Comparison between submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric stromal tumors originating from the muscularis propria layer. Surg Endosc. 2017;31:3376-3382. [PMID: 27864722 DOI: 10.1007/s00464-016-5350-7]

Endoscopic full-thickness resection of a large gastric schwannoma and iatrogenic cervical esophageal perforations: A case report

INTRODUCTION

Gastrointestinal schwannomas are most commonly found in the stomach. Owing to their nonspecific clinical and endoscopic presentations, distinguishing gastric schwannomas (GS) from other gastric submucosal tumors based on typical symptoms and endoscopic features is challenging. Endoscopic full-thickness resection (EFTR) is safe and effective for GS management; however, no standard method exists for the extraction of large gastric specimens after endoscopic treatment.

CASE PRESENTATION

We report the case of a 72-year-old Chinese woman who presented with abdominal distension.

DIAGNOSIS, INTERVENTIONS, AND OUTCOMES

Gastroscopy revealed a submucosal bulge on the anterior wall of the lower stomach near the greater curvature. Endoscopic ultrasonography and computed tomography suggested a stromal tumor. The patient underwent EFTR of the stomach, and the tumor was successfully removed. The surgical specimen, with a long-axis diameter of approximately 5.5 cm in vitro, was extracted using a snare. Subsequent endoscopic examination revealed longitudinal, full-thickness perforations > 2 cm at the esophageal entrance. Over 10 metal clips were used to seal the mucosa, and a gastrointestinal decompression tube was placed. Follow-up radiography performed at 1 week postoperatively revealed an esophageal mediastinal fistula, which required subsequent endoscopic intervention to close the fistula using metal clips. The patient showed improvement and was discharged at 3 weeks postoperatively. Follow-up esophageal radiography revealed no abnormalities. Postoperative immunohistochemical analysis indicated CD34 (-), CD117 (-), DOG-1 (-), Ki67 (1%), S-100 (+), SDHB (+), SOX-10 (+), and Desmin (-), confirming the diagnosis of GS. Three months postoperatively, gastroscopy showed that the esophageal perforation healed well, a white ulcer scar had formed locally, metal clips were found in the stomach body, and no recurrence was found.

CONCLUSION

EFTR is effective for removing giant schwannomas, although the extraction of large specimens may result in iatrogenic cervical esophageal perforations. Perforations > 2 cm can be managed using endoscopic metal clip closure.

Endoscopic resection for the treatment of gastric gastrointestinal stromal tumors: a retrospective study from a large tertiary hospital in China

BACKGROUND AND AIMS

With the continuous development of endoscopic technology, endoscopic resection (ER) has gradually become an optional method for the treatment of gastric gastrointestinal stromal tumors (GISTs). However, studies with a large sample or a long follow-up are lacking. Therefore, this research aims to evaluate the efficacy and safety of ER for gastric GISTs in the real-world setting with more than 300 enrolled patients and a follow-up period longer than 45 months.

METHODS

From January 2013 to February 2023, 409 patients with a pathological diagnosis of GISTs after ER were retrospectively enrolled in this study. After excluding 86 patients with non-gastric GISTs, we assessed 323 patients with gastric GISTs. The main outcome measures were en bloc resection, complete resection, residual disease, recurrence, and complications.

RESULTS

There were 194 (60.06%) females and 129 (39.94%) males, and the median age of the included patients was 58 years (51, 63). The median tumor size was 15.0 (10.0, 20.0) mm. According to the modified NIH criteria, 246 (75.85%) patients were classified as very low risk, 62 (19.20%) were classified as low risk, 12 (3.72%) were classified as moderate risk, and 3 (0.93%) were classified as high risk. A total of 287 (88.85%) patients achieved en bloc resection, and 287 (88.85%) also achieved complete resection. Only one patient showed residual and no recurrent lesions were noted during the follow-up. Regarding complications, three patients had complications, with a complication rate of 0.93%, and no severe complications requiring surgical intervention occurred.

CONCLUSION

ER is an appropriate alternative method for the treatment of gastric GISTs, with an en bloc resection rate of 88.85% and a complication rate of 0.93%. No recurrence was noted during follow-up, even for GISTs with piecemeal resection.

Postoperative encapsulated hemoperitoneum in a patient with gastric stromal tumor treated by exposed endoscopic full-thickness resection: A case report

BACKGROUND

Gastric stromal tumors, originating from mesenchymal tissues, are one of the most common tumors of the digestive tract. For stromal tumors originating from the muscularis propria, compared with conventional endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR) can remove deep lesions and digestive tract wall tumors completely. However, this technique has major limitations such as perforation, postoperative bleeding, and post-polypectomy syndrome. Herein, we report a case of postoperative serous surface bleeding which formed an encapsulated hemoperitoneum in a patient with gastric stromal tumor that was treated with exposed EFTR. Feasible treatment options to address this complication are described.

CASE SUMMARY

A 47-year-old male patient had a hemispherical protrusion found during gastric endoscopic ultrasonography, located at the upper gastric curvature adjacent to the stomach fundus, with a smooth surface mucosa and poor mobility. The lesion was 19.3 mm × 16.1 mm in size and originated from the fourth ultrasound layer. Computed tomography (CT) revealed no significant evidence of lymph node enlargement or distant metastasis. Using conventional ESD technology for mucosal pre-resection, exposed EFTR was performed to resect the intact tumor in order to achieve a definitive histopathological diagnosis. Based on its morphology and immunohistochemical expression of CD117 and DOG-1, the lesion was proven to be consistent with a gastric stromal tumor. Six days after exposed EFTR, CT showed a large amount of encapsulated fluid and gas accumulation around the stomach. In addition, gastroscopy suggested intracavitary bleeding and abdominal puncture drainage indicated serosal bleeding. Based on these findings, the patient was diagnosed with serosal bleeding resulting in encapsulated abdominal hemorrhage after exposed EFTR for a gastric stromal tumor. The patient received combined treatments, such as hemostasis under gastroscopy, gastrointestinal decompression, and abdominal drainage. All examinations were normal within six months of follow-up.

CONCLUSION

This patient developed serous surface bleeding in the gastric cavity following exposed EFTR. Serosal bleeding resulting in an encapsulated hemoperitoneum is rare in clinical practice. The combined treatment may replace certain surgical techniques.

Comparison of Modified Cap-Assisted Endoscopic Mucosal Resection and Endoscopic Submucosal Dissection in Treating Intraluminal Gastric Gastrointestinal Stromal Tumor (≤20 mm)

INTRODUCTION

A modified cap-assisted endoscopic mucosal resection (mEMR-C), introduced in this study, was a novel variation of the standard EMR. We aimed to compare the outcomes of mEMR-C and endoscopic submucosal dissection (ESD) for the treatment of small (≤20 mm) intraluminal gastric gastrointestinal stromal tumors (gGISTs).

METHODS

This retrospective study included 43 patients who underwent mEMR-C and 156 patients who received ESD at Nanjing Drum Tower Hospital. Baseline characteristics, adverse events, and clinical outcomes were compared between the 2 groups. Univariate and multivariable analyses were conducted to adjust for confounders. After propensity score matching using sex, year, location, and tumor size, outcomes were compared with 41 patients in each group.

RESULTS

A total of 199 patients underwent endoscopic resection and the en bloc resection rate was 100%. The complete resection rate was comparable in both groups ( P = 1.000). Approximately 9.5% of all patients had a positive margin. There was no significant difference in positive margin for patients undergoing mEMR-C or ESD (9.3% vs 9.6%, P = 1.000). No difference in adverse events in both groups ( P = 0.724). The mEMR-C was associated with shorter operation time and lower cost than the ESD. Recurrence was reported in 2 patients at 1 and 5 years after ESD during a median follow-up of 62 months. No metastasis and disease-related death were identified in both groups. Propensity score matching analysis revealed similar results.

DISCUSSION

The mEMR-C was found to be the preferable technique for small (≤20 mm) intraluminal gGISTs with shorter operation time and lower cost as compared with ESD.

A novel technique for endoscope progression in gastroscopy resection: forward-return way for dissection of stromal tumor in the muscularis propria of the gastric fundus

Background

The fundus of the stomach is a challenging region for endoscopic resection of gastrointestinal stromal tumors (GISTs), especially in the anterior wall of the fornix at the side of the greater curvature. This study aimed to introduce the Forward-Return Way (FRW) technique in gastric fundus operations and provide evidence of its advantages. The FRW technique allows the gastroscope to access the stomach fornix without entering the gastric antrum after passing through the gastric cardia. Using FRW, the gastroscope body makes a forward return along the wall of the posterior wall of the upper gastric body and the wall of the greater curvature.

Methods

The clinical data of patients with stromal tumors in muscularis propria at the gastric fundus (STMF) at the Fourth Hospital of China Medical University between May 2020- March 2021 were reviewed. The novel FRW technique was used in the procedures, and the beneficial effects, suitability, applicable lesion site, and success rates of FRW were analyzed.

Results

A total of 10 cases were reviewed, and the FRW technique was successfully performed in 7 cases (70%). The gastroscope's tip reached the area just below the gastric cardia, allowing endoscopists to successfully access all angles and sites of the stomach's fundus in all seven patients. The lesion was easily accessed, and the gastroscope was stable with good left-right and forward-backwards movements.

Conclusion

The FRW technique significantly facilitates the resection of the GISTs by aligning the endoscopy body movement direction with the observation direction. Gastrointestinal Stromal Tumor; forward-return of gastroscopy along the gastric body wall; muscularis propria; gastric fundus.

Endoscopic full‑thickness resection with clip‑ and snare‑assisted traction for gastric submucosal tumours in the fundus: A single‑centre case series

Exposed endoscopic full-thickness resection (Eo-EFTR) has been recognized as a feasible therapy for gastrointestinal submucosal tumours (SMTs) originating deep in the muscularis propria layer; however, Eo-EFTR is difficult to perform in a retroflexed fashion in the gastric fundus. As a supportive technique, clip- and snare-assisted traction may help expose the surgical field and shorten the operation time in endoscopic resection of difficult regions. However, the application of clip- and snare-assisted traction in Eo-EFTR of SMTs in the gastric fundus is limited. Between April 2018 and December 2021, Eo-EFTR with clip- and snare-assisted traction was performed in 20 patients with SMTs in the gastric fundus at The First Affiliated Hospital of Soochow University. The relevant clinical data were collected retrospectively for all of the patients and analysed. All 20 patients underwent Eo-EFTR successfully without conversion to open surgery or severe adverse events. The en bloc resection rate and R0 resection rate were both 100%. Two patients had abdominal pain and fever after the operation, and five patients had fever, which recovered with medical therapy. No complications, such as delayed bleeding or delayed perforation, were observed. The postoperative pathology indicated that 19 cases were gastrointestinal stromal tumours and one case was leiomyoma. During the follow-up, no residual tumour, local recurrence or distant metastasis was detected by endoscopy or abdominal computed tomography. In conclusion, Eo-EFTR with clip- and snare-assisted traction appears to be a relatively safe and effective treatment for gastric SMTs in the fundus. However, prospective studies on a larger sample size are required to verify the effect of the clip- and snare-assisted traction in Eo-EFTR.

Clinical Efficacy and Safety of Endoscopic Treatment of Gastrointestinal Stromal Tumors in the Stomach

Background/Aims

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the stomach. We evaluated the clinical outcomes of endoscopic treatment for gastric GISTs.

Methods

This is a single center, retrospective study that enrolled 135 cases of gastric subepithelial tumors (SETs) resected by endoscopic procedures and confirmed as GISTs by histopathology from March 2005 to July 2019. The immediate and long-term clinical outcomes were analyzed retrospectively.

Results

The mean patient age was 57.9 years, and the mean tumor size was 2.1 cm. Of the tumors, 43.0% were located in the body, followed by the fundus (26.7%) and cardia (17.0%). Most tumors (85.2%) were resected by endoscopic submucosal dissection, followed by endoscopic mucosal resection (6.7%), submucosal tunneling endoscopic resection (5.9%), and endoscopic full-thickness resection (2.2%). Macroperforation occurred in 4.4% and microperforation in 6.7% of the cases. The R0 resection rate was 15.6%. However, the rate of complete resection by the endoscopic view was 90.4%, of which 54.8% of cases were in the very-low-risk group, followed by the low-risk group (28.1%), intermediate-risk group (11.9%), and high-risk group (5.2%). During 36.5 months of follow-up, recurrence was found in four (3.4%) of the 118 patients who were monitored for more than 6 months (low-risk group, 1/37 [2.7%]; intermediate-risk group, 2/11 [18.2%]; high-risk group, 1/6 [16.7%]).

Conclusions

Endoscopic treatment of a GIST appears to be a feasible procedure in selected cases. However, additional surgery should be considered if the pathologic results correspond to intermediate- or high-risk groups.

Third-space endoscopy: the final frontier

Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.

Pure endoscopic resection versus laparoscopic assisted procedure for upper gastrointestinal stromal tumors: Perspective from a surgical endoscopist

Management of upper gastrointestinal (UGI) tract gastrointestinal stromal tumor (GIST) has evolved significantly over the past two decades. For GIST size smaller than 5 cm, laparoscopic resection has become the current standard. To avoid postoperative gastric deformity and preserve gastric function, laparoscopic endoscopic cooperative surgery (LECS) was developed and various modifications have been reported and utilized successfully. Pure endoscopic resection techniques have also been reported at a similar period of time, which further push the boundary of incisionless surgery in managing these lesions. Both tunneling and nontunneling exposed type endoscopic full thickness resection are well described procedures for resection of small UGI GIST. In this review, a summary of these procedures is provided, and the pros and cons of each technique from the perspective of a surgical endoscopist are discussed in detail. LECS and endoscopic resection are complementary to each other. The choice of technique should be tailored to the location, morphology, and size of the target lesions, taking into account the experience of the laparoscopic surgeons and endoscopists.

Advances of endoscopic and surgical management in gastrointestinal stromal tumors

As one of the most common mesenchymal malignancies in the digestive system, gastrointestinal stromal tumors (GISTs) occur throughout the alimentary tract with diversified oncological characteristics. With the advent of the tyrosine kinase inhibitor era, the treatment regimens of patients with GISTs have been revolutionized and GISTs have become the paradigm of multidisciplinary therapy. However, surgery resection remains recognized as the potentially curative management for the radical resection and provided with favorable oncological outcomes. The existing available surgery algorithms in clinical practice primarily incorporate open procedure, and endoscopic and laparoscopic surgery together with combined operation techniques. The performance of various surgery methods often refers to the consideration of risk evaluation of recurrence and metastases; the degree of disease progression; size, location, and growth pattern of tumor; general conditions of selected patients; and indications and safety profile of various techniques. In the present review, we summarize the fundamental principle of surgery of GISTs based on risk assessment as well as tumor size, location, and degree of progress with an emphasis on the indications, strengths, and limitations of current surgery techniques.

Updates in the Field of Submucosal Endoscopy

Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.

Subepithelial tumors: How does endoscopic full-thickness resection & submucosal tunneling with endoscopic resection compare with laparoscopic endoscopic cooperative surgery?

Background and study aims  Endoscopic techniques are rapidly emerging for resection of subepithelial tumors (SETs). Submucosal tunneling for endoscopic resection (STER), endoscopic full-thickness resection (EFTR) and laparoscopic endoscopic cooperative surgery (LECS) are current alternatives to open surgery. In this study, we aimed to compare the three endoscopic techniques. Patients and methods  Consecutive patients who underwent resection of a submucosal esophageal or gastric lesion at several tertiary care centers were included in a dedicated registry over 3 years. Demographics, size and location of resected lesion, histology of specimen, length of procedure, adverse events (AEs), duration of hospital stay, and follow-up data were collected. Results  Ninety-six patients were included (47.7 % male, mean age 62): STER n = 34, EFTR n = 34, LECS n = 280. The lesions included leiomyoma, gastrointestinal stromal tumors (GISTs) and other. The mean lesion size was 28 mm (STD 16, range 20-72 mm). The majority of lesions in the EFTR and laparoscopic-assisted resection group were GISTs. There was no significant difference in clear resection margins, post-procedure complication rates, recurrence rate and total follow-up duration between the groups. However, the LECS group had a procedure time at least 30 minutes longer than STER or EFTR ( P  < 0.01). Total hospital stay for the laparoscopic-assisted resection group was also longer when compared to STER (1.5) and EFTR (1.8) ( P  < 0.01). Conclusions  STER, EFTR, and laparoscopic-assisted resection are efficacious approaches for resection of SETs with similar R0 resection rates, complication rates, and AE rates. Laparoscopic assisted resection appears more time-consuming and is associated with a longer hospital stay.

Effects of endoscopic therapy and surgical resection on long-term survival outcomes in patients with duodenal gastrointestinal stromal tumors: a surveillance, epidemiology, and end result program analysis

BACKGROUND

With the rapid development of endoscopic technology, endoscopic therapy (ET) has gradually become a new treatment choice for gastrointestinal stromal tumors (GISTs). However, due to the low incidence of duodenal GIST and the difficulty of ET, there is a lack of data to compare the long-term results of ET and surgical resection.

METHODS

Duodenal GIST patients from 2004 to 2015 were selected from the surveillance, epidemiology, and end result (SEER) database. We used the Kaplan-Meier method and log-rank test to describe the 5- and 10-year survival differences between the ET and the surgery groups. The multivariate Cox proportional hazard model was used for analyzing the risk factors influencing the prognosis of patients. We used a 1:1 propensity score-matched (PSM) to reduce confounding factors, and then we compared survival differences between the two groups again.

RESULTS

A total of 294 patients with duodenal GIST were enrolled, including 41 (13.9%) patients with ET and 253 (86.1%) patients with surgical resection. Before PSM, the long-term survival of patients with duodenal GIST after ET and surgical resection was similar [5-year overall survival (OS) (79.7 vs. 79.3%, p = 0.876), 10-year OS (66.5 vs. 68.1%, p = 0.876)]. After adjusting the relevant variables using multivariate Cox analysis, we found that the ET and surgery groups were comparable in OS and cancer-specific survival (CSS). After PSM, there was also no significant difference between ET and surgical resection for long-term OS and CSS.

CONCLUSION

Our study found no significant difference in long-term survival between ET and surgical resection in patients with duodenal GIST. However, to obtain high-quality evidence, more extensive sample size studies are needed in the future to evaluate the long-term effects of ET on patients.

Endoscopic Full Thickness Resection: A Systematic Review

Background Endoscopic full thickness resection (EFTR) is an emerging therapeutic option for resecting subepithelial lesions (SELs) and epithelial neoplasms. We aimed to systematically review the techniques, applications, outcomes, and complications of EFTR.

Methods A systematic literature search was performed using PubMed. All relevant original research articles involving EFTR were included for the review along with case report/series describing novel/rare techniques from 2001 to February 2022.

Results After screening 7,739 citations, finally 141 references were included. Non-exposed EFTR has lower probability of peritoneal contamination or tumor seeding compared with exposed EFTR. Among exposed EFTR, tunneled variety is associated with lower risk of peritoneal seeding or contamination compared with non-tunneled approach. Closure techniques involve though the scope (TTS) clips, loop and clips, over the scope clips (OTSC), full thickness resection device (FTRD), and endoscopic suturing/plicating/stapling devices. The indications of EFTR range from esophagus to rectum and include SELs arising from muscularis propria (MP), non-lifting adenoma, recurrent adenoma, and even early gastric cancer (EGC) or superficial colorectal carcinoma. Other indications include difficult locations (involving appendicular orifice or diverticulum) and full thickness biopsy for motility disorders. The main limitation of FTRD is feasibility in smaller lesions (<20–25 mm), which can be circumvented by hybrid EFTR techniques. Oncologic resection with lymphadencetomy for superficial GI malignancy can be accomplished by hybrid natural orifice transluminal endoscopic surgery (NOTES) combining EFTR and NOTES. Bleeding, perforation, appendicitis, enterocolonic fistula, FTRD malfunction, peritoneal tumor seeding, and contamination are among various adverse events. Post OTSC artifacts need to be differentiated from recurrent/residual lesions to avoid re-FTRD/surgery.

Conclusion EFTR is safe and effective therapeutic option for SELs, recurrent and non-lifting adenomas, tumors in difficult locations and selected cases of superficial GI carcinoma.

New Applications for Submucosal Tunneling in Third Space Endoscopy: A Comprehensive Review

Third space endoscopy (TSE), a type of natural orifice transluminal endoscopic surgery, was first introduced a decade ago, and since then, has revolutionized the field of therapeutic endoscopy. TSE involves tunneling into the submucosal space between the intestinal mucosa and the muscularis propria. By accessing this "third space," endoscopists can perform minimally invasive myotomies, resections, and dissections while maintaining the mucosa and preventing full-thickness perforation. TSE procedures can be used to treat motility disorders as well as neoplasms throughout the gastrointestinal tract, which were traditionally conditions that would require open or laparoscopic surgery. The main TSE procedures include peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, endoscopic submucosal tunnel dissection, peroral endoscopic tunneling for restoration of the esophagus, and per-rectal endoscopic myotomy. Some of those procedures have now been accepted as viable alternative to surgical techniques due to their limited invasiveness, safety and cost. This review will explore the different techniques recently added to our arsenal while describing their potential efficacy and limitations.

Safety and efficacy of surgical and endoscopic resection in the treatment of duodenal subepithelial lesions

BACKGROUND

Duodenal subepithelial lesions (D-SELs) are rare and their resection is challenging. Unfortunately, data on surgical and endoscopic resection of D-SELs are scarce. This study aimed to assess the safety and efficacy of surgical resection and endoscopic resection (ER) for D-SELs.

METHODS

We retrospectively analyzed clinical data of patients with non-ampullary D-SELs who underwent ER or surgery and compared the outcomes between ER and surgery with no/low-risk SELs over 15 mm from March 2010 to August 2020. Clinicopathologic findings, procedure-related parameters, and follow-up data were analyzed.

RESULTS

A total of 107 patients (108 lesions) were enrolled; 52 patients (53 lesions) received ER and 55 patients (55 lesions) received surgery. In ER group, en bloc resection rate and R0 resection rate were 94 and 89%, respectively. Major adverse events rate was 6%. One (2%) patient experienced local recurrence. In surgery group, R0 resection was achieved in all cases. Major adverse events rate was 20%. Recurrence rate and distant metastases rate were 4 and 8%, respectively. One (2%) patient died from septicemia during follow-up. Thirty-three patients in each group were enrolled in the comparison. There were no significant differences in age, sex, lesion size and location (P > 0.05). More histologically GISTs and muscularis propria-originated lesions were treated by surgery (P < 0.05). ER was significantly associated with a shorter operation time, shorter hospital stay, lower cost, less estimated blood loss, and lower major adverse events rate compared to the surgery group (P < 0.05). However, R0 resection rate, mortality, recurrence rate, and metastases rate were not significant different (P > 0.05).

CONCLUSIONS

ER is an effective and safe treatment modality for selected patients with non-ampullary D-SELs by expert endoscopists. Surgery is a radical method for D-SELs that should be reserved for D-SELs not amenable to ER.

Advanced Endoscopic Resection Techniques: Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection

Endoscopic resection is first-line therapy in the management of superficial neoplasms throughout the gastrointestinal tract, as well as an increasingly viable therapeutic alternative in the resection of selected small deep lesions throughout the upper and lower gastrointestinal tract. The mainstay of therapy has traditionally been endoscopic snare polypectomy and endoscopic mucosal resection. However, recent innovative advancements in therapeutic endoscopy have provided for the ability to resect large superficial lesions and selected subepithelial lesions in en bloc and margin-negative fashion. In this review, we discuss the current state of the art in advanced endoscopic resection techniques including endoscopic submucosal dissection and endoscopic full-thickness resection.

