Background/Aims: The outcomes of salvage surgery for recurrence after non-curative endoscopic submucosal dissection (ESD) without additional radical surgery for early gastric cancer (EGC) remain unclear. We determined the recurrence patterns and outcomes of salvage surgery in such cases using data from a multicenter, retrospective study. Methods: Of 15,785 patients who underwent ESD for EGC at 19 participating institutions between January 2000 and August 2011, 1,969 failed to meet the current curative criteria after ESD. Of these, 905 patients received no additional treatment. We evaluated the pattern of recurrence, clinical course after salvage surgery, and long-term survival rate for these patients. Results: Over a median 64-month follow-up period, recurrence was detected in 27 patients. Two patients with missing data were excluded. Three, seven, and 15 (60%) patients showed intragastric relapse, regional lymph node metastasis, and distant metastasis, respectively. The first line of treatment for recurrence in 1, 7, 6, and 11 patients was endoscopic treatment, salvage surgery, chemotherapy, and best supportive care, respectively. One patient survived without recurrence for 31 months after salvage surgery, one died of acute myocardial infarction 1 month after salvage surgery, and 5 showed recurrence at 0, 2, 3, 5, and 30 months after salvage surgery and eventually succumbed to the disease. The median survival times for all patients with recurrence and the 7 patients who underwent salvage surgery were 5 months after recurrence and 7 months after salvage surgery, respectively. Conclusion: The survival rate after salvage surgery for recurrence after non-curative ESD without additional radical surgery for EGC is quite low, with distant metastasis being the most common recurrence pattern in these cases.

Colonic diverticular bleeding is the most common cause of bleeding in the lower gastrointestinal tract [1]. Endoscopic identification of stigmata of recent hemorrhage (SRH), such as active bleeding, adherent clot, or visible vessel, is important but often difficult [2] [3]. The waterjet scope, the use of which has been reported to be an independent predictive factor for identifying SRH, is primarily used to wash away feces or clots inside the diverticulum [4]. Herein, we describe a useful case of water pressure observation for the detection of SRH and endoscopic direct clipping of diverticular bleeding. A 75-year-old man with hematochezia had undergone repeated colonoscopies. Multiple diverticula were observed in the right colon, but spontaneous hemostasis prevented the identification of bleeding points. Therefore, the patient was transferred to our hospital. He developed hematochezia again 2 days later. We performed an urgent colonoscopy with bowel preparation. We used a colonoscope with waterjet function (PCF-H290TI; Olympus Medical Systems, Tokyo, Japan). We attached a super-soft transparent hood without slits (Space adjuster; TOP, Tokyo, Japan). Fresh blood and multiple diverticula with hemostatic clips applied by a previous physician were observed in the right colon; however, the bleeding stopped spontaneously ([Fig. 1 a]). We placed the tip hood of the scope in close contact with each diverticulum and inflated it with water. The water pressure opened the diverticulum, which facilitated observation of the interior. We detected a pulsating visible vessel within a diverticulum in the ascending colon ([Fig. 1 b]). Although the diverticulum could not be inverted, we inflated it with water to create a working space that allowed direct pinpoint clipping with a short-armed hemostatic clip (HX-610-135XS; Olympus) ([Fig. 2], [Video 1]). Video 1 Water pressure observation for detection and direct clipping of source of colonic diverticular bleeding. The patient was discharged without additional intervention. The patient had no rebleeding during the 2-month follow-up period. Endoscopy_UCTN_Code_TTT_1AQ_2AZ Article published online: 26 May 2023 © 2023. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/) Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany