Endoscopic submucosal dissection in early gastric cancer in elderly patients and comorbid conditions

Table 1 Endoscopic submucosal dissection in elderly patient n (%)

Ref.	Age(yr)	Patients n, lesions n	En-bloc resection,with R0, %	Perforation	Late bleeding	Pneumonia
Hirasaki et al[53]	≥ 75	53, 53	96, 81	1 (1.9)	(43%)1	NE
Kakushima et al[14]	≥ 75	42, 49	NE, 96	1 (2)	3 (7)	NE
Akasaka et al[15]	≥ 75	459, 459	NE	20 (4.4)	12 (2.6)	15 (3.3)
Toyokawa et al[54]	≥ 75	200, 229	92, 80	4 (1.7)	22 (9.6)	2 (0.87)
Abe et al[55]	≥ 80	440, 470	NE, 77.9	12 (2.8)	14 (3.2)	NE
Park et al[17]	≥ 70	132, 132	NE	6 (4.5)	5 (3.8)	6 (4.5)
Zhang et al[56]	≥ 75	171, 187	98, 94.1		(15.2%)2	NE

¹Bleeding was defined in cases that required endoscopic management with methods such as clip placement and/or monopolar electrocoagulation to stop the bleeding, including early and late bleeding. One patient required surgery to treat the bleeding;

²Immediate bleeding. NE: Not evaluated.

Table 2 Endoscopic submucosal dissection in patients treated with antithrombotic agents n (%)

Ref.	Patients n, lesions n	En-bloc resection,with R0, %	Perforation	Late bleeding	HR No., bleeding	Thrombogenic event
Ono et al[21]	471, 56	96.4/82.1	1 (1.8)	6 (10.7)	1, 3 (33)	0 (0)
Lim et al[24]	274, ND	NE	0 (0)	26 (12.6)2	NA	1 (0.5)3
Koh et al[26]	175, ND	NE	NE	17 (9.7)4	NA	0 (0)
Takeuchi et al[27]	90, 90	NE	NE	21 (23.3)5	12, 21 (57)	1 (1)
Yoshio et al[22]	24, 24	100/100	0 (0)	9 (38)6	9, 24 (38)	1 (4.2)

¹Forty-four low-risk patients stopped treatment with antithrombotic agents for 1 wk before and after endoscopic submucosal dissection (ESD). Three high-risk patients underwent intravenous heparin replacement during the cessation period;

²A total of 274 patients were treated with antiplatelet medication, 102 of whom discontinued the use of these drugs for 7 d or more before ESD, whereas the remaining patients continued use;

³One (1%) of the 102 patients who discontinued the use of antiplatelet medication developed an acute cerebral infarction;

⁴Antithrombotic drug therapy was principally interrupted preoperatively and restarted when hemostasis was confirmed by second-look endoscopy. The rate of early postoperative bleeding during the first 5 postoperative days was 4%, and the rate of subsequent bleeding was 5.7%;

⁵All patients commenced treatment with proton pump inhibitors immediately following surgery. Antiplatelet agents were discontinued for 7 d preoperatively until postoperative day 1, and anticoagulants were discontinued for 5 d preoperatively until postoperative day 1. A total of 46 patients received low-dose aspirin (LDA) only, 23 received LDA + thienopyridine, and 21 received LDA + warfarin. Anticoagulants were discontinued from preoperative day 4 to postoperative day 2. Heparin was substituted for anticoagulants after the latter were discontinued;

⁶All patients underwent intravenous heparin replacement during the cessation period because of an increased risk of thromboembolism. HR: Heparin replacement; NA: Not applicable; NE: Not evaluated.

Table 3 Endoscopic submucosal dissection in patients with chronic kidney disease n (%)

Ref.	CKD, n/lesions, n	Hemodialysis,n	HR, n	En-bloc resection, with R0, %	Perforation	Late bleeding
Goto et al[34]	7/9	7	ND	100/100	0 (0)	1 (14)
Kwon et al[35]	171/19	8	ND	94.7/94.7	0 (0)	3 (17.6)2
Numata et al[36]	63 /79	12	2	89.9/89.9	3 (4.8)	11 (17.5)3
Yoshioka et al[37]	144/ 144	19	7	95.8/86.1	6 (4.2)	8 (5.6)

¹Includes 2 patients with peritoneal dialysis;

²Original paper reported 15.5%, which represented the percentage of perforation per lesion;

³The rate of late bleeding was 33.3% (5/15) in hemodialysis patients and 9.4% (6/64) in non-hemodialysis patients; the difference was significant (P < 0.05). ND: Not described; HR: Heparin replacement.

Table 4 Endoscopic submucosal dissection in patients with liver cirrhosis

Ref.	Patients N (Child-Pugh A, B, C)/lesion, n	En-bloc resection,with R0, %	Perforation n (%)	Late bleedingn (%)	Median observation period (mo)Prognosis
Ogura et al[51]	15 (9, 6, 0)/18	88.9, 77.8	0 (0)	3 (20)	21.4 mo No recurrence but 3 patients underwent additional ER or surgery
Kwon et al[35]	18 (13, 3, 2)/22	90.9, 86.4	1 (5.6)	ND (approximately 9)	NE
Choi et al[57]	23 (20, 3, 0)/23	86.2, 82.6	0 (0)	1 (4.3)	17.5 mo (range, 2 to 72 mo) No local recurrence was found in either group during the follow-up period
Repici et al[58]	5 (4, 1, 0) /5	100, 100	0 (0)	2 (40)	22 mo (range, 18 to 36 mo) No recurrence
Kato et al[52]	69 (53, 15, 1)/69	99, 90	1 (1.5)	4 (5.8)	33.4 mo (range, 0.5-96.9 mo) The 5-yr overall survival rates were 60%

ND: Not described; NE: Not evaluated.