Esophageal bronchogenic cyst treated with submucosal tunneling endoscopic resection: two case reports

INTRODUCTION

Although esophageal bronchogenic cysts are benign diseases, they may be accompanied by serious complications and have the possibility of recurrence. Therefore, once confirmed, it is necessary to treat the esophagobronchial cyst when the contraindication is excluded. Endoscopic treatment is usually used for lesions with small diameter and shallow origin, and has the advantages of small surgical trauma and risk, which can reduce the psychological burden of patients to a certain extent, help them to recover quickly, and lower hospital costs.

CASE PRESENTATION

Case 1 is a 54-year-old Han Chinese man admitted to our hospital who complained of difficulty swallowing in the past 6 months. Case 2 is a 41-year-old Han Chinese man who was hospitalized in the past 3 months due to chest discomfort. Endoscopic ultrasound revealed a hypoechoic cystic lesion arising from the muscularis propria. Submucosal tunneling endoscopic resection was performed using a dual knife, and a cystic mass was observed between the mucosa and the muscular layers of the esophagus. On locating the cyst, an incision was made on the oral side of the lesion for evacuation. The cyst wall was excised using endoscopic argon plasma coagulation. We successfully removed the esophageal bronchogenic cyst lesion in the intrinsic muscle layer using submucosal tunneling endoscopic resection.

CONCLUSION

Esophageal bronchogenic cysts are rare in clinical practice and lack specificity in clinical manifestations. Multiple methods can be used to determine the location and nature of the lesion and ultimately determine the treatment plan. Surgical resection and endoscopic treatment are two different treatment methods, and appropriate treatment plans need to be selected on the basis of the origin layer, size, and relationship with the esophagus of the lesion to reduce complications and improve prognosis.

The efficacy of full-thickness endoscopic resection of subepithelial tumors in the gastric cardia

BACKGROUND

Gastric subepithelial tumors (SETs) may harbor potential malignancy. Although it is well recognized that large SETs should be resected, the precise treatment strategy remains controversial. Compared to surgical resection, endoscopic resection (ER) has many advantages; however, ER of SETs in the cardia is challenging.

AIM

To evaluate the safety and efficacy of endoscopic full-thickness resection (EFTR) for the treatment of gastric cardia SETs.

METHODS

We retrospectively reviewed data from all patients with SETs originating from the muscularis propria layer in the gastric cardia that were treated by EFTR or submucosal tunneling ER (STER) at Zhongshan Hospital Fudan University between November 2014 and May 2022. Baseline characteristics and clinical outcomes, including procedure times and complications rates, were compared between groups of patients receiving EFTR and STER.

RESULTS

A total of 171 tumors were successfully removed [71 (41.5%) tumors in the EFTR and 100 (58.5%) tumors in the STER group]. Gastrointestinal stromal tumors (GISTs) were the most common SET. The en bloc resection rate was 100% in the EFTR group vs 97.0% in STER group (P > 0.05). Overall, the EFTR group had a higher complete resection rate than the STER group (98.6% vs 91.0%, P < 0.05). The procedure time was also shorter in the EFTR group (44.63 ± 28.66 min vs 53.36 ± 27.34, P < 0.05). The most common major complication in both groups was electrocoagulation syndrome. There was no significant difference in total complications between the two groups (21.1% vs 22.0%, P = 0.89).

CONCLUSION

EFTR of gastric cardia SETs is a very promising method to facilitate complete resection with similar complications and reduced operative times compared to STER. In cases of suspected GISTs or an unclear diagnosis, EFTR should be recommended to ensure complete resection.

Management of delayed bleeding of upper gastrointestinal endoscopic submucosal tunneling procedures: a retrospective single-center analysis and brief meta-analysis

OBJECTIVES

Delayed bleeding is a rare but important major adverse event (mAE) after endoscopic submucosal tunneling procedures (ESTP), which is scarcely reported. We aimed to characterize the clinical characteristics of delayed bleeding and provide better management of this mAE.

METHOD

From August 2010 to October 2022, we reviewed 3852 patients with achalasia receiving peroral endoscopic myotomy (POEM) and 1937 patients with upper gastrointestinal tumors receiving submucosal tunneling endoscopic resection (STER). Among these, records of 22 patients (15 POEM, 7 STER) with delayed bleeding were collected. Clinical characteristics, treatment, and outcomes of delayed bleeding were analyzed.

RESULTS

The mean age was 43.6 years. Ten patients (45.5%) were intratunnel bleeding, seven (31.8%) were intratunnel bleeding accompanied by mucosal bleeding, and five (22.7%) were mucosal bleeding. The most common accompanied symptoms were hematemesis, fever, and melena. The most common accompanied mAEs were fistula, pulmonary inflammation, and pleural effusion with atelectasis. The mean duration from ESTP to endoscopic intervention was 5.3 ± 4.9 days. Active bleeding was identified in 21 patients (95.5%). The bleeding was successfully controlled by electrocoagulation (19 cases), endoscopic clipping (six cases), and Sengstaken-Blakemore tube insertion (three cases), and no patient required surgical intervention. The mean hemostatic procedure duration was 61.8 ± 45.8 min. The mean post-bleeding hospital stay was 10.0 ± 6.2 days. A brief meta-analysis of previous studies showed the pooled estimate delayed bleeding rate after POEM, STER, and G-POEM was 0.4%.

CONCLUSIONS

Delayed bleeding is uncommon and could be effectively managed by timely emergency endoscopic procedures without requiring subsequent surgical interventions.

Total removal of a large esophageal schwannoma by submucosal tunneling endoscopic resection: A case report and review of literature

BACKGROUND

Primary schwannoma is a rare submucosal tumor of the esophagus, which is most often benign, and surgery is the only effective treatment. So far, only a few cases have been reported. Herein, we reported a single case diagnosed with primary esophageal schwannoma that was totally removed by submucosal tunneling endoscopic resection (STER).

CASE SUMMARY

A 62-year-old man presented to the hospital with a history of resection of a malignant gastric tumor and mild dysphagia. Endoscopic examination revealed a large submucosal elevated lesion in the esophagus 25-30 cm from the incisors. Endoscopic ultrasonography detected a 45 mm × 35 mm × 31 mm hypoechoic lesion; chest computed tomography showed a mass of approximately 55 mm × 35 mm × 29 mm. A preliminary examination showed features suggestive of a stromal tumor. Pathological findings indicated esophageal schwannoma. Next, STER alone was performed to completely resect the mass, and the patient recovered well post-surgery. Afterward, the patient was discharged and showed no tumor recurrence at 33 mo of follow-up.

