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Mo1251 Clinical Characteristics and Management of Delayed Perforation Occurring After Endoscopic Submucosal Dissection for Early Gastric Cancer
Abstracts
dysplasia, between July 2006, and July 2010, and observed for⬎1 year were included. Patients previously treated with subtotal gastrectomy were excluded. EMR and ESD were performed in 196 (77.8%) and 56 (22.2%) patients, respectively. EGD was performed at follow-up at 3,6,and 12 months after endoscopic treatment. Results: Unevaluable resection margins were more frequently reported in patients treated with EMR (12.8%) than in those treated with ESD (1.8%) (P⫽0.017). En bloc resection rate was significantly lower in EMR (31.1%) than in ESD (75.0%) (P⬍0.001). However, no significant difference was observed in remnant lesions and recurrence rates of gastric adenoma. Complication risks, such as bleeding and stricture, were higher in ESD (2%) than in EMR (10.7%) (P ⫽ 0.003). Moreover,the procedure time was longer with ESD (43.1 ⫾ 23.7 min) than with EMR (10.8 ⫾ 13.4 min) (P⫽0.001). Progression of LGD to HGD or EGC increased in tumor lesions ⬎1cm with surface redness and depressions. Conclusion: In the case of LGD, EMR showed increased incidences of uncertain resection margins and low en bloc resection rates compared with ESD.However, no significant difference in recurrence rates was observed during the follow-up period. When endoscopic follow-up examination is possible, EMR can be an effective therapeutic option for non-depressed LGD ⬍1cm without surface redness. 1. Comparisions of endoscopic characteristics according Vienna classification Categories 1-3 (nⴝ202) Age (years) Mean ⫾ SD Range Gender(%) Male Female Longitudinal location Antrum Angle High Body Middle body Lower body Cardia or fundus Circular location Anterior Posterior Lesser curvature Greater curvature Gross type Y-III,Y-IV Elevation Flat Depressed Color change Whitish Mixed Redness Ulceration No Yes Nodular change No Yes Recurrance rate No Yes Tumor size (cm) Mean ⫾ SD Range Resection size (cm) Mean ⫾ SD Range Reseciton time (min) Mean ⫾ SD Range Lesion size ⱕ1.0cm ⬎1.0cm Resection margin Negative Uncertain Positive
Categories 4-5 (nⴝ50)
p
62.5 ⫾ 8.5 40-80
63.5 ⫾ 8.7 44-79
0.488†
14 (70.8%) 59 (29.2%)
36 (72.0%) 14 (28.0%)
0.866‡
104 (51.5%) 20 (9.9%) 7 (3.5%) 20 (9.9%) 50 (24.8%) 1 (0.5%)
26 (52.0%) 12 (24%) 1 (2%) 2 (4%) 9 (18%) 0
53 (26.2%) 32 (15.8%) 76 (37.6%) 40 (19.8%)
14 (28%) 11 (22%) 17 (34%) 8 (16%)
4 (2%) 106 (52.5%) 77 (38.1%) 15 (7.4%)
2 (4%) 20 (40%) 15 (30%) 13 (26%)
0.122§
0.325‡
0.003§
⬍0.001‡ 143 (70.8%) 34 (16.8%) 25 (12.4%)
24 (48%) 8 (16%) 18 (36%)
199 (98.5%) 3 (1.5%)
46 (92%) 4 (8%)
156 (77.2%) 46 (22.8%)
35 (70%) 15 (30%)
197 (97.5%) 5 (2.5%)
49 (98%) 1 (2%)
1.15 ⫾ 0.7 0.3-4.5
1.52 ⫾ 1.1 0.5-6.5
2.28 ⫾ 0.97 0.5-6
2.78 ⫾ 1.2 1-7
15.9 ⫾ 18.4 2-105
15.9 ⫾ 18.4 3-137
120 (59.4%) 82 (40.6%)
21 (42%) 82 (40.6%)
181 (89.6%) 20 (9.9%) 1 (0.5%)
44 (88%) 20 (9.9%) 0
0.03§
0.285‡
0.844§
0.03†
0.03†
0.002†
0.038‡
Table 2. Comparisions of Clinical factors according to Endoscopic procedure