Advances in endoscopic resection: a review of endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER)

Subepithelial lesions are often detected incidentally in patients undergoing an endoscopy. They are common tumors of the gastrointestinal (GI) tract which can originate from different layers of the GI tract wall. These lesions can be further classified based on GI layer of origin and unique histochemical staining. While most are benign and asymptomatic, some of these lesions have malignant potential with distant metastases. However, current diagnostic modalities including endoscopy with biopsy or endoscopic ultrasound with fine needle aspiration are not always reliable. In addition, management of these lesions has historically involved surgical resection via open or laparoscopic approaches. In recent years, with advancement in endoscopic techniques and improvement in endoscopists' skills, less invasive procedures such as endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER) have been developed and now are being used by endoscopists worldwide. Upon reviewing the literature, multiple studies have shown the advantages of these endoscopic techniques when compared with surgical treatment. As a result, there has been a dramatic shift towards minimally invasive endoscopic procedures for the management of these subepithelial lesions. In this review article, we will discuss these endoscopic resection techniques in detail, their safety and efficacy, as well as comparison studies to other therapeutic modalities.

Transesophageal endoscopic resection of mediastinal cysts (with video)

BACKGROUND AND AIMS

Primary mediastinal cysts are infrequent lesions derived from a variety of mediastinal organs or structures. Complete surgical resection is the treatment of choice even in asymptomatic patients to prevent severe adverse events (AEs) and to establish the diagnosis. Transesophageal endoscopic resection of benign mediastinal tumors has been proven feasible. The aim of this study was to evaluate the feasibility, safety, and efficacy of transesophageal endoscopic surgery for mediastinal cysts.

METHODS

From January 2016 to May 2021, patients with mediastinal cysts who underwent transesophageal endoscopic resection were retrospectively included. Clinicopathologic characteristics, procedure-related parameters, AEs, and follow-up outcomes were analyzed.

RESULTS

Ten patients with mediastinal cysts were included in this study. The mean cyst size was 3.3 ± 1.3 cm. Histopathology revealed 3 bronchogenic cysts (30.0%), 4 esophageal duplication cysts (40.0%), 2 gastroenteric cysts (20.0%), and 1 lymphatic cyst (10.0%). All procedures were performed uneventfully without conversion to traditional surgery. En-bloc resection was achieved in 6 patients (60.0%). Aggressive resection was avoided to prevent damage to the surrounding vital organs. Mean resection time and suture time were 58.0 ± 36.4 minutes and 5.4 ± 1.0 minutes, respectively. No major pneumothorax, bleeding, mucosal injury, or fistula occurred. One patient had a transient febrile episode (>38.5°C). Mean postoperative hospital stay was 2.7 ± .9 days. No residual or recurrent lesions were observed in any patient during a mean follow-up period of 29.8 ± 19.5 months.

CONCLUSIONS

Transesophageal endoscopic surgery appears to be a feasible, safe, effective, and much less invasive approach for mediastinal cyst resection. Larger prospective studies are required to fully assess the efficacy and safety of this novel technique.

OTSC assisted EFTR for the treatment of GIST: 40 cases analysis

BACKGROUND AND AIMS

To verify the safety and efficacy of over-the-scope clip (OTSC)-assisted endoscopic full-thickness resection (EFTR) for the excision of stromal tumors.

MATERIAL AND METHODS

Forty patients with gastric stromal tumors treated in the Department of Gastroenterology, Binzhou Medical University Hospital from December 2015 to March 2017 were included in this study. The surgical procedures included marking the lesion boundaries, cutting open the top surface of the lesion, installing an OTS, sucking the lesion into the transparent cap of the anatomical clip which was then released, application of an endoloop for EFTR, and confirming the complete resection and pathological examination of the lesion. Statistical analysis of the tumor site and size, operation time, success rates, complications, pathological examination results, and follow-up status was performed.

RESULTS

The average operation duration was 38.40 ± 24.9 min. Three cases had an incomplete resection, but the lesion was later found to have fallen off together with the OTSC. Therefore, the treatment success rate was 100%. Postoperative pathological examination revealed leiomyomas in four cases and stromal tumors in the remaining 36 cases.

CONCLUSIONS

OTSC-assisted EFTR is safe and effective for resection of gastrointestinal stromal tumors, especially for those <20 mm in size.

Safety and Efficacy of Endoscopic Treatment of Solitary Gastric Neurofibroma

Purpose

The studies on solitary gastric neurofibroma (GN) consist of only individual case reports, with little data and relevant information. We aimed to summarize the clinical features, endoscopic features, imaging findings, and pathological features and study the safety and efficacy of endoscopic treatment of solitary GN.

Patients and Methods

We retrospectively collected and analyzed clinical data of patients who underwent endoscopic treatment in Department of Gastroenterology of a well-known tertiary hospital from August 2007 to September 2019 and were accurately diagnosed as having solitary GN.

Results

A total of 788 patients with gastric submucosal tumors underwent endoscopic treatment, among whom 11 patients were found to have solitary GNs. The incidence of solitary GNs was 1.4%. All 11 patients were treated with endoscopy. Five patients underwent endoscopic full-thickness resection (EFTR) and six patients underwent endoscopic submucosal excavation (ESE). The en bloc resection rate of the 11 lesions was 100.0%. The median endoscopic operation time was 80 minutes. Average length of hospital stay was 6.4 ± 1.6 days. The median follow-up time was 29 months. No recurrence, distant metastasis, or disease-related death occurred during the follow-up.

Conclusion

EFTR and ESE can serve as feasible, safe, and effective treatments for solitary GN.

Near-focus mode for accurate operation during endoscopic submucosal tunneling procedure

INTRODUCTION

When using the endoscopic submucosal tunnel technique (ESTT), the working space in the submucosal tunnel is limited, and the visual field is obscured during close inspection or hemostasis. We aimed to evaluate the efficacy and safety of near-focus mode technique for accurate operation during the submucosal tunneling endoscopic procedure.

MATERIAL AND METHODS

A retrospective two-center study was designed. A total of 51 patients undergoing ESTT procedures with near-focus mode (n = 29) or traditional mode (n = 22) between February 2016 and May 2019 were included in this study.

RESULTS

When using the near-focus mode during the ESTT procedure, it is convenient to ensure a clear image and accurate operation. Adverse events occurred more frequently in the traditional group than in the near-focus group (45.5% vs 17.2%, p = .036). The near-focus group exhibited a lower rate of bleeding compared to the traditional group (0 vs 18.2%, p = .029). Furthermore, the mean hospital stay after the procedure was shorter in the near-focus group than in the traditional group (5.7 days vs 6.7 days, p = .013).

CONCLUSIONS

The visual field is more clearly exposed during submucosal tunneling when using the near-focus mode than when using traditional procedures. This technique appears to be more efficient and secure than the traditional ESTT procedure.

The Value of Endoscopic Ultrasonography in the Endoscopic Resection of Gastrointestinal Stromal Tumors

Objective

This study aimed to explore the clinical value of endoscopic ultrasonography (EUS) in the endoscopic resection of gastrointestinal stromal tumors (GISTs).

Methods

A retrospective study of 92 patients who were confirmed to have GISTs by endoscopic resection after EUS examination was conducted. The preoperative features of the EUS examination, ultrasound diagnosis, endoscopic resection methods, surgical procedures, complications, and complete degree of lesion resection were recorded. And 16 patients who were diagnosed by endoscopy and EUS and confirmed by surgical operation were included and analyzed in the subsequent part of the investigation (gastroscopy and EUS image analysis, EUS image and risk classification).

Results

The preoperative diagnosis rate of EUS and postoperative pathological diagnosis of GISTs was 78.7% (85/108), and the presence of a non-homogeneous echo and liquid anechoic zone in GISTs often indicated higher risk (P < 0.05). There was a positive correlation between tumor size and risk (P < 0.05).

Conclusion

The endoscopic resection of GISTs is feasible and safe. EUS is of great significance for the diagnosis and risk assessment of GISTs and can assist in the endoscopic resection of GISTs.

