Endoscopic submucosal dissection for gastric neoplasm in patients with co-morbidities categorized according to the ASA Physical Status Classification

Abstract

Background Endoscopic submucosal dissection (ESD) has come to be widely performed for reduced invasiveness; however, its safety in patients with co-morbidities is not fully examined. We aimed to evaluate the safety and efficacy of gastric ESD with co-morbidities categorized according to ASA Physical Status Classification. Methods Two hundred and forty patients of ASA 1 (no co-morbidities), 268 of ASA 2 (mild), and 19 of ASA 3 (severe) were treated by ESD for gastric neoplasms. We retrospectively compared clinicopathological features and treatment results of these three groups. Results Cases (by percent) treated with anticoagulant/ platelet agents were more common in the higher ASA grades (ASA 1, 5.8%; ASA 2, 29.1%; ASA 3, 31.6%; P \ 0.0001). There were no significant differences in case numbers treated under guideline criteria, curative resection (ASA 1, 79.6%; ASA 2, 79.9%; ASA 3, 78.9%), or complications related to the ESD procedure (e.g., postoperative bleeding, perforation, thermal injury). By a patient risk prediction model on surgery, i.e., P-POSSUM, morbidity was halved, and no patients died compared to a predicted death rate of 0.5-2%; however, total and complications unrelated to ESD procedure (e.g., aspiration pneumonia, ischemic heat attack) were more common in higher ASA grades (ASA 1, ASA 2, ASA 3: 15.4, 23.9, 26.3%, respectively, P = 0.014; 0.4, 7.1, 0%, respectively, P = 0.00087). Deviation rates from clinical pathway were more frequent and hospital stay (days) longer in higher ASA grades (ASA 1, ASA 2, ASA 3: 11.3, 17.9, 26.3%, respectively, P = 0.014; 8, 8, 9%, respectively, P = 0.0053). Conclusions ESD is an efficient treatment for gastric neoplasms with co-morbidities. However, additional caution is required because co-morbidity is a risk factor for both total complications and complications unrelated to the ESD procedure, and may cause deviations in the clinical course and prolonged hospital stay.

Long-term outcome of endoscopic submucosal dissection for early gastric cancer in patients with severe comorbidities: a comparative propensity score analysis

“…A previous study [14] has reported that there was no significant difference in adverse events associated with ESD, such as delayed bleeding and perforation, among each ASA-PS group. In the present study, a slightly higher rate (10.6%) of adverse events associated with ESD in ASA-PS group 3 was observed; however, it was lower than what we previously reported [22] for patients with surgical gastrectomy (24.4%).…”

“…This study revealed that the long-term surgical outcome for patients with severe comorbidities, who were categorized as ASA-PS 3, was unfavorable. In a different study, no significant differences of adverse events associated with ESD, such as delayed bleeding and perforation, among ASA-PS 1, 2, and 3 patients, were observed [14]. The long-term outcome of ESD for ASA-PS 3 patients with EGC has not been determined.…”

Risk factors for bleeding after gastric endoscopic submucosal dissection: a systematic review and meta-analysis

“…14,17,22,28,30,34,42 However, 3 studies found significantly increased PPB rates in patients with chronic kidney disease 45 and undergoing dialysis. 18,46 Comorbidities 28, 45 and American Society of Anesthesiologists Physical Status Classification System status 47 were not identified to be associated with PPB, although 1 study found increased PPB risk in patients with significant comorbidities. 25 Other clinical factors were analyzed in a few studies.…”

Association between CT-Diagnosed Pneumonia and Endoscopic Submucosal Dissection of Gastric Neoplasms

“…With respect to the safety evaluation of ESD in patients with comorbidities, Man-i et al [22] reported that comorbidity was a significant risk factor associated with complications unrelated to the ESD procedure (aspiration pneumonia, ischemic heart attack, arrhythmia and delirium). To the best of our knowledge, our study is the first to evaluate the relationship between diabetes mellitus and aspiration pneumonia after gastric ESD.…”