• Clinical Endoscopy
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• v.56 no.1
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• pp.55-64
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• 2023

Background/Aims: Endoscopic submucosal dissection (ESD) has been established as a treatment modality for superficial esophageal squamous cell carcinoma (ESCC). Long-term follow-up data are lacking in Western countries. The aim of this study was to analyze long-term survival in a Western center. Methods: Patients undergoing ESD for ESCC were included. The analysis was performed retrospectively using a prospectively collected database. Results: R0 resection rate was 96.7% (59/61 lesions in 58 patients). Twenty-seven patients (46.6%) fulfilled the curative resection criteria (M1/M2) (group A), 11 patients (19.0%) had M3 lesions without lymphovascular invasion (LVI) (group B), and 20 patients (34.5%) had lesions with submucosal invasion or LVI (group C). Additional treatment was recommended after non-curative resection. It was not performed in 20/31 patients (64.5%), mainly because of comorbidities (75%). Twenty-nine out of 58 (50.0%) patients died during a mean follow-up of 3.7 years. Death was related to ESCC in 17.2% (5/29) of patients. The disease-specific survival rate after curative resection was 100%. Overall survival rates after 5 years were 61.5%, 63.6% and 28.1% for groups A, B, and C, respectively. The overall survival was significantly worse after non-curative resection (p=0.038). Conclusions: Non-curative resection is frequent after ESD for ESCC in Western patients. The long-term prognosis is limited and mainly determined by comorbidity. Early diagnosis and pre-interventional assessments need to be improved.

• Journal of the Korea Academia-Industrial cooperation Society
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• v.17 no.2
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• pp.66-74
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• 2016

This study examined the effects of nursing information provision using a booklet on the patients' anxiety and uncertainty with an endoscopic submucosal dissection before the procedure, which is a non-equivalent controlled pre-post test designed study. Twenty three patients in a control group received the existing intervention, which is the general education prior to the procedure without standardized format as well as an oral explanation, and 23 patients in the experimental group received nursing information with a booklet developed by the investigator of this study. The collected data were analyzed using a ${\chi}^2$ test and Fisher's exact t-test on SPSS 21.0. The experimental group reported significantly lower anxiety (t=3.319, p=.002) and anxiety behavioral responses (t=3.508, p=.001) than those in the control group. There were no significant differences in uncertainty between the groups (t=.745, p=.460). Nursing information using the booklet is a useful nursing intervention to reduce the anxiety of patients with endoscopic submucosal dissection before the procedure.

• Journal of Gastric Cancer
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• v.21 no.3
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• pp.258-267
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• 2021

Purpose: As the rate of endoscopic resection for early gastric cancer (EGC) has increased in patients with comorbid diseases, it is necessary to elucidate the efficacy of endoscopic submucosal dissection (ESD) for EGC in patients with comorbidities. This study aimed to analyze the clinical outcomes of ESD for EGC in patients with comorbidities. Materials and Methods: A total of 969 patients with 1,015 lesions who underwent ESD for EGC at Seoul National University Hospital between 2010 and 2014 were analyzed. The short- and long-term clinical outcomes were evaluated according to the comorbidity status. Results: Comorbidities were observed in 558 patients (57.6%). The comorbidity group had a higher proportion of patients using antithrombotic agents (29.5% vs. 0.9%; P<0.0001). Although procedure-related complications (bleeding and perforation) were not significantly different between the two groups, the length of hospital stay was significantly longer (1.8 vs. 1.4 days, P=0.023), while survival was significantly shorter in the comorbidity group (5-year overall survival rate: 90.5% vs. 97.2%, P<0.0001; 5-year disease-specific survival rate: 97.9% vs. 100%, P=0.018; 5-year disease-free survival rate: 83.4% vs. 89.2%, P=0.007). Conclusions: Gastric ESD can be performed in patients with comorbidities without increasing the risk of complications.

