title: Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD.
abstract: Endoscopic submucosal dissection (ESD) is a widely accepted treatment for superficial gastric neoplasms. Difficult ESD can lead to complications, such as bleeding and perforation. To predict difficult ESD procedures, we analyzed the factors associated with difficult ESD.
  
  
  
  The medical records of 1052 ESD procedures were retrospectively reviewed. Difficult ESD was defined by any one of three end points: longer procedure time (≥60 min), piecemeal resection, incomplete (R1) resection, or gastric wall perforation. To determine the factors associated with difficult ESD, clinical and pathologic features and endoscopic findings were analyzed.
  
  
  
  The rates of en bloc resection and curative (R0) resection were 93.3 and 92.4 %, respectively. The mean procedure time was 27.7 ± 16.7 min. After multivariate analysis, larger tumor size (≥20 mm) was an independent risk factor for longer procedure time (OR 4.1, P < 0.001), for piecemeal resection (OR 2.3, P = 0.003) and incomplete (R1) resection (OR 2.1, P = 0.005). Location of the lesion (upper third) was an independent risk factor for longer procedure time (OR 5.8, P < 0.001), for piecemeal resection (OR 4.1, P < 0.001) and incomplete (R1) resection (OR 4.5, P < 0.001). Submucosal fibrosis was an independent risk factor for longer procedure time (OR 9.7, P < 0.001), for piecemeal resection (OR 2.4, P < 0.001) and incomplete (R1) resection (OR 2.6, P < 0.001). Finally, submucosal invasive gastric cancer was an independent risk factor for piecemeal resection (OR 2.6, P = 0.008), for perforation (OR 19.3, P = 0.001) and for incomplete (R1) resection (OR 2.7, P = 0.001).
  
  
  
  Difficult ESD procedures are a function of the lesion size and location, submucosal fibrosis, and submucosal invasive cancer. When a difficult ESD procedure is expected, appropriate preparations should be considered, including consultation with more experienced endoscopists.
authors: Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea.
authors: Ji Ha
authors: JH
authors: Kim
authors: Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea.
authors: Hyeong Seok
authors: HS
authors: Nam
authors: Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea. luckyace@hanmail.net.
authors: Cheol Woong
authors: CW
authors: Choi
authors: Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea. sulsulpul@naver.com.
authors: Dae Hwan
authors: DH
authors: Kang
authors: Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea.
authors: Hyung Wook
authors: HW
authors: Kim
authors: Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea.
authors: Su Bum
authors: SB
authors: Park
authors: Department of Internal Medicine, Medical Research Institute, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Beomeo-ri, Mulgeum-eup, Yangsan-si, Gyeongsangnam-do, 626-770, Korea.
authors: Su Jin
authors: SJ
authors: Kim
authors: Department of Surgery, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
authors: Sun Hwi
authors: SH
authors: Hwang
authors: Department of Surgery, Pusan National University School of Medicine and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea.
authors: Si Hak
authors: SH
authors: Lee
mesh_terms: D002983:Clinical Competence / Q000592:standards*; D004210:Dissection / Q000379:methods; D000069916:Endoscopic Mucosal Resection / Q000009:adverse effects / Q000592:standards; D005260:Female; D005753:Gastric Mucosa / Q000473:pathology* / Q000601:surgery; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D013274:Stomach Neoplasms / Q000473:pathology* / Q000601:surgery; D016896:Treatment Outcome
keywords: Dysplasia; Early gastric cancer; Endoscopic submucosal dissection; Neoplasia