Introduction

Gastric endoscopic submucosal dissection (ESD) has become a common treatment for early gastric cancer. Advances in endoscopic equipment and treatment strategies have made the procedure safe to perform, however often the trainee is unable to complete the procedure due to refractory resection or intraoperative bleeding. We also have several resection devices in gastric ESD, among which we often use the clutch cutter, which is a scissors-type forceps in our hospital after 2017. The clutch cutter can be used to safely perform ESD because it can maintain a distance from the muscle layer during energization. It can also be used for bleeding and prophylactic hemostasis, which we believe allows trainees to perform the treatment.

Aims & Methods

The aim of this study was to evaluate factors associated with trainee completion rates of gastric ESD.
This study was conducted as a single-center retrospective study. Eligible patients were defined as ESD for early gastric cancer performed in our hospital from April 2014 to March 2022, and treated by the trainee from the beginning. Patients whose device at the start of the incision was a clutch cutter were considered the clutch cutter group (CC group), and patients whose device was another device such as an IT knife or flash knife were considered the other group (O group), and the two groups were compared. If the procedure time exceeded one hour or if uncontrolled bleeding or perforation occurred, the surgeon was replaced by an expert. The primary endpoint was trainee completion rate of gastric ESD. The secondary endpoints were procedure time and intraoperative perforation rate.

Results

This study was enrolled 919 cases. CC group were 488 cases and O group were 431cases. There were no differences of sex, history of antithrombotic agent, postoperative stomach, tumor location and tumor size. The median patient age was 74 years old (29-92) in the CC group and 73 years old (36-98) in the O group, which was higher in the CC group. The En block resection rate was 99.8% in the CC group and 100% in the O group. The median procedure time (IQR) was 50 minutes (7-245) minutes in the CC group and 67 minutes (10-313) minutes in the O group and was significantly shorter in the CC group. The completion rate of the trainees was 50.0% in the CC group and 32.0% in the other groups, with the CC group being significantly higher (P <0.001). Intraoperative perforation was 1.2 % in the CC group and 1.6 % in the O group, with no difference between the two groups. The first and second semester completion rates of long-term hospital-trained trainees were compared by initial training device. Trainees whose initial device was a clutch cutter increased the completion rate from 50.9% (29/57) to 60.4% (58/96), and those whose initial device was other increased from 25.6% (22/86) to 47.6% (100/210). Multivariate analysis related to trainee completion rate identified that tumor location was in the lower third (OR 1.88, 95% CI 1.42-2.49, P<0.0001), stomach was not postoperative (OR 2.37, 95% CI 1.16-4.87, P=0.019), tumor diameter was less than 20 mm (OR 3.5, 95% CI 2.32-5.26, P<0.001), and a clutch cutter was used (OR 2.32, 95% CI 1.75-0.07, P<0.001).

Conclusion

ESD using a clutch cutter for lesions of 20 mm or less in the lower third of the stomach without a history of surgery was considered the best way to complete the trainee's procedure.

References

Dohi O, et al. Digestion 2019; 100: 201-209

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 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

Delayed bleeding after gastric endoscopic submucosal dissection (ESD) is one of the most frequent complications (up to 7%). The BEST-J score is a risk predictive model for delayed bleeding following gastric ESD. We aim to assess potential risk factors associated with bleeding and validate the BEST-J score in a population of patients undergoing ESD.

Aims & Methods

Prospective cohort study, single centre, of patients who underwent gastric ESD between 2017 and 2023. The characteristics of the lesion were evaluated, and logistic regression of risk factors associated with bleeding after ESD was performed. The BEST-J score was calculated for each patient and the discriminative ability was evaluated through the area under the receiver operating characteristic curve (AUC-ROC).

Results

Included 101 gastric ESDs (63.4% female), with a mean age of 69.7 ± 8 years. 17.8% of patients were on antiplatelet therapy and 13.9% were on anticoagulant therapy. Among the analyzed lesions: 43.6% measured between 0-20mm, 56.4% were ≥ 20mm; 13.9% were sessile, 60.4% flat, 14.9% depressed and 10.9% subepithelial; 22.8% were located in the cardia, fundus, or body, 17.8% in the incisura angularis and 59.4% in the antrum. The most frequent histological results were: 38.6% low-grade dysplasia, 26.7% high-grade dysplasia and 19.8% intramucosal adenocarcinoma. The mean procedure duration was 87±43 minutes. Delayed bleeding after ESD occurred in 5.9% (n=6) of cases. In the univariate analysis of risk factors, the lesion size ≥ 20mm showed statistical significance (10.5% vs. 0%; p=0.034), but not the location in the antrum (6.7% vs. 4.9%; p=0.5), lesion nature (7.1% vs. 8.2% vs. 0% vs. 0%; p=0.5) or procedure duration ≥60 minutes (5% vs. 9.5%; p=0.3). The BEST-J score predicted the risk of delayed bleeding after gastric ESD with an AUC of 0.70 (95% CI: 0.53-0.87; p=0.1).

Conclusion

The use of bleeding predictive scores may be useful in identifying high-risk patients; in our series, the BEST-J score was not very effective, with only lesion size ≥ 20mm being a relevant factor for bleeding after ESD.

Introduction

Patients on maintenance hemodialysis are considered to have a higher risk of bleeding after endoscopic submucosal dissection (ESD) for gastric lesions. In high-risk cases, second-look endoscopy (SLE) may reduce the risk of post-ESD bleeding¹. At our institution, SLE is routinely performed following gastric ESD. We evaluated the incidence and risk factors of post-ESD bleeding after gastric ESD among patients on maintenance hemodialysis.

Aims & Methods

We conducted a retrospective, single-center study including 32 hemodialysis patients with 37 gastric lesions who underwent ESD at our hospital between July 22, 2003 and August 31, 2024. Patients were divided into two groups based on the occurrence of post-ESD bleeding. Clinical data including age, sex, body mass index (BMI), age-adjusted Charlson comorbidity index (ACCI), Geriatric Nutritional Risk Index (GNRI), extent of atrophic gastritis, laboratory findings, the use of antithrombotic drugs, Best-J score², details of the procedure, pathological findings and the types of anti-acid medicine prescribed after ESD were collected and analyzed.

Results

The median age was 72 years, with 73% of the patients being male. There were no differences in most of patient characteristics, details of lesions and procedures. Submucosal invasion (0% in the no-bleeding group vs. 28.6% in the bleeding group, p = 0.035) were significantly associated with post-ESD bleeding. In contrast, the use of local hemostatic agents appeared to have a protective effect against post-ESD bleeding (51.7% vs. 0%, p = 0.012). The use of perioperative antithrombotic drugs tended to be higher in the bleeding group (51.7% vs. 0%, p = 0.058). The endoscopic hemostasis at 2nd look endoscopy was not associated with post-ESD bleeding.

Conclusion

Despite routine SLE in hemodialysis patients, the rate of post-ESD bleeding at our institution remains high and similar to previously reported rates. Submucosal invasion, perioperative antithrombotic therapy may be associated with increased, and the use of local hemostatic agents may be associated with decreased bleeding risk. Further strategies should be considered to reduce the risk of post-ESD bleeding in hemodialysis patients.

References

1: Usefulness of the Forrest Classification to Predict Artificial Ulcer Rebleeding during Second-Look Endoscopy after Endoscopic Submucosal Dissection. Clin Endosc. 2016 May;49(3):273-81.
2: Prediction model of bleeding after endoscopic submucosal dissection for early gastric cancer: BEST-J score. Gut. 2021 Mar;70(3):476-484.

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.