Initial Endoscopic Submucosal Dissection Research Articles

Repeat endoscopic submucosal dissection close to the initial endoscopic submucosal dissection scar for superficial esophageal squamous cell carcinoma.

Repeat endoscopic submucosal dissection for metachronous recurrence of esophageal squamous cell carcinoma close to previous endoscopic submucosal dissection scars is challenging. Therefore, this study evaluated the efficacy and safety of repeat endoscopic submucosal dissection for recurrent esophageal squamous cell carcinoma. The study included 1680 patients. After propensity score matching, esophageal endoscopic submucosal dissection-related outcomes were compared between the post-endoscopic submucosal dissection scar group (n = 91) and first endoscopic submucosal dissection group (n = 910). The Kaplan-Meier method and log-rank tests were used to compare both groups' survival and local recurrence curves. After propensity score matching, the two groups showed no significant difference in en bloc resection rate (97.80% vs. 99.56%, p = 0.096), treatment time (64.75min vs 61.33min, p = 0.448), recurrence rate (3.30% vs. 2.20%, p = 0.458), and stricture rate (7.69% vs. 4.07%, p = 0.110). However, the perforation rate was higher in the post-endoscopic submucosal dissection scar group than in the first endoscopic submucosal dissection group (4.40% vs. 1.10%, p = 0.031). The 5-year overall survival rates in the post-endoscopic submucosal dissection scar and first endoscopic submucosal dissection groups were 88.6% and 89.0%, respectively. Repeated esophageal endoscopic submucosal dissection for recurrent esophageal squamous cell carcinoma yielded satisfactory clinical outcomes and survival rates. Therefore, repeat endoscopic submucosal dissection may effectively treat esophageal squamous cell carcinoma recurrence close to the initial endoscopic submucosal dissection scars.

The Characteristics and Treatment Outcomes of 71 Duodenal Brunner’s Gland Adenomas with Endoscopic Submucosal Dissection

Introduction: The aim of this study was to investigate outcomes of patients with duodenal Brunner’s gland adenomas (BGAs) that were treated endoscopically. Methods: We identified 71 consecutive patients treated at our center with endoscopic submucosal dissection (ESD) for their duodenal tumors diagnosed pathologically as BGAs over the period between January 1, 2011 and December 31, 2021. We retrospectively analyzed our experience and short- and long-term outcomes of ESD therapy on patients with BGAs. Results: Among 71 BGA patients with an average age of 57 ± 11.7 years (range: 30–82), 48 (67.6%) were male and 23 (32.4%) were female. The accuracy of preoperative diagnosis with endoscopic ultrasonography was 44.0% (22/50). The H. pylori infection was found in 29 patients (29/71, 40.8%). The median size of BGAs was 1.5 cm (interquartile range [IQR] 0.8–2.7 cm). The most common location was the duodenum bulb (50/71, 64.8%). For the ESD procedure, the median operation time was 15.0 min (IQR 9.5–25.5 min). The en bloc and the complete resection rates were 97.2% and 92.3%, respectively. ESD-related mild acute obstructive pancreatitis was present in 2 patients (2/4, 50%) with BGAs located in the ampulla region. During the follow-up period, 1 patient with a positive peripheral margin experienced tumor recurrence 2 years after the initial ESD. There was no disease-related death for the cohort. Conclusion: ESD was an effective and safe therapeutic option for BGA patients with excellent outcomes. Long-term follow-up is needed.

Multiple Epstein-Barr virus-associated Gastric Cancers Arising in a Patient with Autoimmune Gastritis.

Epstein-Barr virus-associated gastric cancer (EBVaGC) has been reported to be associated with chronic inflammation of the gastric epithelium caused by Helicobacter pylori infection. Autoimmune gastritis (AIG) is also believed to increase the risk of carcinogenesis. We herein report a case of multiple EBVaGCs that arose in a patient with AIG, highlighting the potential for multiplicity of this entity. In this case, a total of four metachronous EBVaGCs were found after initial Endoscopic submucosal dissection for EBVaGC, all of which were treated endoscopically. This case demonstrates that patients with AIG should be monitored closely for development of EBVaGC.

