Factors associated with technical difficulty in endoscopic submucosal dissection for undifferentiated early gastric...

Endoscopic submucosal dissection (ESD) is a minimally-invasive curative treatment for early gastric cancer (EGC). Recently, JCOG1009/1010, a multicenter, prospective, single-arm, confirmatory trial, showed that of ESD for undifferentiated early gastric cancer (UD-EGC) ≤ 2 cm without ulceration are comparable with those of gastrectomy, resulting in the expansion of the indications of ESD for UD-EGC. Herein, we explored the factors associated with technical difficulty in ESD in patients with UD-EGC using data from JCOG1009/1010.

The inclusion criteria for JCOG1009/1010 were histologically proven undifferentiated-type adenocarcinoma, cT1aN0M0, absence of ulceration, and tumor size of < 2 cm. The technically difficult cases were defined as those with an ESD procedure time of > 120 min, intraoperative perforation, or incomplete en bloc resection. We compared difficult and non-difficult ESD cases and performed multivariable analysis.

Of 346 patients enrolled in JCOG1009/1010, 332 were analyzed. Technical difficulties were experienced in 70 (21%) patients: procedure > 120 min (55 patients, intraoperative perforation (18 patients), and incomplete en bloc resection (four patients). Upper location (versus [vs.] lower, odds ratio [OR]: 4.20, 95% confidence interval [CI]: 1.52-11.64, p = 0.006), post-eradication of Helicobacter pylori infection (vs. presence, OR: 0.40, 95% CI: 0.17-0.98, p = 0.045), and absence of atrophy in the background mucosa around the lesion (vs. presence, OR: 2.56, 95% CI: 1.22-5.41, p = 0.013) were independent factors significantly associated with technical difficulty in ESD.

Upper location, H. pylori infection, and absence of atrophy in the background mucosa around the lesion were associated with technical difficulty in ESD for UD-EGC.