Clinical advantages of endoscopic submucosal dissection for gastric cancers in remnant stomach surpass conventional endoscopic mucosal resection

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.

Endoscopic Submucosal Dissection Versus Surgery or Endoscopic Mucosal Resection for Metachronous Early Gastric Cancer: a Meta-analysis

BACKGROUND

Resection options for early gastric cancer (EGC) include endoscopic submucosal dissection (ESD), endoscopic mucosal resection (EMR), and surgery. In patients with metachronous EGC following previous resection, the optimal resection technique is not well elucidated. We conducted a systematic review and meta-analysis of studies comparing ESD to EMR, or ESD to surgery, in patients with metachronous EGC.

METHODS

We conducted an electronic search of studies reporting on outcomes and AEs following ESD versus either EMR or surgery for patients with metachronous EGC. Pooled odds ratios (OR) of included studies were obtained using DerSimonian and Laird random effects models. Funnel plots were produced and visually inspected for evidence of publication bias. The quality of the evidence was assessed using GRADE.

RESULTS

A total of 9367 abstracts were screened and 10 observational studies were included. The odds of complete resection were higher amongst patients undergoing ESD compared to EMR (OR 5.88, 95% confidence intervals, CI, 1.79-19.35), whereas the odds of complete resection were no different between ESD and surgery (OR 0.57, 95% CI 0.04-8.24). There were no differences in the odds of local recurrence with ESD versus surgery (OR 5.01, 95% CI 0.86-29.13). Post-procedural bleeding did not differ significantly between ESD and EMR (OR 0.70, 95% CI 0.16-3.00). There was no evidence of publication bias.

DISCUSSION

For metachronous EGC, ESD or surgery is preferred over EMR depending on local expertise and patient preferences, largely due to a higher risk of incomplete resection with EMR.

REVIEW REGISTRATION

PROSPERO CRD42021270445.

Appraisal of gastric stump carcinoma and current state of affairs

Gastric stump carcinoma, also known as remnant gastric carcinoma, is a malignancy arising in the remnant stomach following gastrectomy for a benign or malignant condition. Enterogastric reflux and preexisting risk factors in a patient with gastric cancer are the major contributors to the development of gastric stump carcinoma. The occurrence of gastric stump carcinoma is time-dependent and seen earlier in patients operated on for malignant rather than benign diseases. The tumor location is predominantly at the anastomotic site towards the stomach. However, it can occur anywhere in the remnant stomach. The pattern of lymph node involvement and the type of surgery required is distinctly different compared to primary gastric cancer. Gastric stump carcinoma is traditionally considered a malignancy with a dismal outcome. However, recent advances in diagnostic and therapeutic strategies have improved outcomes. Recent advances in molecular profiling of gastric stump carcinoma have identified distinct molecular subtypes, thereby providing novel therapeutic targets. Also, reports of gastric stump carcinoma following pancreatoduodenectomy and bariatric surgery highlight the need for more research to standardize the diagnosis, staging, and treatment of these tumors. The present review aims to provide an overview of gastric stump carcinoma highlighting the differences in clinicopathological profile and management compared to primary gastric carcinoma.

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

In Vitro and In Vivo Investigation on the Effectiveness of Alginate-Based Gastric Mucosal Protective Gel

Objective

To investigate the feasibility and effectiveness of an alginate-based gastric mucosal protective gel on the gastric ulcer.

Methods

(1) In the physical protection model, after GES-1 cell attachment add the gel to transwell chamber, add different concentrations of HCl to the gel. Absorbance was measured to assess proliferation and images of the cells migrating into the wound were taken; then the migration rate of the cells was quantified by comparing images. (2) In the gastric ulcer model, excise the gastric mucosal of SD rats; the gel and fixative were applied on the artificial ulcer immediately. Dissect rats after 10 days, and calculate the wound healing rate and analyzed histology changes.

Results

The effect of hydrochloric acid on cells in the lower layer was significantly reduced after the use of gastric mucosal protection gel. The protective gel had an isolation effect on different concentrations of acid. A number of GES-1 were significantly higher than those in the control group at 24 h to 72 h (P < 0.01). The migration was observed compared with the control group. The average healing rate of ulcer in the gel group was about 50%, and the control group was about 30%. Inflammation occurred in all wound regions after ten days. In the gel group, inflammatory infiltration depth was lower than that of the control, and part of SD rats' new muscle layer appeared without inflammatory infiltration. The connective tissue proliferation promoted tissue repair. In the control group, necrosis marginal, mucosal hyperplasia, marginal lymphocyte aggregation, and bleeding were observed.

