Submucosal tunnelling endoscopic resection for the treatment of esophageal submucosal tumours originating from the muscularis propria layer: an analysis of 15 cases

Submucosal Tunneling Endoscopic Resection for Upper Gastrointestinal Subepithelial Lesions: A Systematic Review and Meta-Analysis

AIM

Submucosal tunneling endoscopic resection (STER) is an advanced endoscopic technique used for the minimally invasive removal of subepithelial lesions of the gastrointestinal (GI) tract. The aim of this study was to evaluate the safety and efficacy of STER for upper gastrointestinal subepithelial lesions.

METHODS

A comprehensive search of major scholar databases (until December 15, 2023) was performed. Complete resection rate was considered the primary outcome. En bloc resection, operation duration, length of stay (LOS), local recurrence, and periprocedural complications were considered secondary outcomes. Random-effects (RE) and fixed-effects (FE) models were used to generate the outcome estimates.

RESULTS

A total of 37 studies and 3795 patients were included. Pooled proportion of complete resection was 99% (95% CI 98.4-99.6%, p < 0.001). En bloc resection was achieved at 87.7% of cases. Overall mean operation duration was 64.2 min, while mean LOS was estimated at 4.93 days. The local recurrence rate was 0.1%. The two most common complications associated with STER were subcutaneous emphysema (5.5%) and pneumothorax (3%).

CONCLUSION

STER is a highly feasible and safe treatment modality for upper GI subepithelial lesions.

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.

Risk stratification in patients with upper gastrointestinal submucosal tumors undergoing submucosal tunnel endoscopic resection

Background

A substantial heterogeneity exists in patients with upper gastrointestinal submucosal tumors (SMTs). This study aimed to identify predictors of long procedure time (≥60 min), occurrence of procedure-related complications, and long hospital stay (≥6 days) in patients with SMTs undergoing submucosal tunnel endoscopic resection (STER) and stratify risk based on the predictors.

Methods

Sixty-six consecutive patients with upper gastrointestinal SMTs undergoing STER between January 2013 and December 2018 were retrospectively included. Binary logistic regression models were developed to identify predictors of outcomes. Receiver operating characteristic (ROC) curves were constructed to evaluate the discrimination of tumor size.

Results

Complete resection and en bloc resection of tumor were achieved in 66 (100%) and 64 patients (97%), respectively. Twenty-seven patients (41%) had a long procedure time, 10 (15%) developed STER-related complications, and 17 (26%) had a long hospital stay. On multivariable analysis, tumor size was an independent predictor of long procedure time (OR 1.37, 95% CI 1.13-1.67; p = 0.001), occurrence of complications (OR 1.06, 95% CI 1.01-1.10; p = 0.012), and long hospital stay (OR 1.05, 95% CI 1.01-1.09; p = 0.035). ROC curves identified a tumor of size 25 mm as the best cutoff; those who had a tumor above this value had a 76-fold risk of long procedure time, 8.56-fold risk of occurrence of complications, and 6.35-fold risk of long hospital stay.

Conclusion

Patients with a tumor size ≥25 mm had longer procedure time, higher risk of STER-related complications, and longer hospital stay; therefore, they should be classified as a high-risk group.

Subepithelial tumors: How does endoscopic full-thickness resection & submucosal tunneling with endoscopic resection compare with laparoscopic endoscopic cooperative surgery?

