Long-Term Outcomes of Gastric Endoscopic Submucosal Dissection: Focus on Metachronous and Non-Curative Resection Management.

INTRODUCTION: Endoscopic submucosal dissection (ESD) is an effective treatment for gastric superficial neoplasms and curative in 80-85% of the patients. The aims of this study were to identify risk factors for non-curative resection and metachronous development, and to evaluate patient management and outcome after non-curative resection. METHODS: In this single-centre study, the outcome of consecutive patients submitted to gastric ESD was assessed during a minimum follow-up of 18 months. Univariate analysis and multivariate logistic regression were performed to identify risk factors. RESULTS: ESD was performed in 194 lesions (164 patients) between 2005 and 2014. The median follow-up was 40 months. En bloc and complete resection rates were 95.3 and 93.8%, respectively. Male sex, larger tumor size, longer procedural time, and more advanced histology were associated with a non-curative resection (p < 0.05), but only carcinoma detected in biopsies before resection was identified as a significant risk factor on multivariate analysis. Metachronous lesions occurred in 18.4%, and the incidence rate was 4.7 lesions/100 person-years. Older age at diagnosis was identified as the only predictor of metachronous development in logistic regression. In the non-curative resection group, survival did not differ between patients allocated to surveillance and those submitted to gastrectomy; 75% of gastrectomy specimens showed no residual lesion. CONCLUSIONS: The risk factors identified for non-curative resection help to improve patient selection and patient information. Older patients had an increased risk for the development of metachronous lesions. In patients with non-curative resections, individualized patient management and surveillance seems to be an adequate option in selected cases.

INTRODUÇÃO: A disseção endoscópica da submucosa (ESD) é um tratamento eficaz nas neoplasias gástricas precoces, sendo curativa em 80-85%. Os objetivos deste estudo foram identificar fatores de risco para resseção não curativa e para o desenvolvimento de lesões metácronas, bem como avaliar a abordagem e os resultados após resseção não curativa. MÉTODOS: Estudo de coorte, unicêntrico, incluindo doentes consecutivos submetidos a ESD gástrica com tempo mínimo de follow-up de 18 meses. Análise univariada e multivariada utilizadas na identificação de fatores de risco. RESULTADOS: Entre 2005 e 2014, 194 lesões (164 doentes) foram submetidas a ESD (tempo mediano de follow-up 40 meses). Resseções em bloco e completa: 95.3 e 93.8%. Sexo masculino, lesão maior, procedimento demorado e histologia mais avançada associaram-se a resseção não curativa (p < 0.05); na análise multivariada, adenocarcinoma nas biopsias foi identificado como fator preditor. Ocorreram lesões metácronas em 18.4% (taxa de incidência 4.7/100 pessoas-ano), sendo a idade mais avançada fator de risco independente para lesões metácronas. Nos casos de resseção não curativa, a sobrevivência foi semelhante nos doentes alocados para vigilância e nos submetidos a gastrectomia; em 75% não havia doença residual na peça cirúrgica. CONCLUSÕES: Os fatores de risco identificados são úteis na seleção apropriada dos doentes e na transmissão da informação. A incidência de lesões metácronas é significativa, estando os doentes mais velhos em maior risco. Após resseção não curativa a decisão deve ser individualizada, sendo a vigilância apropriada em casos selecionados.

Evaluation and management of gastric epithelial polyps.

Gastric polyps include a wide spectrum of lesions with different histology and neoplastic potential. They are found in up to 6% of upper gastrointestinal endoscopy and are usually asymptomatic and incidentally diagnosed, being in the vast majority epithelial gastric polyps. Hyperplastic, fundic gland and adenomas are the most common types of gastric polyps and, although each type may have typical endoscopic appearances, they all must be sampled at the initial endoscopy for histological assessment. Also, the normal appearing gastric mucosa should be sampled to stage atrophic changes, rule out endoscopically non-visible dysplasia and to diagnose Helicobacter pylori. Polyposis syndromes that affect the stomach are rare but should be taken into account. Hamartomatous polyps can be found in Juvenile polyposis, Cowden syndrome and Peutz-Jeghers syndrome. On the other hand, multiple fundic gland polyps are present in the majority of patients with familial adenomatous polyposis. In this study we provide a comprehensive review on the evaluation and management of gastric epithelial polyps, in this way helping physicians to properly handle this type of lesions.

