Research Article|Articles in Press

Endoscopic causes and characteristics of missed gastric cancers after endoscopic submucosal dissection

Published:February 24, 2023DOI:
      This paper is only available as a PDF. To read, Please Download here.


      Background and Aims

      As endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) preserves the entire stomach, missed gastric cancers (MGCs) are often found in the remaining gastric mucosa. However, the endoscopic causes of MGCs remains unclear. Therefore, we aimed to elucidate the endoscopic causes and characteristics of MGCs after ESD.


      From January 2009 to December 2018, all patients with ESD for initially detected EGC were enrolled. According to a review of esophagogastroduodenoscopy (EGD) images before ESD, we identified the endoscopic causes (perceptual, exposure, sampling errors, and inadequate preparation) and characteristics of MGC in each endoscopic cause.


      In total, 2208 patients who underwent ESD for initial EGC were analyzed. Of these, 82 (3.7%) patients had 100 MGCs. The breakdown of the endoscopic causes of MGCs was as follows: 69 (69%) perceptual errors, 23 (23%) exposure errors, 7 (7%) sampling errors, and 1 (1%) inadequate preparation. Logistic regression analysis showed that the risk factors for perceptual error were male sex (Odds ratio [OR], 2.45; 95% Confidence interval [CI], 1.16-5.18), isochromatic coloration (OR, 3.17; 95% CI, 1.47–6.84), greater curvature (OR, 2.31; 95% CI, 1.121–4.40), and lesion size ≤12 mm (OR, 1.74; 95% CI, 1.07–2.84). The sites of exposure errors were around incisura angularis, 11 (48%); posterior wall of the gastric body, 6 (26%); and antrum, 5 (21%).


      We identified MGCs in four categories and clarified their characteristics. Quality improvements in EGD observation, with attention to the risks of perceptual and site of exposure errors, can potentially prevent missing EGCs.

      Key words

      Abbreviations and Acronyms:

      CI (confidence interval), EGC (early gastric cancer), EGD (esophagogastroduodenoscopy), ESD (endoscopic submucosal dissection), H. Pylori (Helicobacter pylori), IQR (medians and interquartile range), MGC (missed gastric cancer), OR (odds ratio)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Gastrointestinal Endoscopy
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect