Endoscopic submucosal dissection is an effective and safe therapy for early gastric neoplasms: a multicenter feasible study

Unveiling clinicopathologic features and outcomes for endoscopic submucosal dissection of early gastric cancer at gastric angulus in China

BACKGROUND

With advances in endoscopic submucosal dissection (ESD) technique, an increasing number of the Chinese population are being diagnosed with early gastric cancers (EGCs) at gastric angulus. However, the relationship between gastric angulus and EGCs remains obscure.

OBJECTIVES

We aimed to unveil the unreported location characteristics of gastric angulus in Chinese EGC patients and the correlation between the degree of submucosal fibrosis and ESD outcomes.

METHODS

We retrospectively reviewed the medical records of EGC patients treated with ESD from January 2010 to March 2023. We retrospectively investigated and analyzed 740 EGC patients using multiple analyses.

RESULTS

Following gastric antrum (53.1%), the gastric angulus (21.8%) emerged as the second-most prevalent site for EGCs. It had highest incidence of severe submucosal fibrosis and ulceration than the other parts. Multivariate analysis showed independent associations of submucosal fibrosis at the angulus with ulceration (OR: 3.714, 95% CI: 1.041-13.249), procedure duration (OR: 1.037, 95% CI: 1.014-1.061), and perforation complication (OR: 14.611, 95% CI: 1.626-131.277) (all P < 0.05).

CONCLUSIONS

The gastric angulus demonstrates the highest incidence of severe submucosal fibrosis and ulceration for EGCs identified by ESD. This condition is linked to unfavorable outcomes, typically increased perforation risks and prolonged operation duration. Therefore, meticulous dissection is crucial for patients with EGCs in the gastric angulus.

Comparable long-term survival outcomes after endoscopic and gastrectomy treatment of pT1acN0M0 gastric adenocarcinoma in patients who met the expanded criteria

BACKGROUND

Whether the Western pT1acN0M0 gastric cancer (GC) patients who met the Japanese expanded criteria could be the candidates for endoscopic treatment (ET) remains unclear because of unknown long-term survival outcomes.

METHODS

A retrospective cohort study using data from the Surveillance, Epidemiology, and End Results (SEER) program was performed. The survival differences between pT1acN0M0 gastric adenocarcinoma patients who received ET or gastrectomy treatment (GT) were evaluated using multivariate survival analysis.

RESULTS

A total of 314 pT1acN0M0 gastric adenocarcinoma patients who met the expanded criteria were included, 46 patients received ET and 268 patients received GT. pT1acN0M0 gastric adenocarcinoma patients met the expanded criteria underwent ET experienced a similar hazard of cancer-specific death compared with those underwent GT both in the multivariate Cox survival analysis (adjusted hazard ratio [HR]; 1.18, 95% confidence interval [CI] 0.40-3.49; P = 0.766) and the multivariate competing risk model (subdistribution HR [SHR], 1.12, 95% CI 0.38-3.29; P = 0.845). The result that pT1acN0M0 gastric adenocarcinoma patients met the expanded criteria underwent ET experienced comparable survival outcomes to those who underwent GT did not change even compared with those who underwent GT with > 15 lymph nodes examined (adjusted HR, 1.55, 95% CI 0.44-5.49; P = 0.499; SHR, 1.47, 95% CI 0.44-4.88; P = 0.532).

CONCLUSIONS

The ET can be considered in Western pT1acN0M0 gastric adenocarcinoma patients who met the Japanese expanded criteria. However, a prospective study should be warranted.

Treatment for T1 colorectal cancers substratified by site and size: "horses for courses"

Background

Owing to advances in diagnostic technology, the diagnosis of T1 colorectal cancers (CRCs) continues to increase. However, the optimal management of T1 CRCs in the Western Hemisphere remains unclear due to limited population-based data directly comparing the efficacy of endoscopic therapy (ET) and surgical resection (SR). The purpose of this study was to report outcome data from a large Western cohort of patients who underwent ET or SR for early CRCs.

Methods

The SEER-18 database was used to identify patients with T1 CRCs diagnosed from 2004 to 2018 treated with ET or SR. Multivariable logistic regression models were employed to identify variables related to lymph node metastasis (LNM). Rates of ET and 1-year relative survival were calculated for each year. Effect of ET or SR on overall survival and cancer-specific survival was compared using Kaplan-Meier method stratified by tumor size and site.

Results

A total of 28,430 T1 CRCs patients were identified from 2004 to 2018 in US, with 22.7% undergoing ET and 77.3% undergoing SR. The incidence of T1 CRCs was 6.15 per 100,000 person-years, with male patients having a higher incidence. Left-sided colon was the most frequent location of tumors. The utilization of ET increased significantly from 2004 to 2018, with no significant change in 1-year relative survival rate. Predictors of LNM were age at diagnosis, sex, race, tumor size, histology, grade, and location. The 5-year relative survival rates were 91.4 and 95.4% for ET and SR, respectively. Subgroup analysis showed that OS and CSS were similar between ET and SR in T1N0M0 left-sided colon cancers with tumors 2 cm or less and in rectal cancers with tumors 1 cm or less.

Conclusion

Our study showed that ET was feasible and safe for patients with left-sided T1N0M0 colon cancers and tumors of 2 cm or less, as well as T1N0M0 rectal cancers and tumors of 1 cm or less. Therefore, the over- and under-use of ET should be avoided by carefully selecting patients based on tumor size and site.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Demarcation Line Determination for Diagnosis of Gastric Cancer Disease Range Using Unsupervised Machine Learning in Magnifying Narrow-Band Imaging

Background and Aims: It is important to determine an accurate demarcation line (DL) between the cancerous lesions and background mucosa in magnifying narrow-band imaging (M-NBI)-based diagnosis. However, it is difficult for novice endoscopists. We aimed to automatically determine the accurate DL using a machine learning method. Methods: We used an unsupervised machine learning approach to determine the DLs. Our method consists of the following four steps: (1) an M-NBI image is segmented into superpixels using simple linear iterative clustering; (2) the image features are extracted for each superpixel; (3) the superpixels are grouped into several clusters using the k-means method; and (4) the boundaries of the clusters are extracted as DL candidates. The 23 M-NBI images of 11 cases were used for performance evaluation. The evaluation investigated the similarity of the DLs identified by endoscopists and our method, and the Euclidean distance between the two DLs was calculated. For the single case of 11 cases, the histopathological examination was also conducted to evaluate the proposed system. Results: The average Euclidean distances for the 11 cases were 10.65, 11.97, 7.82, 8.46, 8.59, 9.72, 12.20, 9.06, 22.86, 8.45, and 25.36. The results indicated that the proposed method could identify similar DLs to those identified by experienced doctors. Additionally, it was confirmed that the proposed system could generate pathologically valid DLs by increasing the number of clusters. Conclusions: Our proposed system can support the training of inexperienced doctors as well as enrich the knowledge of experienced doctors in endoscopy.

Comparable long-term outcomes after endoscopic therapy and gastrectomy of early adenocarcinoma of esophagogastric junction: a population-based study

BACKGROUND AND AIMS

Current guidelines recommend consideration of endoscopic therapy (ET) when treating selected early gastric cancers. However, clinical decision-making on ET versus gastrectomy for early adenocarcinoma of esophagogastric junction (AEGJ) remains challenging because of uncertain long-term outcomes.

METHODS

We performed a retrospective cohort study using the Surveillance, Epidemiology, and End Results database from 2004 to 2017 of early AEGJ patients underwent ET or gastrectomy. Multivariate models were used to compare cancer-specific survival (CSS).

RESULTS

Of 881 included early AEGJ patients, 227 (36.2%) patients underwent ET and 654 (63.8%) patients underwent gastrectomy. Early AEGJ patients who underwent ET experienced a similar hazard of cancer-specific death compared with those underwent gastrectomy in both multivariate Cox regression (HR [hazard ratio], 0.93; 95% CI [confidence interval], 0.55-1.56; P = 0.78) and the multivariate competing risk model (subdistribution HR [SHR], 0.86; 95% CI 0.50-1.45; P = 0.56). Propensity score matching was used, 210 patients underwent ET were matched with 210 patients underwent gastrectomy. Patients underwent ET experienced a similar hazard of cancer-specific death compared with those underwent gastrectomy in both multivariate Cox regression (HR, 0.97; 95% CI 0.53-1.77; P = 0.92) and the multivariate competing risk model (SHR, 0.96; 95% CI 0.52-1.77; P = 0.89).