Complications of endoscopic resection techniques for upper GI tract lesions.

Adverse events can occur during and after the endoscopic resection of upper gastrointestinal lesions. Their incidence can be minimized through the adoption of preventive measures and their final outcomes can be optimized through prompt identification and adequate treatment. In this evidence-based review we describe the risk factors for adverse events, preventive measures to avoid them and their management when they occur. Algorithms of action are also provided. Oesophageal strictures can be prevented with corticosteroids (either locally injected or systemically administered) and treated with endoscopic dilatation. Bleeding can be minimized through the adoption of prophylactic coagulation and novel preventive measures are emerging and being evaluated. Bleeding management includes coagulation therapy, clips and haemostatic powders. Perforations can nowadays be successfully treated endoscopically in the majority of the cases and conservative treatment is associated with favourable outcomes although optimal management is unclear.

Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system 1 2 was adopted to define the strength of recommendations and the quality of evidence. Main Recommendations: 1 ESGE recommends endoscopic en bloc resection for superficial esophageal squamous cell cancers (SCCs), excluding those with obvious submucosal involvement (strong recommendation, moderate quality evidence). Endoscopic mucosal resection (EMR) may be considered in such lesions when they are smaller than 10 mm if en bloc resection can be assured. However, ESGE recommends endoscopic submucosal dissection (ESD) as the first option, mainly to provide an en bloc resection with accurate pathology staging and to avoid missing important histological features (strong recommendation, moderate quality evidence). 2 ESGE recommends endoscopic resection with a curative intent for visible lesions in Barrett's esophagus (strong recommendation, moderate quality evidence). ESD has not been shown to be superior to EMR for excision of mucosal cancer, and for that reason EMR should be preferred. ESD may be considered in selected cases, such as lesions larger than 15 mm, poorly lifting tumors, and lesions at risk for submucosal invasion (strong recommendation, moderate quality evidence). 3 ESGE recommends endoscopic resection for the treatment of gastric superficial neoplastic lesions that possess a very low risk of lymph node metastasis (strong recommendation, high quality evidence). EMR is an acceptable option for lesions smaller than 10 - 15 mm with a very low probability of advanced histology (Paris 0-IIa). However, ESGE recommends ESD as treatment of choice for most gastric superficial neoplastic lesions (strong recommendation, moderate quality evidence). 4 ESGE states that the majority of colonic and rectal superficial lesions can be effectively removed in a curative way by standard polypectomy and/or by EMR (strong recommendation, moderate quality evidence). ESD can be considered for removal of colonic and rectal lesions with high suspicion of limited submucosal invasion that is based on two main criteria of depressed morphology and irregular or nongranular surface pattern, particularly if the lesions are larger than 20 mm; or ESD can be considered for colorectal lesions that otherwise cannot be optimally and radically removed by snare-based techniques (strong recommendation, moderate quality evidence).(AU)

A multicenter validation of an endoscopic classification with narrow band imaging for gastric precancerous and cancerous lesions.

