Exploring non-curative endoscopic submucosal dissection:Current treatment optimization and future indication expansion

The increasing popularity of endoscopic submucosal dissection(ESD)as a treatment for early gastric cancer has highlighted the importance of quality assessment in achieving curative resections.This article emphasizes the significance of evaluating ESD quality,not only for curative cases but also for non-curative ones.Postoperative assessment relies on the endoscopic curability(eCura)classification,but management strategies for eCuraC-1 tumour with a positive horizontal margin are unclear.Current research primarily focuses on comparing additional surgical procedures in high-risk patients,while studies specifically targeting eCuraC-1 patients are limited.Exploring management strategies and follow-up outcomes for such cases could provide valuable insights.Furthermore,the application of molecular imaging using near-infrared fluorescent tracers holds promise for precise tumour diagnosis and navigation,potentially impacting the management of early-stage gastric cancer patients.Advancing research in these areas is essential for improving the overall efficacy of endoscopic techniques and refining treatment indications.

Efficacy and safety of endoscopic submucosal dissection for early gastric cancer and precancerous lesions in elderly patients

BACKGROUND With advancements in the development of endoscopic technologies,the endo-scopic submucosal dissection(ESD)has been one of the gold-standard therapies for early gastric cancer.AIM To investigate the efficacy and safety ESD in the treatment of early gastric cancer and precancerous lesions in the elderly patients.METHODS Seventy-eight elderly patients with early gastric cancer and precancerous lesions admitted to the Third Affiliated Hospital of Qiqihar Medical University were se-lected and classified into two groups according to the different surgical therapies they received between January 2021 and June 2022.Among them,39 patients treated with ESD were included in an experimental group,and 39 patients treated with endoscopic mucosal resection(EMR)were included in a control group.We compared the basic intraoperative conditions,postoperative short-term recovery,long-term recovery effects and functional status of gastric mucosa between the two groups;the basic intraoperative conditions included lesion resection,intra-operative bleeding and operation time;the postoperative short-term recovery assessment indexes were length of hospital stay and incidence of surgical complic-ations;and the long-term recovery assessment indexes were the recurrence rate at 1 year postoperatively and the survival situation at 1 year and 3 years postoper-atively;and we compared the preoperative and predischarge serum pepsinogen I(PG I)and PG II levels and PG I/PG II ratio in the two groups before surgery and discharge.RESULTS The curative resection rate and the rate of en bloc resection were higher in the experimental group than in the control group.The intraoperative bleeding volume was higher in the experimental group than in the control group.The operation time was longer in the experimental group than that in the control group,and the rate for base residual focus was lower in the experimental group than that of the control group,and the differences were all statistically significant(all P<0.05).The length of hospital stay was longer in the experi-mental group than in the control group,and the incidence of surgical complications,1-year postoperative recu-rrence rate and 3-year postoperative survival rate were lower in the experimental group than in the control group,and the differences were statistically significant(all P<0.05).However,the difference in the 1-year postoperative survival rate was not statistically significant between the two groups(P>0.05).Before discharge,PG I and PG I/PG II ratio were elevated in both groups compared with the preoperative period,and the above indexes were higher in the experimental group than those in the control group,and the differences were statistically significant(both P<0.05).Moreover,before discharge,PG II level was lower in both groups compared with the preoperative period,and the level was lower in the experimental group than in the control group,and the differences were all statistically significant(all P<0.05).CONCLUSION Compared with EMR,ESD surgery is more thorough.It reduces the rate of base residual focus,recurrence rate,surgical complications,and promotes the recovery of gastric cells and glandular function.It is safe and suitable for clinical application.

Role of second look endoscopy in endoscopic submucosal dissection and peptic ulcer bleeding:Meta-analysis of randomized controlled trials

BACKGROUND Second-look endoscopy(SLE)to prevent recurrent bleeding in patients with peptic ulcer disease(PUD)and those undergoing endoscopic submucosal dissection(ESD)is routinely being performed.Conflicting evidence exists regarding efficacy,risk,benefit,and cost-effectiveness.AIM To identify the role and effectiveness of SLE in ESD and PUD,associated rebleeding and PUD-related outcomes like mortality,hospital length of stay,need for endoscopic or surgical intervention and blood transfusions.METHODS A systematic review of literature databases PubMed,Cochrane,and Embase was conducted from inception to January 5,2023.Randomized controlled trials that compared patients with SLE to those who did not have SLE or evaluated the role of prophylactic hemostasis during SLE compared to other conservative interventions were included.The study was conducted per PRISMA guidelines,and the protocol was registered in PROSPERO(ID CRD42023427555:).RevMan was used to perform meta-analysis,and Mantel-Haenszel Odds ratio(OR)were generated using random effect models.RESULTS A total of twelve studies with 2687 patients were included in our systematic review and meta-analysis,of which 1074 patients underwent SLE after ESD and 1613 patients underwent SLE after PUD-related bleeding.In ESD,the rates of rebleeding were 7%in the SLE group compared to 4.4%in the non-SLE group with OR 1.65,95%confidence intervals(CI)of 0.96 to 2.85;P=0.07,whereas it was 11%in the SLE group compared to 13%in the non-SLE group with OR 0.895%CI:0.50 to 1.29;P=0.36.The mean difference in the blood transfusion rates in the SLE and no SLE group in PUD was OR 0.01,95%CI:-0.22 to 0.25;P=0.91.In SLE vs non-SLE groups with PUD,the OR for Endoscopic intervention was 0.29,95%CI:0.08 to 1.00;P=0.05 while it was OR 2.03,95%CI:0.95 to 4.33;P=0.07,for surgical intervention.The mean difference in the hospital length of stay was-3.57 d between the SLE and no SLE groups in PUD with 95%CI:-7.84 to 0.69;P=0.10,denoting an average of approximately 3 fewer days of hospital stay among patients with PUD who underwent SLE.For mortality between SLE and non-SLE groups in PUD,the OR was 0.88,95%CI:0.45 to 1.72;P=0.70.CONCLUSION SLE does not confer any benefit in preventing ESD and PUD-associated rebleeding.SLE also does not provide any significant improvement in mortality,need for interventions,or blood transfusions in PUD patients.SLE decreases the hospital length of stay on average by 3.5 d in PUD patients.

Comparative efficacy and safety between endoscopic submucosal dissection,surgery and definitive chemoradiotherapy in patients with cT1N0M0 esophageal cancer

BACKGROUND Endoscopic submucosal dissection(ESD)and surgical resection are the standard of care for cT1N0M0 esophageal cancer(EC),whereas definitive chemoradiotherapy(d-CRT)is a treatment option.Nevertheless,the comparative efficiency and safety of ESD,surgery and d-CRT for cT1N0M0 EC remain unclear.AIM To compare the efficiency and safety of ESD,surgery and d-CRT for cT1N0M0 EC.METHODS We retrospectively analyzed the hospitalized data of a total of 472 consecutive patients with cT1N0M0 EC treated at Sun Yat-sen University Cancer center between 2017-2019 and followed up until October 30th,2022.We analyzed demographic,medical recorded,histopathologic characteristics,imaging and endoscopic,and follow-up data.The Kaplan-Meier method and Cox proportional hazards modeling were used to analyze the difference of survival outcome by treatments.Inverse probability of treatment weighting(IPTW)was used to minimize potential confounding factors.RESULTS We retrospectively analyzed patients who underwent ESD(n=99)or surgery(n=220)or d-CRT(n=16)at the Sun Yat-sen University Cancer Center from 2017 to 2019.The median follow-up time for the ESD group,the surgery group,and the d-CRT group was 42.0 mo(95%CI:35.0-60.2),45.0 mo(95%CI:34.0-61.75)and 32.5 mo(95%CI:28.3-40.0),respectively.After adjusting for background factors using IPTW,the highest 3-year overall survival(OS)rate and 3-year recurrence-free survival(RFS)rate were observed in the ESD group(3-year OS:99.7% and 94.7% and 79.1%;and 3-year RFS:98.3%,87.4% and 79.1%,in the ESD,surgical,and d-CRT groups,respectively).There was no difference of severe complications occurring between the three groups(P≥0.05).Multivariate analysis showed that treatment method,histology and depth of infiltration were independently associated with OS and RFS.CONCLUSION For cT1N0M0 EC,ESD had better long-term survival and lower hospitalization costs than those who underwent d-CRT and surgery,with a similar rate of severe complications occurring.