CONCLUSION

Endoscopic resection is still an effective treatment for large esophageal schwannomas (> 30 mm) under meticulous morphological evaluation.

Upper gastrointestinal bleeding as an unusual manifestation of localized Ménétrier’s disease with an underlying lipoma: A case report

BACKGROUND

Ménétrier’s disease is a rare condition characterized by enlarged gastric folds, usually located in the whole body and fundus of the stomach. This report presents an unusual case of localized Ménétrier’s disease elevated by a submucosal lipoma and thus looking like a polypoid mass and causing an episode of upper gastrointestinal bleeding. The mass was successfully removed with endoscopic submucosal dissection.

CASE SUMMARY

Esophagogastroduodenoscopy was performed on a 76-year-old male patient after an episode of upper gastrointestinal bleeding, manifesting as fatigue and melena. A large polypoid mass (4 cm × 1 cm) with enlarged mucosal folds was found in the body of the stomach, between the lesser curvature and posterior wall. A small ulcer at the distal end of the mass was identified as the source of the bleeding. Biopsy was negative for neoplasia. Computed tomography showed a submucosal lesion beneath the affected mucosa, most likely a lipoma. The mass was removed en bloc with tunneling endoscopic submucosal dissection. Final pathology determined that the mass included Ménétrier’s disease and a submucosal lipoma. The patient was scheduled for follow-up esophagogastroduodenoscopy.

CONCLUSION

Localized Ménétrier’s disease can coexist with a submucosal lipoma creating a polypoid mass with risk of bleeding.

Efficacy and safety of esophageal submucosal tumors treated with internal traction method-assisted submucosal tunneling endoscopic resection: a single-center, single-blind, randomized controlled study

BACKGROUND AND OBJECTIVES

Submucosal tunnel endoscopic resection (STER) is an effective technique for treating esophageal submucosal tumors, but the efficacy and safety of treating esophageal submucosal tumors with internal traction method-assisted STER have not been determined. The objectives of this study were to assess the feasibility, safety, and efficacy of internal traction method-assisted STER for the removal of esophageal submucosal tumors.

PATIENTS AND METHODS

Eighty patients who underwent STER for esophageal submucosal tumors were included in the study. They were randomized and assigned to the two groups. The dual-knife method was used for STER. Forty patients underwent conventional STER (control group) and 40 underwent internal traction method-assisted STER in which self-made rubber band traction with clips was used (study group). In the study group, one end of the self-made rubber band was fixed on the surface of esophageal submucosal tumors with a clip, and the other end of the self-made rubber band was set on the anal side of the contralateral esophageal wall with a clip.

RESULTS

STER was successful in all cases. Lesion features and demographics were similar between the two groups. In addition, broad exposure of the submucosal tissue was obtained by applying tension to the self-made rubber band traction with clips. The en bloc resection rate and complete resection rate were both 100% in the study group. However, the en bloc resection rate and complete resection rate were 85.0% and 100%, respectively, in the control group. Complications, such as perforation and pneumomediastinum, were significantly reduced in the study group, and there was a significant difference in the number of occurrences of bleeding, operation duration, fasting time, and patient length of stay between the study group and control group (P < 0.05). During the mean 13.7 month follow-up, there were no patients with esophageal fistula, recurrence, or distant metastasis in either group.

CONCLUSIONS

This original study showed that esophageal submucosal tumors could be effectively and safely treated with internal traction method-assisted STER, and this technique might be superior to conventional STER due to its fewer complications, shorter operation duration, and shorter inpatient length of stay.

Landscape of esophageal submucosal tunneling endoscopic resection-related adverse events in a standardized lexicon: a large volume of 1701 cases

BACKGROUND

Submucosal tunneling endoscopic resection (STER) has been widely applied for esophageal submucosal tumors. This large volume study aims to provide a standard landscape of STER-related AEs for reference.

METHODS

1701 patients with esophageal SMTs undergoing STER were included at Zhongshan Hospital, Fudan University. Data of clinical characteristics and adverse events were collected and analyzed in depth. Adverse events were recorded by ASGE lexicon and graded by ASGE grading/Clavien-Dindo system. Risk factors for major AEs were analyzed by univariate and multivariate logistic regression.

RESULTS

Three hundred and twenty (18.8%) patients with 962 cases of adverse events were observed. Accordingly, 84 (5.0%) were classified as major AEs (moderate and severe) by ASGE grading and 37 (2.2%) were classified as major AEs (grades III-V) by Clavien-Dindo grading. First 1 year operation, distance > 6 cm from incision to tumor, piecemeal resection, partially extraluminal location, mucosal injury, and operation time > 60 min were included in the risk score model for major AEs of STER, with 57.1% sensitivity and 87.5% specificity.

CONCLUSIONS

STER was a safe procedure for diagnosis and treatment of esophageal SMTs with a total 18.8% incidence of AEs, among which only 5.0% were major AEs requiring therapeutic measurements.

Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction

BACKGROUND

Endoscopic resection approaches, including endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR), have been widely used for the treatment of submucosal tumors (SMTs) located in the upper gastrointestinal tract. However, compared to SMTs located in the esophagus or stomach, endoscopic resection of SMTs from the esophagogastric junction (EGJ) is much more difficult because of the sharp angle and narrow lumen of the EGJ. SMTs originating from the muscularis propria (MP) in the EGJ, especially those that grow extraluminally and adhere closely to the serosa, make endoscopic resection even more difficult.

AIM

To investigate the predictors of difficult endoscopic resection for SMTs from the MP layer at the EGJ.

METHODS

A total of 90 patients with SMTs from the MP layer at the EGJ were included in the present study. The difficulty of endoscopic resection was defined as a long procedure time, failure of en bloc resection and intraoperative bleeding. Clinicopathological, endoscopic and follow-up data were collected and analyzed. Statistical analysis of independent risks for piecemeal resection, long operative time, and intraoperative bleeding were assessed using univariate and multivariate analyses.

RESULTS

According to the location and growth pattern of the tumor, 44 patients underwent STER, 14 patients underwent EFTR, and the remaining 32 patients received a standard ESD procedure. The tumor size was 20.0 mm (range 5.0–100.0 mm). Fourty-seven out of 90 lesions (52.2%) were regularly shaped. The overall en bloc resection rate was 84.4%. The operation time was 43 min (range 16–126 min). The intraoperative bleeding rate was 18.9%. There were no adverse events that required therapeutic intervention during or after the procedures. The surgical approach had no significant correlation with en bloc resection, long operative time or intraoperative bleeding. Large tumor size (≥ 30 mm) and irregular tumor shape were independent predictors for piecemeal resection (OR: 7.346, P = 0.032 and OR: 18.004, P = 0.029, respectively), long operative time (≥ 60 min) (OR: 47.330, P = 0.000 and OR: 6.863, P = 0.034, respectively) and intraoperative bleeding (OR: 20.631, P = 0.002 and OR: 19.020, P = 0.021, respectively).

