Predictive risk factors of perforation in gastric endoscopic submucosal dissection for early gastric cancer: a large, multicenter study

Abstract

Background Although endoscopic submucosal dissection (ESD) is standard therapy for early gastric cancer, the complication rate is unsatisfactory, with perforation as the major complication during ESD. There have been several reports regarding the complications of ESD for gastric tumor especially perforation; however, little is known about the predictors for complications in patients undergoing ESD. The purpose of this retrospective study was to determine the risk factors for perforation in patients with early gastric cancer during ESD. Methods Between February 2003 and May 2010, we performed ESD for 1,289 lesions in 1,246 patients at six tertiary academic hospitals in Daegu, Kyungpook, Korea. Patient-related variables (age, sex, and underlying disease), endoscopic-related variables (indication of ESD, lesion size, location, type, and mucosal ulceration), procedurerelated variables (operation time, complete resection, and invasion of submucosa/vessel/lymph node), and the pathologic diagnosis were evaluated as potential risk factors. Results The mean age of the patients was 64 years. The mean size of the endoscopic lesion was 19.4 mm. The overall en bloc resection rate was 93.3 %. Perforation (microperforation and macroperforation) was seen in 35 lesions. The location of the lesion (long axis: body/short axis: greater and lesser curvature) and piecemeal resection were associated with perforation (p = 0.01/0.047 and p = 0.049). Upon multivariate analysis, the location (body vs. antrum) of the lesion (odds ratio (OR) 2.636; 95 % confidence interval (CI) 1.319–5.267; p = 0.006) and piecemeal resection (OR 2.651; 95 % CI 1.056–6.656; p = 0.038) were significant predictive factors for perforation. Conclusions The result of this study demonstrated that the location of the lesion (body) and piecemeal resection were related to perforation during ESD. Keywords Endoscopic submucosal dissection Perforation Early gastric cancer more difficult and can result in more complications (particularly perforation and bleeding) compared with conventional EMR [2–6]. The perforation frequency is reported to be higher with ESD (4 %) than with EMR (0.5 %) [7, 8]. This complication has limited the use of ESD, although it provides en bloc complete resection samples. Several recent studies have shown that the recovery rate for patients who have iatrogenic perforations associated with ESD treated conservatively was the same as for patients without such complications [2, 7, 9]. Although there have been several reports regarding the complications of ESD for gastric tumor, especially perforation, little is known about the predictors for complications in patients undergoing ESD. In addition, no reports have included multiple medical center studies. The purpose of the present study was to determine the risk factors for perforation in patients with early gastric cancer (EGC) during ESD and to establish techniques to minimize these complications through a multicenter study.