Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD.

Abstract

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for superficial gastric neoplasms. Difficult ESD can lead to complications, such as bleeding and perforation. To predict difficult ESD procedures, we analyzed the factors associated with difficult ESD. The medical records of 1052 ESD procedures were retrospectively reviewed. Difficult ESD was defined by any one of three end points: longer procedure time (≥60min), piecemeal resection, incomplete (R1) resection, or gastric wall perforation. To determine the factors associated with difficult ESD, clinical and pathologic features and endoscopic findings were analyzed. The rates of en bloc resection and curative (R0) resection were 93.3 and 92.4%, respectively. The mean procedure time was 27.7±16.7min. After multivariate analysis, larger tumor size (≥20mm) was an independent risk factor for longer procedure time (OR 4.1, P<0.001), for piecemeal resection (OR 2.3, P=0.003) and incomplete (R1) resection (OR 2.1, P=0.005). Location of the lesion (upper third) was an independent risk factor for longer procedure time (OR 5.8, P<0.001), for piecemeal resection (OR 4.1, P<0.001) and incomplete (R1) resection (OR 4.5, P<0.001). Submucosal fibrosis was an independent risk factor for longer procedure time (OR 9.7, P<0.001), for piecemeal resection (OR 2.4, P<0.001) and incomplete (R1) resection (OR 2.6, P<0.001). Finally, submucosal invasive gastric cancer was an independent risk factor for piecemeal resection (OR 2.6, P=0.008), for perforation (OR 19.3, P=0.001) and for incomplete (R1) resection (OR 2.7, P=0.001). Difficult ESD procedures are a function of the lesion size and location, submucosal fibrosis, and submucosal invasive cancer. When a difficult ESD procedure is expected, appropriate preparations should be considered, including consultation with more experienced endoscopists.