title: Endoscopic submucosal dissection for gastric neoplasm in patients with co-morbidities categorized according to the ASA Physical Status Classification.
abstract: BACKGROUND
  Endoscopic submucosal dissection (ESD) has come to be widely performed for reduced invasiveness; however, its safety in patients with co-morbidities is not fully examined. We aimed to evaluate the safety and efficacy of gastric ESD with co-morbidities categorized according to ASA Physical Status Classification.
  
  
  METHODS
  Two hundred and forty patients of ASA 1 (no co-morbidities), 268 of ASA 2 (mild), and 19 of ASA 3 (severe) were treated by ESD for gastric neoplasms. We retrospectively compared clinicopathological features and treatment results of these three groups.
  
  
  RESULTS
  Cases (by percent) treated with anticoagulant/platelet agents were more common in the higher ASA grades (ASA 1, 5.8%; ASA 2, 29.1%; ASA 3, 31.6%; P < 0.0001). There were no significant differences in case numbers treated under guideline criteria, curative resection (ASA 1, 79.6%; ASA 2, 79.9%; ASA 3, 78.9%), or complications related to the ESD procedure (e.g., postoperative bleeding, perforation, thermal injury). By a patient risk prediction model on surgery, i.e., P-POSSUM, morbidity was halved, and no patients died compared to a predicted death rate of 0.5-2%; however, total and complications unrelated to ESD procedure (e.g., aspiration pneumonia, ischemic heat attack) were more common in higher ASA grades (ASA 1, ASA 2, ASA 3: 15.4, 23.9, 26.3%, respectively, P = 0.014; 0.4, 7.1, 0%, respectively, P = 0.00087). Deviation rates from clinical pathway were more frequent and hospital stay (days) longer in higher ASA grades (ASA 1, ASA 2, ASA 3: 11.3, 17.9, 26.3%, respectively, P = 0.014; 8, 8, 9%, respectively, P = 0.0053).
  
  
  CONCLUSIONS
  ESD is an efficient treatment for gastric neoplasms with co-morbidities. However, additional caution is required because co-morbidity is a risk factor for both total complications and complications unrelated to the ESD procedure, and may cause deviations in the clinical course and prolonged hospital stay.
authors.affiliation: Department of Gastroenterology, Kobe University, Kobe, Japan. mariko-m@bc5.so-net.ne.jp
authors.forename: Mariko
authors.initials: M
authors.lastname: Man-i
authors.forename: Yoshinori
authors.initials: Y
authors.lastname: Morita
authors.forename: Tsuyoshi
authors.initials: T
authors.lastname: Fujita
authors.forename: James E
authors.initials: JE
authors.lastname: East
authors.forename: Shinwa
authors.initials: S
authors.lastname: Tanaka
authors.forename: Chika
authors.initials: C
authors.lastname: Wakahara
authors.forename: Masaru
authors.initials: M
authors.lastname: Yoshida
authors.forename: Takanobu
authors.initials: T
authors.lastname: Hayakumo
authors.forename: Hiromu
authors.initials: H
authors.lastname: Kutsumi
authors.forename: Hideto
authors.initials: H
authors.lastname: Inokuchi
authors.forename: Takashi
authors.initials: T
authors.lastname: Toyonaga
authors.forename: Takeshi
authors.initials: T
authors.lastname: Azuma
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015897:Comorbidity; D005260:Female; D005753:Gastric Mucosa / Q000473:pathology / Q000601:surgery*; D005773:Gastroscopy / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000453:epidemiology; D012189:Retrospective Studies; D012307:Risk Factors; D013274:Stomach Neoplasms / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome