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Sa1486 Long-Term Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer: a Single Center Experience
Abstracts
Sa1485 Risk Factors and Management Strategy for Ulcer Hemorrhage Following Gastric Endoscopic Submucosal Dissection in Patients on Antithrombotic Therapy Toshihisa Takeuchi*, Kazuhiro Ota, Satoshi Harada, Shoko Edogawa, Yuichi Kojima, Satoshi Tokioka, Eiji Umegaki, Kazuhide Higuchi 2nd Dep of Internal Medicine, Osaka Medical Collage, Takatsuki, Japan Background: There is a lack of consensus regarding the risk of postoperative hemorrhage in patients on antithrombotic therapy who undergo highly invasive endoscopic procedures such as endoscopic submucosal dissection (ESD). Aim: We examined postoperative bleeding rates and risk factors for postoperative hemorrhage from post-ESD gastric ulcers in patients on antithrombotic therapy, in a retrospective study. Patients and Methods: The subjects of this study were 833 patients who underwent ESD of gastric tumors. Of these, 743 were not on antithrombotic therapy (NA group), and 90 were on some form of antithrombotic therapy (A group: 46 on low dose aspirin (LDA) only, 23 on LDA ⫹ thienopyridine, and 21 on LDA ⫹ warfarin). Setting the day of the ESD procedure as Day 1, patients were fasted until Day 2, and allowed to eat from Day 3. Proton pump inhibitor (PPI) therapy was commenced on Day 1, and all patients underwent esophagogastroduodenoscopy (EGD) on Day 2 and if necessary, blood vessels in the ulcer base were cauterized. According to the ESD protocol, antiplatelet agents were ceased from Day -6 until Day 2, and anticoagulants from Day -4 until Day 2, with heparin substituted for warfarin while the latter was ceased. We examined postoperative bleeding rates in the NA and A groups, and risk factors for postoperative hemorrhage in the A group. Results: The postoperative bleeding rate in the A group was 23.3% (21/90), significantly higher than that of 2.0% (15/743) in the NA group (p⬍0.001). Significant differences were seen in patients in the A group with and without postoperative bleeding according to ESD duration, PPI ⫹ mucosal protective agent combination therapy, and LDA ⫹ warfarin combination therapy (p⬍0.05). Multivariate analysis of these factors yielded odds ratios of 1.04 for ESD duration, 14.83 for LDA ⫹ warfarin combination therapy, and 0.27 for PPI ⫹ mucosal protective agent combination therapy. Conclusions: Our results indicate that the risk of postoperative hemorrhage following gastric ESD in patients on antiplatelet therapy is greater than in those not on antiplatelet therapy. In partiicualr, LDA ⫹ warfarin combination therapy was an extremely strong risk factor for postoperative bleeding. Our results also suggest that PPI monotherapy is inadequate for the treatment of post-ESD ulcers, including the prevention of postoperative bleeding, but the addition of a mucosal protective agent may be effective in reducing the risk of post-ESD bleeding.
Sa1486 Long-Term Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer: a Single Center Experience Dong Hoon Baek*, Gwang HA Kim, Geun Am Song, Dong UK Kim, Dong Yup Ryu, Bong Eun Lee, Tae Kyun Kim Internal Medicine, Gastroenterology, Pusan National University Hospital, Busan, Republic of Korea Background and Aims: Endoscopic submucosal dissection (ESD) has been widely accepted for treatment of early gastric cancer (EGC) in Korea. But longterm clinical outcomes of ESD for EGC remain unknown. The aim of the present study was to evaluate tumor recurrence and survival after ESD. Patients and Methods: From January 2006 to December 2010, a total of 631 EGCs in 621 consecutive patients were treated by ESD in our hospital. 515 patients with 522 EGCs that met the following criteria, which are all differentiated adenocarcinoma and with no lymphovascular invasion, were enrolled: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings ⱕ3 cm in diameter; and minute submucosal invasive cancer ⱕ3 cm in size. Resectability (en bloc or piecemeal resection), curability (curative or noncurative), complications, local tumor recurrence, overall and disease-specific survival rates were assessed. All lesions were divided into 2 groups: mucosal cancer without ulcer ⱕ2 cm in size (standard group); cancer that did not meet standard guideline criteria (expanded group). Results: En bloc and curative resection rates were achieved in 96.7% (505/522) and 88.3% (461/522), respectively. During a median endoscopic follow-up of 24 months (range 1-74 months), local recurrence of the cancers was four (1.8%) and eight (7.0%) in the standard and expanded group, respectively; the difference between the groups was significant (p ⫽ 0.025). Local recurrence rate was significantly related to curative resection, but not en bloc resection. The 5-year overall and disease specific survival rates were 88% and 100%, respectively; the difference between the standard and expanded group was not significant.Conculsions: Although a risk for local recurrence remains, ESD for EGC in both the standard and expanded criteria is a feasible and promising management. Close follow-up surveillance after ESD should be taken especially in non-curative resection.
