Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD

127

107

Section: Discussionsupporting

confidence: 87%

Section: Discussionmentioning

confidence: 83%

Short‐term outcomes of multicenter prospective cohort study of gastric endoscopic resection: ‘Real‐world evidence’ in Japan

Suzuki

Takizawa

Hirasawa

et al. 2018

127

107

“…Among a total of 18 articles identified, the perforation rate was 3.02% (512/16 941) and 98.8% of patients (506/512) recovered without surgical intervention . Risk factors for intraoperative perforation during gastric ESD are listed in Table .…”

Section: Adverse Events Related To Gastric Esdmentioning

confidence: 99%

“…For location, upper third, middle third,greater curvature and remnant stomach, were reported to be high‐risk areas for intraoperative perforation. Other risk factors included tumor size, invasion depth,submucosal fibrosis, elevated macroscopic type and old age . Long procedure time and piecemeal resection were also reported to be associated with the incidence of perforation, those might be due to not only tumor‐related factor but also the endoscopist‐related factor.…”

Section: Adverse Events Related To Gastric Esdmentioning

confidence: 99%

Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts

Yamamoto

Kikuchi

Nagami

et al. 2019

Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2–3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self‐expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post‐ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high‐risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over‐the‐scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three‐quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.

“…Presence of submucosal fibrosis is associated with increased procedure time and risk of adverse events in both endoscopic submucosal dissection (ESD) and POEM . Here, we used the same classification of submucosal fibrosis described by Jeong et al .…”

Section: Methodsmentioning

confidence: 99%

Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score

Bechara

Woo

Hookey

et al. 2019

Background Peroral endoscopic myotomy (POEM) for achalasia is technically challenging to carry out in patients with type III, multiple prior treatments, prior myotomy, and sigmoid type. Herein, we present a series of consecutive patients with complex achalasia and introduce the POEM difficulty score (PDS). Aim To demonstrate the application and discuss the utility of PDS and present the feasibility, safety, and efficacy of POEM in complex achalasia patients. Methods Forty consecutive POEM were carried out with 28 meeting the criteria for complex achalasia. Primary outcome was clinical success (Eckardt score ≤3) at a minimum of 3 months follow‐up. Secondary outcomes included adverse events, procedural velocity and PDS. Results Twenty‐eight complex and 12 non‐complex POEM procedures were carried out with 100% and 92% clinical success, respectively, without any major adverse events with a median follow up of 15 months (complex) and 8 months (non‐complex). Mean velocities for non‐complex, type III, prior myotomy, ≥4 procedures and sigmoid type were as follows: 4.4 ± 1.6, 4.8 ± 1.5, 5.9 ± 2.2, 6.9 ± 2.2 and 8.2 ± 3.2 min/cm, respectively. Median PDS for non‐complex, type III, prior myotomy, ≥4 treatments and sigmoid type were 1 (0–3), 2 (0–4), 2.5 (1–6), 3 (2–6) and 3.5 (1–6), respectively. PDS was shown to correlate well with procedural velocity with a correlation coefficient of 0.772 (Spearman's P < 0.001). Conclusions PDS identifies the factors that contribute to challenging POEM procedures and correlates well with procedural velocity. The order of increasing difficulty of POEM in complex achalasia appears to be type III, prior myotomy, ≥4 treatments and sigmoid type.