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    Gut and Liver is an international journal of gastroenterology, focusing on the gastrointestinal tract, liver, biliary tree, pancreas, motility, and neurogastroenterology. Gut atnd Liver delivers up-to-date, authoritative papers on both clinical and research-based topics in gastroenterology. The Journal publishes original articles, case reports, brief communications, letters to the editor and invited review articles in the field of gastroenterology. The Journal is operated by internationally renowned editorial boards and designed to provide a global opportunity to promote academic developments in the field of gastroenterology and hepatology. +MORE

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Outcomes of Endoscopic Resection for Early Gastric Cancer in Very Elderly Patients: A Nationwide Population-Based Study

Tae Jun Kim1 , Jeung Hui Pyo2 , Hyuk Lee1 , Sung Chul Choi2 , Yang Won Min1 , Byung-Hoon Min1 , Jun Haeng Lee1 , Poong-Lyul Rhee1 , Minku Song3 , Yoon-Ho Choi2 , Jae J. Kim1

1Department of Medicine and 2Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, and 3Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University, Seoul, Korea

Correspondence to: Hyuk Lee
ORCID https://orcid.org/0000-0003-4271-7205
E-mail leehyuk@skku.edu

Tae Jun Kim and Jeung Hui Pyo contributed equally to this work as first authors.

Received: October 19, 2021; Revised: August 20, 2022; Accepted: August 26, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Gut Liver.

Published online December 29, 2022

Copyright © Gut and Liver.

Background/Aims: Few studies have investigated the long-term outcomes of endoscopic resection for early gastric cancer (EGC) in very elderly patients. The aim of this study was to determine the appropriate treatment strategy and identify the risk factors for mortality in these patients.
Methods: Patients with EGC who underwent endoscopic resection from 2006 to 2017 were identified using National Health Insurance Data and divided into three age groups: very elderly (≥85 years), elderly (65 to 84 years), and non-elderly (≤64 years). Their long- and short-term outcomes were compared in the three age groups, and the survival in the groups was compared with that in the control group, matched by age and sex. We also evaluated the risk factors for long- and short-term outcomes.
Results: A total of 8,426 patients were included in our study: 118 very elderly, 4,583 elderly, and 3,725 non-elderly. The overall survival and cancer-specific survival rates were significantly lower in the very elderly group than in the elderly and the non-elderly groups. Congestive heart failure was negatively associated with cancer-specific survival. A significantly decreased risk for mortality was observed in all groups (p<0.001). The very elderly group had significantly higher readmission and mortality rates within 3 months of endoscopic resection than the non-elderly and elderly groups. Furthermore, the cerebrovascular disease was associated with mortality within 3 months after endoscopic resection.
Conclusions: Endoscopic resection for EGC can be helpful for very elderly patients, and it may play a role in achieving overall survival comparable to that of the control group.

Keywords: Gastric cancer, Endoscopic mucosal resection, Elderly

Globally, the population is aging; the World Health Organization predicts that by 2050 around 2 billion people in the world will be ≥60 years of age, and 400 million will be ≥80 years of age.1 The increasing geriatric population and introduction of mass screening programs, has led to a growing number of early gastric cancer (EGC) cases being diagnosed in the very elderly population (those aged >85 years).

The treatment of EGC is well-established. When a lesion meets the endoscopic treatment criteria, endoscopic resection is the first-line treatment modality and achieves comparable results as surgery concerning patient survival.2 However, the management of very elderly patients with EGC is challenging in comparison to elderly or non-elderly patients with EGC owing to age-specific concerns, including a higher incidence of comorbid conditions and a lower life expectancy.3,4 Reports exist on the long-term outcomes of endoscopic resection in the elderly, but research specific to the very elderly are lacking.5-9 Because the number of elderly patients with EGC has also increased, and will continue to do so in the future, there is a significant need for evidence-based strategies to determine the most appropriate course of treatment for EGC in the very elderly population.

Therefore, this study aimed to evaluate the long- and short-term outcomes of endoscopic resection for EGC for very elderly patients compared to non-elderly and elderly patients, using data from the National Health Insurance Service (NHIS). We also examined the prognostic factors of clinical outcomes.

1. Patients

As a single insurer, the NHIS covers the entire Korean population. In December 2015, the Korean National Health Insurance Big Data Base was developed, based on the treatment data for claims between the NHIS and healthcare providers in Korea.10 The Korean National Health Insurance Big Data Base includes information on patient demographics, reimbursement for medical services, the International Classification of Diseases 10th Revision codes, medical history, and mortality,11 which are then linked to the Korean National Statistical Office, who allow access for research purposes.

Based on the Korean National Health Insurance Big Data Base, we constructed a custom database which included patients with gastric cancer in Korea from 2006 to 2017. Patients with gastric cancer were screened by the main or sub-disease code, C16, according to the International Classification of Diseases 10th Revision.12 We assessed patient characteristics including age, sex, and comorbidities. The exclusion criteria were as follows: (1) those who had an additional cancer code besides C16 or underwent gastrectomy 5 years before enrollment of enrollment (n=8,702); (2) lost to follow-up (n=1,576); and (3) those who did not undergo endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) (n=55,813). The included patients were divided into three age groups based on World Health Organization and geriatric research guidelines:13,14 very elderly (≥85 years), elderly (65 to 84 years), and non-elderly (≤64 years) (Fig. 1).

Figure 1.Study flowchart.

In Korea, endoscopic resection for EGC is considered for tumors that fulfill the criteria according to the Korean Practice Guideline for Gastric Cancer 2018.15

The study protocol was in accordance with the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Institutional Review Board of the Samsung Medical Center (IRB number: 2019-07-128). The requirement for informed consent was waived due to the retrospective study design.

2. Outcomes

1) Long-term outcomes

All-cause mortality was obtained from the NHIS database. We compared overall survival (OS) and cancer-specific survival (CSS) rates between the three groups. The relationships among OS, CSS, and clinical factors were evaluated. We compared the risk of mortality in the three groups in relation to that in the control group matched by age and sex. OS was defined as the interval from the date of gastric cancer diagnosis to any cause of death. CSS was defined as the interval from the date of the primary diagnosis to the date of gastric cancer-specific death.

2) Short-term outcomes

Short-term outcomes were evaluated in terms of the readmission within 3 months after ESD/EMR (including admission for gastrectomy) and mortality within 3 months after ESD/EMR. The relationship between short-term outcomes and clinical factors was also evaluated.

3. Statistical analysis

Continuous values are presented as mean±standard deviation, while categorical variables are shown as number with proportions. The differences between groups were analyzed using the t-test for continuous variables and the chi-square test for categorical variables. OS and CSS were estimated using the Kaplan-Meier method. Survival rates were compared using the log-rank test. Cox proportional hazards regression was performed to identify hazard ratios (HRs) and 95% confidence intervals (CIs). Differences were considered significant at p-value of <0.05. Statistical analyses were performed using SAS version 9.4.1 (Statistical Analysis Software, SAS Institute Inc, Cary, NC, USA) and the statistical program R (version 4.0; R Foundation for Statistical Computing, Vienna, Austria).

