Complications Of Endoscopic Submucosal Dissection Research Articles

Endoscopic Submucosal Dissection for Early Gastric Cancer

The field of endoscopy has progressed markedly and become widespread in recent years, and the role of minimally invasive endoscopic treatment has become increasingly more important with the increase in the number of patients in whom gastric cancer is detected at an early stage. In addition, the characteristics of early gastric cancer, which can be curably treated by mucosal resection alone just as by surgical cancer resection, were clarified, and endoscopic submucosal dissection (ESD) was developed as a highly curable, minimally invasive treatment, that is gaining popularity. In this paper, we describe the technical details and complications of ESD for early gastric cancer, including their management.

Predictive risk factors of perforation in gastric endoscopic submucosal dissection for early gastric cancer: a large, multicenter study

Although endoscopic submucosal dissection (ESD) is standard therapy for early gastric cancer, the complication rate is unsatisfactory, with perforation as the major complication during ESD. There have been several reports regarding the complications of ESD for gastric tumor especially perforation; however, little is known about the predictors for complications in patients undergoing ESD. The purpose of this retrospective study was to determine the risk factors for perforation in patients with early gastric cancer during ESD. Between February 2003 and May 2010, we performed ESD for 1,289 lesions in 1,246 patients at six tertiary academic hospitals in Daegu, Kyungpook, Korea. Patient-related variables (age, sex, and underlying disease), endoscopic-related variables (indication of ESD, lesion size, location, type, and mucosal ulceration), procedure-related variables (operation time, complete resection, and invasion of submucosa/vessel/lymph node), and the pathologic diagnosis were evaluated as potential risk factors. The mean age of the patients was 64 years. The mean size of the endoscopic lesion was 19.4 mm. The overall en bloc resection rate was 93.3 %. Perforation (microperforation and macroperforation) was seen in 35 lesions. The location of the lesion (long axis: body/short axis: greater and lesser curvature) and piecemeal resection were associated with perforation (p = 0.01/0.047 and p = 0.049). Upon multivariate analysis, the location (body vs. antrum) of the lesion (odds ratio (OR) 2.636; 95 % confidence interval (CI) 1.319-5.267; p = 0.006) and piecemeal resection (OR 2.651; 95 % CI 1.056-6.656; p = 0.038) were significant predictive factors for perforation. The result of this study demonstrated that the location of the lesion (body) and piecemeal resection were related to perforation during ESD.

Simultaneous endoscopic submucosal dissection for synchronous double early gastric cancer

This study aims to evaluate the safety and efficacy of simultaneous endoscopic submucosal dissection (ESD) for synchronous double early gastric cancers. We retrospectively evaluated 832 single gastric cancers from 789 patients treated by single ESD (single group) and 124 synchronous double cancers from 62 patients treated by simultaneous ESD (simultaneous group). The overall rate of en bloc resection and curative resection was comparable between the two groups. Procedure time was significantly longer in the simultaneous group than in the single group (131.0 ± 66.5 and 94.8 ± 64.1 min, respectively, P < 0.001). White blood cell count on the day after ESD was significantly higher in the simultaneous group (9310 ± 2774/μl) than in the single group (8633 ± 2341/μl) (P = 0.032). Length of fasting period after ESD was 1.1 ± 0.5 days in the single group and 1.4 ± 1.1 days in the simultaneous group (P = 0.082). Complications were more frequent in the simultaneous group than in the single group (11.3 vs. 5.4 %, respectively), but the difference was not significant (P = 0.082). Complication rate per one lesion did not differ between the two groups (5.6 vs. 5.4 %, respectively, P = 0.914). Multivariate analysis showed procedure time longer than 150 min was independently predictive for complications of simultaneous ESD (P < 0.042, odds ratio = 6.094). Large tumors, upper portion location and tumors not in the standard guideline criteria were significantly associated with long procedure time. Simultaneous ESD for synchronous early gastric cancer can be a feasible and safe option, and it can reduce hospital stay. These results need to be validated by further studies.

