Clinical Factors of Delayed Perforation after Endoscopic Submucosal Dissection for Gastric Neoplasms

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.

Delayed Perforation After Endoscopic Resection of Upper Gastrointestinal Tumors: CT Findings to Identify Patients Requiring Surgery

PURPOSE

To determine the clinical and imaging factors associated with surgical treatment in patients with delayed perforation after endoscopic resection of upper gastrointestinal tumors.

METHODS

We retrospectively included patients with delayed perforation after endoscopic tumor resection for gastric or duodenal tumors between January 2007 and December 2021 in a tertiary hospital. We compared the clinical, endoscopic, and CT findings of the surgical and conservative treatment groups. Univariable and multivariable analyses were performed to identify significant factors associated with surgery.

RESULTS

Among 10,423 patients who had undergone endoscopic tumor resection, 52 (0.50%) experienced delayed perforation, with 20 patients (35.5%) treated surgically and 32 patients (64.5%) treated conservatively. The CT findings of gross perforation (adjusted odds ratio [OR]=6.75, 95% confidence interval [CI], 1.04-43.89; P=0.045) and presence of peritonitis (OR=34.26, 95% CI, 5.52-212.50; P<0.001) were significantly associated with surgical treatment. Other clinical factors as well as CT-measured amount of pneumoperitoneum were not significant factors.

CONCLUSIONS

CT findings of gross perforation and peritonitis are significant factors associated with surgery in delayed perforation after endoscopic tumor resection. These factors can aid in guiding the patients towards an appropriate treatment plan.

Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer

BACKGROUND

Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer.

METHODS

This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG.

RESULTS

This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations.

CONCLUSIONS

This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.

Delayed Perforation Occurring after Gastric Endoscopic Submucosal Dissection: Clinical Features and Management Strategy

Background/Aims

Delayed perforation is a rare but serious adverse event of gastric endoscopic submucosal dissection (ESD). The aim of this study was to clarify the clinical features and appropriate management strategy of patients with delayed perforation.

Methods

Among 11,531 patients who underwent gastric ESD, the clinical features and outcomes of patients who experienced delayed perforation were retrospectively reviewed and compared with those of the control group.

Results

Delayed perforation occurred in 15 of 11,531 patients (0.13%). The patients with delayed perforation were significantly older than those without delayed perforation (p=0.027). The median time to diagnosis of delayed perforation was 28.8 hours (range, 14 to 71 hours). All 15 patients with delayed perforation complained of severe abdominal pain after gastric ESD and underwent subsequent chest X-rays (CXRs) for evaluation. In subsequent CXR, free air was found in 12 patients (80%). For three (20%) patients without free air in CXR, delayed perforation was finally diagnosed by computed tomography. Leukocytosis was significantly less frequent in the patients without free air in CXR (p=0.022). A perforation hole smaller than 1 cm in size was more frequently observed in the six patients who underwent successful non-surgical treatments than in the nine patients who underwent surgery (p<0.001). There was no mortality related to delayed perforation.

Conclusions

One-fifth of the patients with delayed perforation did not show free air in CXR and exhibited less leukocytosis than those with free air. Non-surgical treatments including endoscopic closure might be considered as an initial treatment modality for delayed perforation smaller than 1 cm.

The future of endoscopic resection for early gastric cancer

Endoscopic resection for early gastric cancer is recommended when the risk of lymph node metastasis is negligible and should be performed through submucosal dissection due to well-established short- and long-term results. To overcome technical difficulties and decrease adverse events some techniques have been studied. This review outlines current strategies for improving patient selection and highlights innovative techniques that help minimize adverse events. Moreover, we discuss how to improve management after curative and noncurative resections.

Endoscopic Resection for Gastric Subepithelial Tumor with Backup Laparoscopic Surgery: Description of a Single-Center Experience

The aim of this study was to analyze patients who underwent endoscopic resection (ER) for gastric subepithelial tumors (SETs) with a high probability of surgical intervention. Between January 2013 and January 2021, 83 patients underwent ER at the operation theater and 27 patients (32.5%) required backup surgery mainly due to incidental perforation or uncontrolled bleeding despite endoscopic repairing. The tumor was predominantly located in the upper-third stomach (81%) with a size ≤ 2 cm (69.9%) and deep to the muscularis propria (MP) layer (92.8%) but there were no significant differences between two groups except tumor exophytic growth as a risk factor in the surgery group (37% vs. 0%, p < 0.0001). Patients in the ER-only group had shorter durations of procedure times (60 min vs. 185 min, p < 0.0001) and lengths of stay (5 days vs. 7 days, p < 0.0001) but with a higher percentage of overall morbidity graded III (0% vs. 7.1%, p = 0.1571). After ER, five patients (6%) had delayed perforation and two (2.4%) required emergent laparoscopic surgery. Neither recurrence nor gastric stenosis was reported during long-term surveillance. Here, we provide a minimally invasive strategy of endoscopic resection with backup laparoscopic surgery for gastric SETs.

