Case series of intra-abdominal adhesions induced by artificial ulceration after endoscopic submucosal dissection before additional laparoscopic gastrectomy

Background: As endoscopic submucosal dissection (ESD) for early gastric cancer (EGC) increases, increasing numbers of patients require additional gastrectomy with lymph node dissection after noncurative ESD. ESD may cause intra-abdominal adhesions, making additional laparoscopic gastrectomy technically difficult. Objective: To assess the relation of the presence of intra-abdominal adhesions and ESD treatment to allow safe laparoscopic gastrectomy. Design: Case series from a retrospective review of additional gastrectomy after noncurative ESD. Setting: Tertiary care center. Patients and Interventions: Eight of 333 patients receiving ESD at Oita University Faculty of Medicine from 1999 to 2008 underwent additional laparoscopic gastrectomy because of noncurative ESD. Main Outcome Measurements: Intra-abdominal adhesions were evaluated by using an adhesion scoring system (0-3 points) and clinicopathologic findings, including artificial ulcerations after ESD. Results. All patients successfully underwent laparoscopic gastrectomy within 1 to 2 months after ESD. Three patients with large artificial ulceration (>25 mm) after ESD treatment had severe intra-abdominal adhesions (adhesion score These patients tended to have a large blood loss and long operation times during laparoscopic gastrectomy. Despite the 2-month interval from ESD to laparoscopic gastrectomy, ulcerations in these patients were at healing stage with inflammatory cells infiltrating the muscular deep layer. Limitation: A retrospective study. Conclusions: After ESD with large artificial ulceration (>25 mm), the presence of intra-abdominal adhesions complicating additional laparoscopic gastrectomy was often observed.