Backgrounds and study aim Placement of a self-expandable metallic stent (SEMS) has become a common practice for obstructive colorectal cancer. However, the safety and efficacy of systemic chemotherapy after SEMS placement remain unclear. Patients and methods This multicenter retrospective cohort study was conducted by the Japan Colonic Stent Safe Procedure Group across Japan to investigate the SEMS-related complications and clinical outcomes of chemotherapy in patients with unresectable obstructive colorectal cancer. Results A total of 289 patients were included in the study. The median duration from SEMS placement to chemotherapy initiation was 11 days (range, 6-21 days). SEMS-related complications occurred in 30.1% of the patients, with the most common complications being perforation (8.7%; 95% CI, 5.9-12.5A%), re-obstruction (19.4%), and migration (20.8%). Among the patients with stent migration, 30% required additional intervention. The median progression-free survival (PFS) was 9.2 months (95% confidence interval [CI], 7.5-10.9 months), and the median overall survival (OS) was 17.3 months (95% CI, 14.1-20.5 months). No significant difference in perforation rate was observed with or without bevacizumab use (14.5% vs. 7.3%, P < 0.107). Factors influencing survival outcomes included the number of metastatic organs, presence of perforation, and performance of primary tumor resection (PTR). Survival analyses showed that patients who underwent PTR had significantly better PFS and OS; however, this result should be interpreted with caution due to potential selection bias and immortal time bias inherent in the retrospective design. Conclusions This multicenter retrospective study demonstrated that while chemotherapy after SEMS placement is generally feasible, clinicians should remain vigilant for complications like perforation, migration, and re-obstruction.

Introduction: A 68-year-old man with branch-duct intraductal papillary mucinous neoplasm (IPMN) in the pancreatic head presented with pancreatic ascites due to main duct rupture in the pancreatic body without typical pancreatitis symptoms. Case Presentation: Although the serum amylase level was elevated, the amylase level in the ascitic fluid was markedly higher. We hypothesize that mucin-induced downstream obstruction may have contributed to elevated intraductal pressure and upstream rupture. After conservative management, the patient developed delayed hemorrhage of approximately 4 months from the same site. Conclusion: Based on a PubMed literature search, this appears to be the first reported case of pancreatic ascites followed by delayed hemorrhage from the same site associated with branch-duct IPMN.

Self-expanding metallic stents (SEMSs) are an established palliative option for malignant colonic obstruction, including in cases with proximal lesions. However, SEMS placement across the ileocecal valve (ICV) can be technically challenging because of the anatomical curvature and luminal stenosis. Herein, we report a successful case of colonic stenting for a malignant ileocecal obstruction using an ultra-thin scope and a single-balloon overtube. A 72-year-old man with alcoholic cirrhosis and multiple liver metastases presented with malignant ileocecal obstruction. Given his inoperability, palliative SEMS placement was attempted. Colonoscopy showed a circumferential tumor in the ileocecum, with no passage of contrast medium into the ileum. Guidewire insertion across the ICV failed because of the inability to visualize the direction of the ileal lumen. To overcome this, we used a rescue technique with an ultra-thin scope and a single-balloon overtube. After placing the overtube in the ascending colon, the ultra-thin scope was advanced through it to explore the stenotic lumen directly. This allowed safe insertion of the guidewire into the proximal lumen of the stenosis. The ultra-thin scope was withdrawn, and a standard scope was inserted over the guidewire. Finally, a SEMS was deployed across the ICV through the scope. The patient's obstructive symptoms were resolved without complications, and he was discharged 7 days later. This case demonstrates that in cases of malignant ileocecal obstruction where SEMS placement using conventional methods is difficult, a rescue technique using an ultra-thin scope with a single-balloon overtube may be a viable alternative.

A 58-year-old man was administered anti-programmed death ligand 1 and cytotoxic T-lymphocyte-associated protein 4 antibodies for primary lung cancer with brain metastasis. Subsequent development of diarrhea was diagnosed as immune-related adverse event (irAE) colitis. Initially, his condition improved with prednisolone (1 mg/kg/day). Therefore, the dose was reduced to 5 mg, and his condition was maintained with 5-aminosalicylic acid. However, diarrhea recurred after re-administration of another immune checkpoint inhibitor. Prednisolone (0.5 mg/kg/day) was ineffective for the first relapse. After two doses of infliximab, irAE colitis improved. One year later, diarrhea recurred after steroid tapering. Treatment comprising prednisolone (1 mg/kg/day), two doses of infliximab, granulocyte–monocyte apheresis, and ustekinumab for the second relapse failed to improve his condition. Tacrolimus was initiated 3 months after the second flare occurred, resulting in rapid symptom resolution. Due to frequently relapsed irAE colitis, vedolizumab was administered as maintenance therapy, allowing steroids and tacrolimus to be discontinued and maintaining remission. Tacrolimus may be effective for relapsed refractory irAE colitis, particularly for cases that cannot be successfully treated with infliximab and other treatments. Vedolizumab can be used as maintenance therapy for frequently relapsing irAE colitis.