Age (years) Mean ⫾ SD Gender (%) Male Female Day to Procedure (day) Mean ⫾ SD Tumor lesion (cm) Mean ⫾ SD Resection specimen (cm) Mean ⫾ SD Resection margin Negative Unable to evaluate Positive Reseciton time (minute) Mean ⫾ SD En bloc resection Complication Non Early bleeding Delayed bleeding Microperforation Striucture Follow up duration (day) Mean ⫾ SD Recurrence rate
EMR (nⴝ196)
ESD (nⴝ56)
p
63.0 ⫾ 8.5
61.5 ⫾ 8.7
0.26¶
143 (73.0%) 53 (27.0%)
36 (64.3%) 20 (35.7%)
0.207‡
35.2 ⫾ 36.2
40.9 ⫾ 36.5
0.302¶
1.09 ⫾ 0.68
1.68 ⫾ 1.03
⬍0.001†
2.11 ⫾ 0.85
3.33 ⫾ 1.06
⬍0.001†
170 (86.7%) 25 (12.8%) 1 (0.5%)
55 (98.2%) 1 (1.8%) 0
0.017‡
10.8 ⫾ 13.4
43.1 ⫾ 23.7
⬍0.001†
61 (31.1%) 192 (98%) 1 (0.5%) 2 (1%) 0 1 (0.5%)
42 (75.0%) 50 (75%) 5 (8.9%) 1 (1.8%) 0 0
⬍0.001‡ 0.003‡
742 ⫾ 274 5 (2.6%)
788 ⫾ 307 1 (1.8%)
0.315¶ 0.911‡
Mo1251 Clinical Characteristics and Management of Delayed Perforation Occurring After Endoscopic Submucosal Dissection for Early Gastric Cancer Hisaaki Kita*, Tomoki Michida, Kazuhiro Murai, Yuto Shiode, Hisashi Jo, Yugo Kai, Yuki Matsumura, Rie Morita, Risato Takeda, Tamiko Saito, Tomoyo Kanno, Yuki Nakada, Miho Chiba, Kosaku Maeda, Masafumi Naito, Toshifumi Ito Internal Medicine, Osaka Koseinenkin Hospital, Osaka, Japan Introduction: Delayed perforation occurring after endoscopic submucosal dissection (ESD) is a serious complication which might require emergent surgery. We recently reported a case of delayed perforation subsequent to ESD procedure (Gastric Cancer, in press). However, there have been a few reports of the delayed perforation. Aims and Methods: We aimed to clarify characteristics of delayed perforation. ESD was performed in 1140 patients with early gastric cancer from November 2001 to October 2011. Delayed perforation was defined as a perforation recognized after ESD. Usually we prospectively deal with perforations caused by ESD using a manual, in which they are classified into two types, mild and severe, mainly depending on their endoscopic closure with clipping and fasting period was determined according to the type. The delayed perforation was prospectively managed as the severe type of perforations, so that oral intake started 4 days after ESD in principle. Results: Delayed perforation occurred in 6 patients (0.5%). It was diagnosed within 2 days after ESD without peritoneal irritation sign, by routine endoscopic examination on the next day after ESD in 4 patients and by X-ray examination followed by fever or abdominal pain in the rest. The diameter of the perforations was within 5mm in size, and their shape was round and the color of the surrounding muscle layer had become whitish suggesting that necrosis of the muscle layer might be related to the mechanism. Five perforations were closed with clipping endoscopically whereas one patient without closure was treated only by fasting. All 6 patients were conservatively managed. The median of fasting period and hospitalization after ESD was 6 days (2-12 days) and 11 days (7-25 days), respectively. Conclusion: Delayed perforation occurred less than 1% of the patients and its shape was different from that of usual perforations during ESD. It could be managed with fasting and endoscopical clipping if it is found before oral intake and is enough small to be closed endoscopically.
