We retrospectively reviewed clinical data from a prospectively maintained database of ESD for consecutive patients at Peking University Cancer Hospital between January 2018 and December 2021. The inclusion criteria were receipt of esophageal or gastric ESD and malignant final diagnosis. The exclusion criteria were receipt of laparoscopic endoscopic collaborative surgery, recurrent lesions, multiple lesions, or a history of esophagectomy or gastrectomy. The present study was approved by the Ethics Committee of Peking University Cancer Hospital (2022KT13) in accordance with the Declaration of Helsinki. Written informed consent was obtained from all patients or their families.

According to the length of hospitalization, patients were divided into S-D and M-D groups. Patients in the S-D group were admitted to the ambulatory care unit on the morning of the ESD procedure day, whereas patients in the M-D group were admitted to the hospital ward the day before ESD. After the ESD procedure, patients in the S-D group were discharged from the ambulatory care unit on the S-D, while the M-D group patients returned to the hospital ward for at least one night before discharge. Patients in the S-D group were informed that they might be transferred to a hospital ward for hospital stay after the procedure if there was an intraprocedural perforation, unsatisfactory postanesthesia recovery, or other serious unexpected adverse events (AEs). Concerning patients who received antithrombotic therapy, after consultation with a cardiologist, agents were discontinued 5-7 d before ESD and resumed on day 7 after the procedure.

The following demographic and clinical information were collected: Age, sex, American Society of Anesthesiologists (ASA) physical status classification, comorbidities, history of antithrombic agent use, duration of ESD procedure, length of hospital stay, cost of hospitalization, pathological evaluation of specimen, and AEs during or after the procedure.

In this study, the primary endpoint was the presence of ESD-related major AEs (MAEs) within 30 d of the procedure. MAEs included bleeding and perforation. Bleeding was defined as active or oozing bleeding of the ESD wound requiring hemostasis during scheduled second-look endoscopy (SSLE), with or without a decrease in hemoglobin level of ≥ 2 g/dL. Perforation was defined as a muscle layer defect, allowing the observation of mesenteric fat or intraabdominal space during the procedure or free air found on a radiograph in symptomatic patients after the ESD procedure. AEs were categorized as intraprocedural and postprocedural according to the time point in which they emerged.

The secondary endpoints were the rates of en bloc resection and complete resection, length of hospital stay, and medical expenses. The tumor location was divided into the esophagus, and the upper, middle, and lower stomach. The upper stomach consists of the cardia and upper part of the gastric body, the middle stomach consists of the angle and middle body, and the lower stomach consists of the pylorus, antrum, and lower body. The macroscopic classification was divided into elevated (0-I), flat (0-II), and depressed (0-III) types according to the Paris classification of superficial neoplastic lesions in the digestive tract[17]. En bloc resection was defined as resection of the lesion in a single piece, and complete resection was defined as resection of a tumor without histological evidence of tumor cell involvement on the lateral and vertical resection margins[18].

All ESD patients in our department followed the M-D strategy before 2020. Patients with an estimated specimen size < 4 cm or who lived nearby were selected as S-D strategy candidates since 2020; they were assigned to the S-D or M-D group based on the anesthesiologist‘s recommendation and the patient’s intention after full consultation. All ESD procedures were performed under general anesthesia with tracheal intubation and propofol administration. A single-channel upper gastrointestinal endoscope (GIF Q260J; Olympus Co., Tokyo, Japan) was used in all ESD procedures. A premixed sterilized solution of glycerol (10% glycerol and 5% fructose; Cisen Pharmaceutical, Co., Ltd., Shandong, China) with indigo carmine was injected into the submucosal layer. A single-use electrosurgical knife with water injection function (Micro-Tech Co., Nanjing, China) was used for lesion marking, incision, and dissection with an electrosurgical unit (VIO 200S; ERBE Elektromedizin GmbH, Tübingen, Germany). The ENDO CUT Q mode (parameter setting effect 3, cutting duration 2, and cutting interval 4) was applied for both mucosal incision and submucosal dissection. Hemostasis was achieved with the FORCED COAG E2 mode, and the power was set to 40 W in the esophagus and 50 W in the stomach. If perforation occurred during the procedure, suturing was performed using hemoclips (Micro-Tech Co.). All ESD wounds were sprayed with porcine fibrin sealant (5 mL kit; Guangzhou Bioseal Biotechnology Co., Ltd., Guangzhou, China) after the lesions were resected.

All ESD procedures were performed by the same endoscopist. For patients without intraprocedural perforation, nasogastric tube was not placed. For all patients, water drinking was initiated 2 h after anesthesia recovery. All patients also underwent an SSLE the next day to identify possible bleeding, even if they had been discharged on the same day of ESD. If no bleeding was discovered in the SSLE, oral enteral nutritional suspension was prescribed for 1 wk, followed by soft diet for 1 wk before the full diet resumption. For patients with intraprocedural perforation or postprocedural bleeding, the oral diet was postponed depending on recovery. For all patients, proton pump inhibitor therapy (standard dosing) was administered intravenously until the patient was discharged, followed by oral administration for 4 wk. Follow-up consisted of telephonic contact, and AEs reported after discharge were recorded by a physician associate.

To minimize the effect of selection bias, the propensity score matching (PSM) method was applied to balance the unevenly distributed patient baseline characteristics in this non-randomized trial. Individual propensity scores were generated through a logistic regression model that included the following covariates: Age, sex, ASA physical status, comorbidities, use of antithrombotic agent, tumor location, macroscopic appearance, tumor differentiation, depth of invasion, and specimen size. Subsequently, patients in the S-D and M-D groups were paired using a 1:1 nearest available score match algorithm with a match tolerance of 0.02.

