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Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD

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Abstract

Background and study aim

Endoscopic submucosal dissection (ESD) is a widely accepted treatment for superficial gastric neoplasms. Difficult ESD can lead to complications, such as bleeding and perforation. To predict difficult ESD procedures, we analyzed the factors associated with difficult ESD.

Patients and methods

The medical records of 1052 ESD procedures were retrospectively reviewed. Difficult ESD was defined by any one of three end points: longer procedure time (≥60 min), piecemeal resection, incomplete (R1) resection, or gastric wall perforation. To determine the factors associated with difficult ESD, clinical and pathologic features and endoscopic findings were analyzed.

Results

The rates of en bloc resection and curative (R0) resection were 93.3 and 92.4 %, respectively. The mean procedure time was 27.7 ± 16.7 min. After multivariate analysis, larger tumor size (≥20 mm) was an independent risk factor for longer procedure time (OR 4.1, P < 0.001), for piecemeal resection (OR 2.3, P = 0.003) and incomplete (R1) resection (OR 2.1, P = 0.005). Location of the lesion (upper third) was an independent risk factor for longer procedure time (OR 5.8, P < 0.001), for piecemeal resection (OR 4.1, P < 0.001) and incomplete (R1) resection (OR 4.5, P < 0.001). Submucosal fibrosis was an independent risk factor for longer procedure time (OR 9.7, P < 0.001), for piecemeal resection (OR 2.4, P < 0.001) and incomplete (R1) resection (OR 2.6, P < 0.001). Finally, submucosal invasive gastric cancer was an independent risk factor for piecemeal resection (OR 2.6, P = 0.008), for perforation (OR 19.3, P = 0.001) and for incomplete (R1) resection (OR 2.7, P = 0.001).

Conclusions

Difficult ESD procedures are a function of the lesion size and location, submucosal fibrosis, and submucosal invasive cancer. When a difficult ESD procedure is expected, appropriate preparations should be considered, including consultation with more experienced endoscopists.

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Acknowledgments

Ji Ha Kim and Hyeong Seok Nam contributed equally to this work and share first authorship. Cheol Woong Choi and Dae Hwan Kang contributed equally to this work and are co-correspondences for this article.

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    Authors and Affiliations

    1. Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea

      Ji Ha Kim, Hyeong Seok Nam, Cheol Woong Choi, Dae Hwan Kang, Hyung Wook Kim, Su Bum Park & Su Jin Kim

    2. Department of Surgery, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea

      Sun Hwi Hwang & Si Hak Lee

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    1. Ji Ha Kim
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    Correspondence to Cheol Woong Choi or Dae Hwan Kang.

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    Ji Ha Kim, Hyeong Seok Nam, Cheol Woong Choi, Dae Hwan Kang, Hyung Wook Kim, Su Bum Park, Su Jin Kim, Sun Hwi Hwang, Si Hak Lee have no conflicts of interest or financial ties to declare.

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    Kim, J.H., Nam, H.S., Choi, C.W. et al. Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD. Surg Endosc 31, 1617–1626 (2017). https://doi.org/10.1007/s00464-016-5149-6

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    • DOI: https://doi.org/10.1007/s00464-016-5149-6

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