Atezolizumab and bevacizumab combination therapy was initiated in a 71-year-old female patient with unresectable hepatocellular carcinoma. Severe anemia, which was managed with blood transfusion and demonstrated improvement, was observed after the treatment. However, anemia subsequently reoccurred, accompanied by signs of hemolysis. The condition was diagnosed as autoimmune hemolytic anemia due to atezolizumab. Steroid therapy exhibited improvement, and second-line treatment with lenvatinib was successfully initiated. The possibility of autoimmune hemolytic anemia should be considered when anemia is observed during immunotherapy for hepatocellular carcinoma.

Objectives Clinical outcomes of endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma (ESCC) with esophageal varices (EVs) are obscure. We aimed to elucidate the clinical outcomes of ESD for ESCC with EVs in a multicenter, retrospective study. Methods We established a retrospective cohort of 30 patients with ESCC complicating EVs, who underwent ESD at 11 Japanese institutions. Rates of en bloc resection and R0 resection, procedure time, and adverse events were evaluated as indicators of the feasibility and safety of ESD. Additional treatment, recurrence, and metastasis of the lesions were evaluated as indicators of the long‐term efficacy of ESD. Results Portal hypertension was caused by cirrhosis, of which alcohol was the most common cause. En bloc resection was achieved in 93.3% and R0 resection in 80.0% of the patients. The median procedure time was 92 min. Adverse events included a case of uncontrolled intraoperative bleeding leading to discontinuation of ESD and a case of esophageal stricture due to extensive resection. During the follow‐up period of a median for 42 months, a patient with local recurrence and another patient with liver metastasis were observed. One patient died of liver failure after receiving chemoradiotherapy as an additional treatment after ESD. No patient died of ESCC. Conclusion This multicenter, retrospective cohort study demonstrated the safety and efficacy of ESD for ESCC with EVs. Further studies are needed to establish appropriate treatment methods for EVs before ESD and additional treatments for patients with insufficient ESD.

Background Sodium picosulfate (SP)/magnesium citrate (MC) and polyethylene glycol (PEG) plus ascorbic acid are recommended by Western guidelines as laxative solutions for bowel preparation. Clinically, SP/MC has a slower post-dose defaecation response than PEG and is perceived as less cleansing; therefore, it is not currently used for major bowel cancer screening preparation. The standard formulation for bowel preparation is PEG; however, a large dose is required, and it has a distinctive flavour that is considered unpleasant. SP/MC requires a small dose and ensures fluid intake because it is administered in another beverage. Therefore, clinical trials have shown that SP/MC is superior to PEG in terms of acceptability. We aim to compare the novel bowel cleansing method (test group) comprising SP/MC with elobixibat hydrate and the standard bowel cleansing method comprising PEG plus ascorbic acid (standard group) for patients preparing for outpatient colonoscopy. Methods This phase III, multicentre, single-blind, noninferiority, randomised, controlled, trial has not yet been completed. Patients aged 40–69 years will be included as participants. Patients with a history of abdominal or pelvic surgery, constipation, inflammatory bowel disease, or severe organ dysfunction will be excluded. The target number of research participants is 540 (standard group, 270 cases; test group, 270 cases). The primary endpoint is the degree of bowel cleansing (Boston Bowel Preparation Scale [BBPS] score ≥ 6). The secondary endpoints are patient acceptability, adverse events, polyp/adenoma detection rate, number of polyps/adenomas detected, degree of bowel cleansing according to the BBPS (BBPS score ≥ 8), degree of bowel cleansing according to the Aronchik scale, and bowel cleansing time. Discussion This trial aims to develop a “patient-first” colon cleansing regimen without the risk of inadequate bowel preparation by using both elobixibat hydrate and SP/MC. Trial registration Japan Registry of Clinical Trials (jRCT; no. s041210067; 9 September 2021; https://jrct.niph.go.jp/ ), protocol version 1.5 (May 1, 2023).