BACKGROUND AND STUDY AIM: The reliability and external validity of narrow band imaging (NBI) in the stomach have not been described consistently. The aim of the current study was to describe and estimate the accuracy and reliability of a simplified classification system for NBI in the diagnosis of gastric lesions. METHODS: Consecutive patients undergoing NBI endoscopy at two reference centers (n=85, 33% with dysplasia) were included in two studies. In total, 224 different areas were biopsied and recorded onto video. In the derivation study, previously described NBI features were analyzed in order to develop a simplified classification. In the validation study the accuracy and reliability of this classification were estimated among three groups of endoscopists with different levels of expertise in NBI. RESULTS: The reliability/accuracy results from the derivation study allowed the creation of a simplified NBI classification. In the validation study, "regular vessels with circular mucosa" (pattern A) was associated with normal histology (accuracy 83%; 95% confidence interval [CI] 75 %-90%); "tubulo-villous mucosa" (pattern B) was associated with intestinal metaplasia (accuracy 84%; 95CI 77%-91%; positive likelihood ratio [LR+]=4.75); and "irregular vessels and mucosa" (pattern C) was associated with dysplasia (accuracy 95%; 95CI 90%-99%; LR+=44.33). The reproducibility of these patterns was high (k=0.62). "Light-blue crest" was moderately reliable (k=0.49) but specific (87%) for intestinal metaplasia. A variable vascular density (additional pattern+) was the best feature for Helicobacter pylori gastritis (accuracy 70%; 95CI 59%-80%) but showed only fair reliability (k=0.38). Non-experienced endoscopists presented lower agreement (k=0.6 vs. k=0.75) and accuracy (74% vs. 86%) than international experts/experienced endoscopists. CONCLUSION: A simplified NBI classification is accurate and reliable for the diagnosis of intestinal metaplasia and dysplasia. The classification should be further assessed and validated on a per-patient assessment of NBI, and by comparing NBI with other imaging technologies.

Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy, the European Helicobacter Study Group, the European Society of Pathology, and the Sociedade Portuguesa de Endoscopia Digestiva have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach. A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia and the need for adequate staging in the case of high-grade dysplasia, and they focus on treatment and surveillance indications and methods.

Management of precancerous conditions and lesions in the stomach (MAPS): guideline from the European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter Study Group (EHSG), European Society of Pathology (ESP), and the Sociedade Portuguesa de Endoscopia Digestiva (SPED).

Atrophic gastritis, intestinal metaplasia, and epithelial dysplasia of the stomach are common and are associated with an increased risk for gastric cancer. In the absence of guidelines, there is wide disparity in the management of patients with these premalignant conditions. The European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter Study Group (EHSG), the European Society of Pathology (ESP) and the Sociedade Portuguesa de Endoscopia Digestiva (SPED) have therefore combined efforts to develop evidence-based guidelines on the management of patients with precancerous conditions and lesions of the stomach (termed MAPS). A multidisciplinary group of 63 experts from 24 countries developed these recommendations by means of repeat online voting and a meeting in June 2011 in Porto, Portugal. The recommendations emphasize the increased cancer risk in patients with gastric atrophy and metaplasia, and the need for adequate staging in the case of high grade dysplasia, and they focus on treatment and surveillance indications and methods.

Endoscopic submucosal dissection for gastric lesions: results of an European inquiry.

BACKGROUND AND STUDY AIMS: In Japanese centers, endoscopic submucosal dissection (ESD) is commonly used for the resection of early gastric lesions. However, in Europe, only a few reports have been published. The aim of the current study was to survey the current use of ESD by European endoscopists. METHODS: Between April and May 2009, European endoscopists (n = 490) who had articles published in the journals Endoscopy and/or Gastrointestinal Endoscopy during 2007 and 2008 were asked to complete an online questionnaire. RESULTS: A total of 58 endoscopists completed the questionnaire (12 %). Only 20 centers performed ESD, which was mostly performed by a single endoscopist in each center. Each endoscopist had treated a mean of four cases during the previous year (mean total experience 11 ESDs) bringing a total of 510 ESDs across all European centers that responded (197 during the past year). Lesions were located in the antrum in 35 % of cases; 39 % were Paris classification IIa, 22 % IIa + b, and 18 % IIa + c. Overall, the average of mean lesion diameter was 15.7 mm (range 1 - 70.0 mm). Most cases were non-invasive high-grade intraepithelial neoplasia (44 %) or adenocarcinoma (36 %). An insulated-tipped knife (1 or 2) was used in 70 % of procedures and an average of the mean duration of procedures was 108 minutes. In all, 78 % of lesions were removed en bloc with an R0 rate of 77 %. Endoscopists experienced major complications (perforation or major bleeding) in 13 % of cases. CONCLUSION: ESD in Europe seems to be performed at a few centers, with most endoscopists performing a low number of procedures, achieving a high rate of efficacy and a moderate rate of major complications. However, as a potential selection bias may have occurred, multicenter registries should be conducted to help address the problem of dissemination of this technique.