Endoscopic submucosal dissection vs transanal endoscopic surgery for rectal tumors: A systematic review and meta-analysis

BACKGROUND Endoscopic submucosal dissection(ESD)and transanal endoscopic submucosal dissection(TES)are widely employed surgical techniques.However,the comparative efficacy and safety of both remain inconclusive.AIM To comprehensively analyze and discern differences in surgical outcomes between ESD and TES.METHODS We conducted a systematic search of the electronic databases PubMed,Embase,Cochrane Central Register of Controlled Trials,Scopus,and CINAHL from inception till August 2023.We analyzed outcomes including recurrence rate,en bloc resection,R0 resection rate,perforation rate,procedure length,and hospital stay length applying a random-effects inverse-variance model.We assessed publication bias by conducting an Egger’s regression test and sensitivity analyses.RESULTS We pooled data from 11 studies involving 1013 participants.We found similar recurrence rates,with a pooled odds ratio of 0.545(95%CI:0.176-1.687).En bloc resection,R0 resection,and perforation rate values were also similar for both ESD and TES.The pooled analysis for procedure length indicated a mean difference of-4.19 min(95%CI:-22.73 to 14.35),and the hospital stay was on average shorter for ESDs by about 0.789 days(95%CI:-1.671 to 0.093).CONCLUSION Both ESD and TES displayed similar efficacy and safety profiles across multiple outcomes.Our findings show that individualized patient and surgeon preferences,alongside specific clinical contexts,can be considered when selecting between these two techniques.

Endoscopic submucosal dissection and endoscopic mucosal resection for esophageal and gastric lesions:A comparison of procedures

Objective Esophageal and gastric lesions are effectively managed with minimally invasive upper endoscopic procedures such as endoscopic mucosa resection(EMR)and endoscopic submucosal dissection(ESD),offering patients alternatives to invasive interventions.While ESD is well established in Eastern Asia,its adoption in Denmark for superficial esophageal cancer is recent.This study presents real-world data on the feasibility,safety,and hospitalization duration associated with ESD and EMR for esophageal and gastric lesions.Methods A retrospective analysis was conducted on patients who underwent ESD or EMR at a specialized center in Denmark from October 2016 to June 2022.Data on treatment,indication,lesion location,hospitalization duration,procedure duration,specimen size,complications,recurrence,and one-year overall survival were collected.Statistical comparisons utilized the Mann-Whitney U test,independent sample median test,and chi-squared test.Results The study included 130 patients(144 procedures):72 underwent ESD and 58 underwent EMR.Compared with EMR,ESD resulted in greater percentages of en bloc and R0 resections(98.8%vs.64.1%,p<0.001;and 83.9%vs.23.8%,p<0.001),greater complication rates(28.7%vs.3.1%,p<0.001)and longer procedure times(119.5 min vs.37.0 min,p<0.001).The ESD procedure time significantly decreased over time(p=0.01).The local recurrence rates were 14.5%for ESD and 23.8%for EMR(p=0.767).The one-year overall survival rates were similar between the groups(95.8%vs.94.8%,p=0.553).Conclusion Both ESD and EMR are safe and viable for treating esophageal and gastric lesions.ESD offers advantages but requires more time and skill.These findings support the literature,emphasizing the importance of considering patient-specific factors and surgeon proficiency in selecting the appropriate procedure.

Early gastric cancer recurrence after endoscopic submucosal dissection:Not to be ignored!

This editorial comments on the article“Efficacy of multi-slice spiral computed tomography in evaluating gastric cancer recurrence after endoscopic submucosal dissection”.We focus on the importance of paying more attention to postendoscopic submucosal dissection(ESD)gastric cancer recurrence in patients with early gastric cancer(EGC)and how to manage it effectively.ESD has been a wellknown treatment and the mainstay for EGC,with the advantages of less invasion and fewer complications when compared with traditional surgical procedures.Despite a lower local recurrence rate after ESD,the problem of postoperative recurrence in patients with EGC has become increasingly non-ignorable with the global popularization of ESD technology and the increasing number of post-ESD patients.

