Endoloop ligation of large pedunculated submucosal tumors (with videos)

A retrospective study on the safety, diagnostic yield, and therapeutic effects of endoscopic unroofing for small gastric subepithelial tumors

BACKGROUND AND AIMS

Accurate diagnosis of small gastric subepithelial tumors (SETs) is essential to assess their malignant potential. Endoscopic unroofing has been reported to yield sufficient tissue samples for histologic evaluation. This study aimed to evaluate the safety, diagnostic yield, and potential therapeutic effects of this technique over time.

METHODS

This retrospective analysis of prospectively collected clinical data identified patients who underwent endoscopic unroofing at the Medical University of Vienna from January 2003 to December 2012. Demographic data, indications for endoscopic unroofing, intraprocedural adverse events, hospital stay, histologic results, and follow-up procedures were reviewed.

RESULTS

A total of 14 patients (7 men; 7 women; median age, 70 years; range, 51-95 years) underwent endoscopic unroofing of 14 gastric SETs with a mean diameter of 26 ± 13 mm at EUS. In 9 of 14 cases, endoscopic unroofing was done exclusively for diagnostic purposes; in the remaining cases, it was performed with therapeutic intent because of bleeding from the gastric SETs. Unroofing was technically successful in 13 of 14 cases and revealed 8 cases of GI stromal tumor (GIST) and 1 case each of leiomyoma, fibroid polyp, glomus tumor, pancreatic rest, and nondiagnostic material at histology. Intraprocedural bleeding was the only adverse event (4 cases) and could be managed endoscopically. A follow-up EUS was available (median, 8 months) for 10 of the 14 patients. Notably, most patients showed complete regression of their gastric SETs after unroofing (on white light and EUS), including the glomus tumor, the leiomyoma, and 6 of the 8 cases of GIST.

CONCLUSIONS

Endoscopic unroofing was safe and had a very favorable diagnostic yield in this study. Unexpectedly, it led to complete regression in most gastric SETs. Although it is not an oncologically curative treatment, endoscopic unroofing can be a valuable option to treat local adverse events in patients unfit for surgical therapy. (Clinical trial registration number: NCT02587923.).

Using Forceps Biopsy after Small Submucosal Dissection in the Diagnosis of Gastric Subepithelial Tumors

The current tissue sampling techniques for subepithelial tumors (SETs) of the gastrointestinal (GI) tract have limited diagnostic efficacy. We evaluated the diagnostic yield and safety of forceps biopsies after small endoscopic submucosal dissection (SESD biopsies) in the diagnosis of gastric SETs. A total of 42 patients with gastric SETs > 10 mm were prospectively enrolled between May 2013 and October 2014. A dual knife was used to incise the mucosa and submucosa and forceps biopsies were then introduced deep into the lesion. To compare SESD biopsies with EUS-FNA, we used the retrospective data of 30 EUS-FNA cases. The diagnostic yield of SESD biopsies was comparable to that of EUS-FNA (35/42, 83.3% vs. 24/30, 80.0%, P = 0.717). The mean procedure time of SESD biopsies was shorter than that of EUS-FNA (10 vs. 37 minutes, P < 0.001). There were no procedure-related adverse events in the both group. The pathological diagnoses in SESD biopsies group included 15 leiomyomas, 7 GISTs, 10 heterotopic pancreases, 2 lipomas, and one other lesion. SESD biopsies are an easy, effective and safe technique for the diagnosis of gastric SETs and its diagnostic yield is comparable to that of EUS-FNA. This technique may be a reliable alternative to conventional EUS-FNA (Clinical trial registration No. KCT0000730).

Mechanical Hemostasis Techniques in Nonvariceal Upper Gastrointestinal Bleeding

One of the most important advances in gastroenterology has been the use of endoscopic hemostasis techniques to control nonvariceal upper gastrointestinal bleeding, particularly when high-risk stigmata are present. Several options are available, including injection therapy, sprays/topical agents, electrocautery, and mechanical methods. The method chosen depends on the nature of the lesion and experience of the endoscopist. This article reviews the available mechanical hemostatic modalities.

Endoscopic ligation ("Loop-And-Let-Go") is effective treatment for large colonic lipomas: a prospective validation study

Background

Colonic lipomas (CL) are rare benign adipose tumours usually found incidentally during colonoscopy. Endoscopic resection of symptomatic large CL remains controversial, since significant rates of perforation have been reported. In recent years, a novel technique for removal of large CL has been described, consisting of looping and ligating the lipoma with a nylon snare. The aim of our study was to evaluate the safety and efficacy of the “loop and let go” technique for large colon lipomas in a large case series.

