Long-term outcomes of endoscopic submucosal dissection versus surgery for treating early gastric cancer of undifferentiated-type

Noninferiority of additional gastrectomy after endoscopic submucosal dissection compared with surgery alone on long-term prognosis: a propensity score matching analysis

BACKGROUND

Patients in whom endoscopic submucosal dissection (ESD) has resulted in noncurative resection need further surgical treatment. However, the oncologic outcome of additional gastrectomy after ESD compared with surgery alone remains unclear.

METHODS

The clinical data of 778 patients who underwent gastrectomy for early gastric cancer (EGC) from January 2008 to December 2019 in Ishikawa Prefectural Central Hospital were retrospectively analyzed. Of these 778 patients, 187 underwent additional gastrectomy after ESD [ESD (+) group] and 591 underwent surgery alone [ESD (-) group]. We compared the overall survival and disease-free survival between the ESD (+) and ESD (-) groups, using propensity score matching (PSM) to adjust for baseline characteristics. We also assessed early postoperative outcomes.

RESULTS

After PSM based on sex (male or female), age, tumor diameter, tumor gross type, and operative procedure, each group comprised 144 patients with no significant differences in clinical background characteristics. After matching, the 5-year overall survival rate in the ESD (+) and ESD (-) group was 90.9% and 87.8%, respectively, with no significant difference (P = .470). In addition, there was no significant difference in the disease-free survival rate (97.6% vs 95.8%, respectively; P = .504). The postoperative complication rate was similar in both groups.

CONCLUSION

Additional gastrectomy for patients in whom ESD resulted in noncurative resection did not adversely affect the long-term prognosis. Additional gastrectomy after ESD is oncologically acceptable for EGC.

A meta-analysis of the effect of endoscopic submucosal dissection compared with gastrectomy on the wound infection in early stomach cancer subjects

We conducted a meta-analysis to assess the effect of endoscopic submucosal dissection compared with gastrectomy on the wound infection in early stomach cancer subjects. A systematic literature search up to November 2022 was performed and 2765 related studies were evaluated. The chosen studies comprised 7842 early stomach cancer subjects participated in the selected studies' baseline trials; 3308 of them used the endoscopic submucosal dissection, while 4534 used gastrectomy. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the wound infection in endoscopic submucosal dissection versus gastrectomy for early stomach cancer by the dichotomous methods with a random or fixed effect model. The use of endoscopic submucosal dissection resulted in significantly lower wound infection (OR, 0.45; 95% CI, 0.34-0.60, P < .001) with no heterogeneity (I²  = 8%) compared with the gastrectomy for early stomach cancer. The use of endoscopic submucosal dissection resulted in significantly lower wound infection compared with the gastrectomy for early stomach cancer. The small sample size of some studies in the comparison calls for care when analysing the results.

Endoscopic submucosal dissection versus surgery for patients with undifferentiated early gastric cancer

BACKGROUND AND AIMS

endoscopic submucosal dissection (ESD) is the standard treatment for differentiated early gastric cancer (EGC). However, its expanded indication for undifferentiated EGC is controversial. In this study, the efficacy and safety of ESD versus surgery in patients with undifferentiated EGC were compared.

METHODS

four databases were searched until February 24, 2022, for studies assessing patients with undifferentiated EGC that met an expanded indication for endoscopic resection and who were treated with ESD or surgery. Primary outcomes were all-cause mortality and any recurrence. Secondary outcomes were complete histological resection, local recurrence, metachronous recurrence, synchronous recurrence, distant metastasis, overall complication, and bleeding. All meta-analyses were performed using a random-effects models. Unadjusted (risk ratio [RR]) and adjusted (aRR and hazard ratio [aHR]) estimates with 95 % confidence interval (CI) were calculated.

RESULTS

seven cohort studies were included (n = 2637). The use of ESD was significantly associated with higher all-cause mortality compared to surgery (RR, 2.17; 95 % CI, 1.24-3.81); adjusted all-cause mortality effects were not significant (aRR, 2.28; 95 % CI, 0.95-5.47 and aHR, 1.97; 95 % CI, 0.85-4.53). ESD was associated with a higher risk of any recurrence using unadjusted (RR, 5.24; 95 % CI, 1.49-18.46) and adjusted (aRR, 7.89; 95 % CI, 1.52-40.95 and aHR, 3.73; 95 % CI, 1.17-11.90) estimates. The risk of local recurrence, synchronous recurrence and bleeding were significantly higher for ESD versus surgery. No significant differences were found for other secondary outcomes.