Endoscopic Resection of Gastrointestinal Stromal Tumor: Is It Safe?

Recently, results from clinical studies of endoscopic resection of gastrointestinal stromal tumor (GIST) in the stomach are being reported. This procedure has several advantages, such as the provision of a definite diagnosis and therapeutic plan, avoidance of frequent follow-up examination, and reduction of patients’ anxiety. However, several concerns also exist such as a limited number of studies, low R0 resection rate, and relatively shorter follow-up period compared with surgical resection. Nevertheless, it is encouraging that most of the post-procedural complications have been treated with conservative management and that some of the patients did not show recurrence of the tumor during long-term follow-up. The selection of suitable cases and the experience of the endoscopists are the most important factors for successful endoscopic resection of gastric GIST. Development of novel procedures as well as collaboration with laparoscopic surgeons are currently in progress.

Factors predicting technical difficulties during endoscopic submucosal excavation for gastric submucosal tumor

Objective

Endoscopic submucosal excavation (ESE) has been established as an effective method for removal of gastric submucosal tumors (SMTs). The aim of the present study was to explore risk factors for technical difficulties in ESE.

Methods

In this retrospective study, we collected clinical data from patients who underwent ESE for gastric SMTs. Difficult ESE was defined as a procedure time ≥90 minutes, piecemeal resection, and/or occurrence of major adverse events. Univariate and multivariate analyses were performed to explore the risk factors for a difficult ESE.

Results

ESE was successfully performed in 96.5% (195/202) of patients from April 2011 to December 2019. The average tumor size was 17.41 mm, and en bloc resection was achieved in 97.4% of patients (190/195). Five patients (2.56%, 5/195) had complications, including two with delayed bleeding, two with fever, and one with chest pain accompanying ST-T changes in an electrocardiogram. Twenty-four patients (11.88%, 24/202) had a difficult ESE. Logistic analysis showed that outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE.

Conclusion

ESE may be safe and effective to treat patients with gastric SMTs. Outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE.

Submucosal tunneling endoscopic resection treatment of multiple gastrointestinal submucosal tumors

BACKGROUND AND AIM

Gastrointestinal submucosal tumors (SMTs) can be removed by submucosal tunneling endoscopic resection (STER). However, limited studies have evaluated STER for the removal of multiple upper gastrointestinal SMTs. The aim of this study was to evaluate the feasibility and outcomes of STER in the treatment of multiple upper gastrointestinal SMTs.

METHODS

From January 2011 to April 2020, the cases of patients with multiple upper gastrointestinal SMTs undergoing STER were retrospectively analyzed. Variables of clinicopathological characteristics, major adverse events (mAEs), and follow up were collected and analyzed.

RESULTS

Submucosal tunneling endoscopic resection was performed in 54 patients (48 male and 6 female patients) with 120 SMTs. Forty-four patients had two tumors, eight patients had three tumors, and two patients had four tumors. The median size of each patient was 1.8 cm (range 0.7 to 3.5 cm). Forty-five patients had tumors removed by one tunnel, and nine patients by two tunnels. The median procedure time was 50 min (range 14 to 120 min), and the mAE rate was 16.7% (9/54). No significant differences were found between patients with two tumors and those with > 2 tumors in terms of tunnel length, hospital stay, procedure time, and mAEs (all P > 0.05). In addition, patients with two tunnels had procedure time, hospital stay, and mAE rates comparable with those with one tunnel (all P > 0.05). No local recurrence or distant metastasis occurred during a median follow up of 64 months.

CONCLUSIONS

Submucosal tunneling endoscopic resection is a safe and effective technique for the resection of multiple upper gastrointestinal SMTs.

Closure techniques in exposed endoscopic full-thickness resection: Overview and future perspectives in the endoscopic suturing era

Exposed endoscopic full-thickness resection (EFTR) without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery technique that is emerging as a promising effective and safe alternative to surgery for the treatment of muscularis propria-originating gastric submucosal tumors. To date, various techniques have been used for the closure of the transmural post-EFTR defect, mainly consisting in clip- and endoloop-assisted closure methods. However, the recent advent of dedicated tools capable of providing full-thickness defect suture could further improve the efficacy and safety of the exposed EFTR procedure. The aim of our review was to evaluate the efficacy and safety of the different closure methods adopted in gastric-exposed EFTR without laparoscopic assistance, also considering the recent advent of flexible endoscopic suturing.

A Review of Endoscopic Full-thickness Resection, Submucosal Tunneling Endoscopic Resection, and Endoscopic Submucosal Dissection for Resection of Subepithelial Lesions

Gastrointestinal subepithelial tumors (SETs) are often found while performing routine endoscopy. Recently, there has been the development of new endoscopic techniques such as endoscopic submucosal dissection, submucosal tunnel endoscopic resection, and endoscopic full-thickness resection, all minimally invasive approaches which have made it possible to resect SETs that were previously resected with surgery. This review discusses the endoscopic treatment of patients with SETs, outcomes for endoscopic treatment, procedure-related complications, and advantages and disadvantages of these endoscopic techniques.

Safety and efficacy of endoscopic resection for the treatment of duodenal subepithelial lesions

Background

Endoscopic management of duodenal subepithelial lesions is challenging, and there are only a few studies on this topic. This study aimed to evaluate the safety and efficacy of endoscopic resection for the treatment of duodenal subepithelial lesions.

Methods

We retrospectively analyzed the clinical data, including epidemiologic characteristics, therapeutic outcomes, complications, and follow-up results, of 49 patients with duodenal subepithelial lesions who underwent endoscopic resection at our hospital between August 2010 and September 2019.

Results

We performed 35 endoscopic submucosal dissection, 9 endoscopic mucosal resection, 3 endoscopic submucosal excavation, and 2 endoscopic full-thickness resection. The en bloc resection rate and R0 resection rate were 95.9% and 89.8%, respectively. Delayed perforations developed in 2 (4.1%) patients; surgical intervention was required for both. Coagulation syndrome developed in 1 (2.0%) patient; however, it was treated conservatively. Delayed bleeding or other serious complications did not occur. One patient underwent complementary surgery after endoscopic resection. One (2.3%) recurrence occurred in patients who underwent endoscopic resection at a median follow-up duration of 24 months (range, 1-88 months).

Conclusions

Endoscopic resection is an effective, safe, and minimally invasive method for the histopathologic assessment and curative treatment of duodenal subepithelial lesions originating from the submucosal or muscularis propria.

Retrospective Comparison of Endoscopic Full-Thickness Versus Laparoscopic or Surgical Resection of Small (≤ 5 cm) Gastric Gastrointestinal Stromal Tumors

AIM AND BACKGROUND

The aim of this study was to compare the efficacy and safety between endoscopic full-thickness resection (EFR) and laparoscopic or surgical resection methods for gastric gastrointestinal stromal tumor (GIST) in size of 5.0 cm or less. Gastric GISTs are common, and resection is the most effective treatment.

METHOD

We retrospectively reviewed 216 resections of gastric GISTs in size of up to 5.0 cm at our center from 2009 to 2017.Eligible resection cases were divided into EFR (n = 85), laparoscopic(n = 64), and surgical (n = 67) groups. The clinical records, patient demographic, symptoms, perioperative data, pathological findings, and long-term follow-up outcomes were collected and compared statistically.

RESULTS

No tumor rupture or recurrence occurred in the three groups. The prevalence of complications was significantly lower in EFR (5.9%) than both laparoscopic (7.8%) and surgical group (16.4%) (P < 0.01). In EFR group, the R0 resection rate (95.3%) was significantly lower than in the laparoscopic group and surgical group (100%) (P < 0.001). The hospital cost (OR = 62.79, CI: 12.954-304.363, P < 0.0001) were significantly lower in the EFR than in the laparoscopic group. The hospital cost (OR = 39.032, CI: 8.045-189.371, P < 0.0001) and post-operative diet time (OR = 2.779, CI: 1.225-6.304, P < 0.05) were also significantly lower in the EFR than in the surgical group.

