Salvage underwater endoscopic mucosal resection for early gastric cancer following incomplete endoscopic submucosal dissection in a patient with gastric adenocarcinoma and proximal polyposis syndrome.

Intraluminal Endoscopic Surgery: The Scioto Returns

Endoscopic submucosal dissection for residual early gastric cancer after endoscopic submucosal dissection

Is en bloc resection essential for endoscopic resection of GI neoplasia?

Stomach: Endoscopic resection for early gastric cancer.

“Adjuvant” Therapy after Endoscopic Mucosal Resection of Early Gastric Cancer

4723 Long-term outcome of endoscopic mucosal resection for early gastric cancer.

Endoscopic Mucosal Resection: Not Your Father's Polypectomy Anymore

The aim of this study was to identify the risk factors for residual/recurrent tumors in patients with a tumor-positive lateral resection margin (LRM+) after endoscopic resection of early gastric cancer (EGC) and to establish the criteria for performing additional treatment. A retrospective analysis was performed on consecutive patients who underwent endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of EGC. Clinicopathological characteristics and risk factors for residual/recurrent tumor in LRM+ patients were analyzed. Eighty-two patients (84 lesions) with LRM+ after EMR (n=45) or ESD (n=39) were enrolled. Forty patients underwent additional gastrectomy or ESD, and 44 were closely observed. The residual/recurrent tumor rate was 34.5% (29 of 84 lesions). Univariate analysis found that the residual/recurrent tumor was associated with the endoscopic resection type (EMR), undifferentiated histology, number of involved directions, rate of lateral resection margin involvement and the total length (mm) of the lateral resection margin involved by the tumor. In multivariate logistic regression analysis, undifferentiated histology and rate (%) were independent risk factors (odds ratio [OR] 5.28, 95% confidence interval [CI] 1.13-24.72, p=0.035 and OR 1.08, 95% CI 1.03-1.14, p=0.004, respectively). Clinicopathological factors that were identified from the univariate and multivariate analyses were scored in order to predict residual/recurrent tumors. We suggest a scoring system for additional treatment in patients with LRM+ after endoscopic resection of EGC based on the development of residual/recurrent tumors. This scoring system enables a more detailed selection of cases and may be useful in determining further treatment.

Outcome of endoscopic mucosal resection for early gastric cancer: review of the Japanese literature

The reported outcomes of endoscopic resection (ER) for early gastric cancer (EGC) remain limited to several single-institution studies. A multicenter retrospective study was conducted at 11 Japanese institutions concerning their results for ER, including conventional endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). A total of 714 EGCs (EMR, 411; ESD, 303) in 655 consecutive patients were treated from January to December 2001. Technically, 511 of the 714 (71.6%) lesions were resected in one piece. The rate of one-piece resection with ESD (92.7%; 281/303) was significantly higher compared with that for EMR (56.0%; 230/411). Histologically, curative resection was found in 474 (66.3%) lesions. The rate of curative resection with ESD (73.6%; 223/303) was significantly higher compared with that for EMR (61.1%; 251/411). Blood transfusion because of bleeding was required in only 1 patient (0.1%) with EMR of 714 lesions. Perforation was found in 16 (2.2%). The incidence of perforation with ESD (3.6%; 11/303) was significantly higher than that with EMR (1.2%; 5/411). All complications were managed endoscopically, and there was no procedure-related mortality. The median follow-up period was 3.2 years (range, 0.5-5.0 years). In total, the 3-year cumulative residual-free/recurrence-free rate and the 3-year overall survival rate were 94.4% and 99.2%, respectively. The 3-year cumulative residual-free/recurrence-free rate in the ESD group (97.6%) was significantly higher than that in the EMR group (92.5%). ER leads to an excellent 3-year survival in clinical practice and could be a possible standard treatment for EGC. ESD has the advantage of achieving one-piece resection and reducing local residual or recurrent tumor.

To examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer. Endoscopic mucosal resection of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. Though this minimally invasive technique is a safe, convenient and efficacious method, it is insufficient for larger lesions. Difficulties in correctly assessing the depth of tumour invasion and increases in local recurrence by standard endoscopic mucosal resection have been reported in lesions larger than 15 mm. This is because such lesions are often resected piecemeal due to the technical limitation of standard endoscopic mucosal resection. New developments in endoscopic resection techniques to dissect the submucosa directly, called endoscopic submucosal dissection, allows resections of larger lesions en bloc. There are no limitations in resection size in endoscopic submucosal dissection, which is expected to replace surgery. This technique, however, still has higher complications rates than standard endoscopic mucosal resection and requires highly skilled endoscopists. The techniques, indications, and pathological assessment methods of endoscopic resection of early gastric cancer are described so that proper treatment guidelines can be established and long-term outcome data can be assessed.

The purpose of this review was to examine a remarkable technical advance regarding the indications for and the technique of endoscopic resection of early gastric cancer. Endoscopic mucosal resection (EMR) of early gastric cancer with no risk of lymph node metastasis has been a standard technique in Japan, probably owing to the high incidence of gastric cancer in Japan and the fact that more than half of Japanese gastric cancer cases are diagnosed at an early stage. Very recently, several EMR techniques have become increasingly accepted and regularly used in Western countries. Although these minimally invasive techniques are safe, convenient, and efficacious, they are unsuitable for large lesions in particular. Difficulty in correctly assessing the depth of tumor invasion and an increase in local recurrence when standard EMR procedures are used have been reported in cases of large lesions, because such lesions are often resected piecemeal owing to the technical limitations of standard EMR. A new development in therapeutic endoscopy, called endoscopic submucosal dissection (ESD), allows the direct dissection of the submucosa, and large lesions can be resected en bloc. ESD is not limited by resection size and is expected to replace surgical resection. However, it is still associated with a higher incidence of complications than standard EMR procedures and requires a high level of endoscopic skill. The endoscopic indications, techniques, and management of complications of ESD for early gastric cancer for properly carrying out established therapeutic endoscopy are described.

Majority of the gastric cancers in the world occurred in Asia, especially in Japan and Korea. The prevalence of early gastric cancer (EGC) is up to 60 % of all gastric cancers detected in these two countries, where their governments have adopted a screening program for gastric cancer. Pioneered by Japanese endoscopists, endoscopic submucosal dissection (ESD) has become the current standard of treatment for early gastric cancer. Prospective large-scale clinical studies with 500–1,000 cases showed that the average operative time of ESD ranged from 60 to 80 min, with en bloc resection rate of more than 90 %. Three retrospective cohort studies comparing conventional endoscopic mucosal resection (EMR) against ESD for treatment of early gastric cancer showed that ESD achieved a higher en bloc resection rate and lower local recurrence rate compared with EMR. Although ESD is highly effective for treatment of intramucosal gastric cancer, those with high risk of nodal metastasis cannot be adequately cured by endoscopic resection alone. Japanese Gastric Cancer Association has developed guidelines for treatment of gastric cancer. In the past, only early differentiated intramucosal gastric cancer with size of less than 20 mm was indicated for endoscopic treatment. Gotoda et al. reviewed the histopathology of 5,625 patients with EGC who underwent radical gastrectomy and lymph node dissection. The study confirmed that none of 1,230 differentiated carcinomas less than 30 mm had nodal metastasis, and no nodal metastasis was found in 929 of these without ulceration regardless of tumor size. For tumors of SM1 invasion and less than 30 mm in size, none was shown to have nodal metastasis. Shimada et al. reviewed 1,051 patients with EGC who underwent radical gastrectomy, and the nodal metastasis rate for intramucosal tumors was 2.3 %. For those with submucosal invasion, there was a significant rate of nodal metastasis of 19.8 %. The recommended indication for endoscopic resection of EGC was expanded, especially when techniques of ESD became available. Submucosal infiltration by gastric cancer has been a known risk factor to nodal metastasis. Ahn et al. compared the outcomes of early gastric cancer in 1,370 patients who received endoscopic resection under both absolute indication and expanded indication. Among these, 119 patients had superficial submucosal invasive gastric cancer with a size of less than 30 mm treated by endoscopic resection. These cases would be considered as curative in the expanded criteria. However, 34 patients subsequently received surgery and 1 patient who had no residue cancer in the stomach was found to have a metastatic perigastric lymph node. Therefore, even with the expanded criteria for endoscopic resection, caution should be exercised in choosing the appropriate treatments for superficial submucosal early gastric cancer. In this issue, Eom et al. examined the optimal submucosal invasive of early gastric cancer suitable for endoscopic resection in 1,322 patients who received radical gastrectomy. Among the 1,322 patients who received curative gastrectomy with standard nodal dissection for submucosal gastric cancer, 18.8 % was found to have a positive lymph node. This study showed that a cutoff point of 300 lm of submucosal infiltration achieved the highest negative predictive value of 98 % for predicting lymph node metastasis. The authors proposed for large-scale study to validate the cutoff value. Son et al. examined the risk factors for lymph node metastasis in early gastric cancers treated by endoscopic resection. The important risk factors for nodal metastasis included submucosal invasion, Society of Surgical Oncology 2015

