Repeat endoscopic submucosal dissection for recurrent gastric cancers after endoscopic submucosal dissection

Abstract

AIM:To clarify the safety and efficacy of repeat endoscopic submucosal dissection (re-ESD) for locally recurrent gastric cancers after ESD. METHODS:A retrospective evaluation was performed of the therapeutic efficacy, complications and followup results from ESD treatment for early gastric cancers in 521 consecutive patients with 616 lesions at St. Luke`s International Hospital between April 2004 and November 2012. In addition, tumor size, the size of resected specimens and the operation time were compared between re-ESD and initial ESD procedures. A flex knife was used as the primary surgical device and a hook knife was used in cases with severe fibrosis in the submucosal layer. Continuous variables were analyzed using the non-parametric Mann-Whitney U test and are expressed as medians (range). Categorical variables were analyzed using a Fisher's exact test and are reported as proportions. Statistical significance was defined as a P -value less than 0.05. RESULTS:The number of cases in the re-ESD group and the initial ESD group were 5 and 611, respectively. The median time interval from the initial ESD to re-ESD was 14 (range, 4-44 mo). En bloc resection with free lateral and vertical margins was successfully performed in all re-ESD cases without any complications. No local or distant recurrence was observed during the median follow-up period of 48 (range, 11-56 mo). Tumor size was not significantly different between the re-ESD group and the initial ESD group (median 22 mm vs 11 mm, P = 0.09), although the size of resected specimens was significantly larger in the re-ESD group (median 47 mm vs 34 mm, P < 0.05). There was a nonsignificant increase observed in re-ESD operation time compared to initial ESD (median 202 min vs 67 min, respectively, P = 0.06). CONCLUSION:Despite the low patient number and short follow-up, the results suggest that re-ESD is a safe and effective endoscopic treatment for recurrent gastric cancer after ESD.© 2013 Baishideng Publishing Group Co., Limited. All rights reserved.Key words: Endoscopic submucosal dissection; Recurrent gastric cancer; Gastric cancer; Endoscopic mucosal resection; Therapeutic endoscopy Core tip: Although endoscopic submucosal dissection (ESD) is widely accepted as one of the standard treatments for early gastric cancers, there are few reports on re-ESD in the literature. This study clarifies that re-ESD is a safe and effective endoscopic treatment for locally recurrent gastric cancers after ESD.

Secondary endoscopic submucosal dissection for locally recurrent or incompletely resected gastric neoplasms

“…However, secondary ESD should be performed by an experienced endoscopist with precautions, including the appropriate electrosurgical knife, the appropriate dissection depth, and the careful gradual dissection of the severe fibrotic tissue along the plane of the deep submucosa or superficial proper muscle. Furthermore, the surrounding non-fibrotic tissue should first be dissected sufficiently to make a flap of the specimen and directly visualize the plane of the submucosa from the non-lifting fibrotic area to the fibrotic area[ 27 , 28 ]. Therefore, in this study, we found that the specimen size of the secondary ESD group was significantly larger than the primary ESD group.…”

Management of early gastric cancer with positive horizontal or indeterminable margins after endoscopic submucosal dissection: multicenter survey

“…In addition, there were no complications in the late re-ESD group. Because locally recurrent cancers were within the mucosal layer and ESD is less invasive than gastrectomy, ESD may be considered a more suitable additional treatment for locally recurrent lesions, as suggested in previous reports 7 8 9 .…”

“…ESD is currently performed worldwide because neoplasms can be resected en bloc , and a detailed pathological assessment of resected specimens can be performed 1 2 . However, positive horizontal margins in the resected specimens are sometimes encountered after ESD 1 2 3 4 5 6 7 8 9 . Nevertheless, appropriate treatment strategies for differentiated-type gastric cancers with positive horizontal or indeterminable margins after ESD have not yet been established ( Fig.…”

Concomitant stromal tumor and early cancer of the stomach

“…Occurrence of metachronous EGC lesions was observed in the ESD group only (3/14, 21.3%). Similar to previous studies, [ 33 , 34 ] the rate of metachronous GC is higher in our ESD group than the surgery group. The higher rate in the ESD group may be related to the larger remaining gastric mucosa area in the distal part of the stomach, which may have persistent helicobacter pylori infection [ 35 ] and more severe glandular atrophy or intestinal metaplasia.…”