0.69§
†:Unparied t test, ‡: person k squre, §:Fisher’s test.
AB365 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
dysplasia, between July 2006, and July 2010, and observed for⬎1 year were included. Patients previously treated with subtotal gastrectomy were excluded. EMR and ESD were performed in 196 (77.8%) and 56 (22.2%) patients, respectively. EGD was performed at follow-up at 3,6,and 12 months after endoscopic treatment. Results: Unevaluable resection margins were more frequently reported in patients treated with EMR (12.8%) than in those treated with ESD (1.8%) (P⫽0.017). En bloc resection rate was significantly lower in EMR (31.1%) than in ESD (75.0%) (P⬍0.001). However, no significant difference was observed in remnant lesions and recurrence rates of gastric adenoma. Complication risks, such as bleeding and stricture, were higher in ESD (2%) than in EMR (10.7%) (P ⫽ 0.003). Moreover,the procedure time was longer with ESD (43.1 ⫾ 23.7 min) than with EMR (10.8 ⫾ 13.4 min) (P⫽0.001). Progression of LGD to HGD or EGC increased in tumor lesions ⬎1cm with surface redness and depressions. Conclusion: In the case of LGD, EMR showed increased incidences of uncertain resection margins and low en bloc resection rates compared with ESD.However, no significant difference in recurrence rates was observed during the follow-up period. When endoscopic follow-up examination is possible, EMR can be an effective therapeutic option for non-depressed LGD ⬍1cm without surface redness. 1. Comparisions of endoscopic characteristics according Vienna classification Categories 1-3 (nⴝ202) Age (years) Mean ⫾ SD Range Gender(%) Male Female Longitudinal location Antrum Angle High Body Middle body Lower body Cardia or fundus Circular location Anterior Posterior Lesser curvature Greater curvature Gross type Y-III,Y-IV Elevation Flat Depressed Color change Whitish Mixed Redness Ulceration No Yes Nodular change No Yes Recurrance rate No Yes Tumor size (cm) Mean ⫾ SD Range Resection size (cm) Mean ⫾ SD Range Reseciton time (min) Mean ⫾ SD Range Lesion size ⱕ1.0cm ⬎1.0cm Resection margin Negative Uncertain Positive
Categories 4-5 (nⴝ50)
p
62.5 ⫾ 8.5 40-80
63.5 ⫾ 8.7 44-79
0.488†
14 (70.8%) 59 (29.2%)
36 (72.0%) 14 (28.0%)
0.866‡
104 (51.5%) 20 (9.9%) 7 (3.5%) 20 (9.9%) 50 (24.8%) 1 (0.5%)
26 (52.0%) 12 (24%) 1 (2%) 2 (4%) 9 (18%) 0
53 (26.2%) 32 (15.8%) 76 (37.6%) 40 (19.8%)
14 (28%) 11 (22%) 17 (34%) 8 (16%)
4 (2%) 106 (52.5%) 77 (38.1%) 15 (7.4%)
2 (4%) 20 (40%) 15 (30%) 13 (26%)
0.122§
0.325‡
0.003§
⬍0.001‡ 143 (70.8%) 34 (16.8%) 25 (12.4%)
24 (48%) 8 (16%) 18 (36%)
199 (98.5%) 3 (1.5%)
46 (92%) 4 (8%)
156 (77.2%) 46 (22.8%)
35 (70%) 15 (30%)
197 (97.5%) 5 (2.5%)
49 (98%) 1 (2%)
1.15 ⫾ 0.7 0.3-4.5
1.52 ⫾ 1.1 0.5-6.5
2.28 ⫾ 0.97 0.5-6
2.78 ⫾ 1.2 1-7
15.9 ⫾ 18.4 2-105
15.9 ⫾ 18.4 3-137
120 (59.4%) 82 (40.6%)
21 (42%) 82 (40.6%)
181 (89.6%) 20 (9.9%) 1 (0.5%)
44 (88%) 20 (9.9%) 0
0.03§
0.285‡
0.844§
0.03†
0.03†
0.002†
0.038‡
Table 2. Comparisions of Clinical factors according to Endoscopic procedure
Age (years) Mean ⫾ SD Gender (%) Male Female Day to Procedure (day) Mean ⫾ SD Tumor lesion (cm) Mean ⫾ SD Resection specimen (cm) Mean ⫾ SD Resection margin Negative Unable to evaluate Positive Reseciton time (minute) Mean ⫾ SD En bloc resection Complication Non Early bleeding Delayed bleeding Microperforation Striucture Follow up duration (day) Mean ⫾ SD Recurrence rate