Characteristics of early gastric tumors with different differentiation and predictors of long-term outcomes after endoscopic submucosal dissection

BACKGROUND Gastric cancer is a common malignant tumor of the digestive tract,and endosco-pic submucosal dissection(ESD)is the preferred treatment for early-stage gastric cancer.The analysis of the epidemiological characteristics of gastric mucosal tumors with different differentiation degrees and the influencing factors of long-term ESD efficacy may have certain significance for revealing the development of gastric cancer and ESD.AIM To analyze the features of gastric mucosal tumors at different differentiation levels,and to explore the prognostic factors of ESD.METHODS We retrospectively studied 301 lesions in 285 patients at The Second Affiliated Hospital of Xi'an Jiaotong University from 2014 to 2021,according to the latest Japanese guidelines(sixth edition),and divided them into low-grade intrae-pithelial neoplasia(LGIN),high-grade intraepithelial neoplasia(HGIN),and computed tomography at 3,6 and 12 months after ESD.We compared clinicopathologic characteristics,ESD efficacy,and complications with different degrees of differentiation,and analyzed the related factors associated with ESD.RESULTS HGIN and differentiated carcinoma patients were significantly older compared with LGIN patients(P<0.001)and accounted for more 0-IIc(P<0.001),atrophic gastritis was common(P<0.001),and irregular microvascular patterns(IMVPs)and demarcation lines(DLs)were more obvious(P<0.001).There was more infiltration in the undifferentiated carcinoma tissue(P<0.001),more abnormal folds and poorer mucosal peristalsis(P<0.001),and more obvious IMVPs,irregular microsurface patterns and DLs(P<0.05)than in the LGIN and HGIN tissues.The disease-free survival rates at 2,5,and 8 years after ESD were 95.0%,90.1%,and 86.9%,respectively.Undifferen-tiated lesions(HR 5.066),white moss(HR 7.187),incomplete resection(HR 3.658),and multiple primary cancers(HR 2.462)were significantly associated with poor prognosis.CONCLUSION Differentiations of gastric mucosal tumors have different epidemiological and endoscopic characteristics,which are closely related to the safety and efficacy of ESD.

Effects of integrated management on surgical outcomes and mental health of patients following endoscopic submucosal dissection

BACKGROUND Endoscopic submucosal dissection(ESD)is a less invasive local treatment for diseases throughout the gastrointestinal tract.AIM To develop an integrated management protocol and analyze its effects on surgical outcomes and mental health of patients after ESD.METHODS The study population consisted of patients undergoing ESD before implementation of integrated management and those undergoing ESD by the same pool of surgeons after implementation of integrated management.RESULTS The management group exhibited shortened fasting time and length of hospital stay compared to the control group(P<0.05).The management group exhibited a higher incidence rate of postoperative complications than the control group(3 cases vs 11 cases;P=0.043).The management group exhibited a lower uncertainty score for disease knowledge compared to the control group 12 h after surgery(P<0.05).The management group gave more scores on the domains of patient familiarity to the responsible nurses,professional skills of responsible nurses,and general evaluation compared to the control group.The management group had a higher total score of patient satisfaction towards the responsible nurses in term of health care than the control group(P<0.01).The management group exhibited lower Self-Rating Anxiety Scale and Self-Rating Depression Scale scores compared to the control group 12 h after surgery(P<0.01).CONCLUSION The study demonstrates that integrated management could improve surgical outcomes and mental health of patients undergoing ESD.

Effect of endoscopic submucosal dissection on gastrointestinal function and nutritional status in patients with early gastric cancer

BACKGROUND Gastric cancer(GC)endangers the survival and prognosis of patients worldwide.Improving the prognosis of patients with early GC(EGC)is crucial to prolong their survival time.AIM To analyze the effects of endoscopic submucosal dissection(ESD)on gastrointestinal function and nutritional status in patients with EGC.METHODS Eighty patients with EGC between January 2021 and January 2024 were divided according to different surgical protocol into following two groups:42 patients who underwent ESD in the ESD group and 38 patients treated with endoscopic mucosal resection(EMR)in the EMR group.Two groups were compared in the operative indices,lesion resection rate,postoperative recovery of gastrointestinal function,nutritional status,and incidence of surgical complications.RESULTS The overall resection rate of the lesion in the ESD group was higher.The operative bleeding volume and operation time were higher and gastrointestinal ventilation time was shorter in the ESD group than those in the EMR group(P<0.05).The nutritional statuses of the two groups decreased after operation;however,the levels of albumin,prealbumin,hemoglobin,and transferrin were higher in the ESD group than in the EMR group(P<0.05).The post-operative pepsinogen(PG)I level in the ESD group was higher than that in the EMR group,and the PG II level was lower than that in the EMR group(P<0.05).The incidence of postoperative complications was compared between the two groups(P>0.05).CONCLUSION ESD can promote the immediate recovery of patient’s postoperative gastrointestinal function,improve their nutritional level,and signifies its application in patients with EGC.