Long-term outcome of cervical lymph node metastasis in superficial pharyngeal squamous cell carcinoma after endoscopic submucosal dissection

Superficial pharyngeal squamous cell carcinoma (PSCC) has received increasing attention as a therapeutic target in the GI field with recent innovations in endoscopic submucosal dissection (ESD). However, there are currently no defined criteria for the application of ESD to superficial PSCC. One of the problems encountered during follow-up after ESD is cervical lymph node metastasis (LNM). Identifying the clinicopathologic predictors of cervical LNM can help to provide a basis for the refinement of therapeutic strategies for superficial PSCC. The risk of cervical LNM was evaluated in 331 patients with superficial PSCC who underwent initial ESD between 2008 and 2021. Since tumor size, rather than depth, is the dominant factor in the current TNM classification for PSCC, the correlation between tumor size and thickness was investigated. The median follow-up period was 4.8 years. The cumulative 5-year cervical LNM rate was 6.1%. Multivariate Cox proportional hazards regression analysis identified tumor thickness≥1000 μm and lymphatic invasion as significant independent predictors. Among 204 cases with subepithelial invasion, both factors were also revealed to be significant independent predictors, suggesting that tumor thickness was superior to tumor size in predicting cervical LNM. Despite the positive correlation between tumor thickness and size, there was noticeable variability in the values (R= .20), and the current staging was inadequate to identify groups at high risk for cervical LNM. Tumor thickness and lymphatic invasion are validated as significant independent predictors for cervical LNM and can be useful indicators to optimize the therapeutic strategies for superficial PSCC.

The influence of procedural volume on the outcome of endoscopic submucosal dissection for gastric neoplasm: A nationwide population-based study.

285 Background: Endoscopic submucosal dissection (ESD) is a well-established treatment modality for gastric neoplasms. The aim of this study was to investigate the effect of procedural volume on the outcome of endoscopic submucosal dissection (ESD) for gastric cancer or adenoma. Methods: Patients who underwent ESD for gastric cancer or adenoma from November 2011 to December 2017 were identified using the Korean National Health Insurance Service database. Operational definitions to identify target population and post-procedural complications were created by combining the diagnosis and procedure codes, and validated using individual hospital medical record data. The outcomes were the occurrence of post-procedural complications (bleeding, perforation, pneumonia, and 30-day mortality) and additional resection within 180 days after the initial ESD procedure. Hospital volume was categorized into four groups based on the mean annual number of procedures: very high-, high-, low-, very low-volume hospitals (VHVH, HVH, LVH, VLVH). The outcome of ESD was compared in relation to hospital volume. Results: There were 95,411 procedures in 89,780 patients during the study period. There were 5,607 composite events, which included 5,098 bleeding, 601 perforation, and 712 pneumonia cases, respectively. Additional resection within 180days occurred in 7,900 cases. There were significant differences in ESD-related adverse outcomes among the four hospital volume categories. Multiple logistic regression revealed that VHVH, HVH, and LVH were associated with significantly lower relative risk of composite outcome, when compared to VLVH. Similar tendencies were also shown in terms of bleeding, perforation, and pneumonia. This volume-outcome association was not evident in additional resection. Conclusions: Hospital volume was closely associated with adverse clinical outcome in patients with ESD for gastric cancer or adenoma. The outcomes of gastric ESD should be closely and systemically monitored to ensure the safety of patients. [Table: see text]

Risk factors for vertical incomplete resection in endoscopic submucosal dissection of deep invasive submucosal colorectal cancer

Introduction It has been recently reported that deep invasive submucosal (T1b) colorectal cancer (CRC) without other pathological risk factors for lymph node metastasis has a low rate of lymph node metastasis, increasing the possibility of endoscopic submucosal dissection (ESD) in the future. However, ESD for T1b CRC is technically difficult, and some lesions cannot be resected en bloc. This study aimed to identify the risk factors associated with vertical incomplete ESD in T1b CRC. Methods We retrospectively studied 140 pathological T1b CRC lesions that underwent initial ESD at our institution between January 2011 and October 2020, and categorized them into positive vertical margin (PVM) and negative vertical margin (NVM) groups. The risk factors for PVM were examined using univariate and multivariate analyses, and a subgroup analysis for T1b CRC with an obvious depressed surface was performed. Results Multivariate analysis revealed obvious depression (hazard ratio [HR]: 7.4; 95% confidence interval [CI]: 2.47–22.5) and severe fibrosis (HR: 11.4; 95% CI: 3.95–33.0) as significant risk factors for PVM. Length of depressed surface ≥12 mm (HR: 6.19; 95% CI: 1.56 –24.6) was identified as an independent predictor of PVM for T1b CRC with an obvious depression. Conclusion Pathological T1b CRC cases with an obvious depression and severe fibrosis are at a high risk of vertical incomplete ESD.

Repeat endoscopic submucosal dissection as salvage treatment for local recurrence of esophageal squamous cell carcinoma after initial endoscopic submucosal dissection

Local recurrence of esophageal squamous cell carcinoma (ESCC) after endoscopic resection does not have an established treatment. The efficacy and safety of repeat endoscopic submucosal dissection (ESD) for recurrent ESCC were determined in the study. Forty-three consecutive patients with 45 locally recurrent superficial ESCC lesions undergoing repeat ESD and 909 first ESD lesions for propensity score matching (PSM) at Zhongshan Hospital between January 2011 and January 2020 were retrospectively enrolled. After PSM (1:2), operation-related parameters were compared between repeat ESD and first ESD. In the repeat ESD group, the Kaplan-Meier method and log-rank tests were used for identification of risk factors for local recurrence after repeat ESD. As compared with propensity score-matched first ESD, rates of complete resection (86.7% vs 97.8%, P= .02) and curative resection (86.7% vs 96.7%, P= .06) were lower and procedure duration (54.8 ± 21.7 minutes vs 46.2 ± 20.6 minutes, P= .67) and hospital stay (4.3 ± 1.8 days vs 2.9 ± 1.4 days, P= .25) were longer in the repeat ESD group. The en-bloc resection rate (93.3% vs 98.8%, P > .11) remained comparable. Adverse events including bleeding (4.4% vs 0%, P= .11), perforation (.0% vs .0%, P > .99), and stricture (6.7% vs 2.2%, P= .33) presented with no difference. The 5-year overall survival rate and recurrence-free survival rate for repeat ESD was 100% and 86.0%, respectively. Multiplicity was significantly associated with recurrence after repeat ESD (P= .01). Repeat esophageal ESD showed favorable short- and long-term outcomes and thus provides an alternative choice for recurrent superficial ESCC.

Comprehensive risk evaluation for metachronous carcinogenesis after endoscopic submucosal dissection of superficial pharyngeal squamous cell carcinoma.

Pharyngeal squamous cell carcinoma (PSCC) is associated with a high likelihood of metachronous carcinogenesis, which is known to have a poor prognosis. This study aimed to identify comprehensive risk evaluation indicators for metachronous carcinogenesis after endoscopic submucosal dissection (ESD) of superficial PSCC. The risk of metachronous carcinogenesis was evaluated in 144 patients with superficial PSCC (with no history of PSCC or esophageal squamous cell carcinoma) who underwent initial ESD from 2008 to 2020. Multiple lugol-voiding lesions (LVLs) in the background pharyngeal and esophageal epithelium were evaluated as endoscopic indicators. The hemoglobin, albumin, lymphocyte, and platelet (HALP) score was analyzed as a serum marker. The median follow-up period was 4.3years. The coincidence rate for pharyngeal and esophageal LVL grade was 55%. The cumulative 3-year metachronous PSCC rate was 18.9%. The cumulative 3-year second metachronous PSCC rate was 43.9%. Forward stepwise multivariate Cox proportional hazards regression analysis identified pharyngeal LVL grade and a lower HALP score as significant independent predictors. Pharyngeal LVL grade was superior to esophageal LVL grade as a predictor of metachronous PSCC. A lower HALP score was significantly associated with younger age in forward stepwise multivariate logistic regression analysis. Patients with a history of superficial PSCC remain at risk for metachronous carcinogenesis over time, and long-term follow-up is imperative. Comprehensive evaluation of endoscopic features with a novel serum marker, namely, the HALP score, can help predict metachronous carcinogenesis.

Efficacy of Endoscopic Submucosal Dissection for Superficial Gastric Neoplasia in a Large Cohort in North America

Endoscopic submucosal dissection (ESD) is a widely accepted treatment option for superficial gastric neoplasia in Asia, but there are few data on outcomes of gastric ESD from North America. We aimed to evaluate the safety and efficacy of gastric ESD in North America. We analyzed data from 347 patients who underwent gastric ESD at 25 centers, from 2010 through 2019. We collected data on patient demographics, lesion characteristics, procedure details and related adverse events, treatment outcomes, local recurrence, and vital status at the last follow up. For the 277 patients with available follow-up data, the median interval between initial ESD and last clinical or endoscopic evaluation was 364 days. The primary endpoint was the rate of en bloc and R0 resection. Secondary outcomes included curative resection, rates of adverse events and recurrence, and gastric cancer-related death. Ninety patients (26%) had low-grade adenomas or dysplasia, 82 patients (24%) had high-grade dysplasia, 139 patients (40%) had early gastric cancer, and 36 patients (10%) had neuroendocrine tumors. Proportions of en bloc and R0 resection for all lesions were 92%/82%, for early gastric cancers were 94%/75%, for adenomas and low-grade dysplasia were 93%/ 92%, for high-grade dysplasia were 89%/ 87%, and for neuroendocrine tumors were 92%/75%. Intraprocedural perforation occurred in 6.6% of patients; 82% of these were treated successfully with endoscopic therapy. Delayed bleeding occurred in 2.6% of patients. No delayed perforation or procedure-related deaths were observed. There were local recurrences in 3.9% of cases; all occurred after non-curative ESD resection. Metachronous lesions were identified in 14 patients (6.9%). One of 277 patients with clinical follow up died of metachronous gastric cancer that occurred 2.5 years after the initial ESD. ESD is a highly effective treatment for superficial gastric neoplasia and should be considered as a viable option for patients in North America. The risk of local recurrence is low and occurs exclusively after non-curative resection. Careful endoscopic surveillance is necessary to identify and treat metachronous lesions.

Indocyanine green fluorescence lymphography during gastrectomy after initial endoscopic submucosal dissection for early gastric cancer

Indocyanine green (ICG) fluorescence lymphography can be used to visualize the lymphatic drainage of gastric cancer. Few studies have been performed to identify lymphatic drainage patterns after endoscopic submucosal dissection (ESD). ESD results in changes to lymphatics owing to fibrosis of the submucosal layer. This study aimed to evaluate the efficacy of ICG fluorescence lymphography for visualization of lymphatic drainage after ESD, and to assess its clinical application in additional gastrectomy after ESD for early gastric cancer. All patients who underwent gastrectomy after ESD between 2014 and 2017 in a single centre were reviewed. ICG was injected endoscopically into the submucosal layer around the ESD scar the day before surgery. At the time of surgery, lymph nodes (LNs) were visualized and lymphadenectomy was performed with near-infrared imaging. Ex vivo, all LNs were examined for the presence of fluorescence. Number of LNs resected and number of tumour-positive LNs were compared between patients who underwent near-infrared imaging and those who had conventional lymphadenectomy without intraoperative imaging. Some 290 patients underwent gastrectomy after ESD, 98 with fluorescence lymphography-guided lymphadenectomy and 192 with conventional lymphadenectomy. Fluorescence lymphography visualized lymphatic drainage in all patients, without complications related to ICG injection or near-infrared imaging. Fluorescence lymphography visualized all stations containing metastatic LNs. The sensitivity for detecting LN metastasis in fluorescent stations was 100 per cent (9 of 9 stations), and the negative predictive value was 100 per cent (209 of 209). One patient with LN metastasis had one non-fluorescent metastatic LN within a fluorescent station. Fluorescence lymphography successfully visualized all draining LNs after ESD, with high sensitivity and negative predictive value for detecting LN metastasis. Fluorescence lymphography-guided lymphadenectomy could be an alternative to systematic lymphadenectomy during additional surgery after ESD.

