1. Long-term outcomes of combination of endoscopic submucosal dissection and laparoscopic lymph node dissection without gastrectomy for early gastric cancer patients who have a potential risk of lymph node metastasis Nobutsugu Abe, MD, PhD, Hirohisa Takeuchi, MD, Atsuko Ohki, MD, PhD, Osamu Yanagida, MD, PhD, Tadahiko Masaki, MD, PhD, Toshiyuki Mori, MD, PhD, Masanori Sugiyama, MD, PhD Gastrointest Endosc 2011;74:792-7.) R1. YuJin Uhm /Pf. Jae Young Jang Journal conference

2. early gastric cancers (EGCs) :curatively treated with endoscopy some EGC patients with at least 1 risk factors for lymph node metastasis (LNM) :standard gastrectomy with lymph node dissection BACKGROUND BACKGROUND risk factors for lymph node metastasis (LNM) undifferentiated type size larger than 2 cm the presence of lymphatic/venous involvement submucosal invasion ulcerative change

3. most (91%) of the patients with potential risk of LNM -> eventually found to have no nodal metastases after “unnecessary” Gastrectomy BACKGROUND BACKGROUND Adverse outcomes associated with the gastrectomy Postoperative dumping syndrome impaired food intake reflux esophagitis

4. BACKGROUND BACKGROUND even EGC patients without LNM undergo a standard gastrectomy with LND impossible at present accurate preoperative diagnosis of LNM “unnecessary” gastrectomy

5. combination of ESD & LLND => may lead to the elimination of “unnecessary” gastrectomy in EGC patients having a potential risk of LNM. ESD followed by LLND  enables the complete removal of the primary tumor & Histopathological determination of lymph node status  without gastrectomy BACKGROUND BACKGROUND

6. the long-term outcomes of this combination : still remain unclear. aim of this study 1) to evaluate the long-term (as long as 2 years or more after LLND) outcomes of this combination 2) to investigate its safety to determine whether this combination could be recommended as an optional strategy for EGC patients having a potential risk of LNM BACKGROUND BACKGROUND

7. METHODS METHODS Patients March 2002 and January 2009 Twenty-one EGC patients with potential risk of LNM : ESD and LLND EGC is defined as : lesion confined to the mucosa or submucosa regardless of the presence or absence of LNM according to the Japanese Classification of Gastric Carcinoma

8. METHODS METHODS Patients informed of the need for a standard surgery Expressed preference for the combination of ESD and LLND

9. METHODS METHODS Patients ESD was carefully performed to obtain a sufficient horizontal margin. resected margins of all the lesions : free of cancer cells vertically and horizontally; => completely removed locally.

10. METHODS METHODS LLND without gastrectomy Laparoscopic surgery area for lymph node dissection : on the basis of the location of the primary tumor and/or the lymphatic drainage of the stomach n = 12n = 9 standard laparoscopyinfrared ray electronic laparoscopy after a gastroscopic submucosal injection of indocyanine green (ICG) around the post-ESD ulcerative scars

11. METHODS METHODS Early outcomes of LLND and long-term outcomes of the combination of ESD and LLND Early outcomes of LLNDLong-term outcomes operating time estimated blood loss number of dissected lymph nodes morbidity & mortality the presence or absence of LNM duration of hospital stay survival the presence or absence of cancer recurrence or the development of secondary cancer changes in body weight at 2 years postoperatively symptoms endoscopic findings at 2 years postoperatively

12. METHODS METHODS Early outcomes of LLND and long-term outcomes of the combination of ESD and LLND followed periodically physical examination serum CEA level monitoring chest/abdominal CT every 3 to 6 months for the first 5 years and annually thereafter esophagogastroscopic examinationevery 6 months for the first 3 years and annually thereafter

13. RESULTS RESULTS TABLE 2. Dissected lymph nodes

14. RESULTS RESULTS TABLE 3. Early outcomes of laparoscopic lymph node dissection without gastrectomy

15. RESULTS RESULTS Gastric perforation on the lesser curvature side of the gastric body (n=1) uneventful postoperative course (n=20) POD1 : ischemic gastritis : emergent distal gastrectomy POD 3, : oral intake PODs 7 to 14 (mean 8 PODs). : discharged from the hospital

16. RESULTS RESULTS TABLE 3. Early outcomes of laparoscopic lymph node dissection without gastrectomy

17. RESULTS RESULTS TABLE 4. Data on two patients who had lymph node metastasis informed of the need for additional conventional gastrectomy with extended lymph node dissection but they chose not to undergo any additional surgery.

18. RESULTS RESULTS TABLE 5. Long-term outcomes

19. RESULTS RESULTS TABLE 5. Long-term outcomes Secondary EGC Superficial esophageal cancer n = 2n = 3 removed by ESD esophagectomy with gastric tube reconstruction.

20. RESULTS RESULTS TABLE 5. Long-term outcomes

21. RESULTS RESULTS TABLE 5. Long-term outcomes disturbed gastric emptying between meals

22. RESULTS RESULTS TABLE 5. Long-term outcomes

23. RESULTS RESULTS TABLE 5. Long-term outcomes

24. CONCLUSIONS CONCLUSIONS the combination of ESD and LLND : effective, minimally invasive treatment that maintains long-term quality of life for EGC patients having a potential risk of LNM. This combination can obviate the need for gastrectomy without compromising curability and could be recommended as an optional strategy.