Clinical Evaluation Of Endoscopic Submucosal Dissection For Early Gastric Cancer

Endoscopic mucosal resection (EMR), the so called strip biopsy method was first reported in 1984 and opened up a new era for endoscopic resection of early gastric cancer. With the development of new techniques and devices, a series of advanced techniques were introduced such as EMR after circumferential pre-cutting(EMR-P), EMR with a cap-fitted endoscope (EMR-C) and EMR with a ligating device(EMR-L) and so on. Though bring more convenience without special aided equipments, they are not reliable for en bloc resection of large lesions. Piecemeal resection may mislead the clinicians make incorrect decision for further treatments and consequently cause latent high risk of local recurrence.Endoscopic submucosal dissection(ESD) can provide en bloc resection for large scale lesions through exfoliating the submucosa using the improved needle knife and then overcome the defect of EMR on such lesions. However, ESD requires more advanced operator skill and greater experience than EMR, and may also increase the risk for complications such as sever bleeding and perforation. It is not sensible to extend the indication of ESD blindly to seek curability. Though many papers that compare the treatment results of ESD and EMR for EGC have been described, there still be controversy about which of the two methods is superior in practice. We searched out one meta analysis on these two methods treating for tumors of gastrointestinal tract and found all of studies they enrolled were from Japan and Korea and the patients contained premalignant and malignant lesions from esophagus to rectum.To compare the effect and complications of ESD and EMR, supplying clinical reference on reasonable choice for endoscopic resection of EGC.We make an overall strategy to search both electronically and manually, and accessed the quality of selected articles according to the inclusion and exclusion standard. Meta analysis was conducted using RevMan 5.0 software. 1.559 studies were retrieved initially according to the search strategy and 8 articals achieved inclusive criterias. A total of 3183 lesions were enrolled(ESD:1276; EMR:1907). All of the acquired papers were retrospective (6 full-text and 2 abstracts).2. The mean time required for resection was longer for ESD than for EMR (WMD 59.4,95%CI 16.8-102.0); the en bloc rate in ESD group was significantly higher than that in EMR group (OR 9.74,95%CI 7.61-12.47) and so was the total curability (OR 5.21,95%CI 2.53-10.72). ESD group also got higher rates of curative resection For lesions of size smaller than 10mm,10-20mm, larger than 20mm respectively than EMR group, but lower recurrence frequency (OR 0.12, 95%CI 0.06-0.26).3. Perforations were found more often in ESD group(OR 4.77,95%CI 2.79-8.18), but the bleeding incidences were similar between the two groups.ESD showed higher rates of en bloc and curative resection than EMR even for small size lesions with lower recurrence frequence. Though the bleeding incidences were similar between the two groups, higher risk of another sever complication-perforation in ESD may confine its application in small EGC. All of the results above should be confirmed by well-designed randomized controlled trails with larger samples and long enough follow-up periods from more countries.Endoscopic submucosal dissection; endoscopic mucosal resection; early gastric cancer; meta-analysis With the improvement of cutting tools and relative auxiliary equipments, endoscopic submucosal dissection is becoming the main treatment for early gastric cancer in some countries or areas such as Japan, Korea, HongKong and so on. ESD showed higher en bloc rate and curative rate but also higher risks of perforation and required longer procedure time compared with EMR. In our country, few reports are produced on account of short-time practice on this technique.To evaluate the efficacy and safety of ESD for early gastric cancer, Providing reference dates for its development and popularity in China.A total of 475 patient with gastric mucosal or submucosal lesions were treated by ESD in our endoscope center from Aug.2006 to Oct.2009. We analysed the procedures of those pathologically proved to be high grade intraepithelial neoplasia or early gastric cancer and made a follow-up visit, to eastimate curability and complications.1.66 patients for 66 lesions were enrolled in our study(HGIN:40; EGC:26), the male to female ratio was 3.7:1. Ages from 39-87 years old and the median age was 67 years old, the median size of lesions was 2cm, median procedure time was 45 minutes(range 15-160 minutes). The rates of en bloc and curative resection were 92.4%(61/66) and 87.9%(58/66) respectively. Minor bleeding during ESD occurred in 14 patients(21.2%) and were all managed successfully by endoscopic haemostasis without any massive hemorrhage. The delayed bleeding rate was 6.1%, both of the two patients who were detected hematemesis during 24 hours post-operation were staunched by stiffening agent and metal clips under endoscope. The other two cases were admitted of melena two weeks later but observed no active bleeding endoscopically and were dealed with drugs. After one month, one of them recurred and was treated conservatively again. One small perforation was encountered in stomach corner and was clamped by metal clips. Another 67 year old man was admitted for gastric retention one month after procedure and was managed successfully.2. Comparing with EGC group, HGIN group required shorter time(40min vs.55min, P=0.008) but showed significantly higher curative rates (95% vs.76.9%, P=0.028). No other differences were found such as in the aspects of age, gender, location, type and operation-time.3. Comparing the three different age group:young and middle age group(≤60 years old,13 patients), low aged elder group (60-69 years old,27 patients), high aged elder group(≥70 years old,26 patients), we got no discrepancy among them except that the en bloc resection rate was statistically low in the young and middle age group(P<0.05).4. Immediate intro-operation minor bleeding happened more often in the fundus and cardia of stomach (50%, P=0.009). Bleeding group required significantly longer procedure time than no bleeding occurred group, while also no other differences were calculated.5. The curability was associated with the histological type and the existence of ulcer. Early gastric cancer had a higher risk of non-curative resection than high grade intraepithelial neoplasia. Positive ulcer findings was a main risk factor.6. The median follow-up period was 9 months (range 3-40 months) with 5 patients lost visit, three cases of a local recurrence were observed, another one old patient died during the follow-up period but the cause of death was unknown.Endoscopic submucosal dissection was effective for early gastric cancer with acceptive complications. The intro-operation bleeding was related to location, which happended more frequently in the fundus and cardia of stomach. Positive ulcer findings is a main risk factor of non-curative dissection.