A 37-year-old man with systemic lupus erythematosus underwent esophagogastroduodenoscopy as a screening examination for anemia and bloody stool. A semi-pedunculated edematous lobular polyp of 25 mm in size was detected in the greater curvature of the upper gastric body. At that time, a definitive diagnosis of cancer could not be made based on a biopsy specimen from the lesion. Since the patient was on proton pump inhibitor (PPI) for a long time to prevent peptic ulceration due to prolonged prednisolone administration for systemic lupus erythematosus, we diagnosed the lesion as a PPI-associated hyperplastic polyp and switched lansoprazole to famotidine. Two months later, esophagogastroduodenoscopy revealed that the polyp had decreased in size to 8 mm, whereas the biopsy specimen led to a histological diagnosis of gastric cancer. The polyp was removed by endoscopic submucosal dissection. Immunohistochemistry revealed that the tumor cells were positive for MUC5AC, but negative for MUC2 and MUC6, leading to a final diagnosis of foveolar-type gastric adenocarcinoma. In conclusion, we may suggest that PPI induces reversible morphological changes in foveolar-type gastric adenocarcinoma. Furthermore, short-term follow-up of polypoid lesions should be prepared, considering tumor comorbidity with morphological changes during long-term PPI usage.

Summary Although esophageal cancers invading the muscularis mucosa (pT1a-MM) or submucosa (pT1b-SM) after endoscopic resection (ER) are associated with a risk of lymph node metastasis, details of metastatic recurrence after additional treatment remain unknown. We aimed to identify the risk factors for metastatic recurrence and recurrence patterns in patients receiving additional treatment after ER for esophageal cancer. Between 2006 and 2017, patients with pT1a-MM/pT1b-SM esophageal cancer who underwent ER with additional treatment (esophagectomy, chemoradiotherapy [CRT], and radiation therapy) at 21 institutions in Japan were enrolled. We evaluated the risk factors for metastatic recurrence after ER with additional treatment. Subsequently, the rate and pattern (locoregional or distant) of metastatic recurrence were investigated for each additional treatment. Of the 220 patients who received additional treatment, 57, 125, and 38 underwent esophagectomy, CRT, and radiation therapy, respectively. In the multivariate analysis, lymphatic invasion was the sole risk factor for metastatic recurrence after additional treatment (hazard ratio, 3.50; P = 0.029). Although the risk of metastatic recurrence with additional esophagectomy was similar to that with CRT (hazard ratio, 1.01; P = 0.986), the rate of locoregional recurrence tended to be higher with additional esophagectomy (80.0% (4/5) vs. 36.4% (4/11)), leading to a better prognosis in patients with metastatic recurrence after additional esophagectomy than CRT (survival rate, 80.0% (4/5) vs. 9.1% (1/11)). Patients with lymphatic invasion have a high risk of metastatic recurrence after ER with additional treatment for pT1a-MM/pT1b-SM esophageal cancer. Additional esophagectomy may result in a better prognosis after metastatic recurrence.

Background: Recently, there has been a significant increase in the utilization of self-expandable metallic stents (SEMSs) for treating malignant colorectal obstructions through colorectal stenting. The mechanical properties of SEMSs are usually considered to affect clinical outcomes of patients with malignant colorectal obstructions. Methods: This single-arm, prospective, multicenter study of SEMS with a lower axial force and high axial force zero-border included 200 patients with malignant colorectal obstruction. Technical and clinical success, stent patency, and adverse events associated with SEMS placement were evaluated. Results: One patient was excluded, and 199 patients were evaluated. The treatment intent was bridge-to-surgery in 129 and palliation in 70 patients. Technical and clinical success rates were 99.5% and 97.0%, respectively. The percentage of the ColoRectal Obstruction Scoring System scores of 3 or higher improved significantly from 19.2% before placement to 93.9% after placement. Clinical success was not achieved in five patients due to insufficient stent expansion in four patients and stent occlusion in one patient. Only one patient underwent emergency surgery for perforation of the proximal colon, far from where the stent was placed; the rescue procedure was not performed, despite no improvement in proximal dilatation due to insufficient stent expansion. Among the palliation cohort, 15 patients received chemotherapy, including molecular-targeted agents such as bevacizumab. There were no fatal cases related to stent placement. Conclusions: For management of malignant colorectal obstruction, this newly developed SEMS with low axial force and a high axial force zero-border showed high technical and clinical success rates, and an extremely low perforation rate (0.5%).

