Efficiency and safety of endoscopic resection in the management of subepithelial lesions of the stomach

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

INTRODUCTION

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

METHODS

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

RESULTS

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

DISCUSSION

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

Endoscopic full-thickness resection (EFTR) compared to submucosal tunnel endoscopic resection (STER) for treatment of gastric gastrointestinal stromal tumors

Background and study aims  Submucosal tunnel endoscopic resection (STER) is being increasingly performed for treatment of gastric gastrointestinal stromal tumor (GIST), while STER has been limited by close dissection within tunnel and risking breach of tumor capsule. Endoscopic full-thickness resection (EFTR) allows resection of GIST with margins to prevent recurrence. This study aimed to compare EFTR against STER for treatment of gastric GIST. Patients and methods  We retrospectively reviewed clinical outcomes of patients with gastric GIST who received either STER or EFTR. Patients with gastric GISTs < than 4 cm were included. Clinical outcomes including baseline demographics, perioperative and oncological outcomes were compared between the two groups. Results  From 2013 to 2019, 46 patients with gastric GISTs were treated with endoscopic resection, 26 received EFTR and 20 received STER. Most of the GISTs were in the proximal stomach. There was no difference in operative time (94.9 vs 84.9 mins; P  = 0.401), while endoscopic suturing was applied more for closure after EFTR ( P  < 0.0001). Patients after STER had earlier resumption of diet and shorter hospital stay while there was no difference in adverse event rate between two groups. The en-bloc resection rate for EFTR was significantly higher than for STER (100 % vs 80 %; P  = 0.029), while there was no difference in the local recurrence. Conclusions  This study demonstrated that although patients who received EFTR had longer hospital stays and slower resumption of diet compared to those who underwent STER, EFTR achieved a significantly higher rate of en-bloc resection compared to STER for treatment of gastric GIST.

Efficiency of an endoscopic resection strategy for management of submucosal tumors < 20 mm in the upper gastrointestinal tract

Background and study aims  The histologic diagnosis of submucosal tumors (SMTs) < 20 mm is challenging. Monitoring is the main option offered, but compliance is debatable. Endoscopic resection (ER) of malignant SMTs or those with an uncertain diagnosis is an alternative that has already been reported about and proposed in our center. The aims of this study were to confirm the safety of this resection strategy and to perform long-term follow-up of malignant SMTs after resection. Patients and methods  All patients who underwent ER for SMTs < 2 cm in a single center between 2007 and 2019 were included retrospectively. Patients were classified into two groups according to the need for postresection follow-up: benign SMTs (B-SMTs) and follow-up SMTs (FU-SMTs). Results  One hundred and one patients were included. The mean tumor size was 16.7 mm. In total, 92 of 101 SMTs had an uncertain diagnosis. Macroscopic resection was completed for 95 SMTs (93.1 %), with en bloc resection in 94 (92.1%). The morbidity rate was 3 %, with no mortality. A total of 84 of 101 SMTs (84 %) were B-SMTs and did not need monitoring, and 17 SMTs (19.7 %) were FU-SMTs (8 gastrointestinal stromal tumors, 6 neuroendocrine tumors, and 3 others). No relapse was reported in the FU-SMT group, with a median follow-up duration of 33 months [4-127] (61 months [17-127] for the gastrointestinal stroma tumor group). Conclusions  The study results suggest ER is a potentially reliable and effective strategy for upper gastrointestinal tract SMTs < 20 mm. Although the strategy needs further validation in advanced care units, it could eliminate the need for long-term monitoring, therefore targeting such follow-up efforts to patients with FU-SMTs.

Retrospective analysis of the outcomes of endoscopic submucosal dissection for the diagnosis and treatment of subepithelial lesions in a center with high expertise

Background

Use of endoscopic submucosal dissection (ESD) for the diagnosis and treatment of subepithelial lesions (SELs) is limited in the West, and the best approach for these lesions is still debated. In this study we describe our experience regarding the usefulness, safety and outcomes of ESD for SELs.

Method

We performed a retrospective analysis of ESD in the diagnosis and treatment of SELs between November 2010 and February 2021.

Results

A total of 634 ESDs were reviewed. Fifty-five (9%) were performed in SELs, 6 in the esophagus, 34 in the stomach, and 15 in the rectum. ESD was technically successful in 53 lesions (96%). Most of them (82%) had previous endoscopic ultrasound evaluation, but only 20% had a histological diagnosis previous to the ESD. Neuroendocrine tumors, gastrointestinal stromal tumors, and granular cell tumors accounted for 38% of the procedures, with a 100% rate of en bloc resection and 65% of R0 resection; the main criterion for non-curative resection was a deep positive margin, and none of the patients treated with complementary surgery had lesions on the gastrointestinal wall. Most of the procedures (62%) were performed in lesions with very low malignant potential, providing the definitive diagnosis of SELs where the previous diagnostic workup was inconclusive. We had a total of 2 delayed bleedings and 1 perforation, all treated endoscopically.

Conclusion

Our real-life experience showed that ESD can be an effective and safe diagnostic tool for undetermined SELs, as well as an effective treatment for neoplastic SELs with malignant potential.

