Introduction

Advances in surgical treatments have improved mortality of postoperative patients with gastric cancer and esophageal cancer. Then, the number of residual and gastric-tube cancers is increasing. Re-surgical treatment for postoperative gastric cancers (Po-GCs) has a high incidence and mortality rate, so the contribution of endoscopic therapy might be large. However, endoscopic submucosal dissection (ESD) for Po-GCs is considered technically difficult. Especially during mucosal incision, we sometimes encounter unexpectable bleedings.

Aims & Methods

We investigated the re-construction of blood vessels in the submucosal layer on ESD specimens of Po-GCs.8 cases of Po-GCs (4 cases of residual gastric cancer, 4 cases of gastric-tube cancer) underwent ESD in our hospital from 2016 to 2023 were included. Eligible specimens of cases include the lesion center. Vascular distribution in the shallow submucosal layer (a depth of 500μm from the muscularis mucosae) was well observed and the number of dilatated arteries and veins with a diameter＞100μm are counted and compensated by a specimen diameter. These number of vessels were compared with 16 cases of controls (1:2) extracted from general gastric ESD underwent in the same location and period.

Results

There were 0.4±0.5/cm arteries and 1.1±1.1/cm veins/mm in control. There were 2.3±1.4/cm arteries and 5.5±2.0/cm veins in the cases of residual gastric cancers. And there were 4.1±1.1/cm arteries and 2.7±0.4/cm veins in the cases of gastric-tube cancers. Both cases of residual and gastric-tube cancers involved many dilatated arteries and veins (P<0.05) in superficial submucosal layer compared with control. On the other hands, the cases of residual gastric cancers have lots of veins compared with arteries (P <0.05), and the cases of gastric-tube cancers have lots of arteries compared with veins (P <0.05).

Conclusion

Residual stomach is small and arterial blood flow is maintained, but veins are resected on a process of surgery. These would be the reason for venous congestion is noticeably high in the residual stomach. On the other hand, the gastric-tube mucosa tends to be more abundant of blood flow due to the reconstruction method. As a result, branches of arteries remaining in submucosal layer would be developed. From the above, on the process of ESD, the probability of encountering veinous oozing increases on residual gastric cancer, and arterial bleeding increases on gastric-tube cancer. It’s suggested that paying more attention to these vascular distributions of the submucosal layer is needed while postoperative gastric ESD is performed.

Introduction

In superficial gastric tumors, endoscopic submucosal dissection (ESD) has become the standard of care, and the treatmenttechnique and strategy have been matured. On the other hand, the number of cases performed by trainees as anintroduction to ESD is increasing, and the types and handling of antithrombotic drugs are also changing.

Aims & Methods

On these backgrounds, we examined the transitions to clarify how the treatment outcomes and adverse events of gastric ESD have changed.
From 2014 to 2022, 565 patients of superficial gastric neoplasms who underwent ESD were divided into two groups: the first half (n=435) from 2014 to 2020 and the second half (n=130) from 2021 to 2022, where the number of trainees significantly increased. Treatment outcomes (En bloc resection rate, curability, procedure time, inflammatory response)and adverse events (perforation, postoperative bleeding, postoperative pneumonia, and pyrexia for unknown reasons) were retrospectively compared between two groups, using the propensity score matching analysis. Regarding oral antithrombotic agents, antithrombotic drugs were continued, DOAC stopped only 24 hours before treatment, and warfarin was continued after INR value was controlled at <3.0.

Results

Propensity score matching yielded 130 pairs. Trainee's involvement was 29.7% in the first half and 61.4% in the second half. The comparison demonstrated a significant difference for the following outcomes: curability was 86% in the first half and 90.1% in the second half (P=0.028), the CRP mean [SD] was 1.32 [2.14] in the first half and 0.82 [0.97] in the second half (P=0.032), and postoperative bleeding rate was 5.9% in the first half and 0.0% in the second half (P=0.013). Others were similar values for outcomes.

Conclusion

Even with the increased involvement of trainees, treatment outcomes have not chronologically exacerbated. Additionally, inflammatory response and postoperative bleeding have improved. These results suggest that safe and secure gastric ESD can be performed by appropriate technique and strategy under supervise of experts.

Introduction

Endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) with esophageal varices (EVs) is one of the most challenging endoscopic procedures due to the high risk of bleeding and fibrosis caused by prior treatment of varices. However, due to the small number of such cases, the clinical outcomes of ESD for ESCC with EVs have been reported in only a limited number of cases at single centers^​1-3.

Aims & Methods

We conducted a multicenter, retrospective, cohort study to clarify the safety and efficacy of ESD for ESCC with EVs.Eleven institutions in the Tohoku region of Japan participated in this multicenter, collaborative, retrospective study. We performed endoscopic resection for 3619 patients with esophageal carcinoma at the participating institutions during the period from January 2010 to April 2022. Among those, 30 patients who underwent ESD for ESCC with EVs were recruited for the present study.
Rates of en bloc resection and R0 resection, procedure time and adverse events were evaluated as indicators of the feasibility and safety of ESD. Additional treatment, recurrence and metastasis of the lesions were evaluated as indicators of the long-term efficacy of ESD.