The purpose of this review is to examine recent advances in the techniques and technologies of endoscopic resection of early gastric cancer (EGC). Endoscopic mucosal resection (EMR) of EGC, with negligible risk of lymph node metastasis, is a standard technique in Japan and is increasingly becoming accepted and regularly used in Western countries. EMR is a minimally invasive technique which is safe, convenient, and efficacious; however, it is insufficient when treating larger lesions. The evidence suggests that difficulties with the correct assessment of depth of tumor invasion lead to an increase in local recurrence with standard EMR when lesions are larger than 15 mm. A major factor contributing to this increase in local recurrence relates to lesions being excised piecemeal due to the technical limitations of standard EMR. A new development in endoscopic techniques is to dissect directly along the submucosal layer -- a procedure called endoscopic submucosal dissection (ESD). This allows the en-bloc resection of larger lesions. ESD is not necessarily limited by lesion size and it is predicted to replace conventional surgery in dealing with certain stages of ECG. However, it still has a higher complication rate when compared to standard EMR, and it requires high levels of endoscopic skill and experience. Endoscopic techniques, indications, pathological assessment, and methods of endoscopic resection of EGC need to be established for carrying out appropriate treatment and for the collation of long-term outcome data.

Background/Aims: The impact of Helicobacter pylori (H. pylori) eradication after endoscopic resection (ER) of early gastric cancer (EGC) has not been fully evaluated. We tried to find out the effect of H. pylori eradication therapy on the development of metachronous gastric cancers and changes in Cyclooxygenase-2 (COX-2) expression following attempts to eradicate H. pylori after ER of EGC. Materials and Methods: We eradicated H. pylori in the patients with EGC after ER. Biopsy samples were taken according to the follow-up schedules for surveillance after ER. Results: Fifty five patients were enrolled and finished the follow up schedules. Of the 55, 28 were successfully treated H. pylori infection, and the other 27 were failed eradication of H. pylori. The mean follow-up period was 60.8 months. Five in the H. pylori ongoing infection group developed metachronous gastric cancer, whereas no new gastric cancers were found in the 28 eradication group (P=0.023). COX-2 expression in the eradication group was significantly decreased (1.4±0.2, n=28), compared to that in H. pylori ongoing infection group (3.0±0.4, n=27, P=0.0001) after the follow-up. Conclusions: The eradication of H. pylori seems to have a preventative effect on the development of metachronous adenocarcinomas and a suppressive effect on COX-2 expression in the patients after ER for EGC. (Korean J Helicobacter Upper Gastrointest Res 2011;11:117-123)