Submucosal tunneling endoscopic resection for large symptomatic submucosal tumors of the esophagus: A clinical analysis of 24 cases

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.

Endoscopic resection of giant esophageal subepithelial lesions: experience from a large tertiary center

BACKGROUND AND AIMS

Increased reports on endoscopic resection (ER) of esophageal giant subepithelial lesions (g-SELs) have emerged in recent years. The aim of this study was to evaluate the efficacy, technical difficulty, and safety through our single-center experience.

METHODS

Seventy-five patients with g-SELs undergoing endoscopic resection were included in the training set. Clinicopathologic features, procedure-related characteristics, postprocedural outcomes, and follow-up data were analyzed. A predictive nomogram model for procedural difficulty was proposed based on the multivariable logistic regression analysis. Internal and external validations were conducted to verify the model performance.

RESULTS

The overall en bloc resection rate was 93.3%. Intraoperative and postoperative adverse events occurred in 7 (9.3%) and 13 (17.3%) patients, respectively. No recurrence or metastasis was observed. Thirty-two (42.7%) patients underwent a difficult procedure. Age (adjusted odds ratio [aOR], .915; P = .004), maximal tumor diameter ≥8 cm (aOR, 9.896; P = .009), irregular shape (aOR, 4.081; P = .053), extraluminal growth pattern (aOR, 5.419; P = .011), and submucosal tunneling endoscopic resection (aOR, .109; P = .042) were found to be statistically or clinically significant factors for predicting endoscopic resection difficulty, based on which a nomogram model was developed. Internal and external validations of the nomogram via receiver-operating characteristic curves and calibration curves achieved favorable results.

CONCLUSIONS

Endoscopic resection serves as a promising therapeutic option for esophageal g-SELs. A younger patient age, large tumor size, irregular shape, and extraluminal growth may indicate increased endoscopic resection difficulty, whereas a submucosal tunneling endoscopic resection procedure tends to be of lower difficulty. Our nomogram model performs well for predicting endoscopic resection difficulty for esophageal g-SELs.

Endoscopic resection for the treatment of gastric gastrointestinal stromal tumors: a retrospective study from a large tertiary hospital in China

BACKGROUND AND AIMS

With the continuous development of endoscopic technology, endoscopic resection (ER) has gradually become an optional method for the treatment of gastric gastrointestinal stromal tumors (GISTs). However, studies with a large sample or a long follow-up are lacking. Therefore, this research aims to evaluate the efficacy and safety of ER for gastric GISTs in the real-world setting with more than 300 enrolled patients and a follow-up period longer than 45 months.

METHODS

From January 2013 to February 2023, 409 patients with a pathological diagnosis of GISTs after ER were retrospectively enrolled in this study. After excluding 86 patients with non-gastric GISTs, we assessed 323 patients with gastric GISTs. The main outcome measures were en bloc resection, complete resection, residual disease, recurrence, and complications.

RESULTS

There were 194 (60.06%) females and 129 (39.94%) males, and the median age of the included patients was 58 years (51, 63). The median tumor size was 15.0 (10.0, 20.0) mm. According to the modified NIH criteria, 246 (75.85%) patients were classified as very low risk, 62 (19.20%) were classified as low risk, 12 (3.72%) were classified as moderate risk, and 3 (0.93%) were classified as high risk. A total of 287 (88.85%) patients achieved en bloc resection, and 287 (88.85%) also achieved complete resection. Only one patient showed residual and no recurrent lesions were noted during the follow-up. Regarding complications, three patients had complications, with a complication rate of 0.93%, and no severe complications requiring surgical intervention occurred.

CONCLUSION

ER is an appropriate alternative method for the treatment of gastric GISTs, with an en bloc resection rate of 88.85% and a complication rate of 0.93%. No recurrence was noted during follow-up, even for GISTs with piecemeal resection.

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.

Efficacy and Safety Analysis of Submucosal Tunnel Endoscopic Resection for Submucosal Masses in Esophageal Muscularis Propria

Objective

To analyze the efficacy and safety of submucosal tunnel endoscopic resection (STER) for the treatment of submucosal masses in esophageal muscularis propria.

Method

A total of 272 patients with submucosal masses in esophageal muscularis propria diagnosed and treated in our hospital from February 2019 to January 2022 were randomly selected for the study and then were randomly divided into the STER group (n = 136) and the endoscopic mucosal dissection (ESD) group (n = 136) according to the random number table method. Patients in the STER and ESD groups were treated with STER and ESD, respectively. The clinical data of patients from the two groups were collected and compared. The clinical effects and the changes of surgery-related indexes of patients after ESD and STER treatment were observed. The safety of ESD and STER was compared. The factors influencing the efficacy of STER treatment for submucosal masses in esophageal muscularis propria were analyzed.

Result

There were significant differences between the STER group and the ESD group in terms of tumor size, lesion level, adhesion and surgical approaches (P < 0.05). The effective rates of ESD treatment and STER treatment were 98.53% and 88.97%, respectively. Meanwhile, the effective rates of STER treatment were significantly higher than those in the control group (P < 0.05). In addition, the patients in the STER group had longer operation time, less blood loss, and shorter hospital stay compared with those in the ESD group (P < 0.05). Adverse reactions occurred during ESD treatment and STER treatment included delayed bleeding, adhesion, perforation, and pleural effusion with the total incidence of adverse reactions of 4.41% and 13.97%, respectively. The adverse reactions in STER group were prominently less than these in the ESD group (P < 0.05). Logistic multivariate regression analysis showed that independent risk factors, including tumor size, lesion level, adhesion, and surgical approaches, affected the efficacy of STER in the treatment of submucosal masses in esophageal muscularis propria (P < 0.05).

Conclusion

STER is an effective method for the treatment of submucosal masses in esophageal muscularis propria, which can exhibit a good effect with faster postoperative recovery and higher safety, thereby being worthy of clinical application and promotion. Tumor size, lesion level, adhesion, and surgical approaches are all related factors affecting the effect of STER treatment.

[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.