Endoscopic diagnosis and treatment of gastric dysplasia and early cancer: Current evidence and what the future may hold

Gastric cancer accounts for a significant proportion of worldwide cancer-related morbidity and mortality. The well documented precancerous cascade provides an opportunity for clinicians to detect and treat gastric cancers at an endoscopically curable stage. In high prevalence regions such as Japan and Korea, this has led to the implementation of population screening programs. However, guidelines remain ambiguous in lower prevalence regions. In recent years, there have been many advances in the endoscopic diagnosis and treatment of early gastric cancer and precancerous lesions. More advanced endoscopic imaging has led to improved detection and characterization of gastric lesions as well as superior accuracy for delineation of margins prior to resection. In addition, promising early data on artificial intelligence in gastroscopy suggests a future role for this technology in maximizing the yield of advanced endoscopic imaging. Data on endoscopic resection (ER) are particularly robust in Japan and Korea, with high rates of curative ER and markedly reduced procedural morbidity. However, there is a shortage of data in other regions to support the applicability of protocols from these high prevalence countries. Future advances in endoscopic therapeutics will likely lead to further expansion of the current indications for ER, as both technology and proceduralist expertise continue to grow.

Clinical benefit of the multibending endoscope for gastric endoscopic submucosal dissection: a randomized controlled trial

BACKGROUND

Endoscopic submucosal dissection (ESD) is a technically difficult and time-consuming procedure. We aimed to investigate the efficacy and safety of ESD using a multibending endoscope to treat superficial gastrointestinal neoplasms.

METHODS

Patients with a single early gastric cancer who met the absolute or expanded indications for ESD according to the Japanese gastric cancer treatment guidelines were enrolled and randomly assigned to undergo ESD using a conventional endoscope (C-ESD) or a multibending endoscope (M-ESD). Randomization was stratified by ESD operator experience and tumor location. The primary outcome was ESD procedure time, calculated as the time from the start of submucosal injection to complete removal of the tumor.

RESULTS

60 patients were analyzed (30 C-ESD, 30 M-ESD). The mean (standard deviation [SD]) ESD procedure times for M-ESD and C-ESD were 34.6 (SD 17.2) and 47.2 (SD 26.7) minutes, respectively (P = 0.03). Muscle layer damage occurred significantly less frequently with M-ESD (0.2 [SD 0.7] vs. 0.7 [SD 1.0]; P = 0.04). There were no significant differences between the two techniques in procedure time or damage to muscle layers for tumors located in the lower third of the stomach.

CONCLUSIONS

ESD procedure time was significantly shorter with the multibending endoscope and fewer muscles were damaged. We recommend multibending endoscopy for ESD in the upper and middle thirds of the stomach to reduce procedure time and incidence of complications.

Endoscopic repair of delayed stomach perforation caused by penetrating trauma: A case report

BACKGROUND

Primary endoscopic closure of a perforated gastric wall during endoscopic procedures is mostly effective and well-tolerated; however, there are very few studies on the efficacy of endoscopic management of delayed traumatic gastric perforation. Herein, we report a novel case of a patient who was successfully treated for delayed traumatic stomach perforation using an alternative endoscopic modality.

CASE SUMMARY

A 39-year-old woman presented with multiple penetrating traumas in the back and left abdominal cavity. Initial imaging studies revealed left diaphragmatic disruption and peri-splenic hemorrhage without gastric perforation. An emergency primary repair of the disrupted diaphragm with omental reduction and suturing of the lacerated lung was performed; however, delayed free perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for the primary repair of the gastric wall, re-perforation was noted 15 d postoperatively. The high risk associated with re-surgery prompted an endoscopic intervention using 2 endoloops and 11 endoscopic clips using a novel modified purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications.

CONCLUSION

Endoscopic closure with endoloops and clips can be a useful therapeutic alternative to re-surgery for delayed traumatic gastric perforation.

Life on a knife edge: the optimal approach to the management of perforations during endoscopic submucosal dissection (ESD)

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a well-established procedure that can provide curative resection of malignant and premalignant lesions endoscopically, thereby offering patients an effective non-operative option. Though ESD is safe and highly effective when performed in appropriately selected patients by an experienced ESD expert, it carries risks including intraprocedural and delayed perforation.

AREAS COVERED

This review provides a practical approach to the initial management of perforation to minimize subsequent complications. The importance of prompt recognition of perforation and early intervention cannot be overstated. This review summarizes indications for closure, anatomic considerations impacting closure, and closure techniques. This article also highlights the do's and don'ts of various closure devices, focusing particularly on advanced closure methods, the-over-the-scope clips (OTSCs) and endoscopic suturing.

EXPERT OPINION

As ESD offers surgery-sparing alternatives to patients, advanced closure techniques allow endoscopists to effectively and promptly manage associated complications, improving the possibility of the widespread implementation of ESD in the US. With continued improvements in OTSCs and endoscopic suturing, ESD will become a stalwart of endoscopic management of malignant and premalignant gastrointestinal lesions.

