Endoscopy vs surgery in the treatment of early gastric cancer: Systematic review

A novel cuproptosis-related lncRNA nomogram to improve the prognosis prediction of gastric cancer

Background

Cuproptosis is a copper-triggered modality of mitochondrial cell death and cuproptosis process may play important roles in gastric cancer development. However, little is known about cuproptosis-related lncRNAs in gastric adenocarcinoma (STAD). This study is aimed to investigate the potential prognostic signatures of cuproptosis-related lncRNAs in STAD.

Methods

The Cancer Genome Atlas (TCGA) database were used to obtain gene expression profiles, clinicopathological, and OS information for STAD. Cuproptosis-related genes were collected based on previous studies and cuproptosis-related lncRNAs were screened out by co-expression analysis. The nomogram constructed by Cox regression analysis with the minimum absolute contraction and selection operator (lasso) algorithm. In addition, the potential response of ICB therapy and immune evasion incidence were estimated with Tumor Immune Dysfunction and Exclusion (TIDE) algorithm. Immune checkpoint expressions associated with risk scores were also analyzed. The correlation of immune checkpoint CD209 and HAVCR2 expressions associated with risk scores were experimentally testified by RT-qPCR, Western Blot, and IHC.

Results

Patients were classified into high-risk and low-risk groups based on the risk score calculated in this model. The Kaplan–Meier survival curve analysis revealed that the high-risk group was associated with poor prognosis. Multivariate Cox regression analysis suggested that this lncRNA prediction model was an independent risk factor affecting the OS rate. Furthermore, ROC curve indicates that the nomogram was superior to traditional clinicopathological features in predicting STAD prognosis. Finally, functional enrichment analysis and immune checkpoint investigation revealed that the nomogram is notably associated with cholesterol metabolism and immune functions, RT-qPCR and Western Blotting demonstrated the co-expression relationship of LINC01150 with CD209 and HAVCR2.

Conclusion

A novel cuproptosis-related lncRNAs signature impacts on the prognosis and immunological features of GC.

Assessment of physical stress during the perioperative period of endoscopic submucosal dissection

The advantage of endoscopic submucosal dissection (ESD) is that it is less invasive than surgery. ESD is one of the best treatments for older patients as surgery in this age group of patients is difficult. However, it is unclear how much lower the physical stress of ESD is compared with that of surgery. Thus, objective methods are required to assess physical stress in patients who have undergone ESD. The current review of ESD aimed to summarize the recent advancements in the assessment of physical stress during the perioperative period, focusing on changes in energy metabolism and serum opsonic activity (SOA). Based on metabolic changes, resting energy expenditure (REE) was measured using an indirect calorimeter. The stress factor calculated from the REE and the basal energy expenditure computed using the Harris-Benedict equation can be used to assess physical stress. SOA was assessed using the chemiluminescence method, wherein the use of chemiluminescent probes (i.e., lucigenin and luminol) allowed quantification of reactive oxygen species generated by neutrophils. Using an auto luminescence analyzer, the results were evaluated based on the maximum light emission and area under the emission curve. These quantifiable results revealed the minimal invasiveness of ESD.

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

Background and Aim

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

Methods

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

Results

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

Conclusions

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

Systematic Review Registration

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

Effect of Dietary Modification on Gastric Mucosa, Gastrointestinal Symptoms and Nutritional Status of Patients With Early Gastric Cancer After Endoscopic Submucosal Dissection Surgery: A Retrospective Cohort Study

Food is an important factor affecting the treatment of patients with early gastric cancer (EGC). We have established a hospital cohort to guide dietary patterns and observe the health status of patients with EGC after endoscopic submucosal dissection (ESD) after dietary modification. A total of 273 patients with EGC who underwent ESD were recruited to the cohort. They were given dietary instruction and education through a dietary manual and were followed up for 12 months. If the dietary pattern changed to the “traditional food” pattern (high consumption of vegetables, wheat products, and red meat) after the nutritional guidance, subjects were defined as the improvement diet group. Dietary patterns focused on “alcohol and fish” (drink a lot of wine and beer and eating freshwater and marine fish) or “coarse cereals” (mainly whole grains, beans and poultry) were the main ones in the unimproved diet group. The nutritional status, gastric mucosa, and gastrointestinal symptoms of the two groups of patients before and after the dietary instruction were compared. Compared with the unimproved diet group, the endoscopic performance score and the symptom score in the improved diet group were decreased by an average of 1.31 and 1.90, respectively. Except for lymphocyte count (P = 0.227), total protein (P < 0.000), albumin (P = 0.003), globulin (P = 0.014), red blood cell count (P < 0.000), and hemoglobin (P < 0.000) values were improved to varying degrees. After changing the diet, the intake of wheat products and vegetables in the improved diet group increased by 15.58 and 17.52%, respectively, while the intake of alcohol, fish, and pickled products was reduced by 43.36, 36.43, and 31.41%, respectively. After 1 year of dietary adjustment, the nutritional status, gastric mucosa, and gastrointestinal symptoms of patients with EGC after ESD eating the "traditional food" diet were all improved.