CONCLUSION

Early AEGJ patients who received ET or gastrectomy had comparable long-term outcomes, which lend support to the role of ET in the treatment of these patients.

Feasibility of gastric endoscopic submucosal dissection in elderly patients aged ≥ 80 years

BACKGROUND

Endoscopic resection, especially endoscopic submucosal dissection (ESD), is increasingly performed in elderly patients with early gastric cancer, and lesions beyond the expanded indications are also resected endoscopically in some patients. It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.

AIM

To assess the efficacy and feasibility of gastric ESD for elderly patients, and define high-risk lesions and prognostic indicators.

METHODS

Among a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014, 179 sessions (15.3%) were performed in patients aged ≥ 80 years, and 172 of these sessions were done in patients with a final diagnosis of gastric cancer. These patients were studied retrospectively to evaluate short-term outcomes and survival. The short-term outcomes included the rates of en bloc resection and curative resection, complications, and procedure-related mortality. Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010. Fisher’s exact test was used to statistically analyze risk factors. Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test. Survival rates at each time point were based on Kaplan-Meier estimation. Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test. To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting, we used the least absolute shrinkage and selection operator (LASSO) Cox regression model including factors curative/ noncurative, age, gender, body mass index, prognostic nutritional index, Charlson comorbidity index (CCI), Glasgow prognostic score, neutrophil-to-lymphocyte ratio, and antithrombotic agent use. We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation. P < 0.05 was considered statistically significant.

RESULTS

The en bloc dissection rate was 97.1%, indicating that a high quality of treatment was achieved even in elderly patients. As for complications, the rates of bleeding, perforation and aspiration pneumonitis were 3.4%, 1.1% and 0.6%, respectively. These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients. A dissection incision > 40 mm, lesions associated with depressions, and lesions with ulcers were risk factors for post-ESD bleeding, and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients (P < 0.05). Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding. The overall survival (OS) did not differ significantly between curative and noncurative ESD (P = 0.69). In patients without additional surgery, OS rate was significantly lower in patients with a high CCI (≥ 2) than in those with a low CCI (≤ 1) (P < 0.001).

CONCLUSION

Gastric ESD is feasible even in patients aged ≥ 80 years. Observation without additional surgery after noncurative ESD is reasonable, especially in elderly patients with CCI ≥ 2.

Rebleeding in patients with delayed bleeding after endoscopic submucosal dissection for early gastric cancer

OBJECTIVES

Delayed bleeding is a major adverse event in endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Some patients may experience rebleeding after successful hemostasis for delayed bleeding, yet the details of rebleeding remain unclear. We aimed to clarify the frequency and risk factors of rebleeding.

METHODS

Among 11,452 patients who underwent ESD for EGC at 33 institutions in Japan between 2013 and 2016, we analyzed 489 patients showing delayed bleeding. The rate of rebleeding was investigated. Subsequently, 15 candidate variables were evaluated for their influence on the risk of rebleeding via logistic regression analysis.

RESULTS

Rebleeding occurred in 11.2% (55/489) of the enrolled patients. Multivariate analysis revealed that warfarin [odds ratio (OR), 2.71; 95% confidence interval (CI), 1.26-5.84] and a resection size >40 mm (OR, 1.99; 95% CI, 1.08-3.67) were independent risk factors for rebleeding. In the analysis of the management of warfarin after index bleeding, only warfarin discontinuation (OR, 3.66; 95% CI, 1.37-9.78) was significantly associated with rebleeding in comparison with no use of warfarin. However, many rebleeding events (75.0%) occurred following the resumption of warfarin. The rebleeding rate during discontinuation status and that in taking warfarin (continuation or resumption) were 6.1% and 20.0%, respectively.

CONCLUSIONS

Rebleeding was not a rare event in patients experiencing delayed bleeding after ESD for EGC. In addition to having a resection size >40 mm, warfarin usage placed patients at high risk for rebleeding, especially at the timing of its resumption following discontinuation as well as its continuation.

Optimal procedure-related hospitalization using clinical pathway protocols following gastric endoscopic submucosal dissection

BACKGROUND

The clinical pathway (CP) protocols simplified a systematic process from hospitalization to discharge, and were conducted to achieve standardization of the treatment process as well as improve outcomes. Thus, we investigated the optimal procedure-related hospitalization period following gastric endoscopic submucosal dissection (ESD) by comparing the rate of delayed bleeding (DB) and perforation according to CP protocols.

METHODS

We retrospectively enrolled 630 patients who underwent ESD for gastric dysplasia or early gastric cancer (EGC); Group A (368 patients) followed Protocol A for a hospital stay of a single night; Group B (262 patients) followed Protocol B for a hospital stay of two nights.

RESULTS

The patient characteristics were comparable between the two groups, except for pathologic diagnosis (42.1% in Group A vs. 32.1% in Group B for EGC). DB occurred in 21 patients, and there was no significant difference in the overall DB rates between Group A (12/368 = 3.3%) and Group B (9/262 = 3.4%) (P = 0.904). The DB rates were 2.5% (8/315) and 7.5% (4/53) in Group A, and 2.7% (6/223) and 7.7% (3/39) in Group B, without and with the use of antiplatelets, respectively, and 33.3% (1/3) in Group A and 50.0% (1/2) in Group B with the use of dual antiplatelets. DB developed at various intervals post-discharge from 2 to 17 days, and was successfully controlled by endoscopic hemostasis in most cases. There were no deaths or surgeries required as a result of uncontrolled DB and no postoperative delayed perforation occurred.

CONCLUSIONS

The CP protocols with a one-night hospitalization following gastric ESD decreased the hospital stay and did not influence postoperative complications compared to those with two-night hospitalizations.

Long-term outcomes after endoscopic submucosal dissection for differentiated-type early gastric cancer that fulfilled expanded indication criteria: A prospective cohort study

BACKGROUND AND AIM

Endoscopic resection for early gastric cancer (EGC) is widely performed. However, there is still a paucity of strong evidence regarding long-term outcomes after endoscopic submucosal dissection (ESD) for the expanded indication criteria of the Japanese guidelines (ver. 2010).

METHODS

Endoscopic submucosal dissection was performed in patients with EGC that met the expanded indication criteria: (i) cT1a, differentiated-type EGC of 2 to 5 cm, ulcer negative or (ii) cT1a, differentiated-type EGC of ≤3 cm, ulcer positive. Patients whose pathological examination fulfilled the curative resection criteria were then enrolled in this cohort study: negative vertical margin, negative lymphovascular invasion, and (i) pT1a, differentiated-type, and ulcer negative; (ii) pT1a, differentiated-type, ≤3 cm, and ulcer positive; or (iii) pT1b1 (<500-μm submucosal invasion), differentiated-type, and ≤3 cm. Patients with only a positive horizontal margin as a noncurative factor were included for follow-up.

RESULTS

From September 2003 to February 2012, a total of 356 patients underwent ESD, and 214 were enrolled in the survival analysis. One hundred twenty patients (56%) had >2 cm in diameter and ulcer-negative lesions, and 94 (44%) had ≤3 cm and ulcer-positive lesions. The vital status at 5 years after ESD was confirmed in all (100%) patients. No local or metastatic recurrence was detected; however, 26 metachronous gastric cancers developed, and 1 patient died of metachronous gastric cancer. The 5-year disease-specific and overall survival rates were 99.5% (95% confidence interval [CI], 97.2%-100%) and 93.9% (95% CI, 89.8%-96.4%), respectively.

CONCLUSION

ESD for EGC that fulfills the expanded criteria is feasible and shows favorable long-term outcomes.

Feasibility of a modified search, coagulation, and clipping method with and without the use of polyglycolic acid sheets and fibrin glue for preventing delayed bleeding after gastric endoscopic submucosal dissection

BACKGROUND

Methods have been developed for preventing delayed bleeding (DB) after gastric endoscopic submucosal dissection (GESD). However, none of the methods can completely prevent DB. We hypothesized that DB could be prevented by a modified search, coagulation, and clipping (MSCC) method for patients at low risk for DB and by combining the use of polyglycolic acid sheets and fibrin glue with the MSCC method (PMSCC method) for patients at high risk for DB (antibleeding [ABI] strategy). This study assessed the technical feasibility of this novel strategy.