CONCLUSION

Endoscopic resection is an effective treatment for SMTs in the MP layer at the EGJ. Tumors with large size and irregular shape were independent predictors for difficult endoscopic resection.

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.

Advanced Endoscopic Resection Techniques: Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection

Endoscopic resection is first-line therapy in the management of superficial neoplasms throughout the gastrointestinal tract, as well as an increasingly viable therapeutic alternative in the resection of selected small deep lesions throughout the upper and lower gastrointestinal tract. The mainstay of therapy has traditionally been endoscopic snare polypectomy and endoscopic mucosal resection. However, recent innovative advancements in therapeutic endoscopy have provided for the ability to resect large superficial lesions and selected subepithelial lesions in en bloc and margin-negative fashion. In this review, we discuss the current state of the art in advanced endoscopic resection techniques including endoscopic submucosal dissection and endoscopic full-thickness resection.

Therapeutic Endoscopy and the Esophagus: State of the Art and Future Directions

Therapeutic gastrointestinal endoscopy is rapidly evolving, and this evolution is quite apparent for esophageal diseases. Minimally invasive endoluminal therapy now allows outpatient treatment of many esophageal diseases that were traditionally managed surgically. In this review article, we explore the most exciting new developments. We discuss the use of peroral endoscopic myotomy for treatment of achalasia and other related diseases, as well as the modifications that have allowed its use in treatment of Zenker diverticulum. We cover endoscopic treatment of gastroesophageal reflux disease and Barrett's esophagus. Further, we explore advanced endoscopic resection techniques.

Endoscopic resection of esophageal and gastric submucosal tumors from the muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation: A systematic review and meta-analysis

BACKGROUND

Submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) are less-invasive therapeutic alternatives to surgical resection for the removal of esophageal or gastric submucosal tumors (SMTs). This study aimed to comparing STER versus ESE for the resection of esophageal and gastric SMTs from the muscularis propria.

METHODS

This systematic review and meta-analysis was reported in accordance with PRISMA guidelines through December 2020. Pooled outcome measures included complete resection, en bloc resection, bleeding, perforation, adverse events, recurrence, procedure duration, and length of hospital stay. Risk ratio (RR) and mean difference (MD) was calculated as well as Peto time-to-event analyses to determine recurrence rate.

RESULTS

Five retrospective cohort studies (n = 269 STER versus n = 319 ESE) were included. There was no difference in rates of complete resection [RR: 1.01 (95% CI 0.94, 1.07)], en bloc resection [RR: 0.95 (95% CI 0.84, 1.08)], recurrence [OR: 1.18 (95% CI 0.33, 4.16)], and total adverse events [RR: 1.33 (95% CI 0.78, 2.27)]. Specific adverse events including rates of perforation [RR: 0.57 (95% CI 0.12, 2.74)] and bleeding [RR: 1.21 (95% CI 0.30, 4.88)] were not different between STER and ESE. There was a statistical difference when evaluating procedure time, with the STER group presenting significantly larger values [MD: 24.62 min (95% CI 20.04, 29.20)].

CONCLUSION

STER and ESE were associated with similar efficacy and safety; however, ESE was associated with a significantly decreased time to complete the procedure.

Endoscopic resection of benign esophageal schwannoma: Three case reports and review of literature

BACKGROUND

Esophageal schwannomas are uncommon esophageal submucosal benign tumors and are usually treated with surgery.

CASE SUMMARY

Here, we report three cases of middle/lower thoracic esophageal schwannoma treated successfully with endoscopic resection. These lesions were misdiagnosed as leiomyoma on preoperative imaging. During the endoscopic resection of such tumors, there is a risk of esophageal perforation due to their deep location. If possible, submucosal tunneling endoscopic resection should be used.

CONCLUSION

For larger schwannomas, endoscopy combined with thoracoscopy can be considered for en bloc resection. We performed a mini literature review in order to present the current status of diagnosis and treatment for esophageal schwannoma.

Endoscopic resection of large (≥ 4 cm) upper gastrointestinal subepithelial tumors originating from the muscularis propria layer: a single-center study of 101 cases (with video)

BACKGROUND AND AIMS

Although endoscopic resection (ER) is already established as a minimally invasive technique for small (< 4.0 cm) upper gastrointestinal subepithelial tumors originating from the muscularis propria layer (MP-SETs), published data of ER for large (≥ 4.0 cm) upper gastrointestinal MP-SETs are extremely rare and limited to case reports. This retrospective study aimed to evaluate the feasibility and safety of ER for large (≥ 4.0 cm) upper gastrointestinal MP-SETs in a large case series.

METHODS

Between June 2012 and December 2018, 101 patients with large (≥ 4 cm) upper gastrointestinal MP-SETs were enrolled in this study. The main outcome measures included complete resection, total complications, and local residual or recurrent tumor.

RESULTS

The rate of complete resection was 86.1%. Thirteen patients (12.9%) experienced complications including gas-related complications (6/101, 5.9%), localized peritonitis (4/101, 4.0%), esophageal/cardiac mucosal laceration (2/101, 2.0%), and delayed bleeding (1/101, 1.0%). These 13 patients recovered after endoscopic and conservative treatment. The independent risk factor for incomplete resection was tumor size (P = 0.005), and the independent risk factors for total complications were tumor size (P = 0.011) and tumor extraluminal growth (P = 0.037). During the median follow-up of 36 months, local residual tumor was detected in 1 patient. No local recurrence occurred in any patient.

CONCLUSIONS

Despite being associated with a relatively low complete resection rate, ER is an alternative therapeutic method for large (≥ 4.0 cm) upper gastrointestinal MP-SETs when performed by an experienced endoscopist. This method is especially valuable for patients who are unwilling to undergo surgery.

Peroral endoscopic tumor resection (POET) with preserved mucosa technique for management of upper gastrointestinal tract subepithelial tumors

BACKGROUND

Third space endoscopy technique facilitates therapeutic endoscopy in subepithelial space. This study aimed to investigate peroral endoscopic tumor resection (POET) with preserved mucosa technique for upper gastrointestinal tract subepithelial tumors (UGI-SETs) removal.

METHODS

Between February 2011 and December 2019, consecutive patients with SETs of esophagus and stomach who underwent POET for enlarging size during follow-up, malignant endoscopic ultrasound features or by patient's request were enrolled. Demographic, endoscopic and pathological data were analyzed retrospectively.

