Gastric Epithelial Neoplasms Research Articles

Gastric epithelial neoplasm of fundic-gland mucosa lineage: proposal for a new classification in association with gastric adenocarcinoma of fundic-gland type

BackgroundGastric adenocarcinoma of fundic-gland type (GA-FG) is a rare variant of gastric neoplasia. However, the etiology, classification, and clinicopathological features of gastric epithelial neoplasm of fundic-gland mucosa lineage (GEN-FGML; generic term of GA-FG related neoplasm) are not fully elucidated. We performed a large, multicenter, retrospective study to establish a new classification and clarify the clinicopathological features of GEN-FGML.MethodsOne hundred GEN-FGML lesions in 94 patients were collected from 35 institutions between 2008 and 2019. We designed a new histopathological classification of GEN-FGML using immunohistochemical analysis and analyzed via clinicopathological, immunohistochemical, and genetic evaluation.ResultsGEN-FGML was classified into 3 major types; oxyntic gland adenoma (OGA), GA-FG, and gastric adenocarcinoma of fundic-gland mucosa type (GA-FGM). In addition, GA-FGM was classified into 3 subtypes; Type 1 (organized with exposure type), Type 2 (disorganized with exposure type), and Type 3 (disorganized with non-exposure type). OGA and GA-FG demonstrated low-grade epithelial neoplasm, and GA-FGM should be categorized as an aggressive variant of GEN-FGML that demonstrated high-grade epithelial neoplasm (Type 2 > 1, 3). The frequent presence of GNAS mutation was a characteristic genetic feature of GEN-FGML (7/34, 20.6%; OGA 1/3, 33.3%; GA-FG 3/24, 12.5%; GA-FGM 3/7, 42.9%) in mutation analysis using next-generation sequencing.ConclusionsWe have established a new histopathological classification of GEN-FGML and propose a new lineage of gastric epithelial neoplasm that harbors recurrent GNAS mutation. This classification will be useful to estimate the malignant potential of GEN-FGML and establish an appropriate standard therapeutic approach.

Nature of a white opaque substance visualized by magnifying endoscopy in colorectal hyperplastic polyps.

Background and study aims A white opaque substance (WOS) has been observed in the epithelia of gastric, duodenal, and colorectal epithelial adenomas and carcinomas, using magnifying endoscopy (ME). The WOS has been reported to be derived from a dense accumulation of minute lipid droplets in the epithelium. This study aimed to investigate whether the WOS in colorectal hyperplastic polyps was derived from lipid droplets accumulated in the epithelium, as observed in the case of gastric, duodenal, and colorectal epithelial neoplasms. Patients and methods We analyzed 30 consecutive patients who were positive for the WOS, as visualized in colorectal hyperplastic polyps by ME with narrow-band imaging and 30 consecutive patients who were negative for the WOS. Biopsy specimens obtained from the polyps were immunostained with anti-adipophilin antibody to determine the correlation between the presence of the WOS and that of lipid droplets in the epithelium. Results In all patients, the epithelial cells were histologically positive for adipophilin. However, the area of adipophilin-positive epithelial cells in the WOS-positive group was significantly larger than that in the WOS-negative group ( P < 0.001). The density of the WOS was strongly and positively correlated with the area of adipophilin-positive cells. Conclusions This study reveals that the WOS visualized in the superficial layers of colorectal hyperplastic polyps is produced by a dense accumulation of minute lipid droplets in the epithelia of the polyps.

Sporadic foveolar-type gastric adenoma with a raspberry-like appearance in Helicobacter pylori-naïve patients.

Sporadic foveolar-type gastric adenoma (FGA) has been described as an extremely rare polyp that is whitish and flatly elevated. However, we recently found that sporadic FGA with a raspberry-like appearance (FGA-RA) is not rare in Helicobacter pylori (H. pylori)-naïve gastric mucosa. We endoscopically or surgically treated 647 patients with gastric epithelial neoplasms in the last 5 years, with 7.7% (50/647) being H. pylori-naïve. Among these, 43 FGA-RAs were diagnosed based on histologic and endoscopic features in 34 patients, who were all enrolled in this retrospective study. All lesions were observed by white-light endoscopy (WLE) and narrow-band imaging with magnification endoscopy (NBIME). We subsequently analyzed their endoscopic and microscopic features and patient characteristics. The patients were 22 males and 12 females aged 57±23 years (mean±2SD). WLE showed raspberry-like small polyps mimicking gastric hyperplastic polyps in the oxyntic gastric compartment (body/fundus). Multiple growths were confirmed in 20.6% (7/34) of the patients. NBIME revealed irregularly shaped papillary/gyrus-like microstructures with abnormal capillaries. Histologically, all lesions were intraepithelial neoplasms, and most of lesions (62.8%, 27/43) exhibited low-grade dysplasia. Immunohistochemically, neoplastic cells featured strong and diffuse MUC5AC expression, negative or very low MUC6 expression, and negative MUC2/CD10 expression. They also showed Ki-67 hyperexpression with a mean labeling index of 59.4±48.7%. The coexistence of fundic gland polyps in the background mucosa was significantly higher in multiple FGA-RA cases than in solitary cases (100% vs. 55.5%, P< 0.05). FGA-RA is a newly suggested histologic variant of sporadic FGA whose occurrence is not rare in daily endoscopic practice.