METHOD

We investigated 123 lesions in 121 consecutive patients who underwent GESD in Kushiro Rosai Hospital between April 2018 and January 2020. The decision for continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment.

RESULTS

Oral antithrombotic agents were administered to 28 patients (22.8%). The en bloc R0 resection rate was 98.4%. The MSCC method and the PMSCC method for preventing DB were performed in 114 and 9 lesions, respectively. The median time of the MSCC method was 16 min, and the median speed (the resection area divided by the time of method used) was 3.6 cm2/10 min. The median time of the PMSCC method was 59 min, and the median speed was 1.3 cm2/10 min. The only delayed procedural adverse event was DB in 1 (0.8%) of the 123 lesions.

CONCLUSIONS

The ABI strategy is feasible for preventing DB both in patients at low risk and in those at high risk for DB after GESD, whereas the PMSCC method may be necessary for reduction of time.

Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer (second edition)

In response to the rapid and wide acceptance and use of endoscopic treatments for early gastric cancer, the Japan Gastroenterological Endoscopy Society, in collaboration with the Japanese Gastric Cancer Association, produced "Guidelines for Endoscopic Submucosal Dissection and Endoscopic Mucosal Resection for Early Gastric Cancer" in 2014, as a set of basic guidelines in accordance with the principles of evidence-based medicine. At the time, a number of statements had to be established by consensus (the lowest evidence level), as evidence levels remained low for many specific areas in this field. However, in recent years, the number of well-designed clinical studies has been increasing. Based on new findings, we have issued the revised second edition of the above guidelines that cover the present state of knowledge. These guidelines are divided into the following seven categories: indications, preoperative diagnosis, techniques, evaluation of curability, complications, long-term postoperative surveillance, and histology.

Influence of Tumor Location on Lymph Node Metastasis and Survival for Early Gastric Cancer: a Population-Based Study

BACKGROUND

The question that whether the criteria for endoscopic resection of early gastric non-cardia cancer (GNCC) is appropriate for early gastric cardia cancer (GCC) remains unclear. Thus, our aim was to evaluate the influence of tumor location on lymph node metastasis (LNM) and overall survival (OS) for early gastric cancer (GC).

METHODS

A total of 5440 early GC patients in the Surveillance, Epidemiology, and End Results (SEER) database were identified. Multivariable analysis was performed to evaluate the influence of tumor location on LNM and OS for early GC.

RESULTS

The rate of LNM was 17.48% for early GCC patients (232/1327) and 18.62% for early GNCC patients (766/4113). The early GCC patients experienced no significantly different risk of LNM compared with the early GNCC patients (adjusted OR 0.92, 95% CI 0.76-1.12, P = 0.405). The early GC patients were further stratified by node status. Tumor location was not a predictor of OS for node-negative early GC patients (adjusted HR 1.07, 95% CI 0.96-1.21, P = 0.225) but a predictor of OS for node-positive early GC patients (adjusted HR 1.80, 95% CI 1.48-2.20, P < 0.001).

CONCLUSIONS

Tumor location was not a predictor of LNM for early GC patients. Moreover, tumor location was not a predictor of OS for node-negative early GC patients. Thus, the criteria for endoscopic resection of early GNCC might be appropriate for the treatment of early GCC.

A Pilot Study of Endoscopic Submucosal Dissection Using an Endoscopic Assistive Robot in a Porcine Stomach Model

Background/Aims

Endoscopic assistive devices have been developed to reduce the complexity and improve the safety of surgeries involving the use of endoscopes. We developed an assistive robotic arm for endoscopic submucosal dissection (ESD) and evaluated its efficiency and safety in this in vitro pilot study.

Methods

ESD was performed using an auxiliary transluminal endoscopic robot. An in vitro test bed replicating the intra-abdominal environment and pig stomachs were used for the experiment. Participants were divided into skilled operators and unskilled operators. Each group performed ESD 10 times by using both conventional and robot-assisted methods. The perforation incidence, operation time, and resected mucous membrane size were measured.

Results

For the conventional method, significant differences were noted between skilled and unskilled operators regarding operation time (11.3 minutes vs 26.7 minutes) and perforation incidence (0/10 vs 6/10). Unskilled operators showed a large decrease in the perforation incidence with the robot-assisted method (conventional method vs robot-assisted method, 6/10 vs 1/10). However, the operation time did not differ between the conventional and robot-assisted methods. On the other hand, skilled operators did not show differences in the operation time and perforation incidence between the conventional and robot-assisted methods. Among both skilled and unskilled operators, the operation time decreased with the robot-assisted method as the experiment proceeded.

Conclusions

The surgical safety of unskilled operators greatly improved with robotic assistance. Thus, our assistive robotic arm was beneficial for ESD. Our findings suggest that endoscopic assistive robots have positive effects on surgical safety.

Risk factors for perforation of gastric endoscopic submucosal dissection: a systematic review and meta-analysis

The aim of this systematic review and meta-analysis was to identify significant risk factors for perforation in gastric endoscopic submucosal dissection. Studies published in the English language were searched for in Embase, WEB OF SCIENCE, Medline (PubMed and Ovid) and the Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Inclusion criteria and exclusion criteria were defined in advance in this work. Probable risk factors in a total of eighteen studies were evaluated, and the results are represented in the case of dichotomous variables as an odds ratio (with 95% confidence interval). Analysing the risk factors, the odds ratios were 1.98 (95% confidence interval: 1.02-3.85) for liver disease; 3.62 (95% confidence interval: 2.83-4.65) for vertical localization (the upper portion of the stomach); 1.42 (95% confidence interval: 1.03-1.96) for resected size (>20 mm); 3.05 (95% confidence interval: 1.80-5.17) for depth of invasion (submucosal); 4.12 (95% confidence interval: 1.63-10.39) for operation time (>2 hours); 1.59 (95% confidence interval: 1.25-2.01) for gross type of lesion (depressed or flat); and 3.88 (95% confidence interval: 2.69-5.60) for piecemeal resection. Liver disease, vertical localization (the upper portion of the stomach), resected size (>20 mm), depth of invasion (submucosal), operation time (>2 hours), gross type of lesion (flat or depressed), and piecemeal resection were verified to be risk factors for perforation of gastric endoscopic submucosal dissection.

Gastric endoscopic submucosal dissection: a systematic review and meta-analysis on risk factors for poor short-term outcomes

OBJECTIVE

Endoscopic submucosal dissection (ESD) is now established as the first option to manage early gastric neoplasms, but its efficacy may vary according to diverse factors. We aimed to systematically identify risk factors for poor short-term outcomes of gastric ESD with the purpose to improve patients' selection and management.

METHODS

Three online databases (MEDLINE, ISI Web of Knowledge and Scopus) were searched (last search on June 2018) for poor outcomes of gastric ESD (deep submucosal invasion, piecemeal/incomplete resection, noncurative resection and local recurrence).

RESULTS

One hundred five studies were included referring to 52.126 ESDs. Undifferentiated histology and upper location (vs lower) were associated with submucosal invasion [odds ratio (OR) = 2.42 [95% confidence interval (CI), 1.62-3.61] and OR = 3.20 (1.04-9.86), respectively] and deep submucosal invasion [OR = 2.98 (2.02-4.39) and OR = 2.35 (1.45-3.81), respectively]. Lesion size greater than 30 mm and ulceration were associated with piecemeal resection [OR = 2.78 (1.17-6.60) and OR = 2.76 (1.23, 6.20), respectively]. Lesion size greater than 30 mm, ulceration, upper location and fibrosis were risk factors for incomplete resection [OR = 3.83 (2.68-5.49), OR = 4.06 (1.62-10.16), OR = 3.71 (2.49-5.54) and OR = 4.46 (1.66-11.96), respectively]. A noncurative resection was more often observed for lesions located in the upper third of the stomach [OR = 1.49 (1.24-1.79)], depressed morphology [OR = 1.49 (1.04-2.12)] and those outside standard criteria [OR = 3.56 (2.31-5.48)]. Older age was significantly linked with local recurrence rates [OR = 3.08 (1.13-5.02)].

CONCLUSION

Several risk factors influence poor efficacy short-term outcomes of gastric ESD that may be used to inform both patients and health providers about the expected efficacy.

The search, coagulation, and clipping (SCC) method prevents delayed bleeding after gastric endoscopic submucosal dissection

BACKGROUND

Delayed bleeding is an important complication after gastric endoscopic submucosal dissection (ESD). The search, coagulation, and clipping (SCC) method can be used to prevent delayed bleeding after ESD. However, its safety and efficacy are unclear. We compared the SCC method with post-ESD coagulation (PEC) to clarify the safety and efficacy of the SCC method for preventing delayed bleeding after gastric ESD.

METHODS

This retrospective study included 438 patients (478 lesions) who underwent gastric ESD. Multivariate logistic regression analysis was performed to identify the significant independent factors associated with delayed bleeding and we performed propensity-score matching (PSM) to reduce the effect of procedure-selection bias of SCC method.

RESULTS

Of the 438 patients, 216 underwent PEC and 222 underwent SCC. Delayed bleeding was significantly less common in the SCC than in the PEC (2.6% vs. 7.2%; P = 0.013). Among patients treated with antithrombotic therapy, the delayed bleeding rate was lower in the SCC group than in the PEC group; however, the difference was not significant (P = 0.15). The SCC method was found to be a significant independent factor for the prevention of delayed bleeding. PSM was performed in 156 patients in the PEC group and SCC group. There was a significant difference in the incidence of bleeding in the PEC and SCC groups (P = 0.013). No patient had perforation/bleeding associated with the SCC method.

CONCLUSIONS

Our findings suggest that the SCC method is a simple, safe, and effective approach for preventing delayed bleeding after gastric ESD.

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

OBJECTIVES

A Japanese multicenter prospective cohort study examining endoscopic resection (ER) for early gastric cancer (EGC) has been conducted using a Web registry developed to determine the short-term and long-term outcomes based on absolute and expanded indications. We hereby present the short-term outcomes of this study.

METHODS

All consecutive patients with EGC or suspected EGC undergoing ER at 41 participating institutions between July 2010 and June 2012 were enrolled and prospectively registered into the Web registry. The baseline characteristics were entered before ER, and the short-term outcomes were collected at 6 months following ER.

RESULTS

Nine thousand six hundred and sixteen patients with 10 821 lesions underwent ER (endoscopic submucosal dissection [ESD]: 99.4%). The median procedure time was 76 min, and R0 resections were achieved for 91.6% of the lesions. Postoperative bleeding and intraoperative perforation occurred in 4.4% and 2.3% of the patients, respectively. Significant independent factors correlated with a longer procedure time (120 min or longer) were as follows: tumor size >20 mm, upper-third location, middle-third location, local recurrent lesion, ulcer findings, gastric tube, male gender, and submucosa. Histopathologically, 10 031 lesions were identified as common-type gastric cancers. The median tumor size was 15 mm. Noncurative resections were diagnosed for 18.3% of the lesions. Additional surgery was performed for 48.6% (824 lesions) of the 1695 noncurative ER lesions with a possible risk of lymph node (LN) metastasis. Among them, 64 (7.8%) exhibited LN metastasis.

CONCLUSIONS

This multicenter prospective study showed favorable short-term outcomes for gastric ESD.

The Elevated ASK1 Expression Inhibits Proliferation and Invasion in Gastric Cancer HGC-27 Cells

This study aimed to evaluate the effects and mechanism of action of ASK1 gene on the growth and migration of gastric cancer (GC) cells. Total RNA was extracted from the gastric cell lines and GC tissues. The expression level of ASK1, and the association between ASK1 expression and clinicopathological characteristics was assessed by real-time polymerase chain reaction. The effects of ASK1 on the proliferation of HGC-27 cells were assessed by the CCK-8 assay. In addition, the effects of ASK1 on the migration of HGC-27 cells were analyzed by the migration assay using transwell chambers. The expression levels of signaling proteins related to cell migration were detected by Western blotting. Although no significant differences were observed in the expression levels of ASK1 between the GC tissue samples and the normal tissue samples (P = 0.241), ASK1 expression correlated with tumor lymph node metastasis (P = 0.008). Furthermore, ASK1 inhibited proliferation and migration of HGC-27 cells. The increase in the expression of ASK1 in HGC-27 cells induced the activation of the JNK and p38 signaling pathways. The findings demonstrated that increased ASK1 expression level inhibited migration and proliferation of HGC-27 gastric cancer cells, whereas the possible mechanism of action may be attributed to the activation of the JNK and p38 signaling pathways. Anat Rec, 301:1815-1819, 2018. © 2018 Wiley Periodicals, Inc.

Comparing outcomes for endoscopic submucosal dissection between Eastern and Western countries: A systematic review and meta-analysis

AIM

To compare endoscopic submucosal dissection (ESD) outcomes between Eastern and Western countries.

METHODS

A systematic review and meta-analysis was performed using PubMed, MEDLINE, Web of Science, CINAHL and EBM reviews to identify studies published between 1990 and February 2016. The primary outcome was the efficacy of ESD based on information about either curative resection, en bloc or R0 resection rates. Secondary outcomes were complication rates, local recurrence rates and procedure times.

RESULTS

Overall, 238 publications including 84318 patients and 89512 gastrointestinal lesions resected using ESD were identified. 90% of the identified studies reporting ESD on 87296 lesions were conducted in Eastern countries and 10% of the identified studies reporting ESD outcomes in 2216 lesions were from Western countries. Meta-analyses showed higher pooled percentage of curative, en bloc, and R0 resection in the Eastern studies; 82% (CI: 81%-84%), 95% (CI: 94%-96%) and 89% (CI: 88%-91%) compared to Western studies; 71% (CI: 61%-81%), 85% (CI: 81%-89%) and 74% (CI: 67%-81%) respectively. The percentage of perforation requiring surgery was significantly greater in the Western countries (0.53%; CI: 0.10-1.16) compared to Eastern countries (0.01%; CI: 0%-0.05%). ESD procedure times were longer in Western countries (110 min vs 77 min).

CONCLUSION

Eastern countries show better ESD outcomes compared to Western countries. Availability of local ESD expertise and regional outcomes should be considered for decision making to treat gastrointestinal lesions with ESD.

Conventional versus traction-assisted endoscopic submucosal dissection for gastric neoplasms: a multicenter, randomized controlled trial (with video)

BACKGROUND AND AIMS

The aim of this study was to clarify whether dental floss clip (DFC) traction improves the technical outcomes of endoscopic submucosal dissection (ESD).

METHODS

A superiority, randomized control trial was conducted at 14 institutions across Japan. Patients with single gastric neoplasm meeting the indications of the Japanese guidelines for gastric treatment were enrolled and assigned to receive conventional ESD or DFC traction-assisted ESD (DFC-ESD). Randomization was performed according to a computer-generated random sequence with stratification by institution, tumor location, tumor size, and operator experience. The primary endpoint was ESD procedure time, defined as the time from the start of the submucosal injection to the end of the tumor removal procedure.

RESULTS

Between July 2015 and September 2016, 640 patients underwent randomization. Of these, 316 patients who underwent conventional ESD and 319 patients who underwent DFC-ESD were included in our analysis. The mean ESD procedure time was 60.7 and 58.1 minutes for conventional ESD and DFC-ESD, respectively (P = .45). Perforation was less frequent in the DFC-ESD group (2.2% vs .3%, P = .04). For lesions located in the greater curvature of the upper or middle stomach, the mean procedure time was significantly shorter in the DFC-ESD group (104.1 vs 57.2 minutes, P = .01).

CONCLUSIONS

Our findings suggest that DFC-ESD does not result in shorter procedure time in the overall patient population, but it can reduce the risk of perforation. When selectively applied to lesions located in the greater curvature of the upper or middle stomach, DFC-ESD provides a remarkable reduction in procedure time.

Endoscopic submucosal dissection in the West: Current status and future directions

Endoscopic submucosal dissection (ESD) was first conceptually described almost 30 years ago in Japan and is now widely practiced throughout East Asia. ESD expands the boundaries of endoscopic resection (ER) by allowing en bloc resection of large early neoplastic lesions within the gastrointestinal tract (GIT). This offers advantages over other ER techniques by facilitating definitive histological staging and curative treatment of early cancer in selected cases. Indeed, the experience of ESD in Eastern countries is significant, and excellent outcomes from high-volume centers are reported. The potential benefits of ESD are recognized by Western endoscopists, but its adoption has been limited. A number of factors contribute to this, including epidemiological differences in GIT neoplasia between Western and Eastern populations and limitations in training opportunities. In this review, we discuss the role of ESD, its current status and the future in Western endoscopic practice.

Endoscopic closure after intraluminal surgery

Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.