CONCLUSIONS

although ESD is associated with a higher risk of any recurrence, adjusted all-cause mortality is similar during follow-up. Overall complications were similar between ESD and surgery.

Long-term outcomes and clinical safety of expanded indication early gastric cancer treated with endoscopic submucosal dissection versus surgical resection: a meta-analysis

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) remains an investigational issue for early gastric cancer (EGC) with expanded indications owing to the risk of lymph node metastasis. In this study, we aimed to evaluate the clinical outcomes and safety of ESD versus surgical resection (SR) for EGC with expanded indications.

METHODS

The systematic review selected studies from PubMed, Embase, Cochrane and Web of Science databases from 2010 to 2020, and compared survival and clinical safety data of ESD with those of surgical resection for EGC with expanded indications. The fixed-effects or random-effects model was used to calculate the differences between the two groups. To assess the validity of the eligible studies, risk of bias was measured using the Newcastle-Ottawa Quality Assessment Scale.

RESULTS

Nine retrospective studies were used to calculate the differences in survival and clinical safety data between the two groups for EGC with expanded indications. Differences were not significant between the groups in terms of age, sex, tumour size, tumour histology or lesion morphology. Regarding tumour site, tumours located in the L area (the lower third of the stomach) were more likely to be found in the ESD group. With regard to metachronous and synchronous carcinomas, there was a significant difference favouring SR treatment (metachronous: OR=0.12, 95% CI=0.05 to 0.25, p<0.00001; synchronous: OR=0.11, 95% CI=0.02 to 0.46, p=0.003). Adverse event data were identified in six studies showing a significant difference favouring ESD treatment (ESD vs SR, OR=0.49, 95% CI=0.34 to 0.72. p=0.002). Additionally, six studies evaluating 5-year overall survival showed no significant differences between the two groups (HR=1.22, 95% CI=0.66 to 2.25, p=0.53). With regard to 5-year disease-free survival, patients with expanded indication EGC undergoing SR showed better survival (ESD vs SR, HR=3.29, 95% CI=1.60 to 6.76, p=0.001).

CONCLUSION

ESD provided favourable results for patients with EGC with expanded indications regarding clinical outcomes and safety in retrospective studies. Further, to detect synchronous or metachronous lesions, endoscopic surveillance should be performed following ESD. However, the included studies were observational, some did not have adequate adjustment for confounding factors and their results lacked generalisability due to their origin. Thus, further related randomised controlled trials are urgently encouraged.

PROSPERO REGISTRATION NUMBER

CRD42021251068.

Endoscopic Resection Versus Surgery in the Treatment of Early Gastric Cancer: A Systematic Review and Meta-Analysis

Background and Aim

Endoscopic resection (ER) is the preferred approach to treat early gastric cancer (EGC) in patients without suspected lymph node involvement and that meet the criteria for ER. Surgery is a more aggressive treatment, but it may be associated with less recurrence and the need for reintervention. Previous meta-analyses comparing ER with surgery for EGC did not incorporate the most recent studies, making accurate conclusions not possible.

Methods

This systematic review and meta-analysis aimed to examine complete resection, length of hospital stay (LOHS), adverse events (AEs), serious AEs, recurrence, 5-year overall survival (OS), and 5-year cancer-specific survival (CSS) in patients with EGC.

Results

A total of 29 cohorts studies involving 20559 patients were included. The ER (n = 7709) group was associated with a lower incidence of AEs (RD = -0.07, 95%CI = -0.1, -0.04, p < 0.0001) and shorter LOHS (95% CI -5.89, -5.32; p < 0,00001) compared to surgery (n = 12850). However, ER was associated with lower complete resection rates (RD = -0.1, 95%CI = -0.15, -0.06; p < 0.00001) and higher rates of recurrence (RD = 0.07, 95%CI = 0.06; p < 0.00001). There were no significant differences between surgery and ER in 5-year OS (RD = -0.01, 95%CI = -0.04, 0.02; p = 0.38), 5-year CSS (RD = 0.01, 95%CI = 0.00, 0.02; p < 0.17), and incidence of serious AEs (RD = -0.03, 95%CI = -0.08, 0.01; p = 0.13).

