Efficacy and safety of endoscopic resection for small submucosal tumors originating from the muscularis propria layer in the gastric fundus

A rapid and simple endoscopic resection of gastric fundus submucosal tumors

A 56-year-old male patient was diagnosed with a submucosal tumor in the fundus of the stomach. The conventional operation method is endoscopic submucosal dissection. We present a case of rapid tumor resection without employing traditional endoscopic submucosal dissection instruments such as a mucotomy knife and endoscopic injection needle, resulting in substantial cost savings for the patients.

Endoscopic resection in subepithelial lesions of the upper gastrointestinal tract: Experience at a tertiary referral hospital in The Netherlands

Background and study aims Histological confirmation of subepithelial lesions (SELs) in the upper gastrointestinal tract remains challenging. Endoscopic resection of SELs is increasingly used for its excellent diagnostic yield and opportunity to do away with continued surveillance. In this study, we aimed to evaluate the indications, success rates and complications of different endoscopic resection techniques for SELs at a large, tertiary referral hospital in Rotterdam, The Netherlands. Patients and methods Data between October 2013 and December 2021 were retrospectively collected and analyzed. Main outcomes were R0-resection rate, en bloc resection rate, recurrence rate, and procedure-related adverse events (AEs) (Clavien-Dindo). Secondary outcomes were procedure time, need for surgical intervention, and clinical impact on patient management. Results A total of 58 patients were referred for endoscopic resection of upper gastrointestinal SELs. The median diameter of lesions was 20 mm (range 7-100 mm). Median follow-up time was 5 months (range 0.4-75.7). Forty-eight procedures (83%) were completed successfully leading to en bloc resection in 85% and R0-resection in 63%. Procedure-related AEs occurred in six patients (13%). Severe complications (CD grade 3a) were seen in three patients. The local recurrence rate for (pre)malignant diagnosis was 2%. Additional surgical intervention was needed in seven patients (15%). A total of 32 patients (67%) could be discharged from further surveillance after endoscopic resection. Conclusions Endoscopic resection is a safe and effective treatment for SELs and offers valuable information about undetermined SELs for which repeated sampling attempts have failed to provide adequate tissue for diagnosis.

Effect of endoscopic full-thickness resection assisted by distal serosal turnover with floss traction for gastric submucosal masses

BACKGROUND

Complex and high-risk surgical complications pose pressing challenges in the clinical implementation and advancement of endoscopic full-thickness resection (EFTR). Successful perforation repair under endoscopy, thereby avoiding surgical intervention and postoperative complications such as peritonitis, are pivotal for effective EFTR.

AIM

To investigate the effectiveness and safety of EFTR assisted by distal serosal inversion under floss traction in gastric submucosal tumors.

METHODS

A retrospective analysis of patients with gastric and duodenal submucosal tumors treated with EFTR assisted by the distal serosa inversion under dental floss traction from January 2023 to January 2024 was conducted. The total operation time, tumor dissection time, wound closure time, intraoperative bleeding volume, length of hospital stay and incidence of complications were analyzed.

RESULTS

There were 93 patients, aged 55.1 ± 12.1 years. Complete tumor resection was achieved in all cases, resulting in a 100% success rate. The average total operation time was 67.4 ± 27.0 min, with tumor dissection taking 43.6 ± 20.4 min. Wound closure times varied, with gastric body closure time of 24.5 ± 14.1 min and gastric fundus closure time of 16.6 ± 8.7 min, showing a significant difference (P < 0.05). Intraoperative blood loss was 2.3 ± 4.0 mL, and average length of hospital stay was 5.7 ± 1.9 d. There was no secondary perforation after suturing in all cases. The incidence of delayed bleeding was 2.2%, and the incidence of abdominal infection was 3.2%. No patient required other surgical intervention during and after the operation.

CONCLUSION

Distal serosal inversion under dental-floss-assisted EFTR significantly reduced wound closure time and intraoperative blood loss, making it a viable approach for gastric submucosal tumors.

Efficacy and Safety of Endoscopic Resection for Gastric Gastrointestinal Stromal Tumors Originating from the Muscularis Propria

BACKGROUND

The role of endoscopic resection (ER) in gastric gastrointestinal stromal tumors (GISTs) has not been fully elucidated.

