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.

Risk factors for local recurrence after en bloc endoscopic submucosal dissection for early gastric cancer

AIM: To investigate factors related to recurrence following en bloc resection using endoscopic submucosal dissection(ESD) in patients with early gastric cancer(EGC). METHODS: A total of 1121 patients(1215 lesions) who had undergone ESD for gastric neoplasia between April 2003 and May 2010 were retrospectively reviewed. Data from 401 patients(415 lesions) were analyzed, following the exclusion of those who underwent piecemeal resection, with deep resection margin invasion or lateral margin infiltration, and diagnosed with benign lesions. RESULTS: Local recurrence after en bloc ESD was found in 36 cases(8.7%). Unclear resection margins, long procedure times, and narrow safety margins were identified as risk factors for recurrence. Lesions located in the upper third of the stomach showed a higher rate of recurrence than those located in the lower third of the stomach(OR = 2.9, P = 0.03). The probability of no recurrence for up to 24 mo was 79.9% in those with a safety resection margin ≤ 1 mm and 89.5% in those with a margin > 1 mm(log-rank test, P = 0.03). CONCLUSION: Even in cases in which en bloc ESD is performed for EGC, local recurrence still occurs. To reduce local recurrences, more careful assessment will be needed prior to the implementation of ESD in casesin which the tumor is located in the upper third of the stomach. In addition, clear identification of tumor boundaries as well as the securing of sufficient safety resection margins will be important.

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.

Editorial article to:Animal experimental study on magnetic anchor technique-assisted endoscopic submucosal dissection of early gastric cancer

In this editorial we comment on the article published in the recent issue of the World Journal of Gastrointestinal Endoscopy 2023;15(11):634-680.Gastric cancer(GC)remains the fifth most common malignancy and the fourth leading cause of cancer-related death worldwide.The overall prevalence of GC has declined,although that of proximal GC has increased over time.Thus,a significant proportion of GC cases and deaths can be avoided if preventive interventions are taken.Early GC(EGC)is defined as GC confined to the mucosa or submucosa.Endoscopic resection is considered the most appropriate treatment for precancerous gastrointestinal lesions improving patient quality of life,with reduced rates of complications,shorter hospitalization period,and lower costs when compared to surgical resection.Endoscopic mucosal resection(EMR)and endoscopic sub-mucosal dissection(ESD)are representative endoscopic treatments for EGC and precancerous gastric lesions.Standard EMR implies injection of a saline solution into the sub-mucosal space,followed by excision of the lesion using a snare.Complete resection rates vary depending on the size and severity of the lesion.When using conventional EMR methods for lesions less than 1 cm in size,the complete resection rate is approximately 60%,whereas for lesions larger than 2 cm,the complete resection rate is low(20%-30%).ESD can be used to remove tumors exceeding 2 cm in diameter and lesions associated with ulcers or submucosal fibrosis.Compared with EMR,ESD has higher en bloc resection rates(90.2%vs 51.7%),higher complete resection rates(82.1 vs 42.2%),and lower recurrence rates(0.65%vs 6.05%).Thus,innovative techniques have been introduced.

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.

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.

Combination of endoscopic submucosal dissection and laparoscopic sentinel lymph node dissection in early mucinous gastric cancer:Role of lymph node metastasis

BACKGROUND Recent evidence showed that combining endoscopic submucosal dissection(ESD)and laparoscopic sentinel lymph node dissection may avoid unnecessary gastrectomy in treating early mucinous gastric cancer(EMGC)patients with risks of positive lymph node metastasis(pLNM).AIM To explore the predictive factors for pLNM in EMGC,and to optimize the clinical application of combing ESD and sentinel lymph node dissection in a proper subgroup of patients with EMGC.METHODS Thirty-one patients with EMGC who had undergone gastrectomy with lymph node dissection were consecutively enrolled from January 1988 to December 2016.Univariate and multivariate logistic regression analyses were used to estimate the association between the rates of pLNM and clinicopathological factors,providing odds ratio(OR)with 95%confidence interval.And the association between the number of predictors and the pLNM rate was also investigated.RESULTS Depth of invasion(OR=7.342,1.127-33.256,P=0.039),tumor diameter(OR=9.158,1.348-29.133,P=0.044),and lymphatic vessel involvement(OR=27.749,1.821-33.143,P=0.019)turned out to be significant and might be the independent risk factors for predicating pLNM in the multivariate analysis.For patients with 1,2,and 3 risk factors,the pLNM rates were 9.1%,33.3%,and 75.0%,respectively.pLNM was not detected in seven patients without any of these risk factors.CONCLUSION ESD might serve as a safe and sufficient treatment for intramucosal EMGC if tumor size≤2 cm,and when lymphatic vessel involvement is absent by postoperative histological examination.Combining ESD and sentinel lymph node dissection could be recommended as a safe and effective treatment for EMGC patients with a potential risk of pLNM.