Long-Term Outcomes after Endoscopic Submucosal Dissection for Ulcerative Colitis-Associated Dysplasia

Introduction: The Surveillance for Colorectal Endoscopic Neoplasia Detection and Management in Inflammatory Bowel Disease Patients: International Consensus Recommendations guidelines recommend surveillance colonoscopy instead of colectomy after the complete removal of “endoscopically resectable” dysplastic lesions in ulcerative colitis (UC). There are no studies on long-term outcomes of endoscopic submucosal dissection (ESD) for UC-associated neoplasia (UCAN). We aimed to evaluate the clinical outcomes of ESD for UC-associated dysplasia (UCAD) during long-term follow-up. Methods: We retrospectively enrolled 17 consecutive UC patients with 22 UCADs, who underwent initial ESD or total proctocolectomy at the Hiroshima University Hospital. The clinicopathological features of the patients and neoplasias and clinical outcomes of ESD were evaluated and compared with those of total proctocolectomy. Results: UCAD in the ESD and total proctocolectomy groups was mostly noted on the left side of the colon, and most lesions were superficial macroscopic lesions. In the ESD group, en bloc resection and histological complete resection rates were 83 and 67%, respectively. One patient died of malignant melanoma; however, none of the patients died of UC-associated carcinoma in both groups. Metachronous neoplasias developed in 5 of the 7 patients in the ESD group. Among the 5 patients with metachronous UCAN, 4 finally underwent total proctocolectomy and 1 underwent additional ESD. Conclusions: ESD for UCAD is a useful method for total excisional biopsy. UC patients with UCAD resected by ESD have a high risk of developing metachronous UCAN during the follow-up period.

936 Endoscopic Submucosal Dissection as a Salvage Therapy After Failed Endoscopic Mucosal Resection for Colorectal Lesions: A Single Center Experience

INTRODUCTION: There is limited data in efficacy of Endoscopic Submucosal Dissection (ESD) as a salvage therapy after failed Endoscopic Mucosal Resection (EMR) attempt leading to scar tissue formation. We present a single center experience of ESD in evaluating safety and efficacy of ESD in treatment of colorectal lesions with failed prior attempt of EMR. METHODS: All patients who had ESD for colorectal lesions after prior unsuccessful attempt of removal by EMR, from 1/2013 to 12/2018 were included. Patient and procedure related data points were collected. Technical success was defined as successful completion of ESD to remove colonic lesions and clinical success was defined as complete removal of colonic lesions with negative margins. RESULTS: A total of 19 patients were included. The average age was 68.3 ± 7.5 years, 53% (10/19) patients were female. 10 patients had right sided, 2 patients had left sided and 7 patients had rectal lesions. The average size of the lesion was 3.9 ± 2.5 cm. 10 patients (53%) had en bloc resection and 9 patients (47%) had piecemeal resection despite ESD due to scar tissue formation from prior EMR attempt. Technical success of ESD was 100%. The average duration of the procedure was 103.5 ± 48 minutes. Complications occurred in 2 cases (10.5%), both had En bloc resection. One patient developed bleeding requiring endoscopic treatment and another patient developed microperforation managed conservatively. Of resected lesions, there were 9 tubular adenomas, 5 sessile serrated adenoma, 1 Tubulovillous adenoma, 1 neuroendocrine tumor and 3 samples with histology showing tubular adenoma but with positive margins for adenocarcinoma. ESD specimen added the diagnosis of carcinoma. All of the patients with en bloc resection had negative peripheral margins while of 9 patients who had piecemeal resection, 3 patients had positive margins for carcinoma. Thus clinical success of ESD was 84%. 2 of these patients required surgery while 1 was lost to follow up. Out of 16 patients with initial successful ESD, 13 patients had follow up for average 24 months without any recurrence (3 patients were lost to follow up). A trainee was involved in 60% of the procedures. CONCLUSION: ESD is a safe and effective method of diagnosis and treatment for colorectal lesions as a salvage therapy after failed EMR with overall low complication rates and low recurrence rates. ESD should be considered in centers of expertise prior to referring patients for surgical approach.

Incidence of metachronous gastric cancer in patients whose primary gastric neoplasms were discovered after Helicobacter pylori eradication

The incidence of metachronous gastric cancer (MGC) in patients whose primary gastric neoplasm is discovered after Helicobacter pylori eradication remains unclear. Here, we evaluated the long-term effect of previous H pylori eradication on development of MGC after endoscopic submucosal dissection (ESD). We analyzed prospectively collected data of consecutive patients with successful H pylori eradication more than 1 year before (eradicated group, 180 patients) or after (control group, 602 patients) initial curative ESD. These patients were also followed by endoscopy for over 2 years. Propensity score matching and inverse probability of treatment weighting (IPTW) were used to adjust for confounding variables during data analysis. The main outcome was the incidence of MGC after initial ESD. In a propensity-matched analysis of 174 pairs, the incidence of MGC was similar in the 2 cohorts (33.9 per 1000 person-years vs 40.8 per 1000 person-years in the control group, P= .454) at a median follow-up of 4.1 years (interquartile range, 3.0-5.6). Incidences were also similar in the 2 groups when data were analyzed using IPTW, even after exclusion of 123 patients with successful H pylori eradication<5 years before initial ESD. Multiple Cox regression analysis revealed age, differentiated-type histology, and initial multiplicity were predictors of MGC in patients after initial curative ESD. The frequency of follow-up surveillance after initial curative ESD should be kept constant, irrespective of whether H pylori eradication is performed before or after initial curative ESD.

Reliability of endoscopic biopsy compared with endoscopic submucosal dissection histopathologic diagnosis.

15 Background: Endoscopic biopsy is the most convenient and simple method for approaching gastric neoplasm. Aim of our study was to determine the diagnostic accuracy of biopsy during screening endoscopy compared to endoscopic submucosal dissection (ESD). Methods: 175 patients who underwent both screening endoscopic biopsy and ESD from 2015.01 to 2017.12 in Bucheon St. Mary’s hospital were retrospectively reviewed. Results: Seventeen lesions had different histopathological ESD findings compared with endoscopic biopsy. Among six endoscopic biopsies that showed atypia, four were diagnosed with adenocarcinoma and two maintained the results. 64 out of the 175 lesions showed low grade dysplasia by endoscopic biopsy. After ESD, two cases were diagnosed with high grade dysplasia and two cases were diagnosed with adenocarcinoma. Of 12 lesions which showed high grade dysplasia on endoscopic biopsy, four lesions turned out to be adenocarcinoma (three well differentiated, one moderately differentiated) after ESD. Of 91 adenocarcinoma lesions on endoscopic biopsy, three lesions had discrepancy on differentiation level and one lesion turned out to be signet ring cell carcinoma after all. Patients who were infected with Helicobacter pylori (H. pylori) had tendency to have discrepancy between initial biopsy and ESD histopathology result. (OR 3.68, 95% CI 1.08-11.955, P = 0.018). Conclusions: Discrepancy between endoscopic biopsy and post-ESD histopathology were found. Possibility of coexistence or progression to high grade neoplasm should be considered regarding endoscopic biopsy results especially if infected with H. pylori and active ESD histopathological confirmation needs to be done if necessary.

Characteristics of overlooked synchronous gastric epithelial neoplasia after endoscopic submucosal dissection.