AIMS

The purpose of this work was to evaluate the clinical effectiveness and safety of ER in patients with GISTs originating from the muscularis propria (MP).

METHODS

A total of 233 consecutive patients with gastric GISTs originating from the MP layer, who underwent ER between February 2012 and May 2023, were included in this study. Clinical characteristics, tumor features, and outcomes were recorded and compared between patients who underwent en bloc resection and piecemeal resection.

RESULTS

Among the 233 patients, the median size of GISTs was 12 mm (range 5-60 mm). Risk assessment categorized 190 patients as very low risk, 26 as low risk, 10 as moderate risk, and 7 as high risk. The procedures performed included endoscopic submucosal excavation (127 cases), endoscopic full-thickness resection (103 cases), and submucosal tunneling endoscopic resection (3 cases). The complete and R0 resection rate was 93.1%. Complications occurred in 4.7% of cases (perioperative perforations 1.7%, perioperative bleeding 1.3%, both 0.9%), resulting in conversion to surgery in 1.3% of cases. Risk factors associated with piecemeal resection were tumor size [odds ratio (OR) 0.402, 95% confidence interval (CI) 0.207-0.783; P = 0.007] and shape (OR 0.045, 95% CI 0.009-0.235; P < 0.001).

CONCLUSIONS

ER is proven to be an effective and reasonably safe approach for gastric GISTs originating from the MP. Notably, larger tumor size and irregular shape are identified as risk factors for piecemeal resection during ER procedures.

Precutting Endoscopic Band Ligation-Assisted Resection Is Safe and Effective for Treating Gastric Submucosal Tumors from the Muscularis Propria

BACKGROUND

We previously treated small gastric submucosal tumors originating from the muscularis propria layer by precutting endoscopic band ligation but lacked precise pathological results. Then, precutting endoscopic band ligation was modified by additional snare resection after ligation to obtain tumor specimens, termed precutting endoscopic band ligation-assisted resection.

AIMS

In this study, we aimed to explore the safety, feasibility, and efficacy of precutting endoscopic band ligation-assisted resection.

METHODS

From 2021 to 2022, a total of 16 consecutive patients underwent precutting endoscopic band ligation-assisted resection to treat small gastric submucosal tumors originating from the muscularis propria. The clinical demography, perioperative data, and follow-up outcomes were retrospectively collected.

RESULTS

With a mean operative time of 21.3 min, all lesions were successfully and completely resected, and no severe adverse events or local recurrences occurred postoperatively. More importantly, en bloc and R0 resection were achieved in all 16 patients.

CONCLUSION

Precutting endoscopic band ligation-assisted resection is a safe, effective, and time-saving endoscopic technique for managing gastric small gastric submucosal tumors originating from the muscularis propria for both diagnosis and eradication.

Endoscopic ultrasound-based application system for predicting endoscopic resection-related outcomes and diagnosing subepithelial lesions: Multicenter prospective study

OBJECTIVES

Subepithelial lesions (SELs) are associated with various endoscopic resection (ER) outcomes and diagnostic challenges. We aimed to establish a tool for predicting ER-related outcomes and diagnosing SELs and to investigate the predictive value of endoscopic ultrasound (EUS).

METHODS

Phase 1 (system development) was performed in a retrospective cohort (n = 837) who underwent EUS before ER for SELs at eight hospitals. Prediction models for five key outcomes were developed using logistic regression. Models with satisfactory internal validation performance were included in a mobile application system, SEL endoscopic resection predictor (SELERP). In Phase 2, the models were externally validated in a prospective cohort of 200 patients.

RESULTS

An SELERP was developed using EUS characteristics, which included 10 models for five key outcomes: post-ER ulcer management, short procedure time, long hospital stay, high medication costs, and diagnosis of SELs. In Phase 1, 10 models were derived and validated (C-statistics, 0.67-0.99; calibration-in-the-large, -0.14-0.10; calibration slopes, 0.92-1.08). In Phase 2, the derived risk prediction models showed convincing discrimination (C-statistics, 0.64-0.73) and calibration (calibration-in-the-large, -0.02-0.05; calibration slopes, 1.01-1.09) in the prospective cohort. The sensitivities and specificities of the five diagnostic models were 68.3-95.7% and 64.1-83.3%, respectively.

