Introduction

For gastric neoplasms, endoscopic submucosal dissection (ESD) is a well-known therapeutic option. Our study aimed to investigate the influence of procedural volume on the outcome of gastric ESD.

Aims & Methods

Patients who received ESD for gastric cancer or adenoma from November 2011 to December 2017 were identified using the Korean National Health Insurance Service database. The diagnostic and procedure codes were combined to develop operational definitions, which were validated using individual hospital medical record data. Outcomes included bleeding, perforation, pneumonia, 30-day mortality, composite outcome comprising all these adverse outcomes, and additional resection. Hospital volume was categorized into four groups: very high-, high-, low-, very low-volume hospitals (VHVH, HVH, LVH, VLVH). The outcomes of ESD were compared in relation to hospital volume.

Results

A total of 89,780 patients underwent 95,411 procedures during the research period. There were 5,607 composite events, which included 5,098 bleeding, 601 perforation, and 712 pneumonia cases, respectively. Additional resection occurred within 180days in 7,900 cases. There were significant differences in ESD-related adverse outcomes among the four hospital volume categories. Multiple logistic regression revealed that VHVH, HVH, and LVH were associated with lower risk of a composite outcome, when compared to VLVH (OR, 0.627, 95% CI, 0.445-0.885, p=0.008; OR, 0.542, 95% CI, 0.406-0.722, p<0.001; OR, 0.697, 95% CI, 0.548-0.886, p=0.003). Similar tendencies were also shown for bleeding, perforation, and pneumonia, although this was not evident in additional resection.

Conclusion

The procedural volume at an institutional level was closely associated with clinical outcomes, such as bleeding, perforation, pneumonia, and a composite outcome, in patients with ESD for gastric cancer or adenoma. The outcomes of gastric ESD should be closely and systemically monitored in a nationwide level, to ensure the quality of procedures and the safety of patients.

Introduction

Although an effective and relatively safe procedure, bleeding complications often occur after gastric endoscopic submucosal dissection (ESD). We aimed to comprehensively evaluate the risk factors of post-procedural bleeding following gastric ESD.

Aims & Methods

This study was designed as a nationwide, population-based, retrospective study utilizing the Korean National Health Insurance Service database, comprising patients who underwent gastric ESD for gastric cancer or adenoma from November 2011 to December 2022. Operational definitions were created to identify the target population and post-procedural bleeding using the diagnosis and procedure code, which underwent validation. We established operational definitions to identify the target population and post-procedural bleeding by utilizing diagnosis and procedure codes, which underwent validation. The risk factors analyzed included age, sex, hospital volume, socioeconomic status (SES), histology, lesion numbers, comorbidities, and medication usage.

Results

During the study period, there were 191,932 procedures conducted on 175,779 patients, resulting in 9921 cases of bleeding events. Several factors were associated with increased post-ESD bleeding risk. Following multiple logistic regression, relevant factors with adjusted odds ratios (aORs) were identified. These factors included young age (aOR: 0.990, 95% CI 0.987-0.992), male sex (aOR: 1.377, 95% CI 1.311-1.448), low-volume center compared to high-volume center (aOR: 1.289, 95% CI 1.022-1.621), medical aid compared to the top 25% SES (aOR: 1.307, 95% CI 1.188-1.440), higher Charlson comorbidity index (aOR: 1.040, 95% CI 1.026-1.054), gastric cancer (aOR: 1.369, 95% CI 1.307-1.434), and multiple lesions (aOR: 1.144, 95% CI 1.032-1.267). Furthermore, bleeding risk was significantly higher in groups with several comorbidities and antithrombotic agent users, particularly showing Notably high aORs in groups with renal failure (aOR: 2.086, 95% CI 1.909-2.278), warfarin (aOR: 2.641, 95% CI 2.219-3.143), direct oral anticoagulants (aOR: 2.519, 95% CI 2.220-2.859), and antiplatelet combinations (aOR: 2.073, 95% CI 1.783-2.410).

Conclusion

This study revealed various factors associated with increased bleeding risk after gastric ESD using a large cohort, which could be an important issue in terms of risk stratification and personalized treatment.

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) 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.

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 recommended as a treatment modality for early gastric cancer because it allows organ-sparing, curative en-bloc resection, and complete histopathological evaluation. Although many endoscopists are interested in learning how to perform ESD, the procedure requires a high level of expertise and is technically challenging, especially for less experienced endoscopists.

Aims & Methods

This study aimed to investigate the single-operator learning curve and clinical outcomes of consecutive gastric ESDs. Eight hundred-eleven gastric ESDs were performed between March 2016 and December 2022. The learning curve for ESD was evaluated using the cumulative sum (CUSUM) method to analyze the number of ESDs required for achieving proficiency.

Results

Of the enrolled patients, 310 (40.9%) cases were diagnosed with early gastric cancer. Overall en-bloc resection rates, R0 resection, and curability is 98.6%, 96.3%, and 93.7%, respectively. The median ESD speed was 18.1 cm2/h (IQR 12.2 – 25.3). ESD speed was slower than average in the upper third (9.9 cm2/h), presence of submucosal fibrosis (11.0 cm2/h) and the presence of subcutaneous fat (11.1 cm2/h), and faster than 20 cm2/h in the lower third (20.2 cm2/h) and lesion sized > 3 cm (23.6 cm2/h). According to the existing literature, the proficiency benchmark is defined as en-bloc resection >90%, R0 resection and >80%, and resection speed >9 cm2/h. However, since the first case satisfies all the existing benchmarks, we should establish a new definition of speed among benchmarks. In the changes of resection speed, we defined 16.5 cm2/h as a benchmark for ESD speed, which is the median value of the rapidly changing slope, and the CUSUM curve revealed that 156 cases were needed to achieve proficiency.

Conclusion

Due to the development of endoscopic equipment, a higher level of ESD proficiency benchmark is required. One hundred sixty-five cases were required to attain a higher technical level of successful performance in gastric ESD.