DOI: 10.1007/s00464-008-9743-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2007] [Revised: 09/08/2007] [Accepted: 11/28/2007] [Indexed: 02/07/2023]
Abstract
BACKGROUND Bleeding is a major complication of endoscopic mucosal resection (EMR). This study investigated whether the use of metal hemoclips to close EMR-induced ulcers after gastric EMR was effective in preventing delayed bleeding. METHODS This single-center study retrospectively examined the records for 150 lesions of 140 consecutive patients (107 men and 33 women) with a mean age of 61 years (range, 38-81 years) who underwent EMR. For 60 patients, moderate to severe immediate bleeding occurred during the procedure, and the ulcers had been closed using metal hemoclips (clip group). In the remaining 90 cases, the immediate bleeding was absent or mild, and hemoclips were not used (nonclip group). Postprocedure bleeding (delayed bleeding) was analyzed. RESULTS Overall, delayed bleeding occurred with 14 (9.3%) of the 150 lesions. Delayed bleeding occurred less frequently in the clip group (2 of 60 lesions; 3.3%) than in the nonclip group (12 of 90 lesions; 13.3%; p = 0.04). Of the 60 clip group ulcers, 37 (62%) were completely closed, and none showed delayed bleeding. The median number of hemoclips used for ulcer closure was 10 (range, 4-22), and the median time for ulcer closure was 14 min (range, 4-40 min). CONCLUSIONS Prophylactic closure of gastric EMR-induced ulcers with hemoclips reduced delayed bleeding.
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Affiliation(s)
- Kee Don Choi
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-2dong, Songpa-gu, Seoul, 138-736, South Korea
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Jeong HK, Park CH, Jun CH, Lee GH, Kim HI, Kim HS, Choi SK, Rew JS. A prospective randomized trial of either famotidine or pantoprazole for the prevention of bleeding after endoscopic submucosal dissection. J Korean Med Sci 2007; 22:1055-9. [PMID: 18162722 PMCID: PMC2694634 DOI: 10.3346/jkms.2007.22.6.1055] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) has been reported to have a higher bleeding rate than conventional methods. However, there are few reports on whether a proton pump inhibitor or a histamine2-receptor antagonist is the more effective treatment for preventing bleeding after ESD. In a prospective trial, patients undergoing ESD due to gastric adenoma or adenocarcinoma were randomly assigned to pantoprazole or famotidine. Both drugs were given intravenously for the first 2 days, thereafter by mouth. Eighty-five in the pantoprazole group and 79 in the famotidine group were included for analysis. Primary outcome measure was the delayed bleeding rate. Clinical characteristics were not different between the two groups. The delayed bleeding rate was significantly lower in the pantoprazole group compared with the famotidine group (3.5% vs. 12.7%, p=0.031). On multivariate analysis, the preventive use of pantoprazole (relative hazard: 0.220, 95% CI: 0.051- 0.827, p=0.026) and the specimen size (> or =34 mm, relative hazard: 4.178, 95% CI: 1.229-14.197, p=0.022) were two independent factors predictive of delayed bleeding. There were no significant differences in en bloc and complete resection rate between the two groups. In conclusion, pantoprazole is more effective than famotidine for the prevention of delayed bleeding after ESD.
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Affiliation(s)
- Hye-Kyong Jeong
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chang-Hwan Park
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Chung-Hwan Jun
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Gi-Hoon Lee
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hyung-Il Kim
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Hyun-Soo Kim
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Sung-Kyu Choi
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jong-Sun Rew
- Division of Gastroenterology, Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
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Chiu PWY, Ng EKW, Inoue H. Endoscopic submucosal dissection for early neoplasia of foregut: Current development. SURGICAL PRACTICE 2007. [DOI: 10.1111/j.1744-1633.2007.00366.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kim JW, Kim HS, Park DH, Park YS, Jee MG, Baik SK, Kwon SO, Lee DK. Risk factors for delayed postendoscopic mucosal resection hemorrhage in patients with gastric tumor. Eur J Gastroenterol Hepatol 2007; 19:409-15. [PMID: 17413293 DOI: 10.1097/meg.0b013e32801015be] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Although endoscopic mucosal resection has been recognized as the standard treatment for gastric mucosal neoplasm, postendoscopic mucosal resection hemorrhage remains a major complication of endoscopic mucosal resection, and this problem seems to be increasing owing to the development of invasive techniques. The aims of this study were to determine the incidence and grade of postendoscopic mucosal resection hemorrhage and to identify risk factors for delayed postendoscopic mucosal resection hemorrhage in patients with gastric neoplasm. METHODS Data of endoscopic mucosal resections performed by three endoscopists were retrospectively collected over 8 years and then analyzed. Immediate postendoscopic mucosal resection hemorrhage was defined as bleeding during the procedure. Delayed postendoscopic mucosal resection hemorrhage was defined when two of the four following parameters were satisfied after the endoscopic mucosal resection period; (i) hematemesis, melena or dizziness, (ii) hemoglobin loss >2 g/dl, (iii) blood pressure decrease >20 mmHg or pulse rate increase >20/min and (iv) Forrest I or IIa-IIb on follow-up endoscopy. RESULTS A total of 157 patients (mean age: 64 years, male : female=44 : 113) were reviewed. Twenty-nine (18.5%) and 13 patients (8.3%) presented with immediate and delayed postendoscopic mucosal resection hemorrhage, respectively. Multivariate logistic regression analysis revealed that the patient's age (<or=65 years; odds ratio 6.11, 95% confidence interval 1.12-33.43), the size of lesion (>15 mm; odds ratio 5.90, 95% confidence interval 1.13-30.87) and the experience of the endoscopist (<or=5 years; odds ratio 16.31, 95% confidence interval 1.46-181.97) were significantly predictive variables for the delayed postendoscopic mucosal resection hemorrhage. CONCLUSION Considering the higher risk of delayed postendoscopic mucosal resection hemorrhage, careful preparation and close monitoring are required for patients who are less than 65 years, have large lesions over 15 mm or if the procedures were performed by an inexperienced endoscopist.
