None of the non-elderly with postoperative hemorrhage had received anticoagulant therapy; 15.8% of the lesions (three lesions) were in elderly patients who had received anticoagulant therapy, indicating a significantly higher percentage of such lesions in the elderly group. Ono et al. also reported that 10.7% of lesions in patients with anticoagulant therapy had postoperative hemorrhage.29 Therefore, anticoagulant therapy is suggested to increase the rate of postoperative hemorrhage in the elderly. Two elderly patients in our study had comorbidities exacerbated by discontinuance of the anticoagulant therapy. One of these patients developed a

cerebral infarction and the other underwent reoperation because of insufficient valve motion after mitral valve replacement. In its washout guidelines, the Japan Gastroenterological Endoscopy Obeticholic Acid price Society recommends washout of anticoagulants and antiplatelet agents even for low-risk procedures Dinaciclib in vitro such as biopsy. The American Society

for Gastrointestinal Endoscopy recommends continuing aspirin regardless of the risk of the procedure.25 Further examination of these problems in Japanese, especially the elderly, is needed. Because ESD is suitable for cancer at the earliest stage (i.e. intramucosal carcinoma), most patients are asymptomatic. Although the natural history of cancer is unknown, early cancer is thought to 上海皓元 take at least 5 years to progress to advanced cancer and at least 10 years for intramucosal carcinoma, which is the target of endoscopic treatment.30 When the natural history of gastric cancer is considered, patients must satisfy certain conditions to gain the true benefits of ESD. Elderly patients, considered to be medically vulnerable, have multiple chronic diseases, and their physical condition is generally worse than that

of non-elderly patients. For the elderly, the level of performance of activities of daily living, cognitive function, and maintenance of QOL are important factors in an individual’s life. In the determination of indications for endoscopic treatment, PS is established as the physical indication criterion of the elderly and we used it in the present study. PS has been reported to be a risk factor of complications after open surgery.31 Much like the general indications of chemotherapy, the indication of ESD was established as PS 0, 1, or 2. In the present study, four elderly patients had a PS of 3 but none of the non-elderly patients. As mentioned previously, the PS in some elderly patients worsened because of complications after inpatient treatment. A patient’s PS and QOL should not be allowed to decrease through treatment of a lesion that was not affecting survival. We conclude that ESD is useful in elderly patients because it has similar risk to that in the non-elderly if the approach is individualized.