Application of Machine Learning Algorithms to Predict Lymph Node Metastasis in Early Gastric Cancer

Objective

This study aimed to establish the best early gastric cancer lymph node metastasis (LNM) prediction model through machine learning (ML) to better guide clinical diagnosis and treatment decisions.

Methods

We screened gastric cancer patients with T1a and T1b stages from 2010 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database and collected the clinicopathological data of patients with early gastric cancer who were treated with surgery at the Second Affiliated Hospital of Nanchang University from January 2014 to December 2016. At the same time, we applied 7 ML algorithms—the generalized linear model (GLM), RPART, random forest (RF), gradient boosting machine (GBM), support vector machine (SVM), regularized dual averaging (RDA), and the neural network (NNET)—and combined them with patient pathological information to develop the best prediction model for early gastric cancer lymph node metastasis. Among the SEER set, 80% were randomly selected to train the models, while the remaining 20% were used for testing. The data from the Second Affiliated Hospital were considered as the external verification set. Finally, we used the AUROC, F1-score value, sensitivity, and specificity to evaluate the performance of the model.

Results

The tumour size, tumour grade, and depth of tumour invasion were independent risk factors for early gastric cancer LNM. Comprehensive comparison of the prediction model performance of the training set and test set showed that the RDA model had the best prediction performance (F1-score = 0.773; AUROC = 0.742). The AUROC of the external validation set was 0.73.

Conclusions

Tumour size, tumour grade, and depth of tumour invasion were independent risk factors for early gastric cancer LNM. ML predicted LNM risk more accurately, and the RDA model had the best predictive performance and could better guide clinical diagnosis and treatment decisions.

GIST of the stomach masquerading as recurrent falls in an older adult: a case report and review

BACKGROUND

Gastric tumors become increasingly prevalent with advanced age but can be challenging to diagnose in older adults who may present with non-specific symptoms. Here, we report a rare case of an occult gastric tumor associated with mesenteric panniculitis that presented with recurrent falls precipitated by vertigo.

CASE PRESENTATION

We describe a diagnostically challenging case of cryptogenic gastric tumor associated with mesenteric panniculitis in a 74-year-old female who presented with abdominal bloating and recurrent falls precipitated by vertigo, dehydration, acute kidney injury and electrolyte deficiencies, but had no alarm symptoms. Her symptoms resolved after laparoscopic wedge resection of the gastric tumor.

CONCLUSIONS

Our case highlights that while alarm symptoms such as dysphagia, weight loss, gastrointestinal bleeding and vomiting are considered indications for endoscopy, clinicians should also maintain a high index of suspicion for gastric tumors in older patients who may present with atypical symptoms.

Updates in artificial intelligence in gastroenterology endoscopy in 2020

PURPOSE OF REVIEW

Artificial intelligence is becoming rapidly integrated into modern technology including medicine. Artificial intelligence has a wide range of potential in gastroenterology, particularly with endoscopy, given the required analysis of large datasets of images. The aim of this review is to summarize the advances of artificial intelligence in gastroenterology (GI) endoscopy over the past year.

RECENT FINDINGS

Computer-aided detection (CADe) systems during real-time colonoscopy have resulted in increased adenoma detection rate with no significant increase in procedure times. Deep learning techniques have been utilized to accurately assess bowel preparation quality, which would impact surveillance colonoscopy recommendations. For the upper GI tract, CADe systems have been developed to aid in improving the diagnosis of Barrett's neoplasia during real-time endoscopy. Artificial intelligence-assisted real-time endoscopy has been shown to reduce blind spots during EGD.

SUMMARY

The application of artificial intelligence in gastroenterology endoscopy remains promising. Advances over the past year include improved detection of GI neoplasia during endoscopy and characterization of lesions. Further research including randomized, multicenter trials are needed to further evaluate the use of artificial intelligence for real-time endoscopy.

Beyond the Guidelines: The Grey Zones of the Management of Gastric Cancer. Consensus Statements from the Gastric Cancer Italian Network (GAIN)

BACKGROUND

Management of gastric and gastroesophageal junction (GEJ) adenocarcinoma remains challenging, because of the heterogeneity in tumor biology within the upper gastrointestinal tract. Daily clinical practice is full of grey areas regarding the complexity of diagnostic, staging, and therapeutic procedures. The aim of this paper is to provide a guide for clinicians facing challenging situations in routine practice, taking a multidisciplinary consensus approach based on available literature.

METHODS

The GAIN (GAstric cancer Italian Network) group was established with the aims of reviewing literature evidence, discussing key issues in prevention, diagnosis, and management of gastric and GEJ adenocarcinoma, and offering a summary of statements. A Delphi consensus method was used to obtain opinions from the expert panel of specialists.

RESULTS

Forty-nine clinical questions were identified in six areas of interest: role of multidisciplinary team; risk factors; diagnosis; management of early gastric cancer and multimodal approach to localized gastric cancer; treatment of elderly patients with locally advanced resectable disease; and treatment of locally advanced and metastatic cancer.

CONCLUSIONS

The statements presented may guide clinicians in practical management of this disease.

Endoscopic Submucosal Dissection versus Surgery for Undifferentiated-Type Early Gastric Cancer: A Systematic Review and Meta-Analysis

Background/Aims

The use of endoscopic submucosal dissection (ESD) for treating undifferentiated-type early gastric cancer is controversial. The objective of this study was to perform a meta-analysis to compare the long-term outcomes of ESD and surgery for undifferentiated-type early gastric cancer.

Methods

The PubMed, Cochrane Library, and EMBASE databases were used to search for relevant studies comparing ESD and surgery for undifferentiated-type early gastric cancer. The methodological quality of the included publications was evaluated using the Risk of Bias Assessment tool for Nonrandomized Studies. The rates of overall survival, recurrence, adverse event, and complete resection were determined. Odds ratios (ORs) and 95% confidence intervals (CIs) were also evaluated.

Results

This meta-analysis enrolled five studies with 429 and 1,236 participants undergoing ESD and surgery, respectively. No significant difference was found in the overall survival rate between the ESD and surgery groups (OR, 2.29; 95% CI, 0.98–5.36; p=0.06). However, ESD was associated with a higher recurrence rate and a lower complete resection rate. The adverse event rate was similar between the two groups.

Conclusions

ESD with meticulous surveillance esophagogastroduodenoscopy may be as effective and safe as surgery in patients with undifferentiated-type early gastric cancer. Further large-scale, randomized, controlled studies from additional regions are required to confirm these findings.

Quality in diagnostic upper gastrointestinal endoscopy for the detection and surveillance of gastric cancer precursor lesions: Position paper of AEG, SEED and SEAP

This position paper, sponsored by the Asociación Española de Gastroenterología [Spanish Association of Gastroenterology], the Sociedad Española de Endoscopia Digestiva [Spanish Gastrointestinal Endoscopy Society] and the Sociedad Española de Anatomía Patológica [Spanish Anatomical Pathology Society], aims to establish recommendations for performing an high quality upper gastrointestinal endoscopy for the screening of gastric cancer precursor lesions (GCPL) in low-incidence populations, such as the Spanish population. To establish the quality of the evidence and the levels of recommendation, we used the methodology based on the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). We obtained a consensus among experts using a Delphi method. The document evaluates different measures to improve the quality of upper gastrointestinal endoscopy in this setting and makes recommendations on how to evaluate and treat the identified lesions. We recommend that upper gastrointestinal endoscopy for surveillance of GCPL should be performed by endoscopists with adequate training, administering oral premedication and use of sedation. To improve the identification of GCPL, we recommend the use of high definition endoscopes and conventional or digital chromoendoscopy and, for biopsies, NBI should be used to target the most suspicious areas of intestinal metaplasia. Regarding the evaluation of visible lesions, the risk of submucosal invasion should be evaluated with magnifying endoscopes and endoscopic ultrasound should be reserved for those with suspected deep invasion. In lesions amenable to endoscopic resection, submucosal endoscopic dissection is considered the technique of choice.

Effect and cost-effectiveness of national gastric cancer screening in Japan: a microsimulation modeling study

BACKGROUND

A national endoscopic screening program for gastric cancer was rolled out in Japan in 2015. We used a microsimulation model to estimate the cost-effectiveness of current screening guidelines and alternative screening strategies in Japan.

METHODS

We developed a microsimulation model that simulated a virtual population corresponding to the Japanese population in risk factor profile and life expectancy. We evaluated 15 endoscopic screening scenarios with various starting ages, stopping ages, and screening intervals. The primary outcomes were quality-adjusted life-years (QALYs), costs, and incremental cost-effectiveness ratio. Cost-effective screening strategies were determined using a willingness-to-pay threshold of $50,000 per QALY gained. One-way sensitivity and probabilistic sensitivity analyses were done to explore model uncertainty.

