Negative Impact of Endoscopic Submucosal Dissection on Short-Term Surgical Outcomes of Subsequent Laparoscopic Distal Gastrectomy for Gastric Cancer

Characteristics of early gastric tumors with different differentiation and predictors of long-term outcomes after endoscopic submucosal dissection

BACKGROUND

Gastric cancer is a common malignant tumor of the digestive tract, and endoscopic submucosal dissection (ESD) is the preferred treatment for early-stage gastric cancer. The analysis of the epidemiological characteristics of gastric mucosal tumors with different differentiation degrees and the influencing factors of long-term ESD efficacy may have certain significance for revealing the development of gastric cancer and ESD.

AIM

To analyze the features of gastric mucosal tumors at different differentiation levels, and to explore the prognostic factors of ESD.

METHODS

We retrospectively studied 301 lesions in 285 patients at The Second Affiliated Hospital of Xi'an Jiaotong University from 2014 to 2021, according to the latest Japanese guidelines (sixth edition), and divided them into low-grade intraepithelial neoplasia (LGIN), high-grade intraepithelial neoplasia (HGIN), and differentiated and undifferentiated early carcinoma. They are followed up by endoscopy, chest and abdominal computed tomography at 3, 6 and 12 months after ESD. We compared clinicopathologic characteristics, ESD efficacy, and complications with different degrees of differentiation, and analyzed the related factors associated with ESD.

RESULTS

HGIN and differentiated carcinoma patients were significantly older compared with LGIN patients (P < 0.001) and accounted for more 0-IIc (P < 0.001), atrophic gastritis was common (P < 0.001), and irregular microvascular patterns (IMVPs) and demarcation lines (DLs) were more obvious (P < 0.001). There was more infiltration in the undifferentiated carcinoma tissue (P < 0.001), more abnormal folds and poorer mucosal peristalsis (P < 0.001), and more obvious IMVPs, irregular microsurface patterns and DLs (P < 0.05) than in the LGIN and HGIN tissues. The disease-free survival rates at 2, 5, and 8 years after ESD were 95.0%, 90.1%, and 86.9%, respectively. Undifferentiated lesions (HR 5.066), white moss (HR 7.187), incomplete resection (HR 3.658), and multiple primary cancers (HR 2.462) were significantly associated with poor prognosis.

CONCLUSION

Differentiations of gastric mucosal tumors have different epidemiological and endoscopic characteristics, which are closely related to the safety and efficacy of ESD.

Short-term efficacy of additional laparoscopic-assisted radical gastrectomy after non-curative endoscopic submucosal dissection for early gastric cancer

OBJECTIVE

To investigate short-term efficacy of direct laparoscopic-assisted radical gastrectomy (LAG) versus non-curative endoscopic submucosal dissection (ESD) plus additional LAG for early gastric cancer.

MATERIALS AND METHODS

286 patients were retrospectively assigned into two groups: direct LAG group (n = 255) and additional LAG (ESD plus LAG, n = 31) group. A 1:2 propensity score matching was performed to equalize relevant confounding factors between two groups for analysis.

RESULTS

Ninety-three patients were successfully matched, including 62 in the direct LAG group and 31 in the additional LAG group. A significant (P = 0.013) difference existed in the drainage removal time between the additional LAG and direct LAG group (7 d vs. 6 d). Age, sex, tumor location and surgical approach were significantly (P < 0.05) associated with complications, with age ≥ 60 years (P = 0.002) and total gastrectomy (P = 0.011) as significant independent risk factors. A significant (P = 0.023) difference existed in the surgical time between the early and late groups (193.3 ± 37.6 min vs. 165.5 ± 25.1 min).

CONCLUSION

Additional LAG (D1 + lymphadenectomy) after ESD may be safe and effective even though non-curative ESD may prolong the drainage removal time and increase the difficulty of surgery.

Risk Factors and Timing of Additional Surgery after Noncurative ESD for Early Gastric Cancer

BACKGROUND

Patients with early gastric cancer undergoing noncurative endoscopic submucosal dissection (ESD) have a risk of tumor recurrence and metastasis, and some patients need additional surgery. The purpose of this study was to explore the risk factors of cancer residue and lymph node (LN) metastasis after noncurative ESD for early gastric cancer and to compare the short outcome of early and delayed additional surgery.

METHODS

The clinicopathological characteristics of 30 early gastric cancer patients who received noncurative ESD and additional surgery were studied retrospectively. Multivariable regression was utilized to examine the independent risk factors for residual cancer and LN metastasis. Receiver operating characteristic curve was used to analyze the multivariable model's predictive performance. Furthermore, the perioperative safety and radical tumor performance of early surgery (≤30 days, n = 11), delayed surgery (>30 days, n = 11) after ESD, and upfront surgery (n = 59) were compared.

