Long-term Clinical Outcomes and Risk of Peritoneal Seeding after Endoscopic Submucosal Dissection for Early Gastric Cancer: A Focus on Perforation during the Procedure

Abstract

Background/AimsThe risk of peritoneal seeding following perforation after endoscopic resection in patients with early gastric cancer is unclear. The purpose of this study was to investigate long-term clinical outcomes including peritoneal seeding and overall survival rate following gastric perforation during endoscopic submucosal dissection (ESD).MethodsBetween January 2002 and March 2015, 556 patients were diagnosed with early gastric cancer and underwent ESD. Among them, 34 patients (6.1%) experienced gastric perforation during ESD. Clinicopathological data of these patients were reviewed to determine the clinical outcome and evidence of peritoneal seeding.ResultsAmong 34 patients with perforation, macroperforations occurred during ESD in 17 cases (50%), and microperforation was identified in the remaining 17 cases (50%). All patients except one who underwent emergency surgery due to severe panperitonitis were managed successfully by endoscopic clipping (n=27) or conservative medical treatment (n=6). No evidence of peritoneal seeding after perforation associated with ESD was found in our cohort. Cumulative survival rates did not differ between the perforation and non-perforation groups (p=0.691). Furthermore, mortality was not associated with perforation. In addition, multivariate analysis showed that tumor size and achievement of curative resection were related to cancer recurrence. Perforation was not associated with cancer recurrence and survival.ConclusionsPerforation associated with ESD does not lead to worse clinical outcomes such as peritoneal seeding or cumulative survival rate. Therefore, periodic follow-up might be possible if curative resection was achieved even if perforation occurred during ESD.

Advances in Intraluminal Exfoliative Cytology of Gastric Cancer: Oncologic Implication of the Sixth Metastatic Route (Metastasis VI)

“…In this regard, IEC (Metastasis VI) of early GC has been confirmed by several works (13,19) (Table I) and its seeding through gastric wall perforation to the peritoneal cavity, as occurs accidentally or intentionally during endoscopic submucosal dissection or laparoscopic endoscopic cooperative surgery respectively, assessed as the main cause of early GC-related PM (22)(23)(24)(25). As of 2019, M has been recorded in four patients with early GC who experienced gastric wall perforation during endoscopic submucosal dissection; three of them later died (22)(23)(24) (Table II). IEC of early GC can be also associated with the development of port-site metastasis after ANTICANCER RESEARCH 39: 4019-4022 (2019) 4020 (28,29), we strongly suggest it should be kept in mind and such a topic be further explored in future research.…”

“…Differently from advanced GC, however, early GC shows minimal infiltration of the gastric wall and no cancer cells floating in peritoneal cavity: hence, the four traditional metastatic routes cannot explain the development of PM in such an initial phase of disease and other pathways (such as Metastasis V and VI) might be involved (4-6, 13,15,20). In this regard, IEC (Metastasis VI) of early GC has been confirmed by several works (13,19) (Table I) and its seeding through gastric wall perforation to the peritoneal cavity, as occurs accidentally or intentionally during endoscopic submucosal dissection or laparoscopic endoscopic cooperative surgery respectively, assessed as the main cause of early GC-related PM (22)(23)(24)(25). As of 2019, M has been recorded in four patients with early GC who experienced gastric wall perforation during endoscopic submucosal dissection; three of them later died (22)(23)(24) (Table II).…”

Potential for Peritoneal Metastasis after Gastric Perforation Induced by Endoscopic Submucosal Dissection of Early Gastric Cancer

“…In this issue of Gut and Liver , Huh et al 7. retrospectively reviewed 556 patients who had undergone ESD for EGC between January 2002 and March 2015, and they investigated long-term clinical outcomes especially for peritoneal seeding metastasis in 34 patients who had experienced gastric perforation during ESD.…”