Conclusion

This novel gel mainly has an isolating and shielding effect to prevent the wound from being exposed to gastric acid for a long time, and it can reduce the inflammatory reaction on the wounds to promote the healing of the ulcer. The gastric mucosal protective gel cannot only promote the speed of wound healing but also improve the quality of wound healing.

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

Background/Aims

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

Methods

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

Results

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

Conclusions

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

The risk scoring system for assessing the technical difficulty of endoscopic submucosal dissection in cases of remnant gastric cancer after distal gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for remnant gastric cancer (RGC) after distal gastrectomy (DG) is considered technically challenging due to the narrow working space, and severe fibrosis and staples from the previous surgery. Technical difficulties of ESD for RGC after DG have not been thoroughly investigated. This study aimed to develop and validate a risk-scoring system for assessing the technical difficulty of ESD for RGC after DG in a large multicenter cohort.

METHODS

We investigated patients who underwent ESD for RGC after DG in 10 institutions between April 2008 and March 2018. A difficult case was defined as ESD lasting ≥ 120 min, involving piecemeal resection, or the occurrence of perforation during the procedure. A risk-scoring system for the technical difficulty of the procedure was developed based on multiple logistic regression analyses, and its performance was internally validated using bootstrapping.

RESULTS

A total of 197 consecutive patients with 201 lesions were analyzed. There were 90 and 111 difficult and non-difficult cases, respectively. The scoring model consisted of four independent risk factors and points of risk scores were assigned for each as follows: tumor size > 20 mm: 2 points; anastomosis site: 2 points; suture line: 1 point; and non-expert endoscopist: 2 points. The C-statistics of the scoring system for technical difficulty was 0.72.

CONCLUSIONS

We developed a validated risk-scoring model for predicting the technical difficulty of ESD for RGC after DG that can contribute to its safer and more reliable performance.

Endoscopic submucosal dissection versus endoscopic mucosal resection for patients with early gastric cancer: a meta-analysis

OBJECTIVES

To investigate the treatment effects of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) for early gastric cancer (EGC).

DESIGN

Meta-analysis.

METHODS

We systematically searched three electronic databases, including PubMed, EmBase and the Cochrane library for studies published with inception to January 2018. The eligible studies should be evaluated for the efficacy and safety of ESD versus EMR for patients with EGC. The summary ORs and standard mean differences (SMDs) with 95% CIs were employed as effect estimates. Sensitivity analyses were conducted to evaluate the impact of single study on overall analysis. Subgroup analyses were performed for investigated outcomes to evaluate the treatment effects of ESD versus EMR for patients with EGC with specific subsets.

RESULTS

Eighteen studies, with a total of 6723 patients with EGC, were included in final analysis. The summary ORs indicated that patients with EGC who received ESD were associated with an increased incidence of en bloc resection (OR: 9.00; 95% CI: 6.66 to 12.17; p<0.001), complete resection (OR: 8.43; 95% CI: 5.04 to 14.09; p<0.001) and curative resection (OR: 2.92; 95% CI: 1.85 to 4.61; p<0.001) when compared with EMR. Furthermore, ESD was associated with lower risk of local recurrence (OR: 0.18; 95% CI: 0.09 to 0.34; p<0.001). In addition, there was no significant difference between ESD and EMR for the risk of bleeding (OR: 1.26; 95% CI: 0.88 to 1.80; p=0.203). Though, ESD was correlated with greater risk of perforation (OR: 2.55; 95% CI: 1.48 to 4.39; p=0.001), and longer operation time (SMD: 1.12; 95% CI: 0.13 to 2.10; p=0.026) as compared with EMR. Additionally, several different features observed in included studies and patients could bias the effectiveness of ESD versus EMR in patients with EGC.

CONCLUSIONS

ESD is superior than EMR for en bloc resection, complete resection, curative resection and local recurrence, while it increased perforation risk and longer operation time.

