Duodenogastric Reflux Induced By Endoscopic Submucosal Dissection: Contribution of the Resection Area

Abstract

Background and Aims: As with distal gastrectomy, endoscopic submucosal dissection (ESD) may potentially cause excessive duodenogastric reflux (DGR) as a short- or long-term outcome, particularly after procedures on the antral area, which is thought to play an important role in controlling DGR. Patients and Methods: For patients with gastric neoplasm that ESD was indicated, endoscopy was performed at 3 intervals: pre-ESD; the day after ESD; and 3 months post-ESD, and fasting bile acid (BA) concentration in the gastric juice was analysed. To establish the reliability of the measurement method, simple regrssion analysis between repeated measurements on separate days on eighty-two subjects without active peptic ulcer or gastric cancer was performed. The regression equation indicated: y = 0.6654× + 62.965 (R2= 0.3416, r=0.584, P<0.0001). Results: To establish any time-specific effects, the BA levels of each group were then compared with base-line using the repeated-measure one-way ANOVA. In forty-six patients who underwent ESD for gastric neoplasms located in the L portion according to the UML classification (antral group), fasting BA concentration in gastric juice collected the day after ESD was significantly elevated compared to that collected pre-ESD(1132.8 ± 346.2 vs. 292.8 ± 117.3 μmol/l; ∗ P < 0.004), but not in 49 patients who underwent ESD for lesions located other than the L portion (non-antral group). To establish any group-specific effects, statistical comparisons at each time point between two groups were made by the unpared t-test. The comparison revealed higher BA levels in the antral group than those in the non-antral group the day after ESD(1132.8 ± 346.2 vs. 334.4 ± 96.0 μmol/l;†, P < 0.025), but not base-line and the 3 months later. Furthermore, in the antral group, ESD for lesser curvature lesions showed significantly higher BA concentrations compared to that for the other subgroup which located other than the lesser curvature site. Conclusions: ESD, especially for an antral lesion, leads to a transient increase in the occurrence of DGR immediately after the procedure. However, in the long-term, ESD has not to be concerned about DGR-induced complication, unlike distal gastrectomy. Pathophysiologic effects onto the lesser curvature site in the antrum where the vagus nerve dominantly localized in is rich may most strongly be associated with development of DGR.