Outcomes Of Endoscopic Submucosal Dissection Research Articles

Left colonic localization, non-granular morphology, and pit pattern independently predict submucosal fibrosis of naïve colorectal neoplasms before endoscopic submucosal dissection.

Endoscopic submucosal dissection (ESD) represents the method of choice for removal of large colorectal neoplasms with suspected submucosal invasion. Presence and degree of submucosal fibrosis increases ESD duration and technical complexity, reduces the rate of curative resection and reduces safety profile. The aim of the study was to identify pre-procedural predictive factors of submucosal fibrosis in naïve colorectal neoplasms and to assess the impact of fibrosis on technical and clinical ESD outcomes. All consecutive ESD performed between 2014 and 2021 were retrieved from a prospectively collected database. For each patient, pre-procedural, procedural, and post-procedural data were recorded. Logistic regression was used to identify pre-procedural predictive factors for submucosal fibrosis. The study was approved by Institutional Reviewer Board and registered on ClinicalTrials.gov (NCT04780256). One hundred-74 neoplasms (46.6% rectum, 21.8% left colon, 31.6% right colon; size 34.9 ± 17.5mm) from 169 patients (55.0% male; 69.5 ± 10.4-year-old) were included. 106 (60.9%) neoplasms were granular type laterally spreading tumor (LST-G), 42 (24.1%) non-granular (LST-NG), and 26 (14.9%) sessile; invasive pit pattern was observed in 90 (51.7%) lesions. No fibrosis (F0) mild (F1) and severe (F2) were observed in 62 (35.6%), 92 (52.9%), and 20 (11.5%), respectively. Left colonic localization [OR 3.23 (1.1-9.31)], LST-NG morphology [OR 5.84 (2.03-16.77)] and invasive pit pattern [OR 7.11 (3.11-16.23)] were independently correlated to submucosal fibrosis. Lower curative resection rate (59.8% vs. 93.5%, P < 0.001) was observed in case of fibrosis; the incidence of adverse events was higher in case of severe fibrosis (35.5%) compared to no (3.2%) and mild fibrosis (3.3%; P < 0.001). Procedure time was significantly impacted by presence and degree of fibrosis (P < 0.001). Left colonic localization, LST-NG morphology, and invasive pit pattern are independent predictors of fibrosis, affecting technical and clinical ESD outcomes. Pre-procedural stratification is pivotal to estimate procedure time, required operator's experience and advanced dissection techniques. Cecinato P et al. Left colonic localization, non-granular morphology, and pit pattern independently predict submucosal fibrosis of colorectal neoplasms before endoscopic submucosal dissection. Surg Endosc. 2023.

Endoscopic submucosal dissection for anastomotic lesions after colorectal surgery.

Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging. We aimed to characterize the clinicopathologic characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the lower gastrointestinal tract. We retrospectively investigated 55 patients with anastomotic lesions of the lower gastrointestinal tract who underwent ESD from February 2008 to January 2021. The lesions involving one or both sides of anastomoses were classified into the unilaterally involving anastomosis (UIA) or straddling anastomosis (SA) group, respectively. We collected clinicopathological characteristics, procedure-related parameters and outcomes, and follow-up data and analyzed the impact of anastomotic involvement. The mean age was 62.5years, and the median procedure duration was 30min. The rates of en bloc resection and R0 resection were 90.9% and 85.5%, respectively. Four patients (7.3%) experienced major adverse events (AEs). During a median follow-up of 66months (range 14-169), seven patients had local recurrence, and six patients had metastases. The 5-year disease-free survival and overall survival rates were 82.4% and 90.7%, respectively. The 5-year disease -specific survival (DSS) rate was 93.3%. Compared with the UIA group, the SA group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and R0 resection, and shorter disease-free survival (all P<0.05). However, rates of AEs did not differ significantly between the two groups. The short-term and long-term outcomes of ESD for colorectal anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for lesions at the anastomoses.