RESULTS

Totally 18 esophageal (mean ± SD age, 55.23 ± 4.15 year-old, 38.89% female) and 30 gastric (52.65 ± 2.43 year-old, 53.33% female) SETs in 47 patients (one with both esophageal and gastric lesions) were resected. The mean (± SD) endoscopic/pathological tumor size, procedure time, en-bloc/complete resection rate, and hospital stays of esophageal and gastric SET patients were 12.36 (± 7.89)/11.86 (± 5.67) and 12.57 (± 6.25)/12.35 (± 5.73) mm, 14.86 (± 6.15) and 38.21 (± 15.29) minutes, 88.89%/94.44% and 86.77%/93.30%, and 4.14 (± 0.21) and 4.17 (± 0.20) days, respectively. The overall complication rate was 18.75%, including 6 self-limited fever and 3 pneumoperitoneum relieved by needle puncture. There was no mortality or recurrence reported with mean follow-up period of 23.74 (± 4.12) months.

CONCLUSIONS

POET is a safe and efficient third space endoscopic resection technique for removal of UGI-SETs less than 20 mm. Long term data are warranted to validate these results.

[Interventional endoscopy in the gastrointestinal tract : Indications and limitations]

The spectrum of endoscopic techniques has been greatly enlarged in recent years. Lesions and also (iatrogenic) complications that required surgical procedures in the past can now often be treated endoscopically. Advances in endoscopic mucosal resection and submucosal dissection also enable the resection of large or laterally spreading polyps in the gastrointestinal tract. Full-thickness resection is also possible by means of specially designed clips. By the creation of a submucosal tunnel submucosal lesions can be completely excised and the muscle fibers of the lower esophageal sphincter can be endoscopically severed in achalasia patients. Endosonography-guided interventions have developed into the standard procedure for complicated pancreatitis and the use of cholangioscopy offers new therapeutic procedures for the bile and pancreatic ducts. In this continuing medical education article interventional endoscopic techniques are presented and critically evaluated.

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.

Efficacy and Safety of Endoscopic Treatment for Gastrointestinal Stromal Tumors in the Upper Gastrointestinal Tract

Background/Aims:

Endoscopic treatment (ET) has been applied for decades to treat subepithelial tumors, including gastrointestinal stromal tumors (GISTs). However, the efficacy of ET remains debatable. In this study, we evaluated the efficacy and safety of ET for GISTs in the upper gastrointestinal tract.

Methods:

This retrospective single-center study included 97 patients who underwent ET. All patients were enrolled from July 2014 to July 2018. Parameters such as demographics, size, resection margin, complications, pathological features, procedure time, total cost, and follow-up were investigated and analyzed.

Results:

Our study achieved 100% en bloc resection and 77.4% (72/93) R0 resection. The most common location was the fundus with a mean tumor size of 2.1±1.4 cm. The mean age, procedure time, hospital stay, and cost were 59.7±11.3 years, 64.7±35.2 minutes, 6.8 days, and 5,337 dollars, respectively. According to National Institutes of Health classification, 63 (64.9%), 26 (26.8%), 5 (5.2%), and 3 (3.1%) patients belonged to the very low, low, intermediate, and high risk classification, respectively. Immunohistochemistry results showed a 100% positive rate of CD34, DOG-1, CD117, and Ki67. A mean follow-up of 21.3±13.0 months showed no recurrence or metastasis.

Conclusions:

ET is effective and safe for curative removal of GISTs in the upper gastrointestinal tract, and it can be a treatment of choice for patients with no metastasis.

Comparison of different endoscopic resection techniques for submucosal tumors originating from muscularis propria at the esophagogastric junction

Background

To compare the outcomes of submucosal tunneling endoscopic resection (STER) and submucosal excavation (ESE) for the treatment of submucosal tumors (SMTs) arising from the muscularis propria (MP) at the esophagogastric junction (EGJ).

Methods

A retrospective analysis of patients with SMTs at EGJ who underwent STER and ESE from October 2011 to October 2017 was performed. The outcomes evaluated were operation time, complete resection rate, adverse events, and tumor recurrence.

Results

Ninety patients were included in this study. Complete resection rates in the STER group were higher than those of the ESE group (100 vs. 92%, p < 0.05). For tumors ≤15 mm, both techniques achieved 100% complete resection rate; but for tumors > 15 mm, complete resection rate was higher in the STER group than the ESE group (100% vs. 77.8%, p < 0.05). Subgroup analyses revealed that the operation time of STER for in cardiac-gastric group was longer than that for ESE (145.14 ± 42.43 min vs. 70.32 ± 39.84 min, p <  0.05). The air leakage symptoms were more frequent in STER group (90.9% vs. 50.0%, p < 0.05). No tumor recurrence occurred in both the STER and ESE groups.

Conclusions

For SMTs ≤15 mm, both STER and ESE have similar satisfactory therapeutic outcomes. However, in the cardiac-gastric subgroup, STER had a longer operative time compared to the ESE procedure. For SMTs > 15 mm, STER is the preferred choice due to its higher complete resection rate.

Submucosal Tunneling Endoscopic Resection for Gastric Submucosal Tumors: a Comparison Between Cardia and Non-cardia Location

BACKGROUND AND PURPOSE

Submucosal tunneling endoscopic resection (STER) was initially used to remove submucosal tumors (SMTs) located at the esophagus and cardia; only few researchers have reported the feasibility of STER for gastric SMTs beyond cardia due to the technical difficulty, and little is known about the comparison of STER for cardia and non-cardia gastric SMTs. The purpose was to compare the feasibility and efficacy of STER for cardia and non-cardia gastric SMTs, as well as to explore the risk factors for failure of en bloc resection.

METHODS

We retrospectively collected the clinical data about patients with gastric SMTs who received STER at our hospital from June 2012 to June 2018. Demographics, tumor size, procedure-related parameters, complications, hospital stay, and follow-up data were compared between cardia and non-cardia SMTs. And multivariate analyses were conducted to look for the risk factors for failure of en bloc resection.

RESULTS

A total of 46 SMTs were removed, and 25 of them were located at cardia, while the other 21 at non-cardia position. There was no significant difference between the two groups in terms of gender, age, tumor size, en bloc resection rate, operation time, complications, and hospital stay (p > 0.05). No recurrence was noticed in all the cases. Multivariate analyses revealed that irregular shape was an independent risk factor for failure of en bloc resection.

CONCLUSION

STER is feasible for both cardia and non-cardia gastric SMTs, and the efficacy between cardia and non-cardia location is comparable. Irregular shape was an independent risk factor for failure of en bloc resection.