1. Patient characteristics

Of the 74,517 patients diagnosed with EGC between 2006 and 2017, 66,091 patients were excluded and 8,426 patients who underwent endoscopic resection for EGC were eligible for the study. Among the 8,426 patients, 8,350 patients underwent ESD and only 76 patients underwent EMR. Baseline characteristics of the study population are presented in Table 1. The mean patient age was 65.5 years (standard deviation, 10.4), and among them, 118 (1.4%) were classified as very elderly, 4,583 (54.4%) as elderly, and 3,725 (44.2%) as non-elderly. A total of 5,998 patients (71.2%) were men and 2,428 (28.8%) were women. The elderly and non-elderly groups were predominantly males (75.8% and 68.0%, respectively); however, the very elderly group had a slight female predominance (51.7%). The severity of all comorbidities increased significantly with age, with the exception of liver disease, acquired immunodeficiency syndrome/human immunodeficiency virus infection and renal disease.

Table 1. Baseline Characteristics

CharacteristicTotalAge groupp-value
≤64 yr65–84 yr≥85 yr
No. of patients8,4263,7254,583118
Age, yr65.5±10.455.9±6.572.8±5.087.0±1.9<0.001
Sex<0.001
Male5,998 (71.2)2,825 (75.8)3,116 (68.0)57 (48.3)
Female2,428 (28.8)900 (24.2)1,467 (32.0)61 (51.7)
Comorbidities
Myocardial infarction142 (1.7)40 (1.1)98 (2.1)4 (3.4)<0.001
Congestive heart failure584 (6.9)118 (3.2)449 (9.8)17 (14.4)<0.001
Peripheral vascular disease1,650 (19.6)453 (12.2)1,164 (25.4)33 (28.0)<0.001
Cerebrovascular disease1,512 (17.9)344 (9.2)1,129 (24.6)39 (33.1)<0.001
Dementia233 (2.8)19 (0.5)199 (4.3)15 (12.7)<0.001
Chronic pulmonary disease4,126 (49.0)1,450 (38.9)2,599 (56.7)77 (65.3)<0.001
Connective tissue disease547 (6.5)183 (4.9)346 (7.5)18 (15.3)<0.001
Diabetes2,657 (31.5)905 (24.3)1,700 (37.1)52 (44.1)<0.001
Paraplegia/hemiplegia108 (1.3)26 (0.7)80 (1.7)2 (1.7)<0.001
Liver disease2,516 (29.9)1,111 (29.8)1,374 (30.0)31 (26.3)0.684
AIDS/HIV3 (0.0)1 (0.0)2 (0.0)00.902
Renal disease204 (2.4)47 (1.3)154 (3.4)3 (2.5)<0.001

Data are presented as mean±SD or number (%).

AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus.



2. Comparison of long-term outcomes

The median follow-up periods after endoscopic resection for the very elderly, elderly, and non-elderly groups were 1,200 days (interquartile range, 950 to 1,642 days), 1,379 days (interquartile range, 1,026 to 1,777 days), and 1,475 days (interquartile range, 1,091 to 1,867 days), respectively. The OS rates of the very elderly group were significantly lower than those of the elderly and non-elderly group (1-, 5-, and 10-year OS rates: very elderly patients: 96.6%, 67.8%, and 62.7%; elderly patients: 99.1%, 88.2%, and 85.3%; and non-elderly patients: 99.8%, 97.4%, and 96.5%, respectively; p<0.001) (Fig. 2A). The CSS rate was also significantly lower in the very elderly group than in the other groups (1-, 5-, and 10- year CSS rates: very elderly patients: 98.3%, 90.7%, and 89.8%; elderly patients: 99.7%, 98.5%, 98.3%; and non-elderly patients: 100.0%, 99.7%, and 99.6%, respectively; p<0.001) (Fig. 2B). However, a significant decrease in the risk of mortality was observed among all age groups (HR=0.23, 0.30, and 0.45, for the very elderly, elderly, and non-elderly groups, respectively; all p<0.001) (Table 2), indicating that patients undergoing endoscopic resection for EGC had a lower mortality rate than the control group, regardless of age.

Table 2. Risk of Mortality in the Three Age Groups Compared to General Population Matched Age and Sex

Age groupEndoscopic resectionControl groupp-value
No. of patientsPerson-yearsNo. of casesNo. of casesHR (95% CI)
≤64 yr3,72515,103851,2170.45 (0.36–0.55)<0.001
65–84 yr4,58317,6934279,6330.30 (0.27–0.33)<0.001
≥85 yr118404301,0080.23 (0.15–0.32)<0.001

HR, hazard ratio; CI, confidence interval.


Figure 2.Overall survival (A) and cancer-specific survival (B) of the three age groups.

The risk factors associated with OS were congestive heart failure (HR, 1.92; 95% CI, 1.52 to 2.44; p<0.001), dementia (HR, 1.94; 95% CI, 1.40 to 2.70; p<0.001), paraplegia/hemiplegia (HR, 2.26; 95% CI, 1.46 to 3.50; p<0.001), renal disease (HR, 2.42; 95% CI, 1.72 to 3.40; p<0.001), and increasing Charlson comorbidity index (CCI) score (HR, 1.80; 95% CI, 1.45 to 3.15; p<0.001); however, the only risk factor associated with CSS was congestive heart failure (HR, 2.86; 95% CI, 1.51 to 5.41; p=0.001) (Table 3).

Table 3. Risk Factors for Long-term Outcome

Covariate Overall survivalCancer-specific survival
Adjusted HR (95% CI)p-valueAdjusted HR (95% CI)p-value
Sex
MaleReferenceReference
Female0.60 (0.49–0.74)<0.0011.02 (0.59–1.77)0.950
Comorbidities
Myocardial infarction1.03 (0.62–1.71)0.9080.00 (0.00–Inf)0.994
Congestive heart failure1.92 (1.52–2.44)<0.0012.86 (1.51–5.41)0.001
Peripheral vascular disease0.98 (0.80–1.20)0.8401.32 (0.74–2.33)0.343
Cerebrovascular disease1.13 (0.92–1.38)0.2600.59 (0.30–1.18)0.136
Dementia1.94 (1.40–2.70)<0.0011.98 (0.76–5.18)0.163
Chronic pulmonary disease1.02 (0.85–1.21)0.8570.80 (0.47–1.37)0.416
Connective tissue disease1.11 (0.81–1.52)0.5131.28 (0.54–3.03)0.578
Diabetes0.43 (0.05–3.53)0.4320.62 (0.11–3.63)0.564
Paraplegia/hemiplegia2.26 (1.46–3.50)<0.0012.66 (0.61–11.65)0.194
Liver disease1.10 (0.92–1.32)0.2950.64 (0.34–1.20)0.167
AIDS/HIV0.00 (0.00–Inf)0.9870.00 (0.00–Inf)0.999
Renal disease2.42 (1.72–3.40)<0.0012.55 (0.89–7.27)0.080
Charlson comorbidity index score1.80 (1.45–3.15)<0.0011.21 (0.45–5.78)0.469

HR, hazard ratio; CI, confidence interval; AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; Inf, infinity.



