Introduction

Endoscopic resection (ER) is expected to play a major role in elderly patients with early gastric cancer (EGC) because it is less invasive than gastrectomy. However, data on ER for elderly patients and the consideration of expanding indications and curability criteria are insufficient.

Aims & Methods

We evaluated the clinical outcomes and prognosis of elderly EGC patients treated by ER using data from a Japanese multicenter prospective cohort study using a web registry system (“J-WEB/EGC”)¹ and assessed the potential for expanding ER indications and curability criteria for elderly patients. Patients aged ≥75 years with primary EGC treated with ER at 41 institutions were included. Short- and long-term outcomes (all-cause and gastric cancer deaths) were examined. ER indications and curability criteria were based on the Japanese Gastric Cancer Treatment Guidelines.² Regarding ER curability, we divided “eCuraC-2” (previously known as “noncurative resection,” for which surgical gastrectomy following ER is recommended) into two new subgroups based on previous data on metastatic risk from EGC examined using surgically resected cases³: “elderly-high (EL-H)” (>10% estimated metastatic risk) and “elderly-low (EL-L)” (≤10% risk). Cases with positive lymphovasuclar invasion, positive/unclear vertical cut margin, or >3 cm undifferentiated-type pT1b cancer were classified as “EL-H.”

Results

A total of 3,371 patients (median age: 79.0 years) with 3,821 EGCs were included. Among them, 3,586 EGCs (group A) met the guidelines’ ER indications and 235 (group B) did not. In group A, endoscopic submucosal dissection (ESD) was selected in 99.5% patients, and the proportions of en bloc resection, R0 resection, delayed bleeding, and perforation were 98.9%, 94.4%, 3.7%, and 0.8%, respectively. In group B, ESD was selected in all cases, and the corresponding proportions were 99.5%, 85.4%, 6.5%, and 5.9%, respectively, for 185 lesions diagnosed ≤3 cm, and 96.0%, 64.0%, 14.0%, and 18.0%, respectively, for 50 lesions diagnosed >3 cm. Regarding ER curability, “eCuraA/B” (previously known as “curative resection”) and “EL-L” were observed in 83.6% and 6.2% patients, respectively, in group A, and in 40.4% and 20.0% patients, respectively, in group B. The 5-year follow-up rate was 91.9%, and all-cause and gastric cancer deaths within 5 years were observed in 615 (18.2%) and 24 (0.7%) patients, respectively. Among various patient and lesion factors, relatively high adjusted hazard ratio (aHR) for all-cause death was seen for Eastern Cooperative Oncology Group performance status ≥2 (aHR 3.2 [95% confidence interval (CI) 2.2–4.5]) and body mass index <18.5 kg/m² (aHR 2.8 [2.1–3.8]). Following eCuraA/B (2,652 patients), most (99.7%) were followed without any treatment and the 5-year cumulative gastric cancer death rate was 0.3% (95% CI 0.1–0.6). While the rate was 3.5% (2.0–5.7) following EL-H (386 patients), the rate was lower (0.9% [0.2–3.5]) following EL-L even without treatment (224 patients).

Conclusion

ER for elderly patients with EGCs meeting the Japanese guidelines’ indications safely provided highly favorable curability. Even for EGCs not meeting the guidelines’ indications, ESD was relatively safe for lesions diagnosed ≤3 cm and provided eCura A/B or EL-L, which led to few gastric cancer deaths without treatment, in >60% of cases. Expansion of ER indications and curability criteria may be possible in elderly patients. Assessing the general physical conditions is crucial in deciding treatment for such elderly patients as the findings of factors influencing all-cause mortality indicated.

References

1. Suzuki H, Ono H, Hirasawa T, et al; J-WEB/EGC group. Long-term Survival After Endoscopic Resection For Gastric Cancer: Real-world Evidence From a Multicenter Prospective Cohort. Clin Gastroenterol Hepatol. 2023; 21: 307-18.
2. Japanese Gastric Cancer Association. Japanese Gastric Cancer Treatment Guidelines 2021 (6th edition). Gastric Cancer. 2023; 26: 1-25.
3. Sekiguchi M, Oda I, Taniguchi H, et al. Risk stratification and predictive risk-scoring model for lymph node metastasis in early gastric cancer. J Gastroenterol. 2016; 51: 961-70.

Introduction

Endoscopic submucosal dissection (ESD) offers effective, en bloc resection of large colorectal lesions (1), but can be technically challenging, especially for lesions with poor access. This video showcases successful use of the saline-immersion/irrigation technique (SITE), double-balloon endoscopy (DBE) and a novel type of advanced imaging for resection of such a lesion, in a patient with a long sigmoid colon which compromised stability.

