Complications Of Endoscopic Submucosal Dissection Research Articles

Factors influencing development of non-cardiac chest pain after endoscopic submucosal dissection for esophageal neoplasms: a retrospective case-control study of 309 patients from a single center.

Endoscopic submucosal dissection (ESD) is widely used for early stage esophageal cancer and precancerous lesions. Non-cardiac chest pain (NCCP) is a frequent complication of ESD. However, little is known about its incidence and associated factors. This study investigated the pain incidence and predictive factors for pain development after ESD for esophageal neoplasms. We enrolled a total of 309 patients with esophageal neoplasms, who underwent ESD in our center from January 2018 to June 2019. Sociodemographic and clinicopathological information for all patients was collected, and patients were divided into either a pain-free group (n = 156) or a pain group (n = 153) according to whether there was onset of NCCP 24-48hours after surgery. We made comparisons between groups using Student's t test or the χ2 test. Logistic-regression analysis was used to screen for risk factors. There were statistically significant differences in histories of previous surgery (P = 0.039), lesion size (P = 0.026), operation time (P = 0.009), and postoperative fever (P = 0.001). History of previous surgery (P = 0.043) and postoperative fever (P = 0.007) were independent risk factors for chest pain after esophageal ESD treatment. Chest pain and fever prolonged postoperative hospitalization time (P = 0.005, P = 0.001) and increased hospitalization cost (P = 0.034, P < 0.001). A history of previous surgery and postoperative fever was associated with the occurrence of NCCP after ESD in patients with esophageal neoplasms. NCCP and fever after esophageal ESD increased both hospitalization time and cost.

Endoscopic Submucosal Dissection for Superficial Barrett's Neoplasia in Korea: a Single-Center Experience.

PurposeWhile the incidence of Barrett’s neoplasia has been increasing in Western countries, the disease remains rare in Asian countries. Therefore, very few studies have investigated the endoscopic treatment for Barrett’s neoplasia in Korea. Endoscopic submucosal dissection (ESD) enables en bloc and complete resection of gastrointestinal neoplastic lesions. This study aimed to evaluate the therapeutic outcomes of ESD for Barrett’s neoplasia in a single center in Korea and to examine the predictive factors for incomplete resection.Materials and MethodsWe conducted a retrospective observational study of 18 patients who underwent ESD for superficial Barrett’s neoplasia (dysplasia and early cancer) between January 2010 and December 2019 at Pusan National University Hospital. The therapeutic outcomes of ESD and procedure-related complications were analyzed.ResultsEn bloc resection, complete resection, and curative resection were performed in 94%, 72%, and 61% of patients, respectively. Histopathology (submucosal or deeper invasion of the tumor) was a significant predictive factor for incomplete resection (P=0.047). Procedure-related bleeding and stenosis were not observed, whereas perforation occurred in one case. During the median follow-up period of 12 months (range, 6–74 months), local recurrence occurred in 2 patients with incomplete resection, one patient underwent repeat ESD, and the other patient received concurrent chemoradiotherapy. The 3-year overall and disease-specific survival rates were 73% and 93%, respectively.ConclusionsESD seems to be an effective and safe treatment for superficial Barrett’s neoplasia in Korea. Nevertheless, the suitability of ESD for Barrett’s cancer cases should be determined considering the high risk of deep submucosal invasion.