CONCLUSION

EFR was a feasible treatment for gastric GISTs of size of ≤ 5.0 cm with an acceptable complete resection rate. In addition, EFR had significantly fewer postoperative complications, shorter length of hospital stay, and lower cost.

Efficacy and safety of submucosal tunneling endoscopic resection for gastric submucosal tumors: a systematic review and meta-analysis

INTRODUCTION

submucosal tunneling endoscopic resection (STER) can be an effective treatment for submucosal tumors (SMTs) in the esophagus and cardia. However, STER may be more difficult to perform in the stomach than in the esophagus due to special anatomical and physiological features. The feasibility of STER to remove gastric STMs has not been systematically investigated. Therefore, this meta-analysis aimed to evaluate the safety and efficacy of STER for gastric SMTs.

MATERIAL AND METHODS

a comprehensive literature search of the Medline, Embase, PubMed, and Cochrane Library databases was conducted. Complete resection and en-bloc resection rates were considered as the primary outcome measures. The secondary outcome measure was the pooled estimate of complications.

RESULTS

nine studies including 301 patients with 305 lesions were finally included. The pooled estimate of en-bloc resections was 95.1 % (95 % CI: 88.9-97.9 %), Cochran's Q-test, p = 0.151, and the weighted pooled rate (WPR) for complete resection was 97.9 % (95 % CI: 93.6-99.3 %), Cochran's Q-test, p = 0.778. In addition, the pooled estimate of gas-related complications was 8.7 % (95 % CI: 4.6-15.9 %), Cochran's Q-test, p = 0.057. The pooled estimate for mucosal laceration was 4.2 % (95 % CI: 2.2-7.9 %), Cochran's Q-test, p = 0.572. The pooled estimate for delayed bleeding was 2.1 % (95 % CI: 0.9-4.8 %), Cochran's Q-test, p = 0.985. The pooled estimate of inflammation-related complications was 8.6 % (95 % CI: 5.2-13.9 %), Cochran's Q-test, p = 0.308.

CONCLUSION

STER is an effective and safe technique for removing gastric SMTs with low complications, and complications, when encountered, can be treated conservatively.

Full-thickness resection device (FTRD) for treatment of upper gastrointestinal tract lesions: the first international experience

Background and study aims  The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. Patients and methods  This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Results  Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68-138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Conclusions  Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.

Current status of endoscopic submucosal tunnel dissection for treatment of superficial gastrointestinal neoplastic lesions

INTRODUCTION

With the widespread application of screening endoscopy and development of endoscopy-related instruments, more and more gastrointestinal cancers are detected in an early stage. Endoscopic resection is a preferred method for selected patients with superficial gastrointestinal neoplastic lesions, and endoscopic submucosal dissection (ESD) has become a standard method for its ability to perform en bloc resection regardless of the lesion size. ESD can be performed in a conventional or tunneling way, and the latter is termed endoscopic submucosal tunnel dissection (ESTD).

AREA COVERED

In the present review, we provided a comprehensive review on ESTD for treatment of superficial gastrointestinal neoplastic lesions. We mainly focus on technical details, safety and efficacy of ESTD for esophageal, gastric and colorectal lesions. The present review is expected to provide tips for operators who are going to perform ESTD.

EXPERT OPINION

The best indication of ESTD is large superficial esophageal neoplastic lesions (circumferential extent > 1/3 and longitudinal extent > 3 cm). Although ESTD has shown promising primary results for superficial gastric and colorectal neoplastic lesions, it is technically difficult and should be attempted only in experienced hands. Post-treatment stricture is a major concern, and preventive measures are recommended for patients with high risk of post-ESTD stricture.

Efficacy and Safety of Endoscopic Treatment for Gastrointestinal Stromal Tumors in the Upper Gastrointestinal Tract

Background/Aims:

Endoscopic treatment (ET) has been applied for decades to treat subepithelial tumors, including gastrointestinal stromal tumors (GISTs). However, the efficacy of ET remains debatable. In this study, we evaluated the efficacy and safety of ET for GISTs in the upper gastrointestinal tract.

Methods:

This retrospective single-center study included 97 patients who underwent ET. All patients were enrolled from July 2014 to July 2018. Parameters such as demographics, size, resection margin, complications, pathological features, procedure time, total cost, and follow-up were investigated and analyzed.

Results:

Our study achieved 100% en bloc resection and 77.4% (72/93) R0 resection. The most common location was the fundus with a mean tumor size of 2.1±1.4 cm. The mean age, procedure time, hospital stay, and cost were 59.7±11.3 years, 64.7±35.2 minutes, 6.8 days, and 5,337 dollars, respectively. According to National Institutes of Health classification, 63 (64.9%), 26 (26.8%), 5 (5.2%), and 3 (3.1%) patients belonged to the very low, low, intermediate, and high risk classification, respectively. Immunohistochemistry results showed a 100% positive rate of CD34, DOG-1, CD117, and Ki67. A mean follow-up of 21.3±13.0 months showed no recurrence or metastasis.

Conclusions:

ET is effective and safe for curative removal of GISTs in the upper gastrointestinal tract, and it can be a treatment of choice for patients with no metastasis.

Clinical outcomes of per-oral endoscopic tumor resection for submucosal tumors in the esophagus and gastric cardia

OBJECTIVES

The clinical success of per-oral endoscopic myotomy (POEM) has led to the development of a new field of 'submucosal endoscopy'. This study aimed to evaluate the safety, efficacy, and limitations of per-oral endoscopic tumor resection (POET) in the management of submucosal tumors (SMTs) in the esophagus and the gastric cardia.

METHODS

POET was performed in 47 patients from January 2011 to December 2017. The indication for POET was SMTs ≤ 30 mm in minor axis diameter. Patient and tumor characteristics (age, gender, tumor location, size, and histology), operative and clinical results of POET (procedure time and completion rate, en bloc resection rate, length of hospitalization, adverse events and tumor recurrence) were analyzed retrospectively.

RESULTS

POET was successfully completed in 43 patients (91.5%) without any major adverse events (Clavien-Dindo IIIb-IV). Four patients required conversion to an open surgical procedure due to suboptimal visualization during POET. Four patients underwent piecemeal resection of their SMTs including GISTs. Median follow-up was 44 months (10-96 months), during that time, there were no incidences of tumor recurrence. Tumors that had a minor axis diameter > 30 mm or a tumor mass index (TMI) [major axis diameter (mm) × minor axis diameter (mm)] >1000 had a high likelihood of being converted to surgical resection.

CONCLUSIONS

POET is a safe and effective treatment for SMTs. However, in patients where the minor axis diameter is > 30 mm or the TMI > 1000, surgical excision should be considered. Furthermore, application of POET for SMTs with malignant potential should be carefully considered to ensure optimal oncologic outcomes.

Third Space Endoscopy: Lessons Learnt From a Decade of Submucosal Endoscopy

The field of third space endoscopy (TSE), also called submucosal endoscopy using a mucosal flap valve, allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.

Comparing about three types of endoscopic therapy methods for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

Background: Endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER) have been widely applied to upper gastrointestinal submucosal tumors (SMTs) originating from the muscularis propria (MP) layer in recent years. But until now, there are few studies that comparing the efficacy and safety of three endoscopic therapy methods.Method: From January 2013 to August 2018, a total of 218 patients with SMTs who underwent ESE, EFTR or STER were enrolled in this retrospective study. Clinicopathological characteristics, endoscopic features, complication and follow-up data were analyzed.Result: There were 114 patients underwent ESE, 61 underwent EFTR and 43 underwent STER, respectively. The en bloc and complete resection rates in STER group (83.7% and 90.0%) were significantly lower and postoperative complication rate (62.8%) was significantly higher than those of the other 2 methods. Furthermore, for lesions <40 mm, no significant differences were found in the en bloc rate, complete rate and postoperative complication rate among 3 methods. The perforation rate decreased in the order of EFTR (100%), ESE (23.7%), STER (7.0%). The median number of clips, fasting time and hospital stay were lowest in ESE group (5, 2 days, and 7 days). And the cost was highest in EFTR group ($4993.1). There were no differences in the bleeding and recurrence rates among three groups.Conclusion: For SMTs <40 mm, the efficacy among 3 ER methods are comparative. The choice of ER methods mainly based on the comprehensive consideration of lesion size, location, growth pattern and clinical experience of endoscopists. For benign SMTs ≥40 mm in stomach, ESE and EFTR becomes alternative choices.

