Endoscopic resection of gastrointestinal submucosal lesions: a comparison between strip biopsy and aspiration lumpectomy

Clinical outcomes of cap-assisted endoscopic resection for small rectal subepithelial tumors

OBJECTIVE

To assess the effectiveness and safety of cap-assisted endoscopic resection and the usefulness of endoscopic ultrasonography (EUS) for managing small rectal subepithelial tumors (SETs).

PATIENTS AND METHODS

Patients with small rectal SETs≤10mm in diameter were enrolled in this study at our hospital from October 2014 to December 2017. First, EUS was performed to evaluate the lesions. Then, cap-assisted endoscopic resection was performed by suctioning the SET into a transparent cap, ligating with a metal snare and then resecting the tumor. The wound was closed using endoclips if necessary.

RESULTS

Forty patients were enrolled in the study. EUS showed lesions originating from muscularis mucosa or submucosa with an average diameter of 5.4×3.1mm. The en bloc resection rate was 85.0% obtained by cap-assisted endoscopic resection, with a mean total procedure time of 17.6min. No immediate perforation happened. Immediate bleeding occurred in five patients; all cases were managed successfully by endoscopy. No delayed bleeding was observed. Pathology examination showed that 70.0% of the lesions were neuroendocrine tumors (G1). One case of recurrence was seen in follow-up; it was managed successfully by endoscopic submucosal dissection. There was no tumor recurrence in a median follow-up period of 41 months in the remaining 39 patients.

CONCLUSIONS

Most small rectal SETs arising from the muscularis mucosa or submucosa are neuroendocrine tumors and require proper treatment. Cap-assisted endoscopic resection is simple, effective and safe for resecting such lesions, and EUS is useful for case screening.

Bleeding Gastric Lipoma Resected by Endoscopic Submucosal Dissection

Gastric lipomas are slow-growing benign lesions of the stomach that are often detected incidentally. Most cases are asymptomatic but larger lesions may become symptomatic, thereby requiring treatment. Multiple endoscopic modalities have been used for resection in the past. We present the case of a 67-year-old patient who presented with upper GI bleeding secondary to a gastric lipoma, which was successfully resected by endoscopic submucosal dissection.

Giant gastric lipoma presenting as GI bleed: Enucleation or Resection?

INTRODUCTION

Gastric lipomas are unusual benign lesions and account for less than 1% of all tumours of the stomach and 5% of all gastrointestinal lipomas (Thompson et al.2003; Fernandez et al. 1983 [1,2]). Although predominantly asymptomatic and indolent; they may present with gastric outlet obstruction and upper gastrointestinal (GI) bleeding owing to size and ulceration. Only a few cases have been reported, presenting large in size with massive GI bleeding (Alcalde Escribano et al. 1989; Johnson et al. 1981 [3,4]).

PRESENTATION OF CASE

We report the case of a 62-year-old gentleman who presented to the emergency department with massive upper GI hemorrhage. He was initially resuscitated and stabilized. Later gastroscopy showed a large submucosal tumour (Fig. 1). Biopsy revealed adipose tissue. Computed tomography (CT) scan of the abdomen and pelvis showed a huge well defined oval soft tissue lesion measuring about 16×8×8cm. The mass noted a homogenous fat density arising from the posterior wall of stomach with no extramural infiltration (Fig. 2). The tumour was completely enucleated through an explorative gastrotomy incision (Fig. 4).

DISCUSSION AND CONCLUSION

Massive bleeding secondary to a giant gastric lipoma is a rare finding of a rare disease. The majority of cases in the literature result in major gastric resection. Familiarity with its radiological findings and a high index of suspicion can lead to proper diagnosis in the acute setting. If malignancy is carefully ruled out, stomach preserving surgery is an optimal treatment option.

Cap-aspiration lumpectomy for small submucosal tumors originating from the muscularis propria of the gastric fundus: a preliminary study (with videos)

OBJECTIVE

Small fundal submucosal tumors (SMTs) originated from the muscularis propria pose great difficulties to conventional therapies. We aimed to evaluate the feasibility and safety of endoscopic cap-aspiration lumpectomy (CASL) as a new and simple full-thickness resection for the treatment of small fundal SMTs.