Feasibility study on expanded indication for endoscopic submucosal dissection of intramucosal poorly differentiated early gastric cancer

AIM: To identify clinicopathological factors predictive of lymph node metastasis(LNM) in intramucosal poorly differentiated early gastric cancer(EGC), and further to expand the possibility of using endoscopic submucosal dissection(ESD) for the treatment of intramucosal poorly differentiated EGC.METHODS: Data for 81 surgically treated patients with intramucosal poorly differentiated EGC were collected, and the association between the clinicopathological factors and the presence of LNM was retrospectively analyzed by univariate and multivariate logistic regression analyses. Odds ratios(ORs) with 95% confidence intervals(CIs) were calculated. Several clinicopathologic factors were investigated to identify predictive factors for lymph nodes metastasis, including gender, age, family history of gastric cancer, number of tumors, tumor location, ulceration, tumor size, macroscopic type, lymphatic vessel involvement, and signet-ring-cell component.RESULTS: Tumor size(OR = 7.273, 95%CI: 1.246-29.918, P = 0.042), lymphatic vessel involvement(OR = 42.219, 95%CI: 1.923-97.052, P = 0.018) and signet-ring-cell component(OR = 17.513, 95%CI: 1.647-77.469, P = 0.034) that were significantly associated with LNM by univariate analysis, were found to be significant and independent risk factors for LNM by multivariate analysis. However, gender, age, family history of gastric cancer, number, location, ulceration and macroscopic type of tumor were found not to be associated with LNM. Of these 81 patients diagnosed with intramucosal poorly differentiated EGC, 7(8.6%) had LNM. The LNM rates were 9.1%, 22.2% and 57.1%, respectively, in cases with one, two and three of the risk factors. There was no LNM in 54 patients without the three risk clinicopathological factors.CONCLUSION: Tumor size, lymphatic vessel involvement and signet-ring-cell component are independently associated with the presence of LNM in intramucosal poorly differentiated EGC. Thus, these three risk factors may be used as a simple criterion to expand the possibility of using ESD for the treatment of intramucosal poorly differentiated EGC.

Current indications for endoscopic submucosal dissection of early gastric cancer

The development of endoscopic treatment technology has further promoted the minimally invasive treatment of early gastric cancer(EGC).Endoscopic treatment has achieved better therapeutic effects in terms of safety and prognosis and is the preferred treatment method for patients who meet the indications for endoscopic treatment.However,the consequent problem is that some patients receiving endoscopic treatment may undergo non-curative resection,and the principle of follow-up management for non-curative resection patients deserves further attention.In addition,there are still debates on how to improve the accuracy of clinical staging,select a reasonable treatment method for patients who meet the expanded indications for endoscopic treatment,manage patients with positive endoscopic surgical margins,conduct research on function-preserving surgery,and manage the treatment of EGC under the current situation in China.Consequently,we aim to review current indications for endoscopic submucosal dissection of EGC in order to better inform treatment options.

Endoscopic submucosal dissection for undifferentiated-type early gastric cancer: Do we have enough data to support this?

Although endoscopic submucosal dissection (ESD) is now accepted for treatment of early gastric cancers (EGC) with negligible risk of lymph node (LN) metastasis, ESD for intramucosal undifferentiated type EGC without ulceration and with diameter &#x02264; 2 cm is regarded as an investigational treatment according to the Japanese gastric cancer treatment guidelines. This consideration was largely based on the analysis of surgically resected EGCs that contained undifferentiated type EGCs; however, results from several institutes showed some discrepancies in sample size and incidence of LN metastasis. Recently, some reports about the safety and efficacy of ESD for undifferentiated type EGC meeting the expanded criteria have been published. Nonetheless, only limited data are available regarding long-term outcomes of ESD for EGC with undifferentiated histology so far. At the same time, endoscopists cannot ignore the patients&#x02019; desire to guarantee quality of life after the relatively non-invasive endoscopic treatment when compared to conventional surgery. To satisfy the needs of patients and provide solid evidence to support ESD for undifferentiated EGC, we need more delicate tools to predict undetected LN metastasis and more data that can reveal predictive factors for LN metastasis.

