Comparison Between Submucosal Tunneling Endoscopic Resection (STER) and Other Resection Modules for Esophageal Muscularis Propria Tumors: A Retrospective Study

Efficacy and safety of piecemeal submucosal tunneling endoscopic resection for giant esophageal leiomyoma

BACKGROUND AND AIMS

Giant esophageal leiomyoma usually requires a thoracotomy or thoracoscopic surgery, which is more invasive than an endoscopic treatment. The purpose of this study is to evaluate the efficacy and safety of piecemeal submucosal tunneling endoscopic resection (P-STER) for giant leiomyoma originating from the muscularis propria (MP) layer of the esophagus.

METHODS

This is a retrospective study. Patients with giant esophageal leiomyoma (transverse diameter ≥ 3 cm) who underwent P-STER were enrolled from November 2012 to May 2023. Clinical data and results were investigated.

RESULTS

A total of 16 patients were enrolled for analysis. The lesion mean transverse diameter and longitudinal diameter were 4.22 ± 1.20 cm and 6.20 ± 1.57 cm, respectively. Our mean operation time was 195.38 ± 84.99 min. The mean number of piecemeal resected was 4.31 ± 2.36. An adverse event noted was an esophageal fistula that occurred in one case (6.25%) and was treated conservatively. The mean length of hospital stay was around 11.81 ± 7.30 days. The mean total hospitalization cost was U.S. dollars (USD) $5976.50 ± 2866.39. No recurrence or metastasis was found during the follow-up period.

CONCLUSIONS

P-STER can be an effective and safe treatment for giant leiomyoma originating from the MP layer of the esophagus.

Uniportal video-assisted thoracoscopic surgery in semi-prone position utilising direct endobronchial intubation for oesophagus leiomyoma excision

Leiomyomas are the most common benign tumours of oesophageal smooth muscle origin. In this era of constantly evolving medical technology, video-assisted, robot-assisted and endoscopic approaches are the minimally invasive strategies for the excision of these lesions. Here, we report our modification of this surgery. The lesion was excised with uniportal video-assisted thoracoscopic surgery in a semi-prone position with single-lumen endobronchial intubation.

Submucosal Tunneling Techniques for Tumor Resection

The concept of third space endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa. The mucosal flap safety valve enabled endoscopists to use submucosal space securely. The era of third space endoscopy started with peroral endoscopic myotomy for treatment of achalasia and has expanded to treat various other gastrointestinal disorders, such as mucosal lesions, submucosal tumors, extraluminal tumors, and refractory gastroparesis, Zenker diverticulum, and restoration of the completely obstructed esophageal lumen. Third space endoscopy rapidly emerged as a minimally invasive alternative to conventional surgery. Many studies discovered that this technique is safe and effective with excellent outcomes. Our review focused on the indications, techniques, clinical management, and adverse events of submucosal tunneling techniques for tumor resection.

Updates in the Field of Submucosal Endoscopy

Submucosal endoscopy (third-space endoscopy) can be defined as an endoscopic procedure performed in the submucosal space. This procedure is novel and has been utilized for delivery to the submucosal space in a variety of gastrointestinal diseases, such as a tumor, achalasia, gastroparesis, and subepithelial tumors. The main submucosal endoscopy includes peroral endoscopic myotomy, gastric peroral endoscopic myotomy, Zenker peroral endoscopic myotomy, submucosal tunneling for endoscopic resection, and endoscopic submucosal tunnel dissection. Submucosal endoscopy has been used as a viable alternative to surgical techniques because it is minimally invasive in the treatment and diagnosis of gastrointestinal diseases and disorders. However, there is limited evidence to prove this. This article reviews the current applications and evidence regarding submucosal endoscopy while exploring the possible future clinical applications in this field. As our understanding of these procedures improves, the future of submucosal endoscopy could be promising in the fields of diagnostic and therapeutic endoscopy.

Thoracolaparoscopic esophagectomy for esophageal cancer with a cervical or abdominal incision to extract specimen

Surgery is the only curative approach for resectable esophageal cancer. This retrospective study was to investigate the immediate effect and operative complications of conventional and modified thoracolaparoscopic esophagectomy with a cervical or abdominal incision to extract specimen for the treatment of patients with esophageal cancer. Eighty-one patients were enrolled, among which 55 patients underwent conventional McKeown thoracolaparoscopic esophagectomy (conventional MTE) and 26 patients underwent modified MTE with a cerivical incision (modified MTE). The clinical, surgical, and postoperative data were analyzed. No significant (P > .05) difference was detected in the clinical data between two groups. The surgical procedure was successful in all patients (100%). The surgical time was significantly (P = .018) shorter in the conventional MTE group than in the modified MTE group (280 min vs 317 min). However, no significant (P > .05) difference was found in blood loss (200 mL vs 180 mL), intensive care unit (ICU) stay (31.3 ± 11.3 vs 25.2 ± 6.4 hours), first flatus after surgery (2.9 ± 1.9 vs 3.3 ± 1.6 days), postoperative hospital stay (12.9 ± 5.6 vs 12.6 ± 3.3 days), total number of lymph nodes dissected (27.9 ± 4.1 vs 26.7 ± 5.7), types of carcinoma, and pathological classification. No significant (P > .05) differences were detected in postoperative complications between the two groups. Assessment of postoperative pain using the visual analogue scale (VAS) score showed a significant (P < .05) difference in the VAS score at day 2 (4.81 ± 1.70 vs 3.87 ± 1.14) and day 3 (5.10 ± 0.83 vs 4.61 ± 1.12) between the conventional and modified MTE groups. The modified McKeown thoracolaparoscopic esophagectomy with only one cervical incision is more minimally invasive, more cosmetic, and less painful than the conventional approach.

Endoscopic resection of large subepithelial esophageal lesions via submucosal tunneling endoscopic resection and endoscopic submucosal dissection: a single-center, retrospective cohort study

BACKGROUND

This study aimed to compare the clinical outcomes between submucosal tunneling endoscopic resection (STER) and endoscopic submucosal dissection (ESD) for large subepithelial esophageal lesions (SELs) and analyze risk factors for perforation and piecemeal resection.

METHODS

The clinicopathological features and outcomes of endoscopic treatment of 56 patients with SELs with diameters ≥30 mm, diagnosed between June 2017 and December 2020, were reviewed in this retrospective cohort study. Patients were divided into two groups (ESD group and STER group).

RESULTS

The complete resection rates of the STER and ESD groups were 88.1% and 78.6%, respectively (p = .398). The operation time of STER was longer than ESD (p = .03), while the hospital stay of STER was shorter than ESD (p = .02). The rate of major adverse events associated with ESD was considerably higher than STER group (p = .035). The extraluminal growth pattern was a risk factor for piecemeal resection, and ESD was an independent risk factor for perforation. Regarding tumors with extraluminal growth patterns, the ESD group's perforation rate was significantly higher than the STER group (p = .009). There were no recurrence or metastases found during a mean follow-up of 24.4 months.

CONCLUSION

The STER technique has advantages of shorter hospital stays and fewer major adverse events than ESD. The extraluminal growth pattern seems to be a risk factor for piecemeal resection in both ESD and STER. STER appears to be a preferable choice for large SELs with extraluminal growth patterns.

En bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy based on the mesoesophageal theory

PURPOSE

To investigate the effectiveness and clinical significance of thoracolaparoscopic esophagectomy with mesoesophagus excision.

MATERIALS AND METHODS

Patients who underwent en bloc mesoesophageal esophagectomy through thoracoscopy combined with laparoscopy were retrospectively enrolled. Carbon nanoparticles were used in some patients to label the esophageal drainage lymph nodes. The clinical data were analyzed.

RESULTS

En bloc mesoesophageal esophagectomy was successfully performed in 135 patients (100%). The carbon nanoparticles were used in 10 patients, among which the left gastric arterial lymph nodes were labeled in all patients and excised together with the left gastric mesentery, mesoesophagus, esophageal cancer, lymph nodes, vessels, nerves, and adipose tissues as one intact package. The mean operation time was 182.5 ± 26.4 min, intraoperative blood loss 45.9 ± 17.6 ml, mean number of lymph nodes dissected 20.9 ± 8.12, extubation time of drainage tubes 7.5 ± 3.8 days, first oral feeding time 7.5 ± 1.8 days, and postoperative hospital stay 13 ± 5.11 days. Postoperatively, anastomotic leakage occurred in six patients (4.4%), anastomotic stenosis in eight (5.9%), hoarseness in seven (5.2%), and inflammation of the remnant stomach in four (3.0%), with a complication rate of 18.5%. Patients were followed up for 13-34 months (median 23). Eighteen patients presented with organ metastasis. No local recurrence or death during follow-up.

CONCLUSION

Based on the membrane anatomy or mesoesophagus theory, thoracolaparoscopic en bloc mesoesophageal esophagectomy is safe, with decreased blood loss, and it is necessary to resect the left gastric artery lymph nodes together with the left gastric mesentery and its contents to completely remove the cancer.

Endoscopic treatment can be a viable therapeutic option for esophageal gastrointestinal stromal tumors

BACKGROUND

Esophageal gastrointestinal stromal tumors(GISTs) are extremely rare. We sought to determine whether endoscopic treatment can be a viable therapeutic option for esophageal GISTs.

METHODS

A total of 20 cases with histological diagnosis of esophageal GISTs were obtained from our center between 2008 and 2020. Data on the clinicopathological features and treatment were recorded.

RESULTS

There were 9 males (45%) and 11 females (55%) in this study, with a median age of 56 years. The tumors preferentially occurred in the middle and lower parts of the thoracic esophagus (45 and 40%, respectively). The mean size of the tumors was 2.27 cm and mitotic index was no more than 5/50 high power field (HPF) in all patients. In this study, 11 patients received endoscopic treatment and nine patients underwent surgical resection. Tumors ranged from 0.6 to 4 cm in the endoscopic treatment patients and 0.5 to 7 cm in the surgical patients. There were no significant differences in gender, age, symptoms, tumor location, tumor size, mitotic index, and adjuvant imatinib therapy between the endoscopic treatment group and the surgery group (all p > .05). The Kaplan-Meier curve suggested that there was also no significant difference in disease-free survival between the two groups (p = .264).

CONCLUSIONS

Endoscopic treatment may be an option for the treatment of esophageal GISTs smaller than 5 cm with a mitotic index no more than 5/50 HPF.

[Submucosal tunneling endoscopic resection for large esophageal leiomyoma: technical aspects and risk of complications]

We analyzed the technical aspects and risk of possible complications after submucosal tunneling endoscopic resection for large esophageal leiomyoma. A patient with a 4-cm non-epithelial esophageal tumor underwent STER procedure in June 2018. Surgery time was 130 min. There were no intraoperative complications. Postoperative period was complicated with mediastinitis with reactive pneumonia and pleural effusion accompanied by episodes of hyperthermia up to 38°C for 5 days. The patient was discharged in 12 days after complete resolution of pneumonia confirmed by chest X-ray. Contrast-enhanced examination after 3 postoperative days revealed no contrast agent leakage outside the esophagus. The previously applied clips were visualized. Endoscopic examination in 3 months after surgery visualized postoperative scar without signs of deformation and narrowing of the esophagus. No complaints were observed throughout 3.5-year follow-up period.

CONCLUSION

This report demonstrates the advantages of tunnel dissection ensuring organ-sparing procedure with the best functional result. However, intra- and postoperative complications are possible after STER. The risk of complications and complexity of surgery depend on transverse size (>3.5 cm), shape and localization of tumor. Larger neoplasm is accompanied by more difficult surgery and higher risk of complications. Therefore, adequate selection of patients for STER is essential.

Lymph node metastasis pattern and significance of left gastric artery lymph node dissection in esophagectomy for esophageal cancers

Purpose

To investigate the lymph node metastasis pattern and significance of dissection of the left gastric artery lymph nodes in radical en bloc esophagectomy for esophageal squamous carcinomas based on the lymphatic drainage pathway revealed by carbon nanoparticle labeling.

Materials and methods

Patients who underwent en bloc esophagectomy endoscopically were retrospectively enrolled. Carbon nanoparticles were injected in the submucosa of upper thoracic esophagus to label the relevant draining lymph nodes. The clinical data, lymph nodes dissected, surgical technique, and complications were analyzed.

Results

En bloc esophagectomy was successful in all 179 patients. Metastases to the left gastric artery lymph nodes were positive in 42 patients (23.5%) but negative in 137 (76.5%). The left gastric lymph nodes were labeled, whereas no celiac lymph nodes were labeled by carbon nanoparticles. A total of 4652 lymph nodes were resected, with 26 lymph nodes per patient. Seventy-three patients had lymph node metastasis (73/179). Seventeen patients had metastasis to the recurrent laryngeal nerve lymph nodes (9.5%). The metastasis rate of the lower thoracic esophageal cancer to the left gastric artery lymph nodes was 37.0%, significantly greater than that at the middle (15.4%) or upper (6.7%) thoracic segment. The lymph node metastasis rate was significantly (P < 0.05) increased with the length of the cancerous lesion, infiltration depth, and poor differentiation. Univariate analysis revealed that the metastasis rate to the left gastric artery lymph nodes was significantly (P < 0.05) associated with paraesophageal lymph node metastasis, para-cardial lymph metastasis, and TNM classification. Multivariate analysis indicated that cancer location (odds ratio 8.32, 95% confidence interval 2.12–32.24) was significantly (P < 0.05) associated with metastasis to the left gastric artery lymph nodes, with the cancer at the middle and lower thoracic segments significantly more than in the upper thoracic segment.

Conclusion

Certain patterns exist in lymph node metastasis of esophageal cancer, and in radical esophagectomy of esophageal cancers, dissection of the left gastric artery lymph nodes is necessary to prevent possible residual or metastasis of esophageal squamous carcinomas based on the lymphatic drainage pathway of esophageal carcinomas demonstrated by carbon nanoparticle labeling.

Feasibility and Safety of Mark-Guided Submucosal Tunneling Endoscopic Resection for Treatment of Esophageal Submucosal Tumors Originating from the Muscularis Propria: A Single-Center Retrospective Study

BACKGROUND

Submucosal tunneling endoscopic resection (STER) has effectively removed esophageal submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. However, clinical failure and adverse events of STER remain concerned. In this study, we described a mark-guided STER (markings before creating entry point) and evaluated its feasibility and safety for esophageal SMTs originating from MP.

METHODS

Patients receiving the mark-guided STER from October 2017 to July 2020 were included and followed up (ranged from 3 to 30 months). The primary outcomes included complete resection, en bloc resection, and R0 resection rates. The secondary outcomes included procedure duration, main complication, and residual lesions.

RESULTS

A total of 242 patients with 242 SMTs (median diameter of 22 mm, ranging from 7 mm to 40 mm) received the mark-guided STER. The median procedure duration was 55 min (ranging from 35 min to 115 min). The complete resection, en bloc resection, and R0 resection rates were 100%, 98.3%, and 97.5%, respectively. The adverse event rate was 4.5%. However, there was no severe complication. No residual SMTs were detected during the follow-up period. Logistic regression demonstrated that the SMT size and procedure duration were independent factors associated with en bloc resection (P=0.02 and P=0.04, respectively). Moreover, logistic regression demonstrated that the SMT size was an independent risk factor for main complications (P=0.02).

CONCLUSION

Mark-guided STER was feasible and safe to remove esophageal SMTs ≦40 mm. However, it is necessary to further verify the feasibility and safety for the esophageal SMTs >40 mm.