Background and study aims  Endoscopic techniques are rapidly emerging for resection of subepithelial tumors (SETs). Submucosal tunneling for endoscopic resection (STER), endoscopic full-thickness resection (EFTR) and laparoscopic endoscopic cooperative surgery (LECS) are current alternatives to open surgery. In this study, we aimed to compare the three endoscopic techniques. Patients and methods  Consecutive patients who underwent resection of a submucosal esophageal or gastric lesion at several tertiary care centers were included in a dedicated registry over 3 years. Demographics, size and location of resected lesion, histology of specimen, length of procedure, adverse events (AEs), duration of hospital stay, and follow-up data were collected. Results  Ninety-six patients were included (47.7 % male, mean age 62): STER n = 34, EFTR n = 34, LECS n = 280. The lesions included leiomyoma, gastrointestinal stromal tumors (GISTs) and other. The mean lesion size was 28 mm (STD 16, range 20-72 mm). The majority of lesions in the EFTR and laparoscopic-assisted resection group were GISTs. There was no significant difference in clear resection margins, post-procedure complication rates, recurrence rate and total follow-up duration between the groups. However, the LECS group had a procedure time at least 30 minutes longer than STER or EFTR ( P  < 0.01). Total hospital stay for the laparoscopic-assisted resection group was also longer when compared to STER (1.5) and EFTR (1.8) ( P  < 0.01). Conclusions  STER, EFTR, and laparoscopic-assisted resection are efficacious approaches for resection of SETs with similar R0 resection rates, complication rates, and AE rates. Laparoscopic assisted resection appears more time-consuming and is associated with a longer hospital stay.

Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends endoscopic ultrasonography (EUS) as the best tool to characterize subepithelial lesion (SEL) features (size, location, originating layer, echogenicity, shape), but EUS alone is not able to distinguish among all types of SEL.Strong recommendation, moderate quality evidence. 2: ESGE suggests providing tissue diagnosis for all SELs with features suggestive of gastrointestinal stromal tumor (GIST) if they are of size > 20 mm, or have high risk stigmata, or require surgical resection or oncological treatment.Weak recommendation, very low quality evidence. 3: ESGE recommends EUS-guided fine-needle biopsy (EUS-FNB) or mucosal incision-assisted biopsy (MIAB) equally for tissue diagnosis of SELs ≥ 20 mm in size.Strong recommendation, moderate quality evidence. 4: ESGE recommends against surveillance of asymptomatic gastrointestinal (GI) tract leiomyomas, lipomas, heterotopic pancreas, granular cell tumors, schwannomas, and glomus tumors, if the diagnosis is clear.Strong recommendation, moderate quality evidence. 5: ESGE suggests surveillance of asymptomatic esophageal and gastric SELs without definite diagnosis, with esophagogastroduodenoscopy (EGD) at 3-6 months, and then at 2-3-year intervals for lesions < 10 mm in size, and at 1-2-year intervals for lesions 10-20 mm in size. For asymptomatic SELs > 20 mm in size that are not resected, ESGE suggests surveillance with EGD plus EUS at 6 months and then at 6-12-month intervals.Weak recommendation, very low quality evidence. 6: ESGE recommends endoscopic resection for type 1 gastric neuroendocrine neoplasms (g-NENs) if they grow larger than 10 mm. The choice of resection technique should depend on size, depth of invasion, and location in the stomach.Strong recommendation, low quality evidence. 7: ESGE suggests considering removal of histologically proven gastric GISTs smaller than 20 mm as an alternative to surveillance. The decision to resect should be discussed in a multidisciplinary meeting. The choice of technique should depend on size, location, and local expertise.Weak recommendation, very low quality evidence. 8: ESGE suggests that, to avoid unnecessary follow-up, endoscopic resection is an option for gastric SELs smaller than 20 mm and of unknown histology after failure of attempts to obtain diagnosis.Weak recommendation, very low quality evidence. 9: ESGE recommends basing the surveillance strategy on the type and completeness of resection. After curative resection of benign SELs no follow-up is advised, except for type 1 gastric NEN for which surveillance at 1-2 years is advised.Strong recommendation, low quality evidence. 10: For lower or upper GI NEN with a positive or indeterminate margin at resection, ESGE recommends repeating endoscopy at 3-6 months and another attempt at endoscopic resection in the case of residual disease.Strong recommendation, low quality evidence.

A Review of Endoscopic Full-thickness Resection, Submucosal Tunneling Endoscopic Resection, and Endoscopic Submucosal Dissection for Resection of Subepithelial Lesions

Gastrointestinal subepithelial tumors (SETs) are often found while performing routine endoscopy. Recently, there has been the development of new endoscopic techniques such as endoscopic submucosal dissection, submucosal tunnel endoscopic resection, and endoscopic full-thickness resection, all minimally invasive approaches which have made it possible to resect SETs that were previously resected with surgery. This review discusses the endoscopic treatment of patients with SETs, outcomes for endoscopic treatment, procedure-related complications, and advantages and disadvantages of these endoscopic techniques.

Submucosal Tunneling Endoscopic Resection

Minimally invasive endoscopic resection procedures continue to evolve, with submucosal tunneling endoscopic resection (STER) being a durable option for en bloc resection of submucosal tumors. Whether STER can be effectively used for larger (>3.5 cm) lesions remains to be seen. STER-ET is a novel approach for removal of extraluminal tumors, but data are currently limited to support its use.

The retrospective comparison between submucosal tunneling endoscopic resection and endoscopic submucosal excavation for managing esophageal submucosal tumors originating from the muscularis propria layer

BACKGROUND

Submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) were recently introduced to cure submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. This study aimed to compare clinical performance and safety of STER and ESE in treating esophageal SMTs originating from the MP layer.

METHODS

From January 2011 to December 2017, retrospective data collection and follow-up were applied for all STER or ESE cases with esophageal SMTs originating from the MP layer in our endoscopy center, including clinical characteristics, procedure success, efficacy, and adverse events. Subgroup analysis was further done based on tumor size and origin.

RESULTS

90 STER and 77 ESE were enrolled in this study. There were no significant difference for  patient characteristics, procedure performance, and complications for ESE and STER intervention (P > 0.05). STER was faster than ESE (3.90 mm²/min vs 2.82 mm²/min, P < 0.05). For large tumors (≥ 20 mm), both techniques had the similar performance (P > 0.05), while STER led to the shorter hospitalization (4.0d vs 7.0d, P < 0.05) and lower postoperative complication (16.3% vs 45.5%, P < 0.05). For small tumors (< 20 mm), STER achieved faster operation (STER vs ESE, 2.57 mm²/min vs 1.83 mm²/min, P < 0.05). Regardless of tumor origin, there were no significant difference for both techniques, but STER resulted in short hospitalization for SMTs from the deep MP layer (STER vs ESE, 5.0d vs 7.0d, P < 0.05). During the follow-up, 2 residual and 4 recurrence occurred in the STER group, as well as 1 residual and 2 recurrence in the ESE group.

CONCLUSIONS

Both STER and ESE were effective for treating esophageal SMTs originating from the MP layer. STER might be better due to its faster operation, less complications, and shorter hospitalization.

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.

Current status of submucosal tunneling endoscopic resection for gastrointestinal submucosal tumors originating from the muscularis propria layer

Gastrointestinal submucosal tumors (SMTs) have been increasingly identified via the use of endoscopic ultrasonography, and removal is often recommended for SMTs that are >2 cm in diameter or symptomatic. Submucosal tunneling endoscopic resection (STER), also known as submucosal endoscopic tumor resection, endoscopic submucosal tunnel dissection or tunneling endoscopic muscularis dissection, is a novel endoscopic technique for treating gastrointestinal SMTs originating from the muscularis propria layer, and has been demonstrated to be effective in the removal of SMTs with a decreased rate of recurrence by clinical studies. STER may be performed for patients with esophageal or cardia SMTs, and its application has expanded beyond these types of SMTs due to modifications to the technique. The present study reviewed the applications, procedure, efficacy and complications associated with STER.

Submucosal tunneling endoscopic resection using methylene-blue guidance for cardial subepithelial tumors originating from the muscularis propria layer

