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Lymphatic invasion (LI) is a potent risk factor for lymph node metastasis (LNM) in early gastric cancer (EGC) after endoscopic submucosal dissection (ESD). However, there are also other risk factors for LNM. Hence, to identify the need for additional surgery in some case of EGC without LI, the present study aimed to identify the risk factors for LNM in patients with EGC without LI.Data from 2284 patients diagnosed with EGC who underwent curative surgery at National Cancer Center in Korea from January 2012 to May 2019 were collected. The clinicopathological characteristics of patients with EGC without LI were compared on the basis of LNM status.There were 339 (17.1%) and 1648 (82.9%) patients with and without LI respectively. Among these patients with and without LI, 118 (34.8%) and 91 (5.5%) patients presented with LNM, respectively. In patients with EGC without LI, tumor size larger than 3 cm (OR = 2.12, 95% CI = 1.22-3.68; p = 0.007), submucosal invasion (OR = 4.14, 95% CI = 2.57-6.65; p 0.001), and undifferentiated histologic type (OR = 2.33, 95% CI = 1.45-3.76; p 0.001) were significant risk factors for LNM. Rates of LNM in patients meeting absolute, expanded, and beyond expanded criteria without LI were 0%, 1.5% (OR = 3.27, 95% CI = 0.18-59.41; p = 0.423), and 7.3% respectively. When the expanded criteria were divided into four subtypes patients with EGC, without LI within each subtype did not show significant risk of incidence of LNM compared to the absolute criteria.The current expanded criteria for endoscopic resection (ER) are tolerable in cases without LI, even though minimal risk LNM exists. Therefore, additional surgery may not be needed for patients meeting expanded criteria for ER.

BACKGROUND Gastrectomy is known as one of the risk factors for TB. However, there is no study about the association between TB development and gastrectomy performed in patients with early gastric cancer (EGC). This study evaluated conventional risk factors, including gastrectomy, associated with TB development in patients with EGC. METHODS A retrospective cohort study was performed using the database of the Center for Gastric Cancer of the National Cancer Center, Korea. The patients with EGC whose T1 lesions were pathologically confirmed by gastrectomy or endoscopic resection were included. RESULTS A total of 1,935 patients constituted the EGC cohort. Of these, 1,495 patients were confirmed by gastrectomy and the remaining 440 by endoscopic resection. The median follow-up duration was 4.9 years, and during this period, 31 cases of TB developed (TB incidence, 334/100,000 person-years; 95% CI, 227-475). Multivariate Cox regression analysis showed that old TB lesion on chest radiograph and gastrectomy were significant risk factors (hazard ratio [HR], 5.01; 95% CI, 2.44-10.28; P≤ .001; and HR, 8.95; 95% CI, 1.22-65.78; P = .031; respectively). In the gastrectomy subgroup, old TB lesion and > 15% reduction in weight and albumin level about 1 year after gastrectomy were significant risk factors (HR, 4.80; 95% CI, 2.26-10.18; P ≤ .001; HR, 3.08; 95% CI, 1.47-6.48; P = .003; and HR, 5.02; 95% CI, 1.47-17.12; P = .010; respectively). CONCLUSIONS Old TB lesion and gastrectomy were significant risk factors in the EGC cohort. In addition, old TB lesion and > 15% postoperative reductions in weight and albumin level were significant risk factors in the gastrectomy subgroup.

106 Background: The aim of this study is to compare the long-term outcomes between patients who underwent endoscopic submucosal dissection (ESD) and those who underwent surgery for early gastric cancers (EGCs) turned out to be out-of-indication of ESD. Methods: We retrospectively reviewed database on gastric cancer patient cohort who underwent ESD or surgery from 2004 to 2014. Patients whose lesions revealed to be out-of-indication for endoscopic resection after ESD or surgery were included in the analysis after 1:1 propensity score matching for baseline clinicopathologic characteristics. Overall survival (OS) and gastric cancer recurrence rates were compared between the matched ESD and surgery groups. Results: After propensity score matching, a total of 193 pairs of patients were included, and 126 pairs were ESD with additional operation group and 67 pairs were ESD without additional operation group. OS (5-year OS rates, 89.5% vs. 89.9%; P=.105) and gastric cancer recurrence rates (5-year recurrence rates, 2.6% vs. 1.6%; P=.080) were not different between the ESD and the matched surgery group. In the matched subgroups, ESD with additional operation group had comparable OS and gastric cancer recurrence rates in comparison with matched surgery group. However, ESD without additional operation group had significantly shorter OS (5-year OS rates, 76.8% vs. 86.3%; P=.032) and higher gastric cancer recurrence rates (5-year recurrence rates, 11.9% vs. 0%; P=.002) than matched surgery group. ESD without additional operation was also significant risk factor for overall mortality and gastric cancer recurrence in multivariate analyses. Conclusions: Patients who did not undergo additional operation after ESD for EGCs turned out be the out-of-indication had worse long-term outcomes. Additional operation should be recommended, when EGC was identified to be the out-of-indication after ESD.

Sa1549 Relationship Between Safety Horizontal Resection Margin and Locally Recurrent Early Gastric Cancer After Endoscopic Submucosal Dissection Seon A. Kim*, Young-IL Kim, Myeong-Cherl Kook, Jong Yeul Lee, Chan Gyoo Kim, IL Ju Choi Center for Gastric Cancer, National Cancer Center, Korea, Goyang, Korea (the Republic of) Background and Aims: A current treatment guideline for early gastric cancer (EGC) recommended that a gross safety margin of surgically resected specimen should be at least 2 cm. However, the safety resection margin for endoscopic submucosal dissection (ESD) is still unclear. The aim of this study was to investigate the association between the distance from horizontal margin (HM) and local recurrence after ESD in patients with EGC. Methods: We reviewed clinicopathologic data of patients who underwent ESD for EGC between September 2004 and December 2012 at the National Cancer Center, Korea. The local recurrence after ESD was investigated according to the distance from HM. Results: Among 1,064 patients who had no vertical margin involvement after ESD for EGC, median distance from HM was 7 mm. Of 80 patients (7.5%) with safety HM margin of less than 2 mm, 7 patients underwent additional argon plasma coagulation (APC). During follow-up after ESD, local recurrence occurred in 1 patient (1/80 patients, 1.3%). The locally recurred patient had positive HM on the initial ESD, but additional APC was not performed. EGC recurred at 33 months after ESD, and the tumor successfully treated by repeated ESD. On the contrary, all patients (985 patients, 92.5%) with the safety HM margin of R 2 mm did not undergo additional procedures, and there was no local recurrence during follow-up periods after ESD. Conclusions: In EGC patients who underwent ESD, the safety HM of resected specimen may be at least 2 mm without an additional procedure including APC.

Background Endoscopic resection (ER) of early gastric cancer (EGC) meeting the absolute indication has excellent long-term outcomes. Objective To compare long-term outcomes of ER with those of surgery in patients with EGC who met the absolute indication for ER. Design Retrospective cohort study. Setting A specialized center for the treatment of cancer. Patients and Interventions We retrospectively reviewed data from patients who underwent gastrectomy or ER for EGC between 2002 and 2007. Gastric cancers were differentiated-type adenocarcinoma without ulceration confined to the mucosal layer and 2 cm or smaller in size. Main Outcome Measurements The primary outcome was overall survival (OS). Metachronous cancer rates and adverse event rates were compared. Kaplan-Meier plots and Cox proportional hazard regression analyses were applied for comparisons. Differences in baseline characteristics were adjusted by propensity score. Results Among 375 patients, 261 underwent ER and 114 underwent surgery. The median follow-up duration was 76.4 months. The 5-year OS rates did not significantly differ between the ER and surgery groups (95.7% vs 93.6%, respectively; P = .725 by log-rank test). There were no gastric cancer–related deaths in either group. Metachronous gastric cancer developed more frequently in the ER group (6.1%, 16/261) than in the surgery group (0.9%, 1/114) ( P = .024). However, most patients (93.8%, 15/16) in the ER group were curatively treated with repeat ER. Adverse event rates were higher in the surgery group than those in the ER group (7.9% vs 2.7%, P = .028). Limitations Retrospective, single-center study. Conclusions The OS rate after ER for mucosal gastric cancer that met the absolute indication was comparable to that achieved with surgery. Although metachronous cancers were more common after ER, they were usually treatable and did not affect survival.