Efficacy and safety of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors with more than 1-year' follow-up: a systematic review and meta-analysis

Objectives: Submucosal tunneling endoscopic resection (STER) is a novel therapeutic approach for upper gastrointestinal submucosal tumors (SMTs) especially for tumors originating from the muscularis propria layer. Presently, several studies have reported the efficacy and safety of STER for SMTs. Therefore, we conducted this study to review the clinical outcomes of STER with more than 1-year' follow-up duration. Materials and methods: Medline, Embase and Cochrane databases were searched on November 2018 to identify studies reporting STER for SMTs. Weighted pooled rates were calculated for en bloc resection, complete resection and adverse event (AE). Risk ratios (RR) were calculated and pooled to compare STER with thoracoscopic enucleation (TE). Results: A total of 701 patients with 728 lesions from 12 original studies were review. Pooled WPR for en bloc resection of STER was 86.3% (95% CI: 74.5-93.1%), (I²=82.5). Pooled WPR for complete resection of STER was 97.7% (95% CI: 92.8-99.3%), (I²=77.6). WPR for AE was 18.3% (95% CI: 9.7-31.6%), (I²=90.6%). Two studies with 292 patients compared the performance of STER with TE. Pooled RR for en bloc resection was 1.02 (95% CI: 0.95-1.09). Pooled RR for complete resection was 1.0 (95% CI: 0.98-1.03). Pooled RR for AE was 0.82 (95% CI: 0.33-2.05). Conclusions: Our study showed that STER has relatively long-term efficacy for treating upper gastrointestinal SMTs, and the incidence of AE was not low for STER, but all of them can be managed conservatively.

[Submucosal tunneling endoscopic resection for submucosal tumors originating from muscularis propria layer at esophagogastric junction]

Objective: To evaluate the short-term outcomes and safety of submucosal tunneling endoscopic resection (STER) for submucosal tumors (SMT) originating from muscularis propria (MP) layer at esophagogastric junction. Methods: The clinical data of 31 patients with SMT originating from MP layer at esophagogastric junction underwent STER were collected and retrospectively analyzed. Results: The success rate of STER of the thirty-one patients was 100%. The mean tumor size was (2.5±1.3) cm and the average operative time was (95.9±56.7) min. Perforation occurred in 3 patients and was successfully clipped by endo-clips during operation. One patient developed delayed bleeding and the bleeding was stopped by endoscopic hemostasis. Twenty-nine leiomyomas and two stromal tumors (GIST) were finally pathologically diagnosed. No local recurrence and distant metastasis were noted during the mean 15.4 months follow-up of 20 cases. According to the lesion size, 31 patients who received STER were divided into two groups. The operation time of maximum diameter ≥3.5 cm group was (134.0±70.6) min, significantly longer than (80.3±42.6) min of maximum diameter <3.5 cm group (P=0.014). However, the en bloc removal rate, postoperative hospital stay and the complication incidence between the two groups had no obvious differences (P>0.05). Univariate analysis showed that the piecemeal removal group had longer tumor diameter, higher incidence of irregular tumor morphology, and longer operative time than the en bloc removal group (all P<0.05). Stepwise logistic regression analysis showed that irregular shape was a risk factor for failure of en bloc removal (OR=18.000, 95% CI: 1.885~171.88, P=0.012). Conclusion: As a new method of minimally invasive treatment, STER technology appears to be a safe and effective option for patients with SMT originating from MP layer at esophagogastric junction.

Submucosal tunneling endoscopic resection for treatment of esophageal leiomyomas arising from the muscularis propria

AIM

To investigate the safety and indications of submucosal tunneling endoscopic resection (STER) by comparing the results of STER with other operations for the treatment of esophageal leiomyomas originating from the muscularis propria layer.

METHODS

We enrolled 121 patients with esophageal leiomyomas originating from the muscularis propria layer who underwent resection from November 1, 2011 to March 1, 2018 in this retrospective study. The clinical features and treatment results were collected and analyzed.

RESULTS

There was a significant difference between the thoracoscopic enucleation (TE) group and the endoscopic resection (ER) group in tumor location and size, operation time, en bolc resection rate, average hospital stay and cost (P < 0.05). There was also a significant difference in the en bolc resection rate, operative time, average hospital stay and cost between the STER group and the ER group (P < 0.05). Although tumor diameter of the STER group (2-40 mm; mean, 17.68 mm) was smaller than that of the TE group (5-80 mm; mean, 20.33 mm), the difference was not significant (P = 0.229). Tumor size, en bolc resection rate, average hospital stay and cost also differed significantly between the STER group and the endoscopic submucosal dissection (ESD) group (P < 0.05). The en bolc resection rate of the STER group was lower than those of other groups, but no tumor recurrence or metastasis was detected during the follow-up period (mean: 22.4 mo; range: 3-60 mo) in the three groups.

CONCLUSION

STER is safe and effective for the treatment of esophageal leiomyomas originating from the muscularis propria layer. We recommend STER for the tumors smaller than 4 cm.

Long-term outcomes of endoscopic resection for small (≤ 4.0 cm) gastric gastrointestinal stromal tumors originating from the muscularis propria layer

AIM

To evaluate the long-term efficacy of endoscopic resection (ER) for small (≤ 4.0 cm) gastric gastrointestinal stromal tumors (GISTs) originating from the muscularis propria layer.

METHODS

Between June 2005 and February 2015, we retrospectively analyzed 229 consecutive patients with gastric MP-GISTs who underwent ER with a follow-up at least 36 mo. The main outcome measurements included complete resection rate, complications, and long-term follow-up outcomes.

RESULTS

ER included endoscopic muscularis excavation in 179 cases, endoscopic full-thickness resection in 32 cases, and submucosal tunneling endoscopic resection in 18 cases. The median size of GISTs was 1.90 cm. Of the 229 GISTs, 147 were very low risk, 72 were low risk, 8 were intermediate risk, and 2 were high risk. Short-term outcomes showed the complete resection rate was 96.5%, and 8 patients (3.5%) had complications. Of the 8 patients with complications, only one patient required surgical intervention. Long-term outcomes showed 225 patients were actively followed-up until composition of this manuscript. The remaining 4 patients were lost because of unrelated death. During the follow-up period (median, 57 mo), no residual, recurrent lesions, or distant metastasis were detected in any patients. Binary logistic regression analysis showed tumor size was a risk factor associated with a high mitotic index (≥ 5/50 HPF) of GISTs (P = 0.002).

CONCLUSION

ER seems to be an effective and safe method for gastric MP-GISTs ≤ 4.0 cm, and, for some intermediate or high risk GISTs, adjuvant therapy and/or additional surgery might be required to reduce the risk of recurrence or metastasis.

