Factors associated with the outcomes of endoscopic submucosal dissection in pyloric neoplasms


      Pyloric neoplasms are one of the most technically difficult lesions to remove by endoscopic submucosal dissection (ESD).


      To evaluate the therapeutic outcomes of ESD in pyloric neoplasms according to clinicopathologic characteristics and to assess predictive factors for incomplete resection.


      A retrospective, single-center study.


      A total of 110 cases of pyloric adenomas and early cancers treated with ESD from January 2007 to May 2013 were included.


      ESD procedures with or without retroflexion maneuver were used in all qualifying cases.

      Main Outcome Measurements

      Therapeutic outcomes of ESD and procedure-related adverse events.


      Complete resection rates differed significantly in relation to location (pylorus vs pylorus with duodenal extension, 79% vs 58%), directional distribution (upper hemisphere vs lower hemisphere of the pylorus, 67% vs 90%), tumor size (≤ 10 mm vs > 10 mm, 84% vs 67%), and circumferential extent of pyloric mucosal resection (≤ 1/2 vs > 1/2, 92% vs 62%). On multivariate analysis, tumor location (pylorus with duodenal extension; odds ratio 5.747), hemispheric distribution (upper hemisphere; odds ratio 4.906), and circumferential extent of resection (> 1/2; odds ratio 3.960) were independent factors associated with incomplete resection. The rates of procedure-related bleeding, stenosis, and perforation were 8%, 1%, and 1%, respectively; none of the adverse events required surgical intervention.


      Single-center, retrospective study.


      ESD is a safe, effective, and feasible treatment for pyloric neoplasms. However, the complete resection rate decreases for tumors that have duodenal extension, are located in the upper hemisphere, and have large circumferential extent of resection.


      ESD (endoscopic submucosal dissection), P-type (pylorus only type), PD-type (pylorus-duodenal type)
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        • Chung I.K.
        • Lee J.H.
        • Lee S.H.
        • et al.
        Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study.
        Gastrointest Endosc. 2009; 69: 1228-1235
        • Jung S.W.
        • Jeong I.D.
        • Bang S.J.
        • et al.
        Successful outcomes of endoscopic resection for gastric adenomas and early cancers located on the pyloric ring (with video).
        Gastrointest Endosc. 2010; 71: 625-629
        • Kakushima N.
        • Yahagi N.
        • Fujishiro M.
        • et al.
        Efficacy and safety of endoscopic submucosal dissection for tumors of the esophagogastric junction.
        Endoscopy. 2006; 38: 170-174
        • Lim C.H.
        • Park J.M.
        • Park C.H.
        • et al.
        Endoscopic submucosal dissection of gastric neoplasia involving the pyloric channel by retroflexion in the duodenum.
        Dig Dis Sci. 2012; 57: 148-154
        • Ahn J.Y.
        • Choi K.D.
        • Choi J.Y.
        • et al.
        Procedure time of endoscopic submucosal dissection according to the size and location of early gastric cancers: analysis of 916 dissections performed by 4 experts.
        Gastrointest Endosc. 2011; 73: 911-916
        • Imagawa A.
        • Okada H.
        • Kawahara Y.
        • et al.
        Endoscopic submucosal dissection for early gastric cancer: results and degrees of technical difficulty as well as success.
        Endoscopy. 2006; 38: 987-990
        • Kim K.O.
        • Kim S.J.
        • Kim T.H.
        • et al.
        Do you have what it takes for challenging endoscopic submucosal dissection cases?.
        World J Gastroenterol. 2011; 17: 3580-3584
        • Pallotta N.
        • Cicala M.
        • Frandina C.
        • et al.
        Antro-pyloric contractile patterns and transpyloric flow after meal ingestion in humans.
        Am J Gastroenterol. 1998; 93: 2513-2522
        • Coda S.
        • Oda I.
        • Gotoda T.
        • et al.
        Risk factors for cardiac and pyloric stenosis after endoscopic submucosal dissection, and efficacy of endoscopic balloon dilation treatment.
        Endoscopy. 2009; 41: 421-426
        • Park J.C.
        • Kim J.H.
        • Youn Y.H.
        • et al.
        How to manage pyloric tumours that are difficult to resect completely with endoscopic resection: comparison of the retroflexion vs. forward view technique.
        Dig Liver Dis. 2011; 43: 958-964
        • Ahn J.Y.
        • Choi K.D.
        • Choi J.Y.
        • et al.
        Transnasal endoscope-assisted endoscopic submucosal dissection for gastric adenoma and early gastric cancer in the pyloric area: a case series.
        Endoscopy. 2011; 43: 233-235
        • Takenaka R.
        • Kawahara Y.
        • Okada H.
        • et al.
        Risk factors associated with local recurrence of early gastric cancers after endoscopic submucosal dissection.
        Gastrointest Endosc. 2008; 68: 887-894
        • Onozato Y.
        • Ishihara H.
        • Iizuka H.
        • et al.
        A large flat adenoma located on the pylorus ring successfully treated by endoscopic submucosal dissection.
        Dig Dis Sci. 2007; 52: 1738-1740
        • Lee D.W.
        • Jeon S.W.
        Management of complications during gastric endoscopic submucosal dissection.
        Diagn Ther Endosc. 2012; 2012: 624835
        • Park C.H.
        • Lee S.K.
        Preventing and controlling bleeding in gastric endoscopic submucosal dissection.
        Clin Endosc. 2013; 46: 456-462
        • Toyonaga T.
        • Nishino E.
        • Hirooka T.
        • et al.
        Intraoperative bleeding in endoscopic submucosal dissection in the stomach and strategy for prevention and treatment.
        Dig Endosc. 2006; 18: S123-S127
        • Piasecki C.
        Blood supply to the human gastroduodenal mucosa with special reference to the ulcer-bearing areas.
        J Anat. 1974; 118: 295-335
        • Piasecki C.
        • Wyatt C.
        Patterns of blood supply to the gastric mucosa. A comparative study revealing an end-artery model.
        J Anat. 1986; 149: 21-39
        • Kikuchi D.
        • Iizuka T.
        • Hoteya S.
        • et al.
        Usefulness of endoscopic ultrasound for the prediction of intraoperative bleeding of endoscopic submucosal dissection for gastric neoplasms.
        J Gastroenterol Hepatol. 2011; 26: 68-72