• Journal of Gastric Cancer
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• v.22 no.1
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• pp.47-55
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• 2022

Purpose: The use of direct oral Xa inhibitors (DXaIs) to prevent venothrombotic events is increasing. However, gastrointestinal bleeding, including that related to endoscopic resection, is a concern. In this study, we evaluated bleeding and coagulation times during the perioperative period of gastric endoscopic submucosal dissection (ESD). Materials and Methods: Patients who consecutively underwent gastric ESD from August 2016 to December 2018 were analyzed. Bleeding rates were compared among the 3 groups (antiplatelet, DXaIs, and control). DXaI administration was discontinued on the day of the procedure. Prothrombin time (PT), activated partial thromboplastin time, and the ratio of inhibited thrombin generation (RITG), which was based on dilute PT, were determined before and after ESD. Results: During the study period, 265 gastric ESDs were performed in 239 patients, where 23 and 50 patients received DXaIs and antiplatelets, respectively. Delayed bleeding occurred in 17 patients (7.4%) and 21 lesions (7.1%). The bleeding rate in the DXaI group was significantly higher than that in the other groups (30.4%, P<0.01), and the adjusted odds ratio of bleeding was 5.7 (95% confidence interval, 1.4-23.7; P=0.016). In patients using DXaIs, there was a significant (P=0.046) difference in the median RITG between bleeding cases (18.6%) and non-bleeding cases (3.8%). Conclusions: A one-day cessation of DXaIs was related to a high incidence of bleeding after gastric ESD, and monitoring of residual coagulation activity at trough levels might enable the predicted risk of delayed bleeding in patients using DXaIs.

• Clinical Endoscopy
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• v.56 no.4
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• pp.470-478
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• 2023

Background/Aims: Metachronous recurrence incidences and risk factors following endoscopic submucosal dissection (ESD) for gastric adenocarcinoma and dysplasias were investigated. Methods: Retrospective review of electronic medical records of patients who underwent gastric ESD at The Catholic University of Korea, Yeouido St. Mary's Hospital. Results: A total of 190 subjects were enrolled for analysis during the study period. The mean age was 64.4 years and the male sex occupied 73.7%. The mean observation period following ESD was 3.45 years. The annual incidence rate of metachronous gastric neoplasms (MGN) was about 3.96%. The annual incidence rate was 5.36% for the low-grade dysplasia group, 6.47% for the high-grade dysplasia group, and 2.74% for the EGC group. MGN was more frequent in the dysplasia group than in the EGC group (p<0.05). For those with MGN development, the mean time interval from ESD to MGN was 4.1 (±1.8) years. By using the Kaplan-Meier model, the estimated mean MGN free survival time was 9.97 years (95% confidence interval, 8.53-11.40) The histological types of MGN were not related to the primary histology types. Conclusions: MGN following ESD developed in 3.96% annually and MGN was more frequent in the dysplasia group. The histological types of MGN did not correlate with those of primary neoplasm.

• Clinical Endoscopy
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• v.55 no.6
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• pp.767-774
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• 2022

Background/Aims: Few studies have compared the performances of endoscopic knives. This study aimed to compare the therapeutic outcomes of a novel core knife and the conventional IT knife 2 for endoscopic submucosal dissection (ESD) of gastric mucosal lesions. Methods: This prospective, non-inferiority trial included patients diagnosed with gastric adenoma or early-stage adenocarcinoma at Keimyung University Dongsan Hospital between June and November 2020. The patients were randomly assigned to either the core knife or the IT knife 2 group. The operators and assistants scored the knives' grip convenience and cutting abilities. Results: A total of 39 patients were enrolled (core knife group, 20 patients; IT knife 2 group, 19 patients). There were no significant between-group differences in operator-assessed grip convenience (9.600 vs. 9.526, p=0.753), cutting ability (9.600 vs. 9.105, p=0.158), or assistant-assessed grip convenience (9.500 vs. 9.368, p=0.574). Conclusions: The core knife achieved therapeutic outcomes that were comparable to those of the IT knife 2 for ESD of gastric mucosal lesions.

