Ligation-assisted endoscopic enucleation for the diagnosis and resection of small gastrointestinal tumors originating from the muscularis propria: a preliminary study

Comparison analysis of two different types of endoscopic resection procedures in small gastric subepithelial tumours originating frommuscularis propria

BACKGROUND

For small gastric subepithelial tumours originating from the muscularis propria, there is no uniform standard for selecting the best endoscopic resection method.

OBJECTIVE

To compare the efficacy and safety of endoscopic snare resection with a transparent cap (ESR-C) and endoscopic snare resection with an elastic band (ESR-EB) for small gastric subepithelial tumours originating from the muscularis propria to determine which method is more suitable for these tumours.

METHODS

The data from small gastric subepithelial tumours originating from the muscularis propria treated from Jan 2020 to Dec 2022 were collected. A total of 34 eligible patients were enrolled. Sixteen of these patients were treated with ESR-C, and eighteen were treated with ESR-EB. The general clinical characteristics, tumour location, tumour size,growth pattern,operation time, complete resection rate, and complication rate were compared between the two groups.

RESULTS

There was no difference in age, sex, tumour location, tumour size, growth pattern, or histological diagnosis after resection (p > 0.05). There was no significant difference in operation time, complete resection rate, or follow-up time (p > 0.05). Eight patients (50.5%) in the ESR-C group had complications (6 perforations and 2 bleeding), and 2 (11.11%) in the ESR-EB group had complications (2 perforations). There were significant differences between the two groups (p = 0.037). All perforations were successfully treated. No recurrence or metastasis was observed in either group during the follow-up period.

CONCLUSION

Both ESR-C and ESR-EB are effective and safe in treating small gastric subepithelial tumours originating from the muscularis propria. However, ESR-EB can significantly reduce the incidence of complications. ESR-EB is likely a better option for small gastric subepithelial tumours originating from the muscularis propria.

Comparison of endoscopic full-thickness resection and ligation-assisted endoscopic full-thickness resection for small (≤ 1.5 cm) gastric subepithelial tumors originating from muscularis propria

BACKGROUND

In the treatment of small gastric subepithelial tumors originating from muscularis propria (SET-MPs), endoscopic full-thickness resection (EFTR) has been an effective procedure and ligation-assisted EFTR (EFTR-L) seems a feasible and promising operation. We aimed to compare the therapeutic outcomes of EFTR-L and EFTR to evaluate effect and safety of either method in the treatment of small (≤ 1.5 cm) gastric SET-MPs.

METHODS

Between January 2018 to May 2022, we retrospectively enrolled a total of 119 patients with gastric SET-MPs treated by EFTR-L (79 patients) or EFTR (40 patients) at Xiangya Hospital Central South University. Clinical characteristics, operation efficacy, adverse events (AEs), and operation cost were compared between the 2 groups. Univariate and multiple logistic and linear regressions were applied to analyze the therapeutic outcomes of the procedure, and covariates were adjusted in the multiple analysis.

RESULTS

The operation time of EFTR-L group (16.34 ± 5.75 min) was significantly shorter than EFTR group (51.23 ± 21.21 min, P < 0.001), and the difference remained significant after adjusting the covariates (adjusted mean difference, 30.56; 95% confidence interval, 25.65-35.47; P < 0.001). The operation cost of EFTR-L group was lower than EFTR group (1268.52 ± 457.22 vs 1643.18 ± 295.08 $; P < 0.001). The complete resection rate of the EFTR-L group was 98.72% and of the EFTR group 100%. The incidence of abdominal pain in the EFTR-L group (5.06%) was lower than in the EFTR group (27.50%, P = 0.008). A patient in the EFTR group underwent severe pneumoperitoneum and received abdominocentesis during operation. One case of peritonitis occurred in the EFTR-L group but recovered from intensified antibiotic therapy. No delayed blood or perforation occurred.

CONCLUSIONS

Compared to EFTR, EFTR-L might be a feasible procedure for small (≤ 1.5 cm) gastric SET-MPs due to the acceptable efficacy, shorter operation time, and lower cost.

Small EUS-suspected gastrointestinal stromal tumors of the stomach: An overview for the current state of management

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors found in the gastrointestinal (GI) tract, with the stomach being the most common site. They represent a distinct group of GI tumors originating from the interstitial cells of Cajal and are characterized by gain-of-function mutations of KIT. KIT oncoprotein serves as both diagnostic and therapeutic targets. Prognosis is related to size, mitotic activity, and site of the tumor. Asymptomatic, small endoscopic ultrasonography (EUS)-suspected GISTs are increasingly encountered with the wide availability of endoscopic/endosonographic examination. The majority of small GISTs are biologically indolent, albeit possibly harboring c-KIT gene mutations. An ongoing controversy exists regarding the management and surveillance policy for small gastric GISTs. A number of reports on the management of GISTs have been published, not confidently addressing the issue of gastric GISTs of small size. This work provides an overview on the current state of management considerations, specifically focusing on small EUS-suspected gastric GISTs, which are increasingly encountered by clinicians.