RESULTS

Using the threshold of $50,000 per QALY, a triennial screening program for individuals aged 50 to 75 years was the cost-effective strategy, with an incremental cost-effectiveness ratio of $45,665. Compared with no endoscopic screening, this strategy is predicted to prevent 63% of gastric cancer mortality and confer 27.2 QALYs gained per 1000 individuals over a lifetime period. Current screening guidelines were not on the cost-effectiveness efficient frontier. The results were robust on one-way sensitivity analyses and probabilistic sensitivity analysis.

CONCLUSIONS

This modeling study suggests that the endoscopic screening program in Japan would be cost-effective when implemented between age 50 and 75 years, with the screening repeated every 3 years. These findings underscore the need for further evaluation of the current gastric cancer screening recommendations.

Prognostic factors for ESD of early gastric cancers: a systematic review and meta-analysis

Background and study aims  Gastric neoplasms are one of the leading types of cancer in the world and early detection is essential to improve prognosis. Endoscopy is the gold-standard diagnostic procedure and allows adequate treatment in selected cases. Endoscopic submucosal dissection (ESD) has been reported to safely address most early gastric cancers (EGCs), with high curability rates. However, data on prognostic factors related to ESDs of EGCs are conflicting. Therefore, we aimed to systematically review the available literature and to perform a meta-analysis to identify the relevant prognostic factors in this context. Methods  We performed this study according to PRISMA guidelines. Comparative studies assessing the relationship between curative resection or long-term curability rates and relevant prognostic factors were selected. Prognostic factors were demographic data, lesion features (location, morphology of the lesion, size, and depth of invasion), histological findings, Helycobacter pylori (HP) infection, presence of gastric a atrophy and body mass index (BMI). Finally, we also evaluated risk factors related to metachronous gastric neoplasm. Results  The initial search retrieved 2829 records among which 46 studies were included for systematic review and meta-analysis. The total sample comprised 28366 patients and 29282 lesions. Regarding curative resection, pooled data showed no significant influence of sex [odds ratio (OR): 1.15 (0,97, 1.36) P  = 0.10 I 2  = 47 %] , age [OR: 1.00 (0.61, 1.64) P  = 1.00 I 2  = 58 %], posterior vs non-posterior location [OR: 1.35 (0.81, 2.27) P  = 0.25 I 2  = 84 %], depressed vs von-depressed macroscopic type[OR: 1.21 (0.99, 1.49) P  = 0.07 I 2  = 0 %], non-upper vs upper location [OR: 1.41 (0.93, 2.14) P  = 0.10 I 2  = 77 %] and BMI [OR: 0.84 (0.57; 1.26) P  = 0.41 I 2  = 0 %]. Differentiated neoplasms presented greater chance of cure compare to undifferentiated [OR: 0.10 (0.07, 0.15) P  < 0.00001 I 2  = 0 %]. Ulcerated lesions had lower curative rates compared to non-ulcerated [OR: 3.92 (2.81, 5.47) P  < 0.00001 I 2  = 44 %]. Lesions smaller than 20 mm had greater chance of curative resection [OR: 3.94 (3.25, 4.78) P  < 0.00001 I 2  = 38 %]. Bleeding during procedure had lower curative rates compared to non-bleeding [OR: 2.13 (1.56, 2.93) P  < 0.0001 I 2  = 0 %]. Concerning long-term cure, female gender [OR 1.62 (1.33, 1.97) P  < 0.00001 I 2  = 0 %] and the mucosal over SM1 cancers were protective factors [OR: 0.08 (0.02, 0.39) P  = 0.002 I 2  = 86 %]. Gastric atrophy [OR: 0.60 (0.45, 0.81) P  = 0.0006 I 2  = 42 %] and the pepsinogen I/pepsinogen II ratio [OR 2.29 (1.47, 3.57) P  = 0.0002 I 2  = 0 %] were risk factors to metachronous gastric neoplasm. Conclusions  Ulcerated lesions, histology, bleeding and size > 20 mm are prognostic factors concerning curative resection. Regarding long-term cure, female gender and mucosal over SM1 cancer are predictive factors. Gastric atrophy and the pepsinogen ratio are risk factors for metachronous gastric neoplasm.

Propensity score-matched comparison of short- and long-term outcomes between surgery and endoscopic submucosal dissection (ESD) for intestinal type early gastric cancer (EGC) of the middle and lower third of the stomach: a European tertiary referral center experience

BACKGROUND

Despite the comparable results between ESD and gastrectomy reported in multiple Asiatic studies, limited data are currently present on the long-term efficacy of ESD for EGC in Western countries. The aim of this study was to compare the short- and long-term outcomes of the endoscopic submucosal dissection and surgery for non-diffuse early gastric cancer treatment in a Western cohort of patients.

