1. Hye Won Lee Hyuk Lee Hyunsoo Chung Jun Chul Park Sung Kwan Shin Sang Kil Lee Young Chan Lee Jung Hwa Hong Dong Wook Kim The efficacy of single-dose postoperative intravenous dexamethasone for pain relief after endoscopic submucosal dissection for gastric neoplasm R2. 박민아 Surgical Endoscopy 24 January 2014

2. Introduction Endoscopic submucosal dissection (ESD)  effective treatment for early gastric cancer or premalignant lesions in the stomach enables en bloc resection of gastrointestinal neoplasms increases the rates of histologically complete resections reduces local recurrence rates compared with endoscopic mucosal resection (EMR) ※ complication : major - postoperative bleeding or stricture minor - Pain

3. Introduction Post-ESD pain : prolongation of the hospital stay, and is related to patients’compliance tendency to neglect or underestimate post-ESD pain associated with transmural burn or transmural air leak  Recently, the efficacy of glucocorticoids for reducing pain after surgery has been investigated inhibit collagen deposition and fibrosis locally -> reducing scar-tissue formation systemic steroid -> achieve a continuous effect with stable serum concentration

4. Introduction Purpose assess the efficacy of single-dose postoperative intravenous dexamethasone for pain relief after ESD

5. Methods  Study participants - needed ESD for a diagnosis of early gastric neoplasm - admitted from October 2012 to March 2013 at Severance Hospital, Yonsei University College of Medicine - double-blind, placebo-controlled study i) 20 years of age or older ii) pathologically diagnosed gastric adenoma or cancer that was eligible for ESD i) administration of a painkiller on a regular basis or within 48 h of enrollment ii) confirmation of any other disease that could induce epigastric pain (peptic ulcer, GERD) iii) presence of multiple gastric lesions for ESD iv) history of gastric surgery at enrollment v) presence of a severe underlying disease (infection, cardiopulmonary disease, DM)

6. Methods  Study participants i) histological diagnosis of a well- or moderately differentiated adenocarcinoma or dysplasia (adenoma) ii) tumor invasion of the mucosa or minute submucosal layers defined by EUS iii) tumor size of ≥ 3 cm if minute submucosal invasion or a tumor with ulceration iv) a tumor of any size if it was a differentiated adenocarcinoma without ulceration or submucosal invasion

7. Methods  Study design DEXA group : iv dexamethasone (0.15 mg/kg) immediately after ESD Placebo group : saline only prevent bleeding and other complications - iv pantoprazole 40 mg bid on the day of the ESD and on the following day - oral lansoprazole 40 mg qd, sucralfate suspension tid for 28 days primary outcome - present pain intensity(PPI) measured at 6 h after ESD, scale 0-5 secondary outcome - SF-MG pain score, need for an additional painkiller, complications, second-look endoscopic finding, length of hospital stay

8. Results

10. Group 1 : DEXA group Group 2 : Placebo group

11. Results

13. Conclusion Our study showed that intravenous dexamethasone was effective as an aggressive postoperative modality for pain control after ESD for early gastric neoplasm that takes into consideration the pathophysiology of the inflammatory response