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

Endoscopic detection and diagnostic strategies for minute gastric cancer: A real-world observational study

BACKGROUND

Minute gastric cancers (MGCs) have a favorable prognosis, but they are too small to be detected by endoscopy, with a maximum diameter ≤ 5 mm.

AIM

To explore endoscopic detection and diagnostic strategies for MGCs.

METHODS

This was a real-world observational study. The endoscopic and clinicopathological parameters of 191 MGCs between January 2015 and December 2022 were retrospectively analyzed. Endoscopic discoverable opportunity and typical neoplastic features were emphatically reviewed.

RESULTS

All MGCs in our study were of a single pathological type, 97.38% (186/191) of which were differentiated-type tumors. White light endoscopy (WLE) detected 84.29% (161/191) of MGCs, and the most common morphology of MGCs found by WLE was protruding. Narrow-band imaging (NBI) secondary observation detected 14.14% (27/191) of MGCs, and the most common morphology of MGCs found by NBI was flat. Another three MGCs were detected by indigo carmine third observation. If a well-demarcated border lesion exhibited a typical neoplastic color, such as yellowish-red or whitish under WLE and brownish under NBI, MGCs should be diagnosed. The proportion with high diagnostic confidence by magnifying endoscopy with NBI (ME-NBI) was significantly higher than the proportion with low diagnostic confidence and the only visible groups (94.19% > 56.92% > 32.50%, P < 0.001).

CONCLUSION

WLE combined with NBI and indigo carmine are helpful for detection of MGCs. A clear demarcation line combined with a typical neoplastic color using nonmagnifying observation is sufficient for diagnosis of MGCs. ME-NBI improves the endoscopic diagnostic confidence of MGCs.

Effectiveness and safety of newly introduced endoscopic submucosal dissection in a Western center: a real-life study

OBJECTIVES

Endoscopic submucosal dissection (ESD) is a minimally invasive technique for the resection of superficial gastrointestinal lesions, providing high rates of 'en bloc' and R0 resection. East-West differences in ESD quality indicators have been reported. This study aims to assess feasibility, effectiveness, and safety of ESD for the treatment of superficial gastrointestinal (GI) lesions in a Western cohort.

METHODS

Consecutive patients undergoing ESD at one Italian endoscopic referral center from September 2018 to March 2020 were included in this prospective study. Primary outcomes were technical success, R0 resection rate, curative resection rate, and adverse events (AEs).

RESULTS

In total 111 patients (111 lesions) undergoing ESD were included. Anatomic site of the lesions was rectum in 56.8%, colon in 13.5%, stomach in 24.3%, and esophagus in 5.4% of cases, respectively. For upper GI procedures, technical success was 100%, and R0 and curative resection rates were 84.8% and 78.8%, respectively. For colorectal procedures, technical success was 98.7%, R0 and curative resection rates were 88.5% and 84.6%, respectively. Major AEs were reported in 12 cases (10.8%).

CONCLUSION

The introduction of ESD in a Tertiary Center is feasible, effective, and safe, and should be taken into consideration for the treatment of superficial GI lesions requiring 'en bloc' resection.

Risk factors for intraoperative and delayed perforation related with gastric endoscopic submucosal dissection

BACKGROUND AND AIM

Perforation is one of the most important complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Several studies have examined risk factors for intraoperative and delayed perforations, but most were retrospective analyses with small numbers of patients.

METHODS

This study represents a secondary analysis of a Japanese multicenter prospective cohort study. We investigated the factors associated with each type of perforation using 9015 patients with 9975 EGCs undergoing ESD between July 2010 and June 2012.

RESULTS

Intraoperative perforation occurred in 198 patients (2.2%) with 203 lesions (2.0%), necessitating emergency surgery for four lesions (0.04% [2.0%, 4/203]). Delayed perforation occurred in another 37 patients (0.4%) with 42 lesions (0.4%), requiring emergency surgery for 12 lesions (0.12% [28.6%, 12/42]). Factors showing significant independent correlations with intraoperative perforation were upper or middle third of the stomach; remnant stomach or gastric tube; procedure time ≥100 min; tumor size >35 mm; body mass index (BMI) < 18.5 kg/m2; and ≥72 years. Factors showing significant independent correlations with delayed perforation were procedure time ≥60 min; BMI < 18.5 kg/m2; ≥75 years; ulceration; and tumor size >20 mm. Intraoperative perforation occurred most frequently at the greater curvature in the upper third of the stomach (7.9%), whereas delayed perforation occurred most frequently at the greater curvature in the middle third (1.2%).

CONCLUSION

This multicenter prospective cohort study clarified the risk and risk factors of intraoperative and delayed perforation related to ESD for EGCs, providing information to help endoscopists reduce perforation.

Development of a novel multipoint traction device for gastric and colorectal endoscopic submucosal dissection and evaluation of its efficacy and safety

BACKGROUND

Proper traction allows safer and easier endoscopic submucosal dissection; however, single-point traction may not be sufficient. In this study we assessed the safety, efficacy, and feasibility of our newly developed multipoint traction device.

METHODS

During an ex vivo study using a Konjac training model, two experts and two trainees resected 80 mock lesions of 20-mm diameter by performing endoscopic submucosal dissection with and without multipoint traction. The primary outcome was the success rate of the procedure involving traction. The secondary outcomes were the submucosal dissection time, dissection speed, and perforation during endoscopic submucosal dissection. During the in vivo study, to clarify the initial clinical outcomes, we used data from the electronic medical record of patients at our institution who underwent gastric and colorectal endoscopic submucosal dissection, which was performed by experts with our newly developed multipoint traction device, from March to December 2022.

RESULTS

The ex vivo study indicated that all traction procedures were successful. Higher resection speeds were observed with endoscopic submucosal dissection with traction than without traction (P < 0.001). Perforations were not observed. During the first in vivo clinical study, traction was feasible during 20 gastric and colorectal endoscopic submucosal dissection procedures. No adverse events occurred.

CONCLUSIONS

Our multitraction device can increase the submucosal dissection speed and simplify endoscopic submucosal dissection techniques, thus safely reducing technical challenges. The application of this device for endoscopic submucosal dissection could lead to safer and more efficient procedures. Clinical registration UMIN Clinical Trials Registry, Japan (registration number UMIN000053384).

Prognostic significance of connective tissue growth factor expression in stromal cells in patients with diffuse‑type gastric cancer

Connective tissue growth factor (CTGF) is a target gene of the Hippo signaling pathway. Its differential role in the histological types of gastric cancer (GC) remains unknown; therefore, the present study aimed to confirm the clinical significance of CTGF expression in cancer and stromal cells in patients with GC depending on the histological type. The present study enrolled 589 patients with GC. Immunohistochemistry was used to analyze CTGF expression in cancer and stromal cells. CTGF mRNA expression data and the corresponding clinical information of GC samples were collected from The Cancer Genome Atlas (TCGA) database. Subsequently, the associations between CTGF expression and several clinicopathological factors were investigated. In the present study, CTGF expression was mainly observed in the cytoplasm of cancer and stromal cells. CTGF expression in stromal cells was significantly associated with CTGF expression in cancer cells (P<0.001). CTGF positivity in stromal cells was also significantly associated with intestinal type, non-scirrhous type, tumor depth (T1-2), lymph node metastasis (negative), lymphatic invasion (negative) and tumor size (<5 cm). Low CTGF expression in stromal cells was independently associated with worse overall survival (OS). Furthermore, the OS of patients with low CTGF expression in stromal cells, especially in patients with diffuse-type GC, was significantly worse than patients with high CTGF expression (P=0.022). This trend was similar to that revealed by TCGA data analysis. In conclusion, low CTGF expression was associated with a significantly worse OS in patients with diffuse-type GC. These data indicated that CTGF, and its control by the Hippo pathway, may be considered potential treatment targets in diffuse-type GC.

Randomised controlled, patient-blinded, multicentre, superiority trial to evaluate the efficacy of the line-attached sheath-type traction device for endoscopic submucosal dissection in patients with superficial gastric neoplasms

INTRODUCTION

EndoTrac is a line-attached sheath-type traction device that enables us to control the direction and the force of traction during endoscopic submucosal dissection (ESD). The efficacy of EndoTrac for gastric ESD has not been fully verified.

METHODS AND ANALYSIS

The G-Trac study is a multicentre (nine general hospitals and two university hospitals in Japan) collaborative trial assessing the efficacy of EndoTrac for gastric ESDs. Patients with superficial gastric neoplasms will be enrolled and randomly assigned to undergo either conventional ESD or EndoTrac ESD. Allocation will be stratified according to tumour location, operator experience and tumour diameter at an allocation rate of 1:1. The type of endoknife used will be confirmed before randomisation. The primary outcome, procedure time, will be compared between the groups in both intention-to-treat and per-protocol analyses using the Wilcoxon rank sum test. The efficacy-related, safety-related and device-related outcomes will be assessed in the secondary analysis. The planned sample size of the 142 patients in the two groups will enable us to detect a difference with a power of 80% by using the Wilcoxon rank sum test, assuming an effect size of 0.54, asymptotic relative efficiency of 0.864 and a two-sided type 1 error rate of 5%.

ETHICS AND DISSEMINATION

This trial was approved by the certified review board of Kobe University (22 December 2022). The results from this trial will be disseminated through peer-review journals, presentations at national and international conferences, and data sharing with other researchers.

TRIAL REGISTRATION NUMBER

jRCT1052220166.

Effect of endoscopic mucosal resection and endoscopic submucosal dissection on postoperative wound complications in patients with gastric cancer: A meta-analysis

Endoscopic submucosa dissection (ESD) allows complete excision of the whole lesion, which results in a higher percentage of complete excision and an improved quality of life by minimizing the amount of excision as opposed to an endoscopic mucosal resection (EMR). Although ESD is now being carried out in the majority of hospitals, ESD's possible complications (such as trauma and perforation) have given rise to doubts about ESD practices in patients with early-stage stomach cancer when deciding on therapy and reimbursement. This study was designed to evaluate the effectiveness and safety of ESD over EMR in treating early-stage stomach cancer. Four main databases have been searched, including EMBASE and published. The ROBINS-I tool suggested in the Cochrane Handbook has been applied to evaluate the quality of the chosen trials. It may better reflect the risk of bias in the included studies. The meta-analyses were carried out with ReMan 5.3, and the results were treated with endote. Seven cohort studies have been completed. Meta analysis indicated that EMR and ESD surgery did not differ significantly from each other in terms of postoperative haemorrhage (OR, 0.76; 95%CI, 0.56,1.04 p = 0.09); EMR, however, was associated with a lower rate of postoperative perforation than ESD surgery (OR, 0.36; 95%CI, 0.24,0.54 p < 0.0001). Taking into account that ESD and EMR did not differ significantly in the risk of wound bleeding, even though the risk of perforation is not likely to result in life-threatening illness. In the analysis of these data, however, the potential advantages of EMR might be greater than ESD.

Comparison of Prognosis and Metachronous Gastric Tumor Rates After Endoscopic Submucosal Dissection Between Gastric Neoplasm of Fundic Gland Type Neoplasms and Conventional Gastric Adenocarcinoma

INTRODUCTION

Gastric neoplasm of the fundic gland type (GNFG) is a tumor with a good prognosis. However, since it has not been compared with conventional gastric adenocarcinoma (CGA), it is unknown whether it has a good prognosis or requires surveillance after treatment. The purpose of this study was to determine the prognosis and metachronous gastric tumor rates compared with those of CGA.

METHODS

We conducted a single-center, retrospective, matched-cohort study using our database from January 2010 to December 2021. We extracted GNFG data from the endoscopic submucosal dissection (ESD) database and matched patients with conventional early gastric cancer as controls in a 1:4 ratio by age and sex. GNFG and CGA were compared for the overall survival (OS), disease-specific survival, progression-free survival, and metachronous gastric tumor rates.

RESULTS

Overall, 43 lesions were GNFG and 164 CGAs were matched. There were three deaths in the GNFG group and 11 deaths in the CGA group. There was no significant difference in the OS between the two groups (P=0.81). The five-year OS rates for the GNFG and CGA groups were 90.9% and 92.9%, respectively. No disease-specific deaths or recurrences were observed in either group. There was no significant difference in the cumulative metachronous gastric tumor rate between the two groups (P=0.17). The cumulative five-year metachronous gastric tumor rates for the GNFG and CGA groups were 6.6% and 2.5%, respectively.

CONCLUSIONS

The prognosis for GNFG is good, however, not better than that for CGA. The metachronous gastric tumor rate after ESD in GNFG was not lower than that in CGA. Therefore, after ESD, GNFG may need to be managed in the same way as CGA.

Impact of endoscopic surveillance on the early diagnosis and endoscopic resection likelihood of gastric cancer

BACKGROUND

Endoscopy could help detect early gastric cancer (EGC) and improve the prognosis of patients. The aim of this study was to analyze the impact of endoscopy and endoscopic surveillance on the early detection of gastric cancer (GC), GC staging, and treatment selection.

METHODS

Patients with GC diagnosed at our center from 2010 to 2022 were retrospectively analyzed and allocated to the short-interval group (had received endoscopy within 3 years before diagnosis), the long-interval group (had received endoscopy more than 3 years before diagnosis), and the unchecked group (had not received endoscopy before diagnosis). The differences in GC staging and treatment modalities among the three groups were analyzed, and the differences in the clinical and pathological features of EGC were further analyzed.

RESULTS

One thousand and twenty-five GC patients were included, with 395 cases of EGC and 630 cases of advanced GC. The proportions of EGC in the short-interval, long-interval, and unchecked groups were 98.0%, 84.2%, and 29.8%, respectively (p < 0.001). Among the 387 lesions of 367 EGC patients were resected by endoscopic submucosal dissection (ESD), 341 (88.1%) exhibited curative resection, and 46 (11.9%) involved noncurative resections. Lesions of EGC differed significantly in diameter, depth of invasion, and curative resection rate (p = 0.033, 0.019, and 0.005, respectively). In the short-interval group, 87.8% of the lesions were ≤ 2 cm, 95.6% of the invasion depths were confined to the mucosal layer, and 96.7% of the eCura scores were A or B. Compared with the unchecked group, they had smaller diameters (RR = 0.419, 95% CI 0.234-0.752), shallower invasion depths (RR = 0.286, 95% CI 0.105-0.777), and a higher curative resection rate (RR = 0.215, 95% CI 0.068-0.676).

CONCLUSION

Endoscopic surveillance at 3-year intervals can help detect EGC, and the EGC lesions found have smaller diameters and shallower depths of invasion, helping improve the curative resection rate of ESD.

Early-onset gastrointestinal cancer: An epidemiological reality with great significance and implications

During the last few years, epidemiological data from many countries suggest that the incidence and prevalence of many cancers of the digestive system are shifting from the older to the younger ages, the so-called "early-onset cancer". This is particularly evident in colorectal cancer and secondarily in other malignant digestive neoplasms, mainly stomach and in a lesser degree pancreas, and biliary tract. It should be emphasized that data concerning digestive neoplasms, except for those referring to the colon and stomach, could be characterized as rather insufficient. The exact magnitude of the shift in younger ages is expected to become clearer shortly, as long as relevant epidemiological data from many parts of the world would be available. The most important question concerns the etiology of this phenomenon, since its magnitude cannot be explained solely by the better diagnostic methodology and the preventive programs applied in many countries. The existing data support the assumption that a number of environmental factors may play a primary role in influencing carcinogenesis, sometimes from childhood. Changes that have appeared in the last decades related mainly to eating habits, consistency of gut microbiome and an increase of obese people interacting with genetic factors, ultimately favor the process of carcinogenesis. Even these factors however, are not entirely sufficient to explain the age-related changes in the frequency of digestive neoplasms. Studies of the individual effect of each of the already known factors or factors likely to be involved in the etiology of this phenomenon and studies using state-of-the-art technologies to accurately determine the degree of the population exposure to these factors are required. In this article, we attempt to describe the epidemiological data supporting the age-shifting of digestive malignancies and their possible pathogenesis. Finally, we propose some measures regarding the attitude of the scientific community to this alarming phenomenon.

Comparison of vonoprazan and proton pump inhibitors for the treatment of gastric endoscopic submucosal dissection-induced ulcer: an updated systematic review and meta-analysis

BACKGROUND

Both vonoprazan and proton pump inhibitors (PPIs) are currently used to treat artificial ulcers after gastric endoscopic submucosal dissection. However, evidence-based medicine proving the efficacy of vonoprazan is still lacking. Therefore, this meta-analysis aimed to compare the efficacy of vonoprazan and PPIs for the treatment of artificial ulcers after gastric endoscopic submucosal dissection.

METHODS

The PubMed, EMBASE and Cochrane Library databases were searched up to September 2023 for related randomized controlled trials (RCTs). RCTs that compared the efficacy of vonoprazan and PPIs in treating artificial gastric ulcers after gastric endoscopic submucosal dissection were included. Two independent reviewers screened the included studies, extracted the data and assessed the risk of bias. The following outcomes were extracted for comparison: ulcer healing rate, ulcer shrinkage rate, delayed postoperative bleeding rate, and ulcer perforation rate.

RESULTS

Nine randomized controlled trials involving 926 patients were included. The pooled results showed that vonoprazan had a significantly lower rate of delayed postoperative bleeding than did PPIs (RR = 0.46; 95% CI = 0.23-0.91; P = 0.03). No significant differences were found in terms of ulcer healing, shrinkage rates, or ulcer perforation rates between vonoprazan and PPIs.

CONCLUSIONS

Compared with PPIs, vonoprazan is superior at reducing delayed postoperative bleeding after endoscopic submucosal dissection. However, further studies are needed to prove the efficacy of vonoprazan.

SYSTEMATIC REVIEW REGISTRATION

Identifier CRD42024509227.

Comparison of prognostic outcomes between endoscopic submucosal dissection and surgical treatment for early gastric cancer: a retrospective cohort study

BACKGROUND AND AIM

The optimal management strategy for early gastric cancer (EGC) a topic of contention. This study aims to compare the prognostic outcomes of endoscopic submucosal dissection (ESD) and surgical treatment in patients diagnosed with EGC.

METHODS

In thisretrospective cohort study, we analyzed data from539 patients diagnosed with EGC between January 2012 and December 2020 from two centers. We compared Clinicopathological features, procedure-related complications, recurrence rate, overall survival, and disease specific survival between the 262 patients who underwent ESD and the 277 patients who underwent surgical treatment. ESD procedures were conducted using a dual knife by experienced endoscopists, while surgical treatments included laparoscopic or open gastrectomy. Regular ollow-up examinations were conducted post-treatment.

RESULTS

The two groups exhibited comparable baseline characteristics. Multivariable Cox regression analysis identified vascular invasion as a risk factor for worse recurrence-free survival (RFS), and overall survival (OS) in patients with early gastric cancer. The ESD group experienced fewer overall postoperative complications compared to the surgical treatment group. Kaplan-Meier curves demonstrated no significant differences in recurrence rate or overall survival between the two groups.

CONCLUSIONS

Both ESD and surgical treatment emerged as safe and effective approaches for managing EGC. The choice of treatment should be tailored to individual patient factors. ESD can be considered an alternative treatment option for selected patients who are not suitable candidates for surgery. Further studies are warranted to determine the long-term outcomes of ESD and surgical treatment for EGC.

Effects of 1-kestose on microbiome changes caused by vonoprazan: a randomized, double-blind, placebo-controlled pilot study

BACKGROUND AND AIM

Potassium-competitive acid blockers more strongly suppress the gastric acid barrier than proton pump inhibitors and cause dysbiosis. However, preventive measures in this regard have not been established. We aimed to evaluate whether 1-kestose, a known prebiotic, was effective at alleviating dysbiosis caused by potassium-competitive acid blockers.

METHODS

Patients scheduled to undergo endoscopic resection for superficial gastroduodenal tumors were enrolled and randomized 1:1 to receive either 1-kestose or placebo. All patients were started on potassium-competitive acid blocker (vonoprazan 20 mg/day) and took 1-kestose 10 g/day or placebo (maltose) 5 g/day for 8 weeks. The primary outcome was the effect of 1-kestose on potassium-competitive acid blocker-induced alterations in the microbiome. The fecal microbiome was analyzed before and after potassium-competitive acid blocker treatment via MiSeq (16S rRNA gene V3-V4 region).

RESULTS

Forty patients were enrolled, and 16 in each group were analyzed. In the placebo group, the Simpson index, an alpha diversity, was significantly decreased and relative abundance of Streptococcus was significantly increased by 1.9-fold. In the kestose group, the Simpson index did not change significantly and relative abundance of Streptococcus increased 1.3-fold, but this was not a significant change. In both groups, no adverse events occurred, ulcers were well healed, and pretreatment and posttreatment short-chain fatty acid levels did not differ.

CONCLUSIONS

The potassium-competitive acid blocker caused dysbiosis in the placebo group; this effect was prevented by 1-kestose. Thus, 1-kestose may be useful in dysbiosis treatment.

Incidence and risk factors for fever after endoscopic submucosal dissection and its derivative technology for gastric lesions

Introduction

Fever is one of the postoperative complications of endoscopic submucosal dissection (ESD) and its derivative technology. However, there are few studies on risk factors for fever after ESD and its derivative technology. The aim of this study was to determine the incidence and related risk factors after ESD and its derivative technology for gastric lesions.

Materials and methods

A retrospective review of patients with gastric lesions who were treated by ESD and its derivative technology in our hospital from January 2014 to January 2019 was conducted.

Results

A total of 1955 patients were included in the present study. A total of 451 (23.1 %) patients presented with fever after ESD and its derived techniques. The highest fever temperature was 37.6 ± 3.12 °C, and the number of days with fever was 1.48 ± 0.85. Through single factor and multiple factor analysis, age (OR: 1.261, 95% CI: 1.009-1.576, p < 0.05), procedure time (OR: 1.457, 95% CI: 1.053-2.016, p < 0.05), postoperative gastric tube placement (OR: 2.098, 95% CI: 1:616-2.723, p < 0.05), intraoperative hemorrhage (OR: 1.537, 95% CI: 1.196-1.974, p < 0.05) and perforation (OR: 1.970, 95% CI: 1.531-2.535, p < 0.05) were independent risk factors for postoperative fever.

Conclusion

Age ≥56 years old, procedure time ≥60 min, gastric tube placement, intraoperative hemorrhage and perforation were independent risk factors for postoperative fever after gastric ESD and its derivative technology. Attention should be given to such patients to minimize the risk of postoperative fever.

Prognostic Implication of Lymphovascular Invasion in Early Gastric Cancer Meeting Endoscopic Submucosal Dissection Criteria: Insights from Radical Surgery Outcomes

BACKGROUND

The management of early gastric cancer (EGC) has witnessed a rise in the utilization of endoscopic submucosal dissection (ESD) as a treatment modality, although prognostic markers are needed to guide management strategies. This study investigates the prognostic implications of lymphovascular invasion (LVI) in ESD-eligible EGC patients, specifically its implications for subsequent radical surgery.

MATERIAL AND METHODS

A retrospective, multicenter study from two primary hospitals analyzed clinicopathological data from 1369 EGC patients eligible for ESD, who underwent gastrectomy at Shanghai Cancer Center and Huashan Hospital between 2009 and 2018. We evaluated the relationship between LVI and lymph node metastasis (LNM), as well as the influence of LVI on recurrence-free survival (RFS) and overall survival (OS).

RESULTS

We found a strong association between LVI and LNM (p < 0.001). Advanced machine learning approaches, including Random Forest, Gradient Boosting Machine, and eXtreme Gradient Boosting, confirmed the pivotal role of LVI in forecasting LNM from both centers. Multivariate analysis identified LVI as an independent negative prognostic factor for both RFS and OS, with hazard ratios of 4.5 (95% CI: 2.4-8.5, p < 0.001) and 4.4 (95% CI: 2.1-8.9, p < 0.001), respectively.

CONCLUSIONS

LVI is crucial for risk stratification in ESD-eligible EGC patients, underscoring the necessity for radical gastrectomy. Future research should explore the potential incorporation of LVI status into existing TNM staging systems and novel therapeutic strategies.

Hereditary Diffuse Gastric Cancer Treated by Prophylactic Total Gastrectomy

We herein report a rare case of hereditary diffuse gastric cancer in a Japanese man. A 41-year-old man underwent esophagogastroduodenoscopy which revealed a small gastric erosion. Biopsy specimens showed signet ring cell carcinoma, and endoscopic submucosal dissection was performed. The patient's elder sister had died of gastric cancer at 38 years old. Considering the family history, a genetic test was conducted and revealed a CDH1 germline mutation. Although no carcinomatous lesion was detected endoscopically, prophylactic total gastrectomy was performed. The resection specimen showed seven microlesions of signet ring cell carcinoma confined to the lamina propria mucosae.