A Prospective Validation and Observer Performance Study of a Deep Learning Algorithm for Pathologic Diagnosis of Gastric Tumors in Endoscopic Biopsies.

Gastric cancer remains the leading cause of cancer-related deaths in Northeast Asia. Population-based endoscopic screenings in the region have yielded successful results in early detection of gastric tumors. Endoscopic screening rates are continuously increasing, and there is a need for an automatic computerized diagnostic system to reduce the diagnostic burden. In this study, we developed an algorithm to classify gastric epithelial tumors automatically and assessed its performance in a large series of gastric biopsies and its benefits as an assistance tool. Using 2,434 whole-slide images, we developed an algorithm based on convolutional neural networks to classify a gastric biopsy image into one of three categories: negative for dysplasia (NFD), tubular adenoma, or carcinoma. The performance of the algorithm was evaluated by using 7,440 biopsy specimens collected prospectively. The impact of algorithm-assisted diagnosis was assessed by six pathologists using 150 gastric biopsy cases. Diagnostic performance evaluated by the AUROC curve in the prospective study was 0.9790 for two-tier classification: negative (NFD) versus positive (all cases except NFD). When limited to epithelial tumors, the sensitivity and specificity were 1.000 and 0.9749. Algorithm-assisted digital image viewer (DV) resulted in 47% reduction in review time per image compared with DV only and 58% decrease to microscopy. Our algorithm has demonstrated high accuracy in classifying epithelial tumors and its benefits as an assistance tool, which can serve as a potential screening aid system in diagnosing gastric biopsy specimens.

White Opaque Substance, a New Optical Marker on Magnifying Endoscopy: Usefulness in Diagnosing Colorectal Epithelial Neoplasms.

Background/AimsA white substance that is opaque to endoscopic light is sometimes observed in the epithelium during narrowband imaging with magnifying endoscopy of gastric or colorectal epithelial neoplasms. This prospective observational study aimed to determine whether the morphology of the white opaque substance (WOS) allows differential diagnosis between colorectal adenoma and carcinoma. MethodsA consecutive series of patients with colorectal adenomas or early carcinomas who underwent endoscopic resection or surgical excision were studied. The morphology of the WOS was determined based on endoscopic images before the histopathological diagnosis was performed. The primary outcome was the diagnostic performance of an irregular WOS as a marker of colorectal carcinoma. ResultsThe study analyzed 125 lesions. A total of 33 lesions showed an irregular WOS, and 92 lesions showed a regular WOS. Among the 33 lesions found to show an irregular WOS, 30 were carcinomas. Among the 92 lesions showing a regular WOS, 79 were adenomas. With irregular WOS as a marker of carcinoma, the diagnostic accuracy was 87%, sensitivity was 91%, and specificity was 86%. ConclusionsThis study demonstrated the potential usefulness of the morphology of the WOS as a marker for the differential diagnosis between adenoma and carcinoma in cases of colorectal epithelial neoplasms.

Association between Charlson comorbidity index and complications of endoscopic resection of gastric neoplasms in elderly patients

