Antithrombotic drugs are risk factors for delayed postoperative bleeding after endoscopic submucosal dissection for gastric neoplasms.

BACKGROUND: The discontinuation of antithrombotic drugs is recommended during endoscopic submucosal dissection (ESD) for gastric neoplasms; however, controversy remains as to whether antithrombotic drugs are risk factors for postoperative bleeding. OBJECTIVE: To determine the risk factors for post-ESD bleeding. DESIGN: Single-institution, retrospective review. SETTING: University hospital. PATIENTS: From June 2000 to December 2010, we treated 1192 gastric neoplasms in 1032 consecutive patients. INTERVENTION: The ESD procedures were performed by using the standard techniques. Antithrombotic drug therapy was principally interrupted preoperatively and was restarted when hemostasis was confirmed by second-look endoscopy. MAIN OUTCOME MEASUREMENTS: Risk factors for postoperative bleeding after ESD (early, delayed, and overall [combined] occurrence of bleeding during the first 5 postoperative days or thereafter) were analyzed by using logistic regression analysis. RESULTS: Among 1166 ESD-induced ulcer lesions, overall postoperative bleeding was evident in 62 lesions (5.3%); early and delayed bleeding occurred in 30 and 32 lesions (2.6% and 2.7%), respectively. Based on a multivariate analysis, a specimen size of >40 mm was the sole independent risk factor for overall bleeding. Moreover, oral antithrombotic drug therapy was selected as independent risk factor for delayed but not early bleeding, according to the multivariate analysis. The delayed bleeding rate in patients who had a specimen size of >40 mm and who used antithrombotic drugs was 11.6%. LIMITATIONS: Retrospective design and single-site data collection. CONCLUSION: Interruption of antithrombotic drug therapy may be adequate for preventing early post-ESD bleeding; however, reinitiating antithrombotic drug therapy is a significant independent risk factor for delayed post-ESD bleeding.

Risk assessment chart for curability of early gastric cancer with endoscopic submucosal dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) was introduced worldwide as a new treatment option for early gastric cancer, but curability prediction has not been evaluated on an individual basis. OBJECTIVE: To analyze factors contributing to the curability of early gastric cancer after ESD and to construct a risk assessment chart for the probability of curability. DESIGN: Single-institution retrospective review. SETTING: University hospital. PATIENTS: From June 2000 to April 2010, we treated 961 early gastric cancers in 784 patients (mean age 70.2 years). INTERVENTION: ESD procedures were performed using typical sequences. MAIN OUTCOME MEASUREMENTS: Risk factors related to resectability (en bloc or piecemeal resection) and curability (curative or noncurative resection) after ESD were analyzed using logistic regression analysis. Using this model, we constructed a risk assessment chart to predict the probability of noncurability from patient characteristics. RESULTS: The en bloc and curative resection rates were 98.9% and 88.1%, respectively, after ESD. Significant contributors to noncurative ESD were large lesions, upper location, and ulcer findings. Predicted noncurability probabilities were displayed in 4 colors for each risk level (light blue, blue, yellow, and red) by combining tumor size, tumor location, and ulcer findings. Probability of noncurability was highest (≥ 40%) in ulcerative large tumors (>30 mm in diameter) in the upper location (red) and lowest in nonulcerative small tumors (≤ 20 mm in diameter) in the lower location (light blue). LIMITATIONS: Retrospective design and single-site data collection. CONCLUSIONS: This risk assessment chart shows individuals their pretreatment curability assessment with successful ESD and may be an educational tool for trainees or a decision-making tool.

Superficial adenocarcinoma of the esophagogastric junction: long-term results of endoscopic submucosal dissection.

BACKGROUND: Endoscopic submucosal dissection (ESD) was recently introduced as a treatment option for superficial adenocarcinoma of the esophagogastric junction (EGJ); however, its long-term clinical outcomes have not been fully evaluated. OBJECTIVE: To assess the long-term outcomes of ESD for patients with superficial adenocarcinoma of the EGJ. DESIGN: Retrospective review from a single institution. SETTING: University hospital. PATIENTS: Fifty-eight patients, 46 men and 12 women (mean 69.3 years), with 39 T1m and 19 T1sm adenocarcinomas of the EGJ treated from June 2000 to May 2009. INTERVENTIONS: ESD procedures were performed with typical sequences. MAIN OUTCOME MEASUREMENTS: Complications, en bloc resection rate, curative resection rate, local recurrence, and distant metastases after ESD were evaluated. Curative resection is histologically defined as being free of resection margins and any evidence of deep submucosal invasion, undifferentiated carcinoma, and lymphovascular invasion. RESULTS: There were no major complications except for 3 patients with ulcer bleeding without the need for blood transfusion and 1 patient with esophageal stenosis. The rates of en bloc resection and curative resection were 100% and 79%, respectively. Twelve resections were histologically considered noncurative; these patients underwent additional ESD (n = 1) or surgical resection (n = 8). Local or distant recurrences were not observed in any patient achieving curative resection during follow-up (median 36.6 months, range 4-94 months). LIMITATIONS: Retrospective design and single-site data collection. CONCLUSIONS: Long-term outcomes after ESD are favorable. ESD may be adopted as a treatment of choice for superficial adenocarcinoma of the EGJ.