EMR (nⴝ196)
ESD (nⴝ56)
p
63.0 ⫾ 8.5
61.5 ⫾ 8.7
0.26¶
143 (73.0%) 53 (27.0%)
36 (64.3%) 20 (35.7%)
0.207‡
35.2 ⫾ 36.2
40.9 ⫾ 36.5
0.302¶
1.09 ⫾ 0.68
1.68 ⫾ 1.03
⬍0.001†
2.11 ⫾ 0.85
3.33 ⫾ 1.06
⬍0.001†
170 (86.7%) 25 (12.8%) 1 (0.5%)
55 (98.2%) 1 (1.8%) 0
0.017‡
10.8 ⫾ 13.4
43.1 ⫾ 23.7
⬍0.001†
61 (31.1%) 192 (98%) 1 (0.5%) 2 (1%) 0 1 (0.5%)
42 (75.0%) 50 (75%) 5 (8.9%) 1 (1.8%) 0 0
⬍0.001‡ 0.003‡
742 ⫾ 274 5 (2.6%)
788 ⫾ 307 1 (1.8%)
0.315¶ 0.911‡
Mo1251 Clinical Characteristics and Management of Delayed Perforation Occurring After Endoscopic Submucosal Dissection for Early Gastric Cancer Hisaaki Kita*, Tomoki Michida, Kazuhiro Murai, Yuto Shiode, Hisashi Jo, Yugo Kai, Yuki Matsumura, Rie Morita, Risato Takeda, Tamiko Saito, Tomoyo Kanno, Yuki Nakada, Miho Chiba, Kosaku Maeda, Masafumi Naito, Toshifumi Ito Internal Medicine, Osaka Koseinenkin Hospital, Osaka, Japan Introduction: Delayed perforation occurring after endoscopic submucosal dissection (ESD) is a serious complication which might require emergent surgery. We recently reported a case of delayed perforation subsequent to ESD procedure (Gastric Cancer, in press). However, there have been a few reports of the delayed perforation. Aims and Methods: We aimed to clarify characteristics of delayed perforation. ESD was performed in 1140 patients with early gastric cancer from November 2001 to October 2011. Delayed perforation was defined as a perforation recognized after ESD. Usually we prospectively deal with perforations caused by ESD using a manual, in which they are classified into two types, mild and severe, mainly depending on their endoscopic closure with clipping and fasting period was determined according to the type. The delayed perforation was prospectively managed as the severe type of perforations, so that oral intake started 4 days after ESD in principle. Results: Delayed perforation occurred in 6 patients (0.5%). It was diagnosed within 2 days after ESD without peritoneal irritation sign, by routine endoscopic examination on the next day after ESD in 4 patients and by X-ray examination followed by fever or abdominal pain in the rest. The diameter of the perforations was within 5mm in size, and their shape was round and the color of the surrounding muscle layer had become whitish suggesting that necrosis of the muscle layer might be related to the mechanism. Five perforations were closed with clipping endoscopically whereas one patient without closure was treated only by fasting. All 6 patients were conservatively managed. The median of fasting period and hospitalization after ESD was 6 days (2-12 days) and 11 days (7-25 days), respectively. Conclusion: Delayed perforation occurred less than 1% of the patients and its shape was different from that of usual perforations during ESD. It could be managed with fasting and endoscopical clipping if it is found before oral intake and is enough small to be closed endoscopically.
0.69§
†:Unparied t test, ‡: person k squre, §:Fisher’s test.
AB365 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org