Submucosal tunneling endoscopic resection (STER) of subepithelial tumors (SETs) originating from the muscularis propria (MP) layer in the cardia is rarely performed due to the difficulty of creating a submucosal tunnel for resection. The aim of this study is to evaluate the feasibility of STER using methylene-blue guidance for SETs originating from the MP layer in the cardia. From January 2012 to December 2014, 56 patients with SETs originating from the MP layer in the cardia were treated with STER using methylene-blue guidance. The complete resection rate and adverse event rate were the main outcome measurements. Successful complete resection by STER was achieved in all 56 cases (100%). The median size of the tumor was 1.8 cm. Nine patients (15.3%) had adverse events including subcutaneous emphysema, pneumoperitoneum, pneumothorax, and pleural effusion. These nine patients recovered successfully after conservative treatment without endoscopic or surgical intervention. No residual or recurrent tumors were detected in any patient during the follow-up period (median, 25 months). The adverse event rate was significantly higher for tumors originating in the deeper MP layers (46.7%) than in the superficial MP layers (4.9%) (P < 0.05), differed significantly according to tumor size (5.4% for tumors < 2.0 cm vs. 36.8% for tumors ≥ 2.0 cm; P < 0.05), and also differed significantly in relation to the tumor growth pattern (4.1% for the intraluminal growth vs. 100% for the extraluminal growth; P < 0.001). STER using methylene-blue guidance appears to be a feasible method for removing SETs originating from the MP layer in the cardia.

Submucosal tunneling endoscopic resection using methylene-blue guidance for cardial subepithelial tumors originating from the muscularis propria layer

Submucosal tunneling endoscopic resection (STER) of subepithelial tumors (SETs) originating from the muscularis propria (MP) layer in the cardia is rarely performed due to the difficulty of creating a submucosal tunnel for resection. The aim of this study was to evaluate the feasibility of STER using methylene-blue guidance for SETs originating from the MP layer in the cardia. From January 2012 to December 2014, 56 patients with SETs originating from the MP layer in the cardia were treated with STER using methylene-blue guidance. The complete resection rate and adverse event rate were the main outcome measurements. Successful complete resection by STER was achieved in all 56 cases (100%). The median size of the tumor was 1.8 cm. Nine patients (15.3%) had adverse events including subcutaneous emphysema, pneumoperitoneum, pneumothorax, and pleural effusion. These nine patients recovered successfully after conservative treatment without endoscopic or surgical intervention. No residual or recurrent tumors were detected in any patient during the follow-up period (median, 25 months). The adverse event rate was significantly higher for tumors originating in the deeper MP layers (46.7%) than in the superficial MP layers (4.9%) (P < 0.05), differed significantly according to tumor size (5.4% for tumors < 2.0 cm vs. 36.8% for tumors ≥ 2.0 cm; P < 0.05), and also differed significantly in relation to the tumor growth pattern (4.1% for the intraluminal growth vs. 100% for the extraluminal growth; P < 0.001). STER using methylene-blue guidance appears to be a feasible method for removing SETs originating from the MP layer in the cardia.

Non-Exposed Endoscopic Wall-Inversion Surgery for Gastrointestinal Stromal Tumor of the Stomach: First Case Report in Korea

Laparoscopic wedge resection of the stomach is a widely accepted treatment for primary resectable gastrointestinal stromal tumors (GISTs). However, it is difficult to determine the appropriate incision line from outside of the stomach, and many attempts have been made to avoid unnecessary resection of unaffected gastric tissues. Recently a technique called non-exposed endoscopic wall-inversion surgery (NEWS) was introduced to avoid exposure of GIST to the peritoneum. Here, we describe the first published case of NEWS for GIST of the stomach practiced in Korea.

Safety of Endoscopic Resection for Upper Gastrointestinal Subepithelial Tumors Originating from the Muscularis Propria Layer: An Analysis of 733 Tumors

OBJECTIVES

Although endoscopic resection is an accepted technique for upper gastrointestinal subepithelial tumors (SETs) originating from the muscularis propria (MP) layer, published data regarding its complications are highly variable and limited to small data series. This study aimed to analyze the safety of endoscopic resection in a large case series.

METHODS

A total of 726 consecutive patients with 733 upper gastrointestinal SETs originating from the MP layer underwent endoscopic resection from June 2005 to December 2014. The complete resection rate, perioperative perforation rate, and perioperative bleeding rate were the main outcome measurements.