OGC P15 Outcomes of Endoscopic Submucosal Dissection for Neoplasia in Barrett's Oesophagus at a Single Tertiary UK Centre

Abstract Background Endoscopic therapies for dysplasia or early cancer in Barrett's Oesophagus have become well established over recent years. Endoscopic Submucosal Dissection (ESD) offers the benefit of en bloc resection and accurate histological staging of lesions which is particularly advantageous in cancers and may eliminate the need for major surgery in selected patients. However, ESD is not widely available in the United Kingdom (UK) and it remains a high risk procedure in Western settings with complication rates of up to 12–27% reported in the literature. Here we report our outcomes at a single tertiary referral centre in the UK. Methods Retrospective review of prospectively maintained database. Results 244 consecutive ESD were carried out in patients with Barrett's neoplasia with visible lesions. The mean age was 69.8 years and 201 patients were male. Median Prague classification was C2M5. The median lesion size was 30mm (range 5–120mm). En bloc resection was achieved in 95.5% of cases. Bleeding, perforation and strictures occurred in 0.82%, 0.82% and 6.97% of cases respectively. These were all managed endoscopically. Histology showed low grade dysplasia in 12 cases, high grade dysplasia in 37 cases, and adenocarcinoma in 192 cases. In the cases of adenocarcinoma, 131 were intramucosal (stage pT1a) and 60 were submucosally invasive (pT1b). Of the submucosally invasive cancers, 36 were SM1 and 24 &amp;gt;SM1. R0 resection was achieved in 74% of cancer cases. Following ESD, 93 patients underwent ablation of residual Barrett's, 25 underwent further endoscopic resection, 21 entered endoscopic surveillance only and 25 patients underwent oesophagectomy. Of the patients who underwent oesophagectomy, 9 were for T1b &amp;gt;SM1 disease, 8 for poor prognostic factors (including poorly differentiated adenocarcinoma, lymphovascular invasion or signet ring cells), 4 for R1 resection at deep margin, 3 for patient choice and 2 for difficult recurrence. Conclusions Our data demonstrates that ESD can be effectively targeted for cancers in patients based on endoscopic assessment by experienced endoscopists with 78.7% of procedures being carried out for early cancers. ESD is safe and effective in the majority of patients and informed the need for surgery in the appropriate group of individuals.

Endoscopic submucosal dissection for lesions involving the anastomosis after upper gastrointestinal surgery.

Endoscopic submucosal dissection (ESD) for anastomotic lesions is technically challenging due to severe fibrosis, deformity, staples, and limited space for procedure. We aimed to characterize the clinicopathological characteristics, feasibility, and effectiveness of ESD for anastomotic lesions of the upper gastrointestinal tract. We retrospectively investigated 43 patients with lesions involving the anastomoses of the upper GI tract who underwent ESD from April 2007 to February 2021. We collected clinicopathological characteristics, procedure‑related parameters and outcomes, and follow‑up data and analyzed the impact of anastomotic involvement. The median duration from previous upper GI surgery was 60months and the median procedure duration was 30min. The rate of en bloc resection and en bloc with R0 resection was 90.7% and 81.4%, respectively. Two patients (4.7%) experienced major adverse events, including delayed bleeding and febrile episode. During a median follow-up of 80months, 3 patients had local recurrence and 4 patients had metastases. The 5-year disease-free survival (DFS) and overall survival (OS) rates were 89.6% and 95.1%, respectively. Compared with the unilaterally involving group, the straddling anastomosis group had significantly longer procedure duration, larger specimen, lower rates of en bloc resection and en bloc with R0 resection, and shorter DFS and OS (all P < 0.05). However, rates of adverse events did not differ significantly between the two groups. The short‑ and long-term outcomes of ESD for upper GI anastomotic lesions were favorable. Although with technically challenging, ESD could be performed safely and effectively for anastomotic lesions.

Long-term clinical outcomes of endoscopic submucosal dissection in rectal neuroendocrine tumors based on resection margin status: a real-world study.

Endoscopic submucosal dissection (ESD) has been widely adopted in treating rectal neuroendocrine tumors (NETs). However, clinical outcomes in rectal NETs after ESD with different resection margin status remain scanty, particularly in patients with positive resection margins. This study aimed to evaluate the long-term clinical outcomes of ESD in rectal NET based on the resection margin status. This retrospective study included 436 patients diagnosed with rectal NET who had undergone ESD. Clinical data, including age, sex, tumor size, stage, invasion, and the resection margin status, were collected. Further, the patients were assessed for complications, recurrence, distant metastasis, and long-term outcomes. Among all 436 patients, 395 patients had their primary ESD in our hospital. Complete resection was achieved in 319 patients. Patients who did not achieve complete resection opted for follow-up (n = 73), salvage surgery (n = 1) and salvage ESD (n = 2). Another 41 had their primary ESD in other hospital with incomplete resection and had salvage ESD in our hospital. All 436 patients had a median follow-up period of 61.4months (range 33.4-125.3months). During the follow-up period, two patients developed recurrences, while three patients developed metastasis. There were no significant differences in the 5-year progression-free survival and overall survival between patients with incomplete resection opting for follow-up compared to the other two groups (P = 0.5/0.8). However, the complication rates were significantly higher in patients who received salvage ESD. This study demonstrated that positive resection margins have no influence on survival in patients with rectal NET treated using ESD.

Effective Retrograde Dissection by the Floating Tongue-Like Flap Method for Gastric Neoplasm Involving the Pyloric Channel.

Endoscopic submucosal dissection (ESD) of gastric neoplasm involving the pyloric channel (GNPC) is technically challenging due to difficulty in precise assessment of resection margin and inadequate visualization. The aim of this study was to evaluate the effectiveness and long-term outcome of ESD for GNPC and introduce a noble technique for resection of GNPC. A total of 97 patients with GNPC underwent ESD from January 2007 to October 2017. We divided them into a conventional anterograde resection group and a retrograde resection group according to the method of procedure. We compared their clinical outcomes and investigated risk factors for postprocedural complications. The en bloc resection rate was 87.6%, and complete resection rate was 83.5%. Postprocedure stenosis occurred in 16 cases (16.5%). GNPCs of the retrograde resection group were more frequently located from antrum to bulb, were significantly larger, were related to ≥75% resection of the circumference, and involved significantly longer procedure times than those in the anterograde resection group. Multivariate analysis showed that resection ≥75% of the circumference was the only significant risk factor for postprocedure stenosis. ESD by retrograde resection method is a novel technique to make the procedure easier, depending on the size, location, and circumference of resection.

Outcomes of the Conventional versus Pocket-Creation Method for Endoscopic Submucosal Dissection of Gastric Body Tumors Using a Dual Knife: A Retrospective Study.

Various endoscopic submucosal dissection (ESD) methods for gastric tumors have been tried. However, no studies have yet compared results according to the ESD method for gastric body tumors using a dual knife. The objective of this study was to compare outcomes of two ESD methods for gastric body tumors: the pocket-creation method and conventional method. Patients who underwent ESD for a gastric body tumor were retrospectively reviewed. Patients were divided into two groups according to the ESD method: the conventional method (group I) and pocket-creation method (group II). Characteristics of patients and tumors, hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, and laboratory findings were investigated. Of the total of 100 patients, 52 belonged to group I and 48 to group II. All tumors were successfully resected en bloc. Resection margin involvement was found in six (11.5%) of group I and six (12.5%) of group II. Complications were observed in seven (13.5%; major complication five, minor two) of group I and eight (16.7%; major two, minor six) of group II. There were no significant differences in ESD outcomes such as hospitalization period, incidence of complications, resection margin status, incidence of surgical operation, procedure time, or inflammatory response after ESD between the two groups. Both methods are suitable for treating gastric body tumors with adequate treatment success rates and comparable complication rates.

Perforation During Endoscopic Submucosal Dissection for Early Colon Cancer: Are Oncological Outcomes Impacted?

Introduction: Endoscopic submucosal dissection (ESD) is accepted in the treatment of early colorectal carcinoma with low pathological risk features for lymph node metastasis. ESD provides higher en-bloc resection and lower recurrence rates but is associated with higher perforation rates. Given the limited data available about the impact of intraprocedural perforation during ESD on the oncological outcomes, this study aims to assess the short and long-term oncological outcomes of ESD on malignant colorectal lesions Methods: Retrospectively, patients who underwent ESD in a tertiary care center from Jan 2011 to Dec 2021 and had cancer in the final pathology were included. Patients were divided into 3 groups: 1) patients who successfully underwent ESD followed by survivorship; 2) patients who underwent organ resection during or after ESD either because perforation occurred during the procedure, or the lesion was deemed to be invasive; 3) patients who underwent organ resection within 2-8 weeks of ESD based on pathology results. Primary outcome was cancer recurrence. Results: Sixty-eight of 906 patients (7.5%) who underwent ESD had invasive carcinoma. 63 patients were included in the analysis. There were 12, 10 and 41 patients in the first, second and third groups, respectively. Intergroup demographics were similar. En-bloc and R0 resection rates were 83% in the first group. Mean follow up duration was 21.2 months. Cancer recurrence was not observed. Conclusion: ESD can be safely performed in carefully selected early colorectal cancers. Intraprocedural perforation during ESD does not negatively impact oncological outcomes. Larger series with long-term follow-up are warranted.

Clinical outcomes of endoscopic submucosal dissection for superficial circumferential esophageal squamous cell carcinoma

Our aim was to elucidate the clinical outcomes of endoscopic submucosal dissection (ESD) for superficial circumferential esophageal squamous cell carcinoma (cESCC). Consecutive patients who underwent ESD for cESCC between 2009 and 2020 were retrospectively reviewed. Short-term outcomes were en-bloc resection, R0 resection, procedure time, and adverse events, whereas long-term outcomes were overall survival (OS), disease-specific survival (DSS), cumulative recurrence rate (CRR), and clinical course. Fifty-two patients with 52 cESCCs (median tumor length, 5.0 cm; interquartile range [IQR], 4.0-6.3) were evaluated. The en-bloc resection and R0 resection rates were 100% (95% confidence interval [CI], 94.4-100) and 69.2% (95% CI, 54.9-81.3), respectively. The median procedure time was 112 minutes (IQR, 87-162). Intraoperative perforations and delayed bleeding occurred in 4 (7.7%) and 1 (1.9%) patients, respectively. Among the 42 patients who underwent ESD alone, 36 (85.7%) experienced esophageal strictures. Within a median follow-up of 49.1 months (IQR, 25.7-74.7), the 4-year OS, DSS, and CRR were 86.2% (95% CI, 71.6-93.6), 95.5% (95% CI, 83.1-98.9), and 11.5% (95% CI, 4.1-23.1), respectively. There was no significant difference in the OS between patients with low-risk cESCC (pT1a, negative lymphovascular invasion, and negative vertical margin) and high-risk lesions, regardless of undergoing additional treatment (P= .93). In 31 patients with low-risk cESCC who were treated with ESD alone, the 4-year OS, DSS, and CRR were 93.2%, 100%, and 0%, respectively. ESD is a highly curative treatment for cESCC with favorable long-term outcomes, especially in low-risk patients. Stricture-prevention techniques should be improved to optimize the benefits of ESD for cESCC.

Clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms: A single-center experience in Southern Taiwan.

Endoscopic submucosal dissection (ESD) as an advanced endoscopic procedure can be considered for the removal of colorectal lesions with high suspicion of limited submucosal invasion or cannot be optimally removed by snare-based techniques. We aimed to analyze the clinical outcomes of ESD for colorectal neoplasms in our hospital. We retrospectively enrolled 230 patients with 244 colorectal neoplasms who received ESD procedures from April 2012 to October 2020 at Kaohsiung Chang Gung Memorial Hospital. Clinicopathological data were collected by chart review. We also recorded ESD-related complications and clinical outcomes. The average age was 64 years old, with a mean follow-up time of 22.59 months. There was a loss of follow-up in 34 lesions. Most lesions were lateral spreading tumors of the non-granular type. The average ESD time was 51.9 minutes. Nine cases (3.7%) had procedure-related complications, including two intra-procedure perforations (0.8%) and seven delayed bleeding (2.9%) without procedure-related mortality. 241 lesions (98.8%) achieved en-bloc resection, while 207 lesions (84.8%) achieved R0 resection. Most lesions were tubulo-(villous) adenoma. Malignancy included 35 adenocarcinomas and 5 neuroendocrine tumors. No local recurrence was developed during follow-up. Multivariate analysis for long ESD time revealed significance in size ≥ 10 cm2 and endoscopist's experience < 3 years. Pre-ESD endoscopic ultrasound revealed good prediction in discrimination of mucosal (sensitivity: 0.90) and submucosal lesion (specificity: 0.67). ESD for colorectal neoplasms is an effective and safe technique. Size ≥ 10 cm2 and endoscopist's experience < 3 years were significantly associated with long procedure time. Pre-ESD EUS provided a good prediction for colorectal neoplasms in invasion depth.

Endoscopic submucosal dissection for colorectal polyps: outcome determining factors.

