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Chen Y, Chen M, Wang Z, Wu J, Yang J, Yang L, Deng K. Correlation of preoperative CT features with intra- and postoperative parameters of endoscopic resection in patients with gastric submucosal tumor (1~3 cm). Surg Endosc 2025; 39:259-268. [PMID: 39528660 DOI: 10.1007/s00464-024-11349-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 10/09/2024] [Indexed: 11/16/2024]
Abstract
OBJECTIVES Endoscopic resection of gastric submucosal tumors (SMTs) possesses minimal trauma, expedited recovery, and reduced costs. Nonetheless, intraoperative challenges, including imprecise surgical risk assessment, prevail. Hence, we investigated the correlation between preoperative CT observation features and perioperative parameters for predicting outcomes in SMT patients. METHODS Subjects diagnosed with SMT and undergoing endoscopic surgery conducted at West China Hospital's Endoscopy Center from September 2019 to October 2023 were retrospectively selected. Endoscopic ultrasonography (EUS) and computer tomography (CT) were utilized for evaluating SMT. The study assessed the correlation between preoperative CT findings and perioperative parameters. RESULTS Increased lesion size on contrast-enhanced CT correlates with increased operative duration, hospital stay, postoperative antibiotic use. Of utmost significance, we observed a significantly higher intraoperative perforation rate for patients with tumor outgrowth compared to those with lesion involvement of the lumen (96.88% vs 29.11%, P < 0.001). These patients also demonstrated an increased risk of postoperative blood stream infections (P = 0.012), necessitating higher antibiotic grade (P = 0.048), along with prolonged gastrostomy tube retention (P = 0.001) and hospitalization (P = 0.018). In addition, CT provides a more accurate and comprehensive assessment of tumor size (P = 0.037) and growth pattern (P = 0.026) than EUS. CONCLUSION CT assessment of tumor size closer to reality than EUS. Importantly, these features can assist in pinpointing lesions with elevated surgical complexity and high risk of complications, leading to improved preoperative preparation, thereby increasing anticipation of surgical risks and reducing incidence of complications.
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Affiliation(s)
- Yuxiang Chen
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Mo Chen
- Department of Gerontology, Tibetan Chengdu Branch Hospital of West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
- Department of Gerontology, Hospital of Chengdu Office of People's Government of Tibetan Autonomous Region, Chengdu, 610041, China
| | - Zhu Wang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Junchao Wu
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Jinlin Yang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Li Yang
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China
| | - Kai Deng
- Department of Gastroenterology & Hepatology, West China Hospital, Sichuan University, 37 Guoxue Lane, Chengdu, 610041, Sichuan, China.
- Sichuan University-Oxford University Huaxi Gastrointestinal Cancer Centre, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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Mimura T, Yamamoto Y, Suzuki H, Takizawa K, Hirasawa T, Takeuchi Y, Ishido K, Hoteya S, Yano T, Tanaka S, Kudara N, Nakagawa M, Mashimo Y, Ishigooka M, Fukase K, Shimazu T, Ono H, Tanabe S, Kondo H, Iishi H, Ninomiya M, Oda I. Risk factors for intraoperative and delayed perforation related with gastric endoscopic submucosal dissection. J Gastroenterol Hepatol 2024; 39:1358-1366. [PMID: 38556810 DOI: 10.1111/jgh.16545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 03/01/2024] [Accepted: 03/03/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND AND AIM Perforation is one of the most important complications of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). Several studies have examined risk factors for intraoperative and delayed perforations, but most were retrospective analyses with small numbers of patients. METHODS This study represents a secondary analysis of a Japanese multicenter prospective cohort study. We investigated the factors associated with each type of perforation using 9015 patients with 9975 EGCs undergoing ESD between July 2010 and June 2012. RESULTS Intraoperative perforation occurred in 198 patients (2.2%) with 203 lesions (2.0%), necessitating emergency surgery for four lesions (0.04% [2.0%, 4/203]). Delayed perforation occurred in another 37 patients (0.4%) with 42 lesions (0.4%), requiring emergency surgery for 12 lesions (0.12% [28.6%, 12/42]). Factors showing significant independent correlations with intraoperative perforation were upper or middle third of the stomach; remnant stomach or gastric tube; procedure time ≥100 min; tumor size >35 mm; body mass index (BMI) < 18.5 kg/m2; and ≥72 years. Factors showing significant independent correlations with delayed perforation were procedure time ≥60 min; BMI < 18.5 kg/m2; ≥75 years; ulceration; and tumor size >20 mm. Intraoperative perforation occurred most frequently at the greater curvature in the upper third of the stomach (7.9%), whereas delayed perforation occurred most frequently at the greater curvature in the middle third (1.2%). CONCLUSION This multicenter prospective cohort study clarified the risk and risk factors of intraoperative and delayed perforation related to ESD for EGCs, providing information to help endoscopists reduce perforation.
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Affiliation(s)
- Takuya Mimura
- Department of Gastroenterological Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Yoshinobu Yamamoto
- Department of Gastroenterological Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Haruhisa Suzuki
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
| | - Kohei Takizawa
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Toshiaki Hirasawa
- Department of Gastroenterology, Cancer Institute Hospital, Tokyo, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
- Department of Endoscopy and Endoscopic Surgery, Gunma University Hospital, Maebashi, Japan
| | - Kenji Ishido
- Department of Gastroenterology, Kitasato University School of Medicine, Sagamihara, Japan
| | - Shu Hoteya
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Tomonori Yano
- Department of Gastroenterology and Endoscopy, National Cancer Center Hospital East, Chiba, Japan
| | - Shinji Tanaka
- Department of Endoscopy, Hiroshima University Hospital, Hiroshima, Japan
| | - Norihiko Kudara
- Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Iwate, Japan
| | - Masahiro Nakagawa
- Department of Endoscopy, Hiroshima City Hiroshima Citizens Hospital, Hiroshima, Japan
| | - Yumi Mashimo
- Department of Gastroenterology, Chofu Touzan Hospital, Tokyo, Japan
| | | | - Kazutoshi Fukase
- Department of Gastroenterology, Yamagata Prefectural Central Hospital, Yamagata, Japan
| | - Taichi Shimazu
- Division of Behavioral Sciences, National Cancer Center Institute for Cancer Control, National Cancer Center, Tokyo, Japan
| | - Hiroyuki Ono
- Division of Endoscopy, Shizuoka Cancer Center, Shizuoka, Japan
| | - Satoshi Tanabe
- Department of Advanced Medicine, Research and Development Center for New Medical Frontiers, Kitasato University School of Medicine, Sagamihara, Japan
- Department of Gastroenterology, Ebina General Hospital, Ebina, Japan
| | - Hitoshi Kondo
- Department of Gastroenterology, Tonan Hospital, Sapporo, Japan
| | - Hiroyasu Iishi
- Department of Gastroenterology, Itami City Hospital, Itami, Japan
| | - Motoki Ninomiya
- Digestive Disease Center, Yuuai Medical Center, Okinawa, Japan
| | - Ichiro Oda
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
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Li P, Li Z, Linghu E, Ji J. Chinese national clinical practice guidelines on the prevention, diagnosis, and treatment of early gastric cancer. Chin Med J (Engl) 2024; 137:887-908. [PMID: 38515297 PMCID: PMC11046028 DOI: 10.1097/cm9.0000000000003101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Gastric cancer is one of the most common malignant tumors in the digestive system in China. Few comprehensive practice guidelines for early gastric cancer in China are currently available. Therefore, we created the Chinese national clinical practice guideline for the prevention, diagnosis, and treatment of early gastric cancer. METHODS This clinical practice guideline (CPG) was developed in accordance with the World Health Organization's recommended process and with the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) in assessing evidence quality. We used the Evidence to Decision framework to formulate clinical recommendations to minimize bias and increase transparency in the CPG development process. We used the Reporting Items for practice Guidelines in HealThcare (RIGHT) statement and the Appraisal of Guidelines for Research and Evaluation II (AGREE II) as reporting and conduct guidelines to ensure completeness and transparency of the CPG. RESULTS This CPG contains 40 recommendations regarding the prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer based on available clinical studies and guidelines. We provide recommendations for the timing of Helicobacter pylori eradication, screening populations for early gastric cancer, indications for endoscopic resection and surgical gastrectomy, follow-up interval after treatment, and other recommendations. CONCLUSIONS This CPG can lead to optimum care for patients and populations by providing up-to-date medical information. We intend this CPG for widespread adoption to increase the standard of prevention, screening, diagnosis, treatment, and follow-up of early gastric cancer; thereby, contributing to improving national health care and patient quality of life.
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Affiliation(s)
- Peng Li
- Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University, National Clinical Research Center for Digestive Disease, Beijing 100050, China
| | - Ziyu Li
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
| | - Enqiang Linghu
- Department of Gastroenterology and Hepatology, the First Medical Center, Chinese People’s Liberation Army General Hospital, Beijing 100853, China
| | - Jiafu Ji
- Department of Gastrointestinal Surgery, Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education), Peking University Cancer Hospital and Institute, Beijing 100142, China
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Akashi T, Yamaguchi N, Shiota J, Tabuchi M, Kitayama M, Hashiguchi K, Matsushima K, Akazawa Y, Nakao K. Characteristics and Risk Factors of Delayed Perforation in Endoscopic Submucosal Dissection for Early Gastric Cancer. J Clin Med 2024; 13:1317. [PMID: 38592167 PMCID: PMC10931556 DOI: 10.3390/jcm13051317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 02/22/2024] [Accepted: 02/23/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Delayed perforation after gastric endoscopic submucosal dissection (ESD) for early gastric cancer is a relatively uncommon and serious complication that sometimes requires emergency surgery. This study aimed to determine the clinicopathological features, risk factors, and appropriate management strategies for delayed perforation. (2) Methods: This study included 735 patients with 791 lesions who underwent ESD for early gastric cancer at a single institution between July 2009 and June 2019. We retrospectively compared the clinical features of patients with and without delayed perforations. (3) Results: The incidence of delayed perforations was 0.91%. The identified risk factors included a postoperative stomach condition and histopathological ulceration. A comparison between delayed and intraoperative perforations revealed a postoperative stomach condition as a characteristic risk factor for delayed perforation. Patients with delayed perforation who avoided emergency surgery tended to exhibit an earlier onset of symptoms such as abdominal pain and fever. No peritoneal seeding following delayed perforation was observed for any patient. (4) Conclusions: A postoperative stomach condition and histopathological ulceration were risk factors for delayed perforation. Delayed perforation is a significant complication that requires careful monitoring after gastric ESD for early gastric cancer, particularly in patients with postoperative gastric conditions.
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Affiliation(s)
- Taro Akashi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (J.S.); (M.K.); (K.H.); (K.N.)
| | - Naoyuki Yamaguchi
- Department of Endoscopy, Nagasaki University Hospital, Nagasaki 852-8501, Japan;
| | - Junya Shiota
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (J.S.); (M.K.); (K.H.); (K.N.)
| | - Maiko Tabuchi
- Department of Histology and Cell Biology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8523, Japan; (M.T.); (Y.A.)
| | - Moto Kitayama
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (J.S.); (M.K.); (K.H.); (K.N.)
| | - Keiichi Hashiguchi
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (J.S.); (M.K.); (K.H.); (K.N.)
- Department of Endoscopy, Nagasaki University Hospital, Nagasaki 852-8501, Japan;
| | - Kayoko Matsushima
- Medical Education Development Center, Nagasaki University Hospital, Nagasaki 852-8501, Japan;
| | - Yuko Akazawa
- Department of Histology and Cell Biology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8523, Japan; (M.T.); (Y.A.)
| | - Kazuhiko Nakao
- Department of Gastroenterology and Hepatology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki 852-8501, Japan; (J.S.); (M.K.); (K.H.); (K.N.)
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Wang XL, He XJ, Jiang CS, Hong DG, Zheng YP, Li H, Chen XJ, Huang JX, Dai LS, Liu MY, Li DZ, Wang W. Magnetic ring-assisted endoscopic submucosal dissection for gastric lesions with submucosal fibrosis: A preliminary study in beagle model. Asian J Surg 2023; 46:3673-3679. [PMID: 37120374 DOI: 10.1016/j.asjsur.2023.04.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND During endoscopic submucosal dissection (ESD) for gastric lesions with fibrosis, appropriate traction could provide clear submucosal dissection visualization to improve safety and efficiency of procedures. Therefore, the aim of this study was to evaluate the feasibility of magnetic ring-assisted ESD (MRA-ESD) for gastric fibrotic lesions. METHOD In the eight healthy beagles, 2-3 mL of 50% glucose solution was injected into submucosal layer of the stomach to induce gastric fibrotic lesions. A week after submucosal injection, two endoscopists at different levels performed MRA-ESD or standard ESD (S-ESD) for gastric simulated lesions, respectively. The magnetic traction system consisted of external handheld magnet and internal magnetic ring. The feasibility and procedure outcomes of the magnetic traction system were mainly evaluated. RESULTS Forty-eight gastric simulated lesions with ulceration were confirmed to have submucosal fibrosis formation by preoperative endoscopic ultrasonography. The magnetic traction system could be easily established, only took 1.57 min, and allowed excellent submucosal visualization. The total procedure time was significantly shorter in the MRA-ESD group than in the S-ESD group for both endoscopists (mean: 46.83 vs. 25.09 min, p < 0.001), and this difference was accentuated in non-skilled endoscopist. There was significant difference between two groups in bleeding and perforation rates. Histological analysis showed the depth of resected specimens was a little deeper around the fibrotic portion in the S-ESD group (p < 0.001). CONCLUSION The magnetic ring-assisted ESD technique may be an effective and safe treatment for gastric fibrotic lesions and may shorten the endoscopic learning curve for non-skilled endoscopists.