METHODS

From July 2013 to February 2014, patients with small fundal SMTs of ≤10 mm in diameter that were originated from muscularis propria were included in the study. CASL was performed by suctioning SMTs into a transparent cap, ligating with a metal snare and resecting the tumors. The wall deficit was closed by using endoclips.

RESULTS

Altogether 28 patients were included in the study. CASL achieved an en bloc resection rate of 100%, with a mean total procedure time of 23.9 min. Active perforation was found in 20 (71.4%) patients, and endoclips closed the wall defect in all 20 cases. One patient developed pneumoperitoneum and self-limited peritonitis was found in two patients, all of whom were managed successfully. Pathological examination showed that 71.4% (20/28) of the tumors were gastrointestinal stromal tumors. No tumor recurrence was observed during the follow-up.

CONCLUSIONS

CASL may be a feasible and safe full-thickness resection modality for the treatment of small fundal SMTs arising from the muscularis propria. Further randomized studies are needed to confirm the results.

Expanding indications for ESD: submucosal disease (SMT/carcinoid tumors)

Endoscopic submucosal dissection (ESD) is useful for submucosal tumors (SMTs) within the superficial submucosal layer, but perforation frequently occurs during ESD for SMTs located at the deeper layer. Endoscopic resection for small esophageal SMTs is acceptable, although candidates for endoscopic removal are rare. Laparoscopic assistance will be effective for minimally invasive endoscopic local resection for certain types of gastric SMT. Endoscopic mucosal resection with a ligation device would be better than ESD for rectal carcinoid in terms of simplicity and effectiveness.

Laparoscopic-Assisted Endoscopic Resection of a Gastric Leiomyoma

Leiomyomas are infrequent benign intestinal tumors that can arise at any age and location within the gastrointestinal (GI) tract. These tumors can cause symptoms including abdominal pain, obstruction, intussusception, volvulus, GI bleeding, or a mass and should be resected if symptomatic. Open surgical resection is considered the standard for removing these tumors. However, recent improvements in endoscopic and laparoscopic equipment have made it possible to utilize minimally invasive techniques of tumor removal including complete endoscopic resection or endoscopic-assisted laparoscopic resection. We present the case of an adolescent female with a large mass located at the gastroesophageal junction (GEJ) causing GI bleeding. Given the location of the mass near the GEJ and the morbidity associated with surgical resection, we performed laparoscopic-assisted complete endoscopic resection of tumor. In addition, this tumor had an unusual immunohistochemical-staining pattern, with focal expression of markers more often seen in GI stromal tumors, elucidating a gray area between these two tumor classes with potential implications for patient follow-up. Laparoscopic-assisted endoscopic resection of benign tumors is a useful technique that can be employed to facilitate resection of mucosal and subserosal masses near the GEJ with minimal morbidity.

Factors associated with complete local excision of small rectal carcinoid tumor

PURPOSE

Although small rectal carcinoid tumors can be treated using local excision, complete resection can be difficult because tumors are located in the submucosal layer. We evaluate the factors associated with pathologically complete local resection of rectal carcinoid tumors.

METHODS

Data were analyzed of 161 patients with 166 rectal carcinoid tumors who underwent local excision with curative intent from January 2001 to December 2010. A pathologically complete resection (P-CR) was defined as an en bloc resection with tumor-free lateral and deep margins. The study classified treatments into three categories for analysis: conventional polypectomy (including strip biopsy, snare polypectomy, and hot biopsy), advanced endoscopic techniques (including endoscopic mucosal resection with cap and endoscopic submucosal dissection), and surgical local excision (including transanal excision and transanal endoscopic microsurgery). We evaluated the P-CR rate according to treatment method, tumor size, initial endoscopic impression and the use of endoscopic ultrasound (EUS) or transrectal ultrasound (TRUS).

