Colorectal stent placement assisted by a slim gastroscope: technique and outcomes.

BACKGROUND: The distorted anatomy in patients with obstruction renders colon stent placement difficult. Here, we propose two novel techniques for stent implantation. METHODS: Patients in whom there was difficulty placing the guidewire with the normal method were retrospectively included in our study. All of the patients underwent the technique of combining a slim gastroscope with a normal colonoscope. We assessed the technical success, clinical success, and adverse events associated with self-expanding metal stent placement. RESULTS: From June 2018 to June 2020, 30.5% of patients with difficult catheterization were included in this study. Finally, stents in 17 of 18 patients (3 rectum, 13 sigmoid colon, 1 descending colon, and 1 hepatic flexure) (94.4%) were placed successfully, assisted by a slim gastroscope with or without radiography, and the obstruction was relieved. Only one remaining patient experienced failure. No intraoperative or 30-day postoperative morbidity or mortality was observed. CONCLUSION: The present study showed that the stent implantation technique assisted by a slim gastroscope combined with a normal colonoscope was a relatively safe and effective method for abolishing difficult intestinal stenosis. More studies are needed to compare the advantages and disadvantages of this technique with normal endoscopic implantation.

Improving All-Cause Inpatient Mortality After Percutaneous Endoscopic Gastrostomy.

BACKGROUND AND AIMS: Percutaneous gastrostomy (PEG) is a common inpatient procedure. Prior data from National Inpatient Sample (NIS) in 2006 reported a mortality rate of 10.8% and recommended more careful selection of PEG candidates. This study assessed for improvement in the last 10 years in mortality rate and complications for hospitalized patients. METHODS: A retrospective cohort analysis of all adult inpatients in the NIS from 2006 to 2016 undergoing PEG placement compared demographics and indication for PEG placement per ICD coding. Survey-based means and proportions were compared to 2006, and rates of change in mortality and complication rates were trended from 2006 through 2016 and compared with linear regression. Multivariable survey-adjusted logistic regression was used to determine predictors of mortality and complications in the 2016 sample. RESULTS: A total of 155,550 patients underwent PEG placement in 2016, compared with 174,228 in 2006. Mortality decreased from 10.8 to 6.6% without decreased comorbidities (p < 0.001). This trend was gradual and persistent over 10 years in contrast to a stable overall inpatient mortality rate (p = 0.113). Stroke remained the most common indication (29.7%). The majority of patients (64.6%) had Medicare. Indications for placement were stable. Complication rates were stable from 2006 (4.4%) to 2016 (5.1%) (p = 0.201). CONCLUSIONS: Inpatient PEG placement remains common. Despite similar patient characteristics, mortality has decreased by approximately 40% over the last 10 years without a decrease in complications likely reflecting improved patient selection.

Percutaneous endoscopic gastrostomy: dealing with the issue of dislodgement.

Introduction: Percutaneous Endoscopic Gastrostomy (PEG) is accepted as an efficient method to provide long-term enteral nutrition. PEG accidental dislodgement (device exteriorization confirmed by expert evaluation) rate is high and can lead to major morbidity.Objective: To identify independent risk factors for PEG accidental dislodgement.Methods: Retrospective, single-center study, including consecutive patients submitted to PEG procedure, for 38 consecutive months. Every patient had 12 months minimum follow-up after PEG placement. Univariate analysis selected variables with at least marginal association (p < .15) with the outcome variable, PEG dislodgement, which were included in a logistic regression multivariate model. Discriminative power was assessed using area under curve (AUC) of the receiver operating curve (ROC).Results: We included 164 patients, 67.7% (111) were female, mean age was 81 years. We report 59 (36%) PEG dislodgements, of which 13 (7.9%) corresponded to early dislodgements. The variables with marginal association were hypoalbuminemia (p = .095); living at home (p = .049); living in a nursing home (p = .074); cerebrovascular disease (CVD) (p = .028); weight change of more than 5 kg, either increase or decrease (p = .001); psychomotor agitation (p < .001); distance inner bumper-abdominal wall (p = .034) and irregular appointment follow-up (p = .149). At logistic multivariate regression, the significant variables after model adjustment were CVD OR 4.8 (CI 95% 2.0-11.8), weight change OR 4.7 (CI 95%1.6-13.9) and psychomotor agitation OR 18.5 (CI 95% 5.2-65.6), with excellent discriminative power (AUC ROC 0.797 [CI95% 0.719-0.875]).Conclusion: PEG is a common procedure and accidental dislodgement is a frequent complication. CVD, psychomotor agitation and weight change >5 kg increase the risk of this complication and should be seriously considered when establishing patients' individual care requirements.

Recurrence Patterns and Outcomes of Salvage Surgery in Cases of Non-Curative Endoscopic Submucosal Dissection without Additional Radical Surgery for Early Gastric Cancer.

BACKGROUND/AIMS: The outcomes of salvage surgery for recurrence after non-curative endoscopic submucosal dissection (ESD) without additional radical surgery for early gastric cancer (EGC) remain unclear. We determined the recurrence patterns and outcomes of salvage surgery in such cases using data from a multicenter, retrospective study. METHODS: Of 15,785 patients who underwent ESD for EGC at 19 participating institutions between January 2000 and August 2011, 1,969 failed to meet the current curative criteria after ESD. Of these, 905 patients received no additional treatment. We evaluated the pattern of recurrence, clinical course after salvage surgery, and long-term survival rate for these patients. RESULTS: Over a median 64-month follow-up period, recurrence was detected in 27 patients. Two patients with missing data were excluded. Three, seven, and 15 (60%) patients showed intragastric relapse, regional lymph node metastasis, and distant metastasis, respectively. The first line of treatment for recurrence in 1, 7, 6, and 11 patients was endoscopic treatment, salvage surgery, chemotherapy, and best supportive care, respectively. One patient survived without recurrence for 31 months after salvage surgery, one died of acute myocardial infarction 1 month after salvage surgery, and 5 showed recurrence at 0, 2, 3, 5, and 30 months after salvage surgery and eventually succumbed to the disease. The median survival times for all patients with recurrence and the 7 patients who underwent salvage surgery were 5 months after recurrence and 7 months after salvage surgery, respectively. CONCLUSION: The survival rate after salvage surgery for recurrence after non-curative ESD without additional radical surgery for EGC is quite low, with distant metastasis being the most common recurrence pattern in these cases.

A comparative study on endoscopic submucosal dissection and laparoscopy-assisted radical gastrectomy in the treatment of early gastric carcinoma.

PURPOSE: To compare the clinical efficacy and safety of endoscopic submucosal dissection (ESD) and laparoscopy-assisted radical gastrectomy (LARG) in the treatment of early gastric carcinoma (EGC) with different risks of lymph node metastasis. METHODS: The clinical data of 194 EGC patients who underwent ESD (ESD group, n=58) or LARG (LARG group, n=136) in our hospital from January 2014 to January 2016 were collected. The baseline data, pathological features of tumor, perioperative indexes and long- and short-term complications were compared between the two groups, the overall survival (OS) rate of patients was recorded through follow-up, and the tumor-free survival (TFS) rate was compared after ESD and LARG for EGC with different risks of lymph node metastasis. RESULTS: The general clinical features were comparable between the two groups of patients, and there was no perioperative death. The pathological features of the tumor had no statistically significant differences between the two groups (p>0.05). The operation time in ESD group (73.57±21.30 min) was significantly shorter than that in LARG group (159.22±39.40 min) (p<0.001), and the time of first ambulation after operation in ESD group (1.6±0.8 d) was also overtly shorter than that in LARG group (3.5±1.7 d) (p<0.001). Postoperatively, no drainage tube was placed in the ESD group, while it was placed for 5.7±2.4 days on average in the LARG group. The time of first flatus after operation, time of first liquid diet after operation, and total hospitalization time in the ESD group were significantly compared with the LARG group (p<0.001). The incidence rate of short-term complications after surgery was 10.3% and 7.4% in the two groups, (p=0.570), while long-term complications were 17.6% (9/51) and 20.9% (24/115) in the two groups (p=0.631). The in situ tumor recurrence by the end of follow-up was 3.92% (2/51) and 0.87% (1/115) in the two groups, while the ectopic recurrence rate was 5.89% (3/51) and 0.87% (1/115) (p=0.173, p=0.087). OS survival was 96.1% (49/51) and 97.4% (112/115) in the two groups (p=0.751). The postoperative TFS of EGC patients with a low risk of lymph node metastasis was 93.8% (30/32) and 98.6% (70/71) in the two groups, again without significant difference (p=0.197). The postoperative TFS of EGC patients with a high risk of lymph node metastasis was 84.2% (16/19) and 97.7% (43/44) in the two groups, with statistically significant difference (log-rank, p=0.034). CONCLUSIONS: ESD is characterized by small trauma, rapid postoperative recovery, postoperative recurrence and survival comparable to those after surgical operation and high safety for EGC with a low risk of lymph node metastasis. LARG can reduce the postoperative recurrence rate of EGC in patients with high risk of lymph node metastasis.