3. Comparison of short-term outcomes

The short-term outcomes are presented in Table 4. Readmission rate within 3 months after endoscopic resection was significantly higher in the very elderly group than in the elderly and non-elderly groups (11.0%, 5.8%, and 5.3%, respectively, p=0.028). Mortality within 3 months after endoscopic resection was significantly higher in the very elderly group than in the elderly and non-elderly groups (0.8%, 0.1%, and 0%, respectively, p<0.001). The risk factors associated with the short-term outcomes are presented in Table 5. Risk factors associated with readmission within 3 months after endoscopic resection were female sex (HR, 1.22; 95% CI, 1.01 to 1.49; p=0.045), congestive heart failure (HR, 1.49; 95% CI, 1.12 to 2.00; p=0.007), dementia (HR, 1.77; 95% CI, 1.20 to 2.61; p=0.004), paraplegia/hemiplegia (HR, 3.50; 95% CI, 2.26 to 5.42; p<0.001), liver disease (HR, 1.51; 95% CI, 1.25 to 1.82; p<0.001), and acquired immunodeficiency syndrome/human immunodeficiency virus infection (HR, 31.47; 95% CI, 7.70 to 128.57; p<0.001). Increasing CCI score was associated with the risk for readmission within 3 months, but not with 3-month mortality. The only risk factor associated with a 3-month mortality rate was cerebrovascular disease (HR, 5.75: 95% CI, 1.05 to 31.38; p=0.043).

Table 4. Short-term Outcomes

OutcomeAge group, No. (%)p-value
≤64 yr (n=3,725)65–84 yr (n=4,583)≥85 yr (n=118)
Overall
Readmission rate within 3 mo after endoscopic resection199 (5.3)264 (5.8)13 (11.0)0.028
Mortality within 3 mo after endoscopic resection05 (0.1)1 (0.8)<0.001
For endoscopic submucosal dissection
Readmission rate within 3 mo after endoscopic resection187 (5.1)261 (5.7)13 (11.0)0.023
Mortality within 3 mo after endoscopic resection04 (0.1)1 (0.8)<0.001
For endoscopic mucosal resection
Readmission rate within 3 mo after endoscopic resection2 (5.3)3 (8.6)00.019
Mortality within 3 mo after endoscopic resection01 (2.9)0<0.004

Table 5. Risk Factors for Short-term Outcome

Covariate3 mo readmission3 mo mortality
Adjusted HR (95% CI)p-valueAdjusted HR (95% CI)p-value
Sex
MaleReferenceReference
Female1.22 (1.01–1.49)0.0450.67 (0.36–1.25)0.620
Comorbidities
Myocardial infarction0.85 (0.44–1.66)0.6330.00 (0.00–Inf)0.999
Congestive heart failure1.49 (1.12–2.00)0.0071.79 (0.21–15.34)0.594
Peripheral vascular disease1.15 (0.92–1.42)0.2172.69 (0.54–13.32)0.226
Cerebrovascular disease1.14 (0.91–1.44)0.2525.75 (1.05–31.38)0.043
Dementia1.77 (1.20–2.61)0.0042.00 (0.23–17.15)0.526
Chronic pulmonary disease1.10 (0.91–1.33)0.3141.50 (0.28–8.21)0.638
Connective tissue disease1.21 (0.88–1.67)0.2340.00 (0.00–Inf)0.998
Diabetes0.59 (0.28–1.26)0.1760.00 (0.00–Inf)1.000
Paraplegia/hemiplegia3.50 (2.26–5.42)<0.0010.00 (0.00–Inf)0.999
Liver disease1.51 (1.25-1.82)<0.0010.00 (0.00–Inf)0.996
AIDS/HIV31.47 (7.70–128.57)<0.0010.00 (0.00–Inf)1.000
Renal disease1.16 (0.71–1.90)0.5580.00 (0.00–Inf)0.999
Charlson comorbidity index score18.57 (6.19–83.57)<0.0013.74 (0.35–22.15)0.698

HR, hazard ratio; CI, confidence interval; AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; Inf, infinity.


The major finding of this study was that although the overall and gastric cancer-specific mortality rates were higher in the very elderly group than in the elderly and non-elderly groups, mortality risk was significantly lower for all three groups than in the control group. The survival of the very elderly group indicated a 67% decrease in the mortality rate after endoscopic resection for EGC. These results indicate that in very elderly patients who meet the endoscopic resection criteria, aggressive endoscopic resection for EGC is not harmful and, moreover, it may help patients achieve expected survival rates comparable to those of the control group.

It is often difficult to devise treatment strategies for elderly patients with EGC because of their comorbidities and lower life expectancy. Previous studies have reported that in patients who do not receive timely treatment, EGC progresses to advanced stage and lead to death within 4 to 5 years.16-18 However, the Organisation for Economic Co-operation and Development reports that the current life expectancy for those ≥80 years living within Organisation for Economic Co-operation and Development countries is approximately 9 years,19 and the efficacy and safety of ESD in comorbid or elderly patients has been well-reported.20-28 Kim et al.21 used CCI to divide patients into low and high risk groups and compared complication rates in various comorbid disease between the two groups. Complications (such as bleeding or perforation) did not differ significantly between the two groups. Moreover, none of the comorbid disease made a statistically significant contribution to the occurrence of a specific complication.21 Kato et al.28 compared the short-term outcomes and incidence of complications in elderly (≥75 years of age) and non-elderly groups. The R0 resection rate and curative resection rate did not differ between the two groups. In terms of complication, the incidence of bleeding and incidence of perforation were similar in the two groups.28 In two studies including very elderly patients (≥85 years of age), there were no significant differences in adverse events or in the en bloc resection or complete resection.29,30 Therefore, aggressive endoscopic treatment of EGC in elderly patients may contribute to lengthening life expectancy. Consistent with our findings, the results from recent studies investigating endoscopic treatments for elderly patients have demonstrated comparable long-term outcomes.6,7,29,30 Abe et al.6 conducted a multicenter study including 440 patients aged ≥80 years which showed that in patients undergoing ESD, the cumulative survival at 5 years after ESD was better than the expected survival for general population matched by age and sex. Chang et al.7 reported the long-term outcomes of patients aged ≥75 years who underwent ESD for EGC, were worse for patients with other risk factors such as history of cancer beside gastric cancer or CCI ≥3, than in those without other risk factors.