Comparison between submucosal tunneling endoscopic resection and video-assisted thoracoscopic enucleation for esophageal submucosal tumors originating from the muscularis propria layer: a randomized controlled trial

BACKGROUND AND AIMS

Surgical resection is considered the first treatment option for submucosal tumors (SMTs) originating from the muscularis propria layer while submucosal tunneling endoscopic resection (STER) is proved to be a safe and effective method for treating SMTs. This study aimed to compare video-assisted thoracoscopic enucleation (VATE) with STER for treating esophageal SMTs.

METHODS

Sixty-six patients with small esophageal SMTs were prospectively randomized from July 2014 to December 2015. After exclusion of 8 patients, 58 subjects scheduled for STER or VATE were enrolled. Clinicopathological, endoscopic, and adverse events (AEs) data were collected and analyzed between STER and VATE.

RESULTS

Forty-six males and 12 females with a mean age of 46.1 ± 9.4 years were randomized to the STER (n = 30) and VATE (n = 28) groups, respectively. Demographics and lesion features were similar between the two groups. Median procedure time was shorter in the STER group than the VATE group (44.5 vs. 106.5 min, P < 0.001); cost was lower in the STER group (4499.46 vs. 6137.32 USD, P = 0.010). Median decrease in hemoglobin levels post-procedure was - 1.6 g/L in the STER group and 14.7 g/L after VATE (P = 0.001). Lower postoperative pain scores were found in the STER group compared with the VATE group (2 vs. 4, P < 0.001). No recurrent or residual tumors were found in either group. En bloc resection rates, complete resection rates, hospital times, and post-procedure AEs were similar between two groups. The en bloc resection rates for SMTs < 20.0 mm were 100% in both groups while STER achieved only 71.4% en bloc resection rate for SMTs ≥ 20.0 mm.

CONCLUSION

STER and VATE are comparably effective for esophageal SMTs; however, STER is superior to VATE with shorter operation time and decreased cost, and seems safer than VATE. STER is recommended for SMTs < 20.0 mm while VATE is recommended for SMTs with a transverse diameter > 35.0 mm. Clinical trail registration statement: This study is registered at http://www.chictr.org.cn/showproj.aspx?proj=4814 . The registration identification number is ChiCTR-TRC-14004759. The registration date is April 30, 2014.

Treatment of cardial submucosal tumors originating from the muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation

BACKGROUND AND AIMS

Submucosal tunneling endoscopic resection (STER) is increasingly used for the treatment of submucosal tumors (SMTs) originating from the muscularis propria layer; however, endoscopic submucosal excavation (ESE) is still performed in many hospitals for its low-skill and experience requirements. This study aimed to compare STER with ESE for cardial SMTs.

METHODS

From March 2013 to February 2017, patients with cardial SMTs undergoing STER (n = 47) and ESE (n = 40) were retrospectively assessed. Clinicopathological, endoscopic, and complication data were compared between STER and ESE groups.

RESULTS

The 87 enrolled patients included 31 females and 56 males, aged 48.2 ± 9.8 years. Mean tumor size was 22.0 mm (range 5.0-80.0 mm) as evaluated by pathology. Demographic and lesion features were similar in both groups. Despite similar hospital stay duration and cost, ESE was superior to STER with reduced operation time (34 vs. 46 min, P = 0.013) and less clips required (3 vs. 5, P = 0.000). En bloc resection rates, complete resection rates, hospital stay duration, cost, complications, and hemoglobin levels were similar in both groups. Irregular-shaped SMTs were more likely to achieve piecemeal resection in both STER and ESE groups (all P < 0.05). Meanwhile, the piecemeal resection rate was significantly higher for larger tumors in the STER group.

CONCLUSION

Compared with ESE, STER does not show overt advantages for cardial SMTs. However, ESE is superior to STER for reduced operation time. Irregular tumor shape seems to be a risk factor for piecemeal resection in both STER and ESE.

Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases

OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.

Submucosal Tunneling Endoscopic Resection for the Treatment of Gastrointestinal Submucosal Tumors Originating from the Muscularis Propria Layer

Surgical resection and endoscopic resection comprise two alternative options for the treatment of submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. Endoscopic resection is minimally invasive compared with surgical resection. Conventional non-tunneling techniques, such as endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), and endoscopic full-thickness resection (EFR) have been demonstrated to be safe and effective. However, these techniques fail to maintain the integrity of the mucosa and induce high risk of perforation, infection, and postoperative strictures. Submucosal tunneling endoscopic resection (STER) is a novel surgical technique that can maintain the integrity of the mucosa by establishing a tunnel between the submucosal and the MP layers. STER has been proven to be effective and safe for the treatment of SMTs. Currently, STER has become a standard treatment for gastrointestinal (GI) SMTs originating from the MP layer, notably in China. In the present review, we describe the indications, procedures, postoperative care, efficacy and safety outcomes, and future perspectives of STER for GI SMTs originating from the MP layer.

Factors affecting the effectiveness and safety of submucosal tunneling endoscopic resection for esophageal submucosal tumors originating from the muscularis propria layer. Surg Endosc. 2018;32:1255-1264. [PMID: 28842802 DOI: 10.1007/s00464-017-5800-x]

BACKGROUND AND AIMS

Submucosal tunneling endoscopic resection (STER) has been proved to be effective and safe for esophageal submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. This study was aimed to further evaluate the effectiveness, safety, and influencing factors especially the types of mucosal incision of STER in a larger population.

METHODS

A total of 89 patients undergoing STER with esophageal SMTs were retrospectively enrolled in this study from May 2012 to November 2016. Clinicopathological, endoscopic, and adverse events (AEs) data were collected and analyzed. Different incision methods were compared to evaluate the optimum incision method.

RESULTS

There were 27 females and 62 males with mean age of 46.5 ± 10.3 years. The medium size of the tumors was 16.0 mm (ranging 10.0-60.0 mm). Inverted T incisions were made in 29 (32.6%) patients, transverse incisions in 12 (13.5%) while longitudinal incisions in 48 (53.9%). En bloc resection was achieved in 70 (78.7%) patients. The residual rate was 1.1% (1/89), and no recurrence was noted even after piecemeal resection. The rate of AEs was 21.3% (19/89), and all of the AEs were cured without intervention or treated conservatively without the need for surgery. The en bloc resection rate was comparable among the three incision groups (P = 0.868); however, the incidence of AEs in the inverted T incision was lower than that in the longitudinal incision (P = 0.003). Fewer clips were used in the inverted T incision group than in the transverse incision group (P = 0.003).