Red Dichromatic Imaging Improves the Recognition of Bleeding Points During Endoscopic Submucosal Dissection

BACKGROUND

Previous studies have indicated that red dichromatic imaging (RDI) improved the visibility of gastrointestinal bleeding.

AIMS

To investigate the recognition of bleeding points during endoscopic submucosal dissection (ESD) under RDI compared with that under white light imaging (WLI).

METHODS

Consecutive patients scheduled to undergo esophageal or gastric ESD at a single center were enrolled. Paired videos of active bleeding during ESD under WLI and RDI were created. Six endoscopists identified the virtual hemostasis point on still images after random video viewing. The distance between virtual hemostasis and actual bleeding points was scored in four levels (0-3 points), and the association with the color value was analyzed in both WLI and RDI.

RESULTS

We evaluated 116 videos for 58 bleeding points. The median visibility score and recognition rate were significantly higher for RDI than for WLI (2.17 vs. 1.42, p < 0.001 and 62.1% vs 27.6%, p < 0.001). Additionally, the recognition rate of trainees in RDI was higher than that of experts in WLI (60.3% vs. 43.1%, p = 0.067). The median color difference of RDI was significantly higher than that of WLI (8.97 vs. 3.69, p < 0.001). Furthermore, the correlation coefficient between the visibility score and color difference was 0.712 (strong correlation).

CONCLUSION

RDI can provide better recognition of bleeding points than WLI during ESD. Therefore, further studies are warranted to investigate whether RDI improves ESD outcomes.

Randomized controlled trial of new hemostatic material "sodium calcium alginate" in a preclinical model

BACKGROUND

The demand for nonbiological hemostatic materials has increased in surgical practice; however, few have sufficient hemostatic efficacy. This study investigated whether optimizing the composition of sodium calcium alginate, which forms a stable gel, improves hemostatic efficacy.

METHODS

The sodium calcium alginate was changed for each composition, including powder size, calcium substitution rate, molecular weight, and mannuronic/guluronic acid ratio. The hemostasis in liver punch-out injury and bleeding was evaluated using swine. For the study, sodium calcium alginate with different compositions was randomly applied to bleeding sites. Previous hemostatic materials, including cellulose and sodium alginate, were used as a control. We investigated hemostasis at 2 and 5 minutes after application.

RESULTS

Each powder size (53-150 μm, 150-250 μm, 53-250 μm) had a similar hemostatic effect. However, the hemostatic rate was significantly higher in sodium calcium alginate than in previous hemostatic materials (P value < .01). A 74.1% calcium substitution rate had the highest hemostasis at 2 and 5 minutes after application (2 minutes: 100%, 5 minutes: 95.2%). Regarding molecular weight, the hemostatic rate was significantly higher in 333,000 than in 50,000 (2 minutes: 95% vs 70%, 5 minutes: 95% vs 70%, P = .038). Moreover, a 1.9 mannuronic/guluronic acid ratio had the highest hemostasis compared with the 0.4 mannuronic/guluronic acid ratio (2 minutes: 58.8% vs 11.8%, 5 minutes: 58.8% vs 0%, P = .033) CONCLUSION: The composition of sodium calcium alginate with a high hemostatic effect was optimized. This new hemostatic material demonstrated potential usefulness for bleeding during surgery.

Coexistence of early gastric cancer and benign submucosal lesions mimic invasive cancer: a retrospective multicenter experience

OBJECTIVE

To present a study to identify the characteristics of coexisting early gastric cancer (EGC) and benign submucosal lesions, with the aim of reducing the adverse consequences of overdiagnosis and overtreatment.

METHODS

In this retrospective study, we searched the endoscopic databases of three tertiary centers. We screened of patients suspected of early gastric cancer submucosal infiltration by conventional endoscopy and ultimately selected for endoscopic submucosal dissection treatment after endoscopic ultrasonography and magnifying endoscopy with narrow-band imaging examination. Patients with coexisting EGC and benign submucosal lesions in histological sections were included. Clinical data and endoscopic images were reviewed. To evaluate the precision of endoscopists' diagnoses for this type of lesion, eight endoscopists with different experiences were recruited to judge the infiltration depth of these lesions and analyze the accuracy rate.

RESULTS

We screened 520 patients and retrospectively identified 18 EGC patients with an invasive cancer-like morphology. The most common lesion site was the cardia (12/18, 66.67%). The coexisting submucosal lesions could be divided into solid (5/18, 27.78%) and cystic (13/18, 72.22%). The most common type of submucosal lesion was gastritis cystica profunda (12/18, 66.67%), whereas leiomyoma was the predominant submucosal solid lesion (3/18, 16.67%). Ten (55.56%) patients < underwent endoscopic ultrasonography; submucosal lesions were definitively diagnosed in 6 patients (60.00%). The accuracy of judgement of the infiltration depth was significantly lower in cases of coexistence of EGC with benign submucosal lesions (EGC-SML) than in EGC (38.50% versus 65.60%, P = 0.0167). The rate of over-diagnosis was significantly higher within the EGC-SML group compared to the EGC group (59.17% versus 10.83%, P < 0.0001).

CONCLUSIONS

We should be aware of the coexistence of EGC and benign submucosal lesions, the most common of which is early cardiac-differentiated cancer with gastritis cystica profunda.

Endoscopic resection of early gastric cancer

Endoscopic resection (ER) is an effective treatment for early gastric cancer (EGC) without metastases. Existing endoscopic mucosal resection (EMR) is easy to perform, has few complications, and can be applied when the lesion size is small. However, en bloc and complete resection rates vary depending on the size and severity of the lesion. EMR using the cap-mounted panendoscopic method and EMR after circumferential preamputation of the lesion are useful in the treatment of EGC. However, completely oversized lesions (≥2 cm) and lesions associated with ulcers or submucosal fibrosis are more likely to fail resection. Endoscopic submucosal dissection has been widely used to resect tumors larger than 2 cm in diameter and has a higher acceptable complication rate and en bloc and complete resection rates than EMR. ER for EGC is superior to surgical resection in terms of improving patient quality of life. Additionally, compared to surgery, emergency rooms have a lower rate of treatment-related complications, shorter hospital stays, and lower costs. Accordingly, the indications for ER are expanding in the field of therapeutic endoscopy. Long-term outcomes regarding recurrence are excellent in both absolute and extended criteria for ER in EGC. Close surveillance should be performed after ER to detect early metachronous gastric cancer and precancerous lesions that can be treated with ER. Follow-up gastroscopy and abdominopelvic computed tomography scans every 6 to 12 months are recommended for patients who undergo curative ER for EGC on absolute or extended criteria.

Indications for Dental Floss Clip Traction During Gastric Endoscopic Submucosal Dissection by Less-Experienced Endoscopists

PURPOSE

Dental floss clip (DFC) traction-assisted endoscopic submucosal dissection (ESD) is widely performed owing to its simplicity. This study aimed to clarify the appropriate indications for the DFC traction method in early gastric cancer when ESD is performed by less-experienced endoscopists.

METHODS AND METHODS

We retrospectively analyzed 1,014 consecutive patients who had undergone gastric ESD performed by less-experienced endoscopists between January 2015 and December 2020. Gastric ESD was performed without DFC in all cases before December 2017 [DFC (-) group, 376 cases], and ESD was performed with DFC in all cases after January 2018 [DFC (+) group, 436 cases]. The procedure time and rates of en bloc resection, complete resection, and adverse events of the groups were compared.

RESULTS

The procedure time did not differ significantly between the 2 groups. However, when comparing lesions >20 mm, the procedure time in the DFC (+) group was significantly shorter than that in the DFC (-) group (95±46 vs. 75±31, P<0.01). The procedure time for lesions located in the greater curvature of the upper or middle stomach and lesions >20 mm located in the lesser curvature side of the stomach in the DFC (+) group was significantly shorter than that in the DFC (-) group.

CONCLUSIONS

The indications for DFC during gastric ESD by less-experienced endoscopists include lesions located in the greater curvature of the upper or middle stomach, and lesions >20 mm located in the lesser curvature of the stomach.

Development and Validation of Models to Predict Lymph Node Metastasis in Early Gastric Cancer Using Logistic Regression and Gradient Boosting Machine Methods

PURPOSE

To identify important features of lymph node metastasis (LNM) and develop a prediction model for early gastric cancer (EGC) using a gradient boosting machine (GBM) method.

MATERIALS AND METHODS

The clinicopathologic data of 2556 patients with EGC who underwent gastrectomy were used as training set and the internal validation set (set 1) at a ratio of 8:2. Additionally, 548 patients with EGC who underwent endoscopic submucosal dissection (ESD) as the initial treatment were included in the external validation set (set 2). The GBM model was constructed, and its performance was compared with that of the Japanese guidelines.

RESULTS

LNM was identified in 12.6% (321/2556) of the gastrectomy group (training set & set 1) and 4.3% (24/548) of the ESD group (set 2). In the GBM analysis, the top five features that most affected LNM were lymphovascular invasion, depth, differentiation, size, and location. The accuracy, sensitivity, specificity, and the area under the receiver operating characteristics of set 1 were 0.566, 0.922, 0.516, and 0.867, while those of set 2 were 0.810, 0.958, 0.803, and 0.944, respectively. When the sensitivity of GBM was adjusted to that of Japanese guidelines (beyond the expanded criteria in set 1 [0.922] and eCuraC-2 in set 2 [0.958]), the specificities of GBM in sets 1 and 2 were 0.516 (95% confidence interval, 0.502-0.523) and 0.803 (0.795-0.805), while those of the Japanese guidelines were 0.502 (0.488-0.509) and 0.788 (0.780-0.790), respectively.

CONCLUSION

The GBM model showed good performance comparable with the eCura system in predicting LNM risk in EGCs.

A nomogram based on platelet-to-lymphocyte ratio for predicting lymph node metastasis in patients with early gastric cancer

Background

Preoperative assessment of the presence of lymph node metastasis (LNM) in patients with early gastric cancer (EGC) remains difficult. We aimed to develop a practical prediction model based on preoperative pathological data and inflammatory or nutrition-related indicators.

Methods

This study retrospectively analyzed the clinicopathological characteristics of 1,061 patients with EGC who were randomly divided into the training set and validation set at a ratio of 7:3. In the training set, we introduced the least absolute selection and shrinkage operator (LASSO) algorithm and multivariate logistic regression to identify independent risk factors and construct the nomogram. Both internal validation and external validation were performed by the area under the receiver operating characteristic curve (AUC), C-index, calibration curve, and decision curve analysis (DCA).

Results

LNM occurred in 162 of 1,061 patients, and the rate of LNM was 15.27%. In the training set, four variables proved to be independent risk factors (p < 0.05) and were incorporated into the final model, including depth of invasion, tumor size, degree of differentiation, and platelet-to-lymphocyte ratio (PLR). The AUC values were 0.775 and 0.792 for the training and validation groups, respectively. Both calibration curves showed great consistency in the predictive and actual values. The Hosmer-Lemeshow (H-L) test was carried out in two cohorts, showing excellent performance with p-value >0.05 (0.684422, 0.7403046). Decision curve analysis demonstrated a good clinical benefit in the respective set.

Conclusion

We established a preoperative nomogram including depth of invasion, tumor size, degree of differentiation, and PLR to predict LNM in EGC patients and achieved a good performance.

Outpatient hybrid endoscopic submucosal dissection with SOUTEN for early gastric cancer, followed by endoscopic suturing of the mucosal defect: A case report

BACKGROUND

Although endoscopic submucosal dissection (ESD) is becoming more common for early gastric cancer, it requires more advanced techniques and a longer treatment duration than endoscopic mucosal resection. Hybrid ESD using a multifunctional snare (SOUTEN) has been reported to be effective for colorectal lesions, as it can reduce treatment duration. Endoscopic suturing of post-ESD mucosal defects has been reported to reduce the incidence of ESD-related complications.

CASE SUMMARY

This study reports outpatient hybrid ESD for early gastric cancer using SOUTEN, followed by endoscopic suturing of post-ESD mucosal defects in an 86-year-old man. On referral for ESD, a 10-mm flat, depressed lesion was found on the posterior wall of the gastric antrum, the depth of which was expected to be mucosal. Given his history of delirium, we performed outpatient endoscopic treatment. The procedure used was hybrid ESD using SOUTEN to reduce the duration of treatment and endoscopic suturing of post-ESD mucosal ESD defects to reduce complications. The procedure time was 62 min and the lesion was completely resected based on histopathological examination, with no reported postoperative complications.

CONCLUSION

This safe and useful procedure may be especially important for outpatient endoscopic treatment.

Analysis of clinicopathologic characteristics and prognosis of gastric cancer in patients <40 years

An increase trend and a bad prognosis toward gastric cancer (GC) in individuals <40 years have been observed over the past few decades. GC in Young adult needs further evaluation to identify clear risk factors for early screening and better prognosis. A total of 126 young adult patients with gastric cancer (individuals <40 years) (YG) were collected in Liaocheng hospital in China from Jan 2003 to Dec 2019. The overall median follow-up was 96.5 months (rang 1-192 months). Survival was determined by the Kaplan-Meier method and the difference in survival among different subgroups were assessed using the log-lank test. Correlations between risk factors and overall survival were assessed by univariate and multivariate Cox proportional hazards regression analysis. Advanced stage cancer at onset and undifferentiated histologic tumor type were the prominent clinicopathological features of YG. The 5-year overall survival of the YG was 31.7%. The 5-year survival of the YG differed from tumor staging and treatment methods. The 5-year survival was 100% in stage I group, 58.8% in stage II group, 22.6% in stage III group, and 8.3% in stage IV group respectively. The 5-year survival was 52.1% in the curative resection group versus 3.8% in the non-curative resection group. Multivariate analysis displayed that tumor staging (P = .002) and treatment method (P = .034) were 2 independent prognostic predictors for survival. GC in young adult patients have unique clinicopathological features. Upper gastrointestinal endoscopy should regularly perform for young adult especially those symptomatic patients. Early diagnosis and then proceed to a successful curative resection are vital for a better prognosis.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants

Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection (ESD) for early-stage gastrointestinal tumors. The rate of post-ESD bleeding for gastric cancer is higher (around 5%-8%) than that for esophagus, duodenum and colon cancer (around 2%-4%). Although investigations into the risk factors for post-ESD bleeding have identified several procedure-, lesion-, physician- and patient-related factors, use of antithrombotic drugs, especially anticoagulants [direct oral anticoagulants (DOACs) and warfarin], is thought to be the biggest risk factor for post-ESD bleeding. In fact, the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%, which is higher than that in patients not receiving anticoagulants. However, because clinical guidelines for management of ESD in patients receiving DOACs differ among countries, it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice. Given that the pharmacokinetics (e.g., plasma DOAC level at both trough and T_max) and pharmacodynamics (e.g., anti-factor Xa activity) of DOACs are related to risk of major bleeding, plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.

Tumor budding in gastric cancer

The tumor, nodes, metastasis (TNM) staging system has long been the gold standard for the classification and prognosis of solid tumors. However, the TNM staging system is not without limitations. Prognostic heterogeneity exists within patients at the same stage. Therefore, the pursuit of other biomarkers with the potential to classify patients with cancer has never stopped. One of them, tumor budding (TB), has gained much success in colorectal cancer. In recent years, TB in gastric cancer has attracted much attention from researchers, beginning to reveal the molecular and biological aspects of this phenomenon in gastric cancer, and has emerged as a promising prognostic biomarker in gastric cancer, predicting disease progression and unfavorable survival. Therefore, it is time and essential to provide a holistic overview of TB in gastric cancer, which has not been achieved and is the aim of this review.

