Implementation of endoscopic submucosal dissection in a country with a low incidence of gastric cancer: Results from a prospective national registry

• Published in: United European gastroenterology journal Vol. 9; no. 6; pp. 718 - 726
• Main Authors: Fernández‐Esparrach, Gloria, Marín‐Gabriel, José‐Carlos, Tejada, Alberto H., Albéniz, Eduardo, Nogales, Oscar, Pozo‐García, Andres J., Rosón, Pedro J., Goicotxea, Unai, Uchima, Hugo, Terán, Alvaro, Alberto, Alvarez, Joaquín, Rodríguez‐Sánchez, Liseth, Rivero‐Sánchez, José, Santiago
• Format: Journal Article
• Language: English
• Published: England John Wiley & Sons, Inc 01.07.2021; John Wiley and Sons Inc
• Subjects: Adult; Aged; Aged, 80 and over; Anticoagulants; early gastric cancer; Endoscopic Mucosal Resection - methods; endoscopic resection; endoscopic submucosal dissection; Endoscopy; Endoscopy, Gastrointestinal; en‐bloc; Female; Fibrosis; Gastric cancer; Gastric Mucosa - pathology; Gastric Mucosa - surgery; gastric premalignant lesions; General anesthesia; Histology; Humans; Incidence; Intubation; Logistic Models; Luminal; Male; Middle Aged; Morphology; Original; Patients; Prospective Studies; Registries; resection; Spain - epidemiology; Standard of care; Statistical analysis; Stomach Neoplasms - epidemiology; Stomach Neoplasms - pathology; Stomach Neoplasms - surgery; Treatment Outcome; Variables; Spain; en-bloc; endoscopic submucosal dissection; gastric premalignant lesions; endoscopic resection; resection; early gastric cancer
• ISSN: 2050-6406; 2050-6414
• DOI: 10.1002/ueg2.12101

Introduction Endoscopic submucosal dissection (ESD) has become the treatment of choice for early gastric malignancies. In recent years, the ESD technique has been implemented in Western countries with increasing use. Objectives To describe the results of gastric ESD in a Western country with a low incidence of gastric cancer. Patients and Methods The prospective national registry was conducted over 4 years in 23 hospitals, including 30 endoscopists. Epithelial and subepithelial lesions (SEL) qualified to complete removal with ESD were assessed. The technique, instruments, and solution for submucosal injection varied at the endoscopist's discretion. ESD was defined as difficult when: en‐bloc resection was not achieved, had to be converted to a hybrid resection, lasted more than 2 h or an intraprocedural perforation occurred. Additionally, independent risk factors for difficult ESD were analyzed. Results Two hundred and thirty gastric ESD in 225 patients were performed from January 2016 to December 2019 (196 epithelial and 34 SEL). Most lesions were located in the lower stomach (111; 48.3%). One hundred and twenty‐eight (55.6%) ESD were considered difficult. The median procedure time was 105 min (interquartile range [IQR]: 60–150). The procedure time for SEL was shorter than for epithelial lesions (90 min [45–121] vs. 110 min [62–160]; p = 0.038). En‐bloc, R0, and curative resection rates were 91.3%, 75.2%, and 70.9%, respectively. Difficult ESD had lower R0 resection rates than ESD that did not meet the difficulty criteria (64.8% and 87.6%; p = 0.000, respectively). Fibrosis and poor maneuverability were independent factors associated with difficult ESD (OR 3.6, 95%CI 1.1–11.74 and OR 5.07, 95%CI 1.6–16.08; respectively). Conclusions Although the number of cases is limited, the results of this analysis show acceptable en‐bloc and R0 rates in gastric ESD considering the wide variability in experience among the operators. Fibrosis and poor maneuverability were associated with more difficulty in completing ESD. Key Summary Summarize the established knowledge on this subject Endoscopic submucosal dissection (ESD) is the standard of care for treatment of early gastric cancers (GC). Due to a lower incidence of GC in European countries, the introduction of gastric ESD has been more gradual than in the East. ESD complications, technical and clinical success depend on the endoscopist's experience, the presence of submucosal fibrosis or invasive cancer, and poor access location. What are the significant and/or new findings of this study? This study shows the results from a prospective nationwide registry of gastric ESD in a low GC incidence country. Despite a relative low number of cases, quite acceptable outcomes (en‐bloc, R0 and curative resection of 91.3%, 75.2% and 70.9%, respectively) were observed considering the wide variability in experience among the operators. Difficult ESD were mainly associated with the presence of submucosal fibrosis and poor maneuverability; however, independent pre‐procedural factors were not identified. There was a trend of association between ESD difficulty and the location of the lesion in the upper/middle stomach