Ligation-assisted endoscopic submucosal resection with circumferential mucosal incision for duodenal carcinoid tumor

Here we present the case of a 64-year-old female with a duodenal carcinoid tumor treated by ligation-assisted endoscopic submucosal resection (ESMR-L) with circumferential mucosal incision (CMI). Band ligation was effective in resecting the duodenal carcinoid tumor after CMI, with an uneventful post-procedural course. Histopathological examination showed clear tumor margins at deeper tissue levels. Thus, in the present case, ESMR-L with CMI was useful for the treatment of duodenal carcinoid tumor.

Ligation-assisted endoscopic enucleation for the treatment of colorectal submucosal tumours originating in the muscularis propria

AIM

A ligation-assisted endoscopic enucleation (EE-L) technique was developed and was evaluated to determine its efficacy and safety for treating colorectal submucosal tumours (< 10 mm) originating in the muscularis propria.

METHOD

EE-L was used to treat 13 patients between January 2011 and January 2014. The tumour was sucked into a transparent cap and ligated at its base by a rubber band ligature attached to the tip of the endoscope. With the creation of a pseudo-stalk, the tumour was then enucleated using endoscopic dissection and the wound was closed with clips.

RESULTS

All tumours [median diameter 6.8 (4-10) mm] were successfully enucleated [procedure time 19 (11-27) min]. Histopathological examination identified 11 (84.6%) to be leiomyoma and 2 (15.4%) low-risk gastrointestinal stromal tumours. No perforations or massive haemorrhage occurred and there were no recurrences during a follow-up of 3-39 months.

CONCLUSION

EE-L is a successful technique for the removal of small colorectal tumours in the muscularis propria with few complications and enables a histopathological diagnosis. In this study, all the resected lesions had a benign pathology.

Endoscopic versus open resection for small gastric gastrointestinal stromal tumors: safety and outcomes

Endoscopic resection has been performed to treat small gastric neoplasms. However, this technique for small gastric gastrointestinal stromal tumors (GISTs) remains controversial. This study aims to compare the safety and surgical outcomes of endoscopic versus open resection of small gastric GISTs.The medical records of 54 consecutive gastric GISTs patients with tumor size of ≤2 cm, who were surgically treated with endoscopic resection (endoscopic group) or open surgery (laparotomy group) in a single institution from March 2010 to June 2014, were retrospectively analyzed. The clinical and tumor characteristics, surgical safety, and tumor-related outcomes were evaluated.Of 54 patients, 32 and 22 patients underwent endoscopic resection and laparotomy, respectively. Patients who underwent endoscopic resection yielded a significantly shorter hospital stay compared with patients who underwent laparotomy (P < 0.001). Compared with patients in the endoscopic group, patients in the laparotomy group had more intraoperative blood loss (P < 0.001), had longer nasogastric tube retention (P < 0.001), and required longer operative time (P < 0.001). More laparotomy patients required postoperative analgesic drugs than those in the endoscopic group (n = 9 vs 4; P = 0.016). Gastric perforation occurred in 1 case during operation in the endoscopic group. Patients who underwent these 2 procedures did not differ with respect to tumor size (P = 0.168), perioperative transfusion (P = 1.000), reoperation (P = 1.000), early satiety (P = 0.560), and postoperative bleeding (P = 1.000). With a median follow-up time of 34.5 months, 1 high-risk patient in each group experienced tumor recurrence/metastasis postoperatively.The endoscopic procedure allows safe resection with good surgical outcomes for small gastric GISTs compared with laparotomy. Moreover, larger randomized controlled trials are warranted to confirm endoscopic application for small gastric GISTs.

Ligation-assisted endoscopic enucleation for treatment of esophageal subepithelial lesions originating from the muscularis propria: a preliminary study

An innovative ligation-assisted endoscopic enucleation (EE-L) technique was developed for the diagnosis and treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria by combining endoscopic band ligation and endoscopic enucleation techniques. The aim of the study was to evaluate efficacy and safety of EE-L technique in the treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria. Forty-seven esophageal subepithelial lesions (smaller than 12 mm) originating from the muscularis propria in 44 patients were treated with EE-L between September 2010 and September 2012. The lesion was first aspirated into the transparent cap attached to the tip of endoscope. The elastic band was then released around its base. The purpose of ligation was to force the lesion to assume a polypoid form with a pseudostalk. Endoscopic enucleation was then performed until the tumor was completely enucleated from muscularis propria using a hook knife and forceps. All tumors (median diameter: 8.2 ± 2.3 mm, range: 4-12 mm) were enucleated completely. Histopathology identified 45 tumors (95.7%) as leiomyoma, 2 (4.3%) tumors as gastrointestinal stromal tumor with very low risk. The mean time of the EE-L procedure was 12.5 ± 4.6 minutes (range: 6-23 minutes). Two patients experienced self-limiting, non-life-threatening hemorrhage after EE-L. No perforation and massive hemorrhage requiring further endoscopic or surgical intervention occurred. There were no recurrences during the 6-24 months follow-up period. EE-L offers the option of localized treatment of small esophageal muscularis propria tumors (smaller than 12 mm) with relatively few complications and low mortality, and provides the advantage of allowing a histopathological diagnosis. All the resected lesions in this study had a benign pathology.