Application of machine learning algorithm in predicting distant metastasis of T1 gastric cancer

Distant metastasis (DM) is relatively uncommon in T1 stage gastric cancer (GC). The aim of this study was to develop and validate a predictive model for DM in stage T1 GC using machine learning (ML) algorithms. Patients with stage T1 GC from 2010 to 2017 were screened from the public Surveillance, Epidemiology and End Results (SEER) database. Meanwhile, we collected patients with stage T1 GC admitted to the Department of Gastrointestinal Surgery of the Second Affiliated Hospital of Nanchang University from 2015 to 2017. We applied seven ML algorithms: logistic regression, random forest (RF), LASSO, support vector machine, k-Nearest Neighbor, Naive Bayesian Model, Artificial Neural Network. Finally, a RF model for DM of T1 GC was developed. The AUC, sensitivity, specificity, F1-score and accuracy were used to evaluate and compare the predictive performance of the RF model with other models. Finally, we performed a prognostic analysis of patients who developed distant metastases. Independent risk factors for prognosis were analysed by univariate and multifactorial regression. K-M curves were used to express differences in survival prognosis for each variable and subvariable. A total of 2698 cases were included in the SEER dataset, 314 with DM, and 107 hospital patients were included, 14 with DM. Age, T-stage, N-stage, tumour size, grade and tumour location were independent risk factors for the development of DM in stage T1 GC. A combined analysis of seven ML algorithms in the training and test sets found that the RF prediction model had the best prediction performance (AUC: 0.941, Accuracy: 0.917, Recall: 0.841, Specificity: 0.927, F1-score: 0.877). The external validation set ROCAUC was 0.750. Meanwhile, survival prognostic analysis showed that surgery (HR = 3.620, 95% CI 2.164-6.065) and adjuvant chemotherapy (HR = 2.637, 95% CI 2.067-3.365) were independent risk factors for survival prognosis in patients with DM from stage T1 GC. Age, T-stage, N-stage, tumour size, grade and tumour location were independent risk factors for the development of DM in stage T1 GC. ML algorithms had shown that RF prediction models had the best predictive efficacy to accurately screen at-risk populations for further clinical screening for metastases. At the same time, aggressive surgery and adjuvant chemotherapy can improve the survival rate of patients with DM.

Global research trends of endoscope in early gastric cancer: A bibliometric and visualized analysis study over past 20 years

Objectives

Early gastric cancer (EGC) is defined as aggressive gastric cancer involving the gastric mucosa and submucosa. Early detection and treatment of gastric cancer are beneficial to patients. In recent years, many studies have focused on endoscopic diagnosis and therapy for EGC. Exploring new methods to analyze data to enhance knowledge is a worthwhile endeavor, especially when numerous studies exist. This study aims to investigate research trends in endoscopy for EGC over the past 20 years using bibliometric analysis.

Methods

Original articles and reviews examining the use of endoscopy for EGC published from 2000 to 2022 were retrieved from the Web of Science Core Collection, and bibliometric data were extracted. Microsoft Office Excel 2016 was used to show the annual number of published papers for the top 10 countries and specific topics. VOSviewer software was used to generate network maps of the cooccurrences of keywords, authors, and topics to perform visualization network analysis.

Results

In total, 1,009 published papers met the inclusion criteria. Japan was the most productive country and had the highest number of publications (452, 44.8%), followed by South Korea (183, 18.1%), and China (150, 14.9%). The National Cancer Center of Japan was the institution with the highest number of publications (48, 4.8%). Ono was the most active author and had the highest number of cited publications. Through the network maps, exploring endoscopic diagnosis and therapy were major topics. Artificial intelligence (AI), convolutional neural networks (CNNs), and deep learning are hotspots in endoscopic diagnosis. Helicobacter pylori eradication, second-look endoscopy, and follow-up management were examined.

Conclusions

This bibliometric analysis investigated research trends regarding the use of endoscopy for treating EGC over the past 20 years. AI and deep learning, second-look endoscopy, and management are hotspots in endoscopic diagnosis and endoscopic therapy in the future.

Efficacy of the specialized scissor-type knife for gastric endoscopic submucosal dissection: a propensity score matched retrospective study

Background and study aims  Prevention of bleeding and perforation during gastric endoscopic submucosal dissection (ESD) is important. Scissor-type knives can accurately grasp and incise the targeted tissue using electrosurgical currents, thereby eliminating unexpected incisions. The SB Knife GX, a scissor-type knife specialized for gastric ESD, was released in June 2016 in Japan. The aim of the present study was to evaluate the efficacy and safety of gastric ESD using the SB Knife GX. Patients and methods  A total of 716 patients who underwent gastric ESD at Hiroshima University Hospital between July 2016 and December 2020 were retrospectively reviewed. From these, 671 patients underwent ESD using the IT Knife 2 (IT-2 group), while 45 underwent ESD using an SB Knife GX (SB-GX group). After propensity score matching, the procedure time, specimen size, en bloc and complete resection rates, and intraoperative bleeding, delayed bleeding, and perforation rates were evaluated. Results  No significant differences were observed in mean procedure time (SB-GX group: 115 ± 165 min; IT-2 group: 95 ± 61 min; P  = 0.82) and en bloc and complete resection rates between the two groups. Intraoperative bleeding rates were significantly lower in the SB-GX group than in the IT-2 group (18 % vs. 40 %; P  = 0.01), and there were no differences in delayed bleeding (4 % vs. 4 %) or perforation (0 % vs. 4 %) between the two groups. Conclusions  The SB Knife GX was proven to be useful for control of intraoperative bleeding during gastric ESD, although the procedure time tended to be longer.

Vonoprazan vs. Lansoprazole for the treatment of endoscopic submucosal dissection induced gastric ulcer: a systematic review and meta-analysis

BACKGROUND

Vonoprazan is a potassium competitive acid blocker (P-CAB) approved in Japan in 2014 to treat endoscopic submucosal dissection (ESD)-induced ulcers and bleeding or perforation. Therefore, this meta-analysis aimed to determine whether Vonoprazan is more effective than Lansoprazole in the treatment of ESD-induced ulcers which include ulcer healing and shrinking rate, among others.

METHODS

Randomized controlled trials (RCT) and retrospective studies were collected from the PubMed (Medline), Embase, Web of science and Cochrane Library databases. Meanwhile, studies were selected according to predetermined qualification criteria and data were extracted by two researchers. The quality of the methods for published papers was evaluated using the modified Jadad scale.

RESULTS

Five studies were included in this meta-analysis, the ulcer healing rate effect was not significantly higher in the intervention groups than in the control groups at 4 weeks, [OR：1.07 (0.51, 2.22), 95% CI, I2=2%, Z=0.18, P=0.86]. There was no significant difference in the ulcer shrinkage rate at 4 weeks [MD：0.20 (-1.51, 1.92), 95% CI, I2=0%, P=0.82] and 8 weeks [MD: -0.09 (-0.30, 0.12), 95% CI, I2=0%, P=0.39].

CONCLUSION

There was no significant difference between Vonoprazan and Lansoprazole in the ulcers induced by treatment after 4 weeks and 8 weeks of treatment with ESD.

Comparison of endoscopic submucosal dissection and surgery for early gastric cancer that is not indicated for endoscopic resection in elderly patients

BACKGROUND

Endoscopic submucosal dissection (ESD) is sometimes performed for early gastric cancer (EGC) which is not indicated for endoscopic resection (ER) in elderly patients considering old age and comorbidities. We aimed to compare outcomes between ESD and surgery in elderly patients with EGC that is not indicated for ER.

METHODS

Elderly patients aged ≥ 75 years who underwent either ESD or surgery for EGC which was not indicated for ER between 2005 and 2015 were retrospectively investigated.

RESULTS

Among a total of 294 patients, 59 (20.1%) and 235 (79.9%) patients underwent ESD and surgery as the initial treatment, respectively. The ESD group had smaller size of tumors (25 vs. 30 mm, p = .001) and higher rate of differentiated-type cancer than the surgery group had (88.1% vs. 60.9%, p = 0.001). With a median observation period of 91.8 months (range 11.6-198.1 months), 141 (48.0%) patients died: 25 (42.4%) and 116 (49.4%) patients in the ESD group and the surgery group, respectively. Overall survival and disease-free survival between the two groups had no significant differences (p = 0.982. p = 0.155, respectively).

CONCLUSIONS

ESD may be an alternative option for EGC which is not indicated for ER in elderly patients aged ≥ 75 years, considering old age and comorbidity.

Nomogram for pre-procedural prediction of non-curative endoscopic resection in patients with early gastric cancer

BACKGROUND

Non-curative resection (non-CR) after endoscopic submucosal dissection (ESD) requires additional surgery due to the possibility of lymph node metastasis (LNM). Therefore, it is important to accurately predict the risk of non-CR to avoid unnecessary preoperative procedures. Thus, we aimed to develop and verify a nomogram to predict the risk of non-CR prior to ESD.

METHODS

Patients who underwent ESD for early gastric cancer (EGC) were divided into CR and non-CR groups based on the present ESD criteria. The pre-procedural factors, such as endoscopic features, radiologic findings, and pathology of the lesion, were compared between the groups to identify the risk factors associated with non-CR. A nomogram was developed using multivariate analysis, and its predictive value was assessed using an external validation group.