Clinical importance of colonoscopy in patients with gastric neoplasm undergoing endoscopic submucosal dissection

AIM

To evaluate the usefulness of total colonoscopy (TCS) for patients undergoing gastric endoscopic submucosal dissection (ESD) and to assess risk factors for colorectal neoplasms.

METHODS

Of the 263 patients who underwent ESD at our department between May 2010 and December 2013, 172 patients undergoing TCS during a one-year period before and after ESD were targeted. After excluding patients with a history of surgery or endoscopic therapy for colorectal neoplasms, 158 patients were analyzed. Of the 868 asymptomatic patients who underwent TCS during the same period because of positive fecal immunochemical test (FIT) results, 158 patients with no history of either surgery or endoscopic therapy for colorectal neoplasms who were matched for age and sex served as the control group for comparison.

RESULTS

TCS revealed adenoma less than 10 mm in 53 patients (33.6%), advanced adenoma in 17 (10.8%), early colorectal cancer in 5 (3.2%), and advanced colorectal cancer in 4 (2.5%). When the presence or absence of adenoma less than 10 mm, advanced adenoma, and colorectal cancer and the number of adenomas were compared between patients undergoing ESD and FIT-positive patients, there were no statistically significant differences in any of the parameters assessed. The patients undergoing ESD appeared to have the same risk of colorectal neoplasms as the FIT-positive patients. Colorectal neoplasms were clearly more common in men than in women (P = 0.031). Advanced adenoma and cancer were significantly more frequent in patients with at least two of the following conditions: hypertension, dyslipidemia, and diabetes mellitus (P = 0.019).

CONCLUSION

In patients undergoing gastric ESD, TCS appears to be important for detecting synchronous double neoplasms. Advanced adenoma and cancer were more common in patients with at least two of the following conditions: hypertension, dyslipidemia, and diabetes mellitus. Caution is therefore especially warranted in patients with these risk factors.

Successful Endoscopic Submucosal Dissection of a Large Terminal Ileal Lipoma

A 78-year-old woman who had recurrent right lower abdominal pain for about 1 year underwent computed tomography (CT) because of a follow-up observation 1 year after right breast cancer surgery. CT revealed a tumor in the colon. The patient was referred to our hospital for detailed examinations. An abdominal CT showed a low-density tumor of approximately 30 mm in the ascending colon, and the CT density inside the tumor was same as that of fatty tissues. A subsequent colonoscopy showed a submucosal tumor (SMT) in the proximal ascending colon developing from the terminal ileum. A colonoscopic ultrasonography revealed that the SMT was a high-echoic mass mainly localized in the submucosal layer. Based on the findings from CT, colonoscopy, and colonoscopic ultrasonography, the SMT was diagnosed as a pedunculated lipoma originating from the terminal ileum and treated with endoscopic submucosal dissection (ESD) because of recurrent abdominal pain. The 40-mm tumor was resected en bloc without complications. ESD may be more appropriate than polypectomy and surgery for removal of small intestinal tumors, because ESD allows direct visualization of the cutting line and exactly dissects the submucosal layers without damaging the muscular layers. ESD is a potentially useful treatment to remove intestinal lipomas.

Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis

BACKGROUND AND AIMS

Postprocedural bleeding (PPB) is the most common adverse event associated with endoscopic resection. Several studies have tried to identify risk factors for PPB after gastric EMR and endoscopic submucosal dissection (ESD), with controversial results. This systematic review and meta-analysis aimed to identify significant risk factors for PPB after gastric EMR and ESD.

METHODS

Three online databases were searched. Pooled odds ratio (OR) was computed for each risk factor using a random-effects model, and heterogeneity was assessed by Cochran's Q test and I(2).

RESULTS

Seventy-four articles were included. Pooled PPB rate was 5.1% (95% confidence interval, 4.5%-5.7%), which did not vary according to different study designs. Male sex (OR, 1.25), cardiopathy (OR, 1.54), antithrombotic drugs (OR, 1.63), cirrhosis (OR, 1.76), chronic kidney disease (OR, 3.38), tumor size > 20 mm (OR, 2.70), resected specimen size > 30 mm (OR, 2.85), localization in the lesser curvature (OR, 1.74), flat/depressed morphology (OR, 1.43), carcinoma histology (OR, 1.46), and ulceration (OR, 1.64) were identified as significant risk factors for PPB, whereas age, hypertension, submucosal invasion, fibrosis, and localization (upper, middle, or lower third) were not. Procedure duration > 60 minutes (OR, 2.05) and the use of histamine-2 receptor antagonists instead of proton pump inhibitors (OR, 2.13) were the procedural factors associated with PPB, whereas endoscopist experience and preprocedural proton pump inhibitors were not. Second-look endoscopy was not associated with decreased PPB (OR, 1.34; 95% confidence interval, .85-2.12).

CONCLUSIONS

Risk factors for PPB were identified that can help to guide management after gastric ESD, namely adjusting further management. Second-look endoscopy is not associated with decreased PPB.

Magnifying endoscopy with narrow-band imaging is more accurate for determination of horizontal extent of early gastric cancers than chromoendoscopy

BACKGROUND AND STUDY AIMS

Although magnifying endoscopy with narrow-band imaging (ME-NBI) is reported to be useful for delineating the horizontal extent of early gastric cancers (EGCs), there are few reports which have objectively demonstrated the superiority of ME-NBI over chromoendoscopy with indigo carmine for this purpose. We conducted an exploratory comparison of the diagnostic accuracy of both modalities for the delineation of EGCs using prospectively collected data, and clarified the clinicopathological features related to inaccurate evaluation of the horizontal extent of EGCs.

PATIENTS AND METHODS

EGCs were assigned to the oral narrow-band imaging (O-NBI) group or the oral chromoendoscopy (O-CE) group before endoscopic submucosal dissection (ESD). The oral border was observed according to assignment, and the anal border with the other modality. The horizontal extent of the tumor was evaluated by each modality and a marking dot was placed on the visible delineation line. After ESD, the marking dots were identified pathologically and defined as "accurate evaluation" if they were located within 1 mm of the pathological tumor border. We compared the rate of accurate evaluation of ME-NBI and chromoendoscopy, and analyzed the clinicopathological features related to inaccurate evaluation.

RESULTS

A total of 113 marking dots evaluated by ME-NBI and 116 evaluated by chromoendoscopy were analyzed. The rate of accurate evaluation by ME-NBI was significantly higher than that by chromoendoscopy (89.4 % vs 75.9 %, P = 0.0071). The EGCs with flat borders and large EGCs were significantly related to inaccurate evaluation using ME-NBI. There were no significant factors related to inaccurate evaluation with chromoendoscopy.

CONCLUSIONS

The accurate evaluation rate of the horizontal extent of EGCs by ME-NBI is significantly higher than that by chromoendoscopy.

STUDY REGISTRATION

UMIN000007641.

FV-429 Induced Apoptosis Through ROS-Mediated ERK2 Nuclear Translocation and p53 Activation in Gastric Cancer Cells

Following our previous finding which revealed that FV-429 induces apoptosis in human hepatocellular carcinoma HepG2 cells, in this study, we found that FV-429 could also induce apoptosis in human gastric cancer cells. Firstly, FV-429 inhibited the viability of BGC-823 and MGC-803 cells with IC50 values in the range of 38.10 ± 6.28 and 31.53 ± 6.84 µM for 24 h treatment by MTT-assay. Secondly, FV-429 induced apoptosis in BGC-823 and MGC-803 cells through the mitochondrial-mediated pathway, showing an increase in Bax/Bcl-2 ratios, and caspase-9 activation, without change in caspase-8. Further research revealed that the mitogen-activated protein kinases, including c-Jun N-terminal kinase, extracellular regulated kinase, and p38 mitogen-activated protein kinase, could be activated by FV-429-induced high level ROS. Moreover, FV-429 also promoted the ERK2 nuclear translocation, resulting in the co-translocation of p53 to the nucleus and increased transcription of p53-regulated proapoptotic genes. FV-429 significantly inhibited the nude mice xenograft tumors growth of BGC-823 or MGC-803 cells in vivo.

Delayed bleeding and hemorrhage of mucosal defects after gastric endoscopic submucosal dissection on second-look endoscopy

BACKGROUND

Although second-look endoscopy is performed within several days after gastric endoscopic submucosal dissection (ESD), there has been no evidence supporting the usefulness of the intervention. We investigated the relationship between delayed bleeding and hemorrhage of mucosal defects after ESD on second-look endoscopy and analyzed risk factors of active bleeding on second-look endoscopy.