Outcomes of submucosal tunneling endoscopic resection in upper gastrointestinal sub-epithelial tumors

BACKGROUND

Submucosal tunneling techniques have expanded the horizon of therapeutic endoscopy. One such procedure, submucosal tunneling endoscopic resection (STER), enables the endoscopic removal of gastrointestinal (GI) sub-epithelial tumors. In this study, we aimed to evaluate the safety and efficacy of STER in patients with sub-epithelial lesions localized to the upper GI tract.

METHODS

Consecutive subjects with a sub-epithelial lesion of ≥ 1 cm size in the upper GI tract were enrolled in the study. STER was performed using the standard technique in an endoscopy suite. A modified technique (double-opening STER) was used in cases with difficult en bloc resection of the tumor. Outcome measures included technical success, en bloc resection rates, adverse events, and recurrence.

RESULTS

A total of 104 patients with sub-epithelial tumors were evaluated for STER. Of them, 44 subjects (mean age 44.68 ± 12.82, 52.3% males) underwent standard STER. Majority (31, 70.4%) of the lesions were located in the esophagus and cardia. Technical success and en bloc removal of the tumor were achieved in 97.7% and 88.4% of cases, respectively. There was no major adverse event. Minor adverse events were recorded in 7 (15.9%) cases. Majority (31, 70.4%) of the tumors originated from muscularis propria, followed by submucosa (8, 18.2%) and muscularis mucosa (5, 11.4%). The most common histological diagnosis was leiomyoma (59.1%) followed by GI stromal tumors (20.4%). At a mean follow up of 12.36 ± 7.63 months, there was no incidence of tumor recurrence in en bloc as well as piecemeal resection groups.

CONCLUSION

STER is a safe and efficacious procedure for sub-epithelial tumors in the upper GI tract. Novel strategies need to be developed to ensure en bloc removal of large lesions.

Submucosal Tunneling Endoscopic Resection for Gastric Submucosal Tumors: a Comparison Between Cardia and Non-cardia Location

BACKGROUND AND PURPOSE

Submucosal tunneling endoscopic resection (STER) was initially used to remove submucosal tumors (SMTs) located at the esophagus and cardia; only few researchers have reported the feasibility of STER for gastric SMTs beyond cardia due to the technical difficulty, and little is known about the comparison of STER for cardia and non-cardia gastric SMTs. The purpose was to compare the feasibility and efficacy of STER for cardia and non-cardia gastric SMTs, as well as to explore the risk factors for failure of en bloc resection.

METHODS

We retrospectively collected the clinical data about patients with gastric SMTs who received STER at our hospital from June 2012 to June 2018. Demographics, tumor size, procedure-related parameters, complications, hospital stay, and follow-up data were compared between cardia and non-cardia SMTs. And multivariate analyses were conducted to look for the risk factors for failure of en bloc resection.

RESULTS

A total of 46 SMTs were removed, and 25 of them were located at cardia, while the other 21 at non-cardia position. There was no significant difference between the two groups in terms of gender, age, tumor size, en bloc resection rate, operation time, complications, and hospital stay (p > 0.05). No recurrence was noticed in all the cases. Multivariate analyses revealed that irregular shape was an independent risk factor for failure of en bloc resection.

CONCLUSION

STER is feasible for both cardia and non-cardia gastric SMTs, and the efficacy between cardia and non-cardia location is comparable. Irregular shape was an independent risk factor for failure of en bloc resection.

Evaluation and Management of Premalignant Conditions of the Esophagus: A Systematic Survey of International Guidelines

Esophageal cancer represents one of the most lethal forms of malignancy. The growing incidence of esophageal adenocarcinoma represents an emerging public health concern. This review article summarizes current diagnostic, management, and therapeutic practices of premalignant conditions of the esophagus including Barrett's esophagus, tylosis, granular cell tumors, achalasia, and the ingestion of caustic substances. Our report provides clinicians and academics with a global clinical perspective regarding presentation, surveillance guidelines, and therapeutic management of these esophageal conditions.

ASGE guideline for endoscopic full-thickness resection and submucosal tunnel endoscopic resection

With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.

Endoscopic full thickness resection versus submucosal tunneling endoscopic resection for removal of submucosal tumors: a review article

Submucosal tumors (SMT) are protuberant lesions with intact mucosa that have a wide differential. These lesions may be removed by standard polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgically. However, in lesions that arise from the muscularis propria, full thickness resection is recommended. This can be completed using either endoscopic full thickness resection (EFTR) or submucosal tunneling endoscopic resection (STER). EFTR can be accomplished by completing a full thickness resection followed by defect closure or by securing gastrointestinal wall patency before resection. STER is an option that first creates a mucosal dissection proximal to the lesion to allow a submucosal tunnel to be created. Using this tunnel, the lesion may be resected. When comparing STER to EFTR, there was no significant difference when evaluating tumor size, operation time, rate of complications, or en bloc resection rate. However, suture time, amount of clips used, and overall hospital stay were decreased in STER. With these differences, EFTR may be more efficacious in certain parts of the gastrointestinal tract where a submucosal tunnel is harder to accomplish.

Endoscopic resection for subepithelial lesions-pure endoscopic full-thickness resection and submucosal tunneling endoscopic resection

Endoscopic full-thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER) are the frontier of therapeutic endoscopic. These two methods rely on the skillset and equipment of endoscopic submucosal dissection (ESD) while going beyond the boundaries of the gastrointestinal lumen. They are both representatives of natural orifice transluminal endoscopic surgery, with STER being a direct off-shoot of peroral endoscopic myotomy (POEM). Both techniques are designed for the removal of gastrointestinal tumors originating from the muscularis propria but tend to be used in different organs and come with respective challenges. In this review we will go over the history, indication, technique and literature of these two techniques.

The retrospective comparison between submucosal tunneling endoscopic resection and endoscopic submucosal excavation for managing esophageal submucosal tumors originating from the muscularis propria layer

BACKGROUND

Submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) were recently introduced to cure submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. This study aimed to compare clinical performance and safety of STER and ESE in treating esophageal SMTs originating from the MP layer.

METHODS

From January 2011 to December 2017, retrospective data collection and follow-up were applied for all STER or ESE cases with esophageal SMTs originating from the MP layer in our endoscopy center, including clinical characteristics, procedure success, efficacy, and adverse events. Subgroup analysis was further done based on tumor size and origin.

RESULTS

90 STER and 77 ESE were enrolled in this study. There were no significant difference for  patient characteristics, procedure performance, and complications for ESE and STER intervention (P > 0.05). STER was faster than ESE (3.90 mm²/min vs 2.82 mm²/min, P < 0.05). For large tumors (≥ 20 mm), both techniques had the similar performance (P > 0.05), while STER led to the shorter hospitalization (4.0d vs 7.0d, P < 0.05) and lower postoperative complication (16.3% vs 45.5%, P < 0.05). For small tumors (< 20 mm), STER achieved faster operation (STER vs ESE, 2.57 mm²/min vs 1.83 mm²/min, P < 0.05). Regardless of tumor origin, there were no significant difference for both techniques, but STER resulted in short hospitalization for SMTs from the deep MP layer (STER vs ESE, 5.0d vs 7.0d, P < 0.05). During the follow-up, 2 residual and 4 recurrence occurred in the STER group, as well as 1 residual and 2 recurrence in the ESE group.

CONCLUSIONS

Both STER and ESE were effective for treating esophageal SMTs originating from the MP layer. STER might be better due to its faster operation, less complications, and shorter hospitalization.

Clinical evaluation of endoscopic resection for treatment of large gastric stromal tumors

BACKGROUND

Gastric stromal tumor is a digestive tract mesenchymal tumor with malignant potential, and endoscopic techniques have been widely used in the treatment of gastric stromal tumors, but there is still controversy over their use for large gastric stromal tumors (≥ 3 cm).