BackgroundEndoscopic submucosal dissection (ESD) has gained increasing popularity in the management of complicated colorectal polyps. However, clinical outcomes for ESD have remained highly inconsistent worldwide. This study investigated and analysed factors that significantly affect ESD outcomes.MethodsWe conducted a single-centred retrospective study on 220 colorectal polyps removed by ESD from 1st January 2016 to 31st December 2020. Data were collected and retrieved from clinical records. Variables studied included patient demographics, ESD technicalities and polyp characteristics. The primary outcome was completeness of resection based on en bloc and R0 resection rates. The secondary outcomes were recurrence, complications and hospital stay. Further analysis was performed for significant outcome determining factors.ResultsThe en bloc resection and R0 resection rates were 97.3% and 65% respectively. Intraprocedural and delayed perforation rates were 3.2% and 0.5% respectively. Intraprocedural and delayed bleeding rates were both 1.8%. Post-polypectomy syndrome rate was 2.7%. The median hospital stay was 4 days. Submucosal fibrosis was a significant determining factor for lower en bloc resection (p = 0.004), lower R0 resection (p = 0.002), intraprocedural perforation (p = 0.001), intraprocedural bleeding (p = 0.025) and post-polypectomy syndrome (p = 0.039). Hybrid snaring was associated with lower en bloc resection (p < 0.001), while longer ESD time was associated with lower R0 resection (p = 0.003) and post-polypectomy syndrome (p = 0.025). Other significant factors for post-polypectomy syndrome included young age (p = 0.021) and large polyp size (p = 0.018). Secondary analysis showed that submucosal fibrosis was significantly associated with non-granular lesions (p < 0.001) and prior biopsy (p = 0.003).ConclusionSubmucosal fibrosis, hybrid snaring, ESD time, age and polyp size were significant outcome determining factors for ESD. By identifying these factors, strategies may be formulated to improve ESD outcomes.

S1615 Clinical Outcome of Endoscopic Submucosal Dissection for Early Gastric Cancer: A Retrospective Single Center Study

Introduction: Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer without the risk of lymph node metastasis. However, the outcomes in the United States are not well studied because of the low prevalence of gastric cancer. We aimed to assess the efficacy and safety of ESD for early gastric cancer in the United States. Methods: We performed a single-center retrospective analysis of patients who underwent gastric ESD between June 2018 and December 2021. The main outcome measures were en-bloc resection rate, R0 (complete) resection rate, procedure time, tumor size, hospital length of stay (LOS), histology, and complication rate. Results: In total, 46 patients were included (Table). The median age was 71 years (range, 68.9-76.8 years). En-bloc and R0 resection rates were 94.5% and 81.8%, respectively. The median procedure time was 87.5 min (range, 69.3-118.8 min). The median tumor size was 26mm (range, 20-35 mm). The mean hospital length of stay was 1.87±1.38 days. The most common histologic type was pT1a (45.7%), followed by pT1b (26.1%), adenoma with low-grade dysplasia (13.0%), adenoma with high-grade dysplasia (10.9%), and neuroendocrine tumor (4.3%). There were 3 adverse events all of which were delayed bleeding and no perforations were reported. Conclusion: Our study showed that gastric ESD is a safe and effective method for superficial gastric neoplasia. ESD should be considered for patients with suitable lesions in the U.S. Table 1. - Baseline Characteristics and Outcomes of Gastric Endoscopic Submucosal Dissection ESD, endoscopic submucosal dissection; EMR, endoscopic mucosal dissection; LGD, low-grade dysplasia; HGD, high-grade dysplasia Baseline characteristics Age, y, median (IQR) 71 (68.9-76.8) Sex, men/women, n 30/16 ASA class, n (%) Ⅰ 0 0 II 0 0 Ⅲ 5 10.9 Ⅳ 41 89.1 Lesion site, n (%) Antrum 10 21.7 Body 13 28.3 Greater curvature 1 2.2 Lesser curvature 5 10.9 Cardia 12 26.1 Incisura angularis 5 10.9 Type of injection, n (%) Eleview 11 23.9 Orise 35 76.1 Type of primary knife for ESD, n (%) Dual knife 29 63.0 ProKnife 17 37.0 Anesthesia, n (%) Propofol 7 15.2 General anesthesia 39 84.8 Interventions before ESD, n (%) Tattoo underneath lesion 6 13.0 Scar underneath lesion 10 21.7 Radiofrequency ablation 1 2.2 ESD 4 8.7 EMR 4 8.7 Outcomes En bloc resection, n (%) 43 93.5 R0 resection, n (%) 36 78.3 Procedure time, min, median (IQR) 87.5 (69.3 - 118.8) Tumor size, mm, median (IQR) 26 (20 - 35) Length of hospital stay, d, mean ± SD 1.8 ± 1.4 Histology, n (%) Adenoma with LGD 6 13.0 Adenoma with HGD 5 10.9 pT1a 21 45.7 pT1b 12 26.1 Neuroendocrine tumor 2 4.3 Adverse event, n (%) Delayed bleeding 3 6.5 Perforation 3 6.5 Infection 0 0

The impact of sarcopenia on short- and long-term outcomes of endoscopic submucosal dissection for early gastric cancer.