METHODS

A total of 441 consecutive ESD cases with gastric cancer or adenoma were retrospectively analyzed. Second-look endoscopy was performed in the morning after the day of ESD. Bleeding of mucosal defects on second-look endoscopy was classified according to the Forrest classification, and active bleeding was defined as Forrest Ia or Ib. Delayed bleeding was defined as hematemesis or melena after second-look endoscopy.

RESULTS

A total of 406 second-look endoscopies were performed, and delayed bleeding occurred in 11 patients. The incidence rate of delayed bleeding after second-look endoscopy in patients with Forrest Ia or Ib was significantly higher than that in patients with Forrest IIa, IIb or III (7.69 vs. 2.02 %, p < 0.05). Complication of a histological ulcer, large size of the resected specimen and long ESD procedure time were shown to be risk factors for hemorrhage of mucosal defects after ESD on second-look endoscopy by univariate analysis. Multivariate analysis indicated that only large size of the resected specimen was a risk factor. In a specimen size of >35 mm, the odds ratio of active bleeding on second-look endoscopy was 1.9.

CONCLUSION

Active bleeding of mucosal defects on second-look endoscopy is a risk factor for delayed bleeding.

Guidelines for endoscopic submucosal dissection and endoscopic mucosal resection for early gastric cancer

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.

Endoscopic Submucosal Dissection for Early Gastric Cancer: Getting It Right!

Endoscopic resection is a widely accepted less-invasive treatment technique for local resection of early gastric cancer (EGC) lesions with a negligible risk of lymph node metastasis. Remarkable progress has been made during the last decade in this field, both in terms of expansion of the indications (to larger lesions and to lesions with ulceration) and in terms of technical improvements from endoscopic mucosal resection (EMR) to endoscopic submucosal dissection (ESD). Previously, larger lesions and lesions with ulceration were resected surgically because of the difficulty in effectively using EMR in this context. ESD however allows a high rate of en bloc resections, regardless of tumor location, tumor size, or the presence of ulceration. Nonetheless, ESD also has drawbacks: the procedure time is increased, ESD is more technically challenging compared to EMR, and, finally, ESD is associated with a slightly higher risk of complications. In order to overcome these limitations and minimize complications, a step-by-step process is important for learning ESD techniques. This chapter addresses the indications, results, some technical tips, and complications of ESD for EGC.

Prospective randomized comparison of endoscopic submucosal tunnel dissection and conventional submucosal dissection in the resection of superficial esophageal/gastric lesions in a living porcine model

BACKGROUND AND STUDY AIMS

To assess experimentally endoscopic submucosal tunnel dissection (ESTD) as an alternative technique of endoscopic submucosal resection.

PATIENTS AND METHODS

This was a prospective, randomized, comparative experimental animal study carried out over a period of 9 months at the surgical research and teaching center of Aix-Marseille University, France. Virtual esophageal and gastric lesions measuring 3 cm in diameter were resected in pigs weighing 25 to 30 kg. The primary aim was to evaluate ESTD's efficacy compared with endoscopic submucosal dissection (ESD). The secondary aims were to determine complication rates as well as to assess procedure time and procedure speed, histologic quality of the resected specimen, and procedure cost.

RESULTS

Eighteen procedures (9 ESD and 9 ESTD) were performed in nine pigs. The technical success rate was 88.9 % for both techniques, with one single failure in each. The en bloc resection rate was 100 % for ESTD and 88.9 % for ESD (one failure). The complication rate (22 %) and median procedure time were similar but dissection speed was quicker with ESTD in the esophagus (P = 0.03). Median procedure cost (728 Euros for ESD and ESTD) did not differ. On histologic examination, the lateral margins were healthy in 100 % of ESTD and in 88.9 % of ESD (P = 0.49). Deep resection margins were of better quality in ESTD (median submucosal thickness: 1307.1 µm vs. 884.7 µm; P = 0.039).

CONCLUSIONS

ESTD is feasible and safe but not superior in the treatment of superficial esophageal/gastric lesions in porcine models compared with ESD. Nevertheless it provides a better quality histologic specimen.

Therapeutic outcomes of endoscopic submucosal dissection of differentiated early gastric cancer in a Western endoscopy setting (with video)

BACKGROUND

Large multicenter gastric cancer endoscopic submucosal dissection (ESD) studies conducted at major Japanese institutions have reported en bloc resection, en bloc tumor-free margin resection, and curative resection rates of 92.7% to 96.1%, 82.6% to 94.5%, and 73.6% to 85.4%, respectively, with delayed bleeding and perforation rates of 0.6% to 6.0% and 3.6% to 4.7%, respectively. Although ESD is currently an alternative treatment in some countries, particularly in Asia, it remains uncertain whether ESD therapeutic outcomes in Western endoscopy settings can be comparable to those achieved in Japan.

OBJECTIVE

To evaluate the ESD therapeutic outcomes for differentiated early gastric cancer (EGC) in a Western endoscopy setting.

DESIGN/SETTING

Consecutive case series performed by an expertly trained Western endoscopist.

PATIENTS

Fifty-three patients with 54 lesions.

INTERVENTIONS

ESD for early gastric cancers (T1) satisfying expanded inclusion criteria.

MAIN OUTCOME MEASUREMENTS

En bloc resection, en bloc tumor-free margin resection, and curative resection rates were 98%, 93%, and 83%, respectively. The delayed bleeding rate was 7%, and the perforation rate was 4%.

RESULTS

The mean patient age was 67 years, and the mean tumor size was 19.8 mm, with 54% of the lesions located in the lesser curvature. The median procedure time was 61 minutes, with ESD procedures 60 minutes or longer associated with submucosal fibrosis (P < .001) and tumor size 25 mm or larger (P = .03). In every ESD procedure, both circumferential incision and submucosal dissection were performed by using a single knife. Two of the 4 delayed bleeding cases required surgery, and all perforations were successfully managed by using endoscopic clips.

LIMITATION

Long-term outcome data are currently unavailable.

CONCLUSION

ESD for differentiated EGC resulted in favorable therapeutic outcomes in a Western endoscopy setting comparable to those achieved at major Japanese institutions.

Risk of infection after iatrogenic perforation of the gut wall? Evaluation of preventive strategies in a randomized controlled animal trial

BACKGROUND

Interventional endoscopies entail a risk of infection secondary to perforation of the luminal wall. Thereby, bacteria may be introduced into the sterile environment of the peritoneal cavity (PC). Limited data are available regarding the efficacy of prophylactic anti-infective treatments. The aim of the study was to examine the efficacy/safety of anti-infective means in the prevention of infection by interventional endoscopies in a randomized controlled animal trial.

METHODS

Forty pigs were randomized to: 1: control; 2: oral lavage; 3: gastric lavage; 4: oral/gastric lavage; 5: i.m. antibiotics. Lavage was performed with Octenisept prior to the operation. After gastric wall perforation, peritoneoscopy was performed. Before the procedure, after closure and prior to autopsy, intraabdominal lavage for bacterial culture was taken using mini-laparoscopy. At autopsy, macroscopic appearance of the PC was scored. Lavage fluids were grown to identify/quantify bacterial load. Concentration of intraperitoneal bacteria at autopsy was defined as main outcome parameter.

RESULTS

No major complications occurred in any of the procedures. Bacterial load of the PC at autopsy was significantly reduced with antibiotics compared to all other groups, whereas it did not differ between the lavage groups and control. Macroscopic scoring of the PC showed significant lower rate of intraabdominal abscesses in the antibiotic group compared to the lavage groups and control (p < 0.01).

CONCLUSION

Only antibiotic prophylaxis is effective for the prevention of infection after iatrogenic perforation of the gastrointestinal wall. There was no difference between any form of lavage and the control group. Further studies in humans are required to prove these animal data.

Neutrophil infiltration and the distribution of intestinal metaplasia is associated with metachronous gastric cancer following endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) of early gastric cancer is a minimally invasive procedure. However, the risk for metachronous cancers after successful cancer treatment remains high and the risk factors for metachronous cancers have not been elucidated.

OBJECTIVE

To evaluate the risk factors for metachronous gastric cancers after ESD with a long-term follow-up.