Aims & Methods

A 64-year-old woman was referred for evaluation of a sessile (Paris 0-Is) 80mm adenomatous lesion of the transverse colon. Focal surface irregularity (JNET 2B) was also identified. Multidisciplinary team discussion favored en bloc excision using ESD, under conscious sedation. Stable access to the lesion was challenging due to irreducible looping of the sigmoid colon, hindering any attempt at ESD using a standard colonoscope. A DBE was utilized to enhance access and stability, equipped with a conical short, transparent hood to allow for ESD using the pocket-creation method (PCM) (2-4) . ESD was performed using SITE (4-5), which offers several advantages: enhanced optical clarity and magnification, buoyancy of the lesion, improved conductivity (facilitating of vessel pre-coagulation and bleed-management). SITE also enhances patient comfort due to reduced distension, particularly when combined with external drainage of excess saline (6). Here, the DBE overtube was used for drainage. Severe fibrosis and muscle retraction was also observed at the center of the lesion, impeding access to the submucosal plane, this was overcome through clip-band traction. Additionally, a novel type of imaging: Amber-red color Imaging (ACI) (Fujifilm Healthcare, Tokyo, Japan), designed to enhance visualization of the muscularis propria and any vessels was also used, which further improved visualization of the dissection planes.

Results

The lesion was successfully resected en bloc in 180 minutes (dissection speed of 16.68 mm2/min), without significant adverse events. Hemostasias was achieved with knife-tip coagulation and intra-procedural application of protein-matrix gel coupled with scope-tamponade. The patient was prescribed a 5-day course of antibiotics and discharged on the same day. Histopathology confirmed a tubulo-villous adenoma with low-grade dysplasia, completely excised (R0).

Conclusion

DBE allows optimal access to challenging colonic lesions, where stability is critical for successful ESD. This example highlights the importance of adopting a tailored approach for each case, through a combination of established techniques, such as SITE, the PCM, and clip-band traction, to enhance ESD safety, efficacy and efficiency. Utilization of the latest-generation equipment, with optimized maneuverability, ergonomic comfort, and enhanced imaging, further supports these outcomes. Collectively, these strategies serve to overcome technically difficult scenarios.

References

1. Libânio D, Pimentel-Nunes P, Bastiaansen B, Bisschops R, Bourke MJ, Deprez PH, u. a. Endoscopic submucosal dissection techniques and technology: European Society of Gastrointestinal Endoscopy (ESGE) Technical Review. Endoscopy. 29. März 2023;55(4):361–89
2. Hayashi Y, Sunada K, Takahashi H, et al. Pocket-creation method of endoscopic submucosal dissection to achieve en bloc resection of giant colorectal subpedunculated neoplastic lesions. Endoscopy 2014;46:E421-2
3. Hayashi Y, Miura Y, Yamamoto H. Pocket-creation method for the safe, reliable, and efficient endoscopic submucosal dissection of colorectal lateral spreading tumors. Dig Endosc 2015;27:534-5
4. Yamamoto H, Hayashi Y, Despott EJ. The pocket-creation method for endoscopic submucosal dissection combined with saline-immersion: another potential option to overcome challenges in colorectal endoscopic submucosal dissection. Gastrointest Endosc [Internet]. 1. August 2019 [zitiert 6. August 2023];90(2):288–9
5. Despott EJ, Murino A. Saline-immersion therapeutic endoscopy (SITE): An evolution of underwater endoscopic lesion resection. Digestive and Liver Disease [Internet]. 1. Dezember 2017 [zitiert 25. August 2023];49(12):1376. ​
6. Takaaki Morikawa, Alberto Murino, Hiroaki Ishii, Yoshikazu Hayashi, Yuka Kagaya, Hisashi Fukuda, Edward John Despott, Hironori Yamamoto. The ‘Asclepius tube’: a slim drainage tube wrapped around the distal part of the endoscope, for cecal endoscopic submucosal dissection, VideoGIE, 2024, ISSN 2468-4481

Disclosure

The authors declare the following conflict of interest:
EMB: No disclosures
GK: No disclosures
AR: No disclosures
AM: Personal payments/honoraria/fees: Olympus Medical, Laborie, Boston Scientific, Fujifilm Healthcare Europe
EJD: Educational grants in support of conference organization, and honoraria, from Fujifilm Healthcare Europe, Pentax, and Olympus Medical, and honoraria from Ambu and Fujifilm Healthcare Europe

Introduction

Aims & Methods

Results

Conclusion

References