RESULTS

Among 824 patients, 682 were curative (82.7%) and 142 were non-curative (17.3%). By comparing two groups, endoscopic features including redness, whitish mucosal change, fold convergence, and large lesion size; histologic features such as moderately or poorly differentiated or signet ring cell carcinoma; and abnormal CT findings including non-specific lymph node enlargement and fold thickening were identified as significant predictors of non-CR. The nomogram was developed based on these predictors and showed good predictive performance in the external validation, with an area under the curve of 0.87.

CONCLUSIONS

We developed a nomogram to predict the risk of non-CR prior to ESD. These predictive factors in addition to the existing ESD criteria can help provide the best treatment option for patients with EGC.

Impact of Traction Direction in Traction-Assisted Gastric Endoscopic Submucosal Dissection (with Videos)

BACKGROUND

The impact of traction direction in traction-assisted gastric endoscopic submucosal dissection (ESD) has not been adequately investigated. A clip with line (CWL) is a classical single-directional traction device. In contrast, a spring and loop with clip (SLC; S-O clip) is a newly developed multidirectional traction device.

AIMS

To investigate the impact of traction direction in gastric ESD by comparing the procedure-related outcomes of CWL-assisted ESD (CWL-ESD) and SLC-assisted ESD (SLC-ESD).

METHODS

We retrospectively examined 140 patients with superficial gastric neoplasms who underwent SLC-ESD or CWL-ESD by a single ESD expert during November 2017-September 2020. The traction direction was classified based on the endoscopic finding in the following five categories: proximal, diagonally proximal, vertical, diagonally distal, and distal. In SLC-ESD, we set vertical traction, using the multidirectional traction function. Propensity score matching was conducted to compensate for the differences in lesion size, injection function of electrosurgical knife, ulcerative lesion, lesion location, and lesion position. The primary outcome was gastric ESD procedure time.

RESULTS

Propensity score matching created 42 pairs. The median gastric ESD procedure time in the SLC-ESD group was significantly shorter than that in the CWL-ESD group (28.3 min vs. 51.0 min, P = 0.022). All traction direction in the SLC-ESD group was vertical, while only 16.7% in the CWL-ESD group. En bloc resection was attained without perforation in all the patients in both groups.

CONCLUSION

Our findings suggest that SLC can provide vertical traction, which reduces the gastric ESD procedure time. Multidirectional traction devices can provide vertical traction in most cases of gastric ESD, unlike single-directional traction devices. Vertical traction may reduce the gastric ESD procedure time.

Early Gastric Cancer: Update on Prevention, Diagnosis and Treatment

Gastric cancer (GC) is a relevant public health issue as its incidence and mortality rates are growing worldwide. There are recognized carcinogen agents, such as obesity, tobacco, meat, alcohol consumption and some dietary protective factors. Strategies of early diagnosis through population-based surveillance programs have been demonstrated to be effective in lowering the morbidity and mortality related to GC in some countries. Indeed, the detection of early lesions is very important in order to offer minimally invasive treatments. Endoscopic resection is the gold standard for lesions with a low risk of lymph node metastasis, whereas surgical mini-invasive approaches can be considered in early lesions when endoscopy is not curative. This review outlines the role of lifestyle and prevention strategies for GC, in order to reduce the patients' risk factors, implement the surveillance of precancerous conditions and, therefore, improve the diagnosis of early lesions. Furthermore, we summarize the available treatments for early gastric cancer.

A Prediction Model Based on the Risk Factors Associated with Pathological Upgrading in Patients with Early-Stage Gastric Neoplasms Diagnosed by Endoscopic Forceps Biopsy

Background/Aims

The discrepancies between the diagnosis of preoperative endoscopic forceps biopsy (EFB) and endoscopic submucosal dissection (ESD) in patients with early gastric neoplasm (EGN) exist objectively. Among them, pathological upgrading directly influences the accuracy and appropriateness of clinical decisions. The aims of this study were to investigate the risk factors for the discrepancies, with a particular focus on pathological upgrading and to establish a prediction model for estimating the risk of pathological upgrading after EFB.

Methods

We retrospectively collected the records of 978 patients who underwent ESD from December 1, 2017 to July 31, 2021 and who had a final histopathology determination of EGN. A nomogram to predict the risk of pathological upgrading was constructed after analyzing subgroup differences among the 901 lesions enrolled.

Results

The ratio of pathological upgrading was 510 of 953 (53.5%). Clinical, laboratorial and endoscopic characteristics were analyzed using univariable and binary multivariable logistic regression analyses. A nomogram was constructed by including age, history of chronic atrophic gastritis, symptoms of digestive system, blood high density lipoprotein concentration, macroscopic type, pathological diagnosis of EFB, uneven surface, remarkable redness, and lesion size. The C-statistics were 0.804 (95% confidence interval, 0.774 to 0.834) and 0.748 (95% confidence interval, 0.664 to 0.832) in the training and validation set, respectively. We also built an online webserver based on the proposed nomogram for convenient clinical use.

Conclusions

The clinical value of identifying the preoperative diagnosis of EGN lesions is limited when using EFB separately. We have developed a nomogram that can predict the probability of pathological upgrading with good calibration and discrimination value.

Comparisons of pathologic findings and outcomes of gastric cancer patients younger and older than 40: a propensity score matching study in a single center of Korea

Background and Aim

Gastric cancer (GC) is one of the most common cancers worldwide, with a high incidence rate in Korean men. However, comparative studies are scarce on the pathologic findings and treatment effects of GC in patients aged less than 40 years. We evaluated the characteristics and pathologic findings of GC patients aged younger and older than 40 years.

Methods

We retrospectively analyzed 2307 patients diagnosed with GC between January 2010 and May 2018. Eighty-eight (3.8%) and 2219 (96.2%) patients were younger and older than 40 years, respectively. The patients were divided into younger (n = 70) and older (n = 62) age groups through propensity matching.

Results

Overall, compared to the younger group, the older group (n = 2219) had a significantly higher proportion of male patients (66.7% vs 39.8%; P < 0.001) and patients who underwent endoscopic submucosal dissection (ESD) (2.3% vs 23.1%; P < 0.001). However, young patients more often underwent operations compared to older patients (78.4% vs 60.1%; P = 0.001). In the propensity-matched group, older patients more often showed differentiated carcinoma, including well-differentiated (5.7% vs 11.3%) and moderately differentiated (1.4% vs 32.3%). However, younger patients more often showed signet ring cell carcinoma (SRC) (70.0% vs 25.8%). In multivariate analysis, Helicobacter pylori infection (odds ratio, 12.643; 95% confidence interval, 1.068-1449.665; P = 0.044) independently correlated with SRC risk.

Conclusions

Patients below 40 years were more likely to undergo surgery compared to ESD, and pathologic findings were more common in SRC. Therefore, more active screening and H. pylori eradication are needed even in patients aged less than 40 years.

Endoscopic Resection of Undifferentiated Early Gastric Cancer

Endoscopic resection (ER) is widely performed for early gastric cancer (EGC) with a negligible risk of lymph node metastasis (LNM) in Eastern Asian countries. In particular, endoscopic submucosal dissection (ESD) leads to a high en bloc resection rate, enabling accurate pathological evaluation. As undifferentiated EGC (UD-EGC) is known to result in a higher incidence of LNM and infiltrative growth than differentiated EGC (D-EGC), the indications for ER are limited compared with those for D-EGC. Previously, clinical staging as intramucosal UD-EGC ≤2 cm, without ulceration, was presented as 'weakly recommended' or 'expanded indications' for ER in the guidelines of the United States, Europe, Korea, and Japan. Based on promising long-term outcomes from a prospective multicenter study by the Japan Clinical Oncology Group (JCOG) 1009/1010, the status of this indication has expanded and is now considered 'absolute indications' in the latest Japanese guidelines published in 2021. In this study, which comprised 275 patients with UD-EGC (cT1a, ≤2 cm, without ulceration) treated with ESD, the 5-year overall survival (OS) was 99.3% (95% confidence interval, 97.1%-99.8%), which was higher than the threshold 5-year OS (89.9%). Currently, the levels of evidence grades and recommendations for ER of UD-EGC differ among Japan, Korea, and Western countries. Therefore, a further discussion is warranted to generalize the indications for ER of UD-EGC in countries besides Japan.

