Candidates For Endoscopic Submucosal Dissection Research Articles

Risk factors of postoperative stricture after endoscopic submucosal dissection for superficial esophageal neoplasms: A meta-analysis.

Background:As larger-sized superficial esophageal neoplasms became candidates for endoscopic submucosal dissection (ESD), post-ESD esophageal stricture has inevitably developed into a significant complication during long-term follow-up.Method:The PubMed, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Web of Science, as well as China National Knowledge Infrastructure, the Wanfang Database, and the Chinese Biomedical Literature Database, were searched to identify all the appropriate studies published from January 2000 through October 2019. For risk factor assessment between postoperative stricture and control groups, pooled odds ratios (OR) and weighted mean differences (WMD) estimation was done. All meta-analytical procedures were conducted by using Stata version 15.1 software.Results:The results showed that 11 studies with 2248 patients (284 structure cases and 1964 controls) were eligible for this meta-analysis. Statistical results indicated 6 substantial risk factors: lesion characteristics involving the upper third of the esophagus (OR 1.51, [1.02–2.25]), macroscopic type of IIa/IIc (OR 2.76, [1.55–4.92]), tumor depth of invasion above m1 (OR 7.47, [3.31–16.86]), and m2 (OR 12.67, [4.00–40.10]), longitudinal length (WMD 13.75 mm, [7.76–19.74]), circumferential diameter (WMD 10.87 mm, [8.13–13.60]), and circumferential range >3/4 (OR 38.17, [9.94–146.52]). Each additional 10% of the circumferential range increased the risk of stricture by 149% (OR 9282.46, [978.14–88089.35]).Conclusions:Six risk factors were assessed to have a key role in the elevated risk levels of post-ESD esophageal stricture. The results can help doctors identify patients with increased risk and thus can guide management of the adequate period of surveillance after ESD and take available approaches of stricture prevention.

Clinical impact of Epstein-Barr virus status on the incidence of lymph node metastasis in early gastric cancer.

Epstein-Barr virus-positive gastric cancer (EBVGC) comprises approximately 9% of all gastric cancers and is associated with a low prevalence of lymph node metastasis (LNM). Given that limited data concerning LNM in EBV-related early GC are available, EBV status is not considered an indicator for endoscopic submucosal dissection (ESD). In this review, we focused on pT1 EBVGC and on gastric carcinoma with lymphoid stroma (GCLS), and discuss expanded ESD indications and curative resection criteria. In pT1b EBVGC, the incidence of LNM was low (6/180 patients, 3.3%; 95% confidence interval [CI] 1.2-7.1), especially in lymphovascular invasion-negative EBVGC (1/109 patients, 0.9%). No patients with pT1a EBVGC had LNM (0/38 patients, 0%; 95% CI 0-7.6), even those who did not meet the current curative ESD criteria. Although the frequency of LNM in GCLS was low (5.0-10.6%), the incidence of LNM in non-EBV GCLS was relatively high (10.0-20.0%); therefore, EBV status can be considered a more important factor than GCLS. In summary, the clinicopathological characteristics of EBVGC differ from those of conventional GC, and EBV negativity is a risk factor for LNM in early GC. Therefore, patients in this group are likely to be promising candidates for ESD, and we recommend that EBV status evaluation be included in early GC treatment guidelines.

Is It Reasonable to Treat Early Gastric Cancer with Mucosal Infiltration and Well Differentiation by Endoscopic Submucosal Resection?

BackgroundWhile limited endoscopic submucosal dissection (ESD) is increasingly applied in the treatment of early gastric cancer, preoperative prediction of lymph node metastasis is very critical for determining treatment strategies preoperatively. Thus, the aim of this study was to accurately assess the prevalence and pattern of lymph node metastasis in early gastric cancer patients and to identify the best candidates for ESD. MethodsFrom September 2008 to December 2013, a total of 539 patients with early gastric cancer were retrospectively analyzed in the present study. Of them, 503 patients underwent radical gastrectomy and 36 patients underwent ESD. The clinicopathological features were collected and correlations with lymph node metastasis were analyzed. The survival rates of patients were also analyzed. ResultsLymph node metastasis was observed in 80 of 503 patients (15.9 %). Among these, the rate for mucosal cancer was 8.3 %, and 20.1 % for submucosal cancer. By univariate analysis, risk factors for lymph node metastasis were growth pattern, tumor size, pathological type, depth of invasion, lymphatic-vascular invasion, and neural invasion. By multivariate analysis, risk factors for lymph node metastasis were tumor size, pathological type, depth of invasion, and lymphatic-vascular invasion. The incidence of lymph node metastasis was 0 % in the well-differentiated mucosal cancers, irrespective of tumor size. For the well-differentiated mucosal cancers, the overall survival rates were comparable between patients underwent gastrectomy with lymph node dissection and patients underwent ESD (100 vs 100 %). ConclusionsThe most important factors for predicting lymph node metastasis in early gastric cancer are tumor size, pathological type, depth of invasion, and lymphatic-vascular invasion. Well-differentiated mucosal gastric cancers could be candidates for ESD.

