LAUSR

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are established treatments for esophageal and gastric neoplasms that are now widely carried out throughout Japan. The low risk of lymph node metastasis of esophageal and gastric neoplasms is evidenced in the literature and the indications for EMR/ESD are stated in the guidelines. Techniques for EMR/ESD procedures are thoroughly discussed in academic meetings or workshops. However, how to prevent and tomanage adverse events related to esophageal and gastric EMR/ESD has not been fully investigated. Current Japanese guidelines state recommendations for the management of adverse events as follows: (i) any one of prophylactic balloon dilatation, local steroid injection, or oral steroid administration for the prevention of stenosis after endoscopic treatment for superficial esophageal carcinoma; (ii) endoscopic clip closure for intraprocedural perforation of gastric ESD; and (iii) prophylactic coagulation of visible vessels on the post-ESD/EMR wound just after the endoscopic resection procedure. However, the guidelines for esophageal cancer treatment do not describe which prophylactic treatment is the most recommended for prevention of esophageal stenosis and which recommendation is used in practice for the management of perforation. The guidelines for gastric ESD/EMR do not mention risk factors and prophylactic treatment for delayed bleeding and management of cardiac or pyloric stenosis. Because the incidence of adverse events related to esophageal and gastric EMR/ESD is usually low, it is difficult to conduct a large-scale interventional study to investigate useful methods for the management of adverse events. Meanwhile, some observational studies evaluating the management of adverse events, and case series of new treatment methods have been reported. In the upper gastrointestinal session of Endoscopic Forum Japan (EFJ) 2018, algorithms for the management of adverse events related to esophageal and gastric EMR/ ESD were created and clinical questions relevant to decision-making were raised. These were distributed to a panel of expert endoscopists before the meeting. Each endoscopist was put in charge of a particular adverse event topic, carried out a systematic review, summarized currently available evidence, and proposed recommendations. On 21 July 2018, at the meeting held in Otaru, the review results and recommendations were presented by each endoscopist, and overall consensus was achieved after discussion. Topics and clinical questions for adverse events related to esophagus and stomach EMR/ESD are listed in Table 1. All clinical questions were commonly encountered during clinical practice of esophageal and gastric EMR/ESD. Although the evidence level of related articles was not always high, current information was included in the review which complemented the current guidelines for esophageal and gastric EMR/ESD. As described earlier, the incidence of adverse events is usually low; therefore, experience for managing adverse events is restricted, especially when the case volume is moderate to low. In this regard, this review provided information on how to manage adverse events, and how to conduct studies to provide evidence for the management of adverse events related to esophageal and gastric EMR/ESD.