CONCLUSION

We developed and prospectively validated an application system for the prediction of ER outcomes and diagnosis of SELs, which could aid clinical decision-making and facilitate patient-physician consultation. EUS features significantly contributed to the prediction.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, http://www.chictr.org.cn (ChiCTR2000040118).

Precutting endoscopic band ligation-assisted resection versus endoscopic submucosal dissection in patients with small gastric submucosal tumors originating from the muscularis propria: study protocol of a randomized controlled trial

BACKGROUND

The management of small gastric submucosal tumors (SMTs) originating from the muscularis propria layer (SMT-MPs) remains a subject of debate. Endoscopic submucosal dissection (ESD) is currently considered the optimal treatment for resection. However, high expenses, complex procedures, and the risk of complications have limited its application. Our previously proposed novel operation, precutting endoscopic band ligation (precutting EBL), has been demonstrated in a long-term, single-arm study to be an effective and safe technique for removing small gastric SMTs. However, the absence of a pathological examination and the potential for delayed perforation have raised concerns. Thus, we modified the precutting EBL by adding endoscopic resection to the snare after ligation and closure, yielding the precutting endoscopic band ligation-assisted resection (precutting EBLR). Moreover, the initial pilot study confirmed the safety and efficacy of the proposed approach and we planned a randomized controlled trial (RCT) to further validate its clinical feasibility.

METHODS

This was a prospective, single-center, open-label, parallel group, and randomized controlled trial. Approximately 40 patients with SMT-MPs will be included in this trial. The patients included were allocated to two groups: ESD and precutting EBLR. The basic clinical data of the patients were collected in detail. To better quantify the difference between ESD and precutting EBLR, the primary outcome was set as the operation duration. The secondary outcomes included total operation cost and hospitalization, intraoperative adverse events, and postoperative recurrence. The primary outcome was tested for superiority, while the secondary outcomes were tested for noninferiority. SPSS is commonly used for statistical analysis.

DISCUSSION

This study was designed to validate the feasibility of a novel operation for removing gastric SMT-MPs. To intuitively assess this phenomenon, the operation durations of precutting EBLR and ESD were compared, and other outcomes were also recorded comprehensively.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR2200065473 . Registered on November 5, 2022.

Gastric schwannoma: A retrospective analysis of clinical characteristics, treatments, and outcomes

BACKGROUND

This study aimed to investigate the clinical characteristics, treatment options, and prognosis of patients with gastric schwannoma (GS).

METHODS

Patients who were pathologically diagnosed with GS between April 2011 and October 2022 were enrolled. The data of clinical characteristics, pathological features, treatment options, and clinical outcomes were collected and compared between GS patients who underwent endoscopic resection (ER) and surgical resection (SR).

RESULTS

Of the 32 cases, 23 underwent SR and nine underwent ER. The median tumor size was significantly smaller in ER group than in SR group (12.0 vs. 40.0 mm, P < 0.001), while patients in SR group were older than those in ER group (54.5 ± 10.6 vs. 45.3 ± 10.9 years, P = 0.036). Moreover, tumors in ER group were more likely to exhibit an intraluminal pattern (100% vs. 26.1%, P < 0.001). Patients in ER group had significantly lower hospitalization cost (25859.2 ± 8623.9 vs. 44953.0 ± 13083.8 RMB, P = 0.011) than those in SR group. No differences were found between the two groups in terms of R0 resection rate, operative time, estimated blood loss, adverse events, and recurrence rate. All patients were followed up for 4-96 months (mean: 35 months; median: 23 months), during which no evidence of recurrence or metastasis was observed.

CONCLUSIONS

Both ER and SR are safe and effective treatment modalities for the management of GS, with ER being associated with lower medical costs compared to SR. The majority of GS are benign and do not recur, with little possibility of malignant transformation.

