Endoscopic submucosal dissection for gastric tube cancer after esophagectomy

Abstract

Background: Recent improvements in the survival of patients after esophagectomy have led to an increasing occurrence of gastric tube cancer (GTC). Removal of the reconstructed gastric tube, however, can lead to high morbidity and mortality.

Objective: To assess the feasibility and effectiveness of endoscopic submucosal dissection (ESD) for GTC.

Design: Retrospective study.

Setting: National Cancer Center Hospital, Tokyo, Japan.

Patients: We investigated patients with GTC after esophagectomy undergoing ESD from 1998 to 2011.

Intervention esd main outcome measurements: Patient characteristics, endoscopic findings, technical results, histopathology including curability and Helicobacter pylori gastritis, and long-term outcomes.

Results: There were 51 consecutive patients with 79 lesions including 38 lesions (48%) meeting the absolute indication, 31 (39%) satisfying the expanded indications, and 10 (13%) falling outside such indications. The median procedure time was 90 minutes. There were 73 en bloc resections (92%), 59 en bloc resections with tumor-free margins (R0 resections, 75%), and 51 curative resections (65%) based on the Japanese Gastric Cancer Association criteria. Fifty patients (98%) were assessed as H pylori gastritis positive. Adverse events included 3 perforations (3.8%) during ESD and 2 delayed perforations (2.5%) without any emergency surgery and 3 delayed bleeding (3.8%). Local recurrence was detected in 4 patients (7.8%), and metachronous GTCs were identified in 18 patients (35%). Five patients (10%) died of GTC including 3 metachronous lesions. The 5-year overall survival rate was 68.4%, and the disease-specific survival rate was 86.7% with 100% for curative and 72.7% for non-curative patients during a median follow-up period of 3.8 years (range, 0-12.1 years).

Limitation: Single-center retrospective study.

Conclusions: ESD for GTC was feasible and effective for curative patients; however, long-term outcomes for non-curative patients were less satisfactory.

Keywords: EGC; ESD; GTC; HM1; HMX; IT; LNM; SM1; SM2; early gastric cancer; endoscopic submucosal dissection; gastric tube cancer; horizontal margin inconclusive; horizontal margin positive; insulation-tipped; lymph node metastasis; submucosal deep cancer; submucosal superficial cancer.