Few reports have included very elderly patients, and the long-term outcomes of these patients are not well-known. To the best of our knowledge, only two reports have been published, which included a small number of patients (n=43 and n=85).29,30 Our study included a relatively larger number (n=118) of very elderly patients with a long-term observation period. In addition, we compared the survival rates of the very elderly group with those of the elderly and non-elderly groups, and the survival rate after endoscopic treatment was compared to that of the control group. We also identified prognostic factors for long- and short-term outcomes. The common risk factors for OS and CSS are congestive heart failure, and the risk factor for 3-month mortality was cerebrovascular disease. These results are consistent with reports that patients aged ≥85 with cardiovascular disease showed statistically significant lower OS rate than patients aged ≥85 without cardiovascular disease.29 Cardiovascular and cerebrovascular diseases are major health problems in the elderly, as a result of living to an age when they are likely to suffer the sequelae of chronic atherosclerosis. One study reported the long-term prognosis after ESD for colorectal tumors in patients aged over 80 years and the most common cause of death was heart disease other than pneumonia.31 Because our study stratified comorbid diseases according to the CCI, heart diseases were classified into myocardial infarction and congestive heart failure. While patients who suffer a heart attack often survive their initial events and live into their 80s, many go on to die of chronic heart failure. In fact, age-adjusted mortality rate for heart failure appears to be on the rise.32 In terms of short-term outcomes, bleeding is one of the major complications in endoscopic resection.21 Patients with cerebrovascular diseases are likely to be on antiplatelet or anticoagulant therapy, and continuing it may increase the risk of bleeding while discontinuing it may increase the risk of ischemic stroke, contributing to higher short-term mortality.33,34

Our study has several limitations. First, the study was retrospective and may have a potential bias. For example, the very elderly patients in this study may had a better performance status and less comorbidity compared with general elderly population, which may induce selection bias. Second, the 3-month readmission data included admission for additional surgery after non-curative ESD because we could not discriminate the cause for admission. Third, the follow-up duration among the three age groups was significantly different, likely because of the different life expectancies. Fourth, the data from gastric adenomas were not included in this study. Sometimes, large gastric adenoma are more difficult to perform endoscopic procedures than very small EGCs, and the complication rates could be higher. Fifth, the outcomes related to the procedure such as complete resection rate, recurrence rate, and the incidence of complications during procedure, could not be analyzed because this study is a national population-based study.

In conclusion, our study suggests that aggressive endoscopic resection for patients with EGC can be helpful for very elderly patients who meet the endoscopic resection criteria, with the expected post-procedure survival rate being comparable to that of the control group. Regarding comorbidities, special attention should be paid to very elderly patients with congestive heart failure or cerebrovascular disease.

No potential conflict of interest relevant to this article was reported.

Study conception and design: H.L., T.J.K., J.H.P. Data analysis and interpretation: T.J.K., J.H.P. Drafting of the manuscript: T.J.K., J.H.P. Critical revision of the manuscript for important intellectual content: S.C.C., Y.W.M., B.H.M., J.H.L., P.L.R., M.S., Y.H.C., J.J.K. Study supervision: H.L. Approval of final manuscript: all authors.

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Article

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Gut and Liver

Published online December 29, 2022

Copyright © Gut and Liver.

Outcomes of Endoscopic Resection for Early Gastric Cancer in Very Elderly Patients: A Nationwide Population-Based Study

Tae Jun Kim1 , Jeung Hui Pyo2 , Hyuk Lee1 , Sung Chul Choi2 , Yang Won Min1 , Byung-Hoon Min1 , Jun Haeng Lee1 , Poong-Lyul Rhee1 , Minku Song3 , Yoon-Ho Choi2 , Jae J. Kim1

1Department of Medicine and 2Center for Health Promotion, Samsung Medical Center, Sungkyunkwan University School of Medicine, and 3Department of Digital Health, Samsung Advanced Institute for Health Sciences & Technology (SAIHST), Samsung Medical Center, Sungkyunkwan University, Seoul, Korea

Correspondence to:Hyuk Lee
ORCID https://orcid.org/0000-0003-4271-7205
E-mail leehyuk@skku.edu

Tae Jun Kim and Jeung Hui Pyo contributed equally to this work as first authors.

Received: October 19, 2021; Revised: August 20, 2022; Accepted: August 26, 2022

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background/Aims: Few studies have investigated the long-term outcomes of endoscopic resection for early gastric cancer (EGC) in very elderly patients. The aim of this study was to determine the appropriate treatment strategy and identify the risk factors for mortality in these patients.
Methods: Patients with EGC who underwent endoscopic resection from 2006 to 2017 were identified using National Health Insurance Data and divided into three age groups: very elderly (≥85 years), elderly (65 to 84 years), and non-elderly (≤64 years). Their long- and short-term outcomes were compared in the three age groups, and the survival in the groups was compared with that in the control group, matched by age and sex. We also evaluated the risk factors for long- and short-term outcomes.
Results: A total of 8,426 patients were included in our study: 118 very elderly, 4,583 elderly, and 3,725 non-elderly. The overall survival and cancer-specific survival rates were significantly lower in the very elderly group than in the elderly and the non-elderly groups. Congestive heart failure was negatively associated with cancer-specific survival. A significantly decreased risk for mortality was observed in all groups (p<0.001). The very elderly group had significantly higher readmission and mortality rates within 3 months of endoscopic resection than the non-elderly and elderly groups. Furthermore, the cerebrovascular disease was associated with mortality within 3 months after endoscopic resection.
Conclusions: Endoscopic resection for EGC can be helpful for very elderly patients, and it may play a role in achieving overall survival comparable to that of the control group.

Keywords: Gastric cancer, Endoscopic mucosal resection, Elderly

INTRODUCTION

Globally, the population is aging; the World Health Organization predicts that by 2050 around 2 billion people in the world will be ≥60 years of age, and 400 million will be ≥80 years of age.1 The increasing geriatric population and introduction of mass screening programs, has led to a growing number of early gastric cancer (EGC) cases being diagnosed in the very elderly population (those aged >85 years).

The treatment of EGC is well-established. When a lesion meets the endoscopic treatment criteria, endoscopic resection is the first-line treatment modality and achieves comparable results as surgery concerning patient survival.2 However, the management of very elderly patients with EGC is challenging in comparison to elderly or non-elderly patients with EGC owing to age-specific concerns, including a higher incidence of comorbid conditions and a lower life expectancy.3,4 Reports exist on the long-term outcomes of endoscopic resection in the elderly, but research specific to the very elderly are lacking.5-9 Because the number of elderly patients with EGC has also increased, and will continue to do so in the future, there is a significant need for evidence-based strategies to determine the most appropriate course of treatment for EGC in the very elderly population.