www.giejournal.org
Sa1487 Clinical Outcomes of Endoscopic Submucosal Dissection for Undifferentiated Early Gastric Cancer: Single Center Experiences in Korea Chan Hyuk Park*, Suji Shin, Hyuk Lee, Jun Chul Park, Sung Kwan Shin, Yong Chan Lee, Sang Kil Lee Department of internal medicine, Yonsei University College of Medicine, Seoul, Republic of Korea Background: Expanded criteria of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) have been proposed. It, however, remains controversial whether ESD method for undifferentiated EGC is safe. Patients and Methods: We prospectively collected clinical data of 1,152 patients with 1,175 lesions who had undergone ESD for EGC at our tertiary educational hospital in Seoul, Korea, between March 2005 and November 2011. Of these, 105 patients had an undifferentiated EGC which fulfilled the expanded criteria endoscopically. Results: Of total 105 lesions enrolled in this study, 32 lesions (30.5%) were poorly-differentiated type, and the other 73 lesions (69.5%) were signet ring cell carcinomas. En bloc, complete, and curative resection rate were 91.4%, 79.0%, and 69.5%, respectively. Bleeding and perforation developed in 3 (2.9%) and 4 lesions (3.8%), respectively. Ninety (85.7%) lesions were histologically proven as undifferentiated EGCs after ESD. All lesions were considered that they were met the expanded criteria of ESD before the procedure, but submucosal invasion, large size cancer over 20 mm, and ulceration were identified in 12 (11.4%), 16 (15.2%), and 1 (1.0%) lesion, respectively, through the pathologic evaluation using ESD specimen. Lateral- and vertical-cut end-positive, and lymphovascular invasion also detected in 19 (18.1%), 5 (4.8%), and 2 (1.9%) lesions, respectively. Seventeen (16.2%) and 6 patients (5.7%) underwent surgery and argon plasma coagulation, respectively, as an additional treatment for non-curative resection. Of 43 lesions whose follow-up periods were 2 or more years, residual disease, synchronous lesion, and metachronous lesion developed in each 1 lesion, respectively. These recurred lesions were treated with additional ESD or surgery, and they have not shown further recurrences since secondary treatments were performed. Conclusions: ESD for undifferentiated EGC on expanded criteria may be feasible, but more long-term follow-up data are needed.