The guidelines recommend additional gastrectomy after noncurative endoscopic resection for early gastric cancers (EGCs). However, no additional treatment might be acceptable in some patients aged ≥ 85 years. We aimed to identify this patient group using the data in a highly aged area. We enrolled patients aged ≥ 85 years after noncurative endoscopic resection for EGCs at 30 institutions of the Tohoku district in Japan between 2002 and 2017. Treatment selection and prognosis after noncurative endoscopic resection were investigated. Fourteen candidates were evaluated using the Cox model to identify risk factors for poor overall survival (OS) in patients with no additional treatment. Of 1065 patients aged ≥ 85 years, 143 underwent noncurative endoscopic resection. Despite the guidelines’ recommendation, 88.8% of them underwent no additional treatment. The 5-year OS rates in those with additional gastrectomy and those with no additional treatment were 63.1 and 65.2%, respectively. Multivariate analysis showed independent risk factors for poor OS in patients with no additional treatment were the high-risk category in the eCura system (hazard ratio [HR], 2.91), Charlson comorbidity index (CCI) ≥ 3 (HR, 2.78), and male (HR, 2.04). In patients with no additional treatment, nongastric cancer-specific survival was low (69.0% in 5 years), whereas disease-specific survival rates were very high in the low- and intermediate-risk categories of the eCura system (100.0 and 97.1%, respectively, in 5 years). No additional treatment may be acceptable in the low- and intermediate-risk categories of the eCura system in patients aged ≥ 85 years with noncurative endoscopic resection for EGCs.

A 78-year-old female patient with stomach cancer (with hepatic metastasis and peritoneal dissemination) had received eight courses of an S-1 and oxaliplatin regimen as palliative chemotherapy. Computed tomography revealed liver deformities and incidental gastric varices. Esophagogastroduodenoscopy confirmed the findings of gastric varices in the cardia and fornix. It was suspected that oxaliplatin-based chemotherapy had induced non-variceal portal hypertension in the patient-similar to that which is seen in patients with colon cancer who are treated with oxaliplatin-based chemotherapy. We had chosen balloon-occluded retrograde transvenous obliteration (BRTO) for the preventive treatment of gastric varices because the patient had a gastro-renal shunt, which enabled access to the gastric varices via the vena cava. Our patient had undergone BRTO, which resulted in the endoscopic disappearance of gastric varices. Currently, the patient is continuing chemotherapy without bleeding from gastric varices. Our case suggests that patients with gastric cancer treated with oxaliplatin-based chemotherapy require careful follow-up for portal hypertension.

Department of Endoscopy, Fukushima Medical University Hospital, Japan; Department of Gastroenterology, Fukushima Medical University, Japan; Division of Gastroenterology, Tohoku University Graduate School of Medicine, Japan; Division of Gastroenterology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Japan; Department of Gastroenterology, Sendai City Medical Center, Japan; Department of Minimally Invasive Surgical and Medical Oncology, Fukushima Medical University, Fukushima, Japan; Department of Gastroenterology, Ohara General Hospital, Japan; Division of Gastroenterology Tohoku Medical and Pharmaceutical University, Japan; Department of Gastroenterology, Iwate Prefectural Isawa Hospital, Japan; Department of Gastroenterology, Osaki Citizen Hospital, Japan; Department of Gastroenterology and Neurology, Akita University Graduate School of Medicine, Japan; Department of Gastroenterology, Yokote Municipal Hospital, Japan; Department of Gastroenterology, Miyagi Cancer Center, Japan; Division of Endoscopy, Aomori Prefectural Central Hospital, Japan; Department of Gastroenterology, Iwate Prefectural Central Hospital, Japan; Department of Gastroenterology, Faculty of Medicine, Yamagata University, Japan; Division of Gastroenterology, Noshiro Kosei Medical Center, Japan; Department of Gastroenterology, Akita City Hospital, Japan; Digestive Disease Center, Akita Red Cross Hospital, Japan; Division of Gastroenterology, Aomori city hospital, Japan; Department of Gastroenterology, Hiraka General Hospital, Japan; Department of Gastroenterology, National Hospital Organization Sendai Medical Center, Japan; Department of Gastroenterology, Iwate Prefectural Ninohe Hospital, Japan; Division of Gastroenterology, Tohoku Rosai Hospital, Japan; Department of gastroenterology, Japanese Red Cross Morioka Hospital, Japan; Department of gastroenterology, Hachinohe Red Cross Hospital, Japan; Department of Gastroenterology, Iwate Prefectural Kuji Hospital, Japan; Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Japan; Department of Gastroenterology, Omagari Kosei Medical Center, Japan; Department of Internal Medicine and Gastroenterology, Iwate Prefectural Ofunato Hospital, Japan; Department of Gastroenterology, Iwate Prefectural Miyako Hospital, Japan; Department of Gastroenterology, Southern-Tohoku General Hospital, Japan.

