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

Utility and advantage of the unroofing technique for gastrointestinal subepithelial tumors: A multicenter retrospective cohort study

Background and aim

Various techniques for direct biopsy from gastrointestinal subepithelial tumors (SETs) have been reported, although no standard method has been established. A common feature of these techniques is the removal of overlaying mucosa to enable direct biopsies from the SETs. These methods have been synthesized under the collective term "unroofing technique". We conducted a multicenter retrospective study to assess its efficacy and identify potential complications.

Methods

This study was conducted in 10 hospitals and involved all eligible patients who underwent unroofing techniques to obtain biopsies for gastrointestinal SETs between April 2015 and March 2021. The primary endpoint was the diagnostic accuracy of the unroofing technique, and the secondary endpoints were the incidence of adverse events and the factors contributing to the accurate diagnosis.

Results

The study included 61 patients with 61 gastrointestinal SETs. The median tumor size was 20 mm, and the median procedure time was 38 min, with 82% successful tumor exposure. The rate of pathological diagnosis was 72.1%. In 44 patients with a pathological diagnosis, two showed discrepancies with the postresection pathological diagnosis. No factors, including facility experience, organ, tumor size, or tumor exposure, significantly affected the diagnostic accuracy. There was one case of delayed bleeding and two cases of perforation.

Conclusion

The diagnostic yield of the unroofing technique was acceptable. The unroofing technique was beneficial regardless of institutional experience, organ, tumor size, or actual tumor exposure.

Natural Course of Asymptomatic Upper Gastrointestinal Subepithelial Lesion of 2 cm or Less in Size

There is limited evidence of a natural course of an upper gastrointestinal (UGI)-subepithelial lesion (SEL) of 2 cm or less in size. This study aims to determine the natural course of UGI-SELs and find the risk factors of the endoscopic and endoscopic ultrasonography (EUS) findings associated with an increase in size. The medical records of 2539 patients with UGI-SELs between 2004 and 2016 were reviewed retrospectively. A total of 672 SELs of 2 cm or less in size were analyzed through EUS and followed up for at least 36 months. The mean follow-up duration was 68 months (range: 36-190 months), and 97 SELs (14.4%) showed an increase in size with a mean increase rate of 1.2 mm/year. Initial size (aOR 1.03, 95% confidence interval (CI) 1.01-1.06), an endoscopic finding of a hemorrhagic spot (aOR 3.13, 95% CI 1.14-8.60), and an EUS finding of a lesion in the fourth layer (aOR 1.87, 95% CI (1.21-2.88) were related to an increase in size. An endoscopic finding of translucidity (aOR 0.28, 95% CI (0.10-0.76) and an EUS finding of calcification (aOR 0.30, 95% CI 0.09-0.95) were inversely related to an increase in size. There was no death related to UGI-SELs during the follow-up. While most UGI-SELs of 2 cm or less in size showed no significant size change and favorable prognosis, an individualized follow-up strategy needs to be considered in case of the presence of hemorrhagic spots and lesions in the fourth layer.

Endoscopic Resection of Upper Gastrointestinal Subepithelial Tumours: Our Clinical Experience and Results

Upper gastrointestinal subepithelial tumours (SETs) are generally asymptomatic and clinically insignificant and have malign, borderline and benign variants. In advanced endoscopic procedures, histopathological diagnosis and endoscopic resection are possible and feasible. In this study, we examined our approach to upper gastrointestinal subepithelial tumours and our clinical results. Adult patients who applied to Surgical Endoscopy unit between January 2014 and January 2015 were included in the study. The patients' files and final histopathological diagnoses were recorded and analysed retrospectively for this single-center study. SET lesion lower than 30 mm and the lesion whose endoscopic submucosal dissection attemption was included in the study. The total of 8 patients were four female (50%) and four male (50%), aged 31-66 years (median, 53 years). The tumoral lesions were located 4 (50%) patients in esophagus, 3 (37.5%) patients in stomach and one (12.5%) patient in duodenum and their diameter ranged from 5 to 30 mm (median, 14 mm). Post-interventional no complications or abdominal symptoms were encountered. Also, in early follow-ups for six months, no recurrence was observed. Our experiences together with literature reported here, indicated endoscopic resection is a safe and effective method of treatment for most patients with upper gastrointestinal SETs.

A modified endoscopic full thickness resection for gastric subepithelial tumors from muscularis propria layer: Novel method

BACKGROUND AND AIM

The removal of subepithelial tumors (SETs) is challenging, particularly in tumors originating from the muscularis propria (MP) in the upper gastrointestinal (GI) tract, owing to the high risk of perforation. We developed mechanical spray lumpectomy (MSL), which is a novel method to safely and easily remove the tumor. This study aimed to evaluate the feasibility and safety of MSL as a novel endoscopic treatment for gastric subepithelial lesions.

METHODS

We performed MSL in a total of 13 patients with upper GI SETs originating from the MP layer. First, mucosectomy was performed using a conventional snare. Repeated injections were performed towards the subserosal layer. After injection, the lesion was mechanically pushed to separate the MP layer using an endoscopic cap. Finally, the mucosa, submucosa, and MP layer with SETs were completely dissected using the spray coagulation mode, and the remaining defect was closed with clipping.

RESULTS

All tumors were completely resected. The mean procedure time was 84.38 ± 41.73 min. There were four leiomyomas, six GI stromal tumors, one mucosa-associated lymphoid tissue lymphoma, and two ectopic pancreases. Although small perforation occurred in only one case, the defect was successfully closed using hemostatic clipping. Moreover, no serious complications related to MSL were encountered during or after the procedure. No residual lesion or recurrence was observed during the follow-up period.

CONCLUSIONS

Mechanical spray lumpectomy can be a novel method that provides a safe and minimally invasive endoscopic treatment for upper GI SETs originating from the MP layer.

Endoscopic and Endosonographic Features of Histologically Proven Gastric Ectopic Pancreas by Endoscopic Resection

Backgrounds/Aims

Distinguishing gastric ectopic pancreas (GEP) from malignant tumors is relatively difficult. This study evaluated the endosonography findings of pathologically proven GEP.

Methods

Thirty-one patients diagnosed with GEP based on a histopathological analysis from January 2004 to July 2018 were enrolled in this study. All patients underwent EUS and an endoscopic resection.

Results

Seventeen patients were female, and the median age was 41.1 years (range, 14-74). The lesions were localized most commonly in the antrum. The mean size of the GEP was 10.6 mm (range, 7-15). Superficial type lesions, lesions with heterogeneous echogenicity, mixed pattern lesions, and lesions with indistinct borders were commonly observed on EUS. Calcification, anechoic duct-like structures, and thickening of the muscularis propria were observed in some patients. Endoscopic mucosal resection (41.9%) and endoscopic submucosal dissection (58.1%) were performed. The mean procedure time was 22.5 minutes. Complete resection was achieved for 71% of patients. No statistically significant results between the endosonography findings and complete resection rates were obtained. The mean follow-up esophagogastroduodenoscopy duration was 4.5 months. None of the patients presented with residual lesions on subsequent endoscopy.

Conclusions

EUS can help identify the features of GEP. Careful observations of the EUS findings can avoid unnecessary removal of GEP.

Current Status of Endoscopic Resection of Gastric Subepithelial Tumors

Most gastrointestinal (GI) subepithelial tumors (SETs) are identified incidentally during endoscopic examination and are located in the stomach. Some SETs are malignant or have the potential to become malignant. Tumors originating from deeper layers, such as the muscularis propria or serosa, are not easy to diagnose and resect. Current guidelines recommend yearly endoscopic surveillance of SETs smaller than 2 cm. This recommendation may not be cost-effective in managing GI SETs. Endoscopic resection results not only in obtaining sufficient tissue for pathological diagnosis but also in resection and curing the tumor. Many different endoscopic methods for resection of GI SETs have been published in the literature. To avoid confusion, we have divided these methods into standard endoscopic submucosal dissection, modified endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and nonexposed and exposed endoscopic full-thickness resection. These procedures offer less invasive approaches than surgery for resection of GI SETs and may be the most cost-effective in taking care of patients with GI SETs.

Endoscopic Treatment of Subepithelial Tumors

Gastrointestinal subepithelial tumors (SETs) are generally found during endoscopy and their incidence has gradually increased. Although the indications for the endoscopic treatment of patients with SETs remain to be established, the feasibility and safety of endoscopic dissection, including the advantages of this method compared with surgical treatment, have been validated in many studies. The development of endoscopic techniques, such as endoscopic submucosal dissection, endoscopic enucleation, endoscopic excavation, endoscopic submucosal tunnel dissection, submucosal tunnel endoscopic resection, and endoscopic full-thickness resection has enabled the removal of SETs while reducing the occurrence of complications. Here, we discuss the endoscopic treatment of patients with SETs, outcomes for endoscopic treatment, and procedure-related complications. We also consider the advantages and disadvantages of the various endoscopic techniques.

Endoscopic submucosal resection of gastric subepithelial lesions smaller than 20 mm: a comparison of saline solution-assisted snare and cap band mucosectomy techniques

BACKGROUND AND AIMS

Application of endoscopic submucosal resection (ESMR) in the management of gastric subepithelial lesions (GSLs) less than 20 mm is gradually increasing because it allows diagnosis and treatment at the same operative session. In this study, we compare and evaluate the benefits of ESMR with an endoscopic cap band mucosectomy technique or saline solution-assisted snare technique in GSLs smaller than 20 mm.

METHODS

This was a retrospective analysis of a prospectively maintained database used at 2 academic tertiary care centers. A total of 63 patients (34 females, mean age 52 years) with endoscopically resected GSLs were included in this study.

RESULTS

The mean tumor size determined by EUS was 12.3 mm (range, 5-20 mm). Sixty-seven percent of the GSLs were localized in the antrum in all groups. The endoscopic cap band mucosectomy technique was used to resect 32 (50.8%) GSLs, whereas 31 (49.2%) were resected with the saline solution-assisted snare technique. The en bloc resection rates were 97% for the saline solution-assisted snare technique and 100% for the endoscopic cap band mucosectomy. Intraoperative bleeding occurred in 1 of 31 patients (3.2%) when ESMR was performed with the saline solution-assisted snare technique. Postoperative bleeding was seen in 1 of 32 patients (3.1%) who underwent the endoscopic cap band mucosectomy technique.

CONCLUSIONS

In GSLs smaller than 20 mm, ESMR with saline solution-assisted snare or endoscopic cap band mucosectomy techniques is safe, the adverse event rate is low, accurate diagnosis is achieved, and treatment with en bloc resection is provided in a single session. Given similar success and adverse event rates, saline solution-assisted ESMR may be the preferred technique because of its lower cost advantages.

Endoscopic submucosal dissection of gastric subepithelial tumors: a systematic review and meta-analysis

BACKGROUND/AIMS

To evaluate the therapeutic outcomes of the endoscopic submucosal dissection (ESD) technique for the treatment of gastric subepithelial tumors (SETs).

METHODS

A systematic literature review was conducted using the core databases. Data on the complete resection rates and the procedure-related perforation rates were extracted and analyzed. A random effects model was then applied for this meta-analysis.

RESULTS

In all, 288 patients with 290 SETs were enrolled from nine studies (44 SETs originated from the submucosal layer; 246 SETs originated from the muscularis propria layer). The mean diameter of the lesions ranged from 17.99 to 38 mm. Overall, the pooled complete resection rate was estimated to be 86.2% (95% confidence interval [CI], 78.9 to 91.3). If the analysis was limited to the lesions that originated from the submucosal layer, the pooled complete resection rate was 91.4% (95% CI, 77.9 to 97). If the analysis was limited to the lesions that originated from the muscularis propria, the pooled complete resection rate was 84.4% (95% CI, 78.7 to 88.8). The pooled procedure-related gastric perforation rate was 13% (95% CI, 9.4 to 17.6). Sensitivity analyses showed consistent results. Finally, publication bias was not detected.

CONCLUSIONS

ESD, including endoscopic muscularis dissection, is a technically feasible procedure for the treatment of SETs. However, selection bias is suspected from the enrolled studies. For the development of a proper indication of ESD for SETs, further studies are needed.