Rare primary colonic T cell lymphoma with curative resection by endoscopic submucosal dissection:A case report

BACKGROUND The gastrointestinal tract is a well-known extranodal site of lymphoma.B-cell lymph-oma is the most common type,while T-cell lymphoma is uncommon.Primary gastrointestinal lymphoma mainly occurs in the stomach and small intestine,and the colon is less frequently involved,especially in females.CASE SUMMARY A 45-year-old woman was admitted to our hospital for physical examination.Gastroenteroscopy revealed a visible pedunculated polyp in the transverse colon,for which endoscopic submucosal dissection(ESD)was performed.Pathology suggested highly active proliferation of T lymphocytes with atypical hyperplasia.CONCLUSION A middle-aged female patient was found to have colonic T-cell lymphoma by endoscopy.The lesion was successfully removed by ESD,and the surgical margin was negative.It is essential to raise awareness of colonic T-cell lymphoma and choose the appropriate treatment.

Outcome and risk factors of ulcer healing after gastric endoscopic submucosal dissection: A systematic review and meta-analysis

BACKGROUND Endoscopic submucosal dissection(ESD)is widely utilized for the treatment of large adenomas,submucosal lesions,and early gastric cancer.A significant arti-ficial ulcer typically forms after ESD.Delayed or incomplete healing of these ulcers can result in complications such as delayed bleeding and perforation.However,a comprehensive review of the outcomes and risk factors related to ulcer healing following ESD is currently lacking.AIM To assess ulcer healing outcomes and identify risk factors associated with delayed ulcer healing.RESULTS Our analysis included 12 studies,involving a total of 3430 patients.The meta-analysis revealed an overall healing rate of 65.55%for ulcers following ESD[odds ratio(OR)=2.71;95%confidence interval(CI):2.45-3.00].The healing rate within eight weeks was 48.32%(OR=0.76;95%CI:0.35-1.66),while the rate beyond eight weeks was 88.32%(OR=6.73;95%CI:3.82-11.87).Risk factors included Helicobacter pylori(H.pylori)infection(OR:=5.32;95%CI:1.90-14.87;P=0.001),ulcer size(OR=2.08;95%CI:1.19-3.61;P=0.01),lesion site(OR=2.08;95%CI:1.19-3.11),and pathological type(OR=1.64;95%CI:1.06-2.52).Diabetes(OR=0.56;95%CI:0.05-5.80;P=0.63)and duration of operation(OR=1.00;95%CI:0.99-1.01;P=0.96)were not significant factors.CONCLUSION The healing rate of ulcers following ESD is high after eight weeks.Risk factors affecting the healing process include H.pylori infection,ulcer size,lesion site,and pathological type.

Prospects of polyglycolic acid sheets for the treatment of esophageal stricture after esophageal endoscopic submucosal dissection

Esophageal cancer is the seventh most common type of cancer and the sixth leading cause of cancer-related mortality worldwide.Endoscopic submucosal dissection(ESD)is widely used for the resection of early esophageal cancer.However,post-ESD esophageal stricture is a common long-term complication,which requires attention.Patients with post-ESD esophageal stricture often experience dysphagia and require multiple dilatations,which greatly affects their quality of life and increases healthcare costs.Therefore,to manage post-ESD esophageal stricture,researchers are actively exploring various strategies,such as pharmaceutical interventions,endoscopic balloon dilation,and esophageal stenting.Although steroids-based therapy has achieved some success,steroids can lead to complications such as osteoporosis and infection.Meanwhile,endoscopic balloon dilatation is effective in the short term,but is prone to recurrence and perforation.Additionally,esophageal stenting can alleviate the stricture,but is associated with discomfort during stenting and the complication of easy displacement also present challenges.Tissue engineering has evolved rapidly in recent years,and hydrogel materials have good biodegradability and biocompatibility.A novel type of polyglycolic acid(PGA)sheets has been found to be effective in preventing esophageal stricture after ESD,with the advantages of a simple operation and low complication rate.PGA membranes act as a biophysical barrier to cover the wound as well as facilitate the delivery of medications to promote wound repair and healing.However,there is still a lack of multicenter,large-sample randomized controlled clinical studies focused on the treatment of post-ESD esophageal strictures with PGA membrane,which will be a promising direction for future advancements in this field.