Results

Portal hypertension was caused by cirrhosis, of which alcohol was the most common cause. En bloc resection was achieved in 93.3% and R0 resection in 80.0% of the patients. The median procedure time was 92 minutes. Adverse events included a case of uncontrolled intraoperative bleeding leading to discontinuation of ESD and a case of esophageal stricture due to extensive resection. During the follow-up period of a median for 42 months, a patient with local recurrence and another patient with liver metastasis were observed. One patient died of liver failure after receiving chemoradiotherapy as an additional treatment after ESD. No patient died of ESCC.

Conclusion

This multicenter, retrospective cohort study demonstrated the safety and efficacy of ESD for ESCC with EVs. Further studies are needed to establish appropriate treatment methods for EVs before ESD and additional treatments for patients with insufficient ESD.

References

1. Sawaguchi M, Jin M, Matsuhashi T, et al. The feasibility of endoscopic submucosal dissection for superficial esophageal cancer in patients with cirrhosis (with video). Gastrointest Endosc 2014;79:681-5.
2. Choi YK, Noh JH, Kim DH, et al. Outcomes of endoscopic submucosal dissection for superficial esophageal neoplasms in patients with liver cirrhosis. Clin Endosc 2022;55:381-9.
3. Zhang S, Liu YD, Chai NL, et al. Endoscopic submucosal dissection for early cancers or precancerous lesions of the upper gastrointestinal tract in cirrhotic patients with esophagogastric varices: Ten-year experience from a large tertiary center in China. Gastrointest Endosc 2023 Online ahead of print.

Disclosure

The authors declare that they have no conflicts of interest.

Introduction

Endoscopic submucosal dissection (ESD) is the first-line treatment for superficial gastric lesions with a negligible or very low risk of lymph node metastasis. However, a permanent risk of developing metachronous lesions persists. We intend to analyze the risk factors associated with the development of metachronous lesions in a population of patients undergoing ESD.

Aims & Methods

Prospective cohort study conducted at a single centre, involving patients who underwent gastric ESD for lesions between 2017 and 2023, with a follow-up period of ≥ 6 months. Lesion characteristics were analyzed, including the rate of metachronous lesions, and logistic regression was performed to identify risk factors associated with the development of metachronous lesions.

Results

Included 78 ESDs performed on gastric epithelial lesions (59% female), with a mean age of 70.3±7.9 years. Regarding family history of gastric adenocarcinoma, 17.9% of patients had a first-degree relative. Among the analyzed lesions: 42.3% measured between 0-20mm, 57.7% ≥ 20mm; 12.8% were sessile, 71.8% flat and 15.4% depressed; 19.2% were located in the cardia, fundus or body, 21.8% in the incisura angularis and 59% in the antrum. Regarding histological findings: 42.3% low-grade dysplasia, 30.8% high-grade dysplasia, 23.1% intramucosal adenocarcinoma and 3.8% adenocarcinoma with submucosal invasion. Nine metachronous lesions (11.5%) were detected, with a median time of occurrence of 24 [13-32] months. In the analysis of risk factors, statistical significance was found for location outside the antrum (21.6% vs. 1.9%; p=0.002) and the presence of adenocarcinoma (23.8% vs. 7%; p=0.039), but not for size ≥20mm (13.7% vs. 5.1%; p=0.178) or ulceration of the lesion (9.1% vs. 10.1%; p=0.915). Logistic regression analysis revealed that only location outside the antrum had a significant risk for the development of metachronous lesions (OR 13.4; 95% CI: 1.4-127.1).

Conclusion

Given the permanent risk of developing metachronous lesions, the identification of associated risk factors is important as it may eventually allow for the adaptation of surveillance programs.

Introduction

ESD has become the standard treatment for early gastric cancer. Recently, the number of patients taking antithrombotic agents (ATAs) has increased, and the prevention of post-ESD bleeding is a main concern. EHS after gastric ESD has been developed to solve these problems, but the effectiveness and procedural success rate of EHS is not known. Here we investigate the successful introduction of EHS and evaluate the safety and effectiveness of the EHS.

Aims & Methods

11 patients who underwent EHS after gastric ESD from December 2022 to April 2024 were included in this study. Patient and lesion background, endoscopic findings, and treatment outcomes were reviewed retrospectively. A V-loc 180 available barbed suture (VLOCL0604; Covidien, Mansfield, Mass, USA) and through-the scope flexible needle holder (SutuArt, Olympus, Tokyo, Japan) were used for EHS. The same endoscopist and the assistant performed Ex vivo training model prior to clinical introduction.