Impact of BMI on Complications of Gastric Endoscopic Submucosal Dissection

Background: Gastric endoscopic submucosal dissection (ESD) has a high rate of complications. However, it is unclear whether BMI affects ESD complications. We aimed to investigate the impact of BMI on ESD complications. Methods: A total of 7,263 patients who underwent gastric ESD were classified into 3 groups according to the Asia-Pacific classification of BMI: normal (BMI <23 kg/m², n = 2,466), overweight (BMI 23–24.9 kg/m², n = 2,117), and obese (BMI ≥25 kg/m², n = 2,680). Adjusted logistic regression analyses were conducted to assess the association between BMI and ESD complications. Results: Compared to the normal group, a lower incidence of perforation and a higher incidence of pneumonia and leukocytosis were found in the overweight and obese groups, and intra-ESD desaturation and hypertension were more frequent in the obese group. After adjustment for confounders, the risk of perforation significantly decreased in the overweight (odds ratio [OR] = 0.24, 95% confidence interval [CI]: 0.17–0.33) and obese (OR = 0.12, 95% CI: 0.08–0.18) groups compared to that in the normal group. Meanwhile, the risk of pneumonia significantly increased in the overweight (OR = 11.04, 95% CI: 6.31–19.31) and obese (OR = 10.71, 95% CI: 6.14–18.66) groups compared to the normal group. During sedation, the obese group had a significantly increased risk of desaturation (OR = 2.81, 95% CI: 1.18–6.69) and hypertension (OR = 1.35, 95% CI: 1.11–1.63) compared to the normal group. Conclusions: High BMI was significantly associated with ESD complications. More caution is needed in cases of obese patients undergoing ESD.

S3577 A Case of Early Adenocarcinoma of Gastric Cardia

INTRODUCTION: Gastric cancer can be classified as cardia and non-cardia subtypes according to the anatomic site. One of the main etiological factors involved in the development of both cardia cancers and Esophageal adenocarcinomas (EACs) is central obesity. We discuss a case of a patient who presented with hematochezia and was diagnosed with gastric cardia adenocarcinoma. CASE DESCRIPTION/METHODS: A 60 year-old obese African American male was admitted for hematochezia and loose stools. The patient started having the symptoms 3 days before presentation after eating at a restaurant. His symptoms resolved a day after the admission. Review of symptoms was positive for acid reflux. Family and surgical history were insignificant. He drank socially and had 30 pack-year smoking history. He denied taking any medications for acid reflux and any endoscopic intervention in the past. His vitals were acceptable and physical examination including digital rectal exam was unremarkable. Hemoglobin was 13 and the rest of the blood tests, stool studies were within normal limits. Due to a history of acid reflux and hematochezia, the patient underwent endoscopic intervention. Diverticulosis was noted on colonoscopy. A 8mm nodule was noted in the cardia and biopsy was suggestive of focal high-grade dysplasia. The patient underwent EUS and Endoscopic-submucosal dissection (ESD). Histopathological findings were suggestive of early, well-differentiated, intramucosal adenocarcinoma, with extensive high-grade dysplasia. Immunostains were suggestive of infiltrating single or small groups of tumor cells (AE1, AE3); negative for vascular (CD31), lymphatic (D240), or submucosal invasion (desmin). DISCUSSION: Gastric cardia cancer may develop in patients with chronic GERD without H. pylori infection. High volume reflux content including bile acids play a major role in carcinogenesis. Our patient was a chronic smoker and never sought treatment for acid reflux. In addition to imaging studies, EUS is used for locoregional staging. ESD should be carefully considered after comprehensive pretreatment workup and staging. The common complications of ESD are pain, bleeding, and perforation. Bleeding is the most common complication. Stricture formation is common if ESD is performed at cardia as in our case. The incidence of cardia cancers and esophageal adenocarcinoma (EAC) continues to increase with chronic GERD and obesity being a common risk factor. Early endoscopic intervention can be diagnostic and curative.Figure 1Figure 2Figure 3.: Post-Endoscopic submucosal dissection.

Carotid blowout—a rare but fatal complication of endoscopic submucosal dissection of superficial hypopharyngeal carcinoma after radiotherapy

Endoscopic submucosal dissection (ESD) has gained wide acceptance as a minimally invasive and curative surgery for superficial head and neck carcinoma. However, the safety of ESD for superficial pharyngeal carcinoma after radiotherapy has not been elucidated. Superficial hypopharyngeal carcinoma of the left pyriform sinus developed in a 76-year-old man who had undergone concurrent chemoradiotherapy for T2N2bM0 pyriform sinus carcinoma on the opposite side 12 months before. He underwent ESD without complications. Because tumor invasion into the muscular layer was a concern, the muscular layer was partially resected with the tumor. Twelve days after discharge, he presented with a sore throat and difficulty in swallowing. Endoscopy and computed tomography revealed necrosis due to wound infection with abscess formation around the left carotid artery. The common carotid artery subsequently ruptured. Although the surgical intervention was performed, he passed away 46 days after ESD due to carotid blowout. ESD is a minimally invasive treatment for superficial head and neck carcinoma, but carotid blowout can occur in cases after radiation. Prior radiotherapy and deeper dissection into the muscular layer may hamper wound epithelization, resulting in infection-induced necrosis and carotid blowout. Diligent monitoring of wound healing is essential in patients who have previously undergone irradiation.

