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Calabrese G, Manfredi G, Maida MF, Mandarino FV, Shahini E, Pugliese F, Cecinato P, Laterza L, Sinagra E, Sferrazza S. Challenges and advancing strategies of endoscopic submucosal dissection for early gastric cancer: The puzzle of eCura C1. World J Gastrointest Endosc 2024; 16:439-444. [PMID: 39155999 PMCID: PMC11325872 DOI: 10.4253/wjge.v16.i8.439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Revised: 06/19/2024] [Accepted: 07/05/2024] [Indexed: 08/01/2024] Open
Abstract
In this editorial, we explore the challenges of managing noncurative resections in early gastric cancer after endoscopic submucosal dissection (ESD), starting from the consideration recently made by Zhu et al. Specifically, we evaluate the management of eCura C1 lesions, where decisions regarding further interventions are pivotal yet contentious. Collaboration among endoscopists, surgeons, and pathologists is underscored to refine risk assessment and personalize therapeutic management. Recent advancements in ESD techniques and interdisciplinary collaboration offer opportunities for outcome optimization in managing eCura C1 lesions. Moreover, despite needing further clinical validation, molecular biomarkers have emerged as promising tools for enhancing prognostication. This manuscript highlights the ongoing research attempts to define treatment paradigms effectively and evaluates the potential of emerging options, ultimately aiming to improve patient care and outcomes in this complex clinical scenario.
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Affiliation(s)
- Giulio Calabrese
- Department of Gastroenterology and Endoscopy, ARNAS Civico–Di Cristina–Benfratelli, Palermo 90127, Sicilia, Italy
| | - Guido Manfredi
- Department of Gastroenterology and Digestive Endoscopy, Ospedale Maggiore, Crema 26013, Italy
| | - Marcello F Maida
- Department of Medicine and Surgery, University of Enna "Kore", Enna 94100, Sicilia, Italy
| | - Francesco V Mandarino
- Department of Gastroenterology and Digestive Endoscopy, IRCCS Ospedale San Raffaele, Milan 20132, Lombardy, Italy
| | - Endrit Shahini
- Department of Gastroenterology, National Institute of Gastroenterology-IRCCS “Saverio de Bellis”, Castellana Grotte, Bari 70013, Italy
| | - Francesco Pugliese
- Department of Digestive and Interventional Endoscopy, Niguarda Hospital, ASST Niguarda, Milan 20162, Lombardy, Italy
| | - Paolo Cecinato
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant’Orsola, Bologna 40138, Emilia-Romagna, Italy
| | - Liboria Laterza
- Department of Medical and Surgical Sciences, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico Sant’Orsola, Bologna 40138, Emilia-Romagna, Italy
| | - Emanuele Sinagra
- Department of Gastroenterology and Endoscopy, Fondazione Instituto San Raffaele Giglio, Cefalù 90015, Palermo, Italy
| | - Sandro Sferrazza
- Department of Gastroenterology and Endoscopy, ARNAS Civico–Di Cristina–Benfratelli, Palermo 90127, Sicilia, Italy
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Jiang Z, Liang Y, Huang P, Ning J, Qi J. Value of quantitative microsurface structure analysis for evaluating the invasion depth of type 0-II early gastric cancer. JGH Open 2024; 8:e13055. [PMID: 38628386 PMCID: PMC11019524 DOI: 10.1002/jgh3.13055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 01/31/2024] [Accepted: 03/02/2024] [Indexed: 04/19/2024]
Abstract
Background and Aim The microsurface structure reflects the degree of damage to the glands, which is related to the invasion depth of early gastric cancer. To evaluate the diagnostic value of quantitative microsurface structure analysis for estimating the invasion depth of early gastric cancer. Methods White-light imaging and narrow-band imaging (NBI) endoscopy were used to visualize the lesions of the included patients. The area ratio and depth-predicting score (DPS) of each patient were calculated; meanwhile, each lesion was examined by endoscopic ultrasonography (EUS). Results Ninety-three patients were included between 2016 and 2019. Microsurface structure is related to the histological differentiation and progression of early gastric cancer. The receiver operating characteristic curve showed that when an area ratio of 80.3% was used as a cut-off value for distinguishing mucosal (M) and submucosal (SM) type 0-II gastric cancers, the sensitivity, specificity, and accuracy were 82.9%, 80.2%, and 91.6%, respectively. The accuracies for distinguishing M/SM differentiated and undifferentiated early gastric cancers were 87.4% and 84.8%, respectively. The accuracy of EUS for distinguishing M/SM early gastric cancer was 74.9%. DPS can only distinguish M-SM1 (SM infiltration <500 μm)/SM (SM infiltration ≥500 μm) with an accuracy of 83.8%. The accuracy of using area ratio for distinguishing 0-II early gastric cancers was better than those of using DPS and EUS (P < 0.05). Conclusion Quantitative analysis of microsurface structure can be performed to assess M/SM type 0-II gastric cancer and is expected to be effective for judging the invasion depth of gastric cancer.