Current controversies in treating remnant gastric cancer: Are minimally invasive approaches feasible?

The incidence of remnant gastric cancer (RGC) is still increasing. Minimally invasive approaches including endoscopic resection, laparoscopic and robotic approaches, and function-preserving gastrectomy have been utilized as curative treatment methods for primary gastric cancer. However, adhesions and anatomical alterations due to previous gastrectomy make the use of minimally invasive approaches complicated and difficult for RGC. Application of these approaches for the treatment of RGC is still controversial. Endoscopic submucosal dissection is a favorable alternative therapy for the resection of early gastric cancer that occurs in the remnant stomach and can prevent unnecessary complications. The majority of retrospective studies have shown that endoscopic submucosal dissection is an effective and oncologically safe treatment modality for RGC. Subtotal gastrectomy could serve as a function-preserving gastrectomy for patients with early RGC and improve postoperative late-phase function. However, there are only two studies that demonstrate the feasibility and oncological efficacy of subtotal gastrectomy for RGC. The non-randomized controlled trials showed that compared to open gastrectomy, laparoscopic gastrectomy for RGC led to better short-term outcomes and similar oncologic results. Because of the rarity of RGC, future multicenter studies are required to determine the indications of minimally invasive treatment for RGC.

Short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in the remnant stomach is a minimally invasive treatment. Few studies compared the technical difficulty of ESD involving the suture line and anastomosis, and information on long-term outcomes is insufficient. This study aimed to elucidate the short- and long-term outcomes of ESD for EGC in the remnant stomach.

METHODS

We investigated patients who underwent ESD for EGC in the remnant stomach between September 2002 and March 2016. Clinicopathological data were retrieved to assess en bloc resection rates, complications, and long-term outcomes including overall survival and cause-specific survival.

RESULTS

A total of 136 consecutive patients with 165 lesions resected by 157 ESD procedures were retrospectively evaluated. The en bloc resection rate was 95.5%. Complications included 16 intraoperative perforations (10.2%), 2 delayed perforations (1.3%), and 15 delayed bleeding (9.6%), which were successfully treated with endoscopy. The en bloc resection rate was significantly higher in the suture line group (100%) and the non-anastomosis or suture line group (98.8%) than in the anastomosis group (82.9%). However, the intraoperative perforation rate was significantly higher in the anastomosis group (31.4%) than in other groups. The 5-year overall and cause-specific survival rates were 88.4% and 97.6%, respectively, during a median follow-up period of 50.7 months (interquartile range 30.8-91.3).

CONCLUSIONS

The long-term outcomes of ESD for EGC in the remnant stomach were favorable. However, ESD involving the anastomosis was a technically demanding procedure due to the low en bloc resection rate and high perforation rate.

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

INTRODUCTION AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Efficacy of Endoscopic Management for Early Remnant Gastric Cancer: Is Completion Gastrectomy Truly Necessary in Cases with Marginally Noncurative Histopathologic Features?

BACKGROUND

For patients with early primary gastric cancer, endoscopic management has become a standard of care. However, its efficacy for early remnant gastric cancer (ERGC) remains controversial and an invasive surgical procedure remains the primary choice of treatment.

METHODS

A multi-institutional database of ERGC cases was retrospectively reviewed. Efficacy of endoscopic resection was analyzed by reviewing the clinicopathologic features of patients who underwent endoscopic resection and comparing the long-term outcomes with those of surgical resection.

RESULTS

Of the 121 patients who were histopathologically diagnosed with ERGC after distal gastrectomy, 80 underwent endoscopic resection and 41 underwent completion gastrectomy (Group S). According to the histopathological criteria, 55 of the 80 endoscopic resection cases were classified as "curative resection" (Group E1) and the remaining 25 were classified as "noncurative resection" (Group E2). Tumor recurrence was observed only in three patients (12%) in Group E2, and no tumor recurrence was confirmed in Group S and Group E1. Multivariate analyses confirmed that completion gastrectomy [hazard ratio (HR), 6.2; 95% confidence interval (CI), 1.5-26.3] was associated with poor survival compared with endoscopic resection, and lymphovascular infiltration (HR 9.5; 95% CI 2.5-36.7) was correlated with tumor recurrence. Histopathological positive resection margin, tumor size, or deeper tumor invasion were not correlated with tumor recurrence after endoscopic resection.

CONCLUSIONS

Endoscopic management might be an effective treatment option for ERGC with potential long-term survival advantage over the completion gastrectomy even in cases with histopathological features, suggesting noncurative resection.

Incidence and treatment of metachronous gastric cancer after proximal gastrectomy

BACKGROUND AND PURPOSE

Proximal gastrectomy (PG) is a widely accepted function-preserving surgical procedure; however, the incidence and treatment of metachronous gastric cancer (MGC) after PG have been the subject of a number of reports.

METHODS

We collected data from 1576 consecutive patients who underwent gastrectomy for gastric cancer between January, 2003 and December, 2010, and analyzed the outcomes of 671 patients treated with PG or distal gastrectomy (DG) for cT1N0 disease. We also discuss the treatments for MGC.

RESULTS

MGC was diagnosed within a median follow-up of 52.8 months after PG and DG in six (6.6%) and nine (1.8%) patients, respectively. The cumulative prevalence of MGC after PG was significantly higher than that after DG; P = 0.005. Univariate and multivariate analysis revealed male sex and PG as significant risk factors for MGC (P = 0.014 and P = 0.026, respectively). Five of the six patients who underwent PG were treated by endoscopic submucosal dissection.

CONCLUSIONS

The incidence of MGC after PG was significantly higher than that after DG. However, most of the MGCs that developed after PG could be treated by endoscopic submucosal dissection.

Current status in remnant gastric cancer after distal gastrectomy

Remnant gastric cancer (RGC) and gastric stump cancer after distal gastrectomy (DG) are recognized as the same clinical entity. In this review, the current knowledges as well as the non-settled issues of RGC are presented. Duodenogastric reflux and denervation of the gastric mucosa are considered as the two main factors responsible for the development of RGC after benign disease. On the other hand, some precancerous circumstances which already have existed at the time of initial surgery, such as atrophic gastritis and intestinal metaplasia, are the main factors associated with RGC after gastric cancer. Although eradication of Helicobacter pylori (H. pylori) in remnant stomach is promising, it is still uncertain whether it can reduce the risk of carcinogenesis. Periodic endoscopic surveillance after DG was reported useful in detecting RGC at an early stage, which offers a chance to undergo minimally invasive endoscopic treatment or laparoscopic surgery and leads to an improved prognosis in RGC patients. Future challenges may be expected to elucidate the benefit of eradication of H. pylori in the remnant stomach if it could reduce the risk for RGC, to build an optimal endoscopic surveillance strategy after DG by stratifying the risk for development of RGC, and to develop a specific staging system for RGC for the standardization of the treatment by prospecting the prognosis.

Endoscopic submucosal dissection of colorectal neoplasia located on the suture line of anastomosis

Although endoscopic submucosal dissection (ESD) can remove gastrointestinal neoplasia even with severe fibrosis into the submucosa, the safety and efficacy of ESD for colorectal neoplasia (CRN) located on the suture line of anastomosis (SLA) has not been assessed. The aim of this study was to evaluate the feasibility of ESD for CRN located on the SLA, performed by a highly skilled endoscopist. Three consecutive patients with CRN located on the SLA were treated with ESD. In all cases, ESD was safely performed without any adverse events. The median tumor size of the resected CRN was 30 mm (range 12-75 mm) and the median procedure time was 150 min (range 50-150 min). Curative resection was achieved in two cases without local recurrence during a 12-month observation period. In one case, the CRN were resected in an almost en bloc fashion, but a decision was made to spare the edge of the CRN that was directly on the SLA in order to avoid delayed perforation, and this edge was instead removed with hemostatic forceps. Although the surveillance colonoscopy revealed a small residual neoplasia, it was curatively treated by endoscopically. In all cases, ESD managed to avoid the need for repetitive surgery. This case series suggests the feasibility of ESD performed by a highly skilled endoscopist as a curative treatment for the CRN located on the SLA.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Endoscopic submucosal dissection for gastric tube cancer after esophagectomy

BACKGROUND

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

OBJECTIVE

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

DESIGN

Retrospective study.

SETTING

National Cancer Center Hospital, Tokyo, Japan.

PATIENTS

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

INTERVENTION ESD MAIN OUTCOME MEASUREMENTS

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

RESULTS

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

LIMITATION

Single-center retrospective study.

CONCLUSIONS

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

Endoscopic submucosal dissection for early gastric cancer in the remnant stomach after gastrectomy

BACKGROUND

Endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) after surgical gastrectomy is a technically difficult procedure because of the limited working space in the remnant stomach as well as the presence of severe gastric fibrosis and staples under the suture line.

OBJECTIVE

We evaluated clinical results including long-term outcomes to determine the feasibility and effectiveness of ESD for EGC in the remnant stomach of patients after gastrectomy.

DESIGN

Retrospective study.

SETTING

National Cancer Center Hospital, Tokyo, Japan.

PATIENTS

We investigated patients undergoing ESD for EGC in the remnant stomach from 1997 to 2011.

INTERVENTION ESD MAIN OUTCOME MEASUREMENTS

We examined the patient characteristics, endoscopic findings, technical results, adverse events, and histopathologic results including curability and evaluations of Helicobacter pylori gastritis in addition to the rates of local recurrence, metachronous gastric cancer, overall survival, and cause-specific survival.

RESULTS

A total of 128 consecutive patients with 139 lesions had previously undergone 87 distal (68%), 25 proximal (19.5%) and 16 pylorus-preserving gastrectomies (12.5%). The median period from the original gastrectomy to the subsequent ESD for EGC in the remnant stomach was 5.7 years (range 0.6-51 years), the median tumor size was 13 mm (range 1-60 mm), and the median procedure time was 60 minutes (range 15-310 minutes). There were 131 en bloc resections (94%), with curative resections achieved for 109 lesions (78%); 22 lesions (16%) resulted in non-curative resections, and 8 lesions (6%) had only a horizontal margin positive or had inconclusive results. A total of 118 patients (92%) were assessed as H pylori gastritis-positive, with 7 patients (5%) negative. Adverse events included 2 cases of delayed bleeding (1.4%) and 2 perforations (1.4%), with 1 patient requiring emergency surgery. The 5-year overall and cause-specific survival rates were 87.3% and 100%, respectively, during a median follow-up period of 4.5 years (range 0-13.7 years), with no deaths from EGC in the remnant stomach.

LIMITATIONS

Single-center, retrospective study.

CONCLUSION

ESD for EGC in the remnant stomach of patients after gastrectomy was a feasible and effective therapeutic method and should become the standard treatment in such cases, based on the favorable long-term outcomes.

Endoscopic submucosal dissection and surgical treatment for gastrointestinal cancer

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

A meta-analysis of endoscopic submucosal dissection and EMR for early gastric cancer

BACKGROUND

Endoscopic submucosal dissection (ESD) was developed to overcome the problem caused by incomplete resection by conventional EMR for early gastric cancer. However, the technique of ESD had a relative higher incidence rate of complications such as bleeding and perforation because of its large wound incidence and difficulties.

OBJECTIVE

To evaluate the efficacy and safety of ESD and EMR for early gastric cancer.

DESIGN

We made an overall strategy to search various databases both electronically and manually and assessed the quality of selected articles according to the inclusion and exclusion standard.

SETTING

Meta-analysis of 9 retrospective studies.

PATIENTS

3548 lesions (ESD 1495; EMR 2053).

INTERVENTION

ESD or EMR.

MAIN OUTCOME MEASUREMENTS

En bloc resection rate, histologic curative resection rate, complications, recurrence rate.

RESULTS

Nine retrospective studies were identified (7 full text and 2 abstracts). A total of 3548 lesions were enrolled (ESD 1495; EMR 2053). The mean time required for resection was longer for ESD than for EMR (weighted mean difference 59.4; 95% confidence interval [CI], 16.8-102.0); the en bloc rate in the ESD group was significantly higher than that in the EMR group (OR 9.69; 95% CI, 7.74-12.13), and so was the total histologically complete resection rate (OR 5.66; 95% CI, 2.92-10.96). The ESD group had lower recurrence frequency (OR 0.10; 95% CI, 0.06-0.18). The perforation rate was higher in the ESD group (OR 4.67; 95% CI, 2.77-7.87), whereas the bleeding incidences were similar between the two groups.

LIMITATIONS

Heterogeneity was present among the studies.

CONCLUSION

Compared with EMR for early gastric cancer, ESD showed considerable advantages regarding en bloc resection rate, histologically complete resection rate, and local recurrence even for small lesions, but it had the disadvantages of higher complication rates for perforation. All of the results mentioned should be confirmed by well-designed, randomized, controlled trials from more countries, with larger samples and long enough follow-up periods.

Influential factors in procedure time of endoscopic submucosal dissection for gastric cancer with fibrotic change

BACKGROUND

Factors correlating with the technical difficulty of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) are still unclear. EGC coexisting with fibrosis inside lesions has been a common therapeutic indication for ESD. The aim of this study was to clarify the most important factor related to difficult ESD for EGC.

PATIENTS AND METHODS

Fifty-six patients (49 male and seven female, median age 66 years) who received ESD at a single institute for EGC with fibrosis in the resected lesion were selected. Various clinicopathological factors, including the histological findings of fibrotic changes within the cancer area in the resected specimen, were evaluated statistically for correlation with ESD procedure time.

RESULTS

  Univariate linear regression analysis with logarithmic ESD procedure time revealed the upper-third portion of lesion in the stomach (P = 0.02), histological classification of dense fibrosis (ulcer/ulcer scar-III/IV) within EGC (P < 0.001), and presence of peptic ulcer other than EGC (P = 0.04). Areas of the resected specimen (P < 0.001) and fibrosis (P < 0.001) were significant factors related to prolonged operation times. Multivariate analysis demonstrated that the upper-third portion of lesion (P = 0.007), ulcer/ulcer scar-III/IV findings (P = 0.006), and area of resected specimen (P = 0.006) were significant independent factors influencing ESD procedure time.

CONCLUSION

Histological findings of fibrotic changes coexisting with EGC are closely related to technical difficulty in ESD as well as the location of tumors. Preoperative precise evaluation of fibrotic changes within EGC may be helpful to predict a technical difficulty in ESD.

The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis

BACKGROUND

Endoscopic submucosal dissection (ESD) allows en bloc resection of the entire lesion, permitting a higher curative resection rate and increased quality of life by minimizing the resection size compared with that of endoscopic mucosal resection (EMR). Although ESD has been implemented at most university hospitals in Korea, potential complications of ESD such as bleeding and perforation raise doubts in the therapeutic decision on use of the ESD procedure for early gastric cancer patients and in reimbursement decision making. This systematic review aimed to address both the effectiveness and safety outcomes of ESD versus EMR for early gastric cancer.

METHODS

MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Koreamed were searched using the primary keywords "stomach neoplasm" AND "endoscopic submucosal dissection" AND "endoscopic mucosal resection." To assess the quality of selected studies, the methodologic approach of the Scottish Intercollegiate Guidelines Network was used. Five effectiveness-relevant and three safety-relevant outcome measures were extracted. Bibliography management and metaanalysis for each outcome were conducted using Review Manager 5.0.

RESULTS

Three nonconcurrent cohort studies and nine retrospective cohort studies were identified. Metaanalyses showed ESD to be significantly more effective than EMR for en bloc resection (odds ratio [OR], 8.43; 95% confidence interval [CI], 5.20-13.67), complete resection (OR, 14.11; 95% CI, 10.85-18.35), curative resection (OR, 3.28; 95% CI, 1.95-5.54), and local recurrence (risk ratio [RR], 0.13; 95% CI, 0.04-0.41). Whereas intraoperative bleeding (RR, 2.16; 95% CI, 1.14-4.09), perforation risk (RR, 3.58; 95% CI, 1.95-6.55), and operation time (standard mean difference [SMD], 1.55; 95% CI, 0.74-2.37) were significantly greater for ESD, overall bleeding risk (RR, 1.22; 95% CI, 0.76-1.98) and all-cause mortality (RR, 0.65; 95% CI, 0.08-5.38) did not differ significantly between ESD and EMR.

CONCLUSIONS

Considering that bleeding risk did not differ significantly between ESD and EMR and that perforation risk usually does not lead to life-threatening disease, the effectiveness benefit of ESD can outweigh the overall harm compared with EMR on the condition that ESD is performed by experienced practitioners.