Endoscopic Mucosal Resection For Early Gastric Cancer Research Articles

Long-Term Clinical Efficacy and Perioperative Safety of Endoscopic Submucosal Dissection versus Endoscopic Mucosal Resection for Early Gastric Cancer: An Updated Meta-Analysis.

Background To systematically evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) versus endoscopic mucosal resection (EMR) for early gastric cancer (EGC). Methods We searched the databases of PubMed, Web of Science, EMBASE, and the Cochrane Library from January 2000 to April 2017 and included studies that compared the outcomes of ESD with EMR for EGC. These eligible studies that met the inclusion criteria were screened out and were assessed by two independent investigators. Result In total, 18 retrospective cohort studies were eligible for analysis. Our results indicated that ESD is more beneficial than EMR in increasing the complete resection rate and en bloc resection rate and decreasing the local recurrence rate. However, ESD prolonged operative time and increased incidence of gastric perforation than EMR. No differences were found in postoperative bleeding rate between the two approaches. Conclusion Compared with EMR, ESD offers higher complete resection rate, higher en bloc resection rate, and lower local recurrence rate but has prolonged operative time and increased incidence of gastric perfusion. There is no statistical difference in the rate of postoperative bleeding between the two groups. However, the above conclusion needs further verification by well-designed, randomized trials with larger samples and long follow-up periods.

The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis

Endoscopic submucosal dissection (ESD) allows en bloc resection of the entire lesion, permitting a higher curative resection rate and increased quality of life by minimizing the resection size compared with that of endoscopic mucosal resection (EMR). Although ESD has been implemented at most university hospitals in Korea, potential complications of ESD such as bleeding and perforation raise doubts in the therapeutic decision on use of the ESD procedure for early gastric cancer patients and in reimbursement decision making. This systematic review aimed to address both the effectiveness and safety outcomes of ESD versus EMR for early gastric cancer. MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), and Koreamed were searched using the primary keywords "stomach neoplasm" AND "endoscopic submucosal dissection" AND "endoscopic mucosal resection." To assess the quality of selected studies, the methodologic approach of the Scottish Intercollegiate Guidelines Network was used. Five effectiveness-relevant and three safety-relevant outcome measures were extracted. Bibliography management and metaanalysis for each outcome were conducted using Review Manager 5.0. Three nonconcurrent cohort studies and nine retrospective cohort studies were identified. Metaanalyses showed ESD to be significantly more effective than EMR for en bloc resection (odds ratio [OR], 8.43; 95% confidence interval [CI], 5.20-13.67), complete resection (OR, 14.11; 95% CI, 10.85-18.35), curative resection (OR, 3.28; 95% CI, 1.95-5.54), and local recurrence (risk ratio [RR], 0.13; 95% CI, 0.04-0.41). Whereas intraoperative bleeding (RR, 2.16; 95% CI, 1.14-4.09), perforation risk (RR, 3.58; 95% CI, 1.95-6.55), and operation time (standard mean difference [SMD], 1.55; 95% CI, 0.74-2.37) were significantly greater for ESD, overall bleeding risk (RR, 1.22; 95% CI, 0.76-1.98) and all-cause mortality (RR, 0.65; 95% CI, 0.08-5.38) did not differ significantly between ESD and EMR. Considering that bleeding risk did not differ significantly between ESD and EMR and that perforation risk usually does not lead to life-threatening disease, the effectiveness benefit of ESD can outweigh the overall harm compared with EMR on the condition that ESD is performed by experienced practitioners.

Outcome after endoscopic submucosal dissection for early gastric cancer in Korea.

Endoscopic treatment, such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD), has been established as one of the treatment options for selected cases with early gastric cancer (EGC). Most studies on this topic have been carried out by researchers in Japan. Recently, the experience in EMR/ESD for EGC outside Japan is increasingly reported. In Korea, gastric cancer is the most common malignant disease, and the second leading cause of cancer death. Currently, EMR for EGC is widely performed in many centers in Korea. Early results with a short-term follow-up period are very promising in Korea. The complete resection rate of EMR was 37.8%-94.3%, and that of ESD was 77.4%-93.1%. In this review, we will provide an overview of the outcomes of endoscopic treatments in Korea.