Risk factors for complications and mortality of percutaneous endoscopic gastrostomy insertion.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure; however, acute and chronic complications of PEG have been reported. We aimed to determine risk factors associated with complications and 30-day mortality after PEG, based on 11 years of experience at a single tertiary hospital. METHODS: In total, 401 patients who underwent first PEG insertion at the Asan Medical Center, Seoul, Korea, between January 2005 and December 2015 were eligible. Medical records were retrospectively reviewed to determine clinical characteristics and outcomes of 139 and 262 patients who underwent pull-type and introducer-type PEG, respectively. RESULTS: The median age of the overall population was 68 years, and the median body mass index was 19.5 kg/m2. Acute and chronic complications developed in 96 (23.9%) and 105 (26.2%) patients. Acute ileus and chronic tube obstruction were significantly more frequent in the introducer-type PEG group (p = 0.033 and 0.001, respectively). The 30-day mortality rate was 5.0% (median survival: 10.5 days). Multivariate analysis revealed that underlying malignancy was a predictor of acute complications; age ≥ 70 years and diabetes mellitus were predictors of chronic complications. The median follow-up was 354 days. Neurologic disease and malignancy were the most common indications for PEG. Neurologic diseases were classified into two groups: stroke and the other neurologic disease group (including dementia, Parkinson's disease, neuromuscular disease, and hypoxic brain damage). Multivariate analysis showed that 30-day mortality was significantly lower in the other neurologic disease group and higher in patients with platelet count < 100,000/µL, and C-reactive protein (CRP) ≥ 5 mg/dL. CONCLUSIONS: PEG is a relatively safe and feasible procedure, but it was associated with significantly higher early mortality rate in patients with platelet count < 100,000/µL or CPR≥5mg/dL, and lower early mortality rate in neurologic disease group including dementia, Parkinson's disase, neuromuscular disease, and hypoxic brain damage. In addition, acute complications in patients with underlying malignancy, and chronic complications in patients aged ≥70 and those with diabetes mellitus should be considered during and after PEG.

Endoscopic full-thickness resection for gastrointestinal submucosal tumors.

Endoscopic full-thickness resection (EFTR) is a "changing-concept" endoscopic resection technique, which safely allows resecting deep submucosal tumors (SMTs) in the gastrointestinal (GI) wall. It's a highly promising endoscopic procedure that allows full-thickness excision of a small piece of the complete GI wall by using only a flexible endoscope. EFTR is a meeting point between surgery and endoscopy and probably the onset of many prospective combined minimally invasive therapeutic techniques that science will explore. In this review, use of the EFTR technique for gastrointestinal SMTs is highlighted, focusing on some technical aspects, indications, contraindications and outcomes.

In response to the letter by Cabadas and Álvarez-Escudero about the editorial: 'Will societies of anesthesiologists partake in the take-off of non-anesthesiologist administration of propofol?'

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Comparison of short- and long-term outcomes of laparoscopic vs open resection for gastric gastrointestinal stromal tumors.

AIM: To compare the short- and long-term outcomes of laparoscopic (LR) vs open resection (OR) for gastric gastrointestinal stromal tumors (gGISTs). METHODS: In total, 301 consecutive patients undergoing LR or OR for pathologically confirmed gGISTs from 2005 to 2014 were enrolled in this retrospective study. After exclusion of 77 patients, 224 eligible patients were enrolled (122 undergoing LR and 102 undergoing OR). The demographic, clinicopathologic, and survival data of all patients were collected. The intraoperative, postoperative, and long-term oncologic outcomes were compared between the LR and OR groups following the propensity score matching to balance the measured covariates between the two groups. RESULTS: After 1:1 propensity score matching for the set of covariates including age, sex, body mass index, American Society of Anesthesiology score, tumor location, tumor size, surgical procedures, mitotic count, and risk stratification, 80 patients in each group were included in the final analysis. The baseline parameters of the two groups were comparable after matching. The LR group was significantly superior to the OR group with respect to the operative time, intraoperative blood loss, postoperative first flatus, time to oral intake, and postoperative hospital stay (P < 0.05). No differences in perioperative blood transfusion or the incidence of postoperative complications were observed between the two groups (P > 0.05). No significant difference was found in postoperative adjuvant therapy (P = 0.587). The mean follow-up time was 35.30 ± 26.02 (range, 4-102) mo in the LR group and 40.99 ± 25.07 (range, 4-122) mo in the OR group with no significant difference (P = 0.161). Survival analysis showed no significant difference in the disease-free survival time or overall survival time between the two groups (P > 0.05). CONCLUSION: Laparoscopic surgery for gGISTs is superior to open surgery with respect to intraoperative parameters and postoperative outcomes without compromising long-term oncological outcomes.

Percutaneous endoscopic gastrostomy: confirming the clinical benefits far beyond anthropometry.

OBJECTIVES: The real benefit of gastrostomy is still a matter of debate. We aimed to prospectively evaluate the global impact of percutaneous endoscopic gastrostomy (PEG) in patients followed at a specialized multidisciplinary clinic, namely, the impact on the need for healthcare resources, anthropometric measures, pressure ulcers prevention and healing, and nutritional and hydration status. PATIENTS AND METHODS: From the 201 patients who underwent PEG between May 2011 and September 2014, 60 were included in a prospective study. Anthropometric, clinical, and laboratorial variables were collected and compared before and after PEG. Follow-up duration, mortality, and number of emergency department visits or hospital admissions were also assessed. RESULTS: Thirty-three (55.0%) patients were women and the median age was 79 years. The main indications for PEG were dementia (43.3%) and poststroke dysphagia (30.0%). Four months following PEG, significant decreases in the tricipital skinfold (P=0.002) and brachial perimeter (P=0.003) were found. A decrease in the mean number of hospitalizations (1.4 vs. 0.3; P<0.001) and visits to emergency department (2.2 vs. 1.1; P=0.003) was noted in the next 6 months after PEG compared with the previous semester. In 53.8% of patients with pressure ulcers, complete healing was observed after PEG. PEG was associated with increases in hemoglobin (P=0.024), lymphocytes (P=0.041), cholesterol (P=0.008), transferrin (P<0.001), albumin (P<0.001), and total proteins (P<0.001), and a decrease in serum sodium (P=0.001). CONCLUSION: Anthropometric values may not translate the early benefits of a gastrostomy. PEG decreases the need for hospital health care, facilitates healing of pressure ulcers, and induces biochemical changes that may reflect better nutrition and hydration.

Management of different types of gastric varices with band ligation: a 3-year experience.

BACKGROUND AND AIM: Gastric varices (GVs) occur with an incidence of 20% in patients with portal hypertension. The aim of this study was to evaluate the efficacy of endoscopic band ligation (BL) as an option in the management of small-to-moderate nonbleeding GVs in cirrhotic patients. PATIENTS AND METHODS: A total of 50 patients (GOV2; n=6, IGV1; n=34, IGV2; n=10) with nonbleeding small-to-moderate-sized GVs without local risk signs of bleeding, such as large size, red-colored elevated areas or red wales, and systemic factors of bleeding risk such as an international normalized ratio of at least 2 and a platelet count of 80 000/µl or less were subjected to endoscopic BL. The patients were followed up every 2 weeks for 1 month and then every 1.5 months for 6 months. The primary outcome was GV eradication, detection of complications such as postprocedural bleeding ulceration and mortality. RESULTS: The mean number of BL sessions was 2.2±0.8; post-BL ulceration occurred in two (4%) patients (n=2 in IGV1, P=0.61), bleeding occurred in one (2%) patient (n=1 in IGV1, P=0.79), and epigastric pain occurred in six (12%, n=4 in GOV2, n=2 in IGV1) patients. There was no mortality reported among patients treated with BL. CONCLUSION: Endoscopic BL resulted in better outcome and a lower incidence of complications when used to treat small-to-medium-sized nonbleeding GVs. Further, early eradication can save effort and cost, thus avoiding the future risk of treatment of large or risky GVs with sclerotherapy.

Postoperative Helicobacter pylori Infection as a Prognostic Factor for Gastric Cancer Patients after Curative Resection.

BACKGROUND/AIMS: Few studies have evaluated the effect of Helicobacter pylori infection on the prognosis of patients diagnosed with gastric cancer (GC) after curative surgery. We investigated the association between the H. pylori infection status and clinical outcome after surgery. METHODS: We assessed the H. pylori status of 314 patients who underwent curative resection for GC. The H. pylori status was examined using a rapid urease test 2 months after resection. Patients were followed for 10 years after surgery. RESULTS: An H. pylori infection was observed in 128 of 314 patients. The median follow-up period was 93.5 months. A Kaplan-Meier analysis indicated that patients with H. pylori had a higher cumulative survival rate than those who were negative for H. pylori. Patients with stage II cancer who tested negative for H. pylori were associated with a poor outcome. In a multivariate analysis, H. pylori-negative status was a significant independent prognostic factor for poor overall survival. CONCLUSIONS: Having a negative H. pylori infection status seems to indicate poor prognosis for patients with GC who have undergone curative resection. Further prospective controlled studies are needed to evaluate the mechanism by which H. pylori affects GC patients after curative surgery in Korea.

Sentinel Node Mapping Using a Fluorescent Dye and Visible Light During Laparoscopic Gastrectomy for Early Gastric Cancer: Result of a Prospective Study From a Single Institute.

OBJECTIVE: The aim of this study was to investigate the feasibility of sentinel node mapping using a fluorescent dye and visible light in patients with gastric cancer. BACKGROUND: Recently, fluorescent imaging technology offers improved visibility with the possibility of better sensitivity or accuracy in sentinel node mapping. METHODS: Twenty patients with early gastric cancer, for whom laparoscopic distal gastrectomy with standard lymphadenectomy had been planned, were enrolled in this study. Before lymphadenectomy, the patients received a gastrofiberoscopic peritumoral injection of fluorescein solution. The sentinel basin was investigated via laparoscopic fluorescent imaging under blue light (wavelength of 440-490 nm) emitted from an LED curing light. The detection rate and lymph node status were analyzed in the enrolled patients. In addition, short-term clinical outcomes were also investigated. RESULTS: No hypersensitivity to the dye was identified in any enrolled patients. Sentinel nodes were detected in 19 of 20 enrolled patients (95.0%), and metastatic lymph nodes were found in 2 patients. The latter lymph nodes belonged to the sentinel basin of each patient. Meanwhile, 1 patient (5.0%) experienced a postoperative complication that was unrelated to sentinel node mapping. No mortality was recorded among enrolled cases. CONCLUSIONS: Sentinel node mapping with visible light fluorescence was a feasible method for visualizing sentinel nodes in patients with early gastric cancer. In addition, this method is advantageous in terms of visualizing the concrete relationship between the sentinel nodes and surrounding structures.