Challenges and advancing strategies of endoscopic submucosal dissection for early gastric cancer:The puzzle of eCura C1

In this editorial,we explore the challenges of managing noncurative resections in early gastric cancer after endoscopic submucosal dissection(ESD),starting from the consideration recently made by Zhu et al.Specifically,we evaluate the management of eCura C1 lesions,where decisions regarding further interventions are pivotal yet contentious.Collaboration among endoscopists,surgeons,and pathologists is underscored to refine risk assessment and personalize therapeutic management.Recent advancements in ESD techniques and interdisciplinary collaboration offer opportunities for outcome optimization in managing eCura C1 lesions.Moreover,despite needing further clinical validation,molecular biomarkers have emerged as promising tools for enhancing prognostication.This manuscript highlights the ongoing research attempts to define treatment paradigms effectively and evaluates the potential of emerging options,ultimately aiming to improve patient care and outcomes in this complex clinical scenario.

Predictors of stricture after endoscopic submucosal dissection of the esophagus and steroids application

BACKGROUND Endoscopic submucosal dissection(ESD)is a reliable method to resect early esophageal cancer.Esophageal stricture is one of the major complications after ESD of the esophagus.Steroid prophylaxis for esophageal strictures,particularly local injection of triamcinolone acetonide(TA),is a relatively effective method to prevent esophageal strictures.However,even with steroid prophylaxis,stenosis still occurs in up to 45%of patients.Predicting the risk of stenosis formation after local TA injection would enable additional interventions in risky patients.AIM To identify the predictors of esophageal strictures after steroids application.METHODS Patients who underwent esophageal ESD and steroid prophylaxis and who were comprehensively assessed for lesion-and ESD-related factors at Southeast University Affiliated Zhongda Hospital between February 2018 and March 2023 were included in the study.The univariate and multivariate regression analyses were conducted to identify the predictors of stricture among patients undergoing steroid prophylaxis.RESULTS A total of 120 patients were included in the analysis.In the oral prednisone and oral prednisone combined with local tretinoin injection groups,the stenosis rates were 44/53(83.0%)and 56/67(83.6%),respectively.Among them,univariate analysis showed that the lesion circumference(P=0.01)and submucosal injection solution(P=0.04)showed significant correlation with the risk of stenosis formation.Logistic regression analyses were then performed using predictors that were significant in the univariate analyses and combined with known predictors from previous reports,such as additional chemoradiotherapy and tumor location.We identified a lesion circumference<5/6(OR=0.19;P=0.02)and submucosal injection of sodium hyaluronate(OR=0.15;P=0.03)as independent predictors of on esophageal stricture formation.CONCLUSION Steroid prophylaxis effectively prevents stenosis.Moreover,the lesion circumference and submucosal injection of sodium hyaluronate were independent predictors of esophageal strictures.Additional interventions should be considered in high-risk patients.

Tumor size discrepancy between endoscopic and pathological evaluations in colorectal endoscopic submucosal dissection