METHODS

A total of 155 consecutive patients (119 men, 36 women, mean age 68.9 years) were treated with ESD between September 2000 and September 2009. Biopsy specimens were obtained from the greater curvature of the antrum and middle corpus to evaluate gastric mucosal status, including Helicobacter pylori, intestinal metaplasia (IM) and neutrophil infiltration (NI) before ESD. Follow-up endoscopy after ESD was scheduled at two and six months, one year and annually thereafter. H pylori eradication was recommended when possible.

RESULTS

The median follow-up period was 4.2 years. Metachronous gastric cancers were found in 23 of 155 patients (3.5% per year). No local recurrences were observed. The cumulative incidence of metachronous gastric cancer was significantly high in IM and NI in the corpus (P=0.0093 and P=0.0025, respectively [log-rank test]). The ORs for IM and NI in the corpus were 2.65 and 3.06, respectively, according to the Cox proportional hazards model (P=0.024 and P=0.0091, respectively).

CONCLUSIONS

The presence of IM and NI in the corpus was closely related to the development of metachronous gastric cancer after ESD.

Risk factors and correlations of immediate, early delayed, and late delayed bleeding associated with endoscopic resection for gastric neoplasms

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.

Hospital volume and the occurrence of bleeding and perforation after colorectal endoscopic submucosal dissection: analysis of a national administrative database in Japan

BACKGROUND

Colorectal endoscopic submucosal dissection has gained popularity as a minimally invasive technique for the treatment of colorectal neoplasms in many countries, including Japan. However, most previous studies of endoscopic submucosal dissection had relatively small sample sizes and only included patients treated at specialized centers. Associations between hospital volume and complication rates after colorectal endoscopic submucosal dissection are still poorly understood.

OBJECTIVE

Our aim was to clarify the relationships between hospital volume and the occurrence rates of bleeding and perforation after colorectal endoscopic submucosal dissection.

DESIGN

This was a retrospective cohort study. Hospital volume was defined as the number of colorectal endoscopic submucosal dissections performed at each hospital between April 2012 and March 2013 and was categorized into the following quartiles: 1) very low-volume (18 or less patients during the year), 2) low-volume (19-35 patients), 3) high-volume (36-58 patients), and 4) very high-volume (59 or more).

SETTINGS

This study was based on a national inpatient data from the Japanese Diagnosis Procedure Combination database.

PATIENTS

A total of 7567 patients with colorectal endoscopic submucosal dissection were included.

MAIN OUTCOME MEASURES

Severe postoperative bleeding requiring endoscopic hemostasis or blood transfusion within 1 week after endoscopic submucosal dissection and perforation requiring open surgery were the main outcomes measured.

RESULTS

Severe postoperative bleeding and perforation occurred in 331 (4.4%) and 13 patients (0.2%). Multivariable logistic regression analysis showed that the very high hospital volume group had a significantly lower proportion of severe postoperative bleeding than the very low hospital volume group (OR = 0.48 [95 % CI, 0.27-0.83]; p = 0.009).

LIMITATIONS

This study lacked some information on clinicopathologic features including en bloc resection, curative resection, and relapse. Individual endoscopist experience could not be analyzed.

CONCLUSIONS

The present study clearly showed a significant association between higher hospital volume and lower occurrence of severe postoperative bleeding.

Endoscopic submucosal dissection to treat ileal high-grade dysplasia after ileoanal anastomosis for familial adenomatous polyposis: report of a case

Restorative proctocolectomy has become the most common surgical option for familial adenomatous polyposis patients, based on the premise that the technique yields good functional results and reduces colorectal cancer risk. However, several adenomas may develop in the pouch mucosa in later years, and even cancer (at the anastomosis or in the pouch mucosa) has been reported. Endoscopic submucosal dissection (ESD) would then be indicated, even if severe fibrosis extended into the submucosal layer. Endoscopic resection of an ileal tumor from the thin wall of the ileum carries a high-risk of perforation. Our present case demonstrates the successful use of ESD to treat an ileal neoplasm, a technically difficult lesion with a high-risk of complications.

Gastric endoscopic submucosal dissection is safe for day patients

BACKGROUND/AIMS

Although the advantages of endoscopic submucosal dissection (ESD) are well established, there are important limitations that relate to its higher cost and higher rate of complications compared with endoscopic mucosal resection. This study assessed the therapeutic safety and efficacy of ESD in the treatment of small gastric dysplasia and early gastric cancer (EGC) located within the antrum in an outpatient setting, and it compared the results with those from patients admitted to hospital for ESD treatment.

METHODS

This study was a retrospective analysis of a prospectively maintained database. We reviewed consecutive patients with EGC or gastric dysplasia who underwent ESD between October 2007 and May 2008. The lesions were smaller than 2 cm and were located in the antrum. We analyzed 105 lesions in 105 patients. The patients were assigned to two groups according to each patient's preference.

RESULTS

The overall rates of complete resection were 98.1% in the inpatients group and 94.3% in the outpatients group. Immediate bleeding occurred in four inpatients, which included one patient in the outpatient group. Delayed bleeding occurred in one inpatient within 24 hours of the procedure. Macroperforations did not occur in either group. A microperforation was found in one outpatient.

CONCLUSIONS

The safety and efficacy of ESD used to treat small gastric tumors in the antrum in an outpatient setting appeared to be similar to the safety and efficacy of ESD used to treat patients who were admitted to the hospital.

Bispectral index monitoring during anesthesiologist-directed propofol and remifentanil sedation for endoscopic submucosal dissection: a prospective randomized controlled trial

PURPOSE

Endoscopic submucosal dissection (ESD) is a technically difficult and lengthy procedure requiring optimal depth of sedation. The bispectral index (BIS) monitor is a non-invasive tool that objectively evaluates the depth of sedation. The purpose of this prospective randomized controlled trial was to evaluate whether BIS guided sedation with propofol and remifentanil could reduce the number of patients requiring rescue propofol, and thus reduce the incidence of sedation- and/or procedure-related complications.

MATERIALS AND METHODS

A total of 180 patients who underwent the ESD procedure for gastric adenoma or early gastric cancer were randomized to two groups. The control group (n=90) was monitored by the Modified Observer's Assessment of Alertness and Sedation scale and the BIS group (n=90) was monitored using BIS. The total doses of propofol and remifentanil, the need for rescue propofol, and the rates of complications were recorded.

RESULTS

The number of patients who needed rescue propofol during the procedure was significantly higher in the control group than the BIS group (47.8% vs. 30.0%, p=0.014). There were no significant differences in the incidence of sedation- and/or procedure-related complications.

CONCLUSION

BIS-guided propofol infusion combined with remifentanil reduced the number of patients requiring rescue propofol in ESD procedures. However, this finding did not lead to clinical benefits and thus BIS monitoring is of limited use during anesthesiologist-directed sedation.

Time trend of medical economic outcomes of endoscopic submucosal dissection for gastric cancer in Japan: a national database analysis

BACKGROUND

Little information is available on the analysis of chronological changes in medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer. This study aimed to investigate the recent time trend of medical economic outcomes of ESD for gastric cancer based on the Japanese administrative database.

METHODS

A total of 32,943 patients treated with ESD for gastric cancer were referred to 907 hospitals from 2009 to 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications, risk-adjusted length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into three groups: 2009 (n = 9,727), 2010 (n = 11,052), and 2011 (n = 12,164).

RESULTS

No significant difference was observed in ESD-related complications between three study periods (p = 0.496). However, mean LOS and medical costs during hospitalization of patients with ESD were significantly lower in 2011 than in 2009 and 2010 (p < 0.001). Multiple linear regression analysis showed that patients who received ESD in 2011 had a significantly shorter LOS and lower medical costs during hospitalization compared with those in 2009. The unstandardized coefficient of patients with ESD in 2011 for LOS was -0.78 days [95 % confidence interval (CI), -0.89 to -0.65; p ≤ 0.001], while that of those for medical costs during hospitalization was -290.5 US dollars (95 % CI, -392.3 to -188.8; p ≤ 0.001).

CONCLUSIONS

This study showed that the complication rate of ESD was stable, whereas the LOS and medical costs of patients were significantly reduced from 2009 to 2011.

Factors predictive of inaccurate determination of horizontal extent of intestinal-type early gastric cancers during endoscopic submucosal dissection: a retrospective analysis

BACKGROUND

Certain tumor characteristics may pose challenges when endoscopically determining the horizontal extent of early gastric cancers (EGC). In the present study, clinicopathological features related to inaccurate endoscopic evaluation of horizontal extent of intestinal-type EGC were analyzed.