PEG Insertion in Patients With Dementia Does Not Improve Nutritional Status and Has Worse Outcomes as Compared With PEG Insertion for Other Indications.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) tubes are commonly utilized as a method of enteral feeding in patients unable to obtain adequate oral nutrition. Although some studies have shown improved mortality in select populations, the safety and effectiveness of PEG insertion in patients with dementia compared with those with other neurological diseases or head and neck malignancy remains less well defined. OBJECTIVE: To evaluate the nutritional effectiveness, rate of rehospitalization, and risk of mortality among patients with dementia compared with patients with other neurological diseases or head and neck cancers who undergo PEG placement. MATERIALS AND METHODS: We conducted a retrospective analysis from a prospective database of patients who underwent PEG placement at an academic tertiary center between 2008 and 2013. The following data were collected: indication for PEG, patient demographics, biochemical markers of nutritional status rehospitalization, and survival rates. RESULTS: During the study period, 392 patients underwent PEG tube placement. Indications for PEG were dementia (N=165, group A), cerebrovascular accident (N=124, group B), and other indications such as oropharyngeal cancers and motor neuron disease (N=103, group C). The mean follow-up time after PEG was 18 months (range, 3 to 36 mo). No differences in baseline demographics were noted. PEG insertion in the dementia (group A) neither reduced the rehospitalization rate 6 months' postprocedure compared with groups B and C (2.45 vs. 1.86 and 1.65, respectively; P=0.05), nor reduced the mortality rate within the first year post-PEG placement (75% vs. 58% and 38% for groups A, B, and C, respectively, P=0.001), as well, it did not improve survival at 1 month after the procedure (15% vs. 3.26% and 7.76%, for groups A, B, C, respectively, P<0.01). The presence of dementia was also associated with shorter mean time to death (7.2 vs. 8.85 and 8 mo for groups A, B, C, respectively, P<0.05). The rate of improvement of the nutritional biomarker albumin was lower in the dementia group [3.1. to 2.9 vs. 3.2 to 3.3 and 3 to 3.3 g/dL for groups A, B, and C, respectively (P<0.02)]. Multivariate regression analysis showed that the presence of dementia was an independent predictor for mortality rate within the first year and 1-month mortality rate in patients undergoing PEG insertion with odds ratio 3.22 (95% confidence interval, 1.52-4.32) and odds ratio 2.52 (95% confidence interval, 1.22-3.67). CONCLUSIONS: PEG insertion in patients with dementia neither improve both short-term and long-term mortality nor rehospitalization rate as compared with patients who underwent PEG placement for alternate indications such as other neurological diseases or head and neck malignancy and even was associated with shorter time to death. Furthermore, PEG insertion in patients with dementia did not improve albumin. Therefore, careful selection of patients with dementia is warranted before PEG placement weighing the risks and benefits on a personalized basis.

Surgical treatment and prognosis of gastric neuroendocrine neoplasms: a single-center experience.

BACKGROUND: Gastric neuroendocrine neoplasms (G-NENs) are uncommon, and data on their management is limited. We here investigated the clinicopathological characteristics, surgical and survival outcomes in G-NENs among Chinese. Moreover, we will discuss their prognostic value. METHODS: From existing databases of the West China Hospital, we retrospectively identified 135 consecutive patients who were surgically treated and pathologically diagnosed as G-NENs from January 2009 to August 2015. RESULTS: This entire cohort comprised 98 males and 37 females, with a median age of 60 years. Twenty-five patients underwent endoscopic resection, while 110 patients underwent open/laparoscopic surgery. Thirty-nine patients had neuroendocrine tumor G1 (NET G1), seven patients had neuroendocrine tumor G2 (NET G2), 69 patients had neuroendocrine carcinoma G3 (NEC G3) and 20 patients had mixed adenoneuroendocrine carcinoma (MANEC). The median survival was not achieved for both NET G1 and NET G2 versus 19 months (range 3-48) for NEC G3 and 10.5 months (range 3-45) for MANEC. The 3-year survival rates for stage I, II, III, and IV were 91.1 %, 78.6 %, 51.1 % and 11.8 %, respectively (P < 0.001). As for the prognostic analysis, both surgical margin and the newly updated World Health Organization (WHO) classification were independent predictors of overall survival (OS). CONCLUSIONS: G-NENs are a kind of rare tumors, and patients with NET G3 and MANEC have unfavorable prognosis even surgically treated. Moreover, surgical margin and the new 2010 WHO criteria are closely associated with OS for G-NENs.