Management of small subepithelial tumors by endoscopic banding without resection and single-incision needle-knife-assisted biopsy sampling: a prospective multicenter study

BACKGROUND AND AIMS

Endoscopic band ligation (EBL) without resection combined with single-incision needle-knife (SINK) biopsy sampling may have a positive impact on small GI subepithelial tumor (SET) management, but the method needs to be tested. The aim was to evaluate the feasibility of this strategy in small-sized SETs.

METHODS

This prospective multicenter observational cohort study in 7 centers included patients with SETs ≤15 mm (confirmed by EUS) between March 2017 and March 2020. The primary outcome was clinical success at 4 weeks, defined as complete SET disappearance on EUS. Secondary outcomes were long-term (1-year) clinical success, technical difficulty level, clinical impact, yield pathology, and safety.

RESULTS

Of 273 patients screened, 122 (62.3% women; mean age, 60.9 ± 13.2 years) were included with SETs (mean size, 9 ± 2.8 mm; gastric location, 77%; superficial layer dependence, 63%). The primary endpoint was achieved in 73.6% of patients (95% confidence interval [CI], 64.8-81.2). At the 1-year follow-up, the success rate was 68.4% (95% CI, 59.1-76.8). A favorable clinical impact was observed in 97 cases (79.5%; 95% CI, 71.3-86.3). Pathology diagnosis was known in 70%. Potentially malignant lesions were present in 24.7%. The related adverse events rate was 4.1% (95% CI, 1.3-9.3; all mild: 2 bleeding, 2 abdominal pain). On multivariable analysis, the ≤10-mm SET group was associated with a greater success rate (1 year, 87%; relative risk, 5.07; 95% CI, 2.63-9.8) and clinical impact rate (92.7%; relative risk, 6.15; 95% CI, 2.72-13.93).

CONCLUSIONS

EBL plus SINK biopsy sampling seems to be feasible and safe, and it may offer a favorable clinical impact in small-sized SETs. In particular, SETs ≤10 mm are the best candidates. (Clinical trial registration number: NCT03247231.).

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.

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.

Endoscopic ultrasonography is useful for predicting perforation in the endoscopic resection of gastric submucosal tumors originating from the muscularis propria: a retrospective case-control study

PURPOSE

Models for predicting perforation during endoscopic resection (ER) of gastric submucosal tumors (SMTs) originating from the muscularis propria (MP) are rare. Therefore, this study was conducted to determine important parameters in endoscopic ultrasonography (EUS) images to predict perforation and to build predictive models.

METHODS

Consecutive patients with gastric SMTs originating from the MP who received ER from May 1, 2013 to January 15, 2021 were retrospectively reviewed. They were classified into case and control groups based on the presence of perforation. Logistic multivariate analysis was used to identify potential variables and build predictive models (models 1 and 2: with and without information on tumor pathology, respectively).

RESULTS

In total, 199 EUS procedures (194 patients) were finally chosen, with 99 procedures in the case group and 100 in the control group. The ratio of the inner distance to the outer distance (I/O ratio) was significantly larger in the case group than in the control group (median ratio, 2.20 vs. 1.53; P<0.001). Multivariate analysis showed that age (odds ratio [OR], 1.036 in model 1; OR, 1.046 in model 2), the I/O ratio (OR, 2.731 in model 1; OR, 2.372 in model 2), and the pathology of the tumors (OR, 10.977 for gastrointestinal stromal tumors; OR, 15.051 for others in model 1) were risk factors for perforation. The two models to predict perforation had areas under the curve of 0.836 (model 1) and 0.755 (model 2).

CONCLUSION

EUS was useful in predicting perforation in ER for gastric SMTs originating from the MP. Two predictive models were developed.

Efficacy and feasibility of snare-assisted endoscopic resection of small submucosal gastric tumors: A retrospective analysis

Background and aim

The prevalence of small submucosal gastric tumors is rising. Despite the fact that high success rate of endoscopic resection of small submucosal gastric tumors originating from the muscularis propria has been reported, the procedure is technically challenging and has a high rate of complications. In this study, we investigated the efficacy and feasibility of a novel snare-assisted endoscopic resection technique for small submucosal gastric tumors.

Patients and methods

This is a single-center consecutive study of 50 patients who were diagnosed with small submucosal gastric tumors originating from the muscularis propria and who subsequently underwent snare-assisted endoscopic resection between January 2019 and January 2021 at our hospital. Data on the demographic characteristics, procedural success rate, complications, recurrence rate, and histopathology of the resected specimen were collected and analyzed retrospectively.

Results

The majority of the patient’s population was male (66%) with the mean age of 48.4 ± 9 years (range, 20–70 years). The mean size of the tumor confirmed by endoscopic ultrasonography was 6.4 ± 1.6 mm (range, 3.1–9.8 mm). All the tumors were resected successfully using snare-assisted endoscopic resection technique. The mean procedure time was 22.8 ± 9.6 (range, 15–35 min). The technical (performed the procedure successfully without converting to surgery) and clinical (the patient fully recovered after the procedure without experiencing any complications) success rate of the procedure was 100%. Eighteen (24%) patients had very small amount of mucosal damage, and wound closure was not needed in these patients. During 6–24 months of follow-up, no recurrence or metastasis occurred. No adverse event was noted during the follow-up time.

Conclusion

The novel approach of snare-assisted endoscopic resection is simple, feasible, and effective for tumors with small size and originating from the gastric muscularis propria. In addition, it offers a better alternative therapy for the complete resection of small submucosal gastric tumors. Its advantages compared with traditional endoscopic approaches such as endoscopic submucosal resection and endoscopic submucosal dissection include shorter procedure times, lesser cost, and a lower rate of complications (perforation, bleeding, and infection).

Efficacy of endoscopic ultrasound in the evaluation of small gastrointestinal stromal tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs) with a diameter of < 2 cm are called small GISTs. Currently, endoscopic ultrasound (EUS) is widely used as a regular follow-up method for GISTs, which can also provide a preliminary basis for judging the malignancy potential of lesions. However, there are no studies on the accuracy of EUS to assess the malignant potential of small GISTs.

AIM

To evaluate the efficacy of EUS in the diagnosis and risk assessment of small GISTs.

METHODS

We collected data from patients with small GISTs who were admitted to Shengjing Hospital of China Medical University between October 2014 and July 2019. The accurate diagnosis and risk classifications of patients were based on the pathological assessment according to the modified National Institute of Health criteria after endoscopic resection or laparoscopic surgery. Preoperative EUS features (marginal irregularity, cystic changes, homogeneity, ulceration, and strong echogenic foci) were retrospectively analyzed. The assessment results based on EUS features were compared with the pathological features.

RESULTS

A total of 256 patients (69 men and 187 women) were enrolled. Pathological results included 232, 16, 7, and 1 very low-, low-, intermediate-, and high-risk cases, respectively. The most frequent tumor location was the gastric fundus (78.1%), and mitoses were calculated as > 5/50 high power field in 8 (3.1%) patients. Marginal irregularity, ulceration, strong echo foci, and heterogeneity were detected in 1 (0.4%), 2 (0.8%), 22 (8.6%), and 67 (65.1%) patients, respectively. However, cystic changes were not detected. Tumor size was positively correlated with the mitotic index (P < 0.001). Receiver operating curve analysis identified 1.48 cm as the best cut-off value to predict malignant potential (95% confidence interval: 0.824–0.956). EUS heterogeneity with tumor diameters > 1.48 cm was associated with higher risk classification (P < 0.05).

CONCLUSION

Small GISTs (diameters > 1.48 cm) with positive EUS features should receive intensive surveillance or undergo endoscopic surgery. EUS and dissection are efficient diagnostic and therapeutic approaches for small GISTs.

Advances in endoscopic resection techniques of small gastric tumors originating from the muscularis propria

Gastrointestinal stromal tumors are common gastrointestinal tumors typically originating from the muscularis propria layer of the stomach. Small gastric stromal tumors are usually detected incidentally during routine endoscopic examination. Although they may have malignant potentially, controversies remain regarding the need for endoscopic resection of small gastric stromal tumors originating from the muscularis propria. According to the guidelines of the European Society of Medical Oncology, all gastrointestinal stromal tumors >2 cm in size should be resected with endoscopic surveillance recommended for tumors <2 cm. Endoscopic resection including endoscopic mucosal dissection (EMD), endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection and snare assisted endoscopic resection. However, EMD and ESD procedures may be accompanied with serious complications including perforation, bleeding, and abdominal infection. Snare-assisted endoscopic resection is an alternative approach and has the advantages of a shorter procedure time and a low rate of perforation or bleeding. This study summarizes the safety and feasibility of a novel snare-assisted endoscopic resection technique and highlights the pros and cons of the different endoscopic approaches currently used for subepithelia small gastric tumors.