METHODS

All patients with a diagnosis of intestinal type EGC located in the middle and lower third of the stomach from 2005 to 2015 were enrolled in the study. All patients completed a 5-year follow-up. Patients were divided according to the procedure performed (ESD/subtotal gastrectomy). The two groups were matched for age, gender, ASA score, tumor dimension, and grade of infiltration (mucosa/submucosa).

RESULTS

After matching, 84 patients (42 per group) were included in the analysis. Peri-procedural morbidity rate was 7.1% and no difference was observed between the two groups (4.8% vs 9.5% for ESD and STG groups, respectively; p = 0.3). Similar results in terms of 5-year OS and DFS were observed for ESD and STG (77.7% vs 71.8% ; p = 0.78 and 74.9% vs 72% ; p = 0.7, respectively). At the multivariate analysis, ASA3 score was recognized as the only negative predictor factor for the 5-year OS (OR 6.2; 95% CI 2.2-16.8; p < 0.001). Regarding the DFS, both ASA3 score (OR 4.4; 95% CI 1.7-10.9; p < 0.001) and submucosal infiltration(OR 5.1; 95% CI 1.2-22.4 ; p = 0.02) were identified as independent risk factors for a worse outcome.

CONCLUSIONS

Our results confirm the safety and feasibility ESD for EGC treatment in a Western setting. In addition, this is one of the few reports showing comparable results both in terms of short- and long-term outcomes between ESD and surgery for intestinal type ECG treatment in Western countries.

Preoperative imaging evaluation of the absolute indication criteria for endoscopic submucosal dissection in early gastric cancer patients

Introduction

Gastric cancer (GC) is a common malignant tumor with a high mortality rate.

Aim

To determine the accuracy of preoperative imaging information obtained from the combined use of general gastroscopy (GS), endoscopic ultrasonography (EUS), and multi-detector computed tomography (MDCT) regarding absolute indication of endoscopic submucosal dissection (ESD) in early gastric cancer (EGC).

Material and methods

The relationship between clinical features of 794 EGC patients and lymph node metastasis (LNM) was analyzed. Multivariate logistic regression analysis was used to investigate the risk factors for LNM. Additionally, the accuracy of diagnosis of imaging techniques for ESD indications was determined by receiver operating characteristic (ROC) analysis.

Results

Data showed that tumor size > 2 cm (p = 0.0071), T1b stage (p < 0.0001), undifferentiated histology (p < 0.0001), and vascular invasion (p = 0.0007) were independent risk factors for LNM in patients with EGC. Indications for ESD have a specificity of 100% for the diagnosis of patients with LNM. Additionally, the diagnostic efficacy of the use of GS, EUS, and MDCT in identifying node positive status, T1a disease, tumor size ≤ 2 cm, and ulceration was found to be moderate with area under the curve (AUC) of receiver operating characteristic curve (ROC) of 0.71, 0.64, 0.72, and 0.68, respectively. Furthermore, the use of imaging techniques for overall indication criteria for ESD had a moderate utility value with an AUC of 0.71.

Conclusions

Our data suggested that, based on the combined use of GS, EUS, and MDCT, a high specificity of patient selection for ESD treatment can be achieved.

Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is becoming the preferred method for certain early GI malignancies; however, very few U.S. physicians have adopted this technique. This is in part because of the technically challenging nature of the procedure and the long learning curve. Several endoscopic robots are under development to address these complexities.

METHODS

This is a randomized, controlled, pilot study comparing conventional ESD versus robotic-assisted ESD (RESD) in an ex vivo bovine colon model. Five endoscopists without prior ESD or RESD experience were randomized into 2 groups (group 1, RESD after ESD; group 2, RESD before ESD). A standard template was used to create colonic lesions. The primary outcome was completeness of en bloc resection. Secondary outcomes included differences in procedure time, perforation rate, muscle injury rate, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) to assess physical and mental workload.

RESULTS

Five endoscopists each performed 4 tissue resections (2 RESD and 2 ESD), for a total of 20 procedures. Complete en bloc resection was achieved in all RESD and in 50% of ESD (P < .0001). The perforation rate was higher in the ESD group (60% vs 30%, P = .18). Total procedure time (34.1 vs 88.6 min, P = .001) and dissection time (27.8 vs 79.4 minutes, P = .002) were lower for RESD. The NASA-TLX also revealed better results for RESD (28.4 vs 47.4, P = .01).

CONCLUSIONS

RESD appears to be more effective in obtaining en bloc resection with shorter procedure times and a lower perforation rate compared with conventional ESD as performed by ESD novices. RESD is also associated with lower physical and mental workloads.

Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects

A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.