RESULTS

The mean tumor size was 5.51 ± 2.43 mm (range 2-18 mm) and all lesions were confined to the submucosal layer. The P-CR rates were 30.9, 72.0, and 81.8 % for conventional polypectomy, advanced endoscopic techniques, and surgical local excision, respectively. Univariate analysis showed that P-CR was associated with treatment method, use of EUS or TRUS, and initial endoscopic impression. Multivariate analysis showed that only treatment method was associated with P-CR.

CONCLUSION

Pathologically complete resection of small rectal carcinoid tumors was more likely to be achieved when using advanced endoscopic techniques or surgical local excision rather than conventional polypectomy.

Endoscopic ultrasonography-guided diagnosis of subepithelial tumors

Subepithelial lesions are frequently discovered during routine endoscopic examinations. These lesions represent a wide spectrum of heterogeneous benign to malignant conditions. Most of these lesions are asymptomatic. There is no consensus regarding how to manage these lesions. Over the last 2 decades, the approach to these lesions has significantly improved owing to the introduction of endoscopic ultrasonography, fine-needle aspiration, immunohistochemical staining methods, and different treatment options. This article discusses the nature of subepithelial lesions, focusing on the most recent developments that use endoscopic ultrasonography to diagnose and manage these lesions.

Endoscopic submucosal dissection (ESD) for gastrointestinal carcinoid tumors

BACKGROUND

Gastrointestinal (GI) carcinoid tumors less than 10 mm in diameter and limited to the submucosal layer demonstrate a low frequency of lymph node and distant metastasis; endoscopic submucosal dissection (ESD) has been used to treat these tumors. However, the number of reported sample cases of rectal carcinoid tumors treated with ESD remains insufficient, and the safety and efficacy of ESD for gastric and duodenal carcinoid tumors have not been elucidated to date.

METHODS

From January 2004 to March 2011, a series of 42 gastrointestinal carcinoid tumors (37 rectal, 2 gastric, and 3 duodenal) in 41 consecutive patients were treated with ESD. Therapeutic efficacy, complications, and follow-up results were retrospectively evaluated.

RESULTS

Sessile type (type Is) was the most prevalent lesion. Mean procedural time was 41 ± 20 min. The mean sizes of tumors and resected specimens were 5 ± 3 mm and 19 ± 7, respectively. The overall rate of en bloc resection was 100% (42/42). Postoperative bleeding occurred in two rectal cases (5%), which were successfully managed with endoscopic clipping. Perforation occurred in two duodenal cases, which could be conservatively managed with medical treatment after endoscopic clipping, and neither laparoscopy nor emergent surgery was needed. No recurrence was observed during the mean follow-up period of 37 months.

CONCLUSIONS

ESD was a safe and effective endoscopic treatment for rectal and gastric carcinoid tumors, although other treatment modalities were desirable for duodenal carcinoid tumors.

Endoscopic treatment of rectal carcinoid tumors

BACKGROUND

Various methods have been reported for the endoscopic treatment of rectal carcinoid tumors. The present study was designed to identify the optimal treatment strategy for an endoscopic resection.

METHODS

Forty rectal carcinoid tumors of 38 patients were treated endoscopically. The indication criteria, complete resection rate, selection of treatment, local recurrence, distant metastases, and complications were analyzed. All tumors were estimated to measure 1 cm or less in diameter, without muscular invasion, atypical features, and lymph node metastases to the pararectal region.

RESULTS

Complete resection of the lesions was obtained in 75.0% (30/40). The complete resection rates were 20.0% (1/5) by conventional polypectomy, 84.6% (22/26) by a two-channel endoscopic mucosal resection, and 77.8% (7/9) by endoscopic submucosal dissection. The 10 cases that did not show a clear submucosal layer after initial endoscopic treatment received additional endoscopic microwave coagulation therapy. There were no local or distant recurrences in the followed-up periods (median, 6.4 years). No difference was observed in the complete resection rate between two-channel endoscopic mucosal resection and endoscopic submucosal dissection.

