Feasibility of gastric endoscopic submucosal dissection in elderly patients aged ≥ 80 years

Table 1 Short-term outcomes of ESD, n (%)

Location of the lesions (n = 175)1
Upper third	33 (18.9)
Middle third	57 (32.6)
Lower third	85 (48.6)
Size of dissected specimen (n = 174)2
Range	9-110 mm
Median	30 mm
Average	33.4 mm
ESD quality (n = 175)2
En bloc dissection	170 (97.1)
Fractional dissection	4 (2.3)
Not dissected endoscopically	1 (0.6)
Curability (n = 175)1
Curative dissection	135 (77.1)
Non-curative dissection	40 (22.9)
Complications
ESD sessions (n = 172) with any complication	8 (4.7)
Bleeding (n = 175)1	6 (3.4)
Perforation (n = 175)1	2 (1.1)
Aspiration pneumonitis (n = 172)3	1 (0.6)
Procedure-related death (n = 172)3	0

¹Location, Endoscopic submucosal dissection (ESD) quality (en bloc or fractional dissection rate), curability (curative or noncurative dissection rate), and complications of bleeding and perforation calculated with respect to the total number of 175 treated lesions.

²Size of dissected specimen measured only in endoscopically resected cases (n = 174).

³Number of ESD sessions (total n = 172) associated with aspiration pneumonitis. ESD: Endoscopic submucosal dissection.

Table 2 Characteristics of treated lesions and patients, n (%)

(A) Lesions (n = 175)
Macroscopic type
Protruded type (0-I, 0-I+IIa, 0-I+IIb, 0-I+IIc)	24 (13.7)
Flat type (0-IIa, 0-IIa+IIc, 0-IIb, 0-IIc, 0-IIc+IIa)	150 (85.7)
Advanced (type 1)	1 (0.6)
Ulceration
UL (+)	22 (12.6)
UL ()	153 (87.4)
Depth of invasion
M	152 (86.9)
≥ SM	23 (13.1)
(B) Patients (n = 124)
Underlying disease
Circulatory	38 (30.6)
Respiratory	9 (7.3)
Renal	0
Antithrombotic agent
Taking	28 (22.6)

UL: Ulceration; M: Mucosa; SM: Submucosa.

Table 3 Details of noncurative lesions, and estimated noncurative factors of 40 noncurative lesions

(A) Details of noncurative lesions (n = 40)
	Depth of invasion
	M	SM1	SM2		≥ MP
Histological type
Differentiated (tub1, tub2, pap)	19	4	8		1
Undifferentiated (por, sig, muc)	4	2	2		0
(B) Estimated non-curative factors of 40 non-curative lesions, n (%)
Depth of invasion
≥ SM2, differentiated				8 (20)
≥ SM, undifferentiated				4 (10)
Lesion size
≥ 30 mm, differentiated, UL (+)				2 (5)
≥ 30 mm, differentiated, SM1				1 (2.5)
≥ 20 mm, undifferentiated				5 (12.5)
Ulceration
UL (+) with undifferentiated components				5 (12.5)
Lymphovascular invasion
Ly +/uncertain				7 (17.5)
V +/uncertain				7 (17.5)
Surgical margin
Positive				7 (17.5)
Uncertain				21 (52.5)
Not dissected endoscopically				1 (2.5)

M: Mucosa; SM: Submucosa; MP: Muscularis propria; UL: Ulceration; Ly: Lymphatic invasion; V: Venous invasion.

Table 4 Details of patients who had complications of endoscopic submucosal dissection

Age (yr)	Gender	Ps	Underlying disease	Past history	Location1	Size (mm)	Macroscopic type	Final pathology	Curability	Specimen (mm)	Complications
83	F	1		Post-BHA	L, Ant	40	0-IIc, UL (+)	Tub2 > por2, M, ly0, v0, HM0, VM0	Noncurative	60	Bleeding G2
83	M	0			L, Ant	10	0-IIc, UL (+)	Tub1 > tub2, M, ly0, v0, HM0, VM0	Curative	20	Bleeding G2
92	M	0		Laryngeal cancer	U, Post	50	Type1	Surgical resection: pap > tub, SS, ly0, v1, NX, HMX	Noncurative	522	Perforation G3
89	M	3		Brain cancer	M, Les	33	0-IIc, UL (+)	Sig/por2, M, ly0, v0, HM0, VM0	Noncurative	68	Bleeding G3, pneumonitis G2
83	F	2	AD, Depression		U, Les	15	0-IIa	Tub1, M, ly0, v0, HM0, VM0	Curative	30	Perforation G2
82	F	0			(1) L, Ant	(1) 20	(1) 0-IIc	(1) Tub2 > tub1 > por, M, ly0, v0, HM0, VM0	(1) Curative	54	Bleeding G2
					(2) L, Ant	(2)10	(2)0-IIc	(2) Tub1-tub2, M, ly0, v0, HM0, VM0	(2) Curative
84	M	2	AP, COPD		L, Les	15	0-IIc	Por1, M, ly0, v0, HMX, VMX	Noncurative	40	Bleeding G2
80	M	0		Colon cancer, EGC	L, Les	16	0-IIa+IIc, UL (+)	Tub1 > tub2 > por, M, ly0, v0, HM0, VM0	Curative	47	Bleeding G2