Long-term outcomes of endoscopic submucosal dissection versus surgery in early gastric cancer: a systematic review and meta-analysis

Endoscopic submucosal dissection (ESD) and gastrectomy with lymph node dissection are considered acceptable treatment modalities for early gastric cancer (EGC). In the last decade, ESD has become more favorable than surgery as it offers faster recovery, lower costs, and a superior quality of life when compared to gastrectomy. The aim of this study is to compare the long-term outcome of ESD versus surgery in EGC. We performed a systematic and comprehensive search of major reference databases (Medline, Embase, CINHAL) for all studies that compared the outcome of EGC for patients underwent ESD or surgery in the same cohort. A systematic review was conducted through November 2017, using pooled analysis to calculate 5-year overall survival (OS) rate, disease-specific survival (DSS) rate, disease-free survival (DFS) rate, and recurrence-free survival (RFS) rate of ESD versus gastrectomy. Five-year OS and DSS were similar between ESD and gastrectomy groups 96 versus 96% and 99.4 versus 99.2%, respectively. Likewise, DFS was similar in both groups 95.9 versus 98.5% odds ratio 1.86 (0.57-6.0) P=0.3. However, ESD had a lower RFS compared to surgery 92.4 versus 98.3% odds ratio 0.17 (0.1-4.9) P=0.001. Overall, there was a higher recurrence rate in patients who underwent ESD compared to surgery [40/2943 (1.4%) vs. 12/3116 (0.4) risk ratio (RR) 2.5 (1.3-4.8) P=0.005]. Moreover, synchronous and metachronous cancers were more prevalent in the ESD group compared to the surgery group [1.5 vs. 0.1% RR 5.7 (1.5-21.9) P=0.01] [16/1082 (1.5%) vs. 1/1485 (0.1%) RR 10.1 (5.9-17.1) P=0.0001]. Five-year OS, DSS and DFS were similar between ESD and surgery groups. However, recurrent, synchronous and metachronous cancers were more prevalent in patients treated by ESD compared to patients treated by surgery, resulting in a lower RFS. Adequate surveillance with upper endoscopy is crucial after ESD to detect early recurrence and metachronous lesions.

Quality in upper gastrointestinal endoscopic submucosal dissection

Progress in the endoscopy technology field led to an increase in the diagnosis of early gastrointestinal (GI) superficial lesions and to an improvement of their treatment. Endoscopic submucosal dissection (ESD) has been developed in Japan with the aim of removing such lesions in one piece, in order to obtain a curative resection and to minimize the risk of local recurrence, and to preserve the native organ. ESD is widely used in Asia for the treatment of early upper and lower GI lesions and is currently gaining attention in Western countries too. However, ESD can be safely performed only by expert endoscopists and in specific clinical settings. Therefore, prior to decide whether ESD is feasible or not, the target lesion must be carefully assessed, in order to understand whether or not it is eligible for submucosal dissection. The aim of this paper is to review indications, limitations and technical aspects of upper GI ESD.

Study of the standard direct costs of various techniques of advanced endoscopy. Comparison with surgical alternatives

INTRODUCTION

The complexity of endoscopy has carried out an increase in cost that has a direct effect on the healthcare systems. However, few studies have analyzed the cost of advanced endoscopic procedures (AEP).

OBJECTIVES

To carry out a calculation of the standard direct costs of AEP, and to make a financial comparison with their surgical alternatives.

METHODS

Calculation of the standard direct cost in carrying out each procedure. An endoscopist detailed the time, personnel, materials, consumables, recovery room time, stents, pathology and medication used. The cost of surgical procedures was the average cost recorded in the hospital.

RESULTS

Thirty-eight AEP were analyzed. The technique showing lowest cost was gastroscopy + APC (€116.57), while that with greatest cost was ERCP with cholangioscopy + stent placement (€5083.65). Some 34.2% of the procedures registered average costs of €1000-2000. In 57% of cases, the endoscopic alternative was 2-5 times more cost-efficient than surgery, in 31% of cases indistinguishable or up to 1.4 times more costly.

CONCLUSION

Standard direct cost of the majority of AEP is reported using a methodology that enables easy application in other centers. For the most part, endoscopic procedures are more cost-efficient than the corresponding surgical procedure.

Risk Factors for Lymph Node Metastasis in Western Early Gastric Cancer After Optimal Surgical Treatment

BACKGROUND

Lymph node metastasis (LNM) has a strong influence on the prognosis of patients with early gastric cancer (EGC). As minimally invasive treatments are considered appropriate for EGC, and lymphadenectomy may be restricted or even eliminated in some cases; it is imperative to identify the main risk factors for LNM to individualize the therapeutic approach. This study aims to evaluate the risk factors for LNM in EGC and to determine the adequacy of the endoscopic resection criteria in a western population.

METHODS

EGC patients who underwent gastrectomy with lymphadenectomy were retrospectively analyzed utilizing a prospective database. The clinicopathological variables were assessed to determine which factors were associated to LNM.