The therapeutic effect of endoscopic submucosal dissection and risk factors of bleeding

Objective To evaluate the efficacy and safety of endoscopic submucosal dissection （ESD） for digestive tract mucosal lesions, and risk factor of complications. Methods The data of 154 con secutive patients who underwent ESD for superficial digestive tract mueosal lesions were analyzed prospective ly for therapeutic effect and rate of complications. Risk factors for bleeding was analyzed. Results The en bloc resection rate in 145 completed ESD procedures was 100. 0%. Histologically, complete resection rate was 99. 3%. ESD was not completed in 9 patients due to bleeding （n =5） and perforation （n =4）. Acute massive bleeding occurred in 6 patients （6/154,3.9%）, mild bleeding in 5 （3.2%）, delayed bleeding in 1 （0. 6% ） ,perforation in 4 （2. 6% ） and postESD stenosis in 1 （0. 6% ）. All complications were cured. The postESD uleer healing was achieved in 100% at 8 weeks after treatment. During followup of 10. 6 months （ranged from 8 to 18 months）, no residual or local recurrence was found. Statistic analysis showed in dependent risk factors for bleeding in ESD were lesion location （cardiac fundus） , and lesion size. Conclu sion ESD is an effective and safe procedure in treatment of digestive tract mucosal lesions. The complica tions of ESD are preventable and curable. Strictly controlling operation indications, individualized treatment and the proficient operation skills of physicians are the keys to success. Key words: Endoscopes ; Endoscopic submucosal dissection; Efficiency ; Hemorrhage ; Riskfactors

Perforation and Postoperative Bleeding of Endoscopic Submucosal Dissection in Gastric Tumors: Analysis of 1,190 Lesions in Low- and High-Volume Centers in Saga, Japan

Background: This retrospective study aimed to determine risk factors associated with serious complications of endoscopic submucosal dissection of gastric tumors in multicenters compared between high- and low-volume centers. Methods: Between 2001 and 2010, gastric endoscopic submucosal dissection was performed in 1,190 lesions of 1,082 patients in five hospitals in Saga, three high-volume and two low-volume centers. Risk factors for serious complications were evaluated. Patients’ background characteristics were evaluated, including anticoagulants use and underlying diseases. Results: Postoperative bleeding was detected in 75 patients (6.9%), and perforation was detected in 40 patients (3.7%). Most postoperative bleeding and perforation cases were recovered with endoscopic procedures, although one case of each complication was treated by emergency surgery. Multivariate analysis indicated that risk factors for perforation were tumor location, massive submucusal invasion, endoscopists’ experience of 100–149 cases and hypertension, and that risk factors for postoperative bleeding were tumor location, resected tumor size, and scar lesion. The serious complications were not different between high- and low-volume centers. Conclusions: The present study indicated that risk factors for perforation during endoscopic submucosal dissection were tumor, endoscopist and patient related, although risk factors for postoperative bleeding were tumor related. There was no difference in complications between high- and low-volume centers.

Risk factors for delayed bleeding from endoscopic submucosal dissection of gastric neoplasms

Objective. Delayed bleeding is a major complication of endoscopic submucosal dissection (ESD) of gastric neoplasms. We aimed to clarify risk factors for delayed bleeding from ESD. Material and methods. This study included 447 patients in whom 544 gastric neoplasms were resected by ESD between April 2006 and March 2011 in Yamaguchi University Hospital. We analyzed risk factors for delayed bleeding from ESD in relation to various clinical and pathological factors. Results. En bloc resection rate was 95.4% (519/544), and curative resection rate was 87.8% (477/544). Delayed bleeding occurred in 7.0% (38/544) and perforation occurred in 1.8% (10/544) of patients. Univariate analysis revealed platelet count (Plt) <15 × 104/μl (p = 0.013), prothrombin time (PT) <70% (p = 0.044), resected size ≥50 mm (p = 0.038), and positive/indeterminate lateral margin (p = 0.012) to be risk factors for delayed bleeding. Multivariate analysis showed that Plt <15 × 104/μl (odds ratio [OR], 2.62; 95% confidence interval [CI]: 1.17–5.53, p = 0.020) and positive/indeterminate lateral margin (OR, 5.45; 95% CI: 1.39–17.95, p = 0.018) were independent risk factors for delayed bleeding. Conclusions. Low Plt, low PT, large resected size, and positive/indeterminate lateral margin were significant risk factors for delayed bleeding from ESD. Patients with these risk factors must be carefully observed for signs of delayed bleeding.