Predictors for Submucosal Fibrosis in Patients With Superficial Squamous Esophageal Neoplasia Undergoing Endoscopic Submucosal Dissection.

INTRODUCTION:Submucosal fibrosis greatly hinders the success of endoscopic submucosal dissection (ESD). This study determined ESD outcomes in patients with esophageal submucosal fibrosis and further explored the predictors.METHODS:We retrospectively analyzed 163 patients with superficial squamous esophageal neoplasia. The degree of submucosal fibrosis was classified as follows: F0, none; F1, mild; and F2, severe. ESD outcomes as a function of the degree of submucosal fibrosis and biopsy were determined. The potential predictors of submucosal fibrosis were analyzed.RESULTS:En bloc resection, R0 resection, and procedure time were significantly different between the F0-F2 groups (P = 0.009, P = 0.002, and P < 0.001, respectively). Perforation and immediate bleeding rates of F2 were significantly higher than the F0/F1 groups (P < 0.001 and P < 0.001, respectively). However, the nonbiopsy group vs the biopsy group and the delayed ESD group (postbiopsy >21 days) vs the early ESD group (postbiopsy ≤21 days) showed no statistical differences regarding the en bloc resection, R0 resection, and ESD complications (all P > 0.05). Further analysis indicated that it was not the biopsy history and delayed ESD (both P > 0.05), rather submucosal invasion vs intramucosal tumor (odds ratio = 4.534, P = 0.003) and current smoker vs nonsmoker (odds ratio = 2.145, P = 0.043) were independent risk factors for endoscopic submucosal fibrosis.DISCUSSION:Esophageal submucosal fibrosis was shown to be closely related to unsatisfactory ESD outcomes. Biopsy history and delayed ESD had no adverse effect on submucosal fibrosis and ESD outcomes. Submucosal invasion and current cigarette smoking were predictors of submucosal fibrosis.

Outcomes of Endoscopic Submucosal Dissection for Subepithelial Lesions Localized Within the Submucosa, Including Neuroendocrine Tumors: A Multicenter Prospective Study.

Endoscopic submucosal dissection (ESD) seems to be a reasonable option for gastrointestinal subepithelial lesions (SELs) localized within the submucosa. Indications for ESD include small neuroendocrine tumors (NETs) and indeterminate SELs. However, the prospective data regarding ESD and surveillance remain unclear. This study was performed to prospectively investigate the outcomes of ESD, including organ-specific outcomes and the mid-term prognosis. This prospective multicenter study included 57 patients who underwent ESD for SELs localized within the submucosa [definite NETs (n = 42) and indeterminate SELs (n = 15)]. The efficacy and safety of ESD were evaluated in the whole cohort and in subgroups (NETs and indeterminate SELs). All patients were followed up. The rates of en bloc resection, curative resection, and complications were 98.2%, 66.7%, and 7.7% for the overall population (n=57); 100%, 61.9%, and 2.4% for NETs (n=42); and 93.3%, 80.0%, and 20.0% for indeterminate SELs (n=15), respectively. The rates of curative resection for NETs were poorer in the stomach (20%, n=5) and duodenum (33%, n=3) than in the rectum (71%, n=34). Including 11 of 16 patients with NETs who underwent a conservative approach resulting in non-curative resection, no patients developed tumor recurrence during the follow-up period (median, 24.5 months; range, 1-60 months). ESD followed by surveillance demonstrated acceptable mid-term outcomes for non-curative NETs. ESD can be an efficient therapy for SELs localized within the submucosa. However, gastric and duodenal ESD for NETs may be limited in terms of its curative and technical aspects. Clinicians should be aware of the potential complications of ESD for indeterminate SELs.