Since endoscopic submucosal dissection (ESD) has been accepted as the treatment of choice for early gastric cancer (EGC) without risk of lymph node metastasis, synchronous gastric epithelial neoplasia is no longer rare in the clinical practice. Knowledge about the characteristics associated with synchronous gastric epithelial neoplasia is of great importance to prevent delayed diagnosis.Between November 2008 and December 2014, a retrospective study was conducted in a single tertiary referral hospital. Consecutive patients who underwent ESD due to EGC or high-grade dysplasia were analyzed to evaluate the incidence of synchronous gastric epithelial neoplasia and the factors associated with synchronous and overlooked synchronous lesions.A total of 488 patients were analyzed in this study. Synchronous lesions were found in 59 patients (12.1%) during the mean 37.7 months of follow-up. Among 77 synchronous lesions, 25 lesions (32.4%) were overlooked at the time of initial ESD. Age of ≥ 65 years, moderate to severe endoscopic atrophic gastritis, and elevated morphology of primary lesions were associated with synchronous gastric epithelial neoplasia. An important factor associated with overlooked lesions is the non-elevated morphology of lesions.Careful endoscopic examination of the whole stomach is necessary in patients who are older and who have moderate to severe atrophic gastritis and elevated morphology of lesions to prevent delayed diagnosis of synchronous gastric epithelial neoplasia, especially non-elevated lesions.

Early Detection is Important to Reduce the Economic Burden of Gastric Cancer.

PurposeEarly detection of gastric cancer is important to improve prognosis. Early detection enables local treatment, such as endoscopic submucosal dissection (ESD). Therefore, we investigated whether early detection of gastric cancer could reduce healthcare costs by comparison according to stage and treatment modalities.Materials and MethodsMedical care costs were investigated according to tumor stage and initial treatment modality in 1,188 patients newly diagnosed with gastric cancer at 7 medical institutions from December 2011 to June 2012. Total medical care costs during the first-year after diagnosis (total first-year costs) were examined, including the costs of initial treatment, post-initial treatment, and inpatient and outpatient visits.ResultsStage I (75.3%) was the most common cancer stage. ESD was the second most common treatment following surgery. Total first-year costs increased significantly from stages I to IV. The costs of initial treatment and post-initial treatment were lowest in patients with stage I cancer. Among patients with stage I cancer, total first-year costs were significantly lower when treated by ESD; in particular, initial ESD treatment costs were much lower than others.ConclusionsThe cost of healthcare has increased significantly with increasing cancer stages. ESD can greatly reduce medical care costs of gastric cancer. Thus, early detection of gastric cancer is important to reduce healthcare costs.

Risk factors for early metachronous tumor development after endoscopic resection for early gastric cancer.

BackgroundMetachronous gastric tumor (MGT) is one of major concerns after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Optimal follow-up strategy has not been yet well-established. The aim of this study was to identify the different clinical features of the patients according to the time interval to development of MGT.MethodsAmong 1,780 consecutive patients with EGC who underwent ESD between 2005 and 2014, 115 patients with MGT were retrospectively reviewed. MGT was defined as secondary gastric cancer or dysplasia detected > 1 year after initial ESD. Clinicopathological factors associated with early development of MGT were evaluated.ResultsThe median interval to development of MGT was 37 months. In univariate analysis, the median interval to MGT was shorter if EGC lesion was non-elevated type (39.4 vs 57.0 months, p = 0.011), or synchronous primary lesion was absent (39.8 vs 51.4 months, p = 0.050). In multivariate Cox’s proportional hazards analysis, the hazard ratios for early occurrence of MGT were 1.966 (95% CI: 1.141–3.386, p = 0.015) and 1.911 (95% CI: 1.163–3.141, p = 0.011), respectively. There was no significant difference in overall survival after diagnosis of MGT between the early occurrence group and the late occurrence group.ConclusionsNon-elevated gross type and absence of synchronous gastric tumor were independent risk factors for early development of MGT. Meticulous endoscopic inspection is especially important for the detection of MGT during the early follow-up period in patients with these initial tumor characteristics.

Factors Associated With Metachronous Gastric Cancer Development After Endoscopic Submucosal Dissection for Early Gastric Cancer.