RESULTS

Among 474 enrolled patients, 105 had EGC (22.1%). LNM occurred in 13.3% of all EGC (10% T1a; 15.4% T1b). Tumor size, venous, lymphatic, and perineural invasions were confirmed as independent predictors of LNM by multivariate analysis. Expanded criteria were safely adopted only in selected cases, and 13.6% of patients who matched expanded indication had LNM.

CONCLUSIONS

Tumor size, venous, lymphatic, and perineural invasions were associated with LNM and should be considered as surrogate markers for surgical treatment of EGC. Expanded criteria for endoscopic resection can be safely adopted only in selected cases.

Energy metabolism during the perioperative period of gastric endoscopic submucosal dissection

The aim of this study was to investigate the change in the energy metabolism and invasiveness in the perioperative period of endoscopic submucosal dissection for early gastric cancer. Fifty-two consecutive patients were enrolled into the study between July 2013 and May 2014 and examined resting energy expenditure using an indirect calorimeter, body weight and basal energy expenditure using the Harris-Benedict equation before and after endoscopic submucosal dissection. Resting energy expenditure/body weight and resting energy expenditure/basal energy expenditure were 20.2 ± 3.0 kcal/kg/day and 0.96 ± 0.11 on the day of endoscopic submucosal dissection, whereas one day after the endoscopic submucosal dissection they were 21.7 ± 3.2 kcal/kg/day and 1.03 ± 0.14, showing significant increases (p<0.001, respectively). The stress factor on the postoperative day 1 was computed as 1.07. This increase was low in comparison to that experienced for surgery, suggesting that the degree of perioperative invasiveness in patients receiving endoscopic submucosal dissection is lower in comparison to that during surgery (The study of the resting energy metabolism and stress factor using an indirect calorimeter in the perioperative period of endoscopic operation: UMIN000027135).

A nomogram to predict lymph node metastasis in patients with early gastric cancer

Background

Lymph node status is crucial to determining treatment for early gastric cancer (EGC). We aim to establish a nomogram to predict the possibility of lymph node metastasis (LNM) in EGC patients.

Methods

Medical records of 952 EGC patients with curative resection, from 2002 to 2014, were retrospectively retrieved. Univariate and multivariate analysis were performed to examine risk factors associated with LNM. A nomogram for predicting LNM was established and internally validated.

Results

Five variables significantly associated with LNM were included in our model, these are sex (Odd ratio [OR] = 1.961, 95% confidence index [CI], 1.334 to 2.883; P = 0.001), depth of tumor (OR = 2.875, 95% CI, 1.872 to 4.414; P = 0.000), tumor size (OR = 1.986, 95% CI, 1.265 to 3.118; P = 0.003), histology type (OR = 2.926, 95% CI, 1.854 to 4.617; P = 0.000) and lymphovascular invasion (OR = 4.967, 95% CI, 2.996 to 8.235; P = 0.000). The discrimination of the prediction model was 0.786.

Conclusions

A nomogram for predicting lymph node metastasis in patients with early gastric cancer was successfully established, which was superior to the absolute endoscopic submucosal dissection (ESD) indication in terms of the clinical performance.

Gastric Adenocarcinoma: A Multimodal Approach

Despite its declining incidence, gastric cancer (GC) remains a leading cause of cancer-related deaths worldwide. A multimodal approach to GC is critical to ensure optimal patient outcomes. Pretherapy fine resolution contrast-enhanced cross-sectional imaging, endoscopic ultrasound and staging laparoscopy play an important role in patients with newly diagnosed ostensibly operable GC to avoid unnecessary non-therapeutic laparotomies. Currently, margin negative gastrectomy and adequate lymphadenectomy performed at high volume hospitals remain the backbone of GC treatment. Importantly, adequate GC surgery should be integrated in the setting of a multimodal treatment approach. Treatment for advanced GC continues to expand with the emergence of additional lines of systemic and targeted therapies.

Surveillance for Gastric Cancer

This article discusses the current National Comprehensive Cancer Network guidelines and other available Western and Eastern guidelines for the surveillance of gastric cancer following surgical resection. It reviews the literature assessing the utility of intensive surveillance strategies for gastric cancer, which fails to show an improvement in survival. The unique issues relating to follow-up of early gastric cancer and after endoscopic resection of early gastric cancer are discussed. This article also reviews the available modalities for follow-up. In addition, it briefly discusses the advancements in treatment of recurrent and metastatic disease and the implications for gastric cancer survival and surveillance strategies.