PATIENTS AND METHODS

We analyzed 431 lesions with intestinal-type EGC treated by endoscopic submucosal dissection (ESD) at our hospital. We focused on whether pretreatment demarcation was accurate by comparing positional relationships between marking dots and tumor edges in resected specimens, and factors related to inaccurate evaluation were analyzed. Gender, age, tumor size, location, circumference, depth, ulceration, macroscopic type, presence of a flat (0-IIb) component, predominant histological type, mixture of diffuse-type adenocarcinoma, mixed histology, and use of magnification endoscopy with narrow band imaging were analyzed. Reasons for inaccurate evaluation were also investigated by re-examining endoscopic images and prepared histological slides.

RESULTS

Rate of inaccurate evaluation of horizontal extent was 7.4% (32/431 lesions). Multivariate analysis revealed the following significant independent variables contributing to inaccurate endoscopic evaluation: presence of a flat component, large size, and predominant histological findings of moderately differentiated adenocarcinoma. Re-examination of prepared histological slides of inaccurately evaluated cases revealed a marginal flat spreading area in 28 of the 32 lesions (87.5%). In 14 of the 32 lesions (43.8%), tumor margins were composed of moderately differentiated adenocarcinoma.

CONCLUSIONS

For lesions with a flat component, large lesions, and moderately differentiated adenocarcinoma, determination of the horizontal extent can be challenging in EGC indicated for ESD, even with the best available endoscopic tools.

Training in endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient’s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee’s background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.

Training in endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient's quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee's background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.

Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria

Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation, particularly for tumors located at the gastric fundus and originating from the muscularis propria. Based on our experience with endoscopic submucosal dissection (ESD) and a novel endoscopic device, namely the ‘Resolution clip’ for the endoscopic closure of iatrogenic upper gastrointestinal (upper GI) perforations, we evaluated the clinical feasibility and safety of ESD for gastric fundus subepithelial tumors originating from the muscularis propria. In this prospective study, 11 consecutive patients who presented with gastric SETs ≤3 cm in diameter were enrolled. Regardless of whether perforation occurred, the gastric wall defect was closed with clips. The patients were followed up after the surgery. Endoscopic resection was successfully performed in 10 patients; however, in one patient a pure endoscopic approach was impossible as the lesion was severely adhered to surrounding tissue, and a switch to laparoscopic wedge resection was necessary. The mean resected tumor size was 18.8×17.2 mm and the mean surgery time of the 10 patients with ESD was 81 min (range 45–130 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in eight lesions [very low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in three lesions. Perforation occurred in 3/10 patients. Gastric closure with the Resolution clips was performed successfully in all cases. Early post-ESD bleeding (EPEB) occurred in one patient. Basic ferric sulfate solution was sprayed during the upper GI endoscopy examination and the bleeding stopped. No complications occurred and the follow-up was unremarkable. In this early study, ESD using the Resolution clip was demonstrated to be a feasible and minimally invasive treatment for gastric fundus subepithelial tumors originating from the muscularis propria.

Effects of medical adhesives in prevention of complications after endoscopic submucosal dissection

AIM: To evaluate the use of medical adhesive spray in endoscopic submucosal dissection (ESD).

METHODS: Patients who underwent ESD between January 2009 and June 2012 (n = 173) were enrolled in the prospective randomized study. Two patients undergoing surgery due to severe intraoperative hemorrhage and failed hemostasis were excluded, and the remaining 171 patients were randomly divided into two groups: group A (medical adhesive group, n = 89) and group B (control group, n = 82). In group A, a medical adhesive spray was evenly applied after routine electrocoagulation and hemostasis using hemostatic clip after ESD. Patients in group B only treated with routine wound management. Intraoperative and postoperative data were collected and compared.

RESULTS: In all 171 patients, ESD was successfully completed. There was no significant difference in the average treatment time between groups A and B (59.4 min vs 55.0 min, respectively). The average length of hospital stay was significantly different between group A and B (8.89 d vs 9.90 d, respectively). The incidence of intraoperative perforation was 10.1% in group A and 9.8% in group B, and was not significantly different between the two groups. In all cases, perforations were successfully managed endoscopically and with conservative treatment. The incidence of postoperative delayed bleeding in group A was significantly lower than that in group B (0.00% vs 4.88%, respectively).

CONCLUSION: ESD is an effective minimally invasive treatment for gastrointestinal precancerous lesions or early-stage gastrointestinal cancer. Medical adhesive spray is effective in preventing delayed bleeding after ESD, and can thus reduce the average length of hospital stay.

Outcomes of laparoscopic gastrectomy after endoscopic treatment for gastric cancer: a comparison with open gastrectomy

PURPOSE

Additional gastrectomy is needed after endoscopic resection for early gastric cancer when pathology confirms any possibility of lymph node metastasis or margin involvement. No studies depicted the optimal type of surgery to apply in these patients. We compared the short-term and long-term outcomes of laparoscopic gastrectomy with those of open gastrectomy after endoscopic resection to identify the optimal type of surgery.

MATERIALS AND METHODS

From 2003 to 2010, 110 consecutive patients who underwent gastrectomy with lymphadenectomy either by laparoscopic (n=74) or by open (n=36) for gastric cancer after endoscopic resection were retrospectively analyzed. Postoperative and oncological outcomes were compared according to types of surgical approach.

RESULTS

Clinicopathological characteristics were comparable between the two groups. Laparoscopic group showed significantly shorter time to gas passing and soft diet and hospital day than open group while operation time and rate of postoperative complications were comparable between the two groups. All specimens had negative margins regardless of types of approach. Mean number of retrieved lymph nodes did not differ significantly between the two groups. During the median follow-up of 47 months, there were no statistical differences in recurrence rate (1.4% for laparoscopic and 5.6% for open, P=0.25) and in overall (P=0.22) and disease-free survival (P=0.19) between the two groups. Type of approach was not an independent risk factor for recurrence and survival.

CONCLUSIONS

Laparoscopic gastrectomy after endoscopic resection showed comparable oncologic outcomes to open approach while maintaining benefits of minimally invasive surgery. Thus, laparoscopic gastrectomy can be a treatment of choice for patients previously treated by endoscopic resection.

Endoscopic submucosal dissection for the treatment of neoplastic lesions in the gastrointestinal tract

AIM: To investigate the indications, resection rate, and safety of endoscopic submucosal dissection (ESD) for neoplastic lesions in the gastrointestinal tract at a European referral center.

METHODS: We carried out a retrospective analysis of the ESD procedures performed in our center for mucosal neoplastic and submucosal lesions of the gastrointestinal tract. The duration of the procedure, en bloc and complete (R0) resection rates, and complication rates were evaluated. Variables were reported as mean ± SD or simple proportions. Univariate analysis and comparisons of procedure times and resection rates were performed using Mann-Whitney U tests, or χ² tests for dichotomous variables.

RESULTS: Between 2007 and 2011, ESD was performed in a total of 103 patients (46.7% male, mean age 64.0 ± 12.7 years). The indications for the procedure were epithelial tumor (n = 54), submucosal tumor (n = 42), or other (n = 7). The total en bloc resection rate was 90.3% (93/103) and R0 resection rate 80.6% (83/103). The median speed of the procedure was 15.0 min/cm². The complete resection rate was lower for submucosal tumors arising from the muscle layer (68%, 15/22, P < 0.05). Resection speed was quicker for submucosal tumors localized in the submucosal layer than for lesions arising from the muscularis propria layer (8.1 min/cm²vs 17.9 min/cm², P < 0.05). The R0 resection rate and speed were better in the last 24 mo (90.1%, 49/54 and 15.3 min/cm²) compared to the first 3 years of treatment (73.5%, 36/49, P < 0.05 and 22.0 min/cm², P < 0.05). Complications occurred in 14.6% (n = 15) of patients, including perforation in 5.8% (n = 6), pneumoperitoneum in 3.9% (n = 4), delayed bleeding in 1.9% (n = 2), and other in 2.9% (n = 3). Only one patient with delayed perforation required surgical treatment. During the mean follow-up of 26 ± 15.3 mo, among patients with R0 resection, recurrence occurred in one patient (1.2%).

CONCLUSION: ESD is an effective and safe method for resection of neoplastic lesions with low recurrence. Speed and the R0 resection rate increased after 50 procedures.