Treatment strategy for early gastric cancer with the risk of pyloric stenosis after endoscopic resection

We read with great interest the study by Dr. Coda and his colleagues, ”Risk factors for cardiac or pyloric stenosis after endoscopic submucosal dissection, and efficacy of endoscopic balloon dilation treatment,” regarding early gastric cancer (EGC) [1].

At our center, endoscopic submucosal dissection (ESD) was performed for 433 EGCs (185 located in the lower third of the stomach, 146 in the middle third, and 102 in the upper third) from July 2000 to October 2008, and post-ESD stenosis occurred in five of the 185 pyloric resections. Four of the five had risk factors for post-ESD stenosis, that is a circumferential extent of the mucosal defect of more than Ÿ or longitudinal extent of more than 5 cm, as described in the paper of Coda et al. [1].

The authors concluded that endoscopic balloon dilation was useful for pyloric stenosis after ESD. However, we think that balloon dilation is not always appropriate, considering the frequency of procedures needed, and risk of adverse events to the patient. In our series, four patients suffered from nausea and vomiting for a mean of 38 days (range 31 – 70), although the stenoses finally resolved with frequent balloon dilations. Furthermore, one patient sustained a perforation during her first balloon dilation, requiring an emergency operation ([Fig. 1]).

Fig. 1 Endoscopic image of perforation caused by balloon dilation for pyloric stenosis after endoscopic submucosal dissection (ESD). Omental fat tissue was seen in the anterior side of the pyloric ring.

We believe, therefore, that balloon dilation is not always a safe treatment for post-ESD pyloric stenosis.

Coda and colleagues also reported that one of eight patients with pyloric stenosis had to undergo an additional distal gastrectomy with lymph node dissection following balloon dilation. Since the risk of lymph node metastasis is pathologically evaluated from the resected ESD specimens, the indication for ESD with high risk factors for pyloric stenosis should be decided carefully from the viewpoint of minimizing invasiveness.

Considering the above, we have started to recommend laparoscopic distal gastrectomy (LDG) including lymph node dissection for EGC with high risk of post-ESD pyloric stenosis. LDG for EGC is considered less invasive than open distal gastrectomy and is widely accepted in Korea and Japan. Long-term clinical outcome and survival have not been found to be different for the two surgical methods [2] [3] [4]. Our recent cases of EGC with high risk of pyloric stenosis have been successfully resected by LDG without complication, and with a median hospitalization of 20 days ([Fig. 2 a] [b]).

Fig. 2 a Antral 0 IIa + IIc lesion with ⅔ circumferential extent. Given the risk of pyloric stenosis after ESD, this lesion was resected by laparoscopic distal gastrectomy (LDG). b The resected specimen revealed an intramucosal well-differentiated adenocarcinoma without lymphatic or venous invasion.

We agree that EGC near the cardia should be treated by ESD although this has high risk factors for cardiac stenosis. The standard operation for EGC near the cardia is total gastrectomy, which often makes the quality of life of patients worse because of weight loss, anorexia, dysphagia, and so forth [5] [6] [7]. ESD for cardiac lesions could avoid total gastrectomy if resection is curative, and consequently could preserve gastric function, although balloon dilation is required for cardiac stenosis [8].

ESD for EGC with a negligible risk of lymph node metastasis has been recognized as less invasive and more economical than conventional surgery. However, we should take into consideration the benefits and risks of ESD and LDG when deciding upon treatment strategies for EGC, especially in patients with lesions at high risk of post-ESD stenosis.

Competing interests: None

References

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