RESULTS

The complete resection rate was 97.1%. Ninety-four patients had complications (12.9%), including 88 with perioperative perforations (12.1%), 13 with perioperative bleeding (1.8%), 5 with localized peritonitis (0.7%), and one with delayed bleeding (0.1%). Eleven patients required surgery; the others were treated endoscopically. Risk factors for incomplete resection were extensive connection of the tumor to the MP layer (P=0.007) and extraluminal growth (P=0.048). Risk factors for perioperative perforation were larger tumor size (≤2.0 cm vs. 2.1-3.0 cm vs. >3.0 cm, P=0.021), extraluminal growth (P=0.046), and extensive connection (P<0.001). A risk factor for perioperative bleeding was larger tumor size (P=0.045). No residual or recurrent lesions were detected during the follow-up period (median: 28 months).

CONCLUSIONS

Endoscopic resection is an effective and reasonably safe therapeutic method for treating/removing upper gastrointestinal SETs originating from the MP layer when managed by an experienced endoscopic team.

Value of oral gastric ultrasound contrast agent in diagnosis of gastric submucosal lesions

AIM: To assess the value of oral gastric ultrasound contrast agent in the diagnosis of gastric submucosal lesions.

METHODS: Two hundred and eighty-five patients who were diagnosed with gastric submucosal lesions and treated at the First Affiliated Hospital of Huzhou Teachers College from February 2005 to February 2015 were included. The patients initially underwent ordinary ultrasonic examination, and then the patients were given an oral gastric ultrasound contrast agent to undergo ultrasonic examination again. Ultrasonic examination results were compared with surgical results.

RESULTS: There were many types of gastric lesions, with gastric cyst (127 cases), leiomyoma (58 cases), and ectopic pancreas (46 cases) being the top three. Ultrasonic imaging with an oral gastric ultrasound contrast agent had a significantly higher accuracy in diagnosing gastric cyst, leiomyoma, stromal tumor, ectopic pancreas, gastric varices, inflammatory mucosal hyperplasia, lipoma, and chamber oppression than ordinary ultrasound (P < 0.05).

CONCLUSION: Oral gastric ultrasound contrast agent can help improve the accuracy of ultrasound in the diagnosis of gastric submucosal lesions.

New NOTES Clinical Training and Program Development

Natural orifice translumenal endoscopic surgery (NOTES) is an intense area of research, and is arguably the most significant endoscopic innovation of this decade. Training for new NOTES is a relatively long, encompassing advanced endoscopy training, mastery of endoscopic dexterity within the narrow submucosal or "third space" with an in-depth understanding of the tissue planes. Proficiency with new closure and hemostatic devices is also essential. Few institutions worldwide can provide all the cognitive and technical elements essential to train new NOTES trainees. Trainees may need to spend time across several institutions to ensure safe and effective practice of new NOTES.

Comparison of endoscopic submucosal dissection and surgery for the treatment of gastric submucosal tumors originating from the muscularis propria layer: a single-center study (with video)

INTRODUCTION

Endoscopic submucosal dissection (ESD) has been used for the treatment of gastric submucosal tumors (SMTs). This study aims to compare clinical outcomes of ESD versus laparoscopic wedge resection (LWR) for gastric SMTs.

METHODS

This is a retrospective cohort study. Patients with SMTs who underwent ESD or LWR were enrolled in this study at a university-affiliated hospital from January 2010 to October 2015. Preoperative endoscopic ultrasound and computed tomography were performed to determine origin of layer and growth pattern. Clinical outcomes including baseline demographics, tumor size, operation time, blood loss, hospital stay, cost, pathology and postoperative complications were compared.

RESULTS

From January 2010 to October 2015, 68 patients with SMTs received ESD and 47 patients with SMTs received LWR. There was no difference in age, gender, body mass index, origin of layer and proportion with symptoms between ESD group and LWR group. However, tumor size was significantly larger in the LWR group (37.1 mm) than in the ESD group (25.8 mm, P = 0.041). For patients with tumors smaller than 20 mm, ESD was associated with shorter mean operation time (89.7 ± 23.5 vs 117.6 ± 23.7 min, P = 0.043), less blood loss (4.9 ± 1.7 vs 72.3 ± 23.3 ml, P < 0.001), shorter length of hospital stay (3.6 ± 1.9 vs 6.9 ± 3.7 days, P = 0.024) and lower cost (2471 ± 573 vs 4498 ± 1257 dollars, P = 0.031) when compared with LWR. For patients with tumors between 20 mm and 50 mm, ESD was associated with shorter mean operation time (99.3 ± 27.8 vs 125.2 ± 31.5 min, P = 0.039), less blood loss (10.1 ± 5.3 vs 87.6 ± 31.3 ml, P < 0.001), shorter length of hospital stay (4.0 ± 1.7 vs 7.3 ± 4.5 days, P = 0.027) and lower cost (2783 ± 601 vs 4798 ± 1343 dollars, P = 0.033) when compared with LWR. There were no significant differences in terms of rates of en bloc resection, complete resection and complication and histological diagnosis regardless of tumor size.

CONCLUSIONS

ESD can achieve similar oncological outcomes when compared with surgery for treatment of gastric SMT smaller than 50 mm.

Complete circular endoscopic resection using submucosal tunnel technique combined with esophageal stent placement for circumferential superficial esophageal lesions

BACKGROUND AND AIMS

At present, removing a circumferential superficial esophageal lesion (SEL) via en bloc resection is still a great challenge. Based on the previous success of submucosal tunneling endoscopic resection, this study aimed to evaluate the safety and effectiveness of complete circular endoscopic resection (CER) using a submucosal tunnel technique combined with esophageal stent placement for patients with circumferential SELs.

METHODS

From August 2012 to June 2014, 23 patients with circumferential SELs were treated by CER using a submucosal tunnel technique combined with esophageal stent placement. The following steps were performed: (1) circular mucosa incisions were made at the anal and oral side of the lesion after marking the margin, (2) two submucosal tunnels were created from the oral to anal side using a hybrid knife, which was followed by submucosal dissection, and (3) following the completion of CER, a retrievable esophageal stent was placed to prevent postoperative stricture.

RESULTS

CER using the submucosal tunnel technique combined with esophageal stent placement was successfully performed for all 23 cases. The complete resection and success rate were 100%, while the mean longitudinal diameter of the lesions was 65 mm. Mediastinal emphysema, pneumothorax, and postoperative stenosis were detected in 8.7% (2/23), 4.3% (1/23), and 17.4% (4/23) of the cases, respectively. Pathological diagnoses of the lesions included carcinomas (13/23) and high-grade intraepithelial neoplasias (10/23). No residual or recurrent tumors were detected in any patient during the follow-up period.

CONCLUSIONS

CER using the submucosal tunnel technique combined with esophageal stent placement seems to be a safe and effective procedure for treating patients with SELs that result in a higher en bloc resection rate with fewer or minor complications.

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.

Submucosal tunneling and endoscopic resection of submucosal tumors at the esophagogastric junction

AIM: To evaluate the safety and efficacy of submucosal tunneling and endoscopic resection (STER) for treating submucosal tumors (SMTs).

METHODS: Between August 2012 and October 2013, 21 patients with SMTs originating from the muscularis propria (MP) layer at the esophagogastric junction were treated by STER of their tumors. Key steps of the procedure include: (1) mucosal incision: a 2-cm longitudinal mucosal incision was made 5 cm proximal to the tumor; (2) submucosal tunneling: a submucosal tunnel was created 5 cm proximal to and 1 to 2 cm distal to the tumor; (3) tumor resection: the SMT was resected under direct endoscopic viewing; (4) hemostasis: while finishing the tumor resection, careful hemostasis of the MP defect and the tunnel was performed; and (5) mucosal closure: the mucosal incision site was closed by using hemostatic clips. During the operation, equipment used included a cap-fitted endoscope, an insulated-tip knife, a hook knife, hemostatic forceps, an injection needle, a snare, an endoclip, and a high-frequency generator. Carbon dioxide (CO₂) insufflation was achieved by using a CO₂ insufflator.