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Affiliation(s)
- Xiao-Ling Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Xiao-Jian He
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Chuan-Shen Jiang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Dong-Gui Hong
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Yun-Ping Zheng
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Han Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Xin-Jiang Chen
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Jian-Xiao Huang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Ling-Shuang Dai
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Mei-Yan Liu
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China
| | - Da-Zhou Li
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
| | - Wen Wang
- Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, China; Department of Digestive Diseases, 900TH Hospital of Joint Logistics Support Force, Fuzhou, China.
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Ni M, Tang D, Ren W, Meng R, Yang J, Yan P, Ding X, Xu G, Lv Y, Chen M, Yang H, Wang L. Risk factors of perforation in gastric stromal tumors during endoscopic resection: a retrospective case-control study. Gastric Cancer 2023; 26:590-603. [PMID: 37061602 DOI: 10.1007/s10120-023-01391-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/04/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND AND AIMS Perforation is a common complication during endoscopic resection (ER) of gastric gastrointestinal stromal tumors (gGISTs) associated with secondary infections, sepsis, hospitalization time and cost. However, the risk factors of perforation remain controversial. This study aimed to investigate the risk factors for perforation during ER of gGISTs. METHODS This retrospective case-control study included consecutive patients with gGISTs who underwent ER between June 2009 and November 2021 at the Nanjing Drum Tower Hospital. Univariate and multivariate analyses were performed to investigate the risk factors for perforation. Sensitivity analyses with propensity scoring (PS) were performed to evaluate the stability of the independent effects. RESULTS In total, 422 patients with gGISTs were included. The following factors were associated with perforation during ER: in the non-intraluminal growth patterns (all confounders adjusted odds ratio [aOR]: 5.39, 95% CI 2.99-9.72, P < 0.001), in the gastric fundus (aOR 2.25, 95% CI 1.40-3.60, P = 0.007), sized ≥ 2 cm (aOR 1.70, 95% CI 1.04-2.77, P = 0.035), in the lesser curvature (aOR 0.12, 95% CI 0.05-0.27, P < 0.001), and in the gastric cardia (aOR 0.13, 95% CI 0.04-0.50, P = 0.003). The PS analysis confirmed the stable independent effects of these identified risk factors. CONCLUSIONS ERs of gGISTs in non-intraluminal growth patterns, in the gastric fundus, and with larger tumor size were independent risk factors for perforation. While tumors in the lesser curvature or gastric cardia were independent protective factor for perforation.
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Affiliation(s)
- Muhan Ni
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Dehua Tang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Wei Ren
- Department of Geriatric Medicine, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Rui Meng
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Jinping Yang
- Oncology Department of Integrated Chinese and Western Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China
| | - Peng Yan
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Xiwei Ding
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Guifang Xu
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Ying Lv
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Min Chen
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Hua Yang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China
| | - Lei Wang
- Department of Gastroenterology, Nanjing Drum Tower Hospital, Affiliated Drum Tower Hospital, Medical School of Nanjing University, 321 Zhongshan Road, Nanjing, 210008, Jiangsu, China.
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Yang X, Fu S, Li L, Yang J, Ji R, Li Y, Zuo X. Robot-assisted endoscopic submucosal dissection contributes to efficient and safe learning for novices: Prospective pilot cross-over ex vivo study (with video). Dig Endosc 2023; 35:342-351. [PMID: 36107632 DOI: 10.1111/den.14438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/12/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The lack of effective countertraction to expose the submucosal layer contributes to the technical complication and adverse events in endoscopic submucosal dissection (ESD). We aimed to evaluate the efficacy and safety of a novel endoscopic robot (flexible auxiliary single-arm transluminal endoscopic robot [FASTER]) for ESD learning for novices. METHODS This was a prospective, cross-over designed pilot study in ex vivo porcine stomach. Four ESD novices were randomized to either FASTER-assisted ESD first (FC) group or a conventional ESD first (CF) group, performed 40 gastric ESDs using each technique, then crossed over to another technique. The performance and learning curve were compared between the two groups. RESULTS In the first phase, novices in the FC group demonstrated significantly better performance with shorter procedure time (25.6 ± 7.8 vs. 38.9 ± 13.4 min; P < 0.001) and submucosal dissection time (13.9 ± 5.5 vs. 23.1 ± 11.0 min; P < 0.001), higher direct-vision dissection ratio (84.0 ± 7.9% vs. 43.5 ± 20.7%; P < 0.001), and lower muscular injury (2.5 vs. 40.0%; P < 0.001) and task load (4 vs. 5; P < 0.001). Fewer ESDs were required to gain early proficiency in the FC group. When crossed to the second phase, procedure time in the FC group was prolonged but the muscular injury rate did not increase significantly. In total, endoscopists in the FC group tended to have a lower task load (4 vs. 5; P = 0.008) and less muscular injury (10.0 vs. 21.3%; P = 0.05). CONCLUSION Flexible auxiliary single-arm transluminal endoscopic robot-assisted learning reduces the technical difficulty of ESD for novices and the safety profile can sustain in following conventional ESD. These results indicated that FASTER has potential implications for ESD training in clinical practice.
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Affiliation(s)
- Xiaoxiao Yang
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Shichen Fu
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Lixiang Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Jialin Yang
- Robo Medical Robotics Institute, Shenzhen Robo Medical Technology Co., Ltd, Shenzhen, China
| | - Rui Ji
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Yanqing Li
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
| | - Xiuli Zuo
- Department of Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
- Robot Engineering Laboratory for Precise Diagnosis and Therapy of GI Tumor, Qilu Hospital of Shandong University, Jinan, China
- Laboratory of Translational Gastroenterology, Qilu Hospital of Shandong University, Jinan, China
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Lu Y, Zhuo X, Zhong Q, Sun J, Li C, Zhi M. Endoscopic ultrasonography is useful for predicting perforation in the endoscopic resection of gastric submucosal tumors originating from the muscularis propria: a retrospective case-control study. Ultrasonography 2023; 42:78-88. [PMID: 36458370 PMCID: PMC9816697 DOI: 10.14366/usg.21265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/17/2022] [Indexed: 01/13/2023] Open
Abstract
PURPOSE Models for predicting perforation during endoscopic resection (ER) of gastric submucosal tumors (SMTs) originating from the muscularis propria (MP) are rare. Therefore, this study was conducted to determine important parameters in endoscopic ultrasonography (EUS) images to predict perforation and to build predictive models. METHODS Consecutive patients with gastric SMTs originating from the MP who received ER from May 1, 2013 to January 15, 2021 were retrospectively reviewed. They were classified into case and control groups based on the presence of perforation. Logistic multivariate analysis was used to identify potential variables and build predictive models (models 1 and 2: with and without information on tumor pathology, respectively). RESULTS In total, 199 EUS procedures (194 patients) were finally chosen, with 99 procedures in the case group and 100 in the control group. The ratio of the inner distance to the outer distance (I/O ratio) was significantly larger in the case group than in the control group (median ratio, 2.20 vs. 1.53; P<0.001). Multivariate analysis showed that age (odds ratio [OR], 1.036 in model 1; OR, 1.046 in model 2), the I/O ratio (OR, 2.731 in model 1; OR, 2.372 in model 2), and the pathology of the tumors (OR, 10.977 for gastrointestinal stromal tumors; OR, 15.051 for others in model 1) were risk factors for perforation. The two models to predict perforation had areas under the curve of 0.836 (model 1) and 0.755 (model 2). CONCLUSION EUS was useful in predicting perforation in ER for gastric SMTs originating from the MP. Two predictive models were developed.
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Affiliation(s)
- Yi Lu
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xianhua Zhuo
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Department of Otolaryngology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Qinghua Zhong
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Department of Endoscopic Surgery, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiachen Sun
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Chujun Li
- Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Correspondence to: Chujun Li, MD, Department of Gastrointestinal Endoscopy, The Sixth Affiliated Hospital, Sun Yat-sen University and Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, 26 Yuancun Erheng Road, Guangzhou 510655, China Tel. +86-2038254116 Fax. +86-2038254116 E-mail:
| | - Min Zhi
- Guangdong Provincial Key Laboratory of Colorectal and Pelvic Floor Diseases, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China,Department of Gastroenterology, The Sixth Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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9
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Risk factors for the failure of endoscopic resection of gastric submucosal tumors: a long-term retrospective case-control study. Gastric Cancer 2022; 25:929-942. [PMID: 35752993 DOI: 10.1007/s10120-022-01306-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 05/11/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Endoscopic resection (ER) is an effective treatment method for gastric submucosal tumors (G-SMTs), but endoscopic resection failure requires emergency surgery. The purpose of this study was to assess potential risk factors for endoscopic resection failure. METHODS A total of 1041 patients with G-SMT undergoing endoscopic resection were enrolled. Twenty-five patients in whom endoscopic resection failed, requiring a transition to surgery midway through the operation, were included in the failed group, and 1016 patients who received successful endoscopic resection were included in the successful endoscopic resection group. Baseline and lesion characteristics were recorded, and the differences in tumor characteristics and risk factors for resection failure of G-SMT were analyzed. Sensitivity analysis was performed to detect the stability of the indicator. RESULTS Of the 1041cases included, there were 25 cases (2.4%) of failed endoscopic resection. Binary logistic analysis showed that the independent risk factors included tumors originating from deep muscularis propria(OR = 14.42, 95% CI 4.47-46.52), size > 3 cm (OR = 7.75, 95% CI 2.64-22.70), exophytic growth pattern (OR = 4.98, 95% CI 1.62-15.29), endoscopist with less experience (OR = 5.99, 95% CI 1.07-12.19), and irregular borders (OR = 4.13, 95% CI 1.40-12.19). The stable risk factors were tumors size, tumor origin and growth pattern according to sensitivity analysis. CONCLUSIONS Tumors originating from the deep muscularis propria, tumor size > 3 cm, endoscopists with less experience, an exophytic growth pattern, and irregular boundaries were found to be independent risk factors for endoscopic resection failure. To reduce the risk of endoscopic resection failure, physicians should carefully evaluate G-SMT characteristics preoperative.
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10
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The Safety and Clinical Validity of Endoscopic Submucosal Dissection for Early Gastric Cancer in Patients Aged More Than 85 Years. Cancers (Basel) 2022; 14:cancers14143311. [PMID: 35884373 PMCID: PMC9323451 DOI: 10.3390/cancers14143311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 12/04/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is a safe and minimally invasive method for the treatment of early gastric cancer (EGC). However, whether ESD for EGC is also safe and feasible in patients aged ≥85 years is unclear. The patients enrolled in this study were divided into three groups: age ≥85 years (44 patients, 49 lesions), age 65−84 years (624 patients, 687 lesions), and age ≤64 years (162 patients, 174 lesions). We evaluated the incidence of adverse events (AEs) and overall survival (OS) and disease-specific survival (DSS). We analyzed the factors that had a significant impact on the prognosis of patients aged ≥85 years. No significant differences were found in the incidence of AEs among the three groups (p = 0.612). The OS was significantly lower in patients aged ≥85 years (p < 0.001). Conversely, DSS was not significantly worse in patients aged ≥85 years (p = 0.100). The poor Geriatric Nutritional Risk Index correlated with poor prognosis in patients aged ≥85 years (p < 0.001). ESD is a safe and valid treatment for EGC in patients aged ≥85 years. However, the indications should be carefully decided because it is difficult to estimate the survival contribution of ESD for EGC in patients aged ≥85 years, especially in those with poor nutritional status.