The role of endoscopic submucosal dissection in the management of gastric inflammatory fibroid polyps: a single-center experience

BACKGROUND AND AIM

Gastric inflammatory fibroid polyps constitute only 0.1% of all gastric polyps. They are usually asymptomatic and are most often found in the antrum. These lesions are in the majority of cases amenable to resection by snare polypectomy. However, there are rare case reports of gastric IFP requiring resection by endoscopic submucosal dissection. This study aimed to evaluate the effectiveness and safety of endoscopic submucosal dissection in the management of gastric inflammatory fibroid polyps not amenable to resection with snare polypectomy because of large size and/or deep subepithelial engagement.

METHODS

A retrospective study of all consecutive patients who undergone endoscopic submucosal dissection for gastric inflammatory fibroid polyps between January 2011 and December 2020 was performed.

MAJOR RESULTS

There were 9 cases of gastric inflammatory fibroid polyps resected by endoscopic submucosal dissection. Most patients were female (7/9) with a mean age of 62.2 years. All gastric inflammatory polyps were described as solitary antral subepithelial lesions with mean diameter of 16.7 mm. Helicobacter pylori was detected in only one patient. At endoscopic ultrasound, these lesions were uniformly described as well-circumscribed, homogeneous lesions located at muscularis mucosa and submucosa without invasion of muscularis propria. All lesions were successfully resected en-bloc by endoscopic submucosal dissection and complete resection with free margins was obtained in 8/9 specimens. Adverse events were reported in 2/9 cases including one case of intra-procedural bleeding successfully controlled with hemostatic clips and one case of aspiration pneumonia that evolved favorably. Mean follow-up duration was 33.7 months (range 0-120) and no delayed complications or cases of recurrence were detected during follow-up.

CONCLUSIONS

Endoscopic submucosal dissection appears to be a safe and effective approach for resection of gastric inflammatory fibroid polyps that present as large subepithelial lesions if performed by experienced endoscopists after adequate characterization by endoscopic ultrasound with high rates of technical success and low recurrence rates. .

Laparoscopic-Endoscopic "Rendezvous" Procedure in Pediatric Gastrointestinal Surgery-Case Series

Laparoscopic–endoscopic “rendezvous” procedures were introduced in surgery for common bile duct stone treatment but are now widely used in other fields of abdominal surgery. An endoscopist navigates a surgeon during the same operative procedure and, thus, enables a better visualization of the location, resection margins, bleeding control, less thermal damage, etc. Here, we present case series of 11 patients that were treated using a “rendezvous” procedure for gastrointestinal lesions on different parts of the gastrointestinal tract such as juvenile polyps on the colon (transversum, ascendens, cecum, sigma), leiomyomatosis of the stomach, Peutz–Jeghers intestinal polyposis, hyperplastic gastric polyp, ectopic pancreatic tissue in the stomach, gastric trichobezoar, and gastric schwannoma. “Rendezvous” procedures are suitable for intestinal lesions that could not be resected endoscopically due to their size, morphology and/or location. In our experience this procedure should be used for endoscopically unresectable lesions as it decreases the time of surgery, possibility of iatrogenic injury, bleeding and technical inability. Furthermore, this procedure has been shown to better navigate the surgeon during laparoscopic surgery, especially in treating polyps in particularly difficult locations such as the duodenum or cecum, and it decreases conversion rates. However, conversion is sometimes necessary, in order to assure all oncological principals are respected, and the best option in some cases.

Resection of Mucosal and Submucosal Gastrointestinal Lesions and a Double Endoscope Experience

Aim:

The patients who underwent endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) for mucosal and submucosal lesions of the esophagus, stomach, and duodenum and the advantages of the double endoscope method we used for traction during ESD were evaluated.

Material and Methods:

The patients who underwent ESD and EMR due to upper gastrointestinal lesions were evaluated retrospectively between January 2014 and April 2018 in our endoscopy unit.

Result:

The mean age of 10 patients with esophageal lesions was 53 years. ESD was performed for 7 lesions and EMR for 3 lesions. The most common lesion was leiomyoma and the median size of the lesions was 1.4 cm (range, 0.6–2.5 cm).

The median age of 26 patients with gastric lesions was 61 years. EMR were performed for 11 lesions and ESD for 15 lesions. Double endoscope was used in 6 patients. One patient had intramucosal carcinoma, while the other lesions were benign and dysplasia was the most common lesion. The median size of lesions was 1.8 cm (range, 1–3 cm).

All lesions were evaluated with endoscopic ultrasonography. Bleeding was seen in 4 patients and perforation in 1 patient during ESD and defect was closed with endoscopic clips.

Conclusion:

The advantages of endoscopic resections; short hospitalization, low complication rates, patient comfort, and doesn't require the general anesthesia. For endoscopic resection, we think that the second endoscope shortens the duration of the procedure, reduces the complication rate, and increases the comfort of the endoscopist.