EMR for Early Gastric Cancer

Endoscopic mucosal resection (EMR) has become standard therapy in Asian countries that have a high incidence of early gastric cancer. Such cancer is

Repeated Endoscopic Examination Six Months After H. Pylori Eradication Could Find Masked Gastric Cancer

Background: Detecting early gastric cancer in H. pylori-infected stomach is not easy, when the background gastric mucosa shows severe inflammation with diffuse or patchy redness, edema, and thick mucous. In order to undertake less invasive therapies, such as endoscopic mucosal resection (EMR), it is important to find cancerous lesion(s) as small as possible. Since eradication of H. pylori is known to induce regression of inflamed gastric mucosa, repeated endoscopic examination after eradication could find previously masked cancerous lesion(s). Methods: Twenty-one cases (15 men: 51-88 years old, average 69.7 years of age) of early gastric cancer detected after H. pylori eradication were enrolled in this study. Eradication therapy was performed with LAC regimens (Lansoprazole 60 mg, Clarythromycin 800 mg, and Amoxycillin 1500 mg for 7 days) followed by 13 C-Urea Breath Test. Repeated endoscopic examination with high-resolution endoscopy (Olympus H260) was performed every 3 to 12 months' intervals after the eradication. Interval period detecting gastric cancer after the eradication and the size of lesion(s) were retrospectively analyzed. Results: Of twenty-one cases, 17 had previous EMR for early gastric cancer (13 cases) or gastric adenoma (4 cases). After H. pylori eradication, inflamed gastric mucosa regressed and thick mucous in the stomach decreased or disappeared in all cases. The mean interval period between detection of gastric cancer and eradication was 6.5 ± 0.9 months (range 2 to 12 months). The mean size of cancer was 8.5 ± 1.6 mm in diameter (range 3 to 18 mm). All cases were treated with EMR and only one case required additional operation due to deep invasion of gastric cancer. Conclusion: Eradication of H. pylori may make it easy to detect small early gastric cancer by regressing inflammation of gastric mucosa. It is highly recommended to perform repeated endoscopic examination at least first 6 months after eradication therapy in patients who had gastric cancer.

Endoscopic mucosal resection of early gastric cancer: Experiences in Korea.

Endoscopic mucosal resection (EMR) has been established as one of the treatment options for early gastric cancer (EGC). However, there are many uncertain areas such as indications of EMR, best treatment methods, management of complications and follow-up methods after the procedure. Most studies on this topic have been carried out by researchers in Japan. In Korea, gastric cancer is the most common malignant disease, and the second leading cause of cancer death. In these days, EMR for EGC is widely performed in many centers in Korea. In this review, we will provide an overview of the techniques and outcomes of EMR in Korea.

Long Term Prognosis of the Cases After EMR of Early Gastric Cancer

Aim: There have been passed about 20 years after starting to perform the endoscopic mucosal resection (EMR) for early gastric cancer. Then we studied the long term prognosis of the cases after EMR. Method: Seven hundred and seventeen cases (814 lesions) were entrée for this study. Those cases were performed EMR between 1983 and 2003, and followed up more over two years. Results: Six hundred and eight lesions (74.7%) were indicated cases and 206 lesions (25.3%) were contraindicated cases (indication was according to the guide line of Japanese Gastric Cancer Association). Thirty-two point nine percent of the contraindicated lesions were the cases of over 75 years old that were 24.6% of the whole cases. Ninety-six point five percent were differentiated lesions and the undifferentiated lesions were only 3.5% of all lesions. The cases of EMR for early gastric cancer have increased gradually but the mean age of the patients, which was about 70 years old, has never changed within this interval. The mean interval of the surveillance after EMR was 4 years and 9 months (min 2 years, max 19 years and 9 months). The planned surveillance after EMR was especially difficult in the aged patients. Heterogeneous early gastric cancer has occur in 4% of the whole cases and the relative risk of the heterogeneous early gastric cancer occurring was 3.42 in the simultaneous early gastric cancer cases. We could find about 50% of the heterogeneous early gastric cancer near by the first lesion. There was no difference in the prognosis after EMR between over 75 years patients and less than 75 years patients on the Kaplan-Meier survival curve excluding the death of complication. And there was no case of surgical operation due to the complication of EMR (containing 6 perforation cases) in all patients. Conclusion: Considering about there is no difference of the mean age of the EMR cases of early gastric cancer in spite of the tendency of aging of Japanese population, we are thinking that differentiated gastric cancer has occurred after some settled interval because such cancer grows in the atrophic mucosa after Helicobacter pylori infection. Heterogeneous multiple gastric cancer has occur in 4% cases after EMR of early gastric cancer, so it is suitable to follow continuously especially in the simultaneous multiple gastric cancer case at the first EMR. Even if in the aged patients, the prognosis after EMR for early gastric cancer was not different from the patient's prognosis less than 75 years old. So considering about the QOL after EMR, we are thinking that especially the aged patients should take the benefit of EMR for the treatment of early gastric cancer.

