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.

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 widely implemented in Asia. Experience from the western world is still limited, so the evidence on the description of a learning curve (LC) is sparse.

Aims & Methods

The aim of this study is to evaluate the LC for ESD of gastric lesions using accepted proficiency benchmarks (PB).
Retrospective analysis with a prospectively maintained database of all patients undergoing ESD at a Western tertiary center from June 2016 to December 2022.
Inclusion criteria: ESD of gastric lesions performed by a single operator.
Primary endpoint: a LC to estimate the number of ESDs required to achieve PB (>90% for en bloc resection, >80% for histologic margin-negative (R0) resection and resection speeds (RS) >9cm2/hr), using the CUSUM method.

Results

Of 477 ESD performed, a total of 235 ESD met the inclusion criteria.
The en bloc resection rate was 100%. The R0 resection rate was 97% so no statistically significant differences were found, since it was always within PB.
Using the CUSUM method, the LC was divided into learning periods [Phase I - learning phase (cases 1-48); Phase II - adaptation phase (49-72), Phase III - consolidation (from case 73 on).
Globally, after reaching the level of 9cm2/h and after resection 73, the cumulative moving average remains above this speed for all following resections.
Several locations reach moving average proficiency levels at different number of interventions (antrum: from the beginning, body: 134th).

Conclusion

The PB regarding the en bloc and R0 resection were achieved from the beginning.
The PB regarding de RS was achieved from the beginning for the antrum.
The PB regarding de RS, globally, has a clinically significant first learning inflection at ESD number 49 and at ESD number 73 achieved sustained PB for RS.

Disclosure

There are no conflict of interest.

Introduction

When esophageal cancer is diagnosed at an advanced stage, it requires a highly invasive treatment, and its prognosis is poor. Although the number of endoscopic examinations has been increasing globally, esophageal cancer is still difficult to diagnose at an early stage. The rapidly increasing number of endoscopic examinations performed over a short period might influence diagnostic performance. Accessing the association between calendar month and esophageal cancer detection rates might improve policy and guide institutional support.

Aims & Methods

We aimed to evaluate the association between the increased number of examinations over a certain period and esophageal cancer detection rates (EDR) among a large population in the Korean National Cancer Screening Program (KNCSP). We performed a retrospective population-based study using the KNCSP database for gastric cancer between 2015 and 2019. We included 28,032,590 Koreans aged ≥40 years. We assessed monthly EDR and performed a negative binomial regression model and least square mean evaluation to evaluate the association between the screening month and EDR.

Results

In total, 28,032,590 subjects underwent upper endoscopy, according to KNCSP. The monthly number of subjects who underwent examinations was the highest in December (n=4,819,606, 17.2%). EDR tended to decrease towards the end of the year, and EDR was the lowest in December 2015 – 2019 (0.06 – 0.08). In the multivariable logistic model, the association of calendar month with detected cancer remained after adjusting for other confounding factors (December 2015: odds ratio, 0.58; 95% CI, 0.43 – 0.79; P < .001; 2016: odds ratio, 0.51; 95%CI, 0.38 – 0.67; P < .001). The age group adjusted the calendar month, and the predicted detection rate significantly decreased at the end of the year compared with the beginning of the year in 2015, 2016, and 2017 respectively.

Conclusion

In the KNCSP, the workload of endoscopists increased excessively, with an increasing number of examinations towards the end of the year, as demonstrated by decreased EDR during this period.

Introduction

Safe and effective sedation are important factors when performing gastrointestinal endoscopy. However, clinicians should be cautious when using sedatives in older patients because of their decreased physiological reserves. Remimazolam is an ultrashort active benzodiazepine that has attracted attention because of its efficacy. This study aimed to determine the safety and efficacy of remimazolam compared with midazolam as a sedative for diagnostic upper gastrointestinal endoscopy in older patients aged ≥65 years.

Aims & Methods

We randomly assigned patients aged ≥65 years who were scheduled for diagnostic upper gastrointestinal endoscopy. The average induction time, average recovery time, and side effect profile of patients who received remimazolam as a sedative were compared with those of patients who received midazolam.

Results

Patients who received remimazolam had shorter average induction (102.0 sec vs. 327.5 sec, p<0.001) and recovery times (5.8 min vs. 13.4 min, p<0.001) than those who received midazolam. No significant difference in side effect profiles was observed between the groups.

Conclusion

In performing upper gastrointestinal endoscopy in older patients, remimazolam can be a good alternative sedative to midazolam, whether used as monotherapy or in combination therapy.

References

Kilpatrick GJ, McIntyre MS, Cox RF, et al. CNS 7056: a novel ultra-short-acting Benzodiazepine. Anesthesiology 2007;107:60-6.
Borkett KM, Riff DS, Schwartz HI, et al. A Phase IIa, randomized, double-blind study of remimazolam (CNS 7056) versus midazolam for sedation in upper gastrointestinal endoscopy. Anesth Analg 2015;120:771-80.
Chernik DA, Gillings D, Laine H, et al. Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam. J Clin Psychopharmacol 1990;10:244-51.

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.