• Clinical Endoscopy
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• v.55 no.1
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• pp.43-44
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• 2022

• Journal of Gastric Cancer
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• v.11 no.3
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• pp.155-161
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• 2011

Purpose: To determine the diagnostic utility of a frozen section biopsy in patients undergoing endoscopic submucosal dissection (ESD) for early gastric neoplasms with obscure margins even with chromoendoscopy using acetic acid and indigo carmine (AI chromoendoscopy). Materials and Methods: The lateral spread of early gastric neoplasms was unclear even following AI chromoendoscopy in 38 patients who underwent ESD between June 2007 and May 2011. Frozen section biopsies were obtained by agreement of the degree of lateral spread between two endoscopists. Thus, frozen section biopsies were obtained from 23 patients (FBx group) and not in the other 15 patients (AI group). Results: No significant differences were observed for size, histology, invasive depth, and location of lesions between the AI and FBx groups. No false positive or false negative results were observed in the frozen section diagnoses. Adenocarcinoma was revealed in three patients and tubular adenoma in one, thereby changing the delineation of lesion extent and achieving free lateral margins. The rates of free lateral resection margins and curative resection were significantly higher in the FBx group than those in the AI group. Conclusions: Frozen section biopsy can help endoscopists perform more safe and accurate ESD in patients with early gastric neoplasm.

• Journal of Gastric Cancer
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• v.22 no.4
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• pp.339-347
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• 2022

Purpose: Lymphovascular invasion is a criterion for non-curative resection in patients who have undergone endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). We aimed to determine the rate of extragastric metastasis (EGM) and identify the predictors of EGM in patients with negative resection margins (R0 resection) and lymphovascular invasion in post-ESD pathology. Materials and Methods: A total of 2,983 patients underwent ESD for EGC. Among them, 110 had a pathology of R0 resection and positive lymphovascular invasion. Patients underwent additional gastrectomy (n=63) or further follow-up without gastrectomy (n=47). Results: The 110 patients were assigned to one of the 3 groups according to ESD indications based on post-ESD pathology. The first group satisfied the absolute indication for ESD (n=18), the second group satisfied the expanded indications for ESD (n=34), and the last group satisfied the beyond indication (n=58). The number of occurrences of EGM in each group was 1 (5.6%), 3 (8.8%), and 3 (5.2%), respectively. The logistic regression analysis adjusted for age, sex, tumor size, and indication for ESD, showed that larger tumor size was associated with EGM (odds ratio, 1.76; 95% confidence interval, 1.00-3.10; P=0.048). In contrast, ESD indication criteria did not affect EGM (P=0.349). Conclusions: Tumor size was the only predictive indicator for EGM in patients who underwent R0 resection and lymphovascular invasion on post-ESD pathology. Even patients with pathology corresponding to the absolute indication criteria of ESD had lymphovascular invasion, which means that they require additional gastrectomy due to the risk of EGM.

• Journal of Gastric Cancer
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• v.23 no.3
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• pp.451-461
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• 2023

Purpose: Endoscopic submucosal dissection (ESD) is an effective treatment for early gastrointestinal neoplasms. However, this is a time-consuming procedure requiring various devices. This study aimed to evaluate the efficacy and safety of the ClearCut^TM Knife H-type, which is an integrated needle-tipped and insulated-tipped (IT) knife. Materials and Methods: Between July 2020 and September 2021, 99 patients with gastric epithelial neoplasms scheduled for ESD at three tertiary care hospitals were randomly assigned to H-knife (ClearCut^TM Knife H-type) or IT-knife (conventional IT knife) groups. Procedure times, therapeutic outcomes, and adverse events were analyzed. Results: A total of 98 patients (50 in the H-knife group and 48 in the IT-knife group) were analyzed. The median total procedure time was 11.9 minutes (range, 4.4-47.2 minutes) in the H-knife group and 12.7 minutes (range, 5.2-137.7 minutes) in the IT-knife group (P=0.209). Unlike the IT-knife group, which required additional devices in all cases, no additional devices were used in the H-knife group (P<0.001). En-bloc resection was performed for all lesions in both groups. The incidence of adverse events was not significantly different between groups (4.0% in the H-knife group vs. 8.3% in the IT-knife group; P=0.431). Conclusions: The newly developed hybrid device, the ClearCut^TM Knife H-type, had comparable efficacy to the conventional IT knife for gastric ESD.