Factors Associated With Outcomes in Endoscopic Submucosal Dissection of Gastric Cardia Tumors

Tumors of the gastric cardia are among the most technically difficult lesions to remove by endoscopic submucosal dissection (ESD). This study aimed to evaluate the therapeutic outcomes of ESD in gastric cardia tumors according to clinicopathologic characteristics, and to assess the predictive factors for incomplete resection. We conducted a retrospective observational study of 82 patients with adenomas and early cancers of the gastric cardia who underwent ESD between January 2006 and December 2013 at the Pusan National University Hospital. Therapeutic outcomes of ESD and procedurerelated complications were analyzed. En bloc resection, complete resection, and curative resection rates were 87%, 79%, and 66%, respectively. Deep submucosal invasion was the most common cause of noncurative resection in the cases in which complete resection was achieved. On multivariate analyses, hemispheric distribution (anterior hemisphere; odds ratio [OR] 4.808) and depth of tumor invasion (submucosal cancer; OR 22.056) were independent factors associated with incomplete resection. The rates of procedure-related bleeding, perforation, and stenosis were 6%, 1%, and 0%, respectively; none of the complications required surgical intervention. In conclusion, ESD is a safe, effective, and feasible treatment for gastric cardia tumors. However, the complete resection rate decreases for tumors that are located in the anterior hemisphere or have deep submucosal invasion. (Medicine 94(31):e1201) a Kim, MD, PhD, , MD, PhD, g Uk Kim, MD, and Geun Am Song, MD, PhD dissection, EUS = endoscopic ultrasonography, IQR = interquartile range, LVI = lymphovascular invasion, OR = odds ratio. INTRODUCTION E ndoscopic submucosal dissection (ESD) is a widely accepted treatment for premalignant lesions and early cancers of the stomach. The use of ESD has increased the rate of successful en bloc resection, and has made en bloc resection possible for tumors in difficult locations, such as the pylorus and cardia. However, ESD for tumors in difficult locations remains a technical challenge, with a low rate of successful resection, a long procedure time, and a high rate of complications compared with ESD for tumors in more favorable locations. The gastric cardia is a particularly constricted region located at the most proximal part of the stomach. This location makes a precise preoperative diagnosis and endoscopic resection of theses lesions challenging because of the sharp angle and narrow lumen. Consequently, surgery is often performed for gastric cardia tumors. However, surgical resection involves total or proximal gastrectomy, and may significantly degrade the patient’s postoperative quality of life. Although ESD requires skillful endoscopic technique, it not only averts surgical risk but also improves the patient’s quality of life by preserving the gastrointestinal tract. Few studies have been published on the exact prevalence of gastric cardia tumors because of their rarity and a lack of a standard definition for gastric cardia tumors. A recent study on ESD for early gastric cancers (EGCs) reported that 2% were located at the gastric cardia. At our institution, gastric cardia tumors account for 2.9% of all gastric adenomas and EGCs (unpublished data). The number of ESD procedures performed for the treatment of gastric cardia tumors has increased with improvements in ESD techniques and devices, but published reports are scarce. Several studies have reported the results of ESD in the treatment of gastric cardia tumors as part of esophagogastric junction tumors, but there have been no studies regarding clinical outcomes on the basis of the clinicopathologic characteristics of gastric cardia tumors. Therefore, we aimed to evaluate the therapeutic outcomes of ESD in gastric cardia tumors, and to assess the possible predictive factors for incomplete resection. PATIENTS AND METHODS