Optimization Of Postoperative Management Of Endoscopic Submucosal Dissection For Gastric Superficial Lesions

Background and aim:Enoscopic submucosal dissection(ESD)has been standard treatment for early gastric cancers and precancerous lesions.Postoperative bleeding is the major complication of ESD.It is difficult to get timely diagnosis and treatment due to the different occurrence time.Severe complications such as hemorrhagic shock may occur.Therefore,prevention of bleeding after ESD is an important issue.Pain after ESD is also a common adeverse reaction,but it's usually neglected.At present,pain has become the main factor to measure the quality of life and clinical pathway.Poor control of pain after ESD may lead to prolonged hospitalization time,increased hospitalization costs and reducing patient compliance.Therefore,with the improvement of requirements from patients,more attention should be paid to the pain after ESD.Further decision-making of diagnosis and treatment after ESD is also an important aspect of post-ESD management.The new eCura evaluation system combines the en bloc resetion and risk of lymph node metastasis to evaluate the post-ESD situation comprehensively,so as to formulate appropriate post-ESD management strategies.Methods:From November 2006 to December 2018,patients with gastric superficial lesions resected by ESD in First Medical Center of PLA General Hospital were selected to conduct the following three study parts.The first part included eligible patients to summarize the relevant clinical and pathological data,analyze the influencing factors of bleeding after ESD,and whether fibrin glue(FG)could prevent bleeding after ESD.The second part included eligible patients to retrospectively collect clinical and pathological data and prospective follow-up for pain 1 to 3 days after ESD.The degree of pain after ESD was recorded,and then the influencing factors of pain after ESD were analyzed.At the same time,the role of FG in pain was analyzed.In the third part,patients with early gastric cancer and high grade intraephelial neoplasia were included,and the curative condition after ESD was evaluated by eCura evaluation system.Results:In the first part,1441 lesions were included.The overall bleeding rate was 2.64%and early bleeding accounted for 52.63%.Univariate and multivariate analysis showed that the bleeding after ESD for gastric superfical lesions was related to the resected area,the longitudinal location of lesions,the operation time and FG application.Among the high risk lesions(resected area>10cm2,lower stomach and operation time>60 minutes),FG can significantly reduce the bleeding rate(2.38%vs 14.77%,P<0.05).In the second part,840 patients were retrospectively collected,and 35.48%patients presented pain after ESD.548 patients were prospectively collected,and 68.98%patients complained pain after ESD,and the median score of pain was 2.Univariate and multivariate analysis showed that moderate to severe pain after ESD was related to the area of lesion,the longitudinal location of lesion(lower stomach),muscularis propria injury,FG application and operator's experience.Compared with the control group,the highest score of pain in upper and middle part of stomach was lower in FG group(P<0.05),but there was no significant difference in lower part between the two groups.The third part included 994 lesions,including 701 cases(70.52%),65 cases(6.54%),96 cases(9.66%)and 132 cases(13.28%)in eCrua A,B,C1 and C2,respectively.There were no differences in the proportion of synchronous and metachronous recurrence and overall survival rate among the four grades,but the cancer-specific survival rate of grade C2 was lower than that of the other grades.The residual rate of grade Cl(5.32%vs A 1.46%,B 1.54%,C 2 0.77%)and local recurrence rate(11.70%vs A 3.07%,B 6.15%,C 2 4.62%)were significantly higher than those of other grades.There were no differences in the prognosis after complementary surgery,ESD and APC for residual and local recurrence cancers.The incidence of lymph node metastasis and distant metastasis after ESD in C2 was higher than that in other grades(3.85%vs A 0.15%,B 1.54%,C1 0%).There were no prognosis differences between supplementary surgery after ESD and follow-up observation group.Conclusions:In the first part,local spraying of FG on the ulcer after ESD is a simple method to reduce bleeding risk after ESD,especially for the patients with high-risk bleeding after ESD.The role of FG in preventing bleeding after ESD in patients with antithrombotic drugs and chronic renal insufficiency needs further study.In the second part,pain is common after ESD.The highest degree of pain occurs within 24 hours,and the pain relieves gradually within 2 days after operation.The local spraying of FG on the ulcer after ESD can reduce the degree of pain in the upper and middle part of the stomach,but has no obvious effect on the lower part without increasing the pain in that part.In the third part,eCura A and B need regular monitoring to prevent or detect recurrence and metachronous lesions.The rate of residual and local recurrence in grade C1 is high,and endoscopic treatment for residual and local recurrence is feasible and effective.The rate of lymphatic and distant metastasis in grade C2 is high,but the prognosis between supplementary surgery immediately after ESD and follow-up group,and then the following treatment need to integrate the individual condition.