Retrospective Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Jan 16, 2022; 14(1): 49-62
Published online Jan 16, 2022. doi: 10.4253/wjge.v14.i1.49
Feasibility of gastric endoscopic submucosal dissection in elderly patients aged ≥ 80 years
Yasuhiro Inokuchi, Ayaka Ishida, Kei Hayashi, Yoshihiro Kaneta, Hayato Watanabe, Kazuki Kano, Mitsuhiro Furuta, Kosuke Takahashi, Hirohito Fujikawa, Takanobu Yamada, Kouji Yamamoto, Nozomu Machida, Takashi Ogata, Takashi Oshima, Shin Maeda
Yasuhiro Inokuchi, Ayaka Ishida, Kei Hayashi, Yoshihiro Kaneta, Mitsuhiro Furuta, Nozomu Machida, Department of Gastroenterology, Kanagawa Cancer Center, Yokohama 241-8515, Kanagawa, Japan
Hayato Watanabe, Kazuki Kano, Kosuke Takahashi, Hirohito Fujikawa, Takanobu Yamada, Takashi Ogata, Takashi Oshima, Department of Gastrointestinal Surgery, Kanagawa Cancer Center, Yokohama 241-8515, Kanagawa, Japan
Kouji Yamamoto, Department of Biostatics, Yokohama City University School of Medicine., Yokohama 236-0004, Kanagawa, Japan
Shin Maeda, Department of Gastroenterology, Yokohama City University, Yokohama 236-0004, Kanagawa, Japan
Author contributions: Inokuchi Y and Maeda S designed the study; Inokuchi Y, Ishida A, Hayashi K, Kaneta Y were involved in collection of data; Inokuchi Y, Yamamoto K, and Furuta M were involved in the data analysis; Inokuchi Y, Ishida A, Hayashi K, Kaneta Y, Watanabe H, Kano K, Furuta M, Takahashi K, Fujikawa H, Yamada T, Yamamoto K, Machida N, Ogata T, Oshima T, and Maeda S were involved in data interpretation; Inokuchi Y wrote the manuscript; Ishida A, Hayashi K, Kaneta Y, Watanabe H, Kano K, Furuta M, Takahashi K, Fujikawa H, Yamada T, Yamamoto K, Machida N, Ogata T, Oshima T, and Maeda S edited the manuscript; all authors critically revised the report, commented on drafts of the manuscript, and approved the final report.
Institutional review board statement: This study has been approved by the research ethics committee of Kanagawa Cancer Center, which complies with International Guidelines for Ethical Review of Epidemiological Studies.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed to treatment by written consent. According to "Ethical Guidelines for Medical and Health Research Involving Human Subjects" published by Japanese Ministry of Health, Labor and Welfare, opt-out is accepted for practical procedure to obtain informed consent from the recruited patients, in retrospective study without any invasion or newly investigated information after recruitment. For our study, we have put information concerning the study on Kanagawa Cancer Center HP, to give recruited patients a chance to refuse entry to the study.
Conflict-of-interest statement: The authors have declared no conflict of interest.
Data sharing statement: No additional data are available.
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: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Yasuhiro Inokuchi, MD, PhD, Chief Doctor, Department of Gastroenterology, Kanagawa Cancer Center, 2-3-2 Asahi-ku, Nakao, Yokohama 241-8515, Kanagawa, Japan. inokuchiy@kcch.jp
Received: April 27, 2021
Peer-review started: April 27, 2021
First decision: June 13, 2021
Revised: June 16, 2021
Accepted: December 11, 2021
Article in press: December 11, 2021
Published online: January 16, 2022
Abstract
BACKGROUND

Endoscopic resection, especially endoscopic submucosal dissection (ESD), is increasingly performed in elderly patients with early gastric cancer, and lesions beyond the expanded indications are also resected endoscopically in some patients. It is essential to assess whether gastric ESD is safe and suitable for elderly patients and investigate what type of lesions carry an increased risk of ESD-related complications.

AIM

To assess the efficacy and feasibility of gastric ESD for elderly patients, and define high-risk lesions and prognostic indicators.

METHODS

Among a total of 1169 sessions of gastric ESD performed in Kanagawa Cancer Center Hospital from 2006 to 2014, 179 sessions (15.3%) were performed in patients aged ≥ 80 years, and 172 of these sessions were done in patients with a final diagnosis of gastric cancer. These patients were studied retrospectively to evaluate short-term outcomes and survival. The short-term outcomes included the rates of en bloc resection and curative resection, complications, and procedure-related mortality. Curability was assessed according to the Japanese Gastric Cancer Treatment Guidelines 2010. Fisher’s exact test was used to statistically analyze risk factors. Clinical characteristics of each group were compared using Fisher’s exact test and Mann-Whitney U test. Survival rates at each time point were based on Kaplan-Meier estimation. Overall survival rates were compared between patients with gastric cancer in each group with use of the log-rank test. To identify prognostic factors that jointly predict the hazard of death while controlling for model overfitting, we used the least absolute shrinkage and selection operator (LASSO) Cox regression model including factors curative/ noncurative, age, gender, body mass index, prognostic nutritional index, Charlson comorbidity index (CCI), Glasgow prognostic score, neutrophil-to-lymphocyte ratio, and antithrombotic agent use. We selected the LASSO Cox regression model that resulted in minimal prediction error in 10-fold cross-validation. P < 0.05 was considered statistically significant.

RESULTS

The en bloc dissection rate was 97.1%, indicating that a high quality of treatment was achieved even in elderly patients. As for complications, the rates of bleeding, perforation and aspiration pneumonitis were 3.4%, 1.1% and 0.6%, respectively. These complication rates indicated that ESD was not associated with a particularly higher risk in elderly patients than in nonelderly patients. A dissection incision > 40 mm, lesions associated with depressions, and lesions with ulcers were risk factors for post-ESD bleeding, and location of the lesion in the upper third of the stomach was a risk factor for perforation in elderly patients (P < 0.05). Location of the lesion in the lower third of the stomach tended to be associated with a higher risk of bleeding. The overall survival (OS) did not differ significantly between curative and noncurative ESD (P = 0.69). In patients without additional surgery, OS rate was significantly lower in patients with a high CCI (≥ 2) than in those with a low CCI (≤ 1) (P < 0.001).

CONCLUSION

Gastric ESD is feasible even in patients aged ≥ 80 years. Observation without additional surgery after noncurative ESD is reasonable, especially in elderly patients with CCI ≥ 2.

Keywords: Endoscopic submucosal dissection, Elderly, Charlson comorbidity index, Early gastric cancer, Complications, Prognostic indicators

Core Tip: This was a retrospective study to evaluate the efficacy and feasibility of gastric endoscopic submucosal dissection in elderly patients aged ≥ 80 years. The rates of en bloc dissection, bleeding, perforation and aspiration pneumonitis were 97.1%, 3.4%, 1.1% and 0.6%, respectively. These rates are similar to the rates in nonelderly patients reported previously. Risk factors for bleeding were incision > 40 mm, lesions associated with depressions, and ulcerative lesions. A risk factor for perforation was location in the upper third of the stomach. Charlson comorbidity index ≥ 2 was an indicator of poor prognosis regardless of curability.