Shinya Suto: NO financial relationship with a commercial interest | Tetsuya Tatsuta: NO financial relationship with a commercial interest | Tomohiro Shimada: NO financial relationship with a commercial interest | Waku Hatta: NO financial relationship with a commercial interest | So Takahashi: NO financial relationship with a commercial interest | Tomoyuki Koike: NO financial relationship with a commercial interest | Tetsuya Ohhira: NO financial relationship with a commercial interest | Takuto Hikichi: NO financial relationship with a commercial interest | Yosuke Toya: NO financial relationship with a commercial interest | Ippei Tanaka: NO financial relationship with a commercial interest | Yusuke Onozato: NO financial relationship with a commercial interest | Koichi Hamada: NO financial relationship with a commercial interest | Daisuke Fukushi: NO financial relationship with a commercial interest | Ko Watanabe: NO financial relationship with a commercial interest | Shoichi Kayaba: NO financial relationship with a commercial interest | Hirotaka Ito: NO financial relationship with a commercial interest | Tatsuya Mikami: NO financial relationship with a commercial interest | Tomoyuki Oikawa: NO financial relationship with a commercial interest | Yasushi Takahashi: NO financial relationship with a commercial interest | Yutaka Kondo: NO financial relationship with a commercial interest | Tetsuro Yoshimura: NO financial relationship with a commercial interest | Takeharu Shiroki: NO financial relationship with a commercial interest | Ko Nagino: NO financial relationship with a commercial interest | Norihiro Hanabata: NO financial relationship with a commercial interest | Akira Funakubo: NO financial relationship with a commercial interest | Dai Hirasawa: NO financial relationship with a commercial interest | Jun Nakamura: NO financial relationship with a commercial interest | Takayuki Matsumoto: NO financial relationship with a commercial interest | Katsunori Iijima: NO financial relationship with a commercial interest | Atsushi Masamune: NO financial relationship with a commercial interest | Kei Ito: NO financial relationship with a commercial interest | Shinsaku Fukuda: NO financial relationship with a commercial interest

Background Although post-bulbar duodenal ulcers (PBDUs) could become a source of upper gastrointestinal bleeding, the whole picture of the disease is unknown. We compared the characteristic features and treatment outcomes after endoscopic hemostasis between PBDUs and bulbar duodenal ulcers (BDUs). Methods Data on duodenal ulcers with evidence of endoscopically-active bleeding were extracted from the data that were retrospectively collected from 12 institutes in Japan between 2011 and 2018. Rebleeding and in-hospital mortality were compared between patients with PBDUs and those with BDUs by logistic regression analyses. Results Among 468 consecutive patients with bleeding duodenal ulcers, 96 (20.5%) had endoscopically-confirmed PBDUs. PBDUs were more frequently observed in patients with a poor general condition in comparison to BDUs. The rates of rebleeding and in-hospital mortality in patients with PBDUs were approximately three times higher than those in patients with BDUs (PBDU vs. BDU: 29.2% vs. 10.2% [P < 0.0001] and 14.6% vs. 5.1% [P = 0.0029], respectively). Although the high in-hospital mortality in PBDUs could be explained, to a lesser extent, by the likelihood of rebleeding, and, to a greater extent, by the patients' poor general condition, the presence of a PBDU itself was largely responsible for the high rebleeding rates in PBDUs. Conclusion This is the first study focusing on the nature and treatment outcomes of bleeding PBDUs. PBDUs were associated with much higher rebleeding and mortality rates in comparison to BDUs, and the likelihood of rebleeding may be derived from their unique anatomic location.