A New Method for Endoscopic Sampling of Submucosal Tissue in the Gastrointestinal Tract: A Comparison of the Biopsy Forceps and a New Drill Instrument

Background Sampling of submucosal lesions in the gastrointestinal tract through a flexible endoscope is a well-recognized clinical problem. One technique often used is endoscopic ultrasound-guided fine-needle aspiration, but it does not provide solid tissue biopsies with preserved architecture for histopathological evaluation. To obtain solid tissue biopsies from submucosal lesions, we have constructed a new endoscopic biopsy tool and compared it in a crossover study with the standard double cupped forceps. Methods Ten patients with endoscopically verified submucosal lesions were sampled. The endoscopist selected the position for the biopsies and used the instrument selected by randomization. After a biopsy was harvested, the endoscopist chose the next site for a biopsy and again used the instrument picked by randomization. A total of 6 biopsies, 3 with the forceps and 3 with the drill instrument, were collected in every patient. Results The drill instrument resulted in larger total size biopsies (mm²; Mann-Whitney U test, P = .048) and larger submucosal part (%) of the biopsies (Mann-Whitney U test, P = .003) than the forceps. Two patients were observed because of chest pain and suspicion of bleeding in 24 hours. No therapeutic measures were necessary to be taken. Conclusion The new drill instrument for flexible endoscopy can safely deliver submucosal tissue samples from submucosal lesions in the upper gastrointestinal tract.

Endoscopic ultrasonography of duodenal aberrant pancreas: comparison with histology after endoscopic resection

We present the case of a 45-year-old man with an aberrant pancreas in the duodenum. He was referred to our hospital for gastric cancer screening. On upper gastrointestinal endoscopy, a submucosal tumor was noted in the second portion of the duodenum; it was 10 mm in diameter, with a smooth surface and bridging fold. Endoscopic ultrasonography (EUS) showed a hypoechoic lesion with small anechoic areas located in the third sonographic layer of the duodenum wall. To confirm the exact diagnosis, endoscopic resection was performed. The histological diagnosis was aberrant pancreas, Heinrich type II. The hypoechoic lesion and anechoic areas on EUS findings clearly corresponded with pancreatic acinus cells and duct dilation on histological findings, respectively. EUS findings are useful to diagnosis a duodenal aberrant pancreas that has ductal structures.

Gastric heterotopic pancreas masquerading as a stromal tumor: A case report

Heterotopic pancreas (HP), a rare condition that is generally asymptomatic, is an aberration in the developmental profile of the pancreas. While it can occur in any location in the gastrointestinal tract, it is most typically found in the antrum of the stomach and is usually wrongly considered to be a submucosal tumor (SMT). Despite advances in diagnostic modalities, a HP still poses a diagnostic dilemma to clinicians. Invasive surgery or endoscopic resection have often been inappropriately applied in cases of an ectopic pancreas due to the difficulty in distinguishing it from neoplastic SMTs, such as gastrointestinal stromal tumors (GISTs). The present study reports the unusual case of a middle-aged female with an SMT at the lesser curve of the mid-body of the stomach, which was initially diagnosed as a GIST through endoscopic ultrasonography and computed tomography. However, following removal by endoscopic submucosal dissection, this lesion was finally histopathologically confirmed as an HP. Therefore, although it is rare, the possibility of an HP should always be considered when diagnosing an extramucosal gastric mass. The precise pre-operative diagnosis of this entity may avoid unnecessary extensive treatment intervention.

Forward-viewing versus oblique-viewing echoendoscopes in the diagnosis of upper GI subepithelial lesions with EUS-guided FNA: a prospective, randomized, crossover study

BACKGROUND

The role of the forward-viewing echoendoscope compared with the oblique-viewing echoendoscope for EUS-guided FNA (EUS-FNA) of upper GI subepithelial lesions has not been defined.

OBJECTIVE

To compare the diagnostic yield and clinical efficacy of EUS-FNA by using the 2 echoendoscopes in the same upper GI subepithelial lesion.

DESIGN

Prospective, randomized, crossover study.

SETTING

Tertiary-care medical center.

PATIENTS

Forty-one patients with an upper GI subepithelial lesion.

INTERVENTIONS

All patients first underwent EUS-FNA with a 19-gauge needle by using both echoendoscopes, based on random selection. When required, 22-gauge or 25-gauge needles were used additionally.

MAIN OUTCOME MEASUREMENTS

Comparison of diagnostic yield, tissue sample area, puncture success rates, procedure time, and adverse events.

RESULTS

Forty-one patients (median lesion size 22 mm, range 15-63 mm) were enrolled. Rates of histologic diagnosis were 80.5% (33/41) and 73.2% (30/41) (P=.453) by using forward-viewing and oblique-viewing echoendoscopes, respectively. Median tissue sample area in GI stromal tumors (n=22) obtained with the forward-viewing echoendoscope was larger than with the oblique-viewing echoendoscope (2.46 mm2 vs 1.00 mm2; P=.046). Puncture success rates were 39 of 41 (95.1%) and 35 of 41 (85.4%; P=.289) with forward-viewing and oblique-viewing echoendoscopes, respectively. Median procedure time was 21 minutes with the forward-viewing echoendoscope and 27 minutes with the oblique-viewing echoendoscope (P=.009). An infectious adverse event occurred in a patient and was treated with antibiotics.

LIMITATIONS

Small sample size.

CONCLUSION

Diagnostic yield did not differ between the 2 echoendoscopes. However, tissue sample area and procedure time were superior with the forward-viewing echoendoscope.

[Diagnosis and immediate results of treatment of patients with non-epithelial tumors of upper gastrointestinal tract]

We presented an experience of treatment of 225 patients with non-epithelial tumors of upper gastrointestinal tract. Complicated disease's course was observed in 24% of cases. Tactical approaches are discussed depending on localization, dimensions and nature of tumor growth. Also indications for minimally invasive operations are defined. It was operated 102 (45.3%) of above-mentioned patients. Conventional surgical interventions were performed in 49 (48.0%) cases, laparoscopic operations - in 11 (10.8%) observations, endoscopic techniques using flexible endoscope - in 42 (41.2%) patients. One hundred and twenty-three (54.7%) patients were under dynamic observation. Technical features of the performed operations are described in the article. Complications were diagnosed in 8 patients including intraoperative in 3 cases and postoperative in 5 cases. Postoperative mortality was 2.0% (2 of 102 died). Overall mortality was 1.3% (3 of 225 patients died). Gastrointestinal stromal tumor (38) and leiomyoma (29) were the most frequent findings among removed tumors.