Sa1488 A Retrospective Review of Self-Expandable Metallic Stents and Gastrojejunostomy for Malignant Gastric Outlet Obstruction Atsushi Kubo*, Etsuji Ishida, Tsukasa Yoshida, Yoshie Kiyosuke, Kazuhiro Matsueda, Hiroshi Yamamoto Gastroenterology, Kurashiki Central Hospital, Kurashiki, Japan Background: Self-expandable metallic stent (SEMS) placement is performed as an alternative to gastrojejunostomy (GJ) for the palliation of malignant gastric outlet obstruction (GOO). Clinical outcomes and adverse events are still unclear. In order to assess the clinical outcomes of SEMS placement and GJ, we conducted a retrospective review according to improvement in oral intake (based on the GOO scoring system [GOOSS]), survival time, resumption of chemotherapy, and
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB223
Sa1485 Risk Factors and Management Strategy for Ulcer Hemorrhage Following Gastric Endoscopic Submucosal Dissection in Patients on Antithrombotic Therapy Toshihisa Takeuchi*, Kazuhiro Ota, Satoshi Harada, Shoko Edogawa, Yuichi Kojima, Satoshi Tokioka, Eiji Umegaki, Kazuhide Higuchi 2nd Dep of Internal Medicine, Osaka Medical Collage, Takatsuki, Japan Background: There is a lack of consensus regarding the risk of postoperative hemorrhage in patients on antithrombotic therapy who undergo highly invasive endoscopic procedures such as endoscopic submucosal dissection (ESD). Aim: We examined postoperative bleeding rates and risk factors for postoperative hemorrhage from post-ESD gastric ulcers in patients on antithrombotic therapy, in a retrospective study. Patients and Methods: The subjects of this study were 833 patients who underwent ESD of gastric tumors. Of these, 743 were not on antithrombotic therapy (NA group), and 90 were on some form of antithrombotic therapy (A group: 46 on low dose aspirin (LDA) only, 23 on LDA ⫹ thienopyridine, and 21 on LDA ⫹ warfarin). Setting the day of the ESD procedure as Day 1, patients were fasted until Day 2, and allowed to eat from Day 3. Proton pump inhibitor (PPI) therapy was commenced on Day 1, and all patients underwent esophagogastroduodenoscopy (EGD) on Day 2 and if necessary, blood vessels in the ulcer base were cauterized. According to the ESD protocol, antiplatelet agents were ceased from Day -6 until Day 2, and anticoagulants from Day -4 until Day 2, with heparin substituted for warfarin while the latter was ceased. We examined postoperative bleeding rates in the NA and A groups, and risk factors for postoperative hemorrhage in the A group. Results: The postoperative bleeding rate in the A group was 23.3% (21/90), significantly higher than that of 2.0% (15/743) in the NA group (p⬍0.001). Significant differences were seen in patients in the A group with and without postoperative bleeding according to ESD duration, PPI ⫹ mucosal protective agent combination therapy, and LDA ⫹ warfarin combination therapy (p⬍0.05). Multivariate analysis of these factors yielded odds ratios of 1.04 for ESD duration, 14.83 for LDA ⫹ warfarin combination therapy, and 0.27 for PPI ⫹ mucosal protective agent combination therapy. Conclusions: Our results indicate that the risk of postoperative hemorrhage following gastric ESD in patients on antiplatelet therapy is greater than in those not on antiplatelet therapy. In partiicualr, LDA ⫹ warfarin combination therapy was an extremely strong risk factor for postoperative bleeding. Our results also suggest that PPI monotherapy is inadequate for the treatment of post-ESD ulcers, including the prevention of postoperative bleeding, but the addition of a mucosal protective agent may be effective in reducing the risk of post-ESD bleeding.
Sa1486 Long-Term Outcomes of Endoscopic Submucosal Dissection for Early Gastric Cancer: a Single Center Experience Dong Hoon Baek*, Gwang HA Kim, Geun Am Song, Dong UK Kim, Dong Yup Ryu, Bong Eun Lee, Tae Kyun Kim Internal Medicine, Gastroenterology, Pusan National University Hospital, Busan, Republic of Korea Background and Aims: Endoscopic submucosal dissection (ESD) has been widely accepted for treatment of early gastric cancer (EGC) in Korea. But longterm clinical outcomes of ESD for EGC remain unknown. The aim of the present study was to evaluate tumor recurrence and survival after ESD. Patients and Methods: From January 2006 to December 2010, a total of 631 EGCs in 621 consecutive patients were treated by ESD in our hospital. 515 patients with 522 EGCs that met the following criteria, which are all differentiated adenocarcinoma and with no lymphovascular invasion, were enrolled: mucosal cancer without ulcer findings irrespective of tumor size; mucosal cancer with ulcer findings ⱕ3 cm in diameter; and minute submucosal invasive cancer ⱕ3 cm in size. Resectability (en bloc or piecemeal resection), curability (curative or noncurative), complications, local tumor recurrence, overall and disease-specific survival rates were assessed. All lesions were divided into 2 groups: mucosal cancer without ulcer ⱕ2 cm in size (standard group); cancer that did not meet standard guideline criteria (expanded group). Results: En bloc and curative resection rates were achieved in 96.7% (505/522) and 88.3% (461/522), respectively. During a median endoscopic follow-up of 24 months (range 1-74 months), local recurrence of the cancers was four (1.8%) and eight (7.0%) in the standard and expanded group, respectively; the difference between the groups was significant (p ⫽ 0.025). Local recurrence rate was significantly related to curative resection, but not en bloc resection. The 5-year overall and disease specific survival rates were 88% and 100%, respectively; the difference between the standard and expanded group was not significant.Conculsions: Although a risk for local recurrence remains, ESD for EGC in both the standard and expanded criteria is a feasible and promising management. Close follow-up surveillance after ESD should be taken especially in non-curative resection.