BackgroundAlthough endoscopic resection is safe and effective for gastric epithelial neoplasms, information is limited on its efficacy and safety in extremely elderly patients who have various comorbidities. Further, the relationship between comorbidities and complications of endoscopic resection is not well established. Therefore, we aimed to evaluate the efficacy and safety of endoscopic resection of gastric epithelial neoplasms in extremely elderly patients.MethodsFrom October 2008 to December 2017, 4475 consecutive patients underwent endoscopic resection of gastric epithelial neoplasms. Among them, 242 were 75 years or older. We assessed Charlson comorbidity index (CCI) scores, procedural outcomes, and procedure- and sedation-related complications related to endoscopic resection.ResultsMean patient age was 78.7 ± 3.2 years. Of the 242 patients, 124 (51.2%) had low-grade dysplasia and 112 (46.3%) had adenocarcinoma. The most common comorbidity was hypertension (55.4%), followed by diabetes (23.1%). The mean CCI score was 1.67 ± 1.43. Sixty patients (24.8%) had a CCI score ≥ 3. During the procedure, 10 (4.1%) patients had desaturation that recovered by flumazenil use with mask (n = 2) or Ambu bag (n = 3) ventilation. During subsequent admission, atelectasis or pneumonia occurred in 45 (18.6%) patients, post-procedural bleeding in 12 (5.0%), and perforation in 3 (1.2%). Respiratory complications were more common in patients with a CCI score ≥ 3 (20/60, 33.3%) than in those with a CCI score < 3 (25/182, 13.7%, P = 0.002).ConclusionsCCI score is related to respiratory complications of endoscopic resection in extremely elderly patients. Endoscopic resection must be performed cautiously, particularly in elderly patients with a high CCI score, to prevent respiratory complications.

The relationship of mast cell density in pulmonary, gastric and ovarian malignant epithelial tumors with tumor necrosis and vascularization.

Although many studies have been conducted to explore the relationship between mast cells (MC) and angiogenesis, comparison of this relationship with tumor necrosis has not been investigated to the best of our knowledge. Therefore, the relationship between MC and neovascularization in stomach, lung and ovarian malignant epithelial tumors (165 cases) in necrotizing or non-necrotizing cases was explored in this study. We immunohistochemically studied anti-mast cell tryptase antibody for MC and anti-CD34 antibody for vascular structures. MCs in the intra- tumoral and peritumoral fields, as well as vascular structures with luminal and monocellular appearances in the intratumoral field, were counted in each sample. Ten magnification fields were analyzed for each sample. In stomach and lung cases, the non-necrotizing group exhibited a greater number of MC and vascular structures in total. In ovarian cases, more MCs were counted overall in the necrotizing group, but there were fewer vascular structures. The increase in the number of MC and vascular structures in lungs and stomach in the non-necrotizing group supports the theory that MCs are involved in tumor progression. Necrosis, which can be induced on the basis of restricted neovascularization through inhibition of MCs in lung and stomach tumors, may be a treatment method.

2019 WHO classification of gastric epithelial tumors, 5th edition

2019 WHO classification of gastric epithelial tumors, 5th edition

Efficacy and Safety of a Patient-positioning Device (EZ-FIX® Cushion) during Endoscopic Submucosal Dissection of Gastric Epithelial Neoplasm: A Prospective Randomized Trial

Efficacy and Safety of a Patient-positioning Device (EZ-FIX® Cushion) during Endoscopic Submucosal Dissection of Gastric Epithelial Neoplasm: A Prospective Randomized Trial

Helicobacter pylori Eradication after Endoscopic Resection of Gastric Epithelial Neoplasms

Helicobacter pylori Eradication after Endoscopic Resection of Gastric Epithelial Neoplasms

Factors associated with conversion to snare resection during gastric endoscopic submucosal dissection.

Although gastric endoscopic submucosal dissection (ESD) achieves a higher en-bloc resection rate compared to that with endoscopic mucosal resection (EMR) for gastric epithelial tumors, the higher complication rate and the longer procedure time are obstacles for its widespread use. Rescue EMR may be a valuable treatment option during difficult ESD procedures. We have aimed to identify the clinical outcomes and associated factors of rescue EMR during ESD. The medical records of patients who underwent ESD between January 2009 and February 2016 were reviewed. The clinical outcomes of rescue EMR during ESD and associated factors with rescue EMR were evaluated. A total of 1778 gastric epithelial lesions were enrolled. ESD without using a snare and rescue EMR were performed in 94.5% and 5.5% of patients, respectively. Lesion locations of mid-third [odd ratio (OR 4.470)], upper-third (OR 1.997), and submucosal fibrosis (OR 1.906) were the significant associated factors with rescue EMR. The en-bloc resection rate and complete resection rate of rescue EMR were lower than that of ESD (98.4% vs. 93.8% and 96.2% vs. 83.5%, respectively). Local recurrence rate was higher after rescue EMR than that after ESD (4.1% vs. 1.2%). Procedure-related complications and procedure time were not significantly different between the two groups. In a difficult ESD procedure, rescue EMR may be an alternative treatment option, especially for lesions located at the mid-to-upper third of the stomach, without increasing either the procedure time or the rate of complications.