870 The Efficacy and Safety of Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients With Cirrhosis: A Systematic Review and Meta-Analysis

INTRODUCTION: Cirrhosis is known to increase the risk of bleeding and mortality from procedures. Endoscopic submucosal dissection (ESD) is an approved minimally invasive treatment of early gastric neoplasm. The safety and complications of ESD in cirrhotics in this setting has not been mentioned in the guidelines. We aimed to address it in this meta-analysis. METHODS: We searched the databases of MEDLINE, EMBASE, and CENTRAL from inception to May 2019. A manual review of included studies and references were performed. The inclusion criteria were published studies comparing the efficacy and safety of ESD for gastric cancer in cirrhosis and non-cirrhotics. The outcomes were En bloc resection, R0 resection, post-ESD bleeding, perforation, and mortality rate. Data from each study were combined using the random-effects, generic inverse variance method of DerSimonian and Laird to calculate pooled risk ratio (RR) and 95% confidence intervals (CI). RESULTS: Of 14 included observational studies, four included compensated cirrhosis patients and ten did not mention cirrhosis status. Major etiologies of cirrhosis were hepatitis B infection (49%). Mean platelet counts in compensated cirrhotics was 113000/uL. Cirrhotics have higher risk of post-ESD bleeding compared to others with pooled RR (95% CI) of 1.43 (1.02-2.00, I 2 = 0%) (Figure 1). In subgroup analysis of compensated cirrhosis, the bleeding risk is not different between the groups, pooled RR (95% CI) of 1.22 (0.70-2.12, I 2 = 0%) (Figure 2). The data of decompensated cirrhosis is not available. On the contrary, perforation risk is comparable between the groups with pooled RR (95% CI) of 2.08 (0.51-8.43, I 2 = 0%). ESD procedure time is not different between two groups. We found that the efficacies, En bloc and R0 resection, are not different between cirrhosis and non-cirrhosis with pooled RR (95% CI) of 1.01 (0.97-1.04, I 2 = 12.1%) and 0.98 (0.92-1.04, I 2 = 0%), respectively. The procedure related mortality rate in both cirrhosis and non-cirrhosis patients are 0%. CONCLUSION: Post-ESD bleeding in cirrhosis is a concerning complication as expected in early gastric cancer; but the risk of bleeding in compensated cirrhosis is similar to non-cirrhotics. Perforation and mortality are not different compared to controls. In terms of efficacy, no differences are found between patients with and without cirrhosis. Further studies on subgroup analysis of decompensated cirrhosis are warranted.

Clinicopathological characteristics of patients with pain after endoscopic submucosal dissection for gastric epithelial neoplasm.

Endoscopic submucosal dissection (ESD) is widely used for large superficial gastrointestinal tumors. Epigastric pain is a frequent complication of ESD. However, little is known about its incidence and associated factors. This study evaluated pain incidence and characteristics of patients with pain after gastric ESD. We retrospectively analyzed a prospectively collected registry of clinical, endoscopic, and pathologic results of patients who underwent ESD for gastric adenoma or cancer from January 2010 to December 2015. A Visual Analogue Scale (VAS) was used to assess pain immediately after, and 2, 12, and 24h after ESD. The primary outcome was the use of painkillers (VAS score > 4). Analyzed data included age, sex, pathology, specimen and tumor size, procedure time, and tumor location. Of 1226 patients, 461 (36.4%) needed a painkiller at least once after ESD (pain group). Compared with the no pain group, the pain group had more females, less alcohol consumption, larger tumor and specimen size, and more antral lesions. In multivariate analysis, female sex (OR 1.559, 95% CI 1.217-1.996, p < 0.001), antral tumor location (OR 1.780, 95% CI 1.398-2.265, p < 0.001), and procedure time over 30min (OR 1.443, 95% CI 1.130-1.842, p = 0.003) were predictive factors for pain. This study showed that a considerable number of patients needed one or more painkiller doses after gastric ESD. The factors affecting pain included sex, procedure time, and lesion location. Endoscopists should use preemptive or aggressive pain management in high-risk patients after ESD.

Prophylactic clip closure may reduce the risk of delayed bleeding after colorectal endoscopic submucosal dissection.

Background and study aims Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large superficial colorectal tumors, but delayed bleeding remains one of the most common complications of colorectal ESD. The aim of the present study was to evaluate the clinical efficacy of prophylactic clip closure of mucosal defects for the prevention of delayed bleeding after colorectal ESD. Patients and methods We enrolled consecutive patients with colorectal lesions between January 2012 and May 2017 in this retrospective study. In the early part of this period, post-ESD mucosal defects were not closed (non-closure group); however, from January 2014, post-ESD mucosal defects were prophylactically closed with clips when possible (closure group). The main outcome measured was delayed bleeding. Variables were analyzed using the chi-squared test, Fisher’s exact test, or Student’s t-test. Results Of 156 lesions analyzed, 61 were in the non-closure group and 95 in the closure group. Overall, delayed bleeding occurred in 5 cases (3.2 %). The delayed bleeding rate was 0 % (0/95) in the closure group and 8.2 % (5/61) in the non-closure group ( P = 0.008). The mean procedure time for closure was 10.4 ± 4.6 min (range 3 – 26 min). Conclusions We demonstrated that prophylactic clip closure of mucosal defects might reduce the risk of delayed bleeding after colorectal ESD.

Perforation and Postoperative Bleeding Associated with Endoscopic Submucosal Dissection in Colorectal Tumors: An Analysis of 398 Lesions Treated in Saga, Japan.

Objective The aim of this study was to clarify the safety of colorectal endoscopic submucosal dissection (ESD) during the era of health insurance coverage starting from April 2012 in Japan. Methods Between April 2012 and May 2016, ESD was applied to 398 lesions in 373 patients. Risk factors for serious complications of colorectal ESD, perforation and post-ESD bleeding, were evaluated focusing on the resected specimen size, location, growth pattern, invasion depth, histopathology, postoperative clipping, and procedure time. In addition, the relationship between serious complications and patients' background characteristics was analyzed. Results Among 373 patients, perforation occurred in 12 patients and post-ESD bleeding in 19 patients. A univariate analysis showed that the risk factors for perforation were the lesion size, the resected specimen size, and a long operation time. A multivariate analysis showed that a long operation time was a risk factor for perforation during colorectal ESD. A univariate analysis indicated that significant risk factors for postoperative bleeding were a long operation time, rectal lesion, and cancer. All patients with serious complications were treated by an endoscopic procedure without blood transfusion or the need to convert to open surgery. Conclusion The present study suggests that colorectal ESD may be accepted with relative safety in Japan as a common therapeutic approach for early colorectal cancer.

Diagnostic and therapeutic value of blue laser endoscopy combined with endoscopic submucosal dissection for low grade intraepithelial neoplasia

Objective To evaluate the blue laser imaging(BLI) magnifying endoscopy combined with endoscopic submucosal dissection (ESD) in diagnosis and treatment of low grade intraepithelial detected by normal endoscopic biopsy. Methods A total of 76 patients were diagnosed as having LGIN by preoperative biopsy. But 3 months later, BLI endoscopic re-examination showed that the lesions did not heal or even worsened. Patients who received ESD therapy were included in the retrospective study during January 2014 to January 2016 in Remin Hospital of Wuhan University. The efficacy and complications of ESD, and the consistence rate of diagnosis between general endoscopic biopsy, BLI magnifying endoscopy and pathologic diagnosis of total tumor after ESD were analyzed. Results The complete resection rate and curative rate of ESD were 100.0% (76/76) and 97.4% (74/76) respectively. The incidences of hemorrhage and perforation during the operation were 3.9% (3/76) and 1.3% (1/76), and there was no delayed bleeding or perforation. The consistence rates of diagnosis of common endoscopic biopsy and BLI were 55.3% (42/76) and 92.1% (70/76) respectively, with significant difference (χ2=51.987, P<0.001). Conclusion Low-grade intraepithelial of the upper digestive tract may be easily underestimated by ordinary endoscopy biopsy. For these underestimated low-grade intraepithelial neoplasia lesions, ESD can not only be used to confirm the diagnosis, but also give safe and effective treatment. The examination of BLI combined with magnifying endoscopy is recommended before ESD, because BLI endoscopy classification of the lesions has positive effects on ESD of upper gastrointestinal mucosa lesions. Key words: Endoscopy; Biopsy; Lasers, dye; Carcinoma in situ; Endoscopic submucosal dissection

Application of clip traction to endoscopic submucosal dissection for heterotopic pancreas in stomach

Objective To evaluate the efficacy and safety of clip traction in endoscopic submucosal dissection (ESD) for heterotopic pancreas in stomach. Methods Data of 62 patients with pathologically confirmed heterotopic pancreas treated by ESD between May 2013 and February 2016 were retrospectively studied in Department of Gastroenterology of Xinqiao Hospital, whose lesions were single and origins were submucosal. Thirty-six cases underwent ESD with clip traction (clip group, n=36), and 26 cases underwent ESD without clip traction(non-clip group, n=26). The procedure time, visualization of the submucosal during dissection, complications and the result of follow-up were evaluated between the two groups. Results ESD was successful in all cases. The procedure time was significantly shorter in the clip group than in the non-clip group (19.35±10.34 min VS 27.02±14.27 min, t′=2.333, P=0.023), and good visualization was obtained by applying clip traction. The rate of bleeding in the clip group was 55.6%(20/36), and that in the non-clip group was 61.5%(16/26). There was no significant difference between the two groups(χ2=0.222, P=0.638). Moreover, perforation did not occur in the clip group, but occurred in one patient in the non-clip group(3.8%, 1/26). There was no significant difference between the two groups(P=0.419). All patients were followed up, there was no recurrence. Conclusion ESD is effective and safe for heterotopic pancreas in stomach. Clip traction can shorten the operation time and reduce complications of ESD. Key words: Endoscopes; Heterotopic, pancreas; Adjuvant, traction; Endoscopic submucosal dissection

The expansion of endoscopic submucosal dissection in France: A prospective nationwide survey

Early reports of endoscopic submucosal dissection (ESD) in Europe suggested high complication rates and disappointing outcomes compared to publications from Japan. Since 2008, we have been conducting a nationwide survey to monitor the outcomes and complications of ESD over time. All consecutive ESD cases from 14 centers in France were prospectively included in the database. Demographic, procedural, outcome and follow-up data were recorded. The results obtained over three years were compared to previously published data covering the 2008-2010 period. Between November 2010 and June 2013, 319 ESD cases performed in 314 patients (62% male, mean (±SD) age 65.4 ± 12) were analyzed and compared to 188 ESD cases in 188 patients (61% male, mean (±SD) age 64.6 ± 13) performed between January 2008 and October 2010. The mean (±SD) lesion size was 39 ± 12 mm in 2010-2013 vs 32.1 ± 21 for 2008-2010 (p = 0.004). En bloc resection improved from 77.1% to 91.7% (p < 0.0001) while R0 en bloc resection remained stable from 72.9% to 71.9% (p = 0.8) over time. Complication rate dropped from 29.2% between 2008 and 2010 to 14.1% between 2010 and 2013 (p < 0.0001), with bleeding decreasing from 11.2% to 4.7% (p = 0.01) and perforations from 18.1% to 8.1% (p = 0.002) over time. No procedure-related mortality was recorded. In this multicenter study, ESD achieved high rates of en bloc resection with a significant trend toward better outcomes over time. Improvements in lesion delineation and characterization are still needed to increase R0 resection rates.

Clinical Factors of Delayed Perforation after Endoscopic Submucosal Dissection for Gastric Neoplasms.

Background Delayed perforation is a rare but severe complication of endoscopic submucosal dissection (ESD) for early gastric neoplasm (EGN). The aim of this study was to clarify clinical factors related to delayed perforation after ESD. Methods A total of 1158 consecutive patients with 1199 EGNs underwent ESD at our hospital between January 2000 and December 2015. Univariate analysis was used to identify clinicopathological factors related to delayed perforation. Moreover, duration of cautery needed for hemostasis was measured by comparison between perforated and nonperforated points in patients with delayed perforation. Results Delayed perforation occurred in 5 of 1158 consecutive patients with 1199 EGNs who underwent ESD (0.42%). All cases were diagnosed within 24 h after ESD and recovered with conservative management. On univariate analysis, location in the upper stomach was the factor most significantly associated with delayed perforation (P < 0.01). Duration of cautery needed for hemostasis was significantly longer at perforated points (9 s) than at nonperforated points (3.5 s) in five patients. Conclusions Location in the upper stomach was the risk factor most prominently associated with delayed perforation after ESD for EGNs. In addition, delayed perforation appears associated with excessive electrocautery for hemostasis.

