Submucosal tunneling and endoscopic resection of a large, esophageal leiomyoma

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.

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.

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.

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.

POEM and Submucosal Tunneling

OPINION STATEMENT

Submucosal endoscopy has introduced new and important aspects into gastrointestinal endoscopic therapeutics by opening the way to interventions even outside of the GI tract. At present, innovative techniques for submucosal endoscopy in different esophageal diseases include peroral endoscopic myotomy (POEM) for idiopathic achalasia and related motility disorders, submucosal tunneling endoscopic resection (STER) for submucosal tumors arising from the muscularis propria, and endoscopic submucosal tunneling dissection (ESTD) for superficial esophageal neoplastic lesions. POEM for achalasia-still a rare disease-is currently evaluated in comparison to endoscopic and surgical standard therapies, while this procedure enabling a long thoracic myotomy might constitute an advantage over the laparoscopic approach in treatments of spastic esophageal diseases. Removal of smaller submucosal esophageal tumors may appear tempting, but the clinical indications are limited by the facts that the vast majority of such smaller tumors are asymptomatic and benign.For all these innovative and technically demanding techniques, learning curves have to be taken into account, not only with regard to technical competence but also to clinical assessment, ranging from proper indication and patient selection to the management of (potential) complications and logistics/back-up. Although preliminary results from high-skilled endoscopic centers have been very encouraging, long-term data as well as prospective randomized controlled trials are needed to validate the efficacy and safety of the modalities.

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.

Submucosal Tunneling Endoscopic Resection (STER) and