Results

Mean age was 74.8±7.3 years, 9 males and 2 females, and 4 with and 7 without ATAs. The lesion locations were as follows: upper/middle/lower = 4/0/7. Mean tumor size was 15.4±5.3 mm, mean defect size was 30.3±5.4 mm, and mean resection time was 46.6±26.4 minutes. The mean time needed for suturing was 30.6±9.6 minutes, and a mean of 4.7±0.4 stitches were placed. Suturing speed （resection area/suturing time) was 20.9±7.5 mm²/min. Complete suture was achieved in all patients, and they began clear fluid on POD1. There were no adverse events during EHS such as bleeding or perforation.

Conclusion

In EHS, complete suture was achieved in all cases, with no post-ESD bleeding or delayed perforation. Further data is needed to confirm its effectiveness.

References

1) O. Goto et al. Endoscopic hand-suturing is feasible, safe, and may reduce bleeding risk after gastric endoscopic submucosal dissection: a multicenter pilot study (with video). Gastrointest Endosc 2020 ; 91(5): 1195-1202.

Introduction

Endoscopic submucosal dissection (ESD) is the technique of choice for treating early gastric cancer deemed to have very low risk of lymph node metastasis based on endoscopic evaluation. However, currently, up to 20% of ressected lesions do not meet curative criteria, underlining the importance of patient selection.

Aims & Methods

We aimed to evaluate predictive factors for non curative ressection. We conducted a retrospective cohort study including consecutive gastric epithelial lesions removed by ESD between January of 2005 and June of 2024. Incomplete ESD were excluded. Non curative resection was defined using the high-risk resection criteria from the European Society of Gastrointestinal Endoscopy guidelines. Univariate and multivariate analysis were used to identify predictive factors.

Results

From 990 ESD, 974 were included in the final analysis: median size of lesion 19mm (P25-P75: 15-25), presence of ulceration in 25 (2.8%), deep submucosal invasion in 74 (7.6%), en bloc resection in 944 (96.9%), R0 resection in 901 (92.5%) and non curative resection in 116 (11.9%). In this sample, the following independent predictive factors for non curative resection were identified: location on the superior third of the stomach [adjusted Odds Ratio (aOR) 2.275; IC95% 1.248-4.148], lesion size > 20mm (aOR 4.212; IC95% 2.618-6.775), depressed/ulcerated lesion (aOR 2.394; IC95% 1.328-4.315) or sessile/pedunculated lesion (aOR 4.186; IC95% 2.083-8.411), presence of high-grade dysplasia (aOR 4.372; IC95% 2.139-8.939) or carcinoma (aOR 12.484; IC95% 5.995-25.998) in previous biopsies.

Conclusion

Location, size and morphology of lesion, as well as previous biopsy results are predictive factors for non curative resection, and may assist in decision-making regarding treatment alocation of gastric superficial lesions.

References

Dinis-Ribeiro M, et al. Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025. Endoscopy, 2025 May;57(5):504-554. doi: 10.1055/a-2529-5025.
Vasconcelos AC, et al. Endoscopic Resection of Early Gastric Cancer and Pre-malignant Gastric Lesions. Cancers, 2023 Jun 7;15(12):3084. doi: 10.3390/cancers15123084.

Introduction

Endoscopic submucosal dissection (ESD) is increasingly being used as a minimally invasive treatment option for early gastric cancer (EGC), with a very low risk of lymph node metastasis.

Aims & Methods

This study aimed to evaluate the short-, medium-, and long-term clinical outcomes of patients undergoing gastric ESD at a tertiary hospital center. Patients undergoing ESD for superficial gastric lesions (SGLs) between September 2015 and January 2023 were prospectively evaluated. Demographic, clinical (comorbidities, medication, and relevant family history), endoscopic (location, size, and morphology of the lesion, resection scar evaluation), and pathological data (from the resected specimen, mapping biopsies, and scar biopsies) were collected.

Results

Since 2015, 195 patients with SGLs (mean age 70.7±9.8 years, 58.6% male) underwent ESD, with a median follow-up time of 28 months (interquartile range 13-54). Most patients presented with intestinal metaplasia only in the antrum (n=72) or in the antrum and corpus (n=60), and the most frequent location of SGLs was the antrum (64.6%). Resection was R0 in 95.4% of cases and curative in 87.7% (only one non-curative case had no free horizontal margins). During the follow-up period, 15 metachronous lesions and 8 recurrences were identified, on average 24.1±3.4 months after the index procedure. It should be noted that most recurrences (n=5) were identified at the 36- and 48-month reevaluation endoscopies. The complication rate was 3.6%, corresponding to 3 intra-procedural perforations (2 treated endoscopically) and 4 cases of significant bleeding after the procedure were registered.

Conclusion

Endoscopic submucosal dissection is safe and effective, with a high cure rate and low complication and recurrence rates. The identification of mostly late recurrences suggests the need to develop risk assessment tools that allow for defining personalized follow-up intervals.