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11
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Endoscopic Treatment of Superficial Gastric Cancer: Present Status and Future. Curr Oncol 2022; 29:4678-4688. [PMID: 35877231 PMCID: PMC9319225 DOI: 10.3390/curroncol29070371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 12/02/2022] Open
Abstract
Although the mortality rates of gastric cancer (GC) are gradually declining, gastric cancer is still the fourth leading cause of cancer-related death worldwide. This may be due to the high rate of patients who are diagnosed with GC at advanced stages. However, in countries such as Japan with endoscopic screening systems, more than half of GCs are discovered at an early stage, enabling endoscopic resection (ER). Especially after the introduction of endoscopic submucosal dissection (ESD) in Japan around 2000, a high en bloc resection rate allowing pathological assessment of margin and depth has become possible. While ER is a diagnostic method of treatment and may not always be curative, it is widely accepted as standard treatment because it is less invasive than surgery and can provide an accurate diagnosis for deciding whether additional surgery is necessary. The curability of ER is currently assessed by the completeness of primary tumor removal and the possibility of lymph node metastasis. This review introduces methods, indications, and curability criteria for ER of EGC. Despite recent advances, several problems remain unsolved. This review will also outline the latest evidence concerning future issues.
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12
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Xu S, Chai N, Tang X, Linghu E, Lu Z, Wang S, Li B. Outcomes of simultaneous endoscopic submucosal dissection for synchronous multiple gastric neoplastic lesions: a retrospective comparative study. Surg Endosc 2022; 36:4014-4024. [PMID: 34713340 DOI: 10.1007/s00464-021-08722-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Simultaneous endoscopic submucosal dissection (ESD) is occasionally used in synchronous multiple gastric neoplastic lesions (SMGL). Therefore, we aim to evaluate the safety and efficacy of simultaneous ESD for SMGL compared with ESD for single lesions. METHODS A total of 1058 patients who received ESD from November 2006 to September 2019 were retrospectively evaluated in this study, including 997 single gastric epithelial lesions treated by single ESD (unifocal group) and 125 SMGL from 61 patients treated by simultaneous ESD (multifocal group). RESULTS The mean procedure time was 49.2 ± 41.30 min and 89.5 ± 66.33 min in unifocal group and multifocal group, respectively (p < 0.001). There was no significant difference in postoperative stenosis rate (1.0% vs. 0.0%, p = 1.000), intraoperative bleeding (endoscopic resection bleeding-c3 grade) rate (0.5% vs. 1.6%, p = 0.696), postoperative bleeding rate (1.3% vs. 0.0%, p = 0.461), and perforation rate (0.9% vs. 1.6%, p = 0.449) between the two groups. In addition, en block resection rate (p = 0.825), complete resection rate (p = 0.856) and curative resection rate (p = 0.709) were comparable between the two groups. During the follow-up, the local recurrence rate per patient: p = 0.363; per lesion: p = 0.235) was not significantly different between the two groups, however, the cumulative incidence of metachronous lesions after treatment was significantly higher in the multifocal group than the other group (10.0% vs. 3.2%, p = 0.004). CONCLUSIONS Simultaneous ESD is safe and effective in the treatment of SMGL. However, separate ESD is recommended for SMGL with longer procedure time. Besides, the metachronous gastric neoplastic lesions should be paid attention to during follow-up.
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Affiliation(s)
- Shanshan Xu
- Nankai University School of Medicine, Nankai University, Tianjin, 300071, China.,Department of Gastroenterology and Hepatology, The First Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Ningli Chai
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Xiaowei Tang
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Enqiang Linghu
- Nankai University School of Medicine, Nankai University, Tianjin, 300071, China. .,Department of Gastroenterology and Hepatology, The First Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China.
| | - Zhongsheng Lu
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Shasha Wang
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
| | - Bao Li
- Department of Gastroenterology and Hepatology, The First Medical Center of Chinese, PLA General Hospital, Beijing, 100853, China
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13
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Hatta W, Koike T, Abe H, Ogata Y, Saito M, Jin X, Kanno T, Uno K, Asano N, Imatani A, Masamune A. Recent approach for preventing complications in upper gastrointestinal endoscopic submucosal dissection. DEN OPEN 2022; 2:e60. [PMID: 35310735 PMCID: PMC8828199 DOI: 10.1002/deo2.60] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 08/30/2021] [Accepted: 09/06/2021] [Indexed: 12/15/2022]
Abstract
Although endoscopic submucosal dissection (ESD) is a minimally invasive treatment method for upper gastrointestinal (GI) tumors, patients undergoing upper GI ESD sometimes fall into a serious condition from complications. Thus, it is important to fully understand how to prevent complications when performing upper GI ESD. One of the major complications in esophageal and gastric ESD is intraoperative perforation. To prevent this complication, blind dissection should be avoided. Traction-assisted ESD is a useful technique for maintaining good endoscopic view. This method was proven to reduce the incidence of intraoperative perforation, which would become a standard technique in esophageal and gastric ESD. In gastric ESD, delayed bleeding is the most common complication. Recently, a novel prediction model (BEST-J score) consisting of 10 factors with four risk categories for delayed bleeding in gastric ESD was established, and a free mobile application is now available. For reducing delayed bleeding in gastric ESD, vonoprazan ≥20 mg/day is the sole reliable method in the current status. Duodenal ESD is still challenging with a much higher frequency of complications, such as perforation and delayed bleeding, than ESD in other organs. However, with the development of improved devices and techniques, the frequency of complications in duodenal ESD has been decreasing. To prevent intraoperative perforation, some ESD techniques, such as using the distal tips of the Clutch Cutter, were developed. An endoscopic mucosal defect closure technique would be mandatory for preventing delayed complications. However, several unresolved issues, including standardization of duodenal ESD, remain and further studies are demanded.
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Affiliation(s)
- Waku Hatta
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Tomoyuki Koike
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Hiroko Abe
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Yohei Ogata
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Masahiro Saito
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Xiaoyi Jin
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Takeshi Kanno
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Kaname Uno
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Naoki Asano
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Akira Imatani
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
| | - Atsushi Masamune
- Division of Gastroenterology Tohoku University Graduate School of Medicine Miyagi Japan
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14
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Endoscopic Resection for Gastric Subepithelial Tumor with Backup Laparoscopic Surgery: Description of a Single-Center Experience. J Clin Med 2021; 10:jcm10194423. [PMID: 34640444 PMCID: PMC8509194 DOI: 10.3390/jcm10194423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 09/07/2021] [Accepted: 09/24/2021] [Indexed: 12/12/2022] Open
Abstract
The aim of this study was to analyze patients who underwent endoscopic resection (ER) for gastric subepithelial tumors (SETs) with a high probability of surgical intervention. Between January 2013 and January 2021, 83 patients underwent ER at the operation theater and 27 patients (32.5%) required backup surgery mainly due to incidental perforation or uncontrolled bleeding despite endoscopic repairing. The tumor was predominantly located in the upper-third stomach (81%) with a size ≤ 2 cm (69.9%) and deep to the muscularis propria (MP) layer (92.8%) but there were no significant differences between two groups except tumor exophytic growth as a risk factor in the surgery group (37% vs. 0%, p < 0.0001). Patients in the ER-only group had shorter durations of procedure times (60 min vs. 185 min, p < 0.0001) and lengths of stay (5 days vs. 7 days, p < 0.0001) but with a higher percentage of overall morbidity graded III (0% vs. 7.1%, p = 0.1571). After ER, five patients (6%) had delayed perforation and two (2.4%) required emergent laparoscopic surgery. Neither recurrence nor gastric stenosis was reported during long-term surveillance. Here, we provide a minimally invasive strategy of endoscopic resection with backup laparoscopic surgery for gastric SETs.
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15
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Abstract
With improvements in the early detection of early gastric cancer (EGC) and advances in therapeutic techniques, endoscopic resection (ER) for EGC has become widely adopted in East Asian and Western countries. Endoscopic submucosal dissection has higher rates of en bloc, complete, and curative resections with lower rates of local recurrence than that of endoscopic mucosal resection. ER is a minimally invasive method with low morbidity that provides excellent outcomes. ER for EGC is a safe, effective method, preserving organ function and thus maintaining the patient's quality of life, and is recognized as the first-line treatment of EGC in selected patients.
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Affiliation(s)
- Ga Hee Kim
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, 88, Olympic-ro 43-gil, Songpa-gu, Seoul
| | - Hwoon-Yong Jung
- Department of Gastroenterology, University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, 88, Olympic-ro 43-gil, Songpa-gu, Seoul.
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16
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Shichijo S, Uedo N, Kanesaka T, Ohta T, Nakagawa K, Shimamoto Y, Ohmori M, Arao M, Iwatsubo T, Suzuki S, Matsuno K, Iwagami H, Inoue S, Matsuura N, Maekawa A, Nakahira H, Yamamoto S, Takeuchi Y, Higashino K, Ishihara R, Fukui K, Ito Y, Narahara H, Ishiguro S, Iishi H. Long-term outcomes after endoscopic submucosal dissection for differentiated-type early gastric cancer that fulfilled expanded indication criteria: A prospective cohort study. J Gastroenterol Hepatol 2021; 36:664-670. [PMID: 32663347 PMCID: PMC7983953 DOI: 10.1111/jgh.15182] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 06/21/2020] [Accepted: 06/27/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIM Endoscopic resection for early gastric cancer (EGC) is widely performed. However, there is still a paucity of strong evidence regarding long-term outcomes after endoscopic submucosal dissection (ESD) for the expanded indication criteria of the Japanese guidelines (ver. 2010). METHODS Endoscopic submucosal dissection was performed in patients with EGC that met the expanded indication criteria: (i) cT1a, differentiated-type EGC of 2 to 5 cm, ulcer negative or (ii) cT1a, differentiated-type EGC of ≤3 cm, ulcer positive. Patients whose pathological examination fulfilled the curative resection criteria were then enrolled in this cohort study: negative vertical margin, negative lymphovascular invasion, and (i) pT1a, differentiated-type, and ulcer negative; (ii) pT1a, differentiated-type, ≤3 cm, and ulcer positive; or (iii) pT1b1 (<500-μm submucosal invasion), differentiated-type, and ≤3 cm. Patients with only a positive horizontal margin as a noncurative factor were included for follow-up. RESULTS From September 2003 to February 2012, a total of 356 patients underwent ESD, and 214 were enrolled in the survival analysis. One hundred twenty patients (56%) had >2 cm in diameter and ulcer-negative lesions, and 94 (44%) had ≤3 cm and ulcer-positive lesions. The vital status at 5 years after ESD was confirmed in all (100%) patients. No local or metastatic recurrence was detected; however, 26 metachronous gastric cancers developed, and 1 patient died of metachronous gastric cancer. The 5-year disease-specific and overall survival rates were 99.5% (95% confidence interval [CI], 97.2%-100%) and 93.9% (95% CI, 89.8%-96.4%), respectively. CONCLUSION ESD for EGC that fulfills the expanded criteria is feasible and shows favorable long-term outcomes.
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Affiliation(s)
- Satoki Shichijo
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Noriya Uedo
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Takashi Kanesaka
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Takashi Ohta
- Division of GastroenterologyKansai Rosai HospitalAmagasakiJapan
| | - Kentaro Nakagawa
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Yusaku Shimamoto
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Masayasu Ohmori
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Masamichi Arao
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Taro Iwatsubo
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Sho Suzuki
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Kenshi Matsuno
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Hiroyoshi Iwagami
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Shuntaro Inoue
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Noriko Matsuura
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Akira Maekawa
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Hiroko Nakahira
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Sachiko Yamamoto
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Yoji Takeuchi
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Koji Higashino
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Ryu Ishihara
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan
| | - Keisuke Fukui
- Center for Cancer Control and StatisticsOsaka International Cancer InstituteOsakaJapan,Department of Medical Statistics, Research & Development CenterOsaka Medical CollegeOsakaJapan
| | - Yuri Ito
- Center for Cancer Control and StatisticsOsaka International Cancer InstituteOsakaJapan,Department of Medical Statistics, Research & Development CenterOsaka Medical CollegeOsakaJapan
| | - Hiroyuki Narahara
- Department of GastroenterologyHyogo Prefectural Nishinomiya HospitalNishinomiyaJapan
| | | | - Hiroyasu Iishi
- Department of Gastrointestinal OncologyOsaka International Cancer InstituteOsakaJapan,Department of GastroenterologyItami City HospitalItamiJapan
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17
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Kim NY, Lee HS, Lee KY, Jeon S, Choi SY, Joo HJ, Kim JE, Kim SY. Impact of BMI on Complications of Gastric Endoscopic Submucosal Dissection. Dig Dis 2020; 39:301-309. [PMID: 33166954 DOI: 10.1159/000512899] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 11/09/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Gastric endoscopic submucosal dissection (ESD) has a high rate of complications. However, it is unclear whether BMI affects ESD complications. We aimed to investigate the impact of BMI on ESD complications. METHODS A total of 7,263 patients who underwent gastric ESD were classified into 3 groups according to the Asia-Pacific classification of BMI: normal (BMI <23 kg/m2, n = 2,466), overweight (BMI 23-24.9 kg/m2, n = 2,117), and obese (BMI ≥25 kg/m2, n = 2,680). Adjusted logistic regression analyses were conducted to assess the association between BMI and ESD complications. RESULTS Compared to the normal group, a lower incidence of perforation and a higher incidence of pneumonia and leukocytosis were found in the overweight and obese groups, and intra-ESD desaturation and hypertension were more frequent in the obese group. After adjustment for confounders, the risk of perforation significantly decreased in the overweight (odds ratio [OR] = 0.24, 95% confidence interval [CI]: 0.17-0.33) and obese (OR = 0.12, 95% CI: 0.08-0.18) groups compared to that in the normal group. Meanwhile, the risk of pneumonia significantly increased in the overweight (OR = 11.04, 95% CI: 6.31-19.31) and obese (OR = 10.71, 95% CI: 6.14-18.66) groups compared to the normal group. During sedation, the obese group had a significantly increased risk of desaturation (OR = 2.81, 95% CI: 1.18-6.69) and hypertension (OR = 1.35, 95% CI: 1.11-1.63) compared to the normal group. CONCLUSIONS High BMI was significantly associated with ESD complications. More caution is needed in cases of obese patients undergoing ESD.