Feasibility of Endoscopic Submucosal Dissection for Submucosal-invasive Gastric Cancer and the Predictors of Residual or Recurrent Cancer.

PURPOSE OF THE STUDY: The purpose of this study was to determine the feasibility of the endoscopic submucosal dissection (ESD) for submucosal-invasive gastric cancer (SMGC) by assessing the therapeutic outcomes in patients treated with ESD. MATERIALS AND METHODS: From 2002 to 2013, ESD was performed for 597 lesions with early gastric cancer at our institute. ESD of the SMGC was performed for 85 patients. RESULTS: Among these 85 patients, 35 patients underwent additional gastrectomy. Residual or recurrent cancer occurred in 12 patients treated through ESD method. The 5-year disease-specific survival rates were 94.9% for all 85 patients and 97.2% for 49 patients with follow-up examinations after ESD. The multivariate logistic regression analysis indicated that residual or recurrent cancer in the patients with SMGC was significantly associated with a tumor width in submucosa (P=0.0152). CONCLUSIONS: ESD for SMGC can be considered feasible in clinical practice in terms of the favorable long-term oncologic outcomes.

Gastric cancer: Current status of lymph node dissection.

D2 procedure has been accepted in Far East as the standard treatment for both early (EGC) and advanced gastric cancer (AGC) for many decades. Recently EGC has been successfully treated with endoscopy by endoscopic mucosal resection or endoscopic submucosal dissection, when restricted or extended Gotoda's criteria can be applied and D1+ surgery is offered only to patients not fitted for less invasive treatment. Furthermore, two randomised controlled trials (RCTs) have been demonstrating the non inferiority of minimally invasive technique as compared to standard open surgery for the treatment of early cases and recently the feasibility of adequate D1+ dissection has been demonstrated also for the robot assisted technique. In case of AGC the debate on the extent of nodal dissection has been open for many decades. While D2 gastrectomy was performed as the standard procedure in eastern countries, mostly based on observational and retrospective studies, in the west the Medical Research Council (MRC), Dutch and Italian RCTs have been conducted to show a survival benefit of D2 over D1 with evidence based medicine. Unfortunately both the MRC and the Dutch trials failed to show a survival benefit after the D2 procedure, mostly due to the significant increase of postoperative morbidity and mortality, which was referred to splenopancreatectomy. Only 15 years after the conclusion of its accrual, the Dutch trial could report a significant decrease of recurrence after D2 procedure. Recently the long term survival analysis of the Italian RCT could demonstrate a benefit for patients with positive nodes treated with D2 gastrectomy without splenopancreatectomy. As nowadays also in western countries D2 procedure can be done safely with pancreas preserving technique and without preventive splenectomy, it has been suggested in several national guidelines as the recommended procedure for patients with AGC.

Important considerations when contemplating endoscopic resection of undifferentiated-type early gastric cancer.

Endoscopic resection (ER) of undifferentiated-type early gastric cancer (UD-EGC) has a lower curative resection (CR) rate than does ER of differentiated-type EGC (D-EGC). However, a low CR rate does not mean that it is unreasonable to schedule ER of UD-EGC. If ER is in fact curative, the long-term outcomes including survival rate are excellent. Quality of life is good because maximal stomach preservation is possible. However, UD-EGC and D-EGC differ histologically. Thus, when ER is contemplated to treat UD-EGC, a careful approach employing strict criteria is essential because the biology of UD-EGC and D-EGC differ.