Gastric duplication cysts in adults: a report of three cases

Gastric duplication cyst is a rare congenital anomaly of the gastrointestinal tract and is especially uncommon in adults. Most cases in adults are discovered incidentally on radiological examination or gastric endoscopy. Accurate diagnosis of these cysts before resection is difficult. Differential diagnoses are varied. Malignant transformation of a gastric duplication cyst is very rare. We present three cases of asymptomatic noncommunicating gastric duplication cysts in adults.

Ectopic pancreas in the stomach successfully resected by endoscopic submucosal dissection

A 32-year-old Japanese man presented with a gastric submucosal tumor. Esophagogastroduodenoscopy showed a sessile submucosal tumor measuring approximately 10 mm in diameter on the greater curvature of the gastric antrum. Endoscopic ultrasonography examination revealed a solid tumor with a diameter of 11.8 mm, which was located in the deep mucosal and submucosal layers. The internal echogenicity was homogenous and hypoechoic. Biopsy examinations were performed twice but were not diagnostic since only the intact mucosal layer was obtained. The patient was subsequently diagnosed with ectopic pancreas in the stomach by endoscopic submucosal dissection (ESD). This case underscores the usefulness of the ESD technique for the pathological diagnosis of gastric submucosal tumors.

Feasibility and safety of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors, including esophagogastric junction tumors

BACKGROUND AND AIM

Recently, the use of endoscopic submucosal dissection (ESD) for gastric submucosal tumor (gSMT) and the development of laparoscopic and endoscopic cooperative surgery (LECS) have enabled either preservation of the stomach or minimization of the extent of partial resection. In the present study, the outcomes following the recent introduction of LECS for gSMT are presented. The aim of this retrospective study was to evaluate the feasibility and safety of LECS for gSMT, including esophagogastric junction (EGJ) SMT.

METHODS

LECS is indicated for lesions that have an intragastric growth pattern, or for which fundusectomy can be avoided despite an extragastric growth pattern. We retrospectively evaluated the outcome of LECS carried out in 25 patients including five EGJ SMT.

RESULTS

Surgery was completed achieving an R0 resection rate of 100% with no postoperative complications. Mean tumor size was 32.3 ± 13.5 mm and mean resected specimen size was 37.6 ± 13.5 mm. Resection margins were tumor-free in all cases, with adequate minimum surgical margins, and precise conclusive diagnosis was achieved with perfect operative specimens. Endoscopic confirmation of the EGJ enabled the extent of resection to be minimized and the stomach to be preserved, avoiding fundusectomy. Although there were significant differences in tumor size and resected specimen size between EGJ SMT and non-EGJ SMT, there were no significant differences in outcomes of the LECS procedure.

CONCLUSION

LECS is feasible and safe for cases with gSMT including lesions adjacent to the EGJ.

When to puncture, when not to puncture: Submucosal tumors

Subepithelial masses of the gastrointestinal (GI) tract are a frequent source of referral for endosonographic evaluation. Subepithelial tumors most often appear as protuberances in the GI tract with normal overlying mucosa. When there is a need to obtain a sample of the mass for diagnosis, endoscopic ultrasound (EUS) - guided fine-needle aspiration (FNA) is superior to other studies and should be the first choice to investigate any subepithelial lesion. When the decision is made to perform EUS-guided FNA several technical factors must be considered. The type and size of the needle chosen can affect diagnostic accuracy, adequacy of sample size and number of passes needed. The use of a stylet or suction and a fanning or standard technique during EUS-guided FNA are other factors that must be considered. Another method proposed to improve the efficacy of EUS-guided FNA is having an on-site cytopathologist or cytotechnician. Large or well-differentiated tumors may be more difficult to diagnose by standard EUS-FNA and the use of a biopsy needle can be used to acquire a histopathology sample. This can allow preservation of tissue architecture and cellularity of the lesion and may lead to a more definitive diagnosis. Alternatives to FNA such as taking bite-on-bite samples and endoscopic submucosal resection (ESMR) have been studied. Comparison of these two techniques found that ESMR has a significantly higher diagnostic yield. Most complications associated with EUS-FNA such as perforation, infection and pancreatitis are rare and the severity and incidence of these adverse events is not known. Controversy exists as to the optimal method in which to perform EUS-FNA and larger prospective trials are needed.

Endoscopic removal of symptomatic gastric heterotopic pancreas: a report of nine cases

AIMS

The aim of this study was to evaluate the efficacy and safety of endoscopic removal of symptomatic gastric heterotopic pancreas (HP).

PATIENTS AND METHODS

From January 2010 to December 2011, 9 patients with suspected symptomatic HP were enrolled in the study. Endoscopic ultrasonography was performed to clarify the HP tissue location and to choose the endoscopic resection method. Endoscopic mucosal resection or endoscopic submucosal dissection was performed to remove the HP tissue. Symptoms in the enrolled patients were assessed before and after endoscopic removal of the HP tissue. Tumor pathology and complications were recorded after the treatment. A standard follow-up was scheduled at 1 week and 2 months after treatment.

RESULTS

Removal of suspected HP with endoscopic mucosal resection or endoscopic submucosal dissection was successful in all 9 cases. Abdominal pain, leukocytosis, and bleeding occurred in 6 patients, 2 patients, and 1 patient, respectively, after treatment and were relieved by symptomatic treatment. There were no other unpredictable complications. The symptoms related to HP, including epigastric pain, bloating, and postprandial fullness, were relieved significantly after the treatment. During follow-up, there was no recurrence of HP in any patient.