Indications for gastrectomy after incomplete EMR for early gastric cancer

Although the number of patients with early gastric cancer (EGC) treated by endoscopic mucosal resection (EMR) has increased, the appropriate strategy for treating those with incomplete resection has not been established. This study analyzed 726 cases of EGC in patients treated by EMR between 1991 and 2000, in order to clarify the en-bloc and complete resection rates. We classified patients with incomplete resection into four groups according to the estimated risk of residual cancer or lymph node (LN) metastasis, determined from pathological findings of EMR specimens. We then analyzed 45 patients with EGC treated surgically after incomplete EMR, with the aim of eliciting the risk of residual cancer and LN metastasis. Of the 726 patients, 529 (72.9%) had an en-bloc resection, while 378 (52.1%) had a complete resection. Three hundred and nine patients were found to have mucosal cancer and lateral cut-end-positive status with no LN metastasis (group A). In this group, 18 patients (5.8%) had residual cancer, with the lesions in the majority of patients being limited to the mucosal layer. Group B consisted of 14 patients with differentiated and submucosal (sm1) depth cancers, with 1 patient having residual cancer and 2 patients having LN metastasis. Fifteen patients were classified as group C, with sm2 or greater and vertical cut end-negative status, with 2 showing residual cancer and 1 showing LN metastasis. Group D included 10 patients with vertical cut end-positive status. Four of these patients had residual cancer while 1 had LN metastasis. We recommend that patients in group A should have close follow-up or endoscopic treatment, while those in groups B, C, or D should be treated by gastrectomy associated with LN dissection.

CHARACTERISTICS AND ROLE OF ENDOSCOPIC MUCOSAL RESECTION USING CAP‐FITTED PANENDOSCOPE FOR EARLY GASTRIC CANCER

Background: It is accepted in Japan and in the gastric cancer treatment guidelines that small gastric mucosal cancers without lymph node metastasis can be curatively treated by endoscopic mucosal resection (EMR). Various techniques of EMR for early gastric cancer have been reported, and in the present study, the results of EMR using cap‐fitted panendoscope (EMRC) for early gastric neoplastic lesions are examined, and the characteristics and the role of EMRC procedure are discussed.Methods: From August 1992 to March 2003, 181 gastric neoplastic lesions in 155 patients were treated by EMRC at the Department of Surgery, Esophagogastric Division, Tokyo Medical and Dental University. The frequency of residue and the cause of residue following EMRC for 181 gastric neoplastic lesions were examined. Five‐year survival rates were calculated and compared according to the 49 patients who underwent en bloc resection and the 49 patients who underwent planned fractionated resection by EMRC for early gastric cancer.Results: There was residue in nine (5%) of 181 lesions treated by EMRC. Residues from four elevated lesions resulted from muscular resection and insufficient additional resection; residues from five depressed lesions resulted from incorrect diagnosis of the spread of the lesions prior to resection and insufficient additional resection. In the EMRC patients, the survival rates for 49 patients treated by en bloc resection (93%) and 49 patients by planned fractionated resection (91%) were not significantly different.Conclusion: The EMRC technique, that is en bloc and planned fractionated resection by EMRC procedure, has an important role as an easy and curative EMR method for almost all of the indicated early gastric cancers by the gastric cancer treatment guidelines with no limitations from the lesion sites.

