Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Feb 28, 2022; 28(8): 840-852
Published online Feb 28, 2022. doi: 10.3748/wjg.v28.i8.840
Long-term outcomes of endoscopic submucosal dissection and surgery for undifferentiated intramucosal gastric cancer regardless of size
Gil Ho Lee, Eunyoung Lee, Bumhee Park, Jin Roh, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee, Choong-Kyun Noh
Gil Ho Lee, Sun Gyo Lim, Sung Jae Shin, Kee Myung Lee, Choong-Kyun Noh, Department of Gastroenterology, Ajou University School of Medicine, Suwon 16499, South Korea
Eunyoung Lee, Bumhee Park, Department of Biomedical Informatics, Ajou University School of Medicine, Suwon 16499, South Korea
Jin Roh, Department of Pathology, Ajou University School of Medicine, Suwon 16499, South Korea
Author contributions: Lee GH and Lee E contributed equally to this work; Lee GH planned the study design, reviewed the data, analyzed the data and drafted the manuscript; Lee E and Park B analyzed and reviewed the statistical data; Roh J reviewed the pathologic data; Lim SG planned the study design and collected the data; Shin SJ and Lee KM interpreted the data and supervised the report; Noh CK conceptualized, drafted the manuscript and critically revised the manuscript; all the authors approved the final version of the article and agree to be accountable for all aspects of the work.
Institutional review board statement: The study protocol was approved by Ajou University Hospital Institution’s Review Board and Ethics Committee (Approval No. AJIRB-MED-MDB-21-101).
Informed consent statement: Patients were not required to give informed consent because the analysis used anonymous clinical data obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: No potential conflicts of interest were disclosed.
Data sharing statement: The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Choong-Kyun Noh, MD, PhD, Assistant Professor, Department of Gastroenterology, Ajou University School of Medicine, 164, Worldcup-ro, Yeongtong-gu, Suwon 16499, South Korea.
Received: July 30, 2021
Peer-review started: July 30, 2021
First decision: August 19, 2021
Revised: August 30, 2021
Accepted: January 27, 2022
Article in press: January 21, 2022
Published online: February 28, 2022

The clinical outcomes of endoscopic submucosal dissection (ESD) for undifferentiated (UD) intramucosal early gastric cancer (EGC) compared with those of surgery, regardless of lesion size, are not well known. Furthermore, there is a concern regarding the treatment plan before and after ESD in cases of UD intramucosal EGC within expanded indications.


To evaluate clinical outcomes of ESD compared with those of surgery in UD intramucosal EGC patients regardless of tumor size.


We enrolled patients with UD intramucosal EGC after ESD with complete resection or surgery from January 2005 to August 2020 who met the within or beyond expanded indications with lesion size > 2 cm (the only non-curative factor). Overall, 123 and 562 patients underwent ESD and surgery, respectively. After propensity-score matching, clinical and long-term outcomes, i.e., recurrence-free survival (RFS) and overall survival (OS), were analyzed. The multivariable Cox proportional hazard model with treatment modality and ESD indication was used to evaluate the recurrence risk.


After matching, 119 patients each were finally enrolled in the ESD and surgery groups. The median length of hospital stay was shorter in the ESD group than surgery group (4.0 vs 9.0 days, P < 0.001). Four cases of recurrence after ESD were local recurrences, all of which occurred within 1 year. Total recurrence was seven (5.9%) and two (1.7%) in the ESD and surgery groups, respectively. No difference was observed between the two groups with respect to OS (P = 0.948). However, the ESD group had inferior RFS compared with the surgery group (P = 0.031). ESD was associated with the risk of recurrence after initial treatment in all enrolled patients (hazard ratio, 5.2; 95% confidence interval: 1.0-25.8, P = 0.045).


Although OS was similar between the two groups, surveillance endoscopy was important for the ESD than for the surgery group because RFS was inferior and local recurrence was an issue.

Keywords: Early gastric cancer, Undifferentiated cancer, Expanded indication, Endoscopic submucosal dissection, Surgery

Core Tip: This retrospective study evaluated the clinical outcomes of endoscopic submucosal dissection (ESD) compared with those of surgery in patients with undifferentiated (UD) intramucosal early gastric cancer (EGC) after propensity-score matching. No difference in overall survival was observed between two groups, although recurrence-free survival was inferior in the ESD group. Lymph node metastasis was not observed after ESD; however, local recurrence was higher after ESD than surgery. Surveillance endoscopy is important in ESD, even if complete resection is performed for UD intramucosal EGC. A short interval endoscopic follow-up is necessary when observing lesion sizes > 2 cm as the only non-curative factor.