100,000 adults, hospital admissions approaching 400,000 annually, recurrence rates estimated at 20% and mortality approaching 10-14%. Although the early use of a risk stratification score in upper GI bleeding is recommended, existing risk scores are not widely used in clinical practice. The purpose of this study was to construct a simple bedside prediction tool that accurately identifies patients at increased risk for in-hospital mortality after NVUGIB without the need for endoscopic parameters. Methods: This was a retrospective study at a tertiary care referral center between January 2008 and November 2011. All patients O 18 years of age admitted with a diagnosis of acute NVUGIB were included. Rebleeding was defined as NVUGIB following index endoscopic therapy within 30 days of an initial bleed. Demographics, presentation, comorbidities, medications, serum and hemodynamic parameters were collected. Multivariable logistic regression analysis was performed to build a model for prediction of rebleeding. Accuracy to predict mortality was assessed by the area under the receiver operating characteristic (AUROC) curve. Results: A total of 251 patients underwent EGD for NVUGIB (mean age 64 13 years, 39% female, 74% Caucasian). The most common source of bleeding was peptic ulcer disease (42%). A total of 123 (49%) patients had a recurrent bleed after index endoscopy. The average time to an episode of rebleeding was 3.5 6.1 days. The majority of patients only had 1 episode of rebleeding (58%). Average length of ICU stay was 15 days. The in-hospital mortality rate was 18% for all NVUGIB. The 4 factors present on admission with the best discrimination for mortality risk were age, platelets, WBC and diastolic blood pressure as depicted in the nomogram in Figure 1. The model had a high predictive accuracy (AUCROC Z 0.76; Figure 2). Conclusions: Efforts to identify patients at highest risk for recurrent non-variceal upper GI bleeding mortality are of significant clinical utility. This simple, accurate risk score reliably predicts with 76% accuracy in-hospital mortality in patients with recurrent non-variceal upper gastrointestinal bleeding. Figure 1. Nomogram for prediction of ICU mortality. Figure 2. Receiver Operating Characteristics (ROC) plot for prediction of ICU mortality. AB298 GASTROINTESTINAL ENDOSCOPY Volume 79, No. 5S : 2014 Sa1677 Risk Scoring Systems in Predicting Intervention and Clinical Outcomes of Bleeding in Patients With Unresectable Gastric Cancer Young-IL. Kim*, IL Ju Choi, Soo-Jeong Cho, Jong Yeul Lee, Chan Gyoo Kim, MI–Jung Kim, Hark Kyun Kim, Young Iee Park Center for Gastric Cancer, National Cancer Center, Korea, Gyeonggi-do, Republic of Korea Background & Aims: Pre-endoscopic Rockall score (RS), full RS, and Glasgow-Blatchford bleeding Score (GBS) are increasingly used to stratify the risk in patients with upper gastrointestinal bleeding (UGIB). The aim of this study was to evaluate the efficacy of those bleeding risk scoring systems in patients with UGIB due to unresectable advanced gastric cancer (AGC). Methods: We reviewed retrospectively the medical records of patients presenting with UGIB due to unresectable AGC at the National Cancer Center, Korea from May 2001 to June 2012. Pre-endoscopic RS, full RS and GBS were calculated. The area under the receiver operating characteristicscurve (AUC) was used to assess the performance of these scores to predict the need for interventions and clinical outcomes. Results: During the study period, 355 patients who presented with UGIB from unresectable AGC received endoscopy. Of these, interventions were needed in 118 (33.2%). A total of 115 patients (32.4%) underwent endoscopic therapy, 2 (0.6%) required transarterial embolization and one (0.3%) underwent surgery as an initial treatment. Full RS was useful to predict the need for intervention (AUC 0.77, P! 0.001) and 7-day mortality after bleeding (AUC 0.67, PZ 0.024). However, pre-endoscopic RS, full RS and GBS were not useful for the prediction of rebleeding after initial hemostasis (AUC 0.49, 0.54 and 0.54, respectively), the need for admission more than 3 days (AUC 0.57, 0.64 and 0.62, respectively) and 30-day mortality (AUC 0.51, 0.53 and 0.59, respectively). Conclusions: Full RS might be useful in predicting the need for interventions and 7day mortality of patients presented with UGIB due to unresectable AGC. Sa1678 Prevalence of Heyde’s Syndrome: Does It Just Pertain to Aortic Stenosis? a Case-Control Study Karen Draper, Robert J. Huang, Lauren B. Gerson* Gastroenterology, California Pacific Medical Center, San Francisco, CA; Medicine, Stanford University, Stanford, CA Background: Heyde’s syndrome is described as the relationship between aortic stenosis (AS) and gastrointestinal angiodysplastic lesions (GIAD). While prior studies have examined the prevalence of AS in patients with GIAD-associated GIB, there is little data regarding whether this syndrome exists in patients with other cardiac valvular disorders. Our study aimed to determine the prevalence of Heyde’s syndrome in patients with AS compared to a control group of patients with mitral regurgitation by examining rates of iron deficiency anemia and GIAD-associated GIB in these two groups. Methods: We used an echocardiography database at a single large academic medical center to identify adult patients with severe AS and moderate or severe mitral regurgitation (MR). Patients were excluded if they had active malignancy, hematologic conditions, end-stage renal disease, inflammatory bowel disease, history of colectomy, cirrhosis, or if they had no available lab values within 2 years of the echocardiogram. Records from identified patients were then reviewed to assess for the presence of anemia, iron deficiency, and/or overt gastrointestinal bleeding (GIB). GIB was defined as melena, hematochezia, hematemesis, or guaiac positive stool. Values for hemoglobin (Hb), mean corpuscular volume (MCV), and iron panel results from within 2 years of echocardiography were collected. We searched the endoscopy database to determine which patients underwent subsequent endoscopic procedures and location of findings. Estimating that 10% of patients with AS would have GIAD compared to 3% of patients with MR (similar to population controls), the estimate sample size was 152 in each group, using an alpha of 95% and power of 80%. Results: Out of 514 patients who were screened, a total of 298 patients were included in the study (142 MR, 156 AS). Patients with MR were younger and more likely to have congestive heart failure, but otherwise had similar co-morbidities (Table 1). The rates of anemia and microcytic anemia were similar in both groups. The MR group was more likely to have been evaluated for iron deficiency, however rates of confirmed iron deficiency were similar in the two groups. Overall incidence of GIB was similar between the two groups (MR 7.7% vs. AS 8.3%); however, rates of proven GIAD (MR 0% vs. AS 1.3%) and occult GIB (MR 36% vs. AS 54%) appeared higher among patients with aortic stenosis, though again not reaching statistical significance (Table 2). Conclusions: While the prevalence of AS in patients with obscure or GIAD-associated GIB has been shown in previous studies to be relatively common, our study did not suggest that the incidence in AS was greater compared to a control group with MR. Whether MR itself could predispose to GIADassociated GIB is a topic for further research. Table 1 Characteristics of the Study Patients Characteristics Severe AS (N[156) Moderate-Severe MR (N[142) www.giejourn p value Male 93 (60%) 77 (54%) NS Age 79 13.5 66 17 !0.0001

Routine Follow-up Biopsies to Detect Local Recurrence After Complete Endoscopic Resection for Early Gastric Cancer May Be Unnecessary Jong Yeul Lee*, IL Ju Choi, Soo-Jeong Cho, Chan Gyoo Kim, Myeong-Cherl Kook, Jun Ho Lee, Keun Won Ryu, Young-Woo Kim Center for Gastric Cancer, National Cancer Center, Goyang-si, Gyeonggi-do, Republic of Korea Background and study aims: Local recurrence due to residual tumor may occur at the endoscopic resection (ER) site after ER for early gastric cancer (EGC). The aims of this study were to evaluate the predictive factors for local recurrence and suggest an appropriate follow-up biopsy strategy. Patients and methods: We retrospectively reviewed 396 EGCs from 372 consecutive patients who underwent ER between January 2002 and April 2008. Cumulative recurrence rate were determined by the Kaplan-Meier method and Cox proportional hazards analysis was used to determine the risk factors for local recurrence. Results: Local recurrence at ER site was found in 17 cases among 396 lesions during a median follow-up period of 48 months. The 5-year cumulative local recurrence rate was 4.8%. Multivariate analyses determined that tumor involvement at the lateral resection margin [hazard ratio (HR): 35.9; P 0.001], an uncheckable lateral resection margin [HR: 16.8; P 0.001], an uncheckable or involved deep resection margin [HR: 3.76; P 0.047], and a piecemeal resection [HR: 3.95; P 0.007] were associated with local recurrence. If a lesion was positive for any of these risk factors, the 5-year cumulative recurrence rate was 27.0%, while local recurrence was not found in any lesion that lacked these risk factors. Most episodes of recurrence were found during the first or second follow-up endoscopic biopsy at the ulcer scar. Conclusions: Routine follow-up biopsies at the ER site might be unnecessary in cases where an EGC lesion was endoscopically resected en bloc with tumor-free lateral and deep margins.