RESULTS: The median age of the patients was 46.2 years (range, 35-59 years), and the majority were male (18 male vs 3 female). Complete resection rate was 100% (21/21). Eighteen lesions were resected en bloc. Mean tumor size was 23 mm (range, 10-40 mm), and mean procedure time was 62.9 min (range, 45-90 min). Pathological diagnosis of these tumors included leiomyoma (15 out of 21) and gastrointestinal stromal tumor (6 out of 21). Full-thickness MP resection was performed in 9 of 21 patients (42.9%), with mediastinal and subcutaneous emphysema occurring in all nine. At the completion of the procedure, all patients received closure of the incision with hemoclips. One patient required percutaneous drainage. The remaining 20 patients required no further endoscopic or surgical intervention. There were no incidents of massive or delayed bleeding. The median follow-up period after the procedure was 6 mo (range, 2-14 mo). During follow-up, no patients were found to have residual or recurrent tumor or esophageal stricture.

CONCLUSION: STER is safe, effective and feasible, which provides accurate histopathologic evaluation and curative treatment for SMTs originating from the MP layer at the esophagogastric junction.

Submucosal tunneling endoscopic resection for simultaneous esophageal and cardia submucosal tumors originating from the muscularis propria layer (with video)

Submucosal tunneling endoscopic resection (STER) is a new treatment technique for upper gastrointestinal submucosal tumors (SMT) originating from the muscularis propria (MP) layer. In contrast to conventional endoscopic resection, the new therapy can maintain the mucosal integrity of the digestive tract, which effectively prevents mediastinitis and peritonitis. STER, although a known method, has not been widely adopted because of technical difficulties. Here, we describe the case of a 30-year-old patient presenting with two separate SMT originating from the esophageal and cardia MP layer. A 2-cm longitudinal mucosal incision was made approximately 5 cm proximal to the esophageal SMT, and the esophageal and cardia SMT were dissected successively in the same submucosal tunnel. In the relevant literature, this is the first case of STER for resecting esophageal and cardia SMT using the same submucosal tunnel.

Endoscopic full-thickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria

BACKGROUND AND AIMS

This retrospective study evaluated the safety and efficacy of endoscopic full-thickness resection (eFTR) with defect closure using clips and an endoloop for the treatment of gastric subepithelial tumors (SETs) arising from the muscularis propria (MP).

METHODS

From January 2009 to December 2012, 51 patients with gastric SETs arising from the MP underwent eFTR with defect closure using clips and an endoloop. The key steps were (1) several milliliters of mixture solution was injected into the submucosa after dots were marked around the tumor; (2) a cross incision was made in the mucosa to reveal the tumor; (3) subsequently, circumferential excavation was performed as deep as the muscularis propria, and full-thickness resection of the tumor was performed with an insulated-tip knife, including its underlying MP and serosa; (4) the gastric wall defect was closed with clips and an endoloop was then placed to fix and tighten all of the clips together.

RESULTS

Successful complete resection by eFTR was achieved in 50 cases (98.0%). One case failed and was converted into a laparoscopic resection due to the tumor falling into the peritoneal cavity during the procedure. The mean procedure time was 52 min. No patients had severe complications, such as massive bleeding, delayed bleeding, peritonitis, or gastrointestinal tract leakage. The mean tumor length was 2.4 cm. Pathological diagnoses of the tumors were leiomyomas (21/51) and gastrointestinal stromal tumors (30/51). The median follow-up period after the procedure was 22.4 months (range 1-48 months), and no residual tumor or tumor recurrence was detected during the follow-up period.

CONCLUSIONS

eFTR with defect closure with clips and an endoloop appears to be a safe and effective technique for the treatment of patients with gastric SETs originating from the MP, especially for those with extraluminal growth or adhesions to the MP.

Expanding indications for ESD: submucosal disease (SMT/carcinoid tumors)

Endoscopic submucosal dissection (ESD) is useful for submucosal tumors (SMTs) within the superficial submucosal layer, but perforation frequently occurs during ESD for SMTs located at the deeper layer. Endoscopic resection for small esophageal SMTs is acceptable, although candidates for endoscopic removal are rare. Laparoscopic assistance will be effective for minimally invasive endoscopic local resection for certain types of gastric SMT. Endoscopic mucosal resection with a ligation device would be better than ESD for rectal carcinoid in terms of simplicity and effectiveness.