Laparoscopic endoscopic cooperative surgery (LECS) for the gastrointestinal tract: Updated indications.

Laparoscopic and endoscopic cooperative surgery (LECS) is a procedure combining laparoscopic gastric resection with endoscopic submucosal dissection for local resection of gastric tumors with appropriate, minimal surgical resection margins. The LECS concept was initially developed from the classical LECS procedure for gastric submucosal tumor resection. Many researchers reported that classical LECS was a safe and feasible technique for resection of gastric submucosal tumors, regardless of tumor location, including the esophagogastric junction. Recently, LECS was approved for insurance coverage by Japan's National Health Insurance plan and widely applied for gastric submucosal tumor resection. However, the limitations of classical LECS are the risk of abdominal infection, scattering of tumor cells in the abdominal cavity, and tumor cell seeding in the peritoneum. The development of modified LECS procedures, such as inverted‐LECS, non‐exposed endoscopic wall‐inversion surgery, a combination of laparoscopic and endoscopic approaches to neoplasia with a non‐exposure technique, and closed‐LECS, has almost resolved these drawbacks. This has led to a recent increase in the indication of modified LECS to include patients with gastric epithelial neoplasms. The LECS concept is also beginning to be applied to tumor excision in other organs, such as the duodenum, colon and rectum. Further evolution of LECS procedures is expected in the future. Sentinel lymph node mapping could also be combined with LECS, resulting in a portion of early gastric cancers being treated by LECS with sentinel node mapping.

Clinical outcomes of endoscopic treatment for gastric epithelial neoplasm in remnant stomach after distal gastrectomy

Backgrounds/aimWe aimed to evaluate the feasibility of endoscopic treatment for gastric epithelial neoplasm in the remnant stomach after distal gastrectomy and compared the clinical outcomes by tumor location and endoscopic treatment modality. MethodsWe reviewed the data of patients who underwent endoscopic treatment for gastric epithelial neoplasms in the remnant stomach after distal gastrectomy between January 1996 and August 2013. The treatments included endoscopic resection or argon plasma coagulation. ResultsHerein, 107 patients (median age, 65.1 years; 92 men) encompassing 117 cases of gastric neoplasms in the remnant stomach after distal gastrectomy were endoscopically treated. Forty of these lesions were located at anastomotic sites; they were treated with endoscopic resection in 29 cases (72.5%) and argon plasma coagulation in 11 cases (27.5%). For 77 lesions located on the non-anastomotic site, endoscopic resection was performed in 68 cases (88.4%) and argon plasma coagulation was performed in nine cases (11.7%; p = 0.031). The mean endoscopic resection duration was significantly longer in the anastomotic site group than in the non-anastomotic site group (43.6 vs. 26.3 min, p = 0.018). Recurrence was observed in five (12.8%) patients in the former and in one (1.3%) in the latter (p = 0.015); all the patients were successfully retreated with endoscopic resection or APC. ConclusionsEndoscopic treatment for gastric epithelial neoplasm in a remnant stomach after distal gastrectomy is effective and safe. However, closely monitoring for recurrence should be conducted, particularly when the tumor is located at the anastomotic site.

Safety and Efficacy of Nonanesthesiologist-Administrated Propofol during Endoscopic Submucosal Dissection of Gastric Epithelial Tumors.

Objective There is no consensus regarding administration of propofol for performing endoscopic submucosal dissection (ESD) in patients with comorbidities. The aim of this study was to evaluate the safety and efficacy of propofol-induced sedation administered by nonanesthesiologists during ESD of gastric cancer in patients with comorbidities classified according to the American Society of Anesthesiologists (ASA) physical status. Methods Five hundred and twenty-two patients who underwent ESD for gastric epithelial tumors under sedation by nonanesthesiologist-administrated propofol between April 2011 and October 2017 at Dokkyo Medical University Hospital were enrolled in this study. The patients were divided into 3 groups according to the ASA physical status classification. Hypotension, desaturation, and bradycardia were evaluated as the adverse events associated with propofol. The safety of sedation by nonanesthesiologist-administrated propofol was measured as the primary outcome. Results The patients were classified according to the ASA physical status classification: 182 with no comorbidity (ASA 1), 273 with mild comorbidity (ASA 2), and 67 with severe comorbidity (ASA 3). The median age of the patients with ASA physical status of 2/3 was higher than the median age of those with ASA physical status of 1. There was no significant difference in tumor characteristics, total amount of propofol used, or ESD procedure time, among the 3 groups. Adverse events related to propofol in the 522 patients were as follows: hypotension (systolic blood pressure < 90 mmHg) in 113 patients (21.6%), respiratory depression (SpO2 < 90%) in 265 patients (50.8%), and bradycardia (pulse rate < 50 bpm) in 39 patients (7.47%). There was no significant difference in the incidences of adverse events among the 3 groups during induction, maintenance, or recovery. No severe adverse event was reported. ASA 3 patients had a significantly longer mean length of hospital stay (8 days for ASA 1, 9 days for ASA 2, and 9 days for ASA 3, P = 0.003). However, the difference did not appear to be clinically significant. Conclusions Sedation by nonanesthesiologist-administrated propofol during ESD is safe and effective, even for at-risk patients according to the ASA physical status classification.