ObjectsAlthough anti‐thrombotic use is recognized as a risk factor for upper gastrointestinal bleeding (UGIB), there has been no clear evidence that it worsens the outcomes after the bleeding. The aim of this study is to investigate the effects of anti‐thrombotic agents on in‐hospital mortality following UGIB.MethodsInformation on clinical parameters, including usage of anti‐thrombotic agents, was retrospectively collected from consecutive patients with UGIB at 12 high‐volume centers in Japan between 2011 and 2018. The all‐cause in‐hospital mortality rate was evaluated according to the usage of anti‐thrombotic agents.ResultsClinical data were collected from 2205 patients with endoscopically confirmed UGIB. Six hundred and forty‐five (29.3%) patients used anti‐thrombotic agents. The all‐cause in‐hospital mortality rate was 5.7% (125 deaths). After excluding 29 cases in which death occurred due to end‐stage malignancy, 96 deaths (bleeding‐related, n = 22 ; non‐bleeding‐related, n = 74) were considered “preventable.” Overall, the “preventable” mortality rate in anti‐thrombotic users was significantly higher than that in non‐users (6.0% vs. 3.7%, P < 0.05). However, the “preventable” mortality of anti‐thrombotic users showed a marked improvement over time; although the rate in users remained significantly higher than that in non‐users until 2015 (7.3% vs. 4.2%, P < 0.05), after 2016, the difference was no longer statistically significant (4.8% vs. 3.5%).ConclusionsAlthough the usage of anti‐thrombotic agents worsened the outcomes after UGIB, the situation has recently been improving. We speculate that the recent revision of the Japanese guidelines on the management of anti‐thrombotic treatment after UGIB may have partly contributed to improving the survival of users of anti‐thrombotic agents.

BACKGROUND:Although additional treatment is considered for patients with esophageal squamous cell carcinoma (ESCC) invading into the muscularis mucosa (pT1a-MM) or submucosa (pT1b-SM) after endoscopic submucosal dissection (ESD), the actual benefits of this method remain to be elucidated.AIMS:We aimed to evaluate the prognostic benefits of additional treatment in such patients.METHODS:Between 2006 and 2017, we enrolled patients with pT1a-MM/pT1b-SM ESCC after ESD at 21 institutions in Japan. Overall survival (OS) and disease-specific survival (DSS) were compared between the additional treatment and follow-up groups after propensity score matching, to reduce the bias of baseline characteristics. A subgroup analysis was performed according to the pathological findings: category A, pT1a-MM but negative for lymphovascular invasion (LVI) and vertical margin (VM); category B, tumor invasion into the submucosa ≤ 200 μm but negative for LVI and VM; category C, others.RESULTS:Of 593 patients with pT1a-MM/pT1b-SM ESCC after ESD, 101 matched pairs were extracted after propensity score matching. The OSs were similar between the additional treatment and follow-up groups (80.6% vs. 78.6% in 5 years; P = 0.972). In a subgroup analysis, the OS in the additional treatment group was significantly lower than that in the follow-up group (65.7% vs. 95.2% in 5 years; P = 0.037) in category A, whereas OS did not significantly differ in category C (76.8% vs. 69.5% in 5 years; P = 0.360).CONCLUSIONS:Additional treatment after ESD in patients with pT1a-MM/pT1b-SM ESCC was not associated with an improved prognosis.

OBJECTIVES:We aimed to clarify the prognostic factors for patients with esophageal squamous cell carcinoma (ESCC) invading into the muscularis mucosa (pT1a-MM) or submucosa (pT1b-SM) after endoscopic submucosal dissection (ESD).METHODS:This retrospective study enrolled such patients at 21 institutions in Japan between 2006 and 2017. We evaluated 15 factors, including pathological risk categories for ESCC-specific mortality, six non-cancer-related indices, and treatment strategies.RESULTS:In the analysis of 593 patients, the 5-year overall and disease-specific survival rates were 83.0% and 97.6%, respectively. In a multivariate Cox analysis, male sex (hazard ratio [HR] 3.56), Charlson comorbidity index (CCI) ≥3 (HR 2.53), ages of 75-79 (HR 1.61) and ≥80 years (HR 2.04), prognostic nutrition index (PNI) <45 (HR 1.69), and pathological intermediate-risk (HR 1.63) and high-risk (HR 1.89) were prognostic factors. Subsequently, we developed a clinical risk classification for non-ESCC-related mortality based on the number of prognostic factors (age ≥75 years, male sex, CCI ≥3, PNI <45): low-risk, 0; intermediate-risk, 1-2; and high-risk, 3-4. The 5-year non-ESCC-related mortality rates for patients without additional treatment were 0.0%, 10.2%, and 45.8% in the low-, intermediate-, and high-risk groups, respectively. Meanwhile, the 5-year ESCC-specific mortality rates for the pathological low-, intermediate-, and high-risk groups were 0.3%, 5.3%, and 18.2%, respectively.CONCLUSIONS:We clarified prognostic factors for patients with pT1a-MM/pT1b-SM ESCC after ESD. The combined assessment of non-ESCC- and ESCC-related mortalities by the two risk classifications might help clinicians in deciding treatment strategies for such patients.