A Clinical Study of Protruding Lesions That Arise at the Scar of an Endoscopic Mucosal Resection for an Early Gastric Carcinoma and a Gastric Flat Adenoma

Purpose: Several studies of an endoscopic mucosal resection(EMR) have been reported, but reports about benign protruding lesions that arise at the scar of EMR for early gastric cancer (EGC) or a gastric adenoma are rare. The purpose of this study was to elucidate endoscopic and histological characteristics of benign protruding lesions which arise at the scar of an EMR for EGC and a gastric flat adenoma. Materials and Methods: In 101 lesions (73 gastric flat adenomas and 28 EGCs) from 96 patients, 16 lesions developed new protruding lesions that arose at the scar of the EMR. We retrospectively analyzed the endoscopic findings of initial and protruding lesions, and several other clinical factors (H. pylori infection, eradication therapy, and proton pump inhibitor (PPI) or H2-blocker use). Results: 1. The mean duration until detection of the protruding lesion was 8.9 months (). Protruding lesions arose at the scar of the EMR in 1 of 28 EGCs () and from 15 of 73 gastric flat adenomas (). All of the patients were men. 2. With respect to the endoscopic findings, the shapes of the protruding lesions were as follows: 10 Yamada (Y) I, 4 Y-II, 1 Y-III, and 1 flat lesion. Histological examination of the protruding lesions revealed regenerating hyperplasia in 5 lesions, intestinal metaplasia in 5, and both in 6. 3. The incidence of these lesions was higher in cases of tubular adenomas with focal high-grade dysplasia than in cases of tubular adenomas without dysplasia (p) who developed a protruding lesion than in those () who did not develop (p=0.029); also, the incidence of use of PPI was higher in those patients (p=0.045). However, eradication therapy for H. pylori and duration of use of PPI or H2-blocker showed no difference between groups. Conclusions: It may be possible that the potential hyperplasia that may reside in normal mucosa surrounding EGC or a gastric adenoma might awaken during the healing process of the EMR ulcer and develop to benign protruding lesions. And, H. pylori and PPI might also be related to the development of the protruding lesions.

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

BACKGROUND: Endoscopic mucosal resection (EMR) for intramucosal early gastric cancer (EGC) has become popular in Japan. However, its longterm results have not been clearly reported. AIM, PATIENTS AND METHODS: To elucidate the effectiveness of EMR for EGC, we studied the prognosis of 288 EGC patients who were treated by EMR with submucosal saline injection technique and compared with that of non-concurrent 46 EGC patients who took no treatment at all (NTx group). Endoscopy was repeated 1, 3, 6, 12 months or more after endoscopic resection. RESULTS: We resected 320 EGCs in 288 patients between `90 and `97. Of those who treated by EMR, 253 patients had intramucosal differentiated EGC without ulcerative change that absolutely indicates EMR (IND group) and 35 patients had submucosal, undifferentiated or ulcerative EGC (CIND group). In IND group, 143 patients failed to achieve complete resection and residual cancers were revealed in 40 patients. Endoscopic re-treatment was performed in 32 patients and operations in eight patients. In CIND group, additional operations were undergone in 16 patients and were not in 19 patients who were not candidates for surgical resection. There was no procedure-related mortality. 25 patients died of causes other than gastric cancer in IND group, whereas 7 patients died of gastric cancer and 7 died of other causes in CIND group during the mean periods of 43 months. The cumulative 5-years' survival rate was significantly higher in IND group than that of in CIND group and NTx group, (85%, 55% and 53%, respectively). CONCLUSION: EMR is effective treatment for intramucosal differentiated EGC without ulcerative change but not for submucosal, undifferentiated or ulcerative EGC.

Laparoscopic Gastrectomy for Early Gastric Cancer after Endoscopic Mucosal Resection

Abstract: In 1991, we first performed a simple technique of Iaparoscopy‐assisted Bill‐roth I gastrectomy for patients with mucosal gastric cancer. Endoscopic mucosal resection (EMR) sometimes fails to completely resect the early gastric cancer lesion, nor does it give full histopathology of the resected stomach. The aim of this study was to review the surgical and pathological findings of eight patients who underwent laparoscopic gastrectomy after EMR for early gastric cancer. Of 54 patients with early gastric cancer who were treated with laparoscopic gastrectomy between 1994 and 1998, eight patients underwent surgery after EMR. The resected margin of the EMR specimens was positive in three and suspicious in five; and three underwent laparoscopic wedge resection of the stomach, while five underwent Iaparoscopy‐assisted distal gastrectomy with regional lymph node dissection. All but one resected stomach had residual cancer tissue in the mucosa or submucosa, and three patients had multiple gastric cancers. The results indicated that remnant cancer tissue might be present when the resected margin of the EMR specimen was positive or suspicious. Partial resection or distal gastrectomy under laparoscopy is useful for such patients who have undergone EMR for early gastric cancer. (Dig Endooc 1999; 11:132–136)