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Affiliation(s)
- Na Young Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Sun Lee
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ki-Young Lee
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soyoung Jeon
- Department of Research Affairs, Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Yeon Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hye Ji Joo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Eun Kim
- Department of Anesthesiology and Pain Medicine, Ajou University School of Medicine, Suwon, Republic of Korea
| | - So Yeon Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Republic of Korea,
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18
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Inoue S, Uedo N, Tabuchi T, Nakagawa K, Ohmori M, Iwagami H, Matsuno K, Iwatsubo T, Nakahira H, Matsuura N, Shichijo S, Maekawa A, Kanesaka T, Takeuchi Y, Higashino K, Ishihara R. Usefulness of epinephrine-added injection solution to reduce procedure time for gastric endoscopic submucosal dissection. Endosc Int Open 2020; 8:E1044-E1051. [PMID: 32743058 PMCID: PMC7373655 DOI: 10.1055/a-1192-4202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 05/18/2020] [Indexed: 11/25/2022] Open
Abstract
Background and study aims Epinephrine-added submucosal injection solution is used to facilitate hemostasis of non-variceal upper gastrointestinal bleeding and to prevent delayed bleeding of large pedunculated colorectal lesions. However, its benefit in gastric endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unclear. The effectiveness of epinephrine-added injection solution for outcomes of gastric ESD was examined using propensity score matching analysis. Patients and methods A total of 1,599 patients with solitary EGC (83 with non-epinephrine-added solution and 1,516 with epinephrine-added solution) between 2011 and 2018 were enrolled. Propensity scores were calculated to balance the distribution of baseline characteristics: age, sex, tumor location, specimen size, presence of ulcer scar, tumor depth, histological tumor type, and operators' experience, and 1:3 matching was performed. En bloc resection rate, mean procedure time, delayed bleeding rate, and perforation rate were compared between the non-epinephrine (n = 79) and epinephrine (n = 237) groups. Results Mean procedure time was significantly shorter in the epinephrine group than in the non-epinephrine group (60 vs. 78 min, P < 0.001). No significant difference was found in the rate of en bloc resection (both 99 %), incidence of delayed bleeding (both 6 %), or perforation (0 vs. 0.8 %) between the two groups. In multiple linear regression analysis, use of epinephrine-added solution was independently associated with short procedure time ( P < 0.001) after adjustment for other covariates. Conclusion The results suggest that epinephrine-added injection solution is useful for reduction of gastric ESD procedure time, warranting validation in a randomized controlled trial.
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Affiliation(s)
- Shuntaro Inoue
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takahiro Tabuchi
- Cancer Control Center, Osaka International Cancer Institute, Osaka, Japan
| | - Kentaro Nakagawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Masayasu Ohmori
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroyoshi Iwagami
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Kenshi Matsuno
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Taro Iwatsubo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Hiroko Nakahira
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Noriko Matsuura
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Satoki Shichijo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Akira Maekawa
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takashi Kanesaka
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Yoji Takeuchi
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Koji Higashino
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Ryu Ishihara
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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Laparoscopic resection is better than endoscopic dissection for gastric gastrointestinal stromal tumor between 2 and 5 cm in size: a case-matched study in a gastrointestinal center. Surg Endosc 2019; 34:5098-5106. [PMID: 31792690 DOI: 10.1007/s00464-019-07251-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Accepted: 11/05/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND The feasibility of endoscopic dissection for gastric gastrointestinal stromal tumor (gGIST) between 2 and 5 cm in size has been demonstrated. However, its impact on short-term and long-term outcomes, compared with laparoscopic resection, is unknown. The purpose of this study was to compare short-term and long-term outcomes between laparoscopic resection and endoscopic dissection for 2-5-cm gGIST. METHODS A case-matched study was performed using the propensity score. To overcome selection bias, we performed a 1:1 match using six covariates, including age, sex, BMI, ASA score, tumor size, and tumor location. Short-term and long-term outcomes between laparoscopic resection and endoscopic dissection were compared. RESULTS A total of 210 patients with 2-5-cm gGIST were enrolled between 2006 and 2017 in our gastrointestinal center. According to the intention-to-treat approach, 165 patients underwent laparoscopic resection, and 45 patients underwent endoscopic dissection. After the propensity score, 45 pairs were balanced and analyzed. There was no significant difference in the baseline characteristics between the laparoscopic and endoscopic groups after matching. The rate of complications was significantly higher in the endoscopic group compared with the laparoscopic group (P < 0.001). Perforations occurred in 16 patients in the endoscopic group (16/45, 35.6%). The postoperative hospital stay was significantly longer in the endoscopic group compared with the laparoscopic group (P < 0.001). There was no significant difference between the two groups in disease-free survival or overall survival. CONCLUSION Laparoscopic resection is better than endoscopic dissection for 2-5-cm gGIST because of the lower complication rate and shorter hospital stay.
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Risk factors for perforation of gastric endoscopic submucosal dissection: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2019; 31:1481-1488. [PMID: 31688250 DOI: 10.1097/meg.0000000000001543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this systematic review and meta-analysis was to identify significant risk factors for perforation in gastric endoscopic submucosal dissection. Studies published in the English language were searched for in Embase, WEB OF SCIENCE, Medline (PubMed and Ovid) and the Cochrane Central Register of Controlled Trials and Database of Systematic Reviews. Inclusion criteria and exclusion criteria were defined in advance in this work. Probable risk factors in a total of eighteen studies were evaluated, and the results are represented in the case of dichotomous variables as an odds ratio (with 95% confidence interval). Analysing the risk factors, the odds ratios were 1.98 (95% confidence interval: 1.02-3.85) for liver disease; 3.62 (95% confidence interval: 2.83-4.65) for vertical localization (the upper portion of the stomach); 1.42 (95% confidence interval: 1.03-1.96) for resected size (>20 mm); 3.05 (95% confidence interval: 1.80-5.17) for depth of invasion (submucosal); 4.12 (95% confidence interval: 1.63-10.39) for operation time (>2 hours); 1.59 (95% confidence interval: 1.25-2.01) for gross type of lesion (depressed or flat); and 3.88 (95% confidence interval: 2.69-5.60) for piecemeal resection. Liver disease, vertical localization (the upper portion of the stomach), resected size (>20 mm), depth of invasion (submucosal), operation time (>2 hours), gross type of lesion (flat or depressed), and piecemeal resection were verified to be risk factors for perforation of gastric endoscopic submucosal dissection.
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New classifications of intraoperative bleeding and muscularis propria injury in endoscopic resection. Chin Med J (Engl) 2019; 132:1856-1858. [PMID: 31335469 PMCID: PMC6759135 DOI: 10.1097/cm9.0000000000000357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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22
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Endoscopic management of iatrogenic gastrointestinal perforations. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2019. [DOI: 10.1016/j.lers.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Yamamoto Y, Kikuchi D, Nagami Y, Nonaka K, Tsuji Y, Fujimoto A, Sanomura Y, Tanaka K, Abe S, Zhang S, De Lusong MA, Uedo N. Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts. Dig Endosc 2019; 31 Suppl 1:4-20. [PMID: 30994225 DOI: 10.1111/den.13388] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 03/03/2019] [Indexed: 12/15/2022]
Abstract
Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2-3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self-expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post-ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high-risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over-the-scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three-quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.
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Affiliation(s)
- Yorimasa Yamamoto
- Division of Gastroenterology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Daisuke Kikuchi
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Yasuaki Nagami
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - Kouichi Nonaka
- Department of Gastroenterology, Saitama Medical University International Medical Center, Hidaka, Japan
| | - Yosuke Tsuji
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Ai Fujimoto
- Department of Gastroenterology and Hepatology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yoji Sanomura
- Department of Endoscopy, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Kyosuke Tanaka
- Department of Endoscopic Medicine, Mie University Hospital, Tsu, Japan
| | - Seiichiro Abe
- Endoscopy Division, National Cancer Center Hospital, Tokyo, Japan
| | - Shuo Zhang
- Digestive Department, Zhejiang Provincial Hospital of TCM, Hangzhou, China
| | - Mark Anthony De Lusong
- Section of Gastroenterology, Department of Medicine, Philippine General Hospital, University of the Philippines, Manila, Philippines
| | - Noriya Uedo
- Department of Gastrointestinal Oncology, Osaka International Cancer Institute, Osaka, Japan
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Quero G, Saccomandi P, Kwak JM, Dallemagne B, Costamagna G, Marescaux J, Mutter D, Diana M. Modular laser-based endoluminal ablation of the gastrointestinal tract: in vivo dose-effect evaluation and predictive numerical model. Surg Endosc 2018; 33:3200-3208. [PMID: 30456508 DOI: 10.1007/s00464-018-6603-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Accepted: 11/13/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic submucosal dissection allows for "en bloc" removal of early gastrointestinal neoplasms. However, it is technically demanding and time-consuming. Alternatives could rely on energy-based techniques. We aimed to evaluate a predictive numerical model of thermal damage to preoperatively define optimal laser settings allowing for a controlled ablation down to the submucosa, and the ability of confocal endomicroscopy to provide damage information. MATERIALS AND METHODS A Nd:YAG laser was applied onto the gastric mucosa of 21 Wistar rats on 10 spots (total 210). Power settings ranging from 0.5 to 2.5W were applied during 1-12 s, with a consequent energy delivery varying from 0.5 to 30 J. Out of the 210 samples, a total of 1050 hematoxilin-eosin stained slides were obtained. To evaluate thermal injury, the ratio between the damage depth (DD) over the mucosa and the submucosa thickness (T) was calculated. Effective and safe ablation was considered for a DD/T ratio ≤ 1 (only mucosal and submucosal damage). Confocal endomicroscopy was performed before and after ablation. A numerical model, using human physical properties, was developed to predict thermal damage. RESULTS No full-thickness perforations were detected. On histology, the DD/T ratio at 0.5 J was 0.57 ± 0.21, significantly lower when compared to energies ranging from 15 J (a DD/T ratio = 1.2 ± 0.3; p < 0.001) until 30 J (a DD/T ratio = 1.33 ± 0.31; p < 0.001). Safe mucosal and submucosal ablations were achieved applying energy between 4 and 12 J, never impairing the muscularis propria. Confocal endomicroscopy showed a distorted gland architecture. The predicted damage depth demonstrated a significant positive linear correlation with the experimental data (Pearson's r 0.85; 95% CI 0.66-0.94). CONCLUSIONS Low-power settings achieved effective and safe mucosal and submucosal ablation. The numerical model allowed for an accurate prediction of the ablated layers. Confocal endomicroscopy provided real-time thermal damage visualization. Further studies on larger animal models are required.
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Affiliation(s)
- Giuseppe Quero
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Paola Saccomandi
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Department of Mechanical Engineering, Politecnico di Milano, Milan, Italy
| | - Jung-Myun Kwak
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
| | - Bernard Dallemagne
- IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Guido Costamagna
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
| | - Jacques Marescaux
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France
| | - Didier Mutter
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France.,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France.,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Michele Diana
- IHU-Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France. .,IRCAD, Research Institute Against Cancer of the Digestive System, 1, Place de l'Hôpital, 67091, Strasbourg, France. .,Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.