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.

Submucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layer

BACKGROUND

This prospective study was designed to evaluate the safety and efficacy of submucosal tunneling endoscopic resection (STER) for small (≤3 cm) upper gastrointestinal (GI) subepithelial tumors (SETs) originating from the muscularis propria (MP) layer.

METHODS

Between August 2011 and February 2013, a total of 85 patients with upper GI SETs originating from the MP layer were treated with STER. The key steps were as follows: (1) locating the tumor by injection of methylene blue or indigo carmine and then creating a submucosal tunnel from 5 cm above the tumor between the submucosal and muscular layers; (2) resecting the tumor by endoscopic resection techniques; (3) closing the mucosal incision site with several clips after the tumor is removed.

RESULTS

Of the 85 SETs, 60 were located in the esophagus, 16 in the cardia, and 9 in the stomach. STER was successfully performed in all cases (success rate: 100 %). The mean tumor size was 19.2 mm. The mean procedure time was 57.2 min. The average hospital stay after the procedure was 5.9 days. Pathological diagnosis of the tumors were leiomyoma (65/85), gastrointestinal stromal tumor (GIST) (19/85), and calcifying fibrous tumor (1/85). During the procedure, eight patients developed pneumothorax, subcutaneous emphysema, and/or pneumoperitoneum. These patients recovered after conservative treatment. The rate of all complications was significantly higher for lesions originating in the deeper MP layer (70 %) than in the superficial MP layer (1.3 %; p < 0.001). The total complication rate for different histological diagnoses was also significantly different (26.3 % for GISTs, 4.6 % for leiomyomas, 0 % for calcifying fibrous tumors, p < 0.05). No residual or recurrent tumors were detected during the follow-up period (median: 8 months).

CONCLUSIONS

Submucosal tunneling endoscopic resection appears to be a feasible, safe, and effective procedure for treatment of small (≤3 cm) upper GI SETs originating from the MP layer.

Retrospective study of endoscopic submucosal tunnel dissection (ESTD) for surgical resection of esophageal leiomyoma

BACKGROUND

Esophageal leiomyoma is benign and often asymptomatic, but if the tumor is too large or obstructive, it should be resected. The aim of this study was to compare a novel approach, endoscopic submucosal tunnel dissection (ESTD), with a more established method, endoscopic submucosal dissection (ESD).

METHODS

This was a retrospective study of 39 patients in Chongqing Xinqiao Hospital, China, undergoing resection for leiomyoma >2 cm in diameter, or 1.5-2.0 cm in diameter with symptoms of obstructive dysphagia. Epidemiological data, presenting symptoms, diagnostic investigations, tumor location, histopathological findings, and safety and efficacy of surgical resection were analyzed.

RESULTS

Mean tumor sizes in the ESTD (n = 18; mean age = 36.7 ± 6.3 years) and ESD (n = 21; age = 41.0 ± 4.4 years) groups were 3.3 ± 0.7 and 3.0 ± 0.4 cm, respectively. The male:female ratio was 25:14, with a distribution of lesions among the lower, middle, and upper esophagus of 22:14:3. Operating time was significantly shorter (p < 0.05) for ESTD (67.5 ± 9.5 min) than for ESD (87.2 ± 7.7 min), while incision healing was faster (p < 0.05) for ESTD (14.7 ± 2.5 days) than for ESD (57.9 ± 7.5 days). Hospital stay was also shorter (p < 0.05) for ESTD (2.3 ± 0.5 days) than for ESD (5.7 ± 1.0 days). Bleeding was the only complication with ESTD (3/18 patients), with no significant difference in the incidence of complications between groups. ESTD was rapidly learned by surgeons.

CONCLUSION

ESTD is a safe and effective treatment for esophageal leiomyoma, with advantages over ESD.