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Affiliation(s)
- Zhang‐Xiu Jiang
- Division of Gastroenterology, Guangxi Hospital Division of The First Affiliated HospitalSun Yat‐sen University, People's Hospital of Guangxi Zhuang Autonomous RegionNanningGuangxiChina
| | - Yun‐Xiao Liang
- Department of Digestion (Division of Gastroenterology)People's Hospital of Guangxi Zhuang Autonomous RegionNanningChina
| | - Peng‐Yu Huang
- Department of Digestion (Division of Gastroenterology)People's Hospital of Guangxi Zhuang Autonomous RegionNanningChina
| | - Jia‐Juan Ning
- Department of Digestion (Division of Gastroenterology)People's Hospital of Guangxi Zhuang Autonomous RegionNanningChina
| | - Jing‐Jing Qi
- Department of PathologyPeople's Hospital of Guangxi Zhuang Autonomous RegionNanningChina
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Ishiyama A, Namikawa K, Tokai Y, Yoshimizu S, Horiuchi Y, Yoshio T, Hirasawa T, Tsuchida T, Itoh F, Fujisaki J. Effect of spraying l-menthol on peristalsis resumption during endoscopic submucosal dissection of gastric tumors. JGH OPEN 2021; 5:653-657. [PMID: 34124381 PMCID: PMC8171147 DOI: 10.1002/jgh3.12549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Revised: 04/02/2021] [Accepted: 04/07/2021] [Indexed: 11/18/2022]
Abstract
Background and Aim l‐Menthol has smooth muscle‐relaxing and antiperistaltic effects. We examined its effectiveness against peristalsis resumption during endoscopic submucosal dissection (ESD) of gastric tumors. Methods We retrospectively examined clinical data of 485 patients (501 lesions) who underwent ESD for upper gastrointestinal tumors in 2017. We included 119 patients (127 lesions) in whom peristaltic movement resumed during ESD and l‐menthol was applied; 366 patients (374 lesions) without l‐menthol application were used as controls. Video recordings were reviewed to determine whether l‐menthol suppressed peristalsis resumption. Results In cases with l‐menthol application, 2 (2.9%), 36 (14.3%), and 89 (71.2%) lesions were found in the upper (U), middle (M), and lower (L) regions, respectively. In the control group, the corresponding values were 66 (17.6%), 215 (57.5%), and 93 (24.9%), respectively. l‐Menthol efficacy was observed in 116 of the 127 treated lesions (91.3%), over 90% of which were in the posterior wall of the U region, anterior wall and greater curvature of the M region, and anterior wall and lesser curvature of the L region. The most and least effective areas for l‐menthol application were the anterior wall of gastric antrum and posterior wall of the M region, respectively. The mean time from application to peristalsis inhibition was 8.7 s. No adverse effects were observed; perforation and secondary hemorrhage were not significantly different between the groups. Conclusion Direct l‐menthol application to the submucosal layer during mucosal resection affects smooth muscles and rapidly inhibits peristalsis resumption. Clinically, l‐Menthol can be used to suppress peristalsis recurrence during ESD, without adverse effects.
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Affiliation(s)
- Akiyoshi Ishiyama
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Ken Namikawa
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Yoshitaka Tokai
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Shoichi Yoshimizu
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Yusuke Horiuchi
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Toshiyuki Yoshio
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Toshiaki Hirasawa
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Tomohiro Tsuchida
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
| | - Fumio Itoh
- Department of Gastroenterology St. Marianna University School of Medicine Kawasaki Japan
| | - Junko Fujisaki
- Department of Endoscopy Cancer Institute Hospital Gastroenterology Center Tokyo Japan
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Kang HS, Kwon MJ, Haynes P, Liang Y, Ren Y, Lim H, Soh JS, Kim NY, Lee HK. Molecular risk markers related to local tumor recurrence at histological margin-free endoscopically resected early gastric cancers: A pilot study. Pathol Res Pract 2021; 222:153434. [PMID: 33857852 DOI: 10.1016/j.prp.2021.153434] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/24/2021] [Accepted: 04/01/2021] [Indexed: 02/07/2023]
Abstract
Local recurrences in early gastric cancers (EGCs) after complete endoscopic submucosal dissection (ESD) remain problematic. Here, we investigated the spatially sequential molecular changes in various cancer-related proteins along the axis of the histologically clear but recurrent resection margins (TRM) to determine the appropriate tumor-free margin distance and potential molecular risk markers related to local recurrence. Five eligible patients with recurrent EGCs after complete ESD were selected from 548 EGC patients. The specimens, including recurrent resection margin axis, were divided into 5 zones. Digital spatial profiling assay was performed to quantify the expression level of 31 cancer-related proteins along each zone. p-Chk1 level was significantly reduced in TRM zone than non-recurrent resection margin. The expression of p44/42 ERK and p-Chk1 were significantly decreased along the lateral axis of the recurrent resection margin, with no significance toward the normal zone, which may suggest that p44/42 ERK and p-Chk1 may be involved in the recurrent side compared to non-recurrent margin. Although we could not evaluate more than 5.5 mm, the significant linear decreases in p44/42 ERK and p-Chk1 were maintained until at least 5.5 mm from the tumor zone in the TRM direction. We estimated the possible margin distance using scatterplots and linear regression analyses, which also showed the estimated distance more than 5.5 mm. In conclusion, the p-Chk1 and p44/42 ERK may be potential candidates of molecular risk markers that may be related to the local recurrence after complete ESD, and a tumor-free distance of 5.5 mm is not enough for safety margin.