BACKGROUND Tumor size impacts the technical difficulty and histological curability of colorectal endoscopic submucosal dissection(ESD);however,the preoperative evaluation of tumor size is often different from histological assessment.Analyzing influential factors on failure to obtain an accurate tumor size evaluation could help prepare optimal conditions for safer and more reliable ESD.METHODS This was a retrospective study conducted at a single institution.A total of 377 lesions removed by colorectal ESD at our hospital between April 2018 and March 2022 were collected.We first assessed the difference in size with an absolute per-centage of the scaling discrepancy.Subsequently,we compared the clinicopatho-logical characteristics of the correct scaling group(>-33%and<33%)with that of the incorrect scaling group(<-33%or>33%),which was further subdivided into the underscaling group(-33%or less of the discrepancy)and overscaling group(33%or more of the discrepancy),respectively.As secondary outcome measures,parameters on size estimation were compared between the underscaling and correct scaling groups,as well as between the overscaling and correct scaling groups.Finally,multivariate analysis was performed in terms of the following relevant parameters on size estimation:Pathological size,location,and possible influential factors(P<0.1)in the univariate analysis.RESULTS The mean of absolute percentage in the scaling discordance was 21%,and 91 lesions were considered to be incorrectly estimated in size.The incorrect scaling was significantly remarkable in larger lesions(40 mm vs 28 mm;P<0.001)and less experience(P<0.001),and these two factors were influential on the underscaling(75 lesions;P<0.001).Conversely,compared with the correct scaling group,16 lesions in the overscaling group were significantly small(20 mm vs 28 mm;P<0.001),and the small lesion size was influential on the overscaling(P=0.002).CONCLUSION Lesions indicated for colorectal ESD tended to be underestimated in large tumors,but overestimated in small ones.This discrepancy appears worth understanding for optimal procedural preparation.

Using a novel hemostatic peptide solution to prevent bleeding after endoscopic submucosal dissection of a gastric tumor

BACKGROUND Endoscopic mucosal dissection has become the standard treatment for early gastric cancer.However,post-endoscopic submucosal dissection(ESD)ulcer occurs in 4.4%of patients.This study hypothesized whether applying PuraStat,a novel hemostatic peptide solution,prevents post-ESD bleeding.AIM To investigate the preventive potential of PuraStat,a hemostatic formulation,against bleeding in post-ESD gastric ulcers.METHODS Between May 2022 and March 2023,101 patients(Group P)underwent ESD for gastric diseases at our hospital and received PuraStat(2 mL)for post-ESD ulcers.We retrospectively compared this group with a control group(Group C)com-prising 297 patients who underwent ESD for gastric diseases at our hospital between April 2017 and March 2021.P values<0.05 on two-sided tests indicated significance.RESULTS Post-ESD bleeding occurred in 6(5.9%)(95%CI:2.8-12.4)and 20(6.7%)(95%CI:4.4-10.2)patients in Groups P and C,respectively,with no significant between-group difference.The relative risk was 1.01(95%CI:0.95-1.07).The lesser curvature or anterior wall was the bleeding site in all 6 patients who experienced postoperative bleeding in Group P.In multivariate analysis,the odds ratios for resection diameter≥50 mm and oral anticoagulant use were 6.63(95%CI:2.52-14.47;P=0.0001)and 4.04(1.26-0.69;P=0.0164),respectively.The adjusted odds ratio of post-ESD bleeding and PuraStat was 1.28(95%CI:0.28-2.15).CONCLUSION PuraStat application is not associated with post-ESD bleeding.However,the study suggests that gravitational forces may affect the effectiveness of applied PuraStat.

Long-term outcomes of endoscopic submucosal dissection for undifferentiated type early gastric cancer over 2 cm with R0 resection

BACKGROUND Endoscopic submucosal dissection(ESD)for over 2 cm in size undifferentiated type(UD type)early gastric cancer(EGC)confined to the mucosa is not only challenging,but also long-term outcomes are not well known.AIM To evaluate the long-term outcomes of ESD done for UD type EGCs confined to the mucosa over 2 cm in size and compare the results with those where the lesions were less than 2 cm.METHODS 143 patients with UD type EGC confirmed on histology after ESD at a tertiary hospital were reviewed.Cases with synchronous and metachronous lesions and a case with emergency surgery after ESD were excluded.A total of 137 cases were enrolled.79 cases who underwent R0 resection were divided into 2 cm or less(group A)and over 2 cm(group B)in size.RESULTS Among 79 patients who underwent R0 resection,the number in group A and B were 51 and 28,respectively.The mean follow-up period(SD)was 79.71±45.42 months.There was a local recurrence in group A(1/51,2%)and group B(1/28,3.6%)respectively.This patient in group A underwent surgery while the patient in group B underwent repeated ESD with no further recurrences in both patients.There was no regional lymph node metastasis,distant metastasis,and deaths in both groups.With R0 resection strategy for ESD on lesions over 2 cm,20.4%(28/137)of patients were able to avoid surgery compared with expanded indication.CONCLUSION If R0 resection is achieved by ESD,UD type EGCs over 2 cm also showed good and similar clinical outcomes as compared to lesions less than 2 cm when followed for over 5 years.With R0 resection strategy,several patients can avoid surgery.