Therefore, this study aimed to evaluate the long- and short-term outcomes of endoscopic resection for EGC for very elderly patients compared to non-elderly and elderly patients, using data from the National Health Insurance Service (NHIS). We also examined the prognostic factors of clinical outcomes.

MATERIALS AND METHODS

1. Patients

As a single insurer, the NHIS covers the entire Korean population. In December 2015, the Korean National Health Insurance Big Data Base was developed, based on the treatment data for claims between the NHIS and healthcare providers in Korea.10 The Korean National Health Insurance Big Data Base includes information on patient demographics, reimbursement for medical services, the International Classification of Diseases 10th Revision codes, medical history, and mortality,11 which are then linked to the Korean National Statistical Office, who allow access for research purposes.

Based on the Korean National Health Insurance Big Data Base, we constructed a custom database which included patients with gastric cancer in Korea from 2006 to 2017. Patients with gastric cancer were screened by the main or sub-disease code, C16, according to the International Classification of Diseases 10th Revision.12 We assessed patient characteristics including age, sex, and comorbidities. The exclusion criteria were as follows: (1) those who had an additional cancer code besides C16 or underwent gastrectomy 5 years before enrollment of enrollment (n=8,702); (2) lost to follow-up (n=1,576); and (3) those who did not undergo endoscopic submucosal dissection (ESD) or endoscopic mucosal resection (EMR) (n=55,813). The included patients were divided into three age groups based on World Health Organization and geriatric research guidelines:13,14 very elderly (≥85 years), elderly (65 to 84 years), and non-elderly (≤64 years) (Fig. 1).

Figure 1. Study flowchart.

In Korea, endoscopic resection for EGC is considered for tumors that fulfill the criteria according to the Korean Practice Guideline for Gastric Cancer 2018.15

The study protocol was in accordance with the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Institutional Review Board of the Samsung Medical Center (IRB number: 2019-07-128). The requirement for informed consent was waived due to the retrospective study design.

2. Outcomes

1) Long-term outcomes

All-cause mortality was obtained from the NHIS database. We compared overall survival (OS) and cancer-specific survival (CSS) rates between the three groups. The relationships among OS, CSS, and clinical factors were evaluated. We compared the risk of mortality in the three groups in relation to that in the control group matched by age and sex. OS was defined as the interval from the date of gastric cancer diagnosis to any cause of death. CSS was defined as the interval from the date of the primary diagnosis to the date of gastric cancer-specific death.

2) Short-term outcomes

Short-term outcomes were evaluated in terms of the readmission within 3 months after ESD/EMR (including admission for gastrectomy) and mortality within 3 months after ESD/EMR. The relationship between short-term outcomes and clinical factors was also evaluated.

3. Statistical analysis

Continuous values are presented as mean±standard deviation, while categorical variables are shown as number with proportions. The differences between groups were analyzed using the t-test for continuous variables and the chi-square test for categorical variables. OS and CSS were estimated using the Kaplan-Meier method. Survival rates were compared using the log-rank test. Cox proportional hazards regression was performed to identify hazard ratios (HRs) and 95% confidence intervals (CIs). Differences were considered significant at p-value of <0.05. Statistical analyses were performed using SAS version 9.4.1 (Statistical Analysis Software, SAS Institute Inc, Cary, NC, USA) and the statistical program R (version 4.0; R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

1. Patient characteristics

Of the 74,517 patients diagnosed with EGC between 2006 and 2017, 66,091 patients were excluded and 8,426 patients who underwent endoscopic resection for EGC were eligible for the study. Among the 8,426 patients, 8,350 patients underwent ESD and only 76 patients underwent EMR. Baseline characteristics of the study population are presented in Table 1. The mean patient age was 65.5 years (standard deviation, 10.4), and among them, 118 (1.4%) were classified as very elderly, 4,583 (54.4%) as elderly, and 3,725 (44.2%) as non-elderly. A total of 5,998 patients (71.2%) were men and 2,428 (28.8%) were women. The elderly and non-elderly groups were predominantly males (75.8% and 68.0%, respectively); however, the very elderly group had a slight female predominance (51.7%). The severity of all comorbidities increased significantly with age, with the exception of liver disease, acquired immunodeficiency syndrome/human immunodeficiency virus infection and renal disease.

Table 1 . Baseline Characteristics.

CharacteristicTotalAge groupp-value
≤64 yr65–84 yr≥85 yr
No. of patients8,4263,7254,583118
Age, yr65.5±10.455.9±6.572.8±5.087.0±1.9<0.001
Sex<0.001
Male5,998 (71.2)2,825 (75.8)3,116 (68.0)57 (48.3)
Female2,428 (28.8)900 (24.2)1,467 (32.0)61 (51.7)
Comorbidities
Myocardial infarction142 (1.7)40 (1.1)98 (2.1)4 (3.4)<0.001
Congestive heart failure584 (6.9)118 (3.2)449 (9.8)17 (14.4)<0.001
Peripheral vascular disease1,650 (19.6)453 (12.2)1,164 (25.4)33 (28.0)<0.001
Cerebrovascular disease1,512 (17.9)344 (9.2)1,129 (24.6)39 (33.1)<0.001
Dementia233 (2.8)19 (0.5)199 (4.3)15 (12.7)<0.001
Chronic pulmonary disease4,126 (49.0)1,450 (38.9)2,599 (56.7)77 (65.3)<0.001
Connective tissue disease547 (6.5)183 (4.9)346 (7.5)18 (15.3)<0.001
Diabetes2,657 (31.5)905 (24.3)1,700 (37.1)52 (44.1)<0.001
Paraplegia/hemiplegia108 (1.3)26 (0.7)80 (1.7)2 (1.7)<0.001
Liver disease2,516 (29.9)1,111 (29.8)1,374 (30.0)31 (26.3)0.684
AIDS/HIV3 (0.0)1 (0.0)2 (0.0)00.902
Renal disease204 (2.4)47 (1.3)154 (3.4)3 (2.5)<0.001

Data are presented as mean±SD or number (%)..

AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus..