Long-term follow-up of endoscopic submucosal dissection of gastric dysplasia and early neoplasia in a United Kingdom Caucasian population - a tertiary centre experience

Introduction: Endoscopic submucosal dissection (ESD) is extensively performed for the treatment of early gastric cancer (EGC) in the Eastern countries due to its favourable outcomes compared to gastrectomy in terms of lower complication rates, shorter hospital stays, better quality of life, with similar 5-year survival rate. Yet, its use is still limited in the UK.Aim: A long-term follow-up study to evaluate the outcome of ESD in the treatment of EGC in a Caucasian population at a tertiary referral centre in the United Kingdom.Methods: Data for the 35 Caucasian patients, who underwent ESD in a tertiary referral centre between May 2012 and June 2017 were collected. The selected patients were followed-up until May 2018. Curative resection (CR) and survival rates were used to measure the efficacy of ESD.Results: ESD was attempted on 46 lesions and completed on 37. En-bloc and CR rates of 57% and 19% were achieved, respectively. 24% of the lesions were non-CR and 57% were indefinite for non-CR/CR and 41% of the lesions showed change in histological grade post-ESD. Complete reversal of dysplasia/neoplasia was seen in 60% of the 'indefinite' group and 100% of the CR group at latest FU (18 months, mean). Recurrence was seen in 23% of the patients at latest FU. Seventy-one months' survival rate was 77%, while the disease-specific mortality was 0%.Conclusions: This study demonstrates the positive long-term outcome of ESD for gastric neoplasia in a UK Caucasian population, encouraging further development and implementation of ESD in the UK.

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

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

Usefulness of a multibending endoscope in gastric endoscopic submucosal dissection

Background and Aims

Intraoperative perforation is a major adverse event of endoscopic submucosal dissection (ESD). To avoid perforation, it is important for the endoscope to approach the portion to be resected carefully and to ensure that the knife can approach the submucosa at an angle parallel to the muscle layer. The multibending endoscope has 2 bends at its tip and may facilitate the ESD procedure. To the best of our knowledge, very few studies have reported the use of the multibending endoscope during gastric ESD. The aim of this study was, therefore, to introduce the usefulness of the multibending endoscope for gastric ESD.

Methods

We report 2 cases of early gastric cancer in which ESD was performed using a multibending endoscope.

Results

Unlike conventional single-bending endoscopes that have only 1 moveable part, the multibending endoscope allowed difficult areas to be approached more easily. Small adjustments could be made to the upward or downward angle of both the first and the second bending sections of the endoscope. This ensured that the knife would approach the submucosa at an angle parallel to the muscle layer. In patient 1, initially the conventional endoscope was used, but it became more difficult to approach the site, and paradoxic movement occurred. When the conventional endoscope was changed to the multibending endoscope, the ESD procedure became safer and more efficient. Another ESD using the multibending endoscope was performed successfully without any adverse events.

Conclusions

The use of a multibending endoscope for ESD will enable safer and faster treatment of patients.

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.

Safety and location analysis of transumbilical endoscopic submucosal dissection with single-basin lymph node dissection in the upper gastric body: a porcine model

Background

In our previous study, transumbilical endoscopic submucosal dissection (TU-ESD) was revealed to be feasible, but delayed gastric perforation was observed in 30% of ESD sites. In this study, we aimed to verify locations at which it is feasible to perform TU-ESD in the upper gastric body and to demonstrate the safety of TU-ESD in single-basin lymph node dissection (SBLND).

Methods

In vitro, TU-ESD was performed at three lesion sites (anterior wall, AW; posterior wall, PW; and lesser curvature, LC) in each porcine stomach using an EASIE-R tray (cases = 10). In vivo, TU-ESD was performed with SBLND in 9 pigs. Seven days after the operation, the pigs were sacrificed and examined.

Results

In the in vitro feasibility study, the TU-ESD time was significantly faster in the PW group (5.9 ± 2.0 min) than in the LC group (8.5 ± 1.5 min) (p < 0.05) in all 10 cases. In the in vivo survival study, TU-ESD with SBLND was successfully performed without any complications (N = 9). There were no cases of delayed perforation, and healing ulcers were found in all pigs 7 days after the operation. Ulcer size (5.2 ± 3.5 cm²) was approximately 36% smaller than that observed at the ESD operation site (8.1 ± 1.9 cm²) (p = 0.05). Epithelialization in the margin and healing of the gastric ulcers were confirmed by microscopy.

Conclusions

TU-ESD with SBLND is a feasible and safe method. The upper posterior gastric body could be the most feasible location for performing TU-ESD, perhaps because of the difference in the subcutaneous dissection time.

Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts

Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2-3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self-expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post-ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high-risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over-the-scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three-quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.