Clinical Impact of Second-Look Endoscopy after Endoscopic Submucosal Dissection of Gastric Neoplasms

Background/AimsOne major complication of endoscopic submucosal dissection (ESD) is delayed bleeding. Most hospitals routinely perform second-look endoscopy to reduce the chances of delayed bleeding without solid evidence supporting the practice. The aim of this study was to evaluate whether second-look endoscopy prevents delayed bleeding and to verify the clinicopathological features of delayed bleeding to determine how to identify lesions that may require second-look endoscopy.MethodsWe investigated 440 lesions in 397 patients who underwent ESD for gastric neoplasm from January 2008 to June 2010. Two-thirds of the enrolled cases were adenomas, and 290 lesions were located in the lower portion of the stomach. Clinically evident bleeding from mucosal defects 24 hours after ESD was considered as delayed bleeding. We reviewed the data, including the characteristics of patients, lesions, and procedures. Furthermore, the rate of delayed bleeding before and after second-look endoscopy, performed within three days of ESD, was investigated to determine the utility of second-look endoscopy.ResultsDelayed bleeding was evident in 9 of 440 lesions (2.0%), all of which underwent endoscopic hemostasis. The only significant factor predicting delayed bleeding was resected specimen over 40 mm in size (p=0.003). Delayed bleeding occurred in 8 of 9 cases (89%) before the second-look endoscopy, which was performed within 72 hours after ESD.ConclusionsIn this study, second-look endoscopy may be useful for preventing post-ESD bleeding, especially when resected specimens are over 40 mm in size.

CURRENT OPINIONS FOR ENDOSCOPIC SUBMUCOSAL DISSECTION FOR COLORECTAL TUMORS FROM OUR EXPERIENCES: INDICATIONS, TECHNICAL ASPECTS AND COMPLICATIONS

Endoscopic submucosal dissection (ESD) was first applied in the resection of large colorectal tumors 10 years ago. Frequent complications and technical difficulties were serious problems at first, but were gradually improved with experience. Here, we describe the indications, technical aspects and management of complications of ESD for colorectal tumors. In 2009, we introduce the use of small tip insulation-tipped diathermic (IT) knife. Features separating it from the IT knife and IT Knife2 are a smaller ceramic tip and small round disk at the root of the tip. During submucosal dissection, the small tip IT knife could dissect large pieces of tissue intact. This allows us to shorten the procedure time, particularly the submucosal dissection component. A total of 146 ESD for 140 patients were performed between January 2009 and July 2011. En bloc, and en bloc and R0 resection rates were 92.5% and 83.6%, respectively. Median procedural time was 48.5 min for 40.5 mm specimens. Perforation and delayed bleeding occurred in 2.1% and 1.4%, respectively. We successfully performed ESD for colorectal tumors with a shortened procedure time while preserving quality and safety.

Su1116 The Clinical Outcomes of the Treatment for the Complications of Endoscopic Submucosal Dissection for Superficial Esophageal Carcinoma

Su1116 The Clinical Outcomes of the Treatment for the Complications of Endoscopic Submucosal Dissection for Superficial Esophageal Carcinoma

Factors predicting perforation during endoscopic submucosal dissection for gastric cancer

Perforation is a common complication of endoscopic submucosal dissection (ESD), but little is known about the relevant risk factors. To investigate the risk factors for perforation. Retrospective study. A cancer referral center. A total of 1795 early gastric tumors in 1500 patients treated by ESD from July 2002 to December 2010 were included in the analysis. The associations between the incidence of perforation and patient and lesion characteristics were investigated. Perforation during ESD occurred in 50 lesions (2.8%). Univariate analysis identified tumor location (upper, middle, or lower stomach), tumor diameter (≤ 20 or >20 mm), and treatment period (lesions treated in the first or second period) as predictors of perforation. Multivariate analysis identified tumor location (upper stomach), tumor diameter (>20 mm), and treatment period (first half) as independent risk factors for perforation. The odds ratios were 2.4 (95% CI, 1.3-4.7; P = .006) for lesions in the upper stomach and 1.9 (95% CI, 1.0-3.5; P = .04) for lesions larger than 20 mm. Perforation risks were 5.4% for lesions in the upper stomach and 4.4% for lesions larger than 20 mm. Three patients required emergency surgery, but the rest of the patients were successfully treated with endoscopic clipping. There was no perforation-related mortality. Single-center, retrospective study design. Lesions in the upper stomach and lesions larger than 20 mm were independent risk factors for perforation during ESD. Patients should be made aware of the estimated high risks of these lesions before undergoing ESD.

