2015. 11. 2. Journal conference Factors influencing development of pain after gastric endoscopic submucosal dissection: a randomized controlled trial Endoscopy 2015 Jul 10, online published Da Hyun Jung, Young Hoon Youn, Jie-Hyun Kim, Hyojin Park F 1 이태인 / Prof. 김정욱

Introduction Endoscopic submucosal dissection (ESD) Widely used method of resecting gastric neoplasm En bloc resection, histologic evaluation ESD-related complications Perforation, hemorrhage, etc PAIN !!! About 98 % of patients experienced pain following ESD - Dig Liver Dis 2012; 44: 925-929 Little concern to most physicians But, it impacts patients satisfaction and quality of life

Attemptions to relieve post-ESD pain Intravenous dexamethasone, topical bupivacaine and triamcinolone acetonide, fentanyl patches. Etc. However, the mechanisms involved in the development and relief of pain have yet to be clarified Residual mucosal defect, exposure to gastric acid, osmotic or chemical effects of submucosal fluid injection, cautery injury, Etc. Acid hypersensitivity (low visceral pain threshold to acid) Key mechanism for dyspeptic symptoms in patients with functional dyspepsia

Does ‘Hypersensitivity to acid’ play a role in the development of pain after ESD? The incidence and clinicopathologic risk factors of pain Acid infusion test

Patients and methods April 2011 ~ August 2013 at Gangnam Severance Hospital Patients undergoing ESD for gastric neoplasm Prospective, randomized, controlled study Exclusion criteria Acid suppressive medication within 1 week prior to the procedure Known GI disorders which impact epigastric pain assessment Current or regular use of pain medication History of upper GI surgery Multiple lesions requiring ESD Perforation during ESD Significant cardiovascular, renal, hepatic, neurologic, or psychological disorders

Randomization and study design Pre-ESD group Post-ESD group 시술 2시간 전 Standard PPI iv - 시술 당일 저녁 시술 1일 후 Standard PPI iv bid 시술 2일 후 Standard PPI po qd (for 4 weeks) Two groups The timing of proton pump inhibitor (PPI) administration Pre-ESD vs post-ESD Prior to ESD, patients completed a questionnaire, which used Likert scale (0 - 3) the severity and frequency of underlying baseline dyspeptic symptoms

Acid infusion test 21 patients who provided additional informed consent After 8-hour fasting, 5-Fr elemental diet tube was placed in the mid-stomach via nose. 150 mL hydrochloric acid (0.1 mol/L) : 15 mL/minute Check the GI symptoms from the start of infusion to 20 minutes after infusion Visual analog scale (VAS) score was graded every 2 minutes

Main outcome measurement 10-cm VAS score was used to evaluate pain after ESD Two time points (post 3 and 24 hours) Moderate pain : > 3 VAS score Primary outcome The incidence of pain developing within 24 hours after ESD procedure (both PPI groups)

Results

84/156 (53.8 %)

21 patients (acid infusion test) 47.6 %

Conclusion Patients with tumors of the distal stomach and with baseline dyspeptic symptoms were more likely to experience pain after ESD Hypersensitivity to acid was one mechanism implicated in post-ESD pain