PTU-021 Efficacy, Safety and Complications of Endoscopic Submucosal Dissection for Colonic Lesions in the Very Elderly Patients above Eighty Years of Age

Introduction Endoscopic submucosal dissection (ESD) has been safely utilised for resection of colonic lesions. 1,2 More evidence is required in determining the safety profile of ESD in colonic lesion resection, particularly in the super elderly patients ≥80 years of age. In Japan, ESD is approved for both large adenomatous and superficial neoplastic lesions. Our hospital has been a centre for elderly gastroenterology care in North Western Tokyo, and has been an established ESD centre since 2013. The aim of this study is to provide further comparative data on the safety and feasibility of ESD provision in elderly patients ≥80 years of age. Methods A single centre retrospective analysis of our hospital’s ESD database was undertaken. Patients had ESD performed for colonic lesions from July 2013 till December 2015 were included and divided into 2 groups-either ≥80 years old or Results A total of 119 patients were included in this study of which 41 (34%) were ≥80 years of age and 78 (66%) were All complications recorded including bleeding, hypo/hypertension, desaturation and tachy/bradyarrythmia were all successfully corrected during the ESD procedure. Bleeding episodes were treated with needle knife coagulation and/or coagrasper. Post ESD, 2.5% of ≥80 group and 4% of the A colonic ESD video is included for demonstration. Conclusion ESD is a safe and minimally invasive procedure for resection of colonic lesions even in elderly patients above 80 years of age. In addition to an excellent en-bloc resection rate, direct visualisation of the submucosal layer during the dissection process in experienced operators allows a safer and virtually perforation free resection. References 1 Tamegai Y, Saito Y, et al . Endoscopic submucosal dissection: a safe technique for colorectal tumours. Endoscopy . 2007; 39 (5):418–422. 2 Saito Y, Uraoka, et al . Endoscopic treatment of large superficial colorectal tumours: a case series of 200 endoscopic submucosal dissections. GI Endoscopy 2007; 66 (5):966–73. Disclosure of Interest None Declared

Clinical outcomes of and management strategy for perforations associated with endoscopic submucosal dissection of an upper gastrointestinal epithelial neoplasm.

Perforation is one of the major complications of endoscopic submucosal dissection (ESD). In the present study, we investigated the clinical outcomes of and management strategies for ESD-related perforations. Between February 2010 and April 2014, a total of 3821 patients who underwent ESD for an upper gastrointestinal epithelial neoplasm were analyzed using the Yonsei University Severance Hospital database. Clinical outcomes of and management strategies for perforations in 90 patients (2.4%) were analyzed. The risk factors for the development of perforation were also investigated. The mean age of our subjects was 64.7±12.2years (male to female ratio, 3.2:1), and the mean size of the resected specimens was 39.4±12.5mm. Endoscopically visible perforations (visible perforation group) were noted in 74 of the 90 patients (82.2%), and clinically suspected perforations (suspected perforation group) were noted in 16 patients (17.8%). Immediate closure with endoclips was attempted in cases with a visible perforation and was successful in 72 (97.3%) cases. Two patients in whom endoscopic closure failed underwent surgery. Conservative care, including fasting and intravenous antibiotic administration, was attempted in the suspected perforation group, and all the patients were treated successfully without surgery. The mean durations of fasting, antibiotic treatment, and hospital stay were 3.8±3.1, 6.8±4.2, and 8.7±5.3days, respectively. Subgroup analysis of perforation type (visible perforation vs. suspected perforation) revealed no significant difference in the clinical course. Tumor location at the upper or middle third of the stomach was significantly associated with perforation. Most of the ESD-related perforations in upper gastrointestinal epithelial neoplasm could be managed successfully in a non-surgical manner under strict monitoring.