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Gambitta P, Iannuzzi F, Ballerini A, D’Alessandro A, Vertemati M, Bareggi E, Pallotta S, Fontana P, Aseni P. Endoscopic submucosal dissection versus endoscopic mucosal resection for type 0-II superficial gastric lesions larger than 20 mm. Ann Gastroenterol 2018; 31:338-343. [PMID: 29720859 PMCID: PMC5924856 DOI: 10.20524/aog.2018.0237] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Accepted: 01/12/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are increasingly used for the treatment of superficial gastrointestinal neoplasia. However, the limits and the indications for each technique are still debated. Our retrospective study aimed to compare these techniques in patients with gastric flat lesions larger than 20 mm without the non-lifting sign. METHODS Between January 2013 and July 2016, a total of 36 patients with early gastric flat lesions larger than 20 mm and without the non-lifting sign were resected by ESD and were followed up by endoscopy. As a control group, 40 EMR cases from our database were matched. En bloc and curative resection were compared between the two groups according to histological assessment, tumor size, recurrence, complication rate, and procedure time. A Kaplan-Meier comparison was performed for both groups with a log-rank test to compare the survival curves; the chi-square test was employed for other parameters. RESULTS En bloc resection rate and curative resection rate were significantly higher in the ESD group than in the EMR group. Procedure time was significantly longer in the ESD group. No significant differences were found in the recurrence and complication rates, although the former were higher in the EMR group and the latter in the ESD group. Survival curves were similar for both groups. CONCLUSIONS Our retrospective analysis seems to confirm a clear advantage for ESD over EMR in removing early superficial gastric neoplasm. Although ESD has expanded the endoscopic resectability of endoscopic gastric lesions, EMR may still be considered one of the therapeutic options for flat gastric lesions without the non-lifting sign.
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Affiliation(s)
- Pietro Gambitta
- Endoscopy Division, Luigi Sacco Hospital, University of Milan (Pietro Gambitta, Francesca Iannuzzi, Alessandro Ballerini, Emilia Bareggi, Stefano Pallotta, Paola Fontana), Italy
| | - Francesca Iannuzzi
- Endoscopy Division, Luigi Sacco Hospital, University of Milan (Pietro Gambitta, Francesca Iannuzzi, Alessandro Ballerini, Emilia Bareggi, Stefano Pallotta, Paola Fontana), Italy
| | - Alessandro Ballerini
- Endoscopy Division, Luigi Sacco Hospital, University of Milan (Pietro Gambitta, Francesca Iannuzzi, Alessandro Ballerini, Emilia Bareggi, Stefano Pallotta, Paola Fontana), Italy
| | - Alessandra D’Alessandro
- Department of Clinical Medicine and Surgery, University of Naples Federico II (Alessandra D’Alessandro), Italy
| | - Maurizio Vertemati
- Department of Biomedical and Clinical Science, Luigi Sacco Hospital, University of Milan (Maurizio Vertemati), Italy
| | - Emilia Bareggi
- Endoscopy Division, Luigi Sacco Hospital, University of Milan (Pietro Gambitta, Francesca Iannuzzi, Alessandro Ballerini, Emilia Bareggi, Stefano Pallotta, Paola Fontana), Italy
| | - Stefano Pallotta
- Endoscopy Division, Luigi Sacco Hospital, University of Milan (Pietro Gambitta, Francesca Iannuzzi, Alessandro Ballerini, Emilia Bareggi, Stefano Pallotta, Paola Fontana), Italy
| | - Paola Fontana
- Endoscopy Division, Luigi Sacco Hospital, University of Milan (Pietro Gambitta, Francesca Iannuzzi, Alessandro Ballerini, Emilia Bareggi, Stefano Pallotta, Paola Fontana), Italy
| | - Paolo Aseni
- Department of Emergency, ASST Grande Ospedale Metropolitano Niguarda, Milan (Paolo Aseni), Italy
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Preoperative predictors of beyond endoscopic submucosal dissection indication or lymphovascular invasion in endoscopic resection for early gastric cancer. Surg Endosc 2017; 32:2948-2957. [PMID: 29280013 DOI: 10.1007/s00464-017-6009-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 12/06/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND To successfully resect early gastric cancer (EGC), prediction of lymph node metastasis is essential. Beyond endoscopic submucosal dissection (ESD) indication or lymphovascular invasion (LVI) are known risk factors associated with lymph node metastasis. However, accurate prediction of tumor invasion depth or LVI is impossible before endoscopic resection even when endoscopic ultrasound is used. The aim of this study was to identify the predictive factors associated with beyond ESD indication or LVI after ESD for EGC. METHODS Between Jan 2011 and Feb 2015, 532 lesions from 506 patients who received ESD for EGCs were included. We reviewed the data of patients diagnosed as EGCs without ulceration or those smaller than 3 cm with ulceration. RESULTS The incidence of EGCs found to be beyond expanded ESD indications or present of LVI after ESD was 11.1% (59/532). On multivariable analysis, endoscopic features of SM invasion, surface color changes, and elevated lesions were associated with beyond ESD indication or LVI. In particular, submucosal (SM) invasive features such as SM tumor-like marginal elevation [odds ratio (OR) 17.2; 95% confidence interval (CI) 2.0-146.7], fusion of convergent folds (OR 12.9; 95% CI 3.9-42.1), irregular surface (OR 17.8; 95% CI 5.6-56.8), and discoloration of the tumor surface (OR 16.1; 95% CI 2.4-105.9) were significant risk factors for beyond ESD indication or LVI. CONCLUSIONS The decision to proceed with endoscopic resection for EGCs with endoscopic features of SM invasion, surface color changes, or elevated forms must be made cautiously.
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Saccomandi P, Quero G, Costamagna G, Diana M, Marescaux J. Effects of Nd:YAG laser for the controlled and localized treatment of early gastrointestinal tumors: Preliminary in vivo study. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2017:4533-4536. [PMID: 29060905 DOI: 10.1109/embc.2017.8037864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Endoscopic submucosal dissection (ESD) is a minimally invasive technique allowing for the removal of early gastrointestinal (GI) tumors, widely considered as a valid alternative to conventional surgery. However, ESD is technically demanding, and potentially severe complications, such as bleeding and perforation, may occur. Energy-based techniques (e.g., radiofrequency ablation) might offer a potential alternative to ESD. However, their use mandates the ability to predict the damage induced and to identify a "signature" of the complete ablation, without the need for a physical specimen. Ideally, an energy-based procedure should be tunable in order to limit the ablation to the superficial layers, namely mucosa (M) and submucosa (SM), without injuring the muscularis propria (MP), thereby minimizing GI perforation. This experimental study aims to investigate thermal damage induced by Nd:YAG laser on the gastric wall, at different laser settings such as power (P) and time (t). Laser ablation was performed on the stomach wall of 6 Wistar rats. Two powers (2.5W and 1.0W) and 3 exposure times (12s, 6s and 2s) were tested, for a total of 30 ablations. Histological analysis allowed to assess thermal damage, in terms of damage depth (DD) and identification of involved layers. The ratio (R) between DD and the total depth (TD) of target layers (M+SM) was used as an index to evaluate the effectiveness of laser settings. At P=2.5W, MP was damaged (R>1) in the majority of cases (11/15). At P=1.0W, MP was preserved in all tests (R<;1), and rarely (4/15) did the damage reach the whole SM (R=1). Histopathological analysis evidenced that tissue damage was strongly related to the variable tissue thickness. These preliminary results seem to support the fact that endoscopic tunable laser ablation is feasible with a consistent damage/power correlation. Further tests are required to optimize the settings for applications on early GI tumors.
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Chen ZS, Jin XF, Wu HL, Guo JQ. Simultaneous endoscopic submucosal dissection for multiple early gastric cancers in a low volume center. Medicine (Baltimore) 2017; 96:e7745. [PMID: 28885329 PMCID: PMC6393059 DOI: 10.1097/md.0000000000007745] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The aim of the study is to evaluate the safety and efficacy of simultaneous endoscopic submucosal dissection (ESD) for multiple early gastric cancers.A total of 70 solitary early gastric cancers from 70 patients and 20 multiple early gastric cancers from 10 patients were included in this retrospective study. The curative resection rate, en bloc resection rate, procedure-related complications, and local recurrence were compared between the 2 groups.There was no statistical difference in the rate of complete resection, en bloc resection, and curative resection between the 2 groups (P > .05). No significant difference was found with respect to the occurrence of postoperative bleeding (P > .05). Procedure time was significantly longer in the simultaneous group than that in the single group (87.6 ± 25.1 min vs 54.6 ± 22.0 min, P = .004). The overall incidence of synchronous early gastric cancer was 7.5%.Simultaneous ESD for multiple early gastric cancers is a safe and feasible choice in low-volume hospital. The entire stomach should be examined meticulously during and after ESD. Larger randomized studies are needed to validate our results.
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Affiliation(s)
- Zhao-Sheng Chen
- Department of Gastroenterology, The Second Hospital of Shandong University
| | - Xi-Feng Jin
- Department of Gastroenterology, Tengzhou Central People's Hospital , Tengzhou, Shandong Province, China
| | - Hong-Lei Wu
- Department of Gastroenterology, The Second Hospital of Shandong University
| | - Jian-Qiang Guo
- Department of Gastroenterology, The Second Hospital of Shandong University
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Efficacy, Safety, and Overall Quality of Life of Endoscopic Submucosal Dissection for Early Colorectal Cancer in Elderly Patients. Gastroenterol Res Pract 2017; 2017:2386291. [PMID: 28757866 PMCID: PMC5512118 DOI: 10.1155/2017/2386291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 06/01/2017] [Accepted: 06/05/2017] [Indexed: 02/06/2023] Open
Abstract
Purpose Studies reporting the treatment of early colorectal cancer (ECC) by endoscopic submucosal dissection (ESD) in elderly patients are lacking in China. The aim was to evaluate the efficacy, safety and overall quality of life of elderly patients with ECC who undergoing ESD. Methods Three hundred and seventy-nine patients with 401 colorectal lesions entered into our study from March 2013 to March 2016 (Patients with an age 70 years old or older were divided into the elderly group and those who were less than 70-year-old entered the non-elderly group). Results No significant differences were found in sex ratio, body mass index, location, endoscopic classification, pathological pattern, lesion size, mean procedure time, hospitalization days, complete excision, and en bloc resection rate between the two groups (P > 0.05). No significant differences were observed between the groups in terms of complications during and after ESD procedure (P > 0.05). There were no statistical differences between two groups in Quality of life index (QL-Index) and European Organization for Research and Treatment quality of life version 3.0 questionnaire (EORTC QLQ-C30) scores (P > 0.05). Conclusion ESD was relatively safe and effective for elderly patients with ECC, and it may be an recommended first-line treatment.
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Yamamoto Y, Nishisaki H, Sakai H, Tokuyama N, Sawai H, Sakai A, Mimura T, Kushida S, Tsumura H, Sakamoto T, Miki I, Tsuda M, Inokuchi H. Clinical Factors of Delayed Perforation after Endoscopic Submucosal Dissection for Gastric Neoplasms. Gastroenterol Res Pract 2017; 2017:7404613. [PMID: 28894466 PMCID: PMC5574302 DOI: 10.1155/2017/7404613] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2017] [Revised: 07/02/2017] [Accepted: 07/10/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Delayed perforation is a rare but severe complication of endoscopic submucosal dissection (ESD) for early gastric neoplasm (EGN). The aim of this study was to clarify clinical factors related to delayed perforation after ESD. METHODS A total of 1158 consecutive patients with 1199 EGNs underwent ESD at our hospital between January 2000 and December 2015. Univariate analysis was used to identify clinicopathological factors related to delayed perforation. Moreover, duration of cautery needed for hemostasis was measured by comparison between perforated and nonperforated points in patients with delayed perforation. RESULTS Delayed perforation occurred in 5 of 1158 consecutive patients with 1199 EGNs who underwent ESD (0.42%). All cases were diagnosed within 24 h after ESD and recovered with conservative management. On univariate analysis, location in the upper stomach was the factor most significantly associated with delayed perforation (P < 0.01). Duration of cautery needed for hemostasis was significantly longer at perforated points (9 s) than at nonperforated points (3.5 s) in five patients. CONCLUSIONS Location in the upper stomach was the risk factor most prominently associated with delayed perforation after ESD for EGNs. In addition, delayed perforation appears associated with excessive electrocautery for hemostasis.