RESULTS

Multivariable regression showed that diffuse type of Lauren classification, submucosal invasion, and positive human epidermal growth factor receptor-2 (HER-2) were risk factors for residual cancer. Undifferentiated carcinoma, vascular invasion, and positive vertical margin were risk factors for LN metastasis. The area under the curve (AUC) of the multifactor model predicting cancer residue and LN metastasis was 0.761 and 0.792, respectively. The early surgery group experienced higher intraoperative blood loss and a longer operation time than the delayed surgery and upfront surgery groups. There was no significant difference in the number of LN dissections, LN metastasis rate, and postoperative complications among the three groups.

CONCLUSION

Diffuse type of Lauren classification, submucosal invasion, and positive HER-2 are risk factors for residual cancer, while undifferentiated carcinoma, vascular invasion, and positive vertical margin are risk factors for LN metastasis. Delayed additional surgery after ESD (>30 days) has higher intraoperative safety, without affecting the radical resection in early gastric cancer patients.

Effect of endoscopic resection on short-term surgical outcomes of subsequent laparoscopic gastrectomy: a meta-analysis

BACKGROUND

Endoscopic resection (ER) might affect subsequent laparoscopic gastrectomy (LG) because of the electrical coagulation, but the effect remains controversial. The purpose of this meta-analysis was to analyze the effect of ER on the short-term surgical outcomes of subsequent LG.

MATERIALS AND METHODS

The PubMed, EMBASE, and Cochrane Library databases were searched to find eligible studies published from inception to March 21, 2021. Short-term surgical outcomes were compared between the ER-LG group and the LG-only group. The registration ID of this current meta-analysis on PROSPERO is CRD42021238031.

RESULTS

Nine studies involving 3611 patients were included in this meta-analysis. The LG-only group had a higher T stage (T1-T2: OR=2.42, 95% CI=1.09 to 5.34, P=0.03; T3-T4: OR=0.41, 95% CI=0.19 to 0.91, P=0.03) than the ER-LG group. The ER-LG group showed a shorter operation time than the LG-only group (MD=-5.98, 95% CI=-10.99 to -0.97, P=0.02). However, no difference was found in operation time after subgroup analysis of propensity score matching studies. No significant difference was found in intraoperative blood loss, time to first oral feeding, or postoperative hospital stay between the ER-LG group and the LG-only group. And no significance was found in overall complications (OR=1.16, 95% CI=0.89 to 1.50, P=0.27), complications of grade ≥ II (OR=1.11, 95% CI=0.71 to 1.73, P=0.64), complications of grade ≥ III b (OR=1.47, 95% CI=0.49 to 4.43, P=0.49) between the ER-LG group and the LG-only group.

CONCLUSIONS

ER did not affect subsequent LG in terms of short-term outcomes, and the ER-LG group might have a shorter operation time than the LG-only group.

Comparison of Outcomes Between Additional Esophagectomy After Noncurative Endoscopic Resection and Upfront Esophagectomy for T1N0 Esophageal Squamous Cell Carcinoma

BACKGROUND

Esophagectomy with lymph node dissection is a choice of additional treatment after noncurative endoscopic resection (ER) of T1N0 esophageal squamous cell carcinoma (ESCC). The efficacy and safety of esophagectomy in this situation remain unclear when compared with upfront esophagectomy.

METHODS

We investigated the short- and long-term outcomes of 321 patients with clinical T1N0M0 ESCC who underwent curative esophagectomy, and compared the status of lymph node metastasis, surgical results, and the prognosis between the ER and non-ER groups.

RESULTS

The ER group consisted of 57 patients (17.8%), while the non-ER group consisted of 264 patients (82.2%). The incidence of lymph node metastasis was not significantly different between the ER (24.6%) and non-ER groups (30.7%), and there was no significant difference in surgical outcomes between the groups. The distribution of metastatic lymph nodes was very similar between the groups. However, 13 of 14 patients (93%) with lymph node metastasis in the ER group and 63 of 82 patients (77%) with lymph node metastasis in the non-ER group had pN1 disease, while the remaining 18 patients (23%) with lymph node metastasis in the non-ER group had pN2 or N3 disease. Overall and relapse-free survival rates were significantly better in the ER group than in the non-ER group (p < 0.05 and p < 0.01, respectively). To date, no patients in the ER group experienced disease recurrence.

CONCLUSIONS

Additional esophagectomy is a safe and effective treatment modality for patients after noncurative ER.