AIM

To evaluate the clinical long-term efficacy and safety of endoscopic resection for large (≥ 3 cm) gastric stromal tumors.

METHODS

All patients who underwent endoscopic resection or surgery at our hospital from 2012 to 2017 for pathologically confirmed gastric stromal tumor with a maximum diameter of ≥ 3 cm were collected. The clinical data, histopathologic characteristics of the tumors, and long-term outcomes were recorded.

RESULTS

A total of 261 patients were included, including 37 patients in the endoscopy group and 224 patients in the surgical group. In the endoscopy group, the maximum tumor diameter was 3-8 cm; the male: Female ratio was 21/16; 34 cases had low-risk tumors, 3 had intermediate-risk, and 0 had high-risk; the mean follow-up time was 30.29 ± 19.67 mo, no patient was lost to follow-up, and no patient received chemotherapy after operation; two patients with recurrence had low-risk stromal tumors, and neither had complete resection under endoscopy. In the surgical group, the maximum tumor diameter was 3-22 cm; the male: Female ratio was 121/103; 103 cases had low-risk tumors, 75 had intermediate-risk, and 46 had high-risk; the average follow-up time was 38.83 ± 21.50 mo, 53 patients were lost to follow-up, and 8 patients had recurrence after operation (6 cases had high-risk tumors, 1 had intermediate-risk, and 1 had low-risk). The average tumor volume of the endoscopy group was 26.67 ± 26.22 cm³ (3.75-120), all of which were less than 125 cm³. The average volume of the surgical group was 273.03 ± 609.74 cm³ (7-4114). Among all patients with a tumor volume < 125 cm³, 7 with high-risk stromal tumors in the surgical group (37.625 cm³ to 115.2 cm³) accounted for 3.8% (7/183); of those with a tumor volume < 125 cm³, high-risk patients accounted for 50% (39/78). We found that 57.1% (12/22) of patients with high-risk stromal tumors also had endoscopic surface ulcer bleeding and tumor liquefaction on ultrasound or abdominal computed tomography; the ratio of tumors positive for both in high-risk stromal tumors with a volume < 125 cm³ was 60% (3/5).

CONCLUSION

Endoscopic treatment is safe for 95.5% of patients with gastric stromal tumors with a tumor diameter ≥ 3 cm and a volume of < 125 cm³ without endoscopic surface ulcer bleeding or CT liquefaction.

Submucosal 1-tunnel endoscopic resection for treating upper gastrointestinal multiple submucosal tumor originating from the muscularis propria layer: A report of 12 cases

To explore the feasibility and efficacy of submucosal 1-tunnel endoscopic resection (1-tunnel STER) for the treatment of multiple upper gastrointestinal submucosal tumors (GI-SMTs) originating from the muscularis propria (MP) layer.A total of 12 patients with multiple upper GI-SMTs (no less than 2 SMTs) who underwent 1-tunnel STER from April 2013 to October 2017 were included. Clinical data on general characteristics, operation-related parameters, adverse events, and follow-up results were recorded and analyzed.All 12 patients underwent 1-tunnel STER successfully, and the mean operation time was 92.1 ± 40.8 minutes. A total of 30 SMTs were resected, out of which 27 were in the esophagus and 3 were in the stomach. The mean diameter was 15.0 ± 8.2 mm (range, 3-38 mm). All the SMTs were resected en bloc uneventfully. The SMTs comprised 28 leiomyomas and 2 gastric stromal tumors (low risk). No recurrence was noticed during a mean follow-up of 24.9 ± 15.3 months (range, 1-52 months).One-tunnel STER may serve as a feasible and effective technique for the treatment of multiple upper GI-SMTs originating from the MP layer. A large-scale prospective study is warranted for a confirmative conclusion.

Submucosal tunneling endoscopic resection: An effective and safe therapy for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

AIM

To evaluate the effectiveness and safety of submucosal tunneling endoscopic resection (STER) and compare its outcomes in esophageal and cardial submucosal tumors (SMTs) of the muscularis propria (MP) layer.

METHODS

From May 2012 to November 2017, 173 consecutive patients with upper gastrointestinal (GI) SMTs of the MP layer underwent STER. Overall, 165 patients were included, and 8 were excluded. The baseline characteristics of the patients and SMTs were recorded. The en bloc resection rate, complete resection rate, residual rate, and recurrence rate were calculated to evaluate the effectiveness of STER, and the complication rate was recorded to evaluate its safety. Effectiveness and safety outcomes were compared between esophageal and cardial SMTs.

RESULTS

One hundred and twelve men and 53 women with a mean age of 46.9 ± 10.8 years were included. The mean tumor size was 22.6 ± 13.6 mm. Eleven SMTs were located in the upper esophagus (6.7%), 49 in the middle esophagus (29.7%), 46 in the lower esophagus (27.9%), and 59 in the cardia (35.7%). Irregular lesions accounted for 48.5% of all lesions. STER achieved an en bloc resection rate of 78.7% (128/165) for GI SMTs with an overall complication rate of 21.2% (35/165). All complications resolved without intervention or were treated conservatively without the need for surgery. The en bloc resection rates of esophageal and cardial SMTs were 81.1% (86/106) and 72.1% (42/59), respectively (P = 0.142), and the complication rates were 19.8% (21/106) and 23.7% (14/59), respectively, (P = 0.555). The most common complications for esophageal SMTs were gas-related complications and fever, while mucosal injury was the most common for cardial SMTs.

CONCLUSION

STER is an effective and safe therapy for GI SMTs of the MP layer. Its effectiveness and safety are comparable between SMTs of the esophagus and cardia.

Long-term outcomes of endoscopic resection for small (≤ 4.0 cm) gastric gastrointestinal stromal tumors originating from the muscularis propria layer

AIM

To evaluate the long-term efficacy of endoscopic resection (ER) for small (≤ 4.0 cm) gastric gastrointestinal stromal tumors (GISTs) originating from the muscularis propria layer.

METHODS

Between June 2005 and February 2015, we retrospectively analyzed 229 consecutive patients with gastric MP-GISTs who underwent ER with a follow-up at least 36 mo. The main outcome measurements included complete resection rate, complications, and long-term follow-up outcomes.

RESULTS

ER included endoscopic muscularis excavation in 179 cases, endoscopic full-thickness resection in 32 cases, and submucosal tunneling endoscopic resection in 18 cases. The median size of GISTs was 1.90 cm. Of the 229 GISTs, 147 were very low risk, 72 were low risk, 8 were intermediate risk, and 2 were high risk. Short-term outcomes showed the complete resection rate was 96.5%, and 8 patients (3.5%) had complications. Of the 8 patients with complications, only one patient required surgical intervention. Long-term outcomes showed 225 patients were actively followed-up until composition of this manuscript. The remaining 4 patients were lost because of unrelated death. During the follow-up period (median, 57 mo), no residual, recurrent lesions, or distant metastasis were detected in any patients. Binary logistic regression analysis showed tumor size was a risk factor associated with a high mitotic index (≥ 5/50 HPF) of GISTs (P = 0.002).

CONCLUSION

ER seems to be an effective and safe method for gastric MP-GISTs ≤ 4.0 cm, and, for some intermediate or high risk GISTs, adjuvant therapy and/or additional surgery might be required to reduce the risk of recurrence or metastasis.

Endoscopic Full Thickness Resection

Recent advances in minimally invasive endoscopic approaches have pushed the boundaries of well-established resection techniques for therapeutic and diagnostic applications. Endoscopic full thickness resection techniques are a key development in the management of challenging epithelial and subepithelial lesions that are not amenable to conventional endoscopic resection methods and previously required a surgical approach. Endoscopic full thickness biopsy represents a paradigm shift in tissue acquisition and will enhance our understanding of the pathophysiology, and guide therapy, of gastrointestinal neuromuscular diseases, as well as other inflammatory and neoplastic conditions. This review highlights current tools and techniques available for endoscopic full thickness resection and biopsy, as well as outcomes from such interventions.