CONCLUSIONS

Small carcinoid tumors measuring less than 1 cm in diameter can therefore be managed endoscopically with no recurrence or spread. The selection of endoscopic treatment should be made after taking such factors as cost-effectiveness, expertise, and experience into careful consideration.

Endoscopic submucosal dissection and preoperative assessment with endoscopic ultrasonography for the treatment of rectal carcinoid tumors

BACKGROUND

Rectal carcinoid tumors 10 mm in diameter or smaller located within the submucosal layer can be cured by local excision including endoscopic treatment. But complete resection of these tumors with endoscopic polypectomy is difficult. This study aimed to evaluate the usefulness of endoscopic submucosal dissection (ESD) and endoscopic ultrasonography (EUS) for the treatment of rectal carcinoid tumors.

METHODS

In this study, 22 rectal carcinoid tumors in 21 patients were evaluated with EUS and treated using ESD from January 2004 to December 2008.

RESULTS

The mean size of the resected tumors was 6.1 mm (range, 2.0-10 mm) on histopathologic evaluations. When the sizes of the tumors shown by EUS and histopathologic evaluation were compared, the mean values were not significantly different. All the tumors were located within the submucosal layer, and the accuracy of the preoperative depth determination with EUS was 100% (22/22). The mean duration of the ESD procedure was 37 min (range, 20-71 min). The overall rate of en bloc resection with ESD was 100% (22/22). Although postoperative bleeding occurred in two cases (9%), both cases were successfully managed by endoscopic hemostasis. No perforation or recurrence was observed during the mean follow-up period of 30 months (range, 7-66 months).

CONCLUSIONS

Endoscopic submucosal dissection and preoperative assessment with EUS are effective for treating rectal carcinoid tumors and enabling en bloc resection.

Endoscopic mucosal resection for early gastric cancer

BACKGROUND

The treatment of early gastric cancer (EGC) using endoscopy, namely endoscopic mucosal resection (EMR), has been adopted for about 20 years, but the effectiveness and safety of the modality are still controversial. Furthermore, the risk of bias of trials of this technique has not been assessed systematically.

OBJECTIVES

The purpose of this review was to compare the effectiveness and safety of endoscopic mucosal resection with gastrectomy for the treatment of early gastric cancer.

SEARCH STRATEGY

Searches were conducted on the Cochrane Central Register of Controlled Trials (CENTRAL) which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group (UGPD) Trials Register (The Cochrane Library 2005, Issue 1), MEDLINE (1966 to March 2005), EMBASE (1980 to March 2005), CINAHL (1985 to March 2005) and CBM (Chinese BioMedical Database 1982 to 2002). The searches of CENTRAL, MEDLINE and EMBASE were updated in February 2006 and January 2009. Reference lists from trials selected by electronic searching were handsearched to identify further relevant trials. Published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut) and Digestive Disease Week (published in Gastroenterology) were handsearched. Members of the Cochrane UGPD Group, and experts in the field were contacted and asked to provide details of outstanding clinical trials and any relevant unpublished materials.

SELECTION CRITERIA

All randomised controlled trials of early gastric cancer patients involving a treatment arm of EMR and a comparison arm of gastrectomy were to be included, but no RCTs were found.

DATA COLLECTION AND ANALYSIS

Three review authors (YP Wang, C Bennett and T Pan) independently assessed the eligibility of potential trials and extracted the data.

MAIN RESULTS

There were no randomised controlled trials identified for systematic review. Available evidence derived from non-randomised controlled trials is discussed in the main text of this review.

AUTHORS' CONCLUSIONS

There is a lack of randomised controlled trials in which endoscopic mucosal resection (EMR) is compared with gastrectomy for early gastric cancer. There is, therefore, a need for well-designed randomised controlled trials to determine the effects of EMR compared to gastrectomy.

Selection of cap size in endoscopic submucosal resection with cap aspiration for rectal carcinoid tumors

BACKGROUND

Small rectal carcinoid tumors (<or=1 cm in diameter) can be treated by endoscopic resection, but complete resection may be difficult if tumors are located in the deep submucosal layer. This study was performed to identify the clinicopathologic factors affecting the complete resection of small rectal carcinoid tumors, using the endoscopic submucosal resection with cap aspiration technique (ESMR-C).

MATERIALS AND METHODS

Forty-one consecutive patients with 42 rectal carcinoid tumors who underwent ESMR-C from October 2003 to November 2006 were assessed. Complete resection was defined as a clean margin that was free of tumor invasion at the lateral and inferior edges.

RESULTS

The rate of complete tumor removal by ESMR-C was 85.7% and no complications occurred. The tumor size, location, and method of resection did not significantly affect the completeness of resection. Univariate analysis showed that the rate of complete resection was significantly higher when using 19.2-mm, compared with 13.9-mm, caps (96.0 vs. 70.6%; P = 0.032). Multivariate analysis showed that the cap size was an independent factor predicting the completeness of resection.

CONCLUSION

The use of large-sized caps increases the completeness of the resection of rectal carcinoid tumors when using ESMR-C.

Role of EUS and MDCT in the diagnosis of gastric submucosal tumors according to the revised pathologic concept of gastrointestinal stromal tumors

Gastric submucosal tumors (SMTs) consist of various lesions arising from the deep layers of the stomach. Gastrointestinal stromal tumors (GISTs) are undoubtedly the commonest malignant SMTs of the stomach, and therefore the attitude towards the general diagnostic approach for GISTs defines the extended diagnostic plan for SMTs. Two recent consensus meetings were assembled concerning the classification and therapeutic plans for GISTs. These meetings shed light upon the need for the modification of the current role of imaging modalities, including endoscopic ultrasound (EUS) and computed tomography (CT). According to the revised concepts of GISTs, the most important and plausible current role of imaging for the diagnostic approach of gastric SMTs is to differentiate GISTs from other gastric SMTs. This review discusses the newly established diagnostic role of radiology according to the revised classification of GISTs and provides the differential diagnoses based on EUS and CT findings.

Successful outcomes of EMR-L with 3D-EUS for rectal carcinoids compared with historical controls

AIM: To assess the results of endoscopic mucosal resection with a ligation device (EMR-L) combined with three dimensional endoscopic ultrasonography (3D-EUS) using an ultrasonic probe for rectal carcinoids. In addition, diagnosis of the depth and size of lesions by EUS was evaluated.

METHODS: Between January 2003 and March 2007, 20 patients underwent EMR-L with 3D-EUS using an ultrasonic probe (group A). 3D-EUS was combined with EMR-L at the time of injection of sterile physiological saline into the submucosal layer. For comparison, 14 rectal carcinoids that had been treated by EMR-L without 3D-EUS between April 1998 and December 2002 were evaluated as historical controls (group B). EUS was conducted for all of the patients before treatment to evaluate tumor diameter and depth of invasion. The percentage of complete resection and the vertical resection margin were compared between the two groups.

RESULTS: The depth of invasion upon histopathological examination was in complete agreement with the pre-operative findings by EUS. The tumor diameter determined by EUS approximated that found in the tissue samples. There were no significant differences in the gender, tumor sites or tumor diameters between the two groups. The rate of complete resection for groups A and B was 100% and 71%, respectively (P < 0.05). The vertical resection margin of group A was longer than that of group B.

CONCLUSION: EMR-L is effective as an endoscopic treatment for rectal carcinoids. In combination with 3D-EUS, safe and complete resection is further assured.

Subepithelial mass lesions in the upper gastrointestinal tract

The finding of a mass lesion in the upper gastrointestinal tract at endoscopy with apparent normal overlying mucosa is common. The differential diagnosis of such lesions is broad and includes those of intramural or extramural origin. Endoscopic ultrasound provides accurate imaging of subepithelial mass lesions and characterizes them according to size, echogenicity, and origin including the histologic layer if the lesion is intramural which narrows the differential diagnosis. Endoscopic ultrasound allows a guided tissue sample to be obtained for histologic confirmation which is especially important for hypoechoic lesions arising from the 3rd or 4th echogenic layers. The purpose of this article is to review the diagnosis of the more common subepithelial mass lesions with an emphasis on endoscopic ultrasound and the subsequent management or monitoring.