Usefulness of clip traction in the early phase of esophageal endoscopic submucosal dissection

The usefulness of clip traction in endoscopic submucosal dissection (ESD) for early esophageal carcinoma was investigated. A total of 87 patients who underwent ESD for esophageal squamous cell carcinoma were included in the study. The hook knife method was used for ESD. Twenty patients underwent ESD without clip traction (non-clip group) and 67 underwent procedures in which clip traction was used (clip group). A clip with a string was attached to the oral edge of the lesion after mucosal incision in the clip group. ESD was successful in all cases. Wide exposure of the submucosal tissue below the lesion was obtained by applying tension to the clip traction. The duration of ESD was shorter in the clip group, and there was a significant difference in duration between the non-clip and clip groups. There were no complications of ESD in the clip group, but muscle layer injury occurred in three patients in the non-clip group. Clip traction shortens operating time and is safer in esophageal ESD. Clip traction is recommended as a useful auxiliary procedure.

Sa1639 Risk Factors for Gastric Perforation During Endoscopic Submucosal Dissection for Early Gastric Cancer and Outcomes of Endoscopic Closure

Gastric perforation is a major complication of endoscopic submucosal dissection (ESD) for early gastric cancer. Several studies has reported efficacy of endoscopic closure of gastric perforation during ESD. However, the long-term outcomes were still unknown. The aim of this study is to analyze the risk factors for gastric perforation during ESD and to assess short and long-term outcomes of endoscopic closure for gastric perforation.

366 Factors Predicting Perforation During Endoscopic Submucosal Dissection for Gastric Cancer

Perforation is a common complication of endoscopic submucosal dissection (ESD) for gastric cancers, but little is known about the relevant risk factors. The risk of perforation needs to be stratified preoperatively, therefore risk factors that can be evaluated before ESD need to be identified. Although procedure time is a known risk factor, it is only evident after ESD. Lesions >20mm and lesions in the upper stomach have also been identified as risk factors in previous studies, but the small numbers of patients and events (4 and 12 perforation) in these studies limit the reliable conclusions that can be drawn.

Mo1232 Clinicopathological Risk Factors for Delayed Postoperative Bleeding After ESD for Gastric Cancer: Comparison With the Factors for Early Bleeding

Postoperative bleeding is a major complication of endoscopic submucosal dissection (ESD). The patients who showed ESD related-bleeding after discharge and urgently readmitted into the hospital are tend to be poor outcomes. The aim of this study is to determine the incidence of delayed postoperative bleeding and analyze clinical factors after ESD in case of gastric neoplasm.

Tu1696 Safety of Endoscopic Submucosal Dissection for Esophageal Cancer in Elderly Patients

Tu1696 Safety of Endoscopic Submucosal Dissection for Esophageal Cancer in Elderly Patients

Efficacy and safety of endoscopic submucosal dissection for colorectal neoplasia: a systematic review

Endoscopic submucosal dissection (ESD) has been proposed for large colorectal lesions, due to the high risk of recurrence following endoscopic mucosal resection. However, data on the efficacy and safety of colorectal ESD are still controversial. The aim of the current systematic review was to assess the efficacy and safety of colorectal ESD. A detailed Medline search of papers published during the period 1999-2010 was performed, using the search terms "Endoscopic submucosal dissection," "Colorectal neoplasia," "Colon," or "Rectum." Published studies that evaluated ESD for colorectal lesions were assessed using well-defined inclusion/exclusion criteria, including histological confirmation and surgery for complications. The process was independently performed by two authors. Forest plots on primary (i.e. histologically verified R0 resection and surgery for ESD complications) and secondary end-points were produced based on random-effect models. Heterogeneity was assessed using the I2 statistic. Risk for within-study bias was also ascertained. A total of 22 studies (20 Asian, two European) provided data on 2841 ESD-treated lesions. The per-lesion summary estimate of R0 resection rate was 88% (95%CI 82%-92%; I2=91%). At meta-regression, carcinoid vs. non-carcinoid series (R0 93% vs. 87%; P=0.04) and Asian vs. European series (R0 88% vs. 65%; P=0.03) appeared to explain the detected heterogeneity. The per-lesion summary estimate of surgery for ESD complications was 1% (95%CI 0%-1%) with a moderate degree of heterogeneity (I2=49%). However, subgrouping of these results according to histological tumor types was not available in the reviewed studies. ESD appeared to be an extremely effective technique to achieve R0 resection of large colorectal lesions. The very low rate of surgery for complications also shows the potential safety of this approach.

Endoscopic submucosal dissection and surgical treatment for gastrointestinal cancer

Endoscopic submucosal dissection (ESD) is widely used in Japan as a minimally invasive treatment for early gastric cancer. The application of ESD has expanded to the esophagus and colorectum. The indication criteria for endoscopic resection (ER) are established for each organ in Japan. Additional treatment, including surgery with lymph node dissection, is recommended when pathological examinations of resected specimens do not meet the criteria. Repeat ER for locally recurrent gastrointestinal tumors may be difficult because of submucosal fibrosis, and surgical resection is required in these cases. However, ESD enables complete resection in 82%-100% of locally recurrent tumors. Transanal endoscopic microsurgery (TEM) is a well-developed surgical procedure for the local excision of rectal tumors. ESD may be superior to TEM alone for superficial rectal tumors. Perforation is a major complication of ESD, and it is traditionally treated using salvage laparotomy. However, immediate endoscopic closure followed by adequate intensive treatment may avoid the need for surgical treatment for perforations that occur during ESD. A second primary tumor in the remnant stomach after gastrectomy or a tumor in the reconstructed organ after esophageal resection has traditionally required surgical treatment because of the technical difficulty of ER. However, ESD enables complete resection in 74%-92% of these lesions. Trials of a combination of ESD and laparoscopic surgery for the resection of gastric submucosal tumors or the performance of sentinel lymph node biopsy after ESD have been reported, but the latter procedure requires a careful evaluation of its clinical feasibility.

Large gastric intramural hematoma: unusual complication of endoscopic submucosal dissection

Large gastric intramural hematoma: unusual complication of endoscopic submucosal dissection

Tu1420 The Second-Look Endoscopy May Have Significant Role in Detecting Post-ESD Bleeding When the Size of a Resected Specimen Is Over 40 mm

Endoscopic submucosal dissection (ESD) is a curative endoluminal surgical procedure for the treatment of gastric epithelial neoplasms. One of the major complications of ESD are post-ESD bleeding. In reality, a second-look endoscopy has been routinely performed to check the possibility of post ESD-bleeding in most hospitals without solid evidence. The aim of this study was to evaluate whether a second-look endoscopy was necessary for preventing delayed bleeding and to verify the clinicopathological features of post-ESD bleeding for determining the specific lesions that may need a second-look endoscopy.

Factors predictive of perforation during endoscopic submucosal dissection for the treatment of colorectal tumors

Although perforation of the colon is known as one of the main complications of endoscopic submucosal dissection (ESD) for colorectal tumor management, factors predictive of perforation have not been fully evaluated. This study aimed to determine the factors associated with perforation during colorectal ESD. Patients with colorectal tumors undergoing ESD were enrolled and their records were reviewed retrospectively. Age, sex, co-morbidity, medication history, procedure time, resection method, tumor size, location, gross morphology, the presence of fibrosis, and histologic findings were included as possible risk factors. In the cases where perforation had occurred, factors associated with the duration of hospitalization were analyzed. One hundred eight lesions in 108 patients were eligible for inclusion in the study (68 patients were male; mean patient age was 63.01 ± 10.71 years). Mean tumor size was 27.59 ± 10.10 mm (range: 8 - 53 mm). Laterally spreading tumor was the most common type (75 %), followed by the protruding type (25 %). Procedure time was 61.95 ± 41.90 minutes (range: 5 - 198 minutes). Complete en bloc resection was achieved for 85 lesions (78.7 %). Perforation occurred in 22 patients (20.4 %). Multivariate analysis confirmed that tumor size [odds ratio (OR): 1.084; 95 % confidence interval (CI): 1.015 - 1.158; P = 0.017] and the presence of fibrosis (OR: 4.551; 95 %CI: 1.092 - 18.960; P = 0.037) were independent risk factors for perforation. All cases of perforation were managed with nonsurgical treatment. Younger age and abdominal pain appeared to be related to prolonged hospitalization. Tumor size and fibrosis are important factors related to complications during colorectal ESD. Younger age and development of abdominal pain can predict the hospital course in patients with perforation after ESD.