Sarcopenia prevalence has increased in proportion to the aging population in Japan. We aimed to investigate the association between sarcopenia and clinical outcomes and the prognostic factors of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). This retrospective study involved patients aged ≥ 65years who had undergone gastric ESD for EGC at our institution between January 2009 and December 2019. Patients were divided into two groups, namely, a sarcopenia group (109 patients) and a non-sarcopenia group (658 patients), based on the skeletal muscle index and intramuscular adipose tissue content (IMAC). Clinicopathological features, ESD-related adverse events, and outcomes were then compared. In the sarcopenia group, the mean age was higher, whereas performance and nutritional statuses were lower. There were no between-group differences in terms of treatment outcomes. Multivariate analyses (odds ratio [95% confidence interval (CI)]) indicated that a geriatric nutritional risk index score (GNRI) < 92 (2.12 [1.09-4.11], p = 0.03), anticoagulant therapy (1.76 [1.13-2.76], p = 0.01), tumor size ≥ 30mm (2.09 [1.23-3.55], p = 0.01), and sarcopenia (1.90 [1.05-3.45], p = 0.03) were significantly associated with ESD-related adverse events. High Charlson comorbidity index, low prognostic nutritional index, low GNRI, and high IMAC were significantly associated with poor overall survival (OS). OS was significantly shorter in the sarcopenia group even after matching. Patients with sarcopenia had significantly more adverse events and shorter OS; therefore, evaluation of a patient's general condition, including sarcopenia, before ESD is important.

Endoscopic submucosal dissection: a country dissemination experience and outcomes.

An increasing use of endoscopic submucosal dissection (ESD) has been reported in Western countries, although some differences in training schemes and outcomes have been described. We aimed to report the training model, implementation, and outcomes of ESD in Portugal. All endoscopists trained at our center from our country (n = 9) were invited to a survey regarding: (a) training period; (b) ESD outcomes and (c) implementation of ESD in each respective center. All endoscopists completed the survey. Learning ESD was centered on human ESD assistance in a high-volume center during a median time of 6 months and complemented mainly by hands-on courses (89%). During the surveyed period, a total of 1229 ESD were performed, mostly in gastric locations (74%). Median complete R0 and curative resection rate were 92% (IQR, 81-96.8) and 87% (IQR, 74-93.3), respectively, and median perforation rate was 0.89% (IQR, 0.25-6.22). The main limitations encountered during the implementation of ESD were related to the lack of initial mentoring or insufficient expertise to progress to more difficult lesions. Learning ESD through participation in hands-on courses and visiting high-volume centers seems to be adequate to achieve a good competence at the initial stage of ESD, which in fact is in consonance with the European Society of Gastrointestinal Endoscopy recommendations. However, mentoring is essential for technical progression, and this represents the fundamental barrier during the adoption of ESD, which may be overcome by increasing hands-on training in animal or artificial simulators, but preferably with the implementation of a structured training program.

Outcomes of endoscopic submucosal dissection (ESD) plus radiofrequency ablation (RFA) for nodular Barrett’s esophagus