Recent advances in third space or intramural endoscopy

Third space endoscopy or intramural endoscopy is based on the principle that the deeper layers of the gastrointestinal tract can be accessed by tunneling in the submucosal space and maintaining the integrity of the overlying mucosa. The era of third space endoscopy started with peroral endoscopic myotomy (POEM) for treatment of achalasia and has expanded to treat various other gastrointestinal disorders. The technique is also currently used for treatment of refractory gastroparesis, Zenker’s diverticulum (ZD), resection of subepithelial tumors and early cancers of the gastrointestinal tract and Hirschsprung’s disease (HD). These procedures are rapidly emerging as minimally invasive alternatives to conventional surgery. They are safe and effective with excellent outcomes. This review focuses on the evolution and current applications of third space endoscopy in various gastrointestinal disorders. Key points: (1) Third space or intramural endoscopy initially started with the POEM procedure for treatment of achalasia; (2) Advancements in procedural techniques have expanded its application to treat other gastrointestinal disorders such as refractory gastroparesis, ZD, HD, resection of subepithelial tumors and early gastrointestinal cancers; (3) These procedures are highly effective with excellent outcomes and low complication rates; and (4) Third space endoscopic procedures are rapidly emerging as minimally invasive alternatives to conventional surgery.

Clinical value of submucosal tunneling endoscopic resection in submucosal tumors of the esophagus and cardia derived from the muscularis propria

BACKGROUND

Submucosal tunneling endoscopic resection (STER) is a new method for treating submucosal tumor in recent years, which is minimally invasive, with few complications and rapid recovery for patients. This study analyzed the data of patients who underwent this surgery at our hospital and explored the feasibility, effectiveness, and safety of this procedure for submucosal tumors.

AIM

To evaluate the efficacy, safety, and clinical value of STER in the treatment of submucosal tumors of the esophagus and cardia derived from the muscularis propria.

METHODS

Sixty patients who underwent STER for submucosal tumors of the esophagus and cardia derived from the muscularis propria were included. The results of endoscopic ultrasonography, procedure success rate, postoperative complications, postoperative pathological results, and postoperative follow-up data were recorded and analyzed statistically.

RESULTS

All of the cases completed the STER, with a success rate of 100%. The diameter of submucosal tumors was 1-5 cm. The operation took 31 to 123 min, and the average operation time was 81.73 min ± 23.23 min. The length of submucosal tunnel was 4-8 cm, with an average value of 5.88 cm ± 1.17 cm. Postoperative pathology confirmed that there were 42 cases of leiomyoma and 18 cases of stromal tumor. Two patients developed subcutaneous emphysema and right-side pneumothorax post operation, who were cured with conservative treatment. All cases were followed for 3 mo without any residual or recurrence of the lesion and no complications such as esophageal stenosis.

CONCLUSION

STER is effective in the treatment of submucosal tumors of the esophagus and cardia derived from the muscularis propria, with few complications and high safety.

Third Space Endoscopy: Lessons Learnt From a Decade of Submucosal Endoscopy

The field of third space endoscopy (TSE), also called submucosal endoscopy using a mucosal flap valve, allows secure access to the submucosal and deeper layers of the gastrointestinal tract without the risk of a full-thickness perforation. Since the first description of per-oral endoscopic myotomy (POEM) for the treatment of achalasia cardia 10 years ago, this field has expanded rapidly. Several new procedures, submucosal tunneling endoscopic resection, gastric-POEM, Zenker POEM, per-rectal endoscopic myotomy, diverticular POEM, and recanalization for complete esophageal obstruction (per-oral endoscopic tunneling for restoration of the esophagus), have been performed. All TSE procedures employ a similar technique-after a mucosal incision, a submucosal tunnel is created, a myotomy is performed, or a subepithelial tumor is resected distal to the site of mucosal incision, after which the mucosal incision is closed. Potential indications for TSE include resection of subepithelial tumors in the esophagus, gastroesophageal junction, or stomach; refractory gastroparesis; Zenker diverticulum; Hirschsprung disease or other forms of megacolon; and recanalization for complete esophageal obstruction. Data are currently available for POEM, submucosal tunneling endoscopic resection, and gastric-POEM, although mainly in the form of retrospective studies, and randomized trials and long-term follow-up data are limited. Submucosal endoscopy has an excellent safety profile with very few intraoperative adverse events, the majority being related to insufflation, although bleeding, perforation, and sepsis have been reported. TSE procedures require special training and have demonstrated a learning curve.