Acute Phlegmonous Gastritis Developing after Endoscopic Submucosal Dissection That Was Successfully Treated by Antibiotics Alone

Endoscopic submucosal dissection (ESD) is widely used to treat a variety of gastric lesions including early gastric cancer and gastric adenoma. Bleeding and perforation are the most common complications of ESD. However, a rare and fatal bacterial stomach infection, termed acute phlegmonous gastritis, can also develop after ESD. We treated a patient with a high fever who complained of severe abdominal pain after ESD. Abdominal computed tomography (CT) revealed a diffuse, submucosal, minimally attenuated lesion and mucosal irregularity. The clincial presentation and the CT findings were compatible with acute phlegmonous gastritis and the patient was successfully treated with antibiotics alone. The case is worth reporting because acute phlegmonous gastritis is a very rare complication of ESD. (Korean J Med 2016;90:127-131)

Endoscopic Submucosal Dissection for Early Gastric Cancer: Getting It Right!

Endoscopic resection is a widely accepted less-invasive treatment technique for local resection of early gastric cancer (EGC) lesions with a negligible risk of lymph node metastasis. Remarkable progress has been made during the last decade in this field, both in terms of expansion of the indications (to larger lesions and to lesions with ulceration) and in terms of technical improvements from endoscopic mucosal resection (EMR) to endoscopic submucosal dissection (ESD). Previously, larger lesions and lesions with ulceration were resected surgically because of the difficulty in effectively using EMR in this context. ESD however allows a high rate of en bloc resections, regardless of tumor location, tumor size, or the presence of ulceration. Nonetheless, ESD also has drawbacks: the procedure time is increased, ESD is more technically challenging compared to EMR, and, finally, ESD is associated with a slightly higher risk of complications. In order to overcome these limitations and minimize complications, a step-by-step process is important for learning ESD techniques. This chapter addresses the indications, results, some technical tips, and complications of ESD for EGC.

Clinical Outcomes and Complications of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasms in the Elderly

The number of elderly people with superficial gastric neoplasms is increasing, but the clinical outcome of endoscopic submucosal dissection (ESD) for treating elderly people with superficial gastric neoplasms remains unclear. We aimed to compare the efficacy and safety of ESD for patients with early gastric cancer (EGC) and precancerous lesions in elderly (≥75 years of age) and nonelderly (<75 years of age) patients.From October 2005 to December 2014, 83 consecutive patients with EGC and precancerous lesions (86 lesions) who were treated using ESD in our hospital were retrospectively reviewed. There were 44 lesions in 42 elderly patients who were at least 75-years old. The following parameters were compared between the 2 groups: preexisting comorbidities, performance status (PS), lesion inclusion criteria, lesion characteristics, treatment outcomes, surgery time, duration of hospitalization, complications, and intraoperative hemodynamic changes.Elderly patients had significantly higher preexisting comorbidity rates (90.9% vs 59.5%, P = 0.001), expanded lesion criteria rates (43.2% vs 19.0%, P = 0.016), and lower best PS rates (38.6% vs 81.0%, P < 0.001) than nonelderly patients. Lesion characteristics were similar in the 2 groups. The elderly had higher intraoperative hypotension rates (47.7% vs 21.4%, P = 0.011) and oxygen desaturation rates (9.1% vs 0.0%, P = 0.045) than nonelderly patients. In addition, the elderly also had a longer surgery time (107.0 ± 51.4 vs 91.5 ± 66.2 minutes, P = 0.049) and duration of hospitalization (7.5 ± 3.8 vs 5.9 ± 2.0 days, P = 0.016) than nonelderly patients. There were no differences in the prevalence rates of en-bloc resection, complete resection, bleeding, perforation, pneumonia, or intraabdominal free air between the 2 groups.Although elderly patients who underwent ESD for superficial gastric neoplasms had an increasing risk of intraoperative hypotension and oxygen desaturation, all patients were treated appropriately without postoperative sequelae. ESD is a safe and feasible intervention for elderly patients who have more comorbidity, a worse PS and more expanded lesions.