Background Although Endoscopic Submucosal Dissection (ESD) was proven superior to Endoscopic Mucosal Resection (EMR) in achieving higher complete remission rates for neoplastic Barrett’s Esophagus (BE), its safety with Radiofrequency Ablation (RFA) remains unstudied. We share our experience with ESD + RFA for nodular BE eradication. Methods A retrospective study of all patients ≥18-years with nodular BE who underwent ESD + RFA between September 2015 and December 2020 at our tertiary center. Patients with advanced adenocarcinoma requiring esophagectomy were excluded. Primary outcomes included adverse events (AE) rates and complete eradication rates for adenocarcinoma (CE-EAC), dysplasia (CE-D), and intestinal metaplasia (CE-IM). Secondary outcomes included local recurrence rates following eradication. Results Eighteen patients were included with a total of 22 ESDs performed and a median of 2 RFA sessions-per-patient [IQR: 1.25, 3]. Sixteen patients were males and/or white (88.9%) with a median BMI of 29.75 kg/m2 [IQR: 26.9, 31.5]. Fourteen patients had long-segment BE (77.7%) while 16 had hiatal hernias (88.9%). Median resection size was 12.1 cm2 [IQR: 5.6, 20.2]. AEs included one intraprocedural micro-perforation (4.5%) and 4 strictures (22.2%), only one of which developed post-RFA. All AEs were successfully treated endoscopically. Over a median of 42.5 months [IQR: 28, 59.25], CE-EAC was achieved in 13 patients (100%), CE-D in 15 patients (100%), and CE-IM in 14 patients (77.8%). Following eradication, 2 patients had recurrent dysplasia (2/15, 13.3%) and one had recurrent intestinal metaplasia (1/14, 7.1%). Conclusion In high-risk patients with long-segment neoplastic BE requiring extensive endoscopic resection, ESD + RFA offers excellent complete eradication rates with rare additional adverse events by RFA. Standard endoscopic surveillance following eradication remains important.

Outcomes of endoscopic submucosal dissection in patients who develop metachronous superficial esophageal squamous cell carcinoma close to a post-endoscopic submucosal dissection scar.

The presence of post-endoscopic submucosal dissection (ESD) scars renders complete metachronous superficial esophageal squamous cell carcinoma resection difficult. We aimed to identify the risk factors for incomplete resection of metachronous esophageal squamous cell carcinoma close to the post-ESD scar by ESD. We enrolled patients who developed post-ESD superficial esophageal squamous cell carcinoma at Hiroshima University Hospital between January 2006 and March 2020. We analyzed the outcomes and risk factors of incomplete resection between patients whose lesions were close to (close-to group) and away from (away-from group) the post-ESD scar. We included 111 patients with 212 lesions. The close-to group had a significantly lower complete resection rate (88.6% [62/70] vs. 98.6% [69/70], p = 0.033), longer procedure time (80.2 ± 47.2min vs. 60.4 ± 29.3min, p < 0.01), higher proportion of lesions with severe fibrosis (72.9% [51/70] vs. 5.7% [4/70], p < 0.01), and higher intraoperative bleeding rate (78.6% [55/70] vs. 60.0% [42/70], p = 0.027) than the away-from group. There was no significant difference in the rate of local recurrence, muscle injury, perforation, and stenosis as well as the pathological tumor depth between the groups. Of the 92 lesions in the close-to group, the proportion of lesions located on the oral side of the post-ESD scar significantly affected the incidence of incomplete resection (91.7% [11/12] vs. 53.8% [43/80], p = 0.013). Complete resection was more difficult for lesions located on the oral side of the post-ESD scar.

Comparison between Endoscopic Submucosal Dissection and Surgery in Patients with Early Gastric Cancer.

Simple SummaryConventional gastrectomy combined with regional lymph node dissection has been the standard treatment for early gastric cancer (EGC). This retrospective case–control study aimed to compare the clinical outcomes of endoscopic submucosal dissection (ESD) and surgical resection for EGC in China. After propensity score-matching, there were no significant differences between the two groups for OS, RFS, and DSS. Additionally, with similar R0 resection and recurrence rates, the ESD group showed less blood loss, fewer adverse events, lower hospital cost, and a shorter operative time and hospital duration than the surgery group. Therefore, ESD can be a first-line treatment of EGC in addition to surgery.Background: Endoscopic submucosal dissection (ESD) has become a preferred treatment option for early gastric cancer (EGC). This study aimed to compare the clinical outcomes of ESD and surgical resection for EGC. Methods: This was a retrospective case–control study. Patients with a diagnosis of EGC who underwent ESD or surgery in our hospital from 2011 to 2020 were enrolled. We compared the clinical characteristics and treatment outcomes of these two groups according to propensity score-matching. The primary outcome comparison was overall survival (OS). Secondary outcomes were disease-specific survival (DSS), recurrence-free survival (RFS), and treatment-related events. Results: In the matched cohort, the ESD group showed comparable OS, RFS, and DSS with the surgery group. Statistical differences were shown in blood loss and adverse events. Furthermore, the ESD group showed lower hospital cost, as well as a shorter operative time and hospital duration than the surgery group. The R0 resection and recurrence rates were similar between the two groups. In Cox regression analysis, age, tumor size, poor differentiation, and lymphovascular invasion were regarded as independent factors of OS. Conclusions: With sufficient safety and advantages, ESD can be a first-line treatment of EGC. Preoperative evaluation is vital to the appropriate treatment and prognosis.

Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients Aged 85 Years Old or Older Is Associated with a Good Prognosis Compared to Conservative Treatment without Any Invasive Procedure

Introduction: Studies have reported the feasibility of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) in elderly people with respect to both short- and long-term outcomes. As the elderly population in society increases, the requirement for managing super-elderly patients aged ≥85 years with EGC will also increase. This study aims to identify the long-term clinical outcomes of ESD for clinical T1N0 EGC in patients aged ≥85 years. Methods: A total of 370 consecutive patients aged ≥85 years with clinical T1N0 EGC who were managed in 11 institutions were reviewed retrospectively. On the basis of treatment strategy, we compared the overall survival (OS) and disease-specific survival (DSS) after performing propensity score-matched analysis between patients undergoing ESD (ESD group) and those not undergoing treatment (conservative treatment group). The potential prognostic factors were also investigated in the propensity score-matched patients. Results: After propensity score matching, we found that the 3-year OS and DSS rates were significantly higher in the ESD group than in the conservative treatment group (OS, 82.2% vs. 50.5%; p < 0.001; DSS, 100% vs. 80.1%; p = 0.008). Furthermore, ESD was identified as a significant factor for prolonged OS, whereas Charlson comorbidity index (CCI) ≥3 and prognostic nutritional index (PNI) <36.2 were associated with reduced OS. Conclusion: ESD was associated with improved OS in patients with clinical T1N0 EGC aged ≥85 years compared with the absence of treatment. Furthermore, CCI and PNI were helpful for patient selection.

Evaluation of Postoperative Outcomes of Endoscopic Submucosal Dissection in Primary Gastric Cancer

Background: Few studies have investigated the changes in postoperative quality of life; serum Livin, epidermal growth factor (EGF), and interleukin (IL)-8 levels; and traumatic stress in patients with early gastric carcinoma after endoscopic submucosal dissection. Objectives: We aimed to determine the effect of endoscopic submucosal dissection on postoperative life satisfaction and serum Livin, EGF, and IL-8 levels in early gastric carcinoma patients. Methods: Seventy-three early gastric carcinoma patients were divided into the control (n = 35, traditional radical surgery) and case (n = 38, endoscopic submucosal dissection) groups based on surgical approaches. Results: The operative time, gastrointestinal recovery time, length of hospital stay, perioperative bleeding, EuroQol visual analog scale scores, gastrin, and motilin levels were significantly superior to those in the control group, whereas serum Livin, EGF, IL-8, and C-reactive protein levels, as well as the total incidence of postoperative complications, were significantly lower in the case group than in the control group (all P &lt; 0.05). Conclusion: Endoscopic submucosal dissection in early gastric carcinoma patients provides the advantages of a short operative time, less perioperative bleeding, rapid postoperative recovery, and less traumatic stress and postoperative complications, as well as reduced serum Livin, EGF, IL-8, and tumor marker levels.

Propensity-score matched analysis to evaluate efficacy of endoscopic submucosal dissection for superficial esophageal cancer in gastrectomized patients

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment option for superficial esophageal cancer (SEC) with high rates of complete resection. However, limited research exists on the efficacy of ESD for SEC in gastrectomized patients. This study aimed to evaluate the efficacy of ESD for SEC in gastrectomized patients. We included 318 patients of SEC treated at our institution between April 2005 and October 2021. To minimize bias between the gastrectomized and non-gastrectomized groups, we conducted a propensity-score matched analysis and compared the ESD outcomes for SEC of the two groups. Of the 318 patients included in the study, 48 and 270 patients were in the gastrectomized and non-gastrectomized groups, respectively. After 1:2 propensity-score matching, we matched 44 patients in the gastrectomized group to 88 patients in the non-gastrectomized group, and found no significant differences in the baseline clinicopathological characteristics. Regarding the ESD outcomes, there were no significant differences in the complete resection rate, procedure time, hospitalized period, and recurrence rates between the two groups. Multivariate analysis also cofirmed that the history of gastrectomy was not a risk factor of the difficult case of esophageal ESD. In conclusion, history of gastrectomy might not negatively affect the ESD outcomes of SECs.