A pilot randomized control study to evaluate endoscopic resection using a ligation device for rectal carcinoid tumors

AIM: Rectal carcinoid tumors smaller than 10 mm can be resected with local excision using endoscopy. In order to remove rectal carcinoid tumors completely, we evaluated endoscopic mucosal resection with a ligation device in this pilot control randomized study.

METHODS: Fifteen patients were diagnosed with rectal carcinoid tumor (less than 10 mm) in our hospital from 1993 to 2002. There were 9 males and 6 females, with a mean age 61.5 years (range, 34-77 years). The patients had no complaints of carcinoid syndrome symptoms. Fifteen patients were randomly divided into 2 groups: 7 carcinoid tumors were treated by conventional endoscopic resection, and 8 carcinoid tumors were treated by endoscopic resection using a ligation device.

RESULTS: All rectal carcinoid tumors were located at the middle to distal rectum. The size of the tumors varied from 3 mm to 10 mm and background characteristics of the patients were not different in the two groups. The rate of complete removal of carcinoid tumors using a ligation device (100%, 8/8) was significantly higher than that of conventional endoscopic resection (57.1%, 4/7). The three patients had tumor involvement of deep margin, for which additional treatment was performed. No complications occurred during or after endoscopic resection using a ligation device. All patients in the both groups were alive during the 3-year observation period.

CONCLUSION: Endoscopic resection using a ligation device is a useful and safe method for resection of small rectal carcinoid tumors.

Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection

BACKGROUND

In most circumstances, subepithelial tumors lack distinct endoscopic and ultrasonographic features. Consequently, definitive diagnosis usually requires tissue acquisition and pathologic confirmation. Establishing a tissue diagnosis is difficult because the yield of forceps biopsies is low. However, prospective data evaluating tissue sampling techniques for subepithelial lesions are currently lacking.

OBJECTIVE

Our purpose was to prospectively determine the diagnostic yield of endoscopic submucosal-mucosal resection (ESMR) compared with forceps biopsy for lesions limited to the submucosa (third endosonographic layer) of the GI tract.

DESIGN

A prospective head-to-head comparison was performed.

SETTING

The study was performed in a tertiary care hospital.

PATIENTS

Study patients were 23 adults with subepithelial lesions limited to the submucosa.

INTERVENTION

All submucosal lesions underwent forceps biopsy followed by endoscopic submucosal resection. Biopsy specimens were obtained with large-capacity "jumbo" forceps. A total of 4 double passes (8 biopsy specimens) were collected from each lesion with use of the bite-on-bite technique. Endoscopic resection was then performed with an electrosurgical snare or cap-fitted endoscopic mucosal resection device.

MAIN OUTCOME MEASUREMENT

The main outcome measurement was the diagnostic yield of biopsy forceps compared with endoscopic submucosal resection.

RESULTS

Twenty-three patients with lesions limited to the submucosa were identified by endoscopic ultrasonography. All lesions underwent forceps biopsy followed by ESMR. The diagnostic yield of the jumbo forceps biopsy was 4 of 23 (17%), whereas the diagnostic yield of ESMR was 20 of 23 (87%) (P = .0001, McNemar test).

CONCLUSION

In the evaluation of subepithelial lesions limited to the submucosa, ESMR has a significantly higher diagnostic yield than jumbo forceps biopsy with use of the bite-on-bite technique.

Endoscopic mucosal resection for early gastric cancer

BACKGROUND

The treatment of early gastric cancer (EGC) using an endoscopy, namely, endoscopic mucosal resection (EMR), has been adopted for about 20 years, but the effectiveness and the safety of the modality are still controversial. The quality of these trials has not been assessed systematically.