Outcome after endoscopic submucosal dissection for early gastric cancer in Korea

Endoscopic treatment,such as endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD),has been established as one of the treatment options for selected cases with early gastric cancer(EGC).Most studies on this topic have been carried out by researchers in Japan.Recently,the experience in EMR/ESD for EGC outside Japan is increasingly reported.In Korea,gastric cancer is the most common malignant disease,and the second leading cause of cancer death.Currently,EMR for EGC is widely performed in many centers in Korea.Early results with a shortterm follow-up period are very promising in Korea.Thecomplete resection rate of EMR was 37.8%-94.3%,and that of ESD was 77.4%-93.1%.In this review,we will provide an overview of the outcomes of endoscopic treatments in Korea.

Current status of endoscopic submucosal dissection for the management of early gastric cancer:A Korean perspective

The early diagnosis of gastric cancer allows patients and physicians to pursue the option of endoscopic resection,which is significantly less invasive than conventional surgical resection.In Korea,the use of endoscopic submucosal dissection(ESD) has been increasing,and many reports on ESD have been published.In addition,Korean gastroenterologists from several hospitals performing ESD have conducted formal meetings to discuss useful information regarding ESD.Here,we discuss the Korean experience with ESD,including outcomes and prospects of endoscopic treatments.

Clinical outcomes of Clutch Cutter endoscopic submucosal dissection for older patients with early gastric cancer

AIM To evaluate the clinical outcome of endoscopic submucosal dissection using the Clutch Cutter(ESDCC) in older patients. METHODS We reviewed 232 consecutive patients with early gastric cancer who underwent ESDCC between June 2010 and February 2014 at Aso Iizuka Hospital. We divided patients into two groups according to age: Older patients(> 80 years, n = 64) and non-older patients(≤ 80 years, n = 168). We retrospectively compared the prevalence rates of pre-existing comorbidities, anticoagulant therapy, en bloc resection, mean duration of hospitalization, incidence of ESDCC-related complications, change in performance status(PS) before and after ESDCC, and financial cost of admission. RESULTS The older group comprised 64 patients with a mean age of 84.1 years, and the non-older group comprised 168 patients with a mean age of 69.5 years. Older patients had significantly more pre-existing comorbidities than did non-older patients, specifically heart disease(P < 0.05). The en bloc resection rate in non-older patients was significantly higher than that in older patients(100% vs 95.3%, P = 0.02). There were no significant differences between the older and non-older groups in the incidence of ESDCC-related complications(i.e., postoperative bleeding and perforation) and the post-ESDCC change in PS. There were also no significant differences between the older and non-older groups in the mean duration of hospitalization(11.4 and 10.7 d, respectively) and financial cost of admission(657040 JPY and 574890 JPY, respectively).CONCLUSION ESDCC has a good clinical outcome in older patients.

Long-term outcomes of endoscopic submucosal dissection and surgery for undifferentiated intramucosal gastric cancer regardless of size

BACKGROUND The clinical outcomes of endoscopic submucosal dissection(ESD)for undifferentiated(UD)intramucosal early gastric cancer(EGC)compared with those of surgery,regardless of lesion size,are not well known.Furthermore,there is a concern regarding the treatment plan before and after ESD in cases of UD intramucosal EGC within expanded indications.AIM To evaluate clinical outcomes of ESD compared with those of surgery in UD intramucosal EGC patients regardless of tumor size.METHODS We enrolled patients with UD intramucosal EGC after ESD with complete resection or surgery from January 2005 to August 2020 who met the within or beyond expanded indications with lesion size>2 cm(the only non-curative factor).Overall,123 and 562 patients underwent ESD and surgery,respectively.After propensity-score matching,clinical and long-term outcomes,i.e.,recurrencefree survival(RFS)and overall survival(OS),were analyzed.The multivariable Cox proportional hazard model with treatment modality and ESD indication was used to evaluate the recurrence risk.RESULTS After matching,119 patients each were finally enrolled in the ESD and surgery groups.The median length of hospital stay was shorter in the ESD group than surgery group(4.0 vs 9.0 days,P<0.001).Four cases of recurrence after ESD were local recurrences,all of which occurred within 1 year.Total recurrence was seven(5.9%)and two(1.7%)in the ESD and surgery groups,respectively.No difference was observed between the two groups with respect to OS(P=0.948).However,the ESD group had inferior RFS compared with the surgery group(P=0.031).ESD was associated with the risk of recurrence after initial treatment in all enrolled patients(hazard ratio,5.2;95%confidence interval:1.0-25.8,P=0.045).CONCLUSION Although OS was similar between the two groups,surveillance endoscopy was important for the ESD than for the surgery group because RFS was inferior and local recurrence was an issue.

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.