CONCLUSIONS

Although STER failed to achieve en bloc resection in 21.3% patients, it was still an effective therapy owing to low residual rate and no recurrence rate after piecemeal resection. STER was safe with no severe AEs; however, minor AEs were common. Inverted T incision seems to be the optimum entry point.

Effect of submucosal tunneling endoscopic resection for submucosal tumors at esophagogastric junction and risk factors for failure of en bloc resection

BACKGROUND AND AIMS

Most submucosal tumors (SMTs) in the esophagogastric junction (EGJ) are irregularly shaped and different from those in the esophagus, where submucosal tunneling endoscopic resection (STER) has been proven effective and safe. However, few reports paid attention to STER for SMTs in the EGJ. The aim of the study was not only to evaluate the effect of STER in patients with SMTs in the EGJ but to analyze the risk factors for failure of en bloc resection.

METHODS

A consecutive of 47 patients with SMTs originating from the muscularis propria (MP) layer in the EGJ underwent STER were retrospectively included between September 2012 and December 2016. Thirty-five tumors underwent en bloc resection, and the other 12 tumors received piecemeal resection. The tumor size, operation time, en bloc resection rate, complications, residual, and local recurrence were achieved and compared between the two groups.

RESULTS

Forty-six of 47 lesions (97.9%) were successfully resected. The mean lesion size was 29.7 ± 16.3 mm. Both the en bloc resection rate and complete resection rate were 74.5% (35/47). No severe complications occurred in the 47 patients. Patients in the piecemeal resection group had more irregularly shaped lesions, longer tumor diameter, larger tumor size (≥40 mm), longer operation time, and longer hospital stay after procedure (P < 0.05), and there were no statistically differences between the two groups in in-operative complications, post-operative complications, and residual rate (P > 0.05). By univariate analysis and stepwise logistic regression analysis, irregular shape and tumor diameter ≥20 mm were two risk factors for failure of en bloc resection.

CONCLUSIONS

STER is an effective and safe technique for the treatment of SMTs arising from the MP layer in the EGJ. Irregular shape and tumor diameter ≥20 mm are the reliable risk factors for en bloc resection failure.

Submucosal tunneling endoscopic resection of upper gastrointestinal tract tumors arising from muscularis propria

The management of incidentally discovered small upper gastrointestinal (GI) tract submucosal tumors (SMT) remains debatable. In this review, we summarize the evolving experience with submucosal tunneling endoscopic resection (STER) of upper GI SMTs originating from the muscularis propria. From 16 original studies, we reviewed a total of 703 patients with 736 lesions. Of these, 436 were located in the esophagus, 146 in the esophagogastric junction (EGJ) and 154 in the stomach. The composite complete resection rate (CRR) for STER of upper GI tumors arising from the muscularis propria layer was 99.8% (445/446). The composite CRR for STER of esophageal, EGJ and gastric SMTs arising from the muscularis propria layer was 100% (208/208),100% (78/78)and 100% (115/115), respectively. The composite en bloc resection rate (EBRR) for STER of upper GI tumors arising from the muscularis propria layer was 94.6% (679/718). The composite EBRR for STER of esophageal, EGJ and gastric SMTs arising from the muscularis propria layer was 98.6% (205/208), 96.2% (75/78) and 97.9% (95/97), respectively. Tumor recurrence rate was 0%. The reported complication rate for STER was high but the majority responded to conservative management. STER is a minimally invasive and efficacious alternative to surgery, especially for patients with small tumors (<3 cm). Careful selection of candidates remains crucial for excluding potentially malignant tumors.

Submucosal Tunneling Endoscopic Resection of a Leiomyoma Originating from the Muscularis Propria of the Gastric Cardia (with Video)

While endoscopic submucosal dissection (ESD) is widely used to treat gastrointestinal tumors, it is rarely used for subepithelial tumors (SETs) originating from the muscularis propria of the esophagus and gastric cardia because of the risk of perforation and problems with inadequate space and field of view during procedures. Submucosal tunneling endoscopic resection (STER) is a new therapeutic method for treating SETs in specific locations in the esophagus and stomach. This technique is highly skill-dependent, using a mucosal flap that covers a deeper part of the gut wall, but is safe and minimally invasive compared with conventional endoscopic approaches such as ESD in SETs originating from the muscularis propria.We report a patient who underwent STER to remove a SET located at the gastric cardia. The patient recovered without any complications. We believe that our case shows the efficacy and safety of the STER technique for patients with a SET originating from the muscularis propria.

Comparison between submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric stromal tumors originating from the muscularis propria layer. Surg Endosc. 2017;31:3376-3382. [PMID: 27864722 DOI: 10.1007/s00464-016-5350-7]

BACKGROUND

Both submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) are effective method for treating gastric gastrointestinal stromal tumors (GISTs); however, little is known about the comparison between STER and EFTR. The aim of the study was to compare the safety and efficacy of STER and EFTR for treating gastric GIST.

METHODS

We retrospectively collected the clinical data about patients with gastric GISTs who received STER or EFTR at our hospital from April 2011 to June 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, length of stay, cost and follow-up data were compared between STER and EFTR.

RESULTS

A total of 52 patients were enrolled, and 20 of them received STER, while the other 32 cases received EFTR. There was no significant difference between the two groups in terms of gender, age, concomitant diseases, tumor size, en bloc resection rate, operation time, complications, pathohistological grade of GIST, hospital stay and cost (P > 0.05). However, patients who received EFTR had a longer suture time and needed more clips to close the gastric-wall defect (STER vs EFTR, 291.5 ± 68.7 vs 380.6 ± 96.9s and 6.0 ± 1.2 vs 7.6 ± 1.6, P < 0.05). No recurrence was noted in the STER and EFTR groups during a mean follow-up of 10.9 and 23.8 months, respectively.

CONCLUSIONS

The treatment efficacy between STER and EFTR for treating gastric GISTs was comparable, and a large-scale, randomized study is necessary for a more confirmed conclusion.

Submucosal tunneling endoscopic resection for gastrointestinal submucosal tumors originating from the muscularis propria layer

Submucosal tunneling endoscopic resection (STER) is a novel endoscopic technique for gastrointestinal submucosal tumors (SMT) originating from the muscularis propria layer, and has been proved to be effective by clinical studies. STER was initially created for esophageal and cardia SMT, but its indications have expanded due to the implication and modification of this technique. Herein, we review the indications, procedure, efficacy and complications of STER.