Further statistical analyses were conducted to compare the differences between the two groups based on the matched data. Quantitative data with normal distribution are presented as the means ± SD, and categorical data are presented as frequencies. Differences between groups were examined using the student’s t-test, χ² test, or Fisher’s exact test where appropriate. Logistic regression was used to identify the risk factors for AEs. Statistical significance was set at P < 0.05. All statistical analyses were performed using SPSS statistical software (version 22.0; IBM Corp., Armonk, NY, United States).

A total of 479 patients who underwent 482 esophageal or gastric ESD procedures were reviewed retrospectively (Figure 1). Among these, 3 patients who underwent laparoscopic endoscopic collaborative surgery, 3 patients with multiple lesions, 2 patients with history of esophagectomy or gastrectomy, and 1 patient with a recurrent lesion were excluded. Therefore, 470 patients were enrolled in the study. The clinicopathological characteristics of the patients are presented in Table 1. Before PSM, there were 91 patients in the S-D group and 379 patients in the M-D group. There were significant differences in ASA score (P = 0.039), tumor differentiation (P = 0.004), depth of invasion (P = 0.022), and specimen size (P < 0.001) between the two groups. After PSM, there were 78 patients in each group, and all baseline parameters were balanced between the two groups.

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Figure 1 Flow chart of patient enrollment for this study. A total of 479 patients received endoscopic submucosal dissection for the esophagus or stomach, and 470 cases met the inclusion and exclusion criteria. After propensity score matching, there were 78 patients in each group for further analysis. ESD: Endoscopic submucosal dissection; ASA: American Society of Anesthesiologists; M-D: Multi-day; S-D: Same-day.

As shown in Table 2, after PSM, no significant difference was found between the groups across pathological parameters including tumor size, rate of free vertical margin, and complete resection. As shown in Table 3, the ESD procedural time was comparable between the two groups after PSM (60.5 ± 34.9 min in the S-D group vs 65.8 ± 43.0 min in the M-D group; P = 0.397). In addition, the duration of hospitalization was significantly shorter in the S-D group than in the M-D group (1 d vs 4.9 ± 2.5 d, respectively; P < 0.001). In this study, the total medical expense was determined by categorizing the costs of the procedure, medical devices, medication, diagnostic tests, and administration. The overall medical expenses and the subitem costs were lower in the S-D group.

Thirty-five MAEs occurred in 35 (7.4%) patients, including 14 intraprocedural perforations (1 in the esophagus), 18 cases of oozing bleeding (1 in the esophagus) without hemoglobin decreased, and 3 cases of active bleeding (all in the stomach) with hemoglobin decreased 2 g/dL to 2.5 g/dL during SSLE. All MAEs were managed endoscopically. There was no recurrent bleeding that occurred after SSLE, and no rehospitalization was needed within 7 d of discharge in either group. Both before and after PSM, no significant differences were found between the groups with respect to intraprocedural and postprocedural MAEs (Table 4). Factors associated with postprocedural bleeding and intraprocedural perforation were also investigated. Following multivariate analysis, lesions located in the middle and lower thirds of the stomach were significantly associated with postprocedural bleeding (odds ratio: 5.3, 95% confidence interval: 1.3-22.2; P = 0.023) (Table 5), whereas no risk factor was identified for intraoperative perforation.

Endoscopic submucosal dissection (ESD) is an established technique for the treatment of early gastrointestinal neoplasia. Generally, a multi-day (M-D) admission is required for patients undergoing ESD due to potential complications. This retrospective study demonstrates that the same-day (S-D) discharge procedures for esophagogastric ESD may be feasible and effective.

ESD is safer, more cost-effective, has greater efficacy, and exhibits a positive impact on health-related quality of life in comparison with surgery. Reducing the length of hospital stay can decrease medical expenses, and some studies have attempted to shorten the duration of postprocedural hospitalization after esophageal, gastric, and colorectal ESD. However, data on the feasibility of S-D discharge after esophagogastric ESD remain limited.

In this study, we describe our preliminary experience with the S-D discharge strategy following ESD of the esophagus or stomach compared with conventional M-D hospital admission.

To minimize the effect of selection bias, the propensity score matching method was applied to balance the unevenly distributed patient baseline characteristics in this non-randomized trial. Subsequently, patients in the S-D and M-D groups were paired using the 1:1 nearest available score match algorithm with a match tolerance of 0.02. Further statistical analyses were conducted to compare the differences between the two groups based on the matched data.

No significant difference was found between the groups with respect to intraoperative and postprocedural major adverse events (AEs). The tumor size, complete resection rate, and procedural duration were comparable between the groups. The S-D group demonstrated a significantly shorter length of hospital stay (P < 0.001) and lower overall medical expenses (P < 0.001) compared to the M-D group.

This is the first retrospective study evaluating S-D discharge procedures for esophagogastric ESD in China. The result demonstrated the S-D discharge strategy may be feasible and effective for esophagogastric ESD, and the procedural-related AEs can be managed successfully.

This first retrospective study evaluating S-D discharge procedures for esophagogastric ESD in China demonstrates that this strategy may be feasible and effective, and that the AEs related to ESD could be managed successfully. Additional prospective studies are warranted to establish more detailed standards to select patients for S-D discharge ESD.