Endoscopic submucosal dissection for early gastric cancer:Quo vadis?

The diagnosis of early gastric cancer(EGC) is of great interest because its endoscopic and surgical treatment presents the best chance for a cure.With technical development,endoscopic submucosal dissection(ESD) has been widely performed for the curative treatment of EGC in Korea.Multinational studies of ESD for EGC will be the next missions that overcome these limitations and global guidelines will be processed for ESD for EGC.

Construction and analysis of an ulcer risk prediction model after endoscopic submucosal dissection for early gastric cancer

BACKGROUND Endoscopic submucosal dissection(ESD) has been widely used in the treatment of early gastric cancer(EGC). A personalized and effective prediction method for ESD with EGC is urgently needed.AIM To construct a risk prediction model for ulcers after ESD for EGC based on LASSO regression.METHODS A total of 196 patients with EGC who received ESD treatment were prospectively selected as the research subjects and followed up for one month. They were divided into an ulcer group and a non-ulcer group according to whether ulcers occurred. The general data, pathology, and endoscopic characteristics of the groups were compared, and the best risk predictor subsets were screened by LASSO regression and tenfold cross-validation. Multivariate logistic regression was applied to analyze the risk factors for ulcers after ESD in patients with EGC. A receiver operating characteristic(ROC) curve was used to estimate the predictive model performance.RESULTS One month after the operation, no patient was lost to follow-up. The incidence of ulcers was 20.41%(40/196)(ulcer group), and the incidence of no ulcers was 79.59%(156/196)(non-ulcer group). There were statistically significant differences in the course of disease, Helicobacter pylori infection history, smoking history, tumor number, clopidogrel medication history, lesion diameter, infiltration depth, convergent folds, and mucosal discoloration between the groups. Gray’s medication history, lesion diameter, convergent folds, and mucosal discoloration, which were the 4 nonzero regression coefficients, were screened by LASSO regression analysis. Further multivariate logistic analysis showed that lesion diameter [Odds ratios(OR) = 30.490, 95%CI: 8.584-108.294], convergent folds(OR = 3.860, 95%CI: 1.060-14.055), mucosal discoloration(OR = 3.191, 95%CI: 1.016-10.021), and history of clopidogrel(OR = 3.554, 95%CI: 1.009-12.515) were independent risk factors for ulcers after ESD in patients with EGC(P < 0.05). The ROC curve showed that the area under the curve of the risk prediction model for ulcers after ESD in patients with EGC was 0.944(95%CI: 0.902-0.972).CONCLUSION Clopidogrel medication history, lesion diameter, convergent folds, and mucosal discoloration can predict the occurrence of ulcers after ESD in patients with EGC.

Endoscopic submucosal dissection for early signet ring cell gastric cancer:A systematic review and meta-analysis

BACKGROUND The use of endoscopic submucosal dissection(ESD)for treating early signet ring cell carcinoma(SRC)is controversial due to the risk of lymph node metastasis.AIM To carry out a meta-analysis to evaluate ESD for therapeutic efficacy and safety in early signet ring cell gastric cancer.METHODS The PubMed,Web of Science,Cochrane Library,and EMBASE databases were used to search for relevant studies evaluating the therapeutic efficacy and safety of ESD in SRC.The rates of recurrence,complete resection,incomplete resection,curative resection,en bloc resection,and adverse events were extracted and analyzed.The methodological quality of the enrolled studies was assessed using the Newcastle-Ottawa Scale.Publication bias was evaluated by the Egger’s test.Institutional review board approval and written consent were not needed for this report.RESULTS This meta-analysis enrolled seven studies with 653 participants undergoing ESD treatment for early SRC.The overall recurrence rate was 0.010[95%confidence interval(CI):0.000-0.040,Z=1.422,P=0.155].The total lymph-ovascular invasion rate was 0.038(95%CI:0.007-0.088,Z=3.026,P=0.002).The total en bloc resection rate was estimated at 0.984(95%CI:0.925-1.000,Z=19.463,P=0.000).The total complete and incomplete resection rates were estimated at 0.785(95%CI:0.596-0.928,Z=9.789,P=0.000)and 0.188(95%CI:0.016-0.468,Z=2.531,P=0.011),respectively.The total procedureassociated gastric hemorrhage and perforation rates were estimated at 0.026(95%CI:0.005-0.061,Z=3.006 P=0.003)and 0.004(95%CI:0.000-0.028,Z=0.938,P=0.348),respectively.The curative resection,vertical margin invasion,and lateral margin invasion rates were 72.1%(145/341),2.3%(8/348),and 34.45%(41/119),respectively.CONCLUSION ESD constitutes a promising therapeutic approach for early undifferentiated SRC gastric cancer.However,further improvements are required for increasing its treatment efficacy and reducing adverse outcomes.

Curative resection with endoscopic submucosal dissection of early gastric cancer in Helicobacter pylori-negative Ménétrier’s disease:A case report

BACKGROUND Adult-onset Ménétrier’s disease is strongly associated with Helicobacter pylori(H.pylori)infection and an elevated risk of carcinogenesis.Cases of early-stage gastric cancer developed in H.pylori-negative Ménétrier’s disease are extremely rare.We report a case of early gastric cancer in H.pylori-negative Ménétrier’s disease that was curatively resected with endoscopic submucosal dissection(ESD).CASE SUMMARY A 60-year-old woman was referred to our hospital after her medical examination detected anemia.Contrast-enhanced upper gastrointestinal(UGI)radiography revealed translucency of the nodule-aggregating surface with giant rugae.Blood tests showed hypoproteinemia and were negative for serum H.pylori immunoglobulin G antibodies.The 99mTc-DTPA-human serum albumin scintigraphy showed protein loss from the stomach.UGI endoscopy showed a 40-mm protruding erythematous lesion on giant rugae of the greater curvature of lower gastric body,suggesting early-stage gastric cancer due to Ménétrier’s disease.En bloc resection with ESD was performed for diagnosis and treatment.Histology of ESD showed well-differentiated tubular adenocarcinoma.The cancer was confined to the mucosa,and complete curative resection was achieved.Foveolar hyperplasia and atrophy of the gastric glands were observed in non-tumor areas,histologically corresponding to Ménétrier’s disease.Three years after ESD,gastric cancer had not recurred,and Ménétrier’s disease remained in remission with spontaneous regression of giant gastric rugae.CONCLUSION Complete curative resection was achieved through ESD in a patient with earlystage gastric cancer and H.pylori-negative Ménétrier’s disease.

Animal experimental study on magnetic anchor technique-assisted endoscopic submucosal dissection of early gastric cancer

BACKGROUND Gastric cancer(GC)has high morbidity and mortality.Moreover,because GC has no typical symptoms in the early stages,most cases are already in the advanced stages by the time the symptoms appear,thus resulting in poor prognosis and a low survival rate.Endoscopic submucosal dissection(ESD)can realize the early detection and diagnosis of GC and become the main surgical method for early GC.However,ESD has a steep learning curve and high technical skill requirements for endoscopists,which is not conducive to its widespread implementation and advancement.Therefore,a series of auxiliary techniques have been derived.AIM To evaluate the safety and efficacy of magnetic anchor technique(MAT)-assisted ESD in early GC.METHODS This was an ex vivo animal experiment.The experimental models were the isolated stomachs of pigs,which were divided into two groups,namely the study group(n=6)with MAT-assisted ESD and the control group(n=6)with traditional ESD.Comparing the total surgical time,incidence of surgical complications,complete mucosal resection rate,specimen size,and the scores of endoscopist’s satisfaction with the procedure reflected their feelings about convenience during the surgical procedure between the two groups.The magnetic anchor device for auxiliary ESD in the study group comprised three parts,an anchor magnet(AM),a target magnet(TM),and a soft tissue clip.Under gastroscopic guidance,the soft tissue clip and the TM were delivered to the pre-marked mucosal lesion through the gastroscopic operating hole.The soft tissue clip and the TM were connected by a thin wire through the TM tail structure.The soft tissue clip was released by manipulating the operating handle of the soft tissue clip in a way that the soft tissue clip and the TM were fixed to the lesion mucosa.In vitro,ESD is aided by maneuvering the AM such that the mucosal dissection surface is exposed.RESULTS The total surgical time was shorter in the study group than in the control group(26.57±0.19 vs 29.97±0.28,P<0.001),and the scores of endoscopist’s satisfaction with the procedure were higher in the study group than in the control group(9.53±0.10 vs 8.00±0.22,P<0.001).During the operation in the study group,there was no detachment of the soft tissue clip and TM and no mucosal tearing.The magnetic force between the AM and TM provided good mucosal exposure and sufficient tissue tension for ESD.The mucosal lesion was completely peeled off,and the operation was successful.There were no significant differences in the incidence of surgical complications(100%vs 83.3%),complete mucosal resection rate(100%vs 66.7%,P=0.439),and specimen size(2.44±0.04 cm vs 2.49±0.02,P=0.328)between the two groups.CONCLUSION MAT-ESD is safe and effective for early GC.It provides a preliminary basis for subsequent internal animal experiments and clinical research.