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Affiliation(s)
- Yoshinobu Yamamoto
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
- *Yoshinobu Yamamoto:
| | - Hogara Nishisaki
- 2Department of Internal Medicine, Kaibara hospital, Hyogo 669-3395, Japan
| | - Hideki Sakai
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Nagahiro Tokuyama
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Hiroaki Sawai
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Aya Sakai
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Takuya Mimura
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Saeko Kushida
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Hidetaka Tsumura
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Takeshi Sakamoto
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Ikuya Miki
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Masahiro Tsuda
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
| | - Hideto Inokuchi
- 1Department of Gastroenterology, Hyogo Cancer Center, Hyogo 673-8558, Japan
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Kim SY, Jung SW, Choe JW, Hyun JJ, Jung YK, Koo JS, Yim HJ, Lee SW. Predictive Factors for Pain After Endoscopic Resection of Gastric Tumors. Dig Dis Sci 2016; 61:3560-3564. [PMID: 27696098 DOI: 10.1007/s10620-016-4325-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 09/21/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Abdominal pain is a common complaint following endoscopic resection (ER). AIMS To investigate the predictive factors for abdominal pain after ER. METHODS Patients who were scheduled to undergo endoscopic mucosal resection or endoscopic submucosal dissection for the treatment of gastric adenoma or cancer were prospectively enrolled. Pain scores were checked every 6 h after ER and whenever patients complained of pain by using a 0-10 pain scale. If the pain score exceeded 5, 25 mg of intravenous (IV) pethidine was administered. RESULTS Among 156 patients who underwent ER, 66 (42.3 %) received IV pethidine due to moderate/severe abdominal pain. Both the number of patients complaining of abdominal pain and the pain scores decreased with time following the procedure, with only a few patients complaining of mild abdominal pain 2 days after ER. Multivariate analysis showed that female sex [odds ratio (OR) 2.88; confidence interval (CI) 1.31-6.33], tumor location in the lower third of the stomach (OR 5.46; CI 2.31-12.92), and procedures time more than 60 min (OR 2.96; CI 1.26-6.98) were significant predictive factors for developing pain after ER. CONCLUSIONS Female sex, tumor location in the lower third of the stomach, and longer procedure time were significantly associated with pain after ER. Close monitoring and active management of pain is recommended for patients who have these risk factors. With these efforts, the majority of patients could experience pain relief within 2 days after the procedure.
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Affiliation(s)
- Seung Young Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Woo Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea. .,Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University Ansan Hospital, Korea University College of Medicine, 123 Jukgumro, Danwon-gu, Ansan, Gyeonggi-do, 425-707, Korea.
| | - Jung Wan Choe
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jong Jin Hyun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Young Kul Jung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ja Seol Koo
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyung Joon Yim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Woo Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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32
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Libânio D, Pimentel-Nunes P, Dinis-Ribeiro M. Complications of endoscopic resection techniques for upper GI tract lesions. Best Pract Res Clin Gastroenterol 2016; 30:735-748. [PMID: 27931633 DOI: 10.1016/j.bpg.2016.09.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 08/12/2016] [Accepted: 09/06/2016] [Indexed: 02/09/2023]
Abstract
Adverse events can occur during and after the endoscopic resection of upper gastrointestinal lesions. Their incidence can be minimized through the adoption of preventive measures and their final outcomes can be optimized through prompt identification and adequate treatment. In this evidence-based review we describe the risk factors for adverse events, preventive measures to avoid them and their management when they occur. Algorithms of action are also provided. Oesophageal strictures can be prevented with corticosteroids (either locally injected or systemically administered) and treated with endoscopic dilatation. Bleeding can be minimized through the adoption of prophylactic coagulation and novel preventive measures are emerging and being evaluated. Bleeding management includes coagulation therapy, clips and haemostatic powders. Perforations can nowadays be successfully treated endoscopically in the majority of the cases and conservative treatment is associated with favourable outcomes although optimal management is unclear.
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Affiliation(s)
- D Libânio
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Porto, Portugal.
| | - P Pimentel-Nunes
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Porto, Portugal; CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
| | - M Dinis-Ribeiro
- Gastroenterology Department, Portuguese Oncology Institute of Porto, Porto, Portugal; CINTESIS - Center for Health Technology and Services Research, Porto, Portugal; CIDES-FMUP - Faculty of Medicine of the University of Porto, Porto, Portugal
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Akintoye E, Obaitan I, Muthusamy A, Akanbi O, Olusunmade M, Levine D. Endoscopic submucosal dissection of gastric tumors: A systematic review and meta-analysis. World J Gastrointest Endosc 2016; 8:517-532. [PMID: 27606044 PMCID: PMC4980641 DOI: 10.4253/wjge.v8.i15.517] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 06/11/2016] [Accepted: 07/13/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To systematically review the medical literature in order to evaluate the safety and efficacy of gastric endoscopic submucosal dissection (ESD).
METHODS: We performed a comprehensive literature search of MEDLINE, Ovid, CINAHL, and Cochrane for studies reporting on the clinical efficacy and safety profile of gastric ESD.
RESULTS: Twenty-nine thousand five hundred and six tumors in 27155 patients (31% female) who underwent gastric ESD between 1999 and 2014 were included in this study. R0 resection rate was 90% (95%CI: 87%-92%) with significant between-study heterogeneity (P < 0.001) which was partly explained by difference in region (P = 0.02) and sample size (P = 0.04). Endoscopic en bloc and curative resection rates were 94% (95%CI: 93%-96%) and 86% (95%CI: 83%-89%) respectively. The rate of immediate and delayed perforation rates were 2.7% (95%CI: 2.1%-3.3%) and 0.39% (95%CI: 0.06%-2.4%) respectively while rates of immediate and delayed major bleeding were 2.9% (95%CI: 1.3-6.6) and 3.6% (95%CI: 3.1%-4.3%). After an average follow-up of about 30 mo post-operative, the rate of tumor recurrence was 0.02% (95%CI: 0.001-1.4) among those with R0 resection and 7.7% (95%CI: 3.6%-16%) among those without R0 resection. Overall, irrespective of the resection status, recurrence rate was 0.75% (95%CI: 0.42%-1.3%).
CONCLUSION: Our meta-analysis, the largest and most comprehensive assessment of gastric ESD till date, showed that gastric ESD is safe and effective for gastric tumors and warrants consideration as first line therapy when an expert operator is available.
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Kato M, Michida T, Kusakabe A, Sakai A, Hibino C, Kato M, Tokuda Y, Kawai T, Hamano M, Chiba M, Maeda K, Yamamoto K, Naito M, Ito T. Safety and short-term outcomes of endoscopic submucosal dissection for early gastric cancer in elderly patients. Endosc Int Open 2016; 4:E521-6. [PMID: 27227108 PMCID: PMC4874799 DOI: 10.1055/s-0042-102650] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 02/01/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) has become widely accepted as a minimally invasive treatment for early gastric cancer (EGC), and opportunities to use ESD to treat EGC in elderly patients are increasing. The objective of this study was to elucidate the safety and efficacy of ESD in elderly patients. PATIENTS AND METHODS Between April 2006 and March 2013, a total of 892 patients with EGC were prospectively recruited to undergo ESD according to definite inclusion criteria. The short-term outcomes and incidence of complications in 345 of these patients who were 75 years of age or older (elderly group) were compared with the short-term outcomes and incidence of complications in the remaining 547 patients (non-elderly group). Factors associated with the occurrence of pneumonia and delirium were also investigated. RESULTS The R0 resection rate did not differ between the two groups (96.2 % in the elderly group vs. 96.7 % in the non-elderly group; P = 0.65). The incidence of pneumonia (7.5 % vs. 1.8 %; P < 0.01) and incidence of delirium (10.1 % vs. 1.1 %; P < 0.01) were significantly higher in the elderly group. The incidence of post-ESD bleeding and incidence of perforation were similar in the two groups. No emergency surgery was required, but one patient in the non-elderly group died of aspiration pneumonia. On multivariate analysis, age 75 years or older, cerebrovascular disease, chronic obstructive pulmonary disease, delirium, and remnant stomach or gastric tube were independent risk factors for pneumonia, and age 75 years or older, diabetes, dementia, and pneumonia were independent risk factors for delirium. CONCLUSION ESD for EGC was feasible for elderly patients in good condition. However, pneumonia and delirium may develop more frequently after ESD in elderly patients with co-morbidities.
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Affiliation(s)
- Minoru Kato
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
- Department of Gastrointestinal Oncology, Osaka Medical Center for Cancer and Cardiovascular Diseases, Osaka, Japan
| | - Tomoki Michida
- Third department of Internal Medicine, Teikyo University Medical Center, Chiba, Japan
| | - Akira Kusakabe
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Ayako Sakai
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Chihiro Hibino
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Mina Kato
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Yuki Tokuda
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Tomoyo Kawai
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Mina Hamano
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Miho Chiba
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Kosaku Maeda
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Katsumi Yamamoto
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Masafumi Naito
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
| | - Toshifumi Ito
- Department of Gastroenterology, Japan Community Healthcare Organization Osaka Hospital, Osaka, Japan
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Ko WJ, Song GW, Kim WH, Hong SP, Cho JY. Endoscopic resection of early gastric cancer: current status and new approaches. Transl Gastroenterol Hepatol 2016; 1:24. [PMID: 28138591 DOI: 10.21037/tgh.2016.03.22] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 03/04/2016] [Indexed: 12/18/2022] Open
Abstract
Endoscopic resection (ER) of early gastric cancer (EGC) has been an optimal treatment for selected patients. As endoscopic submucosal dissection (ESD) has been widely used for treatment of EGC, concerns have been asked to achieve curative resection for EGC while guaranteeing precise prediction of lymph node metastasis (LNM). Moreover, a new microscopic imaging for precise endoscopic diagnosis of EGC is introduced. This review covers the current status and new approaches of ER of EGC.
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Affiliation(s)
- Weon Jin Ko
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea
| | - Ga Won Song
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea
| | - Won Hee Kim
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea
| | - Sung Pyo Hong
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea
| | - Joo Young Cho
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam-si, Korea
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36
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Meng FS, Zhang ZH, Hong YY, Li DJ, Lin JQ, Chen X, Ji F. Comparison of endoscopic submucosal dissection and surgery for the treatment of gastric submucosal tumors originating from the muscularis propria layer: a single-center study (with video). Surg Endosc 2016; 30:5099-5107. [PMID: 27005293 DOI: 10.1007/s00464-016-4860-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 03/03/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) has been used for the treatment of gastric submucosal tumors (SMTs). This study aims to compare clinical outcomes of ESD versus laparoscopic wedge resection (LWR) for gastric SMTs. METHODS This is a retrospective cohort study. Patients with SMTs who underwent ESD or LWR were enrolled in this study at a university-affiliated hospital from January 2010 to October 2015. Preoperative endoscopic ultrasound and computed tomography were performed to determine origin of layer and growth pattern. Clinical outcomes including baseline demographics, tumor size, operation time, blood loss, hospital stay, cost, pathology and postoperative complications were compared. RESULTS From January 2010 to October 2015, 68 patients with SMTs received ESD and 47 patients with SMTs received LWR. There was no difference in age, gender, body mass index, origin of layer and proportion with symptoms between ESD group and LWR group. However, tumor size was significantly larger in the LWR group (37.1 mm) than in the ESD group (25.8 mm, P = 0.041). For patients with tumors smaller than 20 mm, ESD was associated with shorter mean operation time (89.7 ± 23.5 vs 117.6 ± 23.7 min, P = 0.043), less blood loss (4.9 ± 1.7 vs 72.3 ± 23.3 ml, P < 0.001), shorter length of hospital stay (3.6 ± 1.9 vs 6.9 ± 3.7 days, P = 0.024) and lower cost (2471 ± 573 vs 4498 ± 1257 dollars, P = 0.031) when compared with LWR. For patients with tumors between 20 mm and 50 mm, ESD was associated with shorter mean operation time (99.3 ± 27.8 vs 125.2 ± 31.5 min, P = 0.039), less blood loss (10.1 ± 5.3 vs 87.6 ± 31.3 ml, P < 0.001), shorter length of hospital stay (4.0 ± 1.7 vs 7.3 ± 4.5 days, P = 0.027) and lower cost (2783 ± 601 vs 4798 ± 1343 dollars, P = 0.033) when compared with LWR. There were no significant differences in terms of rates of en bloc resection, complete resection and complication and histological diagnosis regardless of tumor size. CONCLUSIONS ESD can achieve similar oncological outcomes when compared with surgery for treatment of gastric SMT smaller than 50 mm.
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Affiliation(s)
- Fan-Sheng Meng
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road No. 79, Hangzhou, 310000, China
| | - Zhao-Hong Zhang
- Department of Hematology, Linyi People's Hospital, Jiefang Road No. 27, Linyi, 276300, China
| | - Yan-Yun Hong
- Department of Gastrointestinal Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road No. 79, Hangzhou, 310000, China
| | - De-Jian Li
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road No. 79, Hangzhou, 310000, China
| | - Jie-Qiong Lin
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road No. 79, Hangzhou, 310000, China
| | - Xin Chen
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road No. 79, Hangzhou, 310000, China
| | - Feng Ji
- Department of Gastroenterology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Qingchun Road No. 79, Hangzhou, 310000, China.