Conclusions

ER and surgery are safe and effective treatments for EGC. ER provides lower rates of AEs and shorter LOHS compared to surgery. Although ER is associated with lower complete resection rates and a higher risk of recurrence, the OS and CSS were similar between both approaches.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021255328.

Comparison of long-term outcomes of endoscopic submucosal dissection and surgery for undifferentiated-type early gastric cancer meeting the expanded criteria: a systematic review and meta-analysis

BACKGROUND

There have been concerns over the long-term outcomes of endoscopic submucosal dissection (ESD) for undifferentiated-type early gastric cancer (UD EGC). We aimed to compare the long-term outcomes of ESD and surgery for patients with UD EGC.

METHODS

We searched PubMed, Embase, and Cochrane Library databases through March 2021 to identify studies that compared the long-term outcomes of ESD and surgery for UD EGC meeting expanded criteria for curative resection. The risk of bias was assessed with the Cochrane tool for non-randomized studies. The risk ratio (RR) was estimated using a fixed-effect model.

RESULTS

Overall, 1863 patients from five retrospective cohort studies, including 908 patients with propensity score matching (PSM), were eligible for meta-analysis. ESD was associated with inferior overall survival (OS) compared to surgery in the overall cohort (RR 2.11; 95% CI 1.26-3.55) but not in the PSM cohort (RR 1.18; 95% CI 0.60-2.32). In the PSM cohort, ESD had a lower disease-free survival (DFS) (RR 2.49; 95% CI 1.42-4.35) and higher recurrence (RR 12.61; 95% CI 3.43-46.37), gastric recurrence (RR 11.25; 95% CI 3.06-41.40), and extragastric recurrence (RR 4.23; 95% CI 0.47-37.93). Recurrence outcomes were similar between the overall and PSM cohorts. Disease-specific survival was not significantly different between the two groups in both the overall and PSM cohorts.

CONCLUSION

Although OS after curative ESD for UD EGC was not different from that after surgery in the PSM cohort, DFS and recurrence were inferior after ESD. Limitations included a lack of randomized trials. Further prospective studies comparing the long-term outcomes of ESD and surgery for UD EGC are needed (PROSPERO CRD 42021237097).

Long-term outcomes of endoscopic submucosal dissection and surgery for undifferentiated intramucosal gastric cancer regardless of size

BACKGROUND

The clinical outcomes of endoscopic submucosal dissection (ESD) for undifferentiated (UD) intramucosal early gastric cancer (EGC) compared with those of surgery, regardless of lesion size, are not well known. Furthermore, there is a concern regarding the treatment plan before and after ESD in cases of UD intramucosal EGC within expanded indications.

AIM

To evaluate clinical outcomes of ESD compared with those of surgery in UD intramucosal EGC patients regardless of tumor size.

METHODS

We enrolled patients with UD intramucosal EGC after ESD with complete resection or surgery from January 2005 to August 2020 who met the within or beyond expanded indications with lesion size > 2 cm (the only non-curative factor). Overall, 123 and 562 patients underwent ESD and surgery, respectively. After propensity-score matching, clinical and long-term outcomes, i.e., recurrence-free survival (RFS) and overall survival (OS), were analyzed. The multivariable Cox proportional hazard model with treatment modality and ESD indication was used to evaluate the recurrence risk.

RESULTS

After matching, 119 patients each were finally enrolled in the ESD and surgery groups. The median length of hospital stay was shorter in the ESD group than surgery group (4.0 vs 9.0 days, P < 0.001). Four cases of recurrence after ESD were local recurrences, all of which occurred within 1 year. Total recurrence was seven (5.9%) and two (1.7%) in the ESD and surgery groups, respectively. No difference was observed between the two groups with respect to OS (P = 0.948). However, the ESD group had inferior RFS compared with the surgery group (P = 0.031). ESD was associated with the risk of recurrence after initial treatment in all enrolled patients (hazard ratio, 5.2; 95% confidence interval: 1.0-25.8, P = 0.045).

CONCLUSION

Although OS was similar between the two groups, surveillance endoscopy was important for the ESD than for the surgery group because RFS was inferior and local recurrence was an issue.