Outcome of endoscopic submucosal dissection for gastric neoplasm in relationship to endoscopic classification of submucosal fibrosis

Abstract

Background Whether submucosal fibrosis is related to ulceration and affects the outcome of endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) is unknown. This study aimed to determine ESD outcome in relationship to degree of submucosal fibrosis of gastric epithelial neoplasms and to identify factors predictive of submucosal fibrosis. Methods Eight hundred ninety-one patients with 1,027 gastric epithelial neoplasms were treated by ESD from April 2005 to January 2011. Complete en bloc resection and perforation rates in relationship to degree of submucosal fibrosis (F0, no fibrosis; F1; mild fibrosis; F2, severe fibrosis) were determined during ESD, as well as degree of concordance between endoscopically observed ulceration and pathologically determined ulceration and pathological fibrosis stained with Masson's trichrome. Results The complete en bloc resection rate was significantly low and the perforation rate was high for F2 versus F0/F1 tumors. Ulceration, tumor size C30 mm, and depressed histological type were independent risk factors for severe (F2) fibrosis. No fibrosis (F0) was observed in 77 % (732/951) of endoscopically negative ulceration cases, whereas fibrosis was observed in 100 % (76/76) of endoscopically positive cases. Masson trichrome staining was weak in 97 % (710/732) of F0, moderate in 85 % (181/ 214) of F1, and strong in 100 % (81/81) of F2 cases. Conclusions Histopathological type of submucosal fibrosis predicts outcome of ESD for EGC. Endoscopic indications of F2 submucosal fibrosis are ulceration, tumor C30 mm, and macroscopic depression.

Therapeutic outcomes of endoscopic submucosal dissection of differentiated early gastric cancer in a Western endoscopy setting (with video)

“…45 A large ESD series has reported SM fibrosis in 20% of the cases with mild F1 and severe F2 in 62% and 38% of those cases, respectively. 29 Similarly, our study revealed SM fibrosis in 24% of the cases with F2 cases accounting for 10 (77%) of the total number of 13 SM fibrosis cases probably due to aggressive or bite-on-bite preoperative biopsy 44 as well as the inclusion of 2 local recurrence cases. Currently, there are no preoperative methods for ascertaining fibrosis, so future studies to establish and evaluate techniques for identifying SM fibrosis would be highly beneficial.…”

Effects of administration of a proton pump inhibitor before endoscopic submucosal dissection for differentiated early gastric cancer with ulcer

“…A previous study reported that the presence of ulceration was associated with a long procedure time [7]. The presence of endoscopic ulceration was associated with submucosal fibrosis, and the fibrosis or inflammation caused by ulceration made it more difficult to lift the tumor tissue from the muscle layer, lengthening the procedure time [17,18]. We speculate that PPI administration improved inflammation, made it easier to dissect the submucosa, and thereby shortened the procedure time.…”

“…Finally, the presence of ulceration was determined only by endoscopic findings without pathologic confirmation. However, concordance between the two methods of identifying ulceration was 99 % in a previous study [17]. Therefore, ulceration can be diagnosed solely on the basis of endoscopic examination.…”

Comparisons of the Mucosal Healing Process between Flat and Protruded Type after Endoscopic Submucosal Dissection for Gastric Neoplasms

“…Lesions with < 2.5 mm elevation were classified as flat type scars and those with ≥2.5 mm were protruded type scars. Submucosal fibrosis was defined when no blue transparent layer appears in the submucosal layer and when the submucosal layer could not be easily separated from the whitish muscular area during lesion dissection [7].…”