¹Location divided into three regions of the stomach; U (upper third), M (middle third), and L (lower third), respectively.

²Size of all-around incision of endoscopic submucosal dissection measured in a surgically resected specimen.

PS: Performance status; BHA: Bipolar hip arthroplasty; AD: Alzheimer disease; UL: Ulceration; AP: Angina pectoris; COPD: Chronic obstructive pulmonary disease; EGC: Early gastric cancer; M: Mucosa; SM: Submucosa; SS: Subserosa; ly: Lymphatic invasion; v: Venous invasion; HM: Horizontal margin; VM: Vertical margin; N: Lymph node metastasis; L: Lower third; M: Middle third; U: Upper third.

Table 5 Relations of complications to location or dissected size of endoscopic submucosal dissection specimens, n (%)

	Bleeding (+)	Bleeding (-)	Perforation (+)	Perforation (-)	Total
	n = 6	n = 169	n = 2	n = 173	n = 175
Location
Upper third	0	33 (100)	2 (6.1)	31 (93.9)	33
Middle third	1 (1.6)	56 (98.4)	0	57 (100)	57
Lower third	5 (5.9)	80 (94.1)	0	85 (100)	85
Size of specimen
≤ 20 mm	1 (3.3)	29 (96.7)	0	30 (100)	30
21-40 mm	1 (1.0)	102 (99.0)	1 (1.0)	102 (99.0)	103
41-60 mm	3 (8.1)	34 (91.9)	1 (2.7)1	36 (97.3)	37
≥ 61 mm	1 (20.0)	4 (80.0)	0	5 (100)	5

¹Not endoscopically dissected case.

Size of all-around incision of endoscopic submucosal dissection measured in a surgically resected specimen.

Table 6 Relative risks of location and size for bleeding or perforation

(A) Relative risk of location lower third, size > 40 mm, macroscopic shape, presence or absence of ulceration, and depth of invasion for bleeding
	Bleeding (+)	Relative risk	P value
Location
Lower third	5.9% (5/85)	5.3	0.11
Upper third, middle third	1.1% (1/90)
Dissected size
≥ 41 mm	9.5% (4/42)	6.3	0.030
≤ 40 mm	1.5% (2/133)
Macroscopic shape
Depressive component (+)	8.2% (6/73)		0.005
Depressive component ()	0% (0/102)
Ulceration
UL (+)	18.2% (4/22)	13.9	0.003
UL ()	1.3% (2/153)
Depth of invasion
≥ SM	3.9% (6/152)		1
M	0% (0/23)
(B) Relative risk of location upper third, size > 40 mm, macroscopic shape, presence or absence of ulceration, and depth of invasion for perforation
	Perforation (+)	Relative risk		P value
Location
Upper third	6.3% (2/32)			0.033
Middle third, lower third	0% (1/143)
Dissected size
≥ 41 mm	2.4% (1/42)	3.2		0.423
≤ 40 mm	0.8% (1/133)
Macroscopic shape
Depressive component (+)	0% (0/73)	-		0.511
Depressive component ()	2.0% (2/102)
Ulceration
UL (+)	0% (0/22)	-		1
UL ()	1.3% (2/153)
Depth of invasion
≥ SM	0.7% (1/152)	6.6		0.246
M	4.3% (1/23)

UL: Ulceration; M: Mucosa; SM: Submucosa.

Table 7 Prognostic factors for overall survival (n = 120)

	Cox LASSO
Curability
Noncurative	–
Patient	–
Age	–
Gender: Male	0.416
BMI	–
PNI	–
CCI > 1	0.477
GPS	–
NLR	–
Antithrombotic agent (+)	–

LASSO: Least absolute shrinkage and selection operator; BMI: Body mass index; PNI: Prognostic nutritional index; CCI: Charlson comorbidity index; GPS: Glasgow prognostic score; NLR: neutrophil-to-lymphocyte ratio.