Continuous Infusion versus Intermittent Dosing with Pantoprazole for Gastric Endoscopic Submucosal Dissection.

Background/AimsProton pump inhibitors are widely used to prevent gastric endoscopic submucosal dissection (ESD)-related bleeding, but no standard administration regimens have been established. We aimed to prospectively compare the effects of continuous infusion and intermittent dosing with pantoprazole on preventing gastric ESD-related bleeding. Additionally, we analyzed the risk factors for bleeding.MethodsFrom April 2012 to May 2013, patients with a gastric epithelial neoplasm scheduled for ESD in the Pusan National University Hospital were randomly assigned to one of two groups according to the pantoprazole administration regimen (continuous infusion or intermittent dosing). The primary outcomes measured were intra- and postprocedural bleeding events.ResultsThe final analysis included 401 patients. The rate of significant intraprocedural bleeding was 25.4% in the C group and 24.0% in the I group, with no significant difference (p=0.419). In addition, there was no significant difference in the postprocedural bleeding rate between the C and I groups (11.7% vs 10.2%, p=0.374). Multivariate analysis showed that intraprocedural bleeding was associated with the proximal tumor location, the presence of fibrosis, and the size of the resected specimen, whereas postprocedural bleeding was associated with the size of the resected specimen and the procedure/coagulation time.ConclusionsIntermittent dosing with pantoprazole is sufficient and cost-effective for the prevention of gastric ESD-related bleeding. Operators should consider tumor characteristics when planning ESD to minimize the risk of intraprocedural bleeding, and patients with large iatrogenic ulcers should be carefully monitored for postprocedural bleeding.

Associated risk factors for psychological distress in patients with gastric epithelial neoplasm undergoing endoscopic submucosal dissection.

This study aimed to evaluate the psychological distress and associated risk factors for distress among patients with gastric epithelial neoplasm undergoing endoscopic submucosal dissection (ESD).A total of 91 patients treated with ESD for gastric epithelial neoplasm between May 2015 and June 2016 were prospectively enrolled. Sociodemographic factors, psychological distress, anxiety, depression, stress, and associated risk factors for psychological distress were evaluated the day before ESD.Twenty-six (28.6%) patients were identified as patients with psychological distress. The psychological distress group had a higher female ratio and more depression and anxiety symptoms than the non-distress group. Distress was also related to stress level. A multivariate analysis showed that unmarried status (odds ratio [OR], 4.94; 95% confidence interval [CI], 1.13–21.56, P = .034), anxiety (OR, 1.24; 95% CI, 1.12–1.39, P <.001), and stress (OR, 1.06; 95% CI, 1.01–1.12, P = .011) were associated with psychological distress.An unmarried status and a high level of anxiety and stress were associated with more psychological distress in patients undergoing gastric ESD. It could be helpful to screen and proactively monitor patients with such conditions before performing gastric ESD.

Efficacy of Surgicel® (Fibrillar) for preventing bleeding after endoscopic submucosal dissection for gastric epithelial tumors.