Risk Stratification According to the Total Number of Factors That Meet the Indication Criteria for Radical Lymph Node Dissection in Patients with Early Gastric Cancer at Risk for Lymph Node Metastasis

BACKGROUND

Extended indications for endoscopic resection for early gastric cancer (EGC) have been widely accepted. However, according to current guidelines, additional gastrectomy with lymph node dissection (LND) is recommended for patients proven to have potential risks of lymph node metastasis (LNM) on histopathological findings. The aim of this study was to elucidate the risk stratification of outcome and LNM according to the number of factors that meet the inclusion criteria for radical LND for possible LNM (LNM risk factors) in patients with negative endoscopic resection margin.

METHODS

We enrolled 511 EGC patients whose tumors did not meet the absolute or extended indications for endoscopic resection, and investigated the risk stratification of prognosis and LNM according to the total number of LNM risk factors.

RESULTS

Recurrence-free and overall survival rates were significantly higher in patients with fewer LNM risk factors for surgical indication (p = 0.0274 and 0.0002, respectively; log-rank test), and the total number of LNM risk factors and frequency of LNM were significantly correlated (p < 0.0001; Kruskal-Wallis test). When only one LNM risk factor was satisfied, the LNM ratio was 0.58 % (1/173, 95 % confidence interval 0.01-3.18).

CONCLUSION

The present study suggested the possibility of using further minimally invasive treatment strategies based on the total number of LNM risk factors.

Survival rates in T1 and T2 gastric cancer: A Western report

BACKGROUND AND OBJECTIVES

The purpose of this study was to identify clinicopathologic factors associated with overall survival (OS) in early T stage gastric cancer in a Western population.

METHODS

Patients with stage T1 or T2 gastric or gastroesophageal adenocarcinoma who had undergone upfront gastrectomy from 1995 to 2013 were identified in an institutional database.

RESULTS

We identified 121 patients with pathologic stage T1 or T2 tumors (49 [41%] T1a; 49 [41%] T1b; and 23 [19%] T2) who underwent R0 resection without preoperative treatment. Of these, 53% were white, 9% African American, 17% Hispanic, and 22% Asian. The median follow-up was 5.7 years, and the 5-year OS rate was 89% (98%, 93%, and 66% for patients with T1a, T1b, and T2 tumors, respectively). Univariate analysis revealed a higher risk of death in patients with T2 tumors and those of African American race. On multivariate analysis, T2 stage was the only variable independently associated with OS (hazard ratio, 2.80; 95% confidence interval, 1.11-7.12; P = 0.03).

CONCLUSION

In this study of a Western population of patients with T1 or T2 gastric cancer, T2 stage was associated with diminished OS, whereas nodal status and race were not. J. Surg. Oncol. 2016;114:602-606. © 2016 Wiley Periodicals, Inc.

miR-409-3b inhibits invasion and metastasis of gastric cancer by downregulating EGFL7 protein expression

AIM: To investigate the inhibitory effect of miR-409-3b on the invasion and migration of gastric adenocarcinoma and the underlying molecular mechanisms.

METHODS: MicroRNA array was used to screen miRNAs which were significantly differentially expressed between gastric cancer and paracancerous tissue. Bioinformatics was employed to predict the miRNAs related to the regulation of epidermal growth factor-like domain-containing protein 7 (EGFL7). Gastric cancer cells were infected with lentiviral vectors or transfected with miR-409-3b mimics to overexpress miR-409-3b. Western blot was used to detect the changes of EGFL7 in gastric cancer cells. Transwell invasion assay was accomplished to analyze cell invasion ability. Quantitative real-time polymerase chain reaction (qRT-PCR) was adopted to detect the expression of miR-409-3b in 80 pairs of gastric cancer tissues and adjacent noncancerous tissues. The relationship between clinical pathological data and EGFL7 expression was analyzed.

RESULTS: MicroRNA array and bioinformatics prediction results supported that miR-409-3b was lowly expressed in gastric carcinoma, and regulated EGFL7. Dual luciferase assay confirmed that miR-409-3b binds to EGFL7. Western blot analysis suggested that EGFL7 was downregulated after miR-409-3b overexpression. qRT-PCR suggested that the relative expression of miR-409-3b in gastric cancer tissues was lower than that in the adjacent noncancerous tissues. Transwell invasion experiments showed that miR-409-3b infection could significantly reduce the invasion ability of gastric cancer cells in vitro. The migration ability of miR-409-3b LV-cells was significantly higher than that of BGC-823 cells. The expression of miR-409-3b was closely related with lymph node metastasis (P < 0.05). The expression ratio of miR-409-3b in gastric cancer tissues to adjacent noncancerous tissues was significantly lower in tissues collected from patients with distant metastasis than in those from patients without distant metastasis (P < 0.05).

CONCLUSION: miR-409-3b regulates EGFL7 expression at the post-transcriptional level, and then suppresses the invasion and metastasis of gastric adenocarcinoma.