Endoscopic submucosal dissection in early gastric cancer in elderly patients and comorbid conditions

The prognosis of early gastric cancer (EGC) is good if there is no concomitant lymph node metastasis. Therefore, the early detection of EGC is important to improve the prognosis of patients with gastric cancer. In Japan, 40% to 50% of all gastric cancers are EGC, and endoscopic submucosal dissection (ESD) is widely accepted as a local treatment for these lesions, particularly for large lesions that at one time were an indication for gastrectomy because of the difficulty of en-bloc resection. Consequently, this procedure can preserve the entire stomach and the patient's postoperative quality of life. ESD has become a general technique with improved procedures and devices, and has become the preferred treatment for EGC rather than gastrectomy. Therefore, ESD may demonstrate many advantages in patients who have several comorbidities, particularly elderly population, patients taking antithrombotic agents, or patients with chronic kidney disease, or liver cirrhosis. However, it is not yet clear whether patients with both EGC and comorbidities are feasible candidates for ESD and whether they would consequently be able to achieve a survival benefit after ESD. In this review, we discuss the clinical problems of ESD in patients with EGC and those comorbid conditions.

Outcomes of ESD for patients with early gastric cancer and comorbid liver cirrhosis: a propensity score analysis.

Gastric cancer and liver cirrhosis (LC) are often comorbid. However, little is known about the clinical outcomes of gastric endoscopic submucosal dissection (ESD) in patients with comorbid LC. This case-control study used a multicentre retrospective cohort. We identified 69 LC patients from the cohort of patients with early gastric cancer, who underwent gastric ESD at 12 hospitals from March 2003 to November 2010. Using the propensity score matching method, 69 patients without LC were used to compare the short- and long-term outcomes of ESD. Among the 69 LC patients, 53 (77 %) were Child-Pugh grade A (CP-A) and 16 (28 %) had past or present histories of hepatocellular carcinoma (HCC). Short-term outcomes did not differ between the LC patients and controls or between the CP-A and CP-B/C patients. Although the LC patients had significantly worse long-term outcomes than the controls (the 5-year overall survival rates were 60 vs. 91 %, respectively), patients with CP-A liver function without HCC histories had an overall survival almost equivalent to that of patients without LC (controls). LC patients appear to be good candidates for ESD if they have CP-A liver function and no history of HCC. Although their short-term outcomes were not inferior, the patients with Child-Pugh grades B/C or with histories of HCC benefited less from ESD.

THE HEALING PROCESS OF GASTRIC ARTIFICIAL ULCERS AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION

Background: Due to the remarkable progress of endoscopic resection techniques, endoscopic submucosal dissection (ESD) has been widely performed for larger mucosal tumors that would result in large artificial ulcers. The healing process of peptic ulcers has been previously studied in detail; however, no precise investigation for artificial ulcers after ESD has been reported. To confirm the validity of the treatment from the aspect of wound healing, we aimed to clarify the healing process of large gastric artificial ulcers after ESD. Methods: Seventy patients with gastric mucosal tumors treated by ESD were enrolled. The size, location and time of scar formation of the ulcers were reviewed using endoscopic pictures taken from the same view and angle. Follow-up endoscopy was performed at 1, 4, 8 and 12 weeks after ESD. For postoperative medication, all patients received normal doses of proton pump inhibitors and sucralfate for 8 weeks. Results: The average size of the resected specimen was 34.7 mm (20–90 mm). Irrespective of ulcer size and location, all of the cases healed up to scarring stages within 8 weeks. Conclusions: Gastric artificial ulcers after ESD healed within 8 weeks regardless of size and location using normal doses of medication as peptic ulcers. The fact that even giant ulcers after ESD heal within 8 weeks could be helpful information for candidates for ESD and for postoperative management of patients after ESD.

Retrospective study of technical aspects and complications of endoscopic submucosal dissection for laterally spreading tumors of the colorectum

Laterally spreading tumors - non granular type (LST-NG) are more often considered candidates for endoscopic submucosal dissection (ESD) than laterally spreading tumors - granular type (LST-G), because of their higher potential for submucosal invasion. However, ESD for LST-NG can be technically difficult. The aim of our study was to compare our ESD results for LST-NG and for LST-G. Ninety-nine LST-NG and 169 LST-G measuring 20 mm in size or more were removed by ESD. We retrospectively evaluated the clinicopathological features of the tumors and treatment results (en bloc resection rate, procedure time and speed, rate of use of ancillary devices, and complication and recurrence rates). Histopathology revealed that there were more submucosally invasive lesions in the LST-NG than in the LST-G group (28 % vs. 9 %; P < 0.0001). The en bloc resection rate, en bloc R0 resection rate, and en bloc curative resection rate of LST-NG were similar to those of LST-G (LST-NG: 99 %, 98 %, and 88 %; LST-G: 99 %, 98 %, and 91 %). In LST-NG, the median procedure time tended to be longer (LST-NG: 69 min; LST-G: 60 min) and the median procedure speed was slower (LST-NG: 0.15 cm (2)/min; LST-G: 0.25 cm (2)/min; P < 0.0001). Use of ancillary devices was higher for LST-NG (38 % vs. 15 % for LST-G; P < 0.0001), as was the perforation rate (5.1 % vs. 0.6 % for LST-G; P = 0.027). No recurrence was seen in either group. ESD was an effective treatment method for both LST-NG and LST-G. However, the degree of technical difficulty appears higher for LST-NG than for LST-G lesions, as shown by the lower dissection speed and higher perforation rate. ESD for LST-NG should probably be performed by those with significant experience of colorectal ESD.