Methods

Consecutive patients referred to our institution for colonoscopy were eligible for the study. The diagnosis of CL was confirmed endoscopically by “pillow” and “naked fat” signs. Following diagnosis, lipomas were looped and ligated by endoloop. Follow-up colonoscopies were scheduled at 1- and 3-months interval.

Results

A total of 11 patients with large CL were enrolled in study. The indications for the colonoscopy included altered bowel habits (7 patients, 64%), screening for colorectal neoplasm (3 pts, 27%) and lower gastrointestinal bleeding (1 pts, 9%). The median lesion size was 3 cm (range 2,5-6 cm). Lesions were located at the hepatic flexure in 4 patients (36%), cecum and ascending colon (4 pts, 36%), rectosigmoid (2 pts, 18%) and transverse colon (1 pts, 9%). There were no immediate and late complications. On follow-up (median follow-up time 11,9 months, range 8–24), there was one small residual lipoma (<1 cm).

Conclusion

The results of this study confirm that “loop-and-let-go” technique is safe and efficacious treatment of large colonic lipomas.

Suck-ligate-unroof-biopsy by using a detachable 20-mm loop for the diagnosis and therapy of small subepithelial tumors (with video)

BACKGROUND

The diagnosis and therapy of subepithelial tumors (SETs) can be challenging.

OBJECTIVE

Proof-of-concept evaluation of the suck-ligate-unroof-biopsy (SLUB) technique for small (<2 cm), non-pedunculated SETs.

DESIGN

Pilot feasibility study.

SETTING

Tertiary-care referral center.

PATIENTS

Twenty-three patients (median age 60 years) meeting the inclusion criteria after preliminary EUS.

INTERVENTION

SET ligation was performed with a detachable 20-mm loop deployed through an 18-mm diameter, soft, oblique, transparent, cap attachment. The SLUB technique comprised (1) suction to draw the SET into the cap; (2) ligation below the SET, confirmation by repeat EUS; (3) unroofing of the overlying mucosa with a needle-knife; and (4) biopsy specimens taken from the exposed tumor.

MAIN OUTCOME MEASUREMENTS

Technical success, histology and/or immunohistochemistry yield, adverse events, completeness of resection.

RESULTS

SLUB was attempted on 24 SETs and was technically successful in all. Location was the stomach (n = 19), small bowel (n = 1), colon (n = 2), and rectum (n = 2). Median size by EUS was 10 mm (range 6-15 mm). Biopsy specimens provided an immunohistologic diagnosis in all cases: GI stromal tumor (n = 5), leiomyoma (n = 8), carcinoid tumor (n = 5), Vanek's tumor (n = 2), granuloma (n =1), and pancreatic heterotopia (n = 3). Follow-up endoscopy and EUS in 13 patients showed well-healed scars with no residual tumor, including all 9 patients with premalignant neoplastic lesions. The only adverse event was self-limited pain in 2 patients.

LIMITATIONS

Single center, single operator, small sample size.

CONCLUSIONS

Loop ligation of small, non-pedunculated SETs is feasible by using a cap attachment for suction. Unroofing after ligation is safe and provides sufficient tissue for immunohistochemistry. Ligation combined with unroofing appears to lead to complete ablation by ischemia and tumor enucleation.

Selective endoscopic ligation for treatment of upper gastrointestinal protuberant lesions

This study explored the clinical value of endoscopic ligation for the treatment of upper gastrointestinal (GI) protuberant lesions in children. According to the appearance and size of lesions, we used different ligation techniques for the treatment of the lesions. Endoscopic ultrasonography was used for preliminary characterization of the lesions. One case diagnosed with Peutz-Jeghers syndrome was successfully treated by a detachable snare. Two cases with semi-pedunculated or broad-base lesions originating from the submucosal layer of the upper GI were treated with endoscopic variceal ligation; endoscopic examination showed that one case had complete healing 11 wk after ligation, while an ulcer scar was observed at the ligation site after 6 wk in the other case. All lesions were successfully ligated at the first attempt. No significant complications occurred either during or after the procedure. Selective endoscopic ligation of upper GI lesions is an effective and safe treatment for upper GI protuberant lesions in children.

Retract-ligate-unroof-biopsy: a novel approach to the diagnosis and therapy of large nonpedunculated stromal tumors (with video)

BACKGROUND

We report a novel technique of retract-ligate-unroof-biopsy (RLUB) for the diagnosis and treatment of large nonpedunculated upper GI stromal tumors originating from the muscularis propria.