OBJECTIVES

The purpose of this review was to compare the effectiveness and the safety of EMR with gastrectomy for the treatment of EGC.

SEARCH STRATEGY

Searches were conducted on the Cochrane Central Register of Controlled Trials - CENTRAL (which includes the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group Trials Register) on The Cochrane Library (Issue 1 2005) MEDLINE (1966 to March 2005) and EMBASE (1980 to March 2005), CINAHL (1985-March 2005) and CBM (Chinese BioMedical Database 1982 -2002). Reference lists from trials selected by electronic searching were handsearched to identify further relevant trials. Published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut) and Digestive Disease Week (published in Gastroenterology) were handsearched. Members of the Cochrane UGPD Group, and experts in the field were contacted and asked to provide details of outstanding clinical trials and any relevant unpublished materials

SELECTION CRITERIA

All randomised controlled trials of EGC patients involving a treatment arm of EMR and a comparison arm of gastrectomy were to be included, but no RCTs were found.

DATA COLLECTION AND ANALYSIS

Three reviewers (YP Wang, C Bennett and T Pan) independently assessed the eligibility of potential trials and extracted the data.

MAIN RESULTS

There are no included randomised control trials for the systematic review. Available evidence derived from non-randomised controlled trials is discussed in the main text of this review.

AUTHORS' CONCLUSIONS

There is a lack of randomised controlled trials in which EMR is compared with gastrectomy for EGC. There is a need for well designed randomised controlled trials to determine the effects of EMR compared to gastrectomy.

Submucosal lesions

Most of the submucosal lesions encountered on endoscopy are benign; however, the fact that some of them may be malignant considerably influences the attitude toward the whole group. This article reviews the current status of endosonography in the management of submucosal lesions and focuses on determining the risk of malignancy. The predictive value of various endoscopic ultrasonography (EUS) features and their combinations and the capabilities and limitations of EUS-guided fine needle biopsy are discussed. Other issues addressed include differentiation between extraluminal compressions and true submucosal lesions, EUS-assisted endoscopic removal of submucosal lesions, and the potential role of catheter-based endosonography in the setting of submucosal lesions. Problems related to the surveillance of patients with submucosal lesions who are not candidates for surgical treatment are outlined. An overview of the recent changes in the pathologic classification of gastrointestinal mesenchymal tumors and their impact on the role of EUS in the management of submucosal lesions is given.

Endoscopic submucosal resection of rectal carcinoid tumors with a ligation device

BACKGROUND

Local endoscopic mucosal resection of rectal carcinoid tumors is often associated with margin involvement that requires further intervention. The efficacy of resection of these tumors with endoscopic submucosal resection with a ligation device (ESMR-L) was evaluated.

METHODS

Fourteen rectal carcinoid tumors were treated by ESMR-L between 1999 and 2002. ESMR-L was performed with a conventional colonoscope with an attached band-ligator device. For comparison, 14 rectal carcinoid tumors, treated by either endoscopic mucosal resection or polypectomy between 1990 and 1997, were evaluated as historical controls. All tumors were estimated to be 1 cm or less in diameter.

OBSERVATIONS

There were no differences between the 2 groups in terms of age, gender, or tumor size. For 6 (43%) patients in the control group, there was tumor involvement at the margin of the resection specimen, whereas all tumors removed by ESMR-L had histopathologically proven negative margins (p < 0.05). The mean vertical resection margin also was significantly deeper in the ESMR-L group (p < 0.05). There was no complication of any procedure.

CONCLUSIONS

ESMR-L is technically simple, minimally invasive, and safe for treatment of small rectal carcinoid tumors contained within the submucosa. ESMR-L provides a deeper resection margin compared with that obtained with conventional endoscopic mucosal resection or polypectomy.

Endoscopic mucosal resection

Endoscopic mucosal resection (EMR), or mucosectomy technique, developed by Japanese endoscopists consists of resecting flat and polypoid neoplasms of the mucosa by longitudinal section through the submucosa. This technique is relatively simple and carries a low morbidity. It represents an important advance for endoscopists in both technical and cancer areas. Compared with the endoscopic methods of tumor destruction (laser, plasma coagulation), EMR presents the advantage of obtaining a complete specimen for histologic analysis.