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Affiliation(s)
- Jae Woo Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, South Korea
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Abstract
The purpose of this review is to examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer (EGC). Endoscopic mucosal resection (EMR) of EGC, with negligible risk of lymph node metastasis, is a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. EMR is a minimally invasive technique which is safe, convenient, and efficacious; however, it is insufficient when treating larger lesions. The evidence suggests that difficulties with the correct assessment of depth of tumor invasion lead to an increase in local recurrence with standard EMR when lesions are larger than 15 mm. A major factor contributing to this increase in local recurrence relates to lesions being excised piecemeal due to the technical limitations of standard EMR. A new development in endoscopic techniques is to dissect directly along the submucosal layer -- a procedure called endoscopic submucosal dissection (ESD). This allows the en-bloc resection of larger lesions. ESD is not necessarily limited by lesion size and it is predicted to replace conventional surgery in dealing with certain stages of ECG. However, it still has a higher complication rate when compared to standard EMR, and it requires high levels of endoscopic skill and experience. Endoscopic techniques, indications, pathological assessment, and methods of endoscopic resection of EGC need to be established for carrying out appropriate treatment and for the collation of long-term outcome data.
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Affiliation(s)
- Takuji Gotoda
- National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Abstract
The purpose of this review is to examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer (EGC). Endoscopic mucosal resection (EMR) of EGC, with negligible risk of lymph node metastasis, is a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. EMR is a minimally invasive technique which is safe, convenient, and efficacious; however, it is insufficient when treating larger lesions. The evidence suggests that difficulties with the correct assessment of depth of tumor invasion lead to an increase in local recurrence with standard EMR when lesions are larger than 15 mm. A major factor contributing to this increase in local recurrence relates to lesions being excised piecemeal due to the technical limitations of standard EMR. A new development in endoscopic techniques is to dissect directly along the submucosal layer -- a procedure called endoscopic submucosal dissection (ESD). This allows the en-bloc resection of larger lesions. ESD is not necessarily limited by lesion size and it is predicted to replace conventional surgery in dealing with certain stages of ECG. However, it still has a higher complication rate when compared to standard EMR, and it requires high levels of endoscopic skill and experience. Endoscopic techniques, indications, pathological assessment, and methods of endoscopic resection of EGC need to be established for carrying out appropriate treatment and for the collation of long-term outcome data.
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Affiliation(s)
- Takuji Gotoda
- National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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Gotoda T, Yamamoto H, Soetikno RM. Endoscopic submucosal dissection of early gastric cancer. J Gastroenterol 2006; 41:929-42. [PMID: 17096062 DOI: 10.1007/s00535-006-1954-3] [Citation(s) in RCA: 489] [Impact Index Per Article: 27.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2006] [Accepted: 09/12/2006] [Indexed: 02/07/2023]
Abstract
The purpose of this review was to examine a remarkable technical advance regarding the indications for and the technique of endoscopic resection of early gastric cancer. Endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan, probably owing to the high incidence of gastric cancer in Japan and the fact that more than half of Japanese gastric cancer cases are diagnosed at an early stage. Very recently, several EMR techniques have become increasingly accepted and regularly used in Western countries. Although these minimally invasive techniques are safe, convenient, and efficacious, they are unsuitable for large lesions in particular. Difficulty in correctly assessing the depth of tumor invasion and an increase in local recurrence when standard EMR procedures are used have been reported in cases of large lesions, because such lesions are often resected piecemeal owing to the technical limitations of standard EMR. A new development in therapeutic endoscopy, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa, and large lesions can be resected en bloc. ESD is not limited by resection size and is expected to replace surgical resection. However, it is still associated with a higher incidence of complications than standard EMR procedures and requires a high level of endoscopic skill. The endoscopic indications, techniques, and management of complications of ESD for early gastric cancer for properly carrying out established therapeutic endoscopy are described.
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Affiliation(s)
- Takuji Gotoda
- Endoscopy Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Tokyo, Japan
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Abstract
PURPOSE OF REVIEW To examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer. RECENT FINDINGS Endoscopic mucosal resection of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. Though this minimally invasive technique is a safe, convenient and efficacious method, it is insufficient for larger lesions. Difficulties in correctly assessing the depth of tumour invasion and increases in local recurrence by standard endoscopic mucosal resection have been reported in lesions larger than 15 mm. This is because such lesions are often resected piecemeal due to the technical limitation of standard endoscopic mucosal resection. New developments in endoscopic resection techniques to dissect the submucosa directly, called endoscopic submucosal dissection, allows resections of larger lesions en bloc. There are no limitations in resection size in endoscopic submucosal dissection, which is expected to replace surgery. This technique, however, still has higher complications rates than standard endoscopic mucosal resection and requires highly skilled endoscopists. SUMMARY The techniques, indications, and pathological assessment methods of endoscopic resection of early gastric cancer are described so that proper treatment guidelines can be established and long-term outcome data can be assessed.
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Affiliation(s)
- Takuji Gotoda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan.
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