Indications, techniques, and outcomes of endoscopic submucosal dissection for esophageal squamous cell carcinoma

Endoscopic submucosal dissection (ESD) has gradually gained acceptance as one of the standard treatments for esophageal squamous cell carcinoma in Japan. Principal indications are little likelihood of nodal metastasis and having technical resectability. All lesions with preoperative diagnosis of high-grade intraepithelial neoplasms, including carcinomas in situ (T1a-EP), carcinomas invading the lamina propria (T1a-LPM), and some with preoperative diagnosis of carcinomas invading the muscularis mucosa (T1a-MM) and minute submucosal invasion (T1b-SM1), may become candidates for ESD, considering the substantial risks and benefits to be obtained. ESD as a staging measure to obtain histological confirmation of invasion depth and lymphovascular infiltration may be acceptable because preoperative prediction is difficult in some cases. In terms of technique, advantages of ESD in comparison with other endoscopic treatment are controllability in size and shape, and that even large and fibrotic neoplasms can be resected. Disadvantages may be longer procedure time, heavier bleeding, and greater possibility of perforation. However, with refinement of the technique, new devices, and the learning curve, acceptable technical safety has been achieved. Our experience with 104 consecutive cases shows favorable outcomes, although further innovation may be necessary. We are convinced that ESD will become a standard treatment for early-stage esophageal squamous cell carcinoma not only in Japan but also all over the world in the near future.

The Prediction of Nodal Metastasis By Computed Tomography in Candidates for Endoscopic Submucosal Dissection (ESD) of Early Gastric Cancer (EGC)

Background/Aims: Nodal metastasis is one of important prognostic factor of EGC. Prediction of nodal metastasis is mandatory for performing ESD of EGC. The aim of this study is to evaluate the accuracy of CT imaging for nodal metastasis in patients planning to receive ESD. Patients/Methods: From Oct. 2003 to Mar 2008, 30 patients had surgery after ESD for high probability of nodal metastasis and 44 patients received ESD had nodal enlargement by CT without surgery were investigated. Nodal metastasis was evaluated of sensitivity, specificity, positive predictive value(PPV) and negative predictive value (NPV) by CT imaging.

Endoscopic submucosal dissection for colorectal neoplasms

Although endoscopic submucosal dissection (ESD) gains acceptance as one of the standard treatments for esophageal and stomach neoplasms in Japan, it is still in the developing stage for colorectal neoplasms. In terms of indications, little likelihood of nodal metastasis and technical resectability are principally considered. Some of intramucosal neoplasms, carcinomas with minute submucosal invasion, and carcinoid tumors, which are technically unresectable by conventional endoscopic treatments, may become good candidates for ESD, considering substantial risks and obtained benefits. ESD as a staging measure to obtain histological information of the invasion depth and lymphovascular infiltration is acceptable because preoperative prediction is difficult in some cases. In terms of techniques, advantages of ESD in comparison with other endoscopic treatments are to be controllable in size and shape, and to be resectable even in large and fibrotic neoplasms. The disadvantages may be longer procedure time, heavier bleeding, and higher possibility of perforation. However, owing to refinement of the techniques, invention of devices, and the learning curve, acceptable technical safety has been achieved. Colorectal ESD is very promising and become one of the standard treatments for colorectal neoplasms in the near future.

THE HEALING PROCESS OF GASTRIC ARTIFICIAL ULCERS AFTER ENDOSCOPIC SUBMUCOSAL DISSECTION

Background: Due to the remarkable progress of endoscopic resection techniques, endoscopic submucosal dissection (ESD) has been widely performed for larger mucosal tumors that would result in large artificial ulcers. The healing process of peptic ulcers has been previously studied in detail; however, no precise investigation for artificial ulcers after ESD has been reported. To confirm the validity of the treatment from the aspect of wound healing, we aimed to clarify the healing process of large gastric artificial ulcers after ESD.Methods: Seventy patients with gastric mucosal tumors treated by ESD were enrolled. The size, location and time of scar formation of the ulcers were reviewed using endoscopic pictures taken from the same view and angle. Follow‐up endoscopy was performed at 1, 4, 8 and 12 weeks after ESD. For postoperative medication, all patients received normal doses of proton pump inhibitors and sucralfate for 8 weeks.Results: The average size of the resected specimen was 34.7 mm (20–90 mm). Irrespective of ulcer size and location, all of the cases healed up to scarring stages within 8 weeks.Conclusions: Gastric artificial ulcers after ESD healed within 8 weeks regardless of size and location using normal doses of medication as peptic ulcers. The fact that even giant ulcers after ESD heal within 8 weeks could be helpful information for candidates for ESD and for postoperative management of patients after ESD.