Granular cell tumors of the colon: report of a case and review of the literature

Granular cell tumors are uncommon, usually benign tumors that can be located anywhere in the body. They commonly occur in the oral cavity and in subcutaneous tissue. In the gastrointestinal tract, granular cell tumors are uncommon and are quite rare in the colon. To date, 55 patients diagnosed with granular cell tumors of the colon have been reported in the literature, only 15 had multiple tumors. We describe the case of a 38-year-old man with a family history of colon cancer who was diagnosed with multiple colonic granular cell tumors after a screening colonoscopy. This seems to be the first report of this type. However, in our patient, the diagnosis of colonic granular cell tumors was incidental and there is no data that correlates adenomas or colorectal cancer with granular cell tumors of the colon. Finally, since granular cell tumors are usually benign, we suggest a conservative approach to patients with multiple granular cell tumors of the colon by means of endoscopic resection and a strict endoscopic follow-up.

Diagnosis of submucosal tumor of the upper GI tract by endoscopic resection

BACKGROUND

Submucosal tumors are frequent findings during endoscopy, although definitive diagnosis based on histologic confirmation presents some difficulties. The aim of this study was to evaluate the efficacy and safety of endoscopic resection based on endoscopic ultrasonography (EUS) findings to reach a definitive diagnosis of submucosal tumor.

METHODS

Fifty-four submucosal tumors of the upper gastrointestinal (GI) tract were included in this study. EUS was performed to determine the layer of origin and location of the lesion and to rule out malignancy. En bloc resection was attempted for lesions originating in the muscularis mucosa or submucosa. For tumors originating in the muscularis propria, we performed partial resection limited to the covering mucosa to expose the lesion and obtained a sample with standard biopsy forceps.

RESULTS

Sufficient samples were obtained in all 54 cases. There was no perforation. Bleeding occurred in only 5 cases (9%) and was easily managed with endoscopic hemostatic methods. EUS and pathologic findings coincided in 74.1% of cases (40 of 54). Benign lesions (leiomyoma, aberrant pancreas, and others) were predominant (52 of 54), although 2 small lesions were confirmed at pathologic study to be malignant (leiomyosarcoma and leiomyoblastoma).

CONCLUSIONS

Endoscopic resection based on EUS findings proved to be an effective and safe method to confirm the histologic diagnosis of submucosal tumor of the upper GI tract. Endoscopic resection should be considered a valuable choice for definitive management of benign submucosal tumors originating in the superficial layers.

Endoscopic Nd:YAG laser therapy for villous adenomas of the right colon

BACKGROUND

Endoscopic laser therapy is considered an acceptable treatment of benign colorectal adenomas. The aim of our study was to evaluate the efficacy of Nd:YAG laser to ablate right-sided colonic sessile adenomas.

METHODS

Between January 1990 and February 1996, 56 patients underwent laser therapy because of high operative risk or refusal of surgery. Lesions were located as follows: cecum (23), ascending, (15), and hepatic flexure (18). Six patients (10.7%) had multiple polyps in the ascending colon. Histologic examination showed a tubulovillous pattern in 20 (35.7%) and a villous pattern in 36 (64.3%). Low-grade dysplasia was detected in 44 patients (78. 5%) and high-grade dysplasia in 12 (21.4%).

RESULTS

The number of laser sessions ranged between 1 and 6 (median 3) and complete ablation, histologically confirmed, was achieved in 49 cases (87.5%). Seven patients (12.5%) underwent surgery: 2 for incomplete tumor destruction, 3 because of invasive carcinoma on repeated biopsies. Two patients (3.6%) had complications (one perforation of the cecum and one hemorrhage). Follow-up ranged from 6 to 60 months and no recurrences were observed.

CONCLUSION

Laser therapy is an effective method for the destruction of sessile adenomas of the right colon in selected patients.