Clinical outcomes of endoscopic treatment for gastric gastrointestinal stromal tumors: a single-center study of 240 cases in China

BACKGROUND AND AIMS

Endoscopic resection (ER) gradually becomes an important treatment method for gastrointestinal stromal tumors (GISTs). The aim of this study is to evaluate the efficacy and safety of ER of gastric GISTs.

METHODS

This retrospective study included 240 patients with gastric GISTs who underwent ER at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 2010 to December 2019. The clinicopathologic, endoscopic and follow-up data of the patients were collected and analyzed.

RESULTS

The mean maximum tumor diameter was 1.67 ± 1.00 cm (range 0.2-6.5 cm), of which 156 cases (65.00%) were small gastric GISTs (tumor diameter < 2 cm). A total of 43 patients (17.92%) had perioperative bleeding, including 40 cases (16.67%) of minor bleeding and three cases (1.25%) of major bleeding. Perioperative perforation occurred in 101 patients (42.08%), of which 51 patients (21.25%) were active perforation and 50 patients (20.83%) were passive perforation. The en bloc resection rate was 97.08% (233/240), and seven cases (2.92%) had piecemeal resection. There were three cases (1.92%) of small gastric GISTs at intermediate risk and one case (0.64%) at high risk. A total of 193 patients were followed up, and no tumor residual, recurrence or metastasis occurred within a median follow-up time of 30 months (range 1-127 months).

CONCLUSIONS

Endoscopic treatment for gastric GISTs is safe and effective. Piecemeal resection does not seem to be related to the patient's prognosis. Endoscopic resection can be performed if patients are willing to remove small gastric GISTs.

Long-term prognosis of small gastric gastrointestinal stromal tumors with high histological grade: a longitudinal nested cohort study

BACKGROUND AND AIMS

Gastrointestinal stromal tumors (GIST) are mostly seen in the stomach. Clinical data on GISTs ≤ 2 cm with > 5 mitosis/50 HPFs are limited. This study aimed to analyze small GISTs with high histological grades to gain a more comprehensive understanding of their clinical characteristics with long-term follow-up.

METHODS

This was a nested cohort study of patients with gastric GISTs ≤ 2 cm and > 5 mitosis/50 HPFs. Individuals with endoscopically resected gastric specimens diagnosed as GISTs between January 2008 and July 2019 were enrolled. We analyzed baseline clinicopathological characteristics, perioperative characteristics, risk of recurrence, and metastasis during follow-up.

RESULTS

A total of 55 patients diagnosed with gastric GISTs ≤ 2 cm and > 5 mitosis/50 HPFs were enrolled. The mean tumor size was 1.6 ± 0.4 cm (median 1.7 cm, range 0.8-2.0 cm). ESD was performed in 33 patients (60.0%) and EFTR in 22 patients (40.0%). Mean mitotic figures were 8.9/50 HPFs. Postoperative bleeding in one patient (1.8%) was the only severe adverse event. The mean follow-up period was 61.2 ± 33.9 months (median 53 months, range 13-133 months). Five patients (5/55, 9.1%) received additional therapies, including partial gastrectomy and adjuvant Imatinib. Only two patients (2/55, 3.6%) showed signs of recurrence. We observed no significant difference regarding baseline clinical characteristics and recurrence among GISTs with mitosis < 10/50 HPF and ≥ 10/50 HPF. No patient had signs of metastasis during follow-up.

CONCLUSION

Endoscopic resection of gastric GISTs ≤ 2 cm with > 5 mitosis/50 HPFs has a low risk of recurrence and metastasis in the long term. Endoscopic resection of GISTs is safe and feasible.