To clarify the factors associated with metachronous gastric cancer development after endoscopic submucosal dissection (ESD) for early gastric cancer. Patients who undergo ESD for early gastric cancer have an appreciable risk of developing metachronous gastric cancer. However, there have been few reports on the association between life style and the development of such cancer. Patients with early gastric cancer who underwent ESD at our institution between 2003 and 2012 were enrolled. Metachronous gastric cancer was defined as secondary gastric cancer detected >1 year after initial ESD. Factors, including age, gender, body mass index, eradication of Helicobacter pylori, cigarette smoking, drinking, and continuous use of a proton pump inhibitor, associated with metachronous gastric cancer development were evaluated by Cox proportional hazard regression analysis. A total of 539 patients with a mean 53.6-month follow-up period were analyzed. The 5-year cumulative incidence of secondary gastric cancer was 13.0%. Multivariate analysis exhibited that age of 60 years and above [hazard ratio (95% confidence interval)=4.05 (1.23-13.4)] and cigarette smoking [2.12 (1.19-3.78)] were independent risk factors for metachronous gastric cancer development. Furthermore, ≥20 pack-years of smoking [1.51 (1.03-2.24)] was a significant risk factor with a dose-response relationship (P for trend=0.042). There was no significant association between Helicobacter pylori eradication and metachronous gastric cancer development. This is the first study to demonstrate the detailed association between cigarette smoking and metachronous gastric cancer development.

Survival benefit of additional surgery after noncurative endoscopic resection in patients with early gastric cancer

Excellent long-term outcome is expected for early gastric cancers (EGCs) after endoscopic submucosal dissection (ESD). However, if ESD is considered noncurative at the pathologic evaluation, additional surgery is recommended. We evaluated whether long-term outcome is compromised if additional surgery is not performed for EGCs that are out-of-indication. We retrospectively analyzed a cohort of patients with EGC not meeting ESD indications whose initial treatment was either ESD (n= 219) or surgery (n= 1799). Among them, 127 patients who underwent additional surgery after initial ESD and 67 patients who did not were matched using propensity scores to patients who initially underwent standard surgery, at a 1:1 ratio. Overall mortality and gastric cancer recurrence were compared. The overall mortality and gastric cancer recurrence rates were not significantly different between the 127patients who underwent initial ESD with additional surgery and the corresponding initial standard surgerypatients. However, the overall mortality of the 67 patients who underwent ESD without additional surgery (5-year mortality, 26.0%; 95% CI, 13.5%-49.9%) was higher than that of the matched initial standard surgery patients (5-year mortality, 14.5%; 95% CI, 6.3%-33.6%; P= .04). Gastric cancer recurrence was also higher in ESD patients without additional surgery (5-year recurrence, 17.0%; 95% CI, 7.6%-37.8%) than in the matched initial surgery group (0%; P= .002). In multivariate analyses, ESD without additional surgery was a significant risk factor for overall mortality and gastric cancer recurrence. Additional surgery should be encouraged after non-curative ESD to obtain long-term outcomes comparable with those of initial standard surgery. (Clinical trial registration number: NCC2015-0093.).

Accuracy of diagnostic demarcation of undifferentiated-type early gastric cancers for magnifying endoscopy with narrow-band imaging: endoscopic submucosal dissection cases.

The usefulness of magnifying endoscopy with narrow-band imaging (ME-NBI) for undifferentiated-type early gastric cancers (UD-type EGCs) is unclear. The present study examined the accuracy of the diagnostic demarcation of lesions using ME-NBI. The study population consisted of 76 patients with UD-type EGC lesions measuring ≤20 mm in diameter using white-light imaging (WLI) and endoscopic ultrasonography and diagnosed as intramucosa and UL(-); all the lesions were confirmed as early gastric cancer based on postoperative pathological examination. All the patients had undergone an initial endoscopic submucosal dissection (ESD) at this hospital between January 2010 and January 2014. After marking with demarcation lines at the utmost oral and anal sites of the lesion using argon plasma coagulation under ME-NBI for intervention, the cases with demarcations that were consistent with the postoperative pathological findings were defined as having been accurately diagnosed. The inflammatory cell infiltration (Updated Sydney System, USS) were also assessed. The diagnostic demarcations of the lesion were consistent in 62 cases (81.6 %). The accurate diagnosis rate was higher for the USS cases with mild neutrophil and monocyte infiltration (P < 0.05). The addition of ME-NBI to WLI improved the accurate diagnosis rate by 27.6 %. The use of ME-NBI in diagnostic demarcation of UD-type EGCs is recommended.