Comparison between submucosal tunneling endoscopic resection and video-assisted thoracoscopic surgery for large esophageal leiomyoma originating from the muscularis propria layer

BACKGROUND

Submucosal tunneling endoscopic resection (STER) has been proved to be safe and effective for removal of esophageal leiomyoma originating from the muscularis propria (MP) layer. However, there are still technical challenges for tumors ≥35 mm due to the limited space of the submucosal tunnel. The aim of the study was to estimate the safety and efficacy of STER for large esophageal leiomyoma originating from the MP layer as well as compare its efficacy with video-assisted thoracoscopic surgery (VATS), which is a standard procedure for treating esophageal leiomyoma.

METHODS

We retrospectively collected the clinical data of the patients with esophageal leiomyoma of 35-55 mm who underwent STER or VATS at our hospital between January 2010 and December 2014. Epidemiological data (gender, age), tumor location, tumor size, procedure-related parameters, complications, length of stay and cost were compared between STER and VATS.

RESULTS

A total of 31 patients were enrolled, and 18 patients underwent STER and the other 13 received VATS. There was no significant difference between the two groups in gender, age, tumor location, tumor size, complications and rate of en bloc resection (P > 0.05). However, patients in the STER groups had a shorter operation time, a less decrease in hemoglobin level, a shorter length of hospital stay and a decreased cost (P < 0.05). No recurrence was noted in the STER and VATS groups during a mean follow-up of 10.9 and 30.8 months, respectively.

CONCLUSIONS

The treatment efficacy was comparable between the STER and VATS for esophageal leiomyoma of 35-55 mm. However, STER is superior to VATS in a shorter operation time, a less decrease in hemoglobin level, a shorter length of hospital stay and a decreased cost.

Endoscopic treatments for small gastric subepithelial tumors originating from muscularis propria layer

Minimally invasive endoscopic resection has become an increasingly popular method for patients with small (less than 3.5 cm in diameter) gastric subepithelial tumors (SETs) originating from the muscularis propria (MP) layer. Currently, the main endoscopic therapies for patients with such tumors are endoscopic muscularis excavation, endoscopic full-thickness resection, and submucosal tunneling endoscopic resection. Although these endoscopic techniques can be used for complete resection of the tumor and provide an accurate pathological diagnosis, these techniques have been associated with several negative events, such as incomplete resection, perforation, and bleeding. This review provides detailed information on the technical details, likely treatment outcomes, and complications associated with each endoscopic method for treating/removing small gastric SETs that originate from the MP layer.

Clinical impact of submucosal tunneling endoscopic resection for the treatment of gastric submucosal tumors originating from the muscularis propria layer (with video). Surg Endosc. 2015;29:3640-3646. [PMID: 25740640 DOI: 10.1007/s00464-015-4120-2]

BACKGROUND

Submucosal tunneling endoscopic resection (STER) can be adequately adopted as an effective treatment for submucosal tumors (SMTs) originating from the muscularis propria (MP) layer at the esophagus and cardia. However, it has been seldom used for gastric SMTs. Our purpose was to evaluate the clinical impact of STER for gastric SMTs arising from the MP layer.

METHODS

Thirty-two patients with gastric SMTs from the MP layer were retrospectively included. The main outcome measurements were complete resection rate, adverse events, local recurrence, and distant metastases during follow-up.

RESULTS

Of the 32 lesions, 12 were located in the gastric corpus close to the cardia, 3 in the gastric fundus close to the cardia, 6 in the lesser curvature of the gastric corpus, and 11 in the greater curvature of the gastric antrum. STER was successfully performed in all patients with en bloc resection of tumors. The mean tumor size was 2.3 cm (range 1.0-5.0 cm). The complete resection rate was 100%. The operation time ranged from 25 to 125 min (mean 51.8 min). All complications related to STER were successfully managed with conservative treatments. Local recurrence or distant metastasis did not occur during a follow-up period of 6-32 months.

CONCLUSION

STER is a safe and effective therapeutic strategy for eligible gastric SMTs originating from the MP layer. Submucosal tunneling in the stomach may be more challenging than that in the esophagus, but does not increase procedure-related adverse events or prevent successful STER for eligible gastric SMTs.

Value of submucosal tunneling endoscopic resection in treatment of upper gastrointestinal muscularis propria tumors

AIM: To assess the feasibility and safety of submucosal tunneling endoscopic resection (STER) in the treatment of upper gastrointestinal muscularis propria tumors, and the value of endoscopic ultrasonography (EUS) in pre-therapy detection of these tumors.

METHODS: All patients with muscularis propria tumors were diagnosed by EUS. Twenty-four patients were treated by STER, and the other 15 patients treated by surgery were used as controls. Clinical effects were compared for the two groups.

RESULTS: In the STER group, three patients were found to have tumors located in the muscularis mucosa and converted to other forms of treatment during operation. For the other cases, the average diameter of resected tumors was similar to that in the control group (P > 0.05). The treatment time for esophagus tumors had no significant difference between the two groups (P > 0.05). However, for stomach tumors, STER was faster than surgery (P < 0.01). Patients in the STER group needed shorter hospitalizing time (P < 0.01) and less cost (P < 0.05) compared with controls. Postoperative pathological examination demonstrated that the rate of correct preoperative diagnosis by EUS was 92.3%.

CONCLUSION: STER is safe and efficient in the treatment of upper gastrointestinal muscularis propria tumors. EUS is important in determining the tumor location and treatment manner.

Submucosal tunneling endoscopic resection of esophageal submucosal tumors originating from the muscularis propria layer: A retrospective analysis

AIM: To evaluate the safety and efficacy of submucosal tunneling endoscopic resection (STER) for esophageal submucosal tumors (SMTs) originating from the muscularis propria layer.

METHODS: Between April 2012 and August 2013, 5 patients with esophageal SMTs originating from the muscularis propria layer were treated by STER. The key steps were as follows: (1) creating a submucosal tunnel to uncover the tumor; (2) resecting the tumor en bloc by endoscopic resection techniques; and (3) closing the mucosal incision site after the tumor was removed.

RESULTS: STER was successfully performed in all 5 cases (success rate: 100%). The mean tumor size was 1.6 cm (range, 1.0-2.5 cm). The mean procedure time was 108.6 min (range, 80-138 min). The average hospital stay was 5.8 d (range, 5-7 d). The mean number of clips used was 7 (5-9). Pathological diagnosis of the tumors was leiomyoma (4/5) and mesenchymal tumor (1/5) with lateral and basal resection margins free of tumor tissue. During the procedure, one patient developed subcutaneous emphysema, who recovered after conservative treatment. No residual or recurrent tumors were detected during the 6-mo (4 patients) and 12-mo (1 patient) follow-up period.

CONCLUSION: STER seems to be a safe and effective procedure for treatment of esophageal SMTs originating from the muscularis propria layer, but its indications need to be further investigated.