www.giejournal.org
Sa1487 Clinical Outcomes of Endoscopic Submucosal Dissection for Undifferentiated Early Gastric Cancer: Single Center Experiences in Korea Chan Hyuk Park*, Suji Shin, Hyuk Lee, Jun Chul Park, Sung Kwan Shin, Yong Chan Lee, Sang Kil Lee Department of internal medicine, Yonsei University College of Medicine, Seoul, Republic of Korea Background: Expanded criteria of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) have been proposed. It, however, remains controversial whether ESD method for undifferentiated EGC is safe. Patients and Methods: We prospectively collected clinical data of 1,152 patients with 1,175 lesions who had undergone ESD for EGC at our tertiary educational hospital in Seoul, Korea, between March 2005 and November 2011. Of these, 105 patients had an undifferentiated EGC which fulfilled the expanded criteria endoscopically. Results: Of total 105 lesions enrolled in this study, 32 lesions (30.5%) were poorly-differentiated type, and the other 73 lesions (69.5%) were signet ring cell carcinomas. En bloc, complete, and curative resection rate were 91.4%, 79.0%, and 69.5%, respectively. Bleeding and perforation developed in 3 (2.9%) and 4 lesions (3.8%), respectively. Ninety (85.7%) lesions were histologically proven as undifferentiated EGCs after ESD. All lesions were considered that they were met the expanded criteria of ESD before the procedure, but submucosal invasion, large size cancer over 20 mm, and ulceration were identified in 12 (11.4%), 16 (15.2%), and 1 (1.0%) lesion, respectively, through the pathologic evaluation using ESD specimen. Lateral- and vertical-cut end-positive, and lymphovascular invasion also detected in 19 (18.1%), 5 (4.8%), and 2 (1.9%) lesions, respectively. Seventeen (16.2%) and 6 patients (5.7%) underwent surgery and argon plasma coagulation, respectively, as an additional treatment for non-curative resection. Of 43 lesions whose follow-up periods were 2 or more years, residual disease, synchronous lesion, and metachronous lesion developed in each 1 lesion, respectively. These recurred lesions were treated with additional ESD or surgery, and they have not shown further recurrences since secondary treatments were performed. Conclusions: ESD for undifferentiated EGC on expanded criteria may be feasible, but more long-term follow-up data are needed.
Sa1488 A Retrospective Review of Self-Expandable Metallic Stents and Gastrojejunostomy for Malignant Gastric Outlet Obstruction Atsushi Kubo*, Etsuji Ishida, Tsukasa Yoshida, Yoshie Kiyosuke, Kazuhiro Matsueda, Hiroshi Yamamoto Gastroenterology, Kurashiki Central Hospital, Kurashiki, Japan Background: Self-expandable metallic stent (SEMS) placement is performed as an alternative to gastrojejunostomy (GJ) for the palliation of malignant gastric outlet obstruction (GOO). Clinical outcomes and adverse events are still unclear. In order to assess the clinical outcomes of SEMS placement and GJ, we conducted a retrospective review according to improvement in oral intake (based on the GOO scoring system [GOOSS]), survival time, resumption of chemotherapy, and
Volume 77, No. 5S : 2013
GASTROINTESTINAL ENDOSCOPY
AB223