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Kim HJ, Chung H, Jung DH, Park JC, Shin SK, Lee SK, Lee YC. Clinical outcomes of and management strategy for perforations associated with endoscopic submucosal dissection of an upper gastrointestinal epithelial neoplasm. Surg Endosc 2016; 30:5059-5067. [PMID: 26983439 DOI: 10.1007/s00464-016-4854-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 03/02/2016] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Perforation is one of the major complications of endoscopic submucosal dissection (ESD). In the present study, we investigated the clinical outcomes of and management strategies for ESD-related perforations. METHODS Between February 2010 and April 2014, a total of 3821 patients who underwent ESD for an upper gastrointestinal epithelial neoplasm were analyzed using the Yonsei University Severance Hospital database. Clinical outcomes of and management strategies for perforations in 90 patients (2.4 %) were analyzed. The risk factors for the development of perforation were also investigated. RESULTS The mean age of our subjects was 64.7 ± 12.2 years (male to female ratio, 3.2:1), and the mean size of the resected specimens was 39.4 ± 12.5 mm. Endoscopically visible perforations (visible perforation group) were noted in 74 of the 90 patients (82.2 %), and clinically suspected perforations (suspected perforation group) were noted in 16 patients (17.8 %). Immediate closure with endoclips was attempted in cases with a visible perforation and was successful in 72 (97.3 %) cases. Two patients in whom endoscopic closure failed underwent surgery. Conservative care, including fasting and intravenous antibiotic administration, was attempted in the suspected perforation group, and all the patients were treated successfully without surgery. The mean durations of fasting, antibiotic treatment, and hospital stay were 3.8 ± 3.1, 6.8 ± 4.2, and 8.7 ± 5.3 days, respectively. Subgroup analysis of perforation type (visible perforation vs. suspected perforation) revealed no significant difference in the clinical course. Tumor location at the upper or middle third of the stomach was significantly associated with perforation. CONCLUSION Most of the ESD-related perforations in upper gastrointestinal epithelial neoplasm could be managed successfully in a non-surgical manner under strict monitoring.
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Affiliation(s)
- Hyun Ju Kim
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea.,Yonsei University Graduate School of Medicine, Seoul, Korea
| | - Hyunsoo Chung
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea. .,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea. .,Yonsei University Graduate School of Medicine, Seoul, Korea.
| | - Da Hyun Jung
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.,Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Korea
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Choe JW, Jung SW, Song JK, Shim E, Choo JY, Kim SY, Hyun JJ, Koo JS, Yim HJ, Lee SW. Predictive Factors of Atelectasis Following Endoscopic Resection. Dig Dis Sci 2016; 61:181-8. [PMID: 26289260 DOI: 10.1007/s10620-015-3844-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 08/02/2015] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Atelectasis is one of the pulmonary complications associated with anesthesia. Little is known about atelectasis following endoscopic procedures under deep sedation. This study evaluated the frequency, risk factors, and clinical course of atelectasis after endoscopic resection. METHODS A total of 349 patients who underwent endoscopic resection of the upper gastrointestinal tract at a single academic tertiary referral center from March 2010 to October 2013 were enrolled. Baseline characteristics and clinical data were retrospectively reviewed from medical records. To identify atelectasis, we compared the chest radiography taken before and after the endoscopic procedure. RESULTS Among the 349 patients, 68 (19.5 %) had newly developed atelectasis following endoscopic resection. In univariate logistic regression analysis, atelectasis correlated significantly with high body mass index, smoking, diabetes mellitus, procedure duration, size of lesion, and total amount of propofol. In multiple logistic regression analysis, body mass index, procedure duration, and total propofol amount were risk factors for atelectasis following endoscopic procedures. Of the 68 patients with atelectasis, nine patients developed fever, and six patients displayed pneumonic infiltration. The others had no symptoms related to atelectasis. CONCLUSIONS The incidence of radiographic atelectasis following endoscopic resection was nearly 20 %. Obesity, procedural time, and amount of propofol were the significant risk factors for atelectasis following endoscopic procedure. Most cases of the atelectasis resolved spontaneously with no sequelae.
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Affiliation(s)
- Jung Wan Choe
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Sung Woo Jung
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea. .,Korea University Ansan Hospital, 123, Jeokgeum-ro, Danwon-gu, Ansan, Gyeonggi-do, 425-707, Korea.
| | - Jong Kyu Song
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Euddeum Shim
- Department of Radiology, Korea University College of Medicine, Ansan, Korea
| | - Ji Yung Choo
- Department of Radiology, Korea University College of Medicine, Ansan, Korea
| | - Seung Young Kim
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Ja Seol Koo
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
| | - Sang Woo Lee
- Department of Internal Medicine, Korea University College of Medicine, Ansan, Korea
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Joh DH, Park CH, Jung S, Choi SH, Kim HK, Lee H, Park JC, Shin SK, Lee YC, Lee SK. Safety and feasibility of simultaneous endoscopic submucosal dissection for multiple gastric neoplasias. Surg Endosc 2015; 29:3690-3697. [PMID: 25783832 DOI: 10.1007/s00464-015-4139-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 02/24/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Synchronous gastric neoplasms are not infrequently detected, thus endoscopic submucosal dissection (ESD) for multiple early gastric neoplasia is occasionally considered. However, there have been few investigations of the safety and feasibility of simultaneous ESD for multiple gastric lesions. This study aims to evaluate the safety and feasibility of simultaneous ESD for multiple gastric neoplasia. METHODS A total of 1823 patients who underwent ESD for 1929 gastric adenomas or early gastric cancers were retrospectively reviewed in this study. Two hundred gastric adenomas or early gastric cancers among 94 patients were treated by ESD simultaneously (multiple group), and 1729 patients were treated with ESD for a single lesion (single group). RESULTS En bloc resection (P = 0.060), complete resection (P = 0.362) and curative resection (P = 0.108) rates did not differ between the two groups. Rates of adverse events including bleeding (P = 0.317), perforation (P = 0.316) and aspiration pneumonia (P = 0.563) were not higher in the multiple group. Long-term follow-up showed more frequent local recurrence (P < 0.001), synchronous neoplasia (P = 0.041) and metachronous neoplasia (P < 0.001) per patient in the multiple group; however, local recurrence per lesion did not differ between the two groups (P = 0.103). CONCLUSIONS Simultaneous ESD for multiple synchronous gastric neoplasms is safe and feasible compared to single ESD. However, thorough examination for local recurrence and synchronous and metachronous neoplasia is required.
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Affiliation(s)
- Dong Hoo Joh
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
| | - Chan Hyuk Park
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Sungmo Jung
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Seung-Ho Choi
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyun Ki Kim
- Department of Pathology, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyuk Lee
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Jun Chul Park
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Sung Kwan Shin
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Yong Chan Lee
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 250 Seongsanno, Seodaemun-gu, Seoul, 120-752, Republic of Korea.
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Suzuki H, Oda I, Sekiguchi M, Abe S, Nonaka S, Yoshinaga S, Nakajima T, Saito Y. Management and associated factors of delayed perforation after gastric endoscopic submucosal dissection. World J Gastroenterol 2015; 21:12635-12643. [PMID: 26640340 PMCID: PMC4658618 DOI: 10.3748/wjg.v21.i44.12635] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 07/15/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify the actual clinical management and associated factors of delayed perforation after gastric endoscopic submucosal dissection (ESD).
METHODS: A total of 4943 early gastric cancer (EGC) patients underwent ESD at our hospital between January 1999 and June 2012. We retrospectively assessed the actual management of delayed perforation. In addition, to determine the factors associated with delayed perforation, after excluding 123 EGC patients with perforations that occurred during the ESD procedure, we analyzed the following clinicopathological factors among the remaining 4820 EGC patients by comparing the ESD cases with delayed perforation and the ESD cases without perforation: age, sex, chronological periods, clinical indications for ESD, status of the stomach, location, gastric circumference, tumor size, invasion depth, presence/absence of ulceration, histological type, type of resection, and procedure time.
RESULTS: Delayed perforation occurred in 7 (0.1%) cases. The median time until the occurrence of delayed perforation was 11 h (range, 6-172 h). Three (43%) of the 7 cases required emergency surgery, while four were conservatively managed without surgical intervention. Among the 4 cases with conservative management, 2 were successfully managed endoscopically using the endoloop-endoclip technique. The median hospital stay was 18 d (range, 15-45 d). There were no delayed perforation-related deaths. Based on a multivariate analysis, gastric tube cases (OR = 11.0; 95%CI: 1.7-73.3; P = 0.013) were significantly associated with delayed perforation.
CONCLUSION: Endoscopists must be aware of not only the identified factors associated with delayed perforation, but also how to treat this complication effectively and promptly.
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Endoscopic submucosal dissection for early gastric cancer in elderly patients: a meta-analysis. World J Surg Oncol 2015; 13:293. [PMID: 26438198 PMCID: PMC4595137 DOI: 10.1186/s12957-015-0705-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 09/22/2015] [Indexed: 02/06/2023] Open
Abstract
Background The effectiveness of endoscopic submucosal dissection (ESD) has been increasingly reported. However, studies addressing the safety and application value of ESD in elderly patients with early gastric cancer (EGC) were still lacking. This meta-analysis was intended to evaluate the feasibility and safety of ESD in elderly patients with EGC. Methods A systematic search was conducted in PubMed, EBSCO, Cochrane Library, EMBASE, and Web of Science. Studies were screened out if data of elderly and non-elderly gastric cancer patients were reported separately. The qualities of included studies were assessed using Newcastle-Ottawa Quality Assessment Scale. The pooled odd ratios (ORs) with 95 % confidence intervals (CIs) were calculated. Statistical analysis was conducted using the Review Manager 5.2 (Cochrane Collaboration, Oxford, UK). Results Nine studies (eight in Japan, one in China), including a total of 30,100 lesions, met the inclusion criteria. The “en bloc” and histological complete resection rates of the elderly and non-elderly groups were similar [OR, 0.98, 95 % CI, 0.56 to 1.71; P = 0.93 and OR, 0.79, 95 % CI, 0.58 to 1.07; P = 0.13, respectively]. As for procedure-related complications, similar perforation rates [OR, 1.19, 95 % CI, 0.94 to 1.51; P = 0.15], and bleeding rates [OR, 1.13, 95 % CI, 0.83 to 1.56); P = 0.43] between the elderly and non-elderly groups were observed. Whereas, the elderly patients had a higher procedure-related pneumonia rate compared with non-elderly ones [OR, 2.18, 95 % CI, 1.55 to 3.08; P < 0.01]. Conclusions The ESD procedure appears to be a safe technique in elderly patients with EGC while appropriate approach should be taken to avoid procedure-related pneumonia.
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Chinda D, Sasaki Y, Tatsuta T, Tsushima K, Wada T, Shimoyama T, Fukuda S. Perioperative complications of endoscopic submucosal dissection for early gastric cancer in elderly Japanese patients 75 years of age or older. Intern Med 2015; 54:267-272. [PMID: 25748734 DOI: 10.2169/internalmedicine.54.3300] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The number of endoscopic submucosal dissection (ESD) procedures for early gastric cancers among patients 75 years of age or older has been increasing. We herein examined both the outcomes and complications of ESD in elderly patients. METHODS We investigated the effects of underlying diseases, lesion characteristics, treatment outcomes and complications during and in the postoperative periods of ESD among elderly patients 75 years of age or older versus non-elderly patients less than 75 years of age. Patients A total of 318 early gastric cancers in consecutive 307 patients, all of whom underwent ESD for gastric cancer, were included in this study. RESULTS The number of patients with hypertension and ischemic heart disease was significantly higher in the elderly group than in the non-elderly group. The proportion of lesions with an absolute indication, extended indication or no indication was not significantly different between the groups. During the ESD procedure, the use of atropine sulfate for bradycardia was significantly more frequent in the elderly group. No significant differences were observed between the groups in terms of the treatment for hypertension, oxygen administration or incidence of perforation. In addition, there were no significant differences with respect to oxygen administration, postoperative bleeding or the occurrence of fever and/or pneumonia after the ESD procedure. CONCLUSION Although bradycardia was more frequently observed in the elderly patients during ESD in this study, ESD was performed safely and managed appropriately, with infrequent postoperative complications. ESD appears to be effective, even in elderly patients.
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Affiliation(s)
- Daisuke Chinda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan
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Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video). Gastrointest Endosc 2014; 80:495-502. [PMID: 24679655 PMCID: PMC4426966 DOI: 10.1016/j.gie.2014.01.050] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/29/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear. OBJECTIVE To objectively analyze efficacy of countertraction using the suture-pulley method for ESD. DESIGN Prospective ex vivo animal study. SETTING Animal laboratory. INTERVENTIONS Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10), ESD was performed by using the standard technique. In the suture-pulley arm (N = 10), a circumferential incision was made, and an endoscopic suturing device was used to place the suture pulley. MAIN OUTCOME MEASUREMENTS The primary outcome of this study was total procedure time. RESULTS The median total procedure time with the suture-pulley method was significantly shorter than the traditional ESD technique (median, 25% to 75%, interquartile range [IQR]: 531 seconds [474.3-549.3 seconds] vs 845 seconds [656.3-1547.5 seconds], P < .001). The median time (IQR) for suture-pulley placement was 160.5 seconds (150.0-168.8 seconds). Although there was a significantly longer procedure time for proximal versus middle/lower stomach lesions with traditional ESD (median, 1601 seconds; IQR, 1547.5-1708.8 seconds vs median, 663 seconds; IQR, 627.5-681.8 seconds; P = .01), there was no significant difference in procedure time for lesions of various locations when using the suture-pulley method. Compared with traditional ESD, the suture-pulley method was less demanding in all categories evaluated by the NASA Task Load Index. LIMITATIONS Ex vivo study. CONCLUSIONS The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.
