1. 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

2. 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:
Little concern to most physicians
But, it impacts patients satisfaction and quality of life

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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)

9. Results

11. 84/156 (53.8 %)

12. 21 patients (acid infusion test)
47.6 %

13. 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