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

BACKGROUND

Gastric small submucosal tumors (SMTs) are becoming increasingly common. However, the fundus of stomach is regarded as a difficult area for endoscopic resection (ER). In this study, we investigated the efficacy, safety, and long-term outcomes of ER for small SMTs of the gastric fundus in a large series of patients, research that was previously lacking.

METHODS

537 consecutive patients with SMTs no more than 20 mm in diameter, occurring in the gastric fundus and originating from the muscularis propria layer, which were treated with endoscopic submucosal excavation or endoscopic full-thickness resection (EFTR) were included in this retrospective study at Zhongshan Hospital of Fudan University from January 2013 to September 2016. Clinicopathological, endoscopic, and follow-up data were collected and analyzed.

RESULTS

En bloc resection was achieved in 100% of patients, and complete resection was achieved for 530 (98.7%) lesions. Although the total rate of complications was 9.3%, few serious adverse events occurred in only three (0.6%) patients, including major pneumoperitoneum, major hydrothorax, and bleeding. Unlike lager tumor sizes and longer procedure times, endoscopist experience had a positive impact on decreasing the likelihood of complications. Based on statistical analysis, tumors with greater size near the cardia, which were treated by EFTR, were the significant contributors to longer operative times. A median follow-up of 32 months was available, and all patients were free from local recurrence or distant metastasis during the study period.

CONCLUSIONS

Although the gastric fundus presents technical difficulties, ER is effective for the resection of small gastric SMTs with a high complete resection rate and rare serious adverse events.

Concomitant stromal tumor and early cancer of the stomach: What should be done?

Concomitant gastric stromal tumor (GST) and gastric cancer (GC) is uncommon; even more uncommon is a concomitant GST and early stage GC (EGC). Tumor resection by endoscopic submucosal dissection (ESD) for concomitant GST and EGC has not been reported. We sought to define the clinical importance of detection of concomitant GST and EGC during the first esophagogastroduodenoscopy (EGD), and compare the clinical outcomes of ESD versus radical surgery for the treatment of concomitant GST and EGC. Our investigation was a retrospective cohort study. Patients with concomitant GST and EGC who underwent ESD or radical surgery were enrolled at the university-affiliated hospital from January 2005 to January 2015. The detection rate of concomitant GST and EGC during the first EGD was 3/25 (12%). Among 25 patients, 14 underwent ESD and 11 underwent surgery. Mean operation time and hospital stay were significantly shorter in the ESD group than the surgery group. There were no significant differences in terms of rates of en bloc resection, complete resection, and early complications. Late complications were more common in the surgery group than in the ESD group. The median follow-up duration was 58.9 months. Three- or 5-year overall survival rates were 100% for both groups and no patient died of EGC and GST. There was no local recurrence in the 2 groups; however, 3 metachronous EGC lesions were found during the follow-up period in the ESD group as follows: the simultaneous occurrence of GST and EGC was uncommon; the detection rate of concomitant GST and EGC was very low at the first EGD; and ESD appeared to be a safe, efficient, and popular treatment option for concomitant GST and EGC, that met the ESD absolute indication, and the outcomes were comparable to those achieved with surgery.

Gastroduodenal Intussusception with a Gastric Gastrointestinal Stromal Tumor Treated by Endoscopic Submucosal Dissection

A 95-year-old Japanese woman presented to our hospital with intermittent vomiting and several episodes of melena. Abdominal computed tomography revealed intussusception of the gastric tumor into the duodenum. After endoscopic reduction, endoscopic ultrasonography identified a hypoechogenic lesion limited to the submucosal layer. Endoscopic resection was performed as a localized treatment for the prevention of recurrent gastroduodenal intussusception. To our knowledge, there have been no other reports describing a gastric gastrointestinal stromal tumor presenting with gastroduodenal intussusception and treated using an endoscopic submucosal dissection technique.

Endoscopic Submucosal Dissection Outcomes for Gastroesophageal Tumors in Low Volume Units: A Multicenter Survey

Background and Aims. Endoscopic submucosal dissection (ESD) outcomes have traditionally been reported from high volume centers in East Asia. Data from low volume centers in other parts of Asia remain sparse. Methods. A retrospective survey with a structured questionnaire of 5 tertiary centers in 3 countries in South East Asia was conducted. Details of training and clinical outcomes of ESD cases, with follow-up data from these centers, were analyzed. Results. Seven endoscopists from the 5 centers performed a total of 35 cases of ESD in the upper gastrointestinal tract (UGIT) over a 6-year duration. Details of the lesions excised were as follows: median size was 20 mm, morphologically 20 (68.6%) were flat/depressed and 6 (17.1%) were submucosal, and histologically 27 (77.1%) were neoplastic. The median duration of ESD procedures was 105 minutes, with an en-bloc resection rate of 91.4%. There was 1 (2.9%) case of delayed bleeding, but no perforation nor mortality in any of the cases. The recurrence rate after ESD was 5.7%. A prolonged ESD duration was influenced by a larger size of lesion (25 mm, p = 0.02) but not by factors related to the training experience of endoscopists. Conclusions. ESD in the UGIT is feasible and safe in low volume centers in Asia.