2. Comparison of long-term outcomes

The median follow-up periods after endoscopic resection for the very elderly, elderly, and non-elderly groups were 1,200 days (interquartile range, 950 to 1,642 days), 1,379 days (interquartile range, 1,026 to 1,777 days), and 1,475 days (interquartile range, 1,091 to 1,867 days), respectively. The OS rates of the very elderly group were significantly lower than those of the elderly and non-elderly group (1-, 5-, and 10-year OS rates: very elderly patients: 96.6%, 67.8%, and 62.7%; elderly patients: 99.1%, 88.2%, and 85.3%; and non-elderly patients: 99.8%, 97.4%, and 96.5%, respectively; p<0.001) (Fig. 2A). The CSS rate was also significantly lower in the very elderly group than in the other groups (1-, 5-, and 10- year CSS rates: very elderly patients: 98.3%, 90.7%, and 89.8%; elderly patients: 99.7%, 98.5%, 98.3%; and non-elderly patients: 100.0%, 99.7%, and 99.6%, respectively; p<0.001) (Fig. 2B). However, a significant decrease in the risk of mortality was observed among all age groups (HR=0.23, 0.30, and 0.45, for the very elderly, elderly, and non-elderly groups, respectively; all p<0.001) (Table 2), indicating that patients undergoing endoscopic resection for EGC had a lower mortality rate than the control group, regardless of age.

Table 2 . Risk of Mortality in the Three Age Groups Compared to General Population Matched Age and Sex.

Age groupEndoscopic resectionControl groupp-value
No. of patientsPerson-yearsNo. of casesNo. of casesHR (95% CI)
≤64 yr3,72515,103851,2170.45 (0.36–0.55)<0.001
65–84 yr4,58317,6934279,6330.30 (0.27–0.33)<0.001
≥85 yr118404301,0080.23 (0.15–0.32)<0.001

HR, hazard ratio; CI, confidence interval..


Figure 2. Overall survival (A) and cancer-specific survival (B) of the three age groups.

The risk factors associated with OS were congestive heart failure (HR, 1.92; 95% CI, 1.52 to 2.44; p<0.001), dementia (HR, 1.94; 95% CI, 1.40 to 2.70; p<0.001), paraplegia/hemiplegia (HR, 2.26; 95% CI, 1.46 to 3.50; p<0.001), renal disease (HR, 2.42; 95% CI, 1.72 to 3.40; p<0.001), and increasing Charlson comorbidity index (CCI) score (HR, 1.80; 95% CI, 1.45 to 3.15; p<0.001); however, the only risk factor associated with CSS was congestive heart failure (HR, 2.86; 95% CI, 1.51 to 5.41; p=0.001) (Table 3).

Table 3 . Risk Factors for Long-term Outcome.

Covariate Overall survivalCancer-specific survival
Adjusted HR (95% CI)p-valueAdjusted HR (95% CI)p-value
Sex
MaleReferenceReference
Female0.60 (0.49–0.74)<0.0011.02 (0.59–1.77)0.950
Comorbidities
Myocardial infarction1.03 (0.62–1.71)0.9080.00 (0.00–Inf)0.994
Congestive heart failure1.92 (1.52–2.44)<0.0012.86 (1.51–5.41)0.001
Peripheral vascular disease0.98 (0.80–1.20)0.8401.32 (0.74–2.33)0.343
Cerebrovascular disease1.13 (0.92–1.38)0.2600.59 (0.30–1.18)0.136
Dementia1.94 (1.40–2.70)<0.0011.98 (0.76–5.18)0.163
Chronic pulmonary disease1.02 (0.85–1.21)0.8570.80 (0.47–1.37)0.416
Connective tissue disease1.11 (0.81–1.52)0.5131.28 (0.54–3.03)0.578
Diabetes0.43 (0.05–3.53)0.4320.62 (0.11–3.63)0.564
Paraplegia/hemiplegia2.26 (1.46–3.50)<0.0012.66 (0.61–11.65)0.194
Liver disease1.10 (0.92–1.32)0.2950.64 (0.34–1.20)0.167
AIDS/HIV0.00 (0.00–Inf)0.9870.00 (0.00–Inf)0.999
Renal disease2.42 (1.72–3.40)<0.0012.55 (0.89–7.27)0.080
Charlson comorbidity index score1.80 (1.45–3.15)<0.0011.21 (0.45–5.78)0.469

HR, hazard ratio; CI, confidence interval; AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; Inf, infinity..



3. Comparison of short-term outcomes

The short-term outcomes are presented in Table 4. Readmission rate within 3 months after endoscopic resection was significantly higher in the very elderly group than in the elderly and non-elderly groups (11.0%, 5.8%, and 5.3%, respectively, p=0.028). Mortality within 3 months after endoscopic resection was significantly higher in the very elderly group than in the elderly and non-elderly groups (0.8%, 0.1%, and 0%, respectively, p<0.001). The risk factors associated with the short-term outcomes are presented in Table 5. Risk factors associated with readmission within 3 months after endoscopic resection were female sex (HR, 1.22; 95% CI, 1.01 to 1.49; p=0.045), congestive heart failure (HR, 1.49; 95% CI, 1.12 to 2.00; p=0.007), dementia (HR, 1.77; 95% CI, 1.20 to 2.61; p=0.004), paraplegia/hemiplegia (HR, 3.50; 95% CI, 2.26 to 5.42; p<0.001), liver disease (HR, 1.51; 95% CI, 1.25 to 1.82; p<0.001), and acquired immunodeficiency syndrome/human immunodeficiency virus infection (HR, 31.47; 95% CI, 7.70 to 128.57; p<0.001). Increasing CCI score was associated with the risk for readmission within 3 months, but not with 3-month mortality. The only risk factor associated with a 3-month mortality rate was cerebrovascular disease (HR, 5.75: 95% CI, 1.05 to 31.38; p=0.043).

Table 4 . Short-term Outcomes.

OutcomeAge group, No. (%)p-value
≤64 yr (n=3,725)65–84 yr (n=4,583)≥85 yr (n=118)
Overall
Readmission rate within 3 mo after endoscopic resection199 (5.3)264 (5.8)13 (11.0)0.028
Mortality within 3 mo after endoscopic resection05 (0.1)1 (0.8)<0.001
For endoscopic submucosal dissection
Readmission rate within 3 mo after endoscopic resection187 (5.1)261 (5.7)13 (11.0)0.023
Mortality within 3 mo after endoscopic resection04 (0.1)1 (0.8)<0.001
For endoscopic mucosal resection
Readmission rate within 3 mo after endoscopic resection2 (5.3)3 (8.6)00.019
Mortality within 3 mo after endoscopic resection01 (2.9)0<0.004

Table 5 . Risk Factors for Short-term Outcome.