OBJECTIVE

Proof-of-concept evaluation of the RLUB technique.

DESIGN

Pilot and feasibility study.

SETTING

Tertiary care center.

PATIENTS

Sixteen patients (median age 71 years) fulfilling the following inclusion criteria: poor surgical candidates with lesions that are broad based with a benign appearance, originating from the muscularis propria, size 2 cm or larger.

INTERVENTIONS

A double-channel endoscope was used to simultaneously retract the stromal tumor while advancing an endoloop beyond the tumor for ligation. The overlying tissue was incised ("unroofed") to expose and partially enucleate the tumor, and multiple biopsy samples were obtained. After unroofing, an additional endoloop was placed below the previous one by using the loop-over-loop technique to reinforce enucleation and ischemic ablation.

MAIN OUTCOME MEASUREMENTS

Successful ligation, immunohistochemistry and mitotic index yield, therapeutic ablation, adverse events.

RESULTS

Technical success was achieved in 13 of 16 patients (81%). Immunohistology of biopsy specimens: GI stromal tumor (n = 10), leiomyoma (n = 3). Twelve of 13 patients (92%) with follow-up (median 22 weeks, range 1-82.5 weeks) had confirmed tumor ablation by endoscopy and EUS. One patient with partial resolution was re-treated, but was subsequently lost to follow-up. Delayed bleeding occurred in 2 patients that required hospitalization and blood transfusions, both successfully controlled with repeat endolooping. One patient reported transient pain.

LIMITATIONS

Single center, single operator, small sample size.

CONCLUSIONS

The RLUB technique is feasible as a platform for full-thickness treatment of stromal tumors. Limitations encountered included technical challenges and delayed bleeding. Further developmental work is needed.

EUS for choosing best endoscopic treatment of mesenchymal tumors of upper gastrointestinal tract

AIM: To evaluate the value of endoscopic ultrasonography (EUS) in the choice of endoscopic therapy strategies for mesenchymal tumors of the upper gastrointestinal tract.

METHODS: From July 2004 to September 2010, 1050 patients with upper gastrointestinal mesenchymal tumors (GIMTs) were diagnosed using EUS. Among them, 201 patients underwent different endoscopic therapies based on the deriving layers, growth patterns and lesion sizes.

RESULTS: Using EUS, we found 543 leiomyomas and 507 stromal tumors. One hundred and thirty-three leiomyomas and 24 stromal tumors were treated by snare electrosection, 6 leiomyomas and 20 stromal tumors were treated by endoloop, 10 stromal tumors were treated by endoscopic mucosal resection and 8 stromal tumors were treated by endoscopic submucosal dissection. Complete resection of the lesion was achieved in all cases. Of the mesenchymal tumors, 90.38% diagnosed by EUS were also identified by pathohistology. All wounds were closed up nicely and no recurrence was found in the follow-up after 2 mo.

CONCLUSION: EUS is an effective means of diagnosis for upper GIMTs and is an important tool in choosing the endoscopic therapy for GIMTs, by which the lesions can be treated safely and effectively.

Endoscopic ligation and resection for the treatment of small EUS-suspected gastric GI stromal tumors

BACKGROUND

GI stromal tumors (GISTs), with their potential for malignant transformation, are usually treated by surgical intervention. Endoscopic treatment remains controversial.

OBJECTIVE

The aim of this study was to investigate clinical outcomes associated with use of endoscopic ligation and resection for diagnosis and treatment of small EUS-suspected gastric GISTs.

DESIGN

Prospective case series.

SETTING

Academic medical center.

PATIENTS

Eight patients with submucosal gastric tumors <2 cm in diameter suspected to be GISTs.

INTERVENTIONS

Endoscopic ligation and resection.

MAIN OUTCOME MEASUREMENTS

Clinical/technical feasibility, success, and adverse events.

RESULTS

Seven patients with small EUS-suspected gastric GISTs were successfully treated by endoscopic ligation, with sloughing of residual tissue within 1 month. All were diagnosed pathologically with GISTs of low malignant potential. One additional patient required a second ligation to remove residual tumor, also diagnosed as a GIST with low malignant potential. No perforation, massive hemorrhage, or other complication requiring endoscopic or surgical intervention occurred.

LIMITATIONS

Small number of patients (n = 8) and limited follow-up; risk of microscopically positive margins, which limits application to lesions strongly suspected to be benign.

CONCLUSIONS

Endoscopic ligation and resection shows promise as a safe and feasible technique to treat small EUS-suspected gastric GISTs. Controlled clinical trials with more subjects and longer follow-up are needed to confirm the value and limitations of this method.