Efficacy and Safety of Endoscopic Resection for Small Gastric Gastrointestinal Stromal Tumors in Elderly Patients

Background

Gastrointestinal stromal tumors (GISTs) are prevalent in elderly patients. Endoscopic resection has become popular for treating small (≤5 cm) gastric GISTs. However, little is known about the outcomes of endoscopic resection in elderly patients.

Aim

To assess the efficacy and safety of endoscopic resection for small (≤5 cm) gastric GISTs in elderly patients (≥65 years old).

Methods

A total of 260 patients (265 lesions) with gastric GISTs treated via endoscopic resection from January 2011 to May 2020 were retrospectively analyzed. Among them, 65 patients were ≥65 years old (elderly group), and 195 patients were <65 years old (nonelderly group). Clinicopathological characteristics, postoperative complications, and tumor recurrence rates between the two age groups were compared.

Results

A total of 260 patients with primary small (≤5 cm) gastric GISTs were treated with endoscopic resection. The median ages of the elderly and nonelderly groups were 68 (range 65-83) years and 55 (range 32-64) years, respectively. Elderly patients showed a higher incidence of comorbidities compared with nonelderly patients (61.5% versus 32.3%s, respectively; p < 0.001). All elderly patients and 99.0% of nonelderly patients underwent en bloc resection; only two nonelderly patients received piecemeal resection. No significant differences were found regarding postoperative complications or tumor recurrence rates between the two groups.

Conclusions

Although elderly patients had more comorbidities than nonelderly patients, both groups had similar postoperative complications and recurrence rates. We suggest that endoscopic resection performed by experienced endoscopists is safe and effective for treating small (≤5 cm) gastric GISTs in elderly patients.

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.

Novel endoscopic management for small gastric submucosal tumors: A single-center experience (with video)

BACKGROUND AND AIMS

To explore the novel treatment of small gastric submucosal tumors (SMTs) originating from the muscularis propria layer (SMT-MPs), we utilized endoscopic band ligation (EBL) with a precut of the covering mucosa.

METHODS

From Jan. 2012 to Dec. 2019, 111 patients with 124 gastric SMT-MPs were treated by precutting EBL. The clinical characteristics, operation duration, postoperative adverse events, and follow-up profiles were retrospectively collected.

RESULTS

A total of 124 tumors from 111 patients were successfully treated by precutting EBL. No adverse events, including perforation and major bleeding, were observed. Furthermore, 93 patients (83.8%) underwent endoscopic surveillance postoperatively, and during the follow-up period, no local recurrence was detected.

CONCLUSIONS

Precutting EBL appears to be a safe and simple method for removing gastric SMT-MPs < 16 mm (mainly indicated for potentially malignant GISTs), but further studies with longer follow-up are needed to assess the radicality of this intervention.

Recent Progress and Challenges in the Diagnosis and Treatment of Gastrointestinal Stromal Tumors

Simple Summary

Gastrointestinal stromal tumors (GIST) are potentially malignant tumors and require evidence-based surgical and/or medical treatment. Laparoscopy has similar safety and prognostic outcomes to those of laparotomy and is currently a standard procedure for localized GISTs. However, surgery for gastric GISTs less than 2 cm may be re-evaluated due to the indolent nature of the GIST and other competing risks among GIST patients. A work-up with endoscopy and endoscopic ultrasonography as well as endoscopic or percutaneous biopsy is important for the preoperative diagnosis of GISTs. Medical treatment with tyrosine kinase inhibitors is the mainstay for recurrent/metastatic GISTs. The activity of an individual drug is well correlated with gene alterations, and, in the era of precision medicine, cancer genome profiling should be considered before medical treatment.