Covariate3 mo readmission3 mo mortality
Adjusted HR (95% CI)p-valueAdjusted HR (95% CI)p-value
Sex
MaleReferenceReference
Female1.22 (1.01–1.49)0.0450.67 (0.36–1.25)0.620
Comorbidities
Myocardial infarction0.85 (0.44–1.66)0.6330.00 (0.00–Inf)0.999
Congestive heart failure1.49 (1.12–2.00)0.0071.79 (0.21–15.34)0.594
Peripheral vascular disease1.15 (0.92–1.42)0.2172.69 (0.54–13.32)0.226
Cerebrovascular disease1.14 (0.91–1.44)0.2525.75 (1.05–31.38)0.043
Dementia1.77 (1.20–2.61)0.0042.00 (0.23–17.15)0.526
Chronic pulmonary disease1.10 (0.91–1.33)0.3141.50 (0.28–8.21)0.638
Connective tissue disease1.21 (0.88–1.67)0.2340.00 (0.00–Inf)0.998
Diabetes0.59 (0.28–1.26)0.1760.00 (0.00–Inf)1.000
Paraplegia/hemiplegia3.50 (2.26–5.42)<0.0010.00 (0.00–Inf)0.999
Liver disease1.51 (1.25-1.82)<0.0010.00 (0.00–Inf)0.996
AIDS/HIV31.47 (7.70–128.57)<0.0010.00 (0.00–Inf)1.000
Renal disease1.16 (0.71–1.90)0.5580.00 (0.00–Inf)0.999
Charlson comorbidity index score18.57 (6.19–83.57)<0.0013.74 (0.35–22.15)0.698

HR, hazard ratio; CI, confidence interval; AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; Inf, infinity..


DISCUSSION

The major finding of this study was that although the overall and gastric cancer-specific mortality rates were higher in the very elderly group than in the elderly and non-elderly groups, mortality risk was significantly lower for all three groups than in the control group. The survival of the very elderly group indicated a 67% decrease in the mortality rate after endoscopic resection for EGC. These results indicate that in very elderly patients who meet the endoscopic resection criteria, aggressive endoscopic resection for EGC is not harmful and, moreover, it may help patients achieve expected survival rates comparable to those of the control group.

It is often difficult to devise treatment strategies for elderly patients with EGC because of their comorbidities and lower life expectancy. Previous studies have reported that in patients who do not receive timely treatment, EGC progresses to advanced stage and lead to death within 4 to 5 years.16-18 However, the Organisation for Economic Co-operation and Development reports that the current life expectancy for those ≥80 years living within Organisation for Economic Co-operation and Development countries is approximately 9 years,19 and the efficacy and safety of ESD in comorbid or elderly patients has been well-reported.20-28 Kim et al.21 used CCI to divide patients into low and high risk groups and compared complication rates in various comorbid disease between the two groups. Complications (such as bleeding or perforation) did not differ significantly between the two groups. Moreover, none of the comorbid disease made a statistically significant contribution to the occurrence of a specific complication.21 Kato et al.28 compared the short-term outcomes and incidence of complications in elderly (≥75 years of age) and non-elderly groups. The R0 resection rate and curative resection rate did not differ between the two groups. In terms of complication, the incidence of bleeding and incidence of perforation were similar in the two groups.28 In two studies including very elderly patients (≥85 years of age), there were no significant differences in adverse events or in the en bloc resection or complete resection.29,30 Therefore, aggressive endoscopic treatment of EGC in elderly patients may contribute to lengthening life expectancy. Consistent with our findings, the results from recent studies investigating endoscopic treatments for elderly patients have demonstrated comparable long-term outcomes.6,7,29,30 Abe et al.6 conducted a multicenter study including 440 patients aged ≥80 years which showed that in patients undergoing ESD, the cumulative survival at 5 years after ESD was better than the expected survival for general population matched by age and sex. Chang et al.7 reported the long-term outcomes of patients aged ≥75 years who underwent ESD for EGC, were worse for patients with other risk factors such as history of cancer beside gastric cancer or CCI ≥3, than in those without other risk factors.

Few reports have included very elderly patients, and the long-term outcomes of these patients are not well-known. To the best of our knowledge, only two reports have been published, which included a small number of patients (n=43 and n=85).29,30 Our study included a relatively larger number (n=118) of very elderly patients with a long-term observation period. In addition, we compared the survival rates of the very elderly group with those of the elderly and non-elderly groups, and the survival rate after endoscopic treatment was compared to that of the control group. We also identified prognostic factors for long- and short-term outcomes. The common risk factors for OS and CSS are congestive heart failure, and the risk factor for 3-month mortality was cerebrovascular disease. These results are consistent with reports that patients aged ≥85 with cardiovascular disease showed statistically significant lower OS rate than patients aged ≥85 without cardiovascular disease.29 Cardiovascular and cerebrovascular diseases are major health problems in the elderly, as a result of living to an age when they are likely to suffer the sequelae of chronic atherosclerosis. One study reported the long-term prognosis after ESD for colorectal tumors in patients aged over 80 years and the most common cause of death was heart disease other than pneumonia.31 Because our study stratified comorbid diseases according to the CCI, heart diseases were classified into myocardial infarction and congestive heart failure. While patients who suffer a heart attack often survive their initial events and live into their 80s, many go on to die of chronic heart failure. In fact, age-adjusted mortality rate for heart failure appears to be on the rise.32 In terms of short-term outcomes, bleeding is one of the major complications in endoscopic resection.21 Patients with cerebrovascular diseases are likely to be on antiplatelet or anticoagulant therapy, and continuing it may increase the risk of bleeding while discontinuing it may increase the risk of ischemic stroke, contributing to higher short-term mortality.33,34

Our study has several limitations. First, the study was retrospective and may have a potential bias. For example, the very elderly patients in this study may had a better performance status and less comorbidity compared with general elderly population, which may induce selection bias. Second, the 3-month readmission data included admission for additional surgery after non-curative ESD because we could not discriminate the cause for admission. Third, the follow-up duration among the three age groups was significantly different, likely because of the different life expectancies. Fourth, the data from gastric adenomas were not included in this study. Sometimes, large gastric adenoma are more difficult to perform endoscopic procedures than very small EGCs, and the complication rates could be higher. Fifth, the outcomes related to the procedure such as complete resection rate, recurrence rate, and the incidence of complications during procedure, could not be analyzed because this study is a national population-based study.

In conclusion, our study suggests that aggressive endoscopic resection for patients with EGC can be helpful for very elderly patients who meet the endoscopic resection criteria, with the expected post-procedure survival rate being comparable to that of the control group. Regarding comorbidities, special attention should be paid to very elderly patients with congestive heart failure or cerebrovascular disease.

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

AUTHOR CONTRIBUTIONS

Study conception and design: H.L., T.J.K., J.H.P. Data analysis and interpretation: T.J.K., J.H.P. Drafting of the manuscript: T.J.K., J.H.P. Critical revision of the manuscript for important intellectual content: S.C.C., Y.W.M., B.H.M., J.H.L., P.L.R., M.S., Y.H.C., J.J.K. Study supervision: H.L. Approval of final manuscript: all authors.

Fig 1.

Figure 1.Study flowchart.
Gut and Liver 2022; :

Fig 2.

Figure 2.Overall survival (A) and cancer-specific survival (B) of the three age groups.
Gut and Liver 2022; :

Table 1 Baseline Characteristics

CharacteristicTotalAge groupp-value
≤64 yr65–84 yr≥85 yr
No. of patients8,4263,7254,583118
Age, yr65.5±10.455.9±6.572.8±5.087.0±1.9<0.001
Sex<0.001
Male5,998 (71.2)2,825 (75.8)3,116 (68.0)57 (48.3)
Female2,428 (28.8)900 (24.2)1,467 (32.0)61 (51.7)
Comorbidities
Myocardial infarction142 (1.7)40 (1.1)98 (2.1)4 (3.4)<0.001
Congestive heart failure584 (6.9)118 (3.2)449 (9.8)17 (14.4)<0.001
Peripheral vascular disease1,650 (19.6)453 (12.2)1,164 (25.4)33 (28.0)<0.001
Cerebrovascular disease1,512 (17.9)344 (9.2)1,129 (24.6)39 (33.1)<0.001
Dementia233 (2.8)19 (0.5)199 (4.3)15 (12.7)<0.001
Chronic pulmonary disease4,126 (49.0)1,450 (38.9)2,599 (56.7)77 (65.3)<0.001
Connective tissue disease547 (6.5)183 (4.9)346 (7.5)18 (15.3)<0.001
Diabetes2,657 (31.5)905 (24.3)1,700 (37.1)52 (44.1)<0.001
Paraplegia/hemiplegia108 (1.3)26 (0.7)80 (1.7)2 (1.7)<0.001
Liver disease2,516 (29.9)1,111 (29.8)1,374 (30.0)31 (26.3)0.684
AIDS/HIV3 (0.0)1 (0.0)2 (0.0)00.902
Renal disease204 (2.4)47 (1.3)154 (3.4)3 (2.5)<0.001

Data are presented as mean±SD or number (%).

AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus.


Table 2 Risk of Mortality in the Three Age Groups Compared to General Population Matched Age and Sex

Age groupEndoscopic resectionControl groupp-value
No. of patientsPerson-yearsNo. of casesNo. of casesHR (95% CI)
≤64 yr3,72515,103851,2170.45 (0.36–0.55)<0.001
65–84 yr4,58317,6934279,6330.30 (0.27–0.33)<0.001
≥85 yr118404301,0080.23 (0.15–0.32)<0.001

HR, hazard ratio; CI, confidence interval.


Table 3 Risk Factors for Long-term Outcome

Covariate Overall survivalCancer-specific survival
Adjusted HR (95% CI)p-valueAdjusted HR (95% CI)p-value
Sex
MaleReferenceReference
Female0.60 (0.49–0.74)<0.0011.02 (0.59–1.77)0.950
Comorbidities
Myocardial infarction1.03 (0.62–1.71)0.9080.00 (0.00–Inf)0.994
Congestive heart failure1.92 (1.52–2.44)<0.0012.86 (1.51–5.41)0.001
Peripheral vascular disease0.98 (0.80–1.20)0.8401.32 (0.74–2.33)0.343
Cerebrovascular disease1.13 (0.92–1.38)0.2600.59 (0.30–1.18)0.136
Dementia1.94 (1.40–2.70)<0.0011.98 (0.76–5.18)0.163
Chronic pulmonary disease1.02 (0.85–1.21)0.8570.80 (0.47–1.37)0.416
Connective tissue disease1.11 (0.81–1.52)0.5131.28 (0.54–3.03)0.578
Diabetes0.43 (0.05–3.53)0.4320.62 (0.11–3.63)0.564
Paraplegia/hemiplegia2.26 (1.46–3.50)<0.0012.66 (0.61–11.65)0.194
Liver disease1.10 (0.92–1.32)0.2950.64 (0.34–1.20)0.167
AIDS/HIV0.00 (0.00–Inf)0.9870.00 (0.00–Inf)0.999
Renal disease2.42 (1.72–3.40)<0.0012.55 (0.89–7.27)0.080
Charlson comorbidity index score1.80 (1.45–3.15)<0.0011.21 (0.45–5.78)0.469

HR, hazard ratio; CI, confidence interval; AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; Inf, infinity.


Table 4 Short-term Outcomes

OutcomeAge group, No. (%)p-value
≤64 yr (n=3,725)65–84 yr (n=4,583)≥85 yr (n=118)
Overall
Readmission rate within 3 mo after endoscopic resection199 (5.3)264 (5.8)13 (11.0)0.028
Mortality within 3 mo after endoscopic resection05 (0.1)1 (0.8)<0.001
For endoscopic submucosal dissection
Readmission rate within 3 mo after endoscopic resection187 (5.1)261 (5.7)13 (11.0)0.023
Mortality within 3 mo after endoscopic resection04 (0.1)1 (0.8)<0.001
For endoscopic mucosal resection
Readmission rate within 3 mo after endoscopic resection2 (5.3)3 (8.6)00.019
Mortality within 3 mo after endoscopic resection01 (2.9)0<0.004

Table 5 Risk Factors for Short-term Outcome

Covariate3 mo readmission3 mo mortality
Adjusted HR (95% CI)p-valueAdjusted HR (95% CI)p-value
Sex
MaleReferenceReference
Female1.22 (1.01–1.49)0.0450.67 (0.36–1.25)0.620
Comorbidities
Myocardial infarction0.85 (0.44–1.66)0.6330.00 (0.00–Inf)0.999
Congestive heart failure1.49 (1.12–2.00)0.0071.79 (0.21–15.34)0.594
Peripheral vascular disease1.15 (0.92–1.42)0.2172.69 (0.54–13.32)0.226
Cerebrovascular disease1.14 (0.91–1.44)0.2525.75 (1.05–31.38)0.043
Dementia1.77 (1.20–2.61)0.0042.00 (0.23–17.15)0.526
Chronic pulmonary disease1.10 (0.91–1.33)0.3141.50 (0.28–8.21)0.638
Connective tissue disease1.21 (0.88–1.67)0.2340.00 (0.00–Inf)0.998
Diabetes0.59 (0.28–1.26)0.1760.00 (0.00–Inf)1.000
Paraplegia/hemiplegia3.50 (2.26–5.42)<0.0010.00 (0.00–Inf)0.999
Liver disease1.51 (1.25-1.82)<0.0010.00 (0.00–Inf)0.996
AIDS/HIV31.47 (7.70–128.57)<0.0010.00 (0.00–Inf)1.000
Renal disease1.16 (0.71–1.90)0.5580.00 (0.00–Inf)0.999
Charlson comorbidity index score18.57 (6.19–83.57)<0.0013.74 (0.35–22.15)0.698

HR, hazard ratio; CI, confidence interval; AIDS, acquired immunodeficiency syndrome; HIV, human immunodeficiency virus; Inf, infinity.


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Gut and Liver

Vol.17 No.1
January, 2023

pISSN 1976-2283
eISSN 2005-1212

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