Associate factors for endoscopic submucosal dissection operation time and postoperative delayed hemorrhage of early gastric cancer

BACKGROUND Endoscopic submucosal dissection(ESD)is a treatment for early gastric cancer with the advantages of small invasion,fewer complications,and a low local recurrence rate.However,there is a high risk of complications such as bleeding and perforation,and the operation time is also longer.ESD operation time is closely related to bleeding and perforation.AIM To investigate the influencing factors associated with ESD operation time and postoperative delayed hemorrhage to provide a reference for early planning,early identification,and prevention of complications.METHODS We conducted a retrospective study based on the clinical data of 520 patients with early gastric cancer in the Second Affiliated Hospital of Hainan Medical University from January 2019 to December 2021.The baseline data,clinical features,and endoscopic and pathological characteristics of patients were collected.The multivariate linear regression model was used to investigate the influencing factors of ESD operation time.Logistic regression analysis was carried out to evaluate the influencing factors of postoperative delayed hemorrhage.RESULTS The multivariate analysis of ESD operation time showed that the maximum lesion diameter could affect 8.815%of ESD operation time when other influencing factors remained unchanged.The operation time increased by 3.766%or 10.247%if the lesion was mixed or concave.The operation time increased by 4.417%if combined with an ulcer or scar.The operation time increased by 3.692%if combined with perforation.If infiltrated into the submucosa,it increased by 2.536%.Multivariate analysis of delayed hemorrhage after ESD showed that the maximum diameter of the lesion,lesion morphology,and ESD operation time were independent influencing factors for delayed hemorrhage after ESD.Patients with lesion≥3.0 cm(OR=3.785,95%CI:1.165-4.277),lesion morphology-concave(OR=10.985,95%CI:2.133-35.381),and ESD operation time≥60 min(OR=2.958,95%CI:1.117-3.526)were prone to delayed hemorrhage after ESD.CONCLUSION If the maximum diameter of the lesion in patients with early gastric cancer is≥3.0 cm,and the shape of the lesion is concave,or accompanied by an ulcer or scar,combined with perforation,and infiltrates into the submucosa,the ESD operation will take a longer time.When the maximum diameter of the lesion is≥3.0 cm,the shape of the lesion is concave in patients and the operation time of ESD takes longer time,the risk of delayed hemorrhage after ESD is higher.

Assessment of delayed bleeding after endoscopic submucosal dissection of early-stage gastrointestinal tumors in patients receiving direct oral anticoagulants

Delayed bleeding is a major and serious adverse event of endoscopic submucosal dissection(ESD)for early-stage gastrointestinal tumors.The rate of post-ESD bleeding for gastric cancer is higher(around 5%-8%)than that for esophagus,duodenum and colon cancer(around 2%-4%).Although investigations into the risk factors for post-ESD bleeding have identified several procedure-,lesion-,physician-and patient-related factors,use of antithrombotic drugs,especially anticoagulants[direct oral anticoagulants(DOACs)and warfarin],is thought to be the biggest risk factor for post-ESD bleeding.In fact,the post-ESD bleeding rate in patients receiving DOACs is 8.7%-20.8%,which is higher than that in patients not receiving anticoagulants.However,because clinical guidelines for management of ESD in patients receiving DOACs differ among countries,it is necessary for endoscopists to identify ways to prevent post-ESD delayed bleeding in clinical practice.Given that the pharmacokinetics(e.g.,plasma DOAC level at both trough and T_(max))and pharmacodynamics(e.g.,anti-factor Xa activity)of DOACs are related to risk of major bleeding,plasma DOAC level and anti-FXa activity may be useful parameters for monitoring the anti-coagulate effect and identifying DOAC patients at higher risk of post-ESD bleeding.