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Nakanishi T, Araki H, Ozawa N, Takada J, Kubota M, Imai K, Onogi F, Ibuka T, Shiraki M, Shimizu M, Moriwaki H. Risk factors for pyrexia after endoscopic submucosal dissection of gastric lesions. Endosc Int Open 2014; 2:E141-7. [PMID: 26134960 PMCID: PMC4440359 DOI: 10.1055/s-0034-1377274] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 04/18/2014] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic submucosal dissection (ESD) is widely used in the resection of gastric tumors en bloc, however, complications such as pyrexia frequently occur following the procedure. The study aim was to elucidate the incidence, clinical characteristics, and risk factors of post-ESD pyrexia. PATIENTS AND METHODS We conducted a retrospective cohort study of 471 consecutive patients with 485 gastric lesions resected by ESD between December 2005 and 2010. Pyrexia was defined as body temperature above 37.5 °C, regardless of its duration. Blood tests and chest radiography were performed three times before and after ESD. Chest and abdominal computed tomography (CT) was taken on postoperative day 1. RESULTS Post-ESD pyrexia developed in 117 patients (24.8 %), including 40 patients with pneumonia as shown by computed tomography. The pyrexia was resolved in all the patients after 1 day (median; range, 1 - 36 days). A multivariate analysis identified age (P = 0.0029) and resection diameter (P = 0.0009) as risk factors for pyrexia in patients without pneumonia, and operation time (P = 0.0025) as a risk factor for pyrexia in patients with pneumonia. CONCLUSION The patient would be at risk for post-ESD pyrexia if a large ESD is performed in the elderly. The longer operation time would raise the risk for pneumonia-associated fever.
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Affiliation(s)
- Takayuki Nakanishi
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Hiroshi Araki
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan,Corresponding author Hiroshi Araki, M.D.,
Ph.D Department of
GastroenterologyGifu University Graduate School
of Medicine1–1 Yanagido, Gifu
501–1194Japan+81–58–230–6310
| | - Noritaka Ozawa
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Jun Takada
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Masaya Kubota
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Kenji Imai
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Fumito Onogi
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Takashi Ibuka
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Makoto Shiraki
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Masahito Shimizu
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
| | - Hisataka Moriwaki
- Department of Gastroenterology, Gifu University Graduate School of
Medicine, Gifu, Japan
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Technical difficulty according to location, and risk factors for perforation, in endoscopic submucosal dissection of colorectal tumors. Surg Endosc 2014; 29:133-9. [PMID: 24993172 DOI: 10.1007/s00464-014-3665-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Accepted: 05/31/2014] [Indexed: 12/23/2022]
Abstract
BACKGROUND Colorectal endoscopic submucosal dissection (ESD) is a widely accepted treatment for colorectal tumors, but is technically more difficult and has a higher risk of complications such as perforation than gastric ESD. Few studies have investigated the factors associated with technical difficulty and perforation in colorectal ESD. This study aimed to evaluate the technical difficulty according to location, and the risk factors for perforation, in colorectal ESD. METHODS This retrospective study included 134 consecutive colorectal tumors treated by ESD in 122 patients at the Division of Endoscopy of Hokkaido University Hospital and the Department of Gastroenterology of Kitami Red Cross Hospital from November 2011 to February 2013. To evaluate the technical difficulty of performing ESD for colorectal tumors at specific locations, the en bloc R0 resection rate, specimen diameter, procedure speed, and procedure time were compared among tumor locations using the χ (2) test or analysis of variance. Risk factors for perforation were identified by multiple logistic regression analysis. RESULTS The en bloc R0 resection rate was 86.6 % (116/134), the mean tumor diameter was 27.1 mm, and the mean procedure time was 63.5 min. The mean speed of procedures was significantly slower in the sigmoid colon (24.7 min/cm(2)) than in other areas. Perforation occurred in nine cases (6.7 %). Submucosal fibrosis was the only factor independently associated with perforation (odds ratio 5.684, 95 % confidence interval 1.307-24.727). CONCLUSIONS ESD was slower for sigmoid colon tumors than for tumors in other areas, suggesting that ESD was technically more difficult in the sigmoid colon than in other colorectal areas. Submucosal fibrosis was independently associated with perforation during colorectal ESD.
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Murata A, Okamoto K, Muramatsu K, Matsuda S. Endoscopic submucosal dissection for gastric cancer: the influence of hospital volume on complications and length of stay. Surg Endosc 2014; 28:1298-1306. [PMID: 24337914 DOI: 10.1007/s00464-013-3326-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2013] [Accepted: 11/06/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little information is available about the relationship between hospital volume and the clinical outcome of endoscopic submucosal dissection (ESD) for gastric cancer. The purpose of this study was to investigate the influence of hospital volume on clinical outcomes of ESD using a national administrative database. METHODS A total of 27,385 patients treated with ESD for gastric cancer were referred to 867 hospitals between 2009 and 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications and length of stay (LOS) in relation to hospital volume. Hospital volume was categorized into three groups based on the number of cases treated over the study period: low-volume hospitals (LVHs, <50 cases), medium-volume hospitals (MVHs, 50-100 cases), and high-volume hospitals (HVHs, >100 cases). These analyses were performed for each location of gastric cancer [upper (cardia and fundus), middle (body), and lower third (antrum and pylorus)]. RESULTS Significant differences in ESD-related complications among the three hospital volume categories were observed for upper gastric cancer (6.5 % in LVHs vs. 5.2 % in MVHs vs. 3.4 % in HVHs; p = 0.017). Multiple logistic regression revealed that HVHs were significantly associated with decreased relative risk of ESD-related complications in upper gastric cancer (odds ratio for HVHs 0.51; 95 % confidence interval, 0.31-0.83, p = 0.007). However, no significant differences for ESD-related complications were seen for middle and lower gastric cancers among the different hospital volume categories (p > 0.05). Additionally, hospital volume was significantly associated with a decreasing LOS for all locations of gastric cancers (p < 0.001). CONCLUSIONS The present study has demonstrated that hospital volume was mainly associated with clinical outcome in patients with ESD for upper gastric cancer. Further studies for successive monitoring of outcomes of ESD should be conducted in the near future.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, Fukuoka, 807-8555, Japan,
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Murata A, Okamoto K, Muramatsu K, Matsuda S. Time trend of medical economic outcomes of endoscopic submucosal dissection for gastric cancer in Japan: a national database analysis. Gastric Cancer 2014; 17:294-301. [PMID: 23801338 DOI: 10.1007/s10120-013-0282-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Accepted: 06/13/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND Little information is available on the analysis of chronological changes in medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer. This study aimed to investigate the recent time trend of medical economic outcomes of ESD for gastric cancer based on the Japanese administrative database. METHODS A total of 32,943 patients treated with ESD for gastric cancer were referred to 907 hospitals from 2009 to 2011 in Japan. We collected patients' data from the administrative database to compare ESD-related complications, risk-adjusted length of stay (LOS), and medical costs during hospitalization. The study periods were categorized into three groups: 2009 (n = 9,727), 2010 (n = 11,052), and 2011 (n = 12,164). RESULTS No significant difference was observed in ESD-related complications between three study periods (p = 0.496). However, mean LOS and medical costs during hospitalization of patients with ESD were significantly lower in 2011 than in 2009 and 2010 (p < 0.001). Multiple linear regression analysis showed that patients who received ESD in 2011 had a significantly shorter LOS and lower medical costs during hospitalization compared with those in 2009. The unstandardized coefficient of patients with ESD in 2011 for LOS was -0.78 days [95 % confidence interval (CI), -0.89 to -0.65; p ≤ 0.001], while that of those for medical costs during hospitalization was -290.5 US dollars (95 % CI, -392.3 to -188.8; p ≤ 0.001). CONCLUSIONS This study showed that the complication rate of ESD was stable, whereas the LOS and medical costs of patients were significantly reduced from 2009 to 2011.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan,
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The efficacy of single-dose postoperative intravenous dexamethasone for pain relief after endoscopic submucosal dissection for gastric neoplasm. Surg Endosc 2014; 28:2334-41. [DOI: 10.1007/s00464-014-3463-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 01/24/2014] [Indexed: 12/14/2022]
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Murata A, Muramatsu K, Ichimiya Y, Kubo T, Fujino Y, Matsuda S. Endoscopic submucosal dissection for gastric cancer in elderly Japanese patients: an observational study of financial costs of treatment based on a national administrative database. J Dig Dis 2014; 15:62-70. [PMID: 24127880 DOI: 10.1111/1751-2980.12106] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE There is currently little information on the medical economic outcomes of endoscopic submucosal dissection (ESD) for gastric cancer (GC) in elderly patients. This study therefore aimed to investigate the medical economic outcomes of ESD in elderly patients with GC using a national administrative database. METHODS A total of 27 385 patients treated with ESD for GC were referred to 867 hospitals in Japan from 2009 to 2011. We collected data from the national administrative database and divided them into two groups according to age: elderly patients (≥80 years; n = 5525) and non-elderly patients (<80 years; n = 21 860). We compared ESD-related complications, risk-adjusted length of stay (LOS) and medical costs during hospitalization between elderly and non-elderly patients. RESULTS There was no significant difference in ESD-related complications between elderly and non-elderly patients (4.3% vs 3.9%, P = 0.152). However, significant differences were observed in mean LOS and medical costs during hospitalization between the two groups (P < 0.001). Multiple linear regression analysis showed that elderly patients experienced a significantly longer LOS and higher medical costs. The unstandardized coefficient for LOS in elderly patients was 2.71 days (95% confidence interval [CI] 2.59-2.84, P < 0.001), while that for medical costs during hospitalization was USD952.1 (95% CI 847.7-1056.5, P < 0.001). CONCLUSIONS LOS and medical costs during hospitalization were significantly higher in elderly patients undergoing ESD for GC than in non-elderly patients, although there was no difference in the incidence of ESD-related complications.
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Affiliation(s)
- Atsuhiko Murata
- Department of Preventive Medicine and Community Health, School of Medicine, University of Occupational and Environmental Health, Fukuoka, Japan
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Mitsui T, Niimi K, Yamashita H, Goto O, Aikou S, Hatao F, Wada I, Shimizu N, Fujishiro M, Koike K, Seto Y. Non-exposed endoscopic wall-inversion surgery as a novel partial gastrectomy technique. Gastric Cancer 2014; 17:594-9. [PMID: 23974429 PMCID: PMC4072061 DOI: 10.1007/s10120-013-0291-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2013] [Accepted: 07/30/2013] [Indexed: 02/07/2023]
Abstract
In gastric full-thickness resection employing both endoscopy and laparoscopy, intraabdominal contamination or even possibly tumor seeding is unavoidable as a result of iatrogenic perforation and the resultant spread of gastric juice. To minimize contamination and resected tissue volume, we developed a new technique without perforation termed non-exposed endoscopic wall-inversion surgery (NEWS), and present here the preliminary results. In a clinical observation cohort study, NEWS was attempted in six patients with gastric SMT to investigate the procedure, mortality, and morbidity. NEWS consists of several steps: marking around a tumor on the mucosal as well as the serosal surface, submucosal injection of sodium hyaluronate with indigo carmine dye, circumferential seromuscular dissection with suture closure under laparoscopy, and circumferential mucosubmucosal incision under gastric endoscopy. The resected specimen is then retrieved perorally. Perforation occurred as a result of misidentification and technical inadequacy in the first three patients. After modification of the devices, the entire procedure was successfully achieved in the latter three. There were no complications in any of our six cases. NEWS allows en bloc full-thickness resection, theoretically avoiding contamination and tumor dissemination into the peritoneal cavity.
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Affiliation(s)
- Takashi Mitsui
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Keiko Niimi
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroharu Yamashita
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Osamu Goto
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Susumu Aikou
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Fumihiko Hatao
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Ikuo Wada
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Nobuyuki Shimizu
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
| | - Mitsuhiro Fujishiro
- Department of Endoscopy and Endoscopic Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuyuki Seto
- Department of Gastrointestinal Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo, 113-8655 Japan
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