CONCLUSIONS

Endoscopic removal appears to be a safe and effective method to treat gastric lesions suspected to be HP with symptoms. The symptoms, such as epigastric pain, bloating, and postprandial fullness were well resolved after endoscopic treatment.

Indications of endoscopic submucosal dissection for symptomatic benign gastrointestinal subepithelial or carcinoid tumors originating in the submucosa

Endoscopic submucosal dissection (ESD) for upper gastrointestinal (GI) subepithelial tumors (SETs) originating in the muscularis propria (MP) layer is associated with numerous issues regarding secure closure and measures against accidental perforation. However, symptomatic benign GI SETs or carcinoid tumors originating in the submucosa (SM) may be safely resected en-bloc using ESD. In this study, the feasibility and safety of ESD as a novel method for endoscopic resection for such GI SETs revealed on endoscopic ultrasonography (EUS) was investigated. A total of 12 consecutive cases of patients with symptomatic benign SETs (n=3; 1 esophageal hemangioma and 2 gastric lipomas) or small carcinoid tumors (n=9; <10 mm, with an extremely low risk of metastasis) originating in the SM as determined on EUS, between March, 2009 and April, 2013, were retrospectively reviewed. The lesions were resected by ESD after confirming that the tumors originated from the SM. The complication rate following en-bloc resection was also determined. En-bloc resection was achieved in all 12 cases, the mean procedure time was 45 min (range, 20-120 min) and no complications occurred intra- or postoperatively. There was no tumor recurrence or disease-related mortality reported during the follow-up period (median follow-up time, 13.4 months). Histopathological curative resection was achieved with ESD without complications in all 9 cases with carcinoid tumors. Therefore, if EUS reveals a SET originating in the SM without infiltration of the MP and resection is indicated due to the presence of abdominal symptoms, ESD may be a feasible option for diagnostic treatment with minimal invasiveness. However, larger-scale prospective studies are required to establish the feasibility and safety of this procedure.

Concordance of endoscopic ultrasonography-guided fine needle aspiration diagnosis with the final diagnosis in subepithelial lesions

Background/Aims

In this study we aimed to determine the rate of concordance of endoscopic ultrasonography (EUS)-guided fine needle aspiration (FNA) diagnosis with the final diagnosis obtained by surgery or endoscopic resection and follow-up in upper gastrointestinal subepithelial lesions.

Methods

We retrospectively studied patients with subepithelial lesions who underwent EUS at our center from 2007 to 2011.

Results

We had a final diagnosis in 67 patients (mean age±SD, 51.23±12.48 years; 23 [34.3%] female, 44 [65.6%] male). EUS-FNA was performed in all of the patients. On-site pathology was not performed. In nine of the patients, the obtained material which was obtained was insufficient. The cytologic examination was benign in 31 and malignant in 27 of the patients. Based on the final diagnosis, the EUS-FNA had a sensitivity of 96%, a specificity of 100%, and a diagnostic yield of 85%.

Conclusions

The diagnostic yield of EUS-FNA, in the absence of the on-site cytopathologist, is feasible for the diagnosis of subepithelial lesions of the upper gastrointestinal system.

Endoscopic submucosal dissection for treatment of gastric submucosal tumors originating from the muscularis propria layer

BACKGROUND AND AIMS

We aimed to study the feasibility of endoscopic submucosal dissection (ESD) for the removal of gastric muscularis propria tumors and to evaluate the efficacy and safety of ESD for this treatment.

METHODS

Eighteen patients with gastric SMTs originating from the muscularis propria were treated by ESD between July 2008 and July 2011. Tumor characteristics, complications, en bloc resection rate, and local recurrence rate were evaluated.

RESULTS

Among the 18 patients, 11 were women (61.1 %). The median age was 65.3 ± 6.3 years old (range 30-71 years old). Seventeen tumors were resected completely by ESD (success rate 94.4 %). The mean tumor size as determined by endoscopic ultrasound was 2.6 ± 1.2 cm (range 1.0-3.5 cm). The histological diagnosis was gastrointestinal stromal tumor for 13 lesions and leiomyoma for four tumors. The mean operation time was 90 ± 38 min (range 50-120 min), and the average blood loss was 20 ml. Two patients developed perforation, which was closed by endoscopic methods with metallic clips. The tumor was closely adhered to the muscularis propria and was convex to the enterocoelia in one case. No single case had severe complications, such as GI bleeding, peritonitis, or abdominal abscess, and there were no other immediate post-procedure complications.

CONCLUSIONS

ESD is a safe, effective, well-tolerated, and minimally invasive therapy for the intraluminal SMTs originating from gastric muscularis propria with relatively few complications. Although there is a risk of perforation which has become manageable endoscopically.

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.

Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications

Background

Endoscopic submucosal dissection (ESD) is a well-established method for the treatment of gastrointestinal epithelial tumors. However, the treatment of gastric subepithelial tumors (SETs) that originate from the muscularis propria layer still depends primarily on surgical techniques. We evaluated the appropriate indications for ESD in the treatment of SETs that originate from the muscularis propria layer.

Methods

Thirty-five patients with gastric SETs that originate from the muscularis propria layer who underwent ESD were enrolled, and the charts were retrospectively reviewed to investigate the parameters predictive complete resection and complications.

Results

The mean age of the patients was 54.15 ± 9.3 years, and the male/female ratio was 2:3. Twenty-eight of the 35 SETs (85.7 %) were movable, and 15 (45.7 %) had a positive rolling sign. The most frequent location of the SETs was high body (n = 14). The most common pathological diagnoses were leiomyoma (60 %) and gastrointestinal stromal tumor (28.6 %). The complete resection rate was 74.3 %. A positive rolling sign (p = 0.022) and small tumor size (≤20 mm; p = 0.038) were significantly associated with complete resection. Two patients (6.1 %) developed perforations that required surgical treatment; their SMTs were neurogenic tumors with fixed lesion. Tumor mobility was significantly associated with perforation (p = 0.017).

Conclusions

The ESD method appears to be relatively safe for use in the complete resection of SETs that originate from the muscularis propria layer. Small tumor size (≤20 mm) and a positive rolling sign are appropriate indications for ESD.