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Affiliation(s)
- Ho Suk Kang
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, 14068, Republic of Korea.
| | - Mi Jung Kwon
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, 14068, Republic of Korea.
| | - Premi Haynes
- Bristol Myers Squibb, 400 Dexter Ave N, Seattle, WA, 98109, USA
| | - Yan Liang
- NanoString Technologies, 500 Fairview Ave N, Seattle, WA, 98109, USA
| | - Yuqi Ren
- NanoString Technologies, 500 Fairview Ave N, Seattle, WA, 98109, USA
| | - Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, 14068, Republic of Korea
| | - Jae Seung Soh
- Division of Gastroenterology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, 14068, Republic of Korea
| | - Nan Young Kim
- Hallym Institute of Translational Genomics and Bioinformatics, Hallym University Medical Center, Anyang, Gyeonggi-do, 14068, Republic of Korea
| | - Hye Kyung Lee
- Department of Pathology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, 14068, Republic of Korea
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Liu L, Guo HM, Miao F, Li N, Jiao SH, Cai S, Liu PL, Zhang SS, Ma J, Weng Y, Sun Y, Tang YS, Zhao F, Zheng Y, Zhang S, Yang Y, Zhao ZF. Endoscopic Esophageal Submucosal Tunnel Dissection for Cystic Lesions Originating from the Muscularis Propria of the Gastric Cardia. JOURNAL OF ONCOLOGY 2020; 2020:5259717. [PMID: 32884570 PMCID: PMC7455822 DOI: 10.1155/2020/5259717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/12/2020] [Accepted: 08/04/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze the types and properties of cystic lesions originating from the muscularis propria of the gastric cardia (CLMPGC), explore the growth pattern and anatomical characteristics, and evaluate the safety, feasibility, and clinical efficacy of endoscopic esophageal submucosal tunnel dissection (ESTD). METHODS From September 2013 to July 2018, we treated 6 patients with CLMPGC whom we had diagnosed using endoscopy, endoscopic ultrasound (EUS), and Computed Tomography (CT) before the operations. ESTD was the best option for treatment for all these patients. Postoperative observation and follow-ups were performed, and the operational, clinical data, and treatment results are analyzed. RESULTS The mean age of the patients was 50.67 ± 11.59 years (male : female = 1 : 1). The only clinical manifestations the patients exhibited were upper abdominal discomfort. The diameter of the masses was 2.05 ± 0.73 (1.1-3.0) cm. The duration of the ESTD operation was 93.5 (82-256) mins, and the length of hospital stay was 7.50 ± 1.38 days. Postoperative pathology showed 4 cases of an epithelioid cyst, and 2 cases of mucocele with xanthogranuloma. There were no complications, such as hemorrhage, pneumothorax, and pleural effusion during and after the operation. No recurrence during the follow-ups was observed. CONCLUSION The CLMPGC were mainly mucocele and epidermoid cyst, in an expansive growth pattern, and these lesions had no distinct borders with the muscularis propria. The muscularis propria formed a complete wall of the lesion. There was no direct blood supply to the lesions from big blood vessels. Endoscopic esophageal submucosal tunnel dissection was a safe, feasible, and effective treatment for CLMPGC.