Surgicel (Fibrillar), i.e. oxidized regenerated cellulose, is used to control oozing bleeding after surgery, but few studies have assessed its effect on complications after endoscopic treatment. The aim of this study was to evaluate the efficacy of Surgicel for preventing bleeding after endoscopic submucosal dissection (ESD) for gastric epithelial tumors. From November 2012 to December 2013 patients scheduled for ESD of gastric epithelial tumors were prospectively enrolled in this study. Patients were assigned randomly to monotherapy with a proton pump inhibitor (PPI) (the MT group) or combination therapy with Surgicel and histamine-2 receptor antagonist (H2 RA) (the CT group) for preventing bleeding after ESD. Major bleeding rates and changes in hemoglobin at 1 and 7 days after ESD were evaluated. Among the 157 patients enrolled (111 men, 46 women), 78 were assigned to the MT group and 79 to the CT group; finally, 72 and 74 patients were included in the MT and CT groups. The major bleeding rate was lower in the CT group (6/74, 8.1%) than in the MT group (12/72, 16.7%), but the difference was not significant (P = 0.354). The change in hemoglobin was significantly less marked in the CT group than the MT group 1 day after ESD ([-6.2 ± 9.0] g/L vs [-8.9 ± 6.2] g/L, P = 0.045). Combination therapy with Surgicel and an H2 RA decreased the rate of bleeding similarly to PPI. Adding Surgicel to H2 RA could be considered for patients with bleeding tendencies, or who require continuous antiplatelet therapy to prevent bleeding after ESD.

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.

Outcomes of endoscopic submucosal dissection for gastric epithelial neoplasm in chronic kidney disease patients: propensity score-matched case–control analysis

Little is known about the outcomes of gastric endoscopic submucosal dissection (ESD) in patients with chronic kidney disease (CKD). We compared the efficacy and safety of ESD between CKD and non-CKD patients. From January 2005 to December 2014, 102 CKD patients underwent ESD for gastric neoplasms at a tertiary medical institution were reviewed retrospectively. A propensity score-matched control group (102 patients) was selected from non-CKD patients to compare clinical outcomes between CKD and non-CKD patients. En bloc resection (96.1%) and curative resection (88.2%) rates in the CKD group did not significantly differ from those in the non-CKD group. Median procedure times (25.0 vs. 21.5min, p = 0.734) and perforation risk (p = 0.480) were similar between groups. The CKD group showed a tendency towards more bleeding events (p = 0.052) and had a significantly longer hospital stay (p = 0.001). In a subgroup analysis, stage 3 CKD patients exhibited a bleeding risk comparable to that exhibited by non-CKD patients (HR 1.35; 95% CI 0.36-5.06; p = 0.654), whereas stage 4 (HR 5.79; 95% CI 1.52-22.0; p = 0.010) and stage 5 (HR 4.80; 95% CI 1.58-14.6; p = 0.006) patients showed higher bleeding risks than non-CKD patients. In a multivariate analysis, stage 4/5 CKD was a significant predictor for bleeding risk (HR 4.99; 95% CI 1.32-18.8; p = 0.018). ESD for gastric epithelial neoplasms can be performed in stage 3 CKD patients with comparable efficacy and safety to that performed in non-CKD patients. Stage 4 and 5 CKD patients should be closely monitored for bleeding events after ESD.

Efficacy and safety of endoscopic submucosal dissection for gastric neoplasms in patients with compensated liver cirrhosis: a propensity score–matched case-control study

The clinical outcomes of endoscopic submucosal dissection (ESD) for gastric neoplasms in liver cirrhosis patients have not been adequately reported, leading to clinician concerns about adverse events, including bleeding and the deterioration of liver function. We compared the efficacy and safety of ESD between cirrhosis and noncirrhosis patients. Between January 2005 and December 2014, 158 cirrhosis patients underwent ESD for gastric neoplasms at a tertiary medical institution. Their clinical outcomes were compared with those of a propensity score-matched control group (158 patients) selected from noncirrhosis patients, using age, sex, histology, tumor location, and lesion size as variables. En bloc resection (96.8%), curative resection (89.9%), and adverse event (bleeding [10.1%] and perforation [1.9%]) rates in the cirrhosis group did not differ significantly from those in the noncirrhosis group. The median procedure time (25.0 vs 23.0 minutes) was also comparable between the groups. In a survival analysis cirrhosis patients exhibited a significantly higher mortality risk than noncirrhosis patients (hazard ratio [HR], 3.52; 95% confidence interval [CI], 1.35-9.23; P= .01). Cirrhosis patients without hepatocellular carcinoma (HCC) showed no statistically significant difference in mortality compared with the noncirrhosis group (HR, 2.14; 95% CI, .72-6.39; P= .171). Three of 153 patients (2%) exhibited a deterioration of prognosis from Child-Pugh class A to B. In compensated cirrhosis patients, especially those without HCC, ESD for gastric epithelial neoplasms can be performed with safety and efficacy comparable with that in noncirrhosis patients, without deterioration in liver function.