Endoscopic submucosal dissection of gastric ectopic pancreas

Patients with gastric tumors usually present with symptoms of discomfort or pain in the epigastrium, regurgitations, nausea, vomiting or melena. Treatment options include open and laparoscopic total or partial gastrectomy and recently endoscopic mucosal resection. A case of successful endoscopic submucosal dissection is described with the unusual pathological finding of heterotopic pancreatic tissue forming a gastric tumor. The 67-year-old male patient was operated on due to the initial diagnosis of gastro-intestinal stromal tumor of the gastric trunk. Two intra-operative biopsies were negative for cancer cells. Submucosal endoscopic dissection was performed with IT and Hook knives (Olympus). A literature review was performed. The operative time was 180 min with hospital stay of 6 days. During the injection of the carmine dye and the air insufflation pneumoperitoneum occurred and remained clinically silent during the observation period. The pathology result showed a heterotopic pancreatic tissue type 2 according to Heinrich's classification with microfoci of intestinal metaplasia. Preoperative diagnostics of gastric masses might be misleading and such tumors not necessarily should be excised. There are several surgical options with endoscopic submucosal dissection being probably the safest one and a non-disabling approach. Patients tolerate that kind of surgery well with good postoperative functional outcomes.

Modified endoscopic submucosal dissection with enucleation for treatment of gastric subepithelial tumors originating from the muscularis propria layer

Background

Gastric subepithelial tumors are usually asymptomatic and observed incidentally during endoscopic examination. Although most of these tumors are considered benign, some have a potential for malignant transformation, particularly those originating from the muscularis propria layer. For this type of tumor, surgical resection is the standard treatment of choice. With recent advent of endoscopic resection techniques and devices, endoscopic submucosal dissection (ESD) has been considered as an alternative way of treatment. The aim of this study is to demonstrate the feasibility of a modified ESD technique with enucleation for removal of gastric subepithelial tumors originating from the muscularis propria layer, and to evaluate its efficacy and safety.

Methods

From November 2009 to May 2011, a total of 16 patients received a modified ESD with enucleation for their subepithelial tumors. All tumors were smaller than 5 cm and originated from the muscularis propria layer of the stomach, as shown by endoscopic ultrasonography (EUS). The procedure was conducted with an insulated-tip knife 2. Patient’s demographics, tumor size and pathological diagnosis, procedure time, procedure-related complication, and treatment outcome were reviewed.

Results

Fifteen of the sixteen tumors were successful complete resection. The mean tumor size measured by EUS was 26.1 mm (range: 20–42 mm). The mean procedure time was 52 minutes (range: 30–120 minutes). Endoscopic features of the 4 tumors were pedunculated and 12 were sessile. Their immunohistochemical diagnosis was c-kit (+) stromal tumor in 14 patients and leiomyoma in 2 patients. There was no procedure-related perforation or overt bleeding. During a mean follow up duration of 14.8 months (range: 6–22 months), there was no tumor recurrence or metastasis.

Conclusions

Using a modified ESD with enucleation for treatment of gastric subepithelial tumors originating from the muscularis propria layer and larger than 2 cm, complete resection can be successfully performed without serious complication. It is a safe and effective alternative to surgical therapy for these tumors of 2 to 5 cm in size.

Endoscopic resection of subepithelial tumors

Subepithelial tumors (SETs) are often incidentally found during endoscopic examinations. Endoscopic ultrasonography (EUS) is a good method for differential diagnosis of SETs, but a definite diagnosis cannot be made based on EUS features alone in some cases. Periodic follow-up examinations by endoscopy and EUS remains the recommended management strategy, which involves issues related to patient compliance, cost-effectiveness, and the risk associated with repeated endoscopic procedures and delayed diagnosis of malignancy. Endoscopic resection of the SETs is another technique to treat them as well as to obtain tissue specimens for accurate histologic diagnosis. Herein, a various endoscopic techniques ranging from simple snare resection to endoscopic submucosal tunnel dissection for the management of SETs will be reviewed.

Endoscopic muscularis dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria

BACKGROUND AND AIMS

Based on our experience with endoscopic submucosal dissection (ESD) and new endoscopic techniques for endoscopic closure of iatrogenic upper gastrointestinal (upper-GI) perforations, we developed methods to remove upper-GI subepithelial tumors (SETs) originating from the muscularis propria by endoscopic muscularis dissection (EMD). The aim of this study is to evaluate the clinical feasibility and safety of EMD.

METHODS

31 patients with upper-GI SETs originating from the muscularis propria were treated by EMD. The EMD differed from ESD in (1) precutting the overlying mucosa above the lesion by using snare or longitudinal incision instead of circumferential incision, (2) dissecting the complete tumors away from submucosal and muscularis propria tissue by electrical dissection combined with blunt dissection, and (3) closing the wound with clips. Perforations occurring during dissection were closed by endoscopic methods.

RESULTS

30 of 31 tumors were resected completely (96.8 %). One esophageal lesion was resected partially because of severe adhesions with surrounding tissue. Mean resected tumor size was 22.1 mm × 15.5 mm, and mean operation time was 76.8 min (range 15-330 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in 16 lesions [6 esophageal, 3 cardial, 7 gastric; 6 very low risk and 10 low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in 15 lesions (8 esophageal, 4 cardial, 3 gastric). No patient developed delayed hemorrhage. Perforation occurred in four patients (12.9 %), all of which were managed successfully by endoscopic techniques. The mean follow-up time was 17.7 months (range 7-35 months). Follow-up found no tumor recurrence in any patient.

CONCLUSIONS

In this early experience, EMD appears to be a feasible and minimally invasive treatment for some patients with upper-GI SETs originating from the muscularis propria. Although there is a higher risk of perforation than with ESD, this will improve with extended practice, and perforations have become manageable endoscopically.

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.

Endosonographic features of esophageal granular cell tumors using a high-frequency catheter probe

OBJECTIVE

Submucosal tumors (SMTs) are occasionally found in the esophagus during upper endoscopy. Granular cell tumors (GCTs) are reported to be the second most common esophageal mesenchymal tumors, after leiomyomas. Endoscopic ultrasonography (EUS) is an effective tool for predicting the histologic characteristics of SMTs by providing an accurate image of the layering structure of the esophagus, but it is hard to differentiate GCTs from submucosal leiomyomas accurately with conventional EUS. The aim of the present study was to characterize the EUS features of GCTs compared with those of submucosal leiomyomas using a high-frequency catheter probe EUS.

MATERIAL AND METHODS

A total of 41 patients with GCTs or submucosal leiomyomas were included. All of the patients underwent EUS before histologic confirmation by endoscopic resection or biopsy.

RESULTS

There were 14 GCTs in 12 patients and 30 leiomyomas in 29 patients. GCTs had a white-to-yellow surface color more frequently than leiomyomas. In comparison with the surrounding normal proper muscle layer, the echogenicity of the leiomyomas was similar to that of the surrounding muscle layer, but more than half of the GCTs were hyperechoic compared to the surrounding muscle layer. Unclear borders were observed more frequently in GCTs than in leiomyomas. The presence of at least two of these three features in a given tumor had a sensitivity of 85.7%, a specificity of 96.7%, and an accuracy of 93.2% for predicting GCTs.

CONCLUSIONS

High-frequency probe EUS is helpful for differentiating esophageal GCTs from submucosal leiomyomas.

Endoscopic removal of gastric ectopic pancreas: An initial experience with endoscopic submucosal dissection

AIM: To evaluate the therapeutic usefulness and safety of endoscopic resection in patients with gastric ectopic pancreas.

METHODS: A total of eight patients with ectopic pancreas were included. All of them underwent endoscopic ultrasonography before endoscopic resection. Endoscopic resection was performed by two methods: endoscopic mucosal resection (EMR) by the injection-and-cut technique or endoscopic mucosal dissection (ESD).

RESULTS: We planned to perform EMR in all eight cases but EMR was successful in only four cases. In the other four cases, saline spread into surrounding normal tissues and the lesions became flattened, which made it impossible to remove them by EMR. In those four cases, we performed ESD and removed the lesions without any complications.

CONCLUSION: If conventional EMR is difficult to remove gastric ectopic pancreas, ESD is a feasible alternative method for successful removal.

Diagnosis of subepithelial tumors in the upper gastrointestinal tract by endoscopic ultrasonography

Endoscopic ultrasonography (EUS) is the most accurate procedure for detecting and diagnosing subepithelial tumors, due to its higher sensitivity and specificity than other imaging modalities. EUS can characterize lesions by providing information on echogenic origin, size, borders, homogeneity, and the presence of echogenic or anechoic foci. Linear echoendoscopes, and recently also electronic radial echoendoscopes, can be used with color Doppler or power Doppler to assess the vascular signals from subepithelial masses, and thus permit the differentiation of vascular structures from cysts, as well as the assessment of the tumor blood supply. However, the diagnostic accuracy of EUS imaging alone has been shown to be low in subepithelial lesions with 3rd and 4th layers. It is also difficult to differentiate exactly between benign and malignant tumors and to gain an accurate picture of histology using EUS. On the other hands, EUS guided fine needle aspiration (EUS-FNA) can provide samples for cytologic or histologic analysis. Hypoechoic lesions of the 3rd and the 4th EUS layers, more than in 1 cm diameter are recommended, and histologic confirmation using endoscopic submucosal resection or EUS-FNA should be obtained when possible. Therefore, EUS-FNA plays an important role in the clinical management of subepithelial tumors. Furthermore improvements in endoscopic technology are expected to be more useful modalities in differential diagnosis and discrimination between benign and malignant subepithelial tumors.

Endoscopic enucleation for gastric subepithelial tumors originating in the muscularis propria layer

BACKGROUND

Subepithelial tumors (SETs) of the stomach are considered benign. However, they have the potential for malignant transformation, especially if they originate in the muscularis propria layer. This study aimed to determine the feasibility of endoscopic enucleation (EEN) for SETs in the muscularis propria layer and to evaluate the diagnostic efficacy and safety of EEN for SETs.

METHODS

A total of 65 lesions in 64 patients were eligible for inclusion in the study during the period between June 2006 and September 2009. En bloc enucleation using an insulated-tip knife and snare was attempted for removal of gastric SETs from the muscularis propria.

RESULTS

A total of 60 tumors were successfully resected by EEN (success rate, 92.3%). The mean tumor size, determined by endoscopic ultrasound, was 13.8 mm (range, 5-30 mm). A histologic diagnosis was obtained for 63 tumors (diagnostic yield, 96.9%), which was leiomyoma for 32 lesions, gastrointestinal stromal tumor for 26 tumors, and other for 5 tumors. The rate for complete resection in relation to the location of the lesion in the stomach was higher for the cardia, the mid/lower body (100%), and the high body (96%) than for the fundus (75%) or the antrum (50%, p=0.006). The rate of perforation was significantly higher for the fundus (50%) than for other locations (0% for the cardia and 4% for the high body) (p<0.001).

CONCLUSIONS

Endoscopic enucleation of gastric SETs originating in the muscularis propria layer was a safe and effective method for the histologic diagnosis and removal of small gastric SETs, especially those located in the cardia and the high body of the stomach.

Endoscopic submucosal dissection for gastric submucosal tumor, endoscopic sub-tumoral dissection

Gastric submucosal tumor (SMT) is frequently found during screening endoscopy, but definitive diagnosis based on histological confirmation is relatively difficult. Even without accurate diagnosis before treatment, open or laparoscopic surgery is currently carried out to remove SMT. The purpose of this study was to demonstrate the feasibility of endoscopic submucosal dissection (ESD) in diagnostic treatment for submucosal tumor (SMT) of the stomach. Subjects in this case study comprised nine patients who had undergone ESD for gastric SMT. Before treatment, endoscopic ultrasonography was carried out in all cases to evaluate depth and origin of the SMT. Then ESD was only indicated for tumors of submucosal layer or muscularis mucosa origin. Using an endoscopic sub-tumoral dissection technique with a hook knife and a flex knife, local complete resections were achieved in all patients without severe complications. These results suggest the clinical benefits of ESD avoiding oversurgery for the diagnostic treatment of gastric SMT of the submucosal layer and muscularis mucosa origin.