Abstract

Gastrointestinal stromal tumors (GISTs) are the most frequent malignant mesenchymal tumors in the gastrointestinal tract. The clinical incidence of GISTs is estimated 10/million/year; however, the true incidence is complicated by frequent findings of tiny GISTs, of which the natural history is unknown. The initial work-up with endoscopy and endoscopic ultrasonography plays important roles in the differential diagnosis of GISTs. Surgery is the only modality for the permanent cure of localized GISTs. In terms of safety and prognostic outcomes, laparoscopy is similar to laparotomy for GIST treatment, including tumors larger than 5 cm. GIST progression is driven by mutations in KIT or PDGFRA or by other rare gene alterations, all of which are mutually exclusive. Tyrosine kinase inhibitors (TKIs) are the standard therapy for metastatic/recurrent GISTs. Molecular alterations are the most reliable biomarkers for TKIs and for other drugs, such as NTRK inhibitors. The pathological and genetic diagnosis prior to treatment has been challenging; however, a newly developed endoscopic device may be useful for diagnosis. In the era of precision medicine, cancer genome profiling by targeted gene panel analysis may enable potential targeted therapy even for GISTs without KIT or PDGFRA mutations.

Endoscopic submucosal excavation and endoscopic full-thickness resection for gastric schwannoma: five-year experience from a large tertiary center in China

BACKGROUND AND AIMS

Endoscopic resection (ER) is an effective and safe method for gastric submucosal tumors, mostly composed of gastrointestinal stromal tumors and leiomyomas. The role of ER in gastric schwannoma (GS) has rarely been described. Our aim was to evaluate the efficacy and safety of ER for GS.

METHODS

This is a retrospective study in consecutive patients who underwent ER for GS from March 2013 to October 2018 at our center. Clinicopathological, endoscopic, and follow-up data were collected and analyzed.

RESULTS

A total of 16 consecutive patients (9 females, 56.3%) were included, with a mean age of 50.4 years (range 25-75 years). The mean tumor size was 22.9 ± 15.1 mm (range 10-55 mm). Thirteen tumors (81.3%) were located in the middle third of the stomach and 12 tumors (75%) grew with intraluminal pattern. Endoscopic submucosal excavation (ESE) was performed in 7 patients while endoscopic full-thickness resection (EFTR) was done in 9 patients. R0 resection was achieved in 14 patients (87.5%). The mean operative time was 91.6 ± 52.8 min (range 36-203 min) and the mean postoperative length of hospital stays was 8.3 ± 2.7 days (range 6-13 days). No adverse events were encountered except for fevers in 2 patients. No patients required surgical resection or intervention. During long-term follow-up of mean 21.8 months (range 6-62 months), no residue, recurrence, or metastasis was observed.

CONCLUSIONS

ER is effective and safe for patients with GS with favorable long-term outcomes.

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.

Endoscopic full-thickness resection for treating small tumors originating from the muscularis propria in the gastric fundus: An improvement in technique over 15 years

BACKGROUND

The fundus of the stomach is regarded as a difficult area for endoscopic resection of small tumors originating from the muscularis propria (MP tumors). Three endoscopic resection techniques have been developed to treat these tumors, including ligation-assisted endoscopic full-thickness resection (L-EFTR), snare-assisted EFTR (S-EFTR), and endoscopic submucosal dissection-assisted EFTR (E-EFTR). To date, no studies have compared these techniques.

AIM

We aimed to evaluate and compare S-EFTR with L-EFTR and E-EFTR for treating small MP tumors in the gastric fundus.

METHODS

We retrospectively reviewed patients with primary small MP tumors in the gastric fundus and treated by these three techniques between January 2016 and December 2018 at Shengjing Hospital, China. Standard demographic and clinicopathologic data, including sex, age, tumor size, surgeon details, and pathological results, were collected. Data regarding operation duration, cost, en-bloc resection, and severe complications were also extracted and compared.

RESULTS

A total of 36 patients (27 women) with a mean age of 55.8 ± 10.20 years were included in this study. The mean tumor size was 9.0 ± 3.98 mm. All the methods showed a 100% en-bloc resection rate and 0% severe complication rate. There was no statistically significant difference among the three groups in the operation duration (P = 0.148). The cost comparison for the whole procedure was as follows: E-EFTR > L-EFTR > S-EFTR (5837.5 ± 7212.96 CNY, 5970.7 ± 3465.27 CNY, 5852.0 ± 6438.25 CNY, respectively, P < 0.001).

CONCLUSION

S-EFTR, L-EFT, and E-EFTR are all effective for resection of small MP tumors in the gastric fundus. S-EFTR is superior in terms of cost-effectiveness.