Secondary endoscopic submucosal dissection for locally recurrent or incompletely resected gastric neoplasms

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.

Comparison between Endoscopic Submucosal Dissection and Surgery in Patients with Early Gastric Cancer

Simple Summary

Conventional gastrectomy combined with regional lymph node dissection has been the standard treatment for early gastric cancer (EGC). This retrospective case–control study aimed to compare the clinical outcomes of endoscopic submucosal dissection (ESD) and surgical resection for EGC in China. After propensity score-matching, there were no significant differences between the two groups for OS, RFS, and DSS. Additionally, with similar R0 resection and recurrence rates, the ESD group showed less blood loss, fewer adverse events, lower hospital cost, and a shorter operative time and hospital duration than the surgery group. Therefore, ESD can be a first-line treatment of EGC in addition to surgery.

Abstract

Background: Endoscopic submucosal dissection (ESD) has become a preferred treatment option for early gastric cancer (EGC). This study aimed to compare the clinical outcomes of ESD and surgical resection for EGC. Methods: This was a retrospective case–control study. Patients with a diagnosis of EGC who underwent ESD or surgery in our hospital from 2011 to 2020 were enrolled. We compared the clinical characteristics and treatment outcomes of these two groups according to propensity score-matching. The primary outcome comparison was overall survival (OS). Secondary outcomes were disease-specific survival (DSS), recurrence-free survival (RFS), and treatment-related events. Results: In the matched cohort, the ESD group showed comparable OS, RFS, and DSS with the surgery group. Statistical differences were shown in blood loss and adverse events. Furthermore, the ESD group showed lower hospital cost, as well as a shorter operative time and hospital duration than the surgery group. The R0 resection and recurrence rates were similar between the two groups. In Cox regression analysis, age, tumor size, poor differentiation, and lymphovascular invasion were regarded as independent factors of OS. Conclusions: With sufficient safety and advantages, ESD can be a first-line treatment of EGC. Preoperative evaluation is vital to the appropriate treatment and prognosis.

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.

Salvage endoscopic submucosal dissection for incompletely resected esophageal or gastric neoplasms (case series)

Background and study aims  Given that positive lateral margins indicate possible residual carcinoma, salvage endoscopic submucosal dissection (ESD) should be considered for curative therapy. Presence of submucosal fibrosis, however, makes the procedure difficult to perform. We present our case series to discuss the feasibility of salvage ESD and the timing of the procedure.