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue. Treatment of heterotopic pancreas may include expectant observation, endoscopic resection or surgery. The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection (EMR) for resection of heterotopic pancreas of the stomach. Two patients (both female, mean age 32 years) were referred for management of gastric subepithelial tumors. Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa. Band ligation-assisted EMR was performed in both cases without complications. Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa. Margins were free of pancreatic tissue. Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue. Treatment of heterotopic pancreas may include expectant observation, endoscopic resection or surgery. The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection (EMR) for resection of heterotopic pancreas of the stomach. Two patients (both female, mean age 32 years) were referred for management of gastric subepithelial tumors. Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa. Band ligation-assisted EMR was performed in both cases without complications. Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa. Margins were free of pancreatic tissue. Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

Diagnostic yield of tissue sampling using a bite-on-bite technique for incidental subepithelial lesions

BACKGROUND/AIMS

Techniques for endoscopic evaluation of gastrointestinal subepithelial lesions include conventional endoscopy, jumbo biopsy, endoscopic ultrasonogrphy (EUS), EUS-guided fine needle aspiration, and endoscopic submucosal resection. However, these procedures have many limitations, such as low diagnostic yields and high complication rates. We therefore evaluated the diagnostic yield for tissue sampling of incidental subepithelial lesions using the bite-on-bite technique.

METHODS

One hundred and forty subepithelial lesions were found in 129 patients during conventional diagnostic esophagogastroduodenoscopy by one examiner from October 2003 to November 2004. Bite-on-bite biopsies with conventional-sized forceps were taken from 36 patients having 37 lesions that did not appear to be hypervascular or to have a thick overlying epithelium. Two to eight bites were performed to obtain submucosal tissue for one lesion.

RESULTS

The bite-on-bite technique was diagnostic in 14 of the 37 lesions (38%). Blood oozing for more than 30 seconds occurred in five cases, but was easily controlled by epinephrine injection (2 cases) or hemoclip (3 cases). The diagnostic yield tended to be higher in the esophagus than in the stomach and duodenum (54% vs. 28%, p=0.109).

CONCLUSIONS

The bite-on-bite technique for subepithelial lesions is an effective and safe method in selected cases. This technique may be useful for incidental subepithelial lesions, especially those of the esophagus, except for ones with a high risk of bleeding or thick overlying epithelium.

The value of endoscopic ultrasonography on diagnosis and treatment of esophageal hamartoma

OBJECTIVE

To examine the values of endoscopic ultrasonography (EUS) on diagnosis and treatment of esophageal hamartoma.

METHODS

We compared and analyzed various kinds of imaging examinations such as barium esophagram, contrast-enhanced computed tomography (CT) and conventional gastroscopy in retrospectively reviewing the clinical data of an esophageal hamartoma patient seen in our clinic in the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China. Having received various imaging examinations, this patient was finally diagnosed with esophageal hamartoma and underwent gastroscopic resection of hamartoma with the diagnostic information obtained from EUS. The patient had been regularly followed up for 13 months after treatment.

RESULTS

Barium esophagram, CT and conventional gastroscopy detected the lesion, but were unable to distinguish it from common esophagopolypus and other submucosal lesions, and unable to determine etiopathogenisis. EUS detected the hamartoma and identified its internal structure, echo, exact size, depth of invasion, origin and the relationship between adjacent tissues and organs, differentiating the lesion from other submucosal tumors and clearly defining the diagnosis. EUS-guided fine needle aspiration (FNA) also helped to identify the etiological diagnosis.

CONCLUSION

EUS was superior to other imaging means in diagnosis and treatment of hamartoma.

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.

[Heterotopic pancreas in the gallbladder. Diagnosis, therapy, and course of a rare developmental anomaly of the pancreas]

Ectopic pancreas is a rare entity but the second most prevalent pancreatic anomaly. Heterotopic pancreas is defined as the presence of pancreatic tissue without any anatomic or vascular continuity with the main body of the pancreas. Its aetiology is not clearly established. In 1916, Poppi published for the first time evidence of heterotopic pancreas in the gallbladder. A review of the literature up to the present showed only 28 more cases worldwide of ectopic pancreas in the gallbladder. Aberrant pancreas is incidentally discovered in 2% of autopsies and has been estimated to occur once in every 500 upper abdominal explorations. Ninety per cent of ectopic pancreas is found in the stomach, duodenum, and jejunum. Mostly it is asymptomatic and benign. For this reason, therapy is indicated only in patients with symptoms such as pyloric obstruction, bleeding, and malignant transformation. Surgical resection or endoscopic mucosal resection as a newer method are recommended.

Endoscopic management of gastrointestinal smooth muscle tumor

AIM: To systematically evaluate the efficacy and safety of endoscopic resection of gastrointestinal smooth muscle tumors (SMTs, including leiomyoma and leiomyosarcoma) and to review our preliminary experiences on endoscopic diagnosis of gastrointestinal SMTs.

METHODS: A total of 69 patients with gastrointestinal SMT underwent routine endoscopy in our department. Endoscopic ultrasonography (EUS) was also performed in 9 cases of gastrointestinal SMT. The sessile submucosal gastrointestinal SMTs with the base smaller than 2 cm in diameter were resected by “pushing” technique or “grasping and pushing” technique while the pedunculated SMTs were resected by polypectomy. For those SMTs originating from muscularis propria or with the base size ≥ 2 cm, ordinary biopsy technique was performed in tumors with ulcers while the “Digging” technique was performed in those without ulcers.

RESULTS: 54 cases of leiomyoma and 15 cases of leiomyosarcoma were identified. In them, 19 cases of submucosal leiomyoma were resected by “pushing” technique and 10 cases were removed by “grasping and pushing” technique. Three cases pedunculated submucosal leiomyoma were resected by polypectomy. No severe complications developed during or after the procedure. No recurrence was observed. The diagnostic accuracy of ordinary and the “Digging” biopsy technique was 90.0% and 94.1%, respectively.

CONCLUSION: Endoscopic resection is a safe and effective treatment for leiomyomas with the base size ≤ 2 cm. The “digging” biopsy technique would be a good option for histologic diagnosis of SMTs.