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Affiliation(s)
- Lu Liu
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Hai-Mei Guo
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Feng Miao
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Nuo Li
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Shu-Hua Jiao
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Shuang Cai
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Peng-Liang Liu
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Shan-Shan Zhang
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Jia Ma
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Yang Weng
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Ying Sun
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Yin-Si Tang
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Feng Zhao
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Yan Zheng
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Shen Zhang
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Yan Yang
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
| | - Zhi-Feng Zhao
- Department of Gastroenterology, The Fourth Affiliated Hospital of China Medical University, Shenyang 110000, Liaoning Province, China
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The Role of Helicobacter pylori and Serum Pepsinogen Levels in Metachronous Gastric Cancer After Endoscopic Gastrectomy. Surg Laparosc Endosc Percutan Tech 2020; 30:447-450. [PMID: 32555069 DOI: 10.1097/sle.0000000000000810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE The current study aimed to explore the role of Helicobacter pylori (Hp) infection and serum pepsinogen (PG) levels in the occurrence of metachronous gastric cancer after endoscopic gastrectomy. MATERIALS AND METHODS Totally, 50 patients with metachronous gastric cancer, 50 patients with chronic atrophic gastritis and 50 healthy subjects were collected from October 2015 to October 2018. Patients in the gastric cancer group underwent endoscopic gastrectomy. Serum samples were collected for detection and correlation analysis of serum PG I, PG II, and Hp. In addition, the contents of serum PG and gastrin and postoperative adverse events were statistically analyzed. RESULTS There was a statistically significant difference in serum PG I levels, positive Hp infection rate, the number of mast cells, plasma motilin levels and postoperative adverse events among the 3 groups (P<0.01). There was also a significant difference in PG II levels among the groups (P<0.05). On the basis of the results, the amount of inflammatory cells in the gastric cancer group was significantly higher than that in the gastritis group, and there was a remarkable difference in gastric cancer patients before and after operation. Through data analysis, it was found that the levels of PG I and II were the highest in the healthy control group and the lowest in the gastric cancer group, the number of mast cells was the largest in the gastric cancer group, and the level of motilin was the highest in the healthy control group. CONCLUSION Hp infection and serum PG levels are associated with metachronous gastric cancer.
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Park JY. [Second Primary Cancer after Treating Gastrointestinal Cancer]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2019; 74:193-196. [PMID: 31650794 DOI: 10.4166/kjg.2019.74.4.193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 10/02/2019] [Accepted: 10/02/2019] [Indexed: 11/03/2022]
Abstract
Advances in diagnosis and therapeutic technologies have brought increased life expectancy for most cancers, but paradoxically it also has increased the risk of second primary malignancies. Cancer survivors have a higher risk of developing cancer than the general population. This suggests that more studies are needed to develop screen and management programs for cancer survivors, especially patients with gastrointestinal cancers, which are the most common cancers in Korea.
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Affiliation(s)
- Jeong Youp Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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Mun YG, Choi MG, Lim CH, Lee HH, Kang DH, Park JM, Song KY. Factors Affecting Endoscopic Curative Resection of Gastric Cancer in the Population-Based Screening Era. Clin Endosc 2018; 51:478-484. [PMID: 29852731 PMCID: PMC6182285 DOI: 10.5946/ce.2018.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/31/2018] [Indexed: 02/07/2023] Open
Abstract
Background/Aims Since population-based screening for gastric cancer in Korea was implemented, endoscopic treatment of early gastric cancer has become increasingly popular. This study investigates factors affecting endoscopic curative resection of early gastric cancer in population-based screening for gastric cancer.
Methods We retrospectively reviewed data of patients with newly diagnosed gastric cancer who underwent treatment at Seoul St. Mary’s Hospital. All patients completed questionnaires about clinical information, including interval between surveillance tests for gastric cancer.
Results Of 469 gastric cancer patients, 147 (31.3%) had undergone curative endoscopic resection, 260 (55.4%) had undergone curative surgical resection, and 62 (13.3%) underwent non-curative resection or were in an inoperable state. Patients with curative endoscopic resection had fewer alarm symptoms/signs than other groups. In multivariate analysis, regular surveillance endoscopy was the only factor predicting curative endoscopic resection (odds ratio [OR], 6.099; 95% confidence interval [CI], 2.532–14.933). In addition, patients undergoing gastric cancer screening had a significantly higher rate of endoscopic curative resection compared with subjects who had never been screened. (1-year interval: OR, 49.969; 95% CI, 6.340–393.827, 2-year interval: OR, 15.283; 95% CI, 1.833–127.406, over 2-year interval: OR, 10.651; 95% CI, 1.248–90.871). Shorter screening test intervals were associated with higher rates of endoscopic curative resection.
Conclusions Regular surveillance testing was the independent factor predicting curative endoscopic resection of gastric cancer.
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Affiliation(s)
- Yoon Gwon Mun
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung-Gyu Choi
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chul-Hyun Lim
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Han Hee Lee
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Hoon Kang
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Myung Park
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Kyo Young Song
- Division of Gastrointestinal Surgery, Department of Surgery, Uijeongbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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