Research trends in endoscopic applications in early gastric cancer: A bibliometric analysis of studies published from 2012 to 2022

Background

Endoscopy is the optimal method of diagnosing and treating early gastric cancer (EGC), and it is therefore important to keep up with the rapid development of endoscopic applications in EGC. This study utilized bibliometric analysis to describe the development, current research progress, hotspots, and emerging trends in this field.

Methods

We retrieved publications about endoscopic applications in EGC from 2012 to 2022 from Web of Science™ (Clarivate™, Philadelphia, PA, USA) Core Collection (WoSCC). We mainly used CiteSpace (version 6.1.R3) and VOSviewer (version 1.6.18) to perform the collaboration network analysis, co-cited analysis, co-occurrence analysis, cluster analysis, and burst detection.

Results

A total of 1,333 publications were included. Overall, both the number of publications and the average number of citations per document per year increased annually. Among the 52 countries/regions that were included, Japan contributed the most in terms of publications, citations, and H-index, followed by the Republic of Korea and China. The National Cancer Center, based in both Japan and the Republic of Korea, ranked first among institutions in terms of number of publications, citation impact, and the average number of citations. Yong Chan Lee was the most productive author, and Ichiro Oda had the highest citation impact. In terms of cited authors, Gotoda Takuji had both the highest citation impact and the highest centrality. Among journals, Surgical Endoscopy and Other Interventional Techniques had the most publications, and Gastric Cancer had the highest citation impact and H-index. Among all publications and cited references, a paper by Smyth E C et al., followed by one by Gotoda T et al., had the highest citation impact. Using keywords co-occurrence and cluster analysis, 1,652 author keywords were categorized into 26 clusters, and we then divided the clusters into six groups. The largest and newest clusters were endoscopic submucosal dissection and artificial intelligence (AI), respectively.

Conclusions

Over the last decade, research into endoscopic applications in EGC has gradually increased. Japan and the Republic of Korea have contributed the most, but research in this field in China, from an initially low base, is developing at a striking speed. However, a lack of collaboration among countries, institutions, and authors, is common, and this should be addressed in future. The main focus of research in this field (i.e., the largest cluster) is endoscopic submucosal dissection, and the topic at the frontier (i.e., the newest cluster) is AI. Future research should focus on the application of AI in endoscopy, and its implications for the clinical diagnosis and treatment of EGC.

Histopathologic Diagnosis Discrepancies Between Preoperative Endoscopic Forceps Biopsies and Specimens Resected by Endoscopic Submucosal Dissection in Superficial Gastric Neoplasms

BACKGROUND

The standard of practice when a superficial lesion was identified during upper GI endoscopy is to take an endoscopic forceps biopsy (EFB) of the lesion. The histopathologic findings then will determine the management plan. Endoscopic submucosal dissection (ESD) enables en-bloc resection for early neoplasms of the gastrointestinal tract and provides an adequate specimen that permits a more reliable histopathologic assessment. The objective of this study was to determine the rate of histopathologic discrepancy between EFB and specimens resected by ESD, and to identify the predisposing risk factors for this discordance.

MATERIALS AND METHODS

This is a retrospective study, enrolling patients with superficial gastric neoplasms that underwent EFB followed by ESD. We divided cases to concordant or discordant group according to the histopathologic diagnosis of EFB and ESD specimens. We also analyzed the features that may have influenced the occurrence of histopathologic discordance and the association between discordant samples of adenocarcinoma and neoplastic invasion to deeper layers.

RESULTS

A total of 115 gastric ESD procedures were performed with 84 patients meeting the inclusion criteria. Histopathologic discordance between EFB and ESD specimens were observed in 35.8% of cases (30/84 lesions). The univariant-bivariant analysis and multivariate logistic regression analysis showed that histologic discordance was closely related to the size of the lesions ( P =0.028).

CONCLUSION

Histopathologic discrepancy between EFB and ESD specimens may occur in approximately one-third of cases, particularly for lesions over 20 mm, which may lead to crucial delays in gastric cancer precise diagnosis and treatment.

Endoscopic Submucosal Dissection in the Stomach and Duodenum: Techniques, Indications, and Outcomes

Gastric endoscopic submucosal dissection (ESD) is established for management of early gastric cancer (EGC). Diagnosis of EGC relies on adequate endoscopic assessment involving lesion size, histopathology, presence of ulceration, and depth of invasion. Absolute indications for endoscopic resection of EGC are if patients are presumed to have a less than 1% risk of lymph node metasta endoscopic submucosal dissectionsis, and long-term outcomes are similar to those with surgical gastrectomy. Duodenal ESD is more technically difficult and requires expertise in ESD in other locations.

The Journey from Endoscopic Submucosal Dissection to Third Space Endoscopy

With the advent of endoscopic submucosal dissection, a variety of endoscopic devices including knives and high-frequency electrosurgical unit have become available. In addition, the concept of natural orifice transluminal endoscopic surgery pushed flexible endoscopic surgery ahead. In this review, the birth of peroral endoscopic myotomy and its expansion into the field of submucosal endoscopy are reviewed.

Feasibility of Enhanced Recovery After Surgery Protocols Implemented Perioperatively in Endoscopic Submucosal Dissection for Early Gastric Cancer: A Single-Center Retrospective Study

Background: Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) has advantages over traditional radical gastrectomy. We investigated whether enhanced recovery after surgery (ERAS) protocols are appropriate in the ESD perioperative period. Materials and Methods: We screened 129 consecutive patients, and 12 were excluded. All study patients underwent ESD for EGC. Of the 117 included patients, 57 received traditional perioperative care between January 2017 and December 2018, and 60 patients received perioperative care according to ERAS protocols between January 2019 and September 2020. The primary study endpoint was ESD-related complications. Secondary endpoints included the following postoperative parameters: anal exhaust time, incidence of nausea or vomiting, length of hospitalization, fever rate, abdominal pain on the visual analog scale (VAS), and reported perioperative satisfaction. Results: Complications were comparable between the 2 groups. In the ERAS group, no patients experienced delayed bleeding or perforation. One traditional group patient bled, and one perforated. Postoperative anal exhaust time, nausea or vomiting incidence, hospitalization, fever rate, and VAS pain scores were significantly lower, and perioperative satisfaction rate was significantly higher in the ERAS group. Conclusions: ERAS protocols are both feasible and safe for patients undergoing ESD. ERAS protocols enhance the advantages of ESD for EGC without increasing complications.

Scoring system for predicting the prognosis of elderly gastric cancer patients after endoscopic submucosal dissection

OBJECTIVES

Comprehensive assessments of the long-term outcomes of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the elderly are unavailable. We aimed to create a scoring system to predict the long-term prognosis after ESD for EGC among patients aged ≥75 years.

METHODS

We conducted retrospective studies of two cohorts: a single-center cohort (2006-2011) for developing the scoring system, and a multicenter cohort for validating the developed system (2012-2016). In the development cohort, factors related to death after ESD were identified using multivariable Cox regression analysis, and a predictive scoring system was developed. In the validation cohort, the scoring system was validated in 295 patients.

RESULTS

In the development cohort, Charlson comorbidity index (CCI) ≥3 (hazard ratio [HR] 3.017), high psoas muscle index (PMI) (HR 2.206), and age ≥80 years (HR 1.978) were significantly related to overall survival after ESD. Therefore, high CCI, low PMI, and age ≥80 years were assigned 1 point each. The patients were categorized into low (≤1 point) and high (≥2 points) score groups based on their total scores. In the validation cohort, 184 and 111 patients were assigned to the low- and high-score groups, respectively. In comparisons based on Kaplan-Meier curves, the 5-year survival rate was 91.5% in the low-score group and 57.8% in the high-score group (log-rank test; P < 0.001).

CONCLUSION

Our scoring system including high CCI, low PMI, and age ≥80 years could stratify the long-term prognosis of elderly patients aged ≥75 years after ESD for EGC.

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.

Interventional gastroenterology in oncology

Cancer is one of the foremost health problems worldwide and is among the leading causes of death in the United States. Gastrointestinal tract cancers account for almost one third of the cancer-related mortality globally, making it one of the deadliest groups of cancers. Early diagnosis and prompt management are key to preventing cancer-related morbidity and mortality. With advancements in technology and endoscopic techniques, endoscopy has become the core in diagnosis and management of gastrointestinal tract cancers. In this extensive review, the authors discuss the role endoscopy plays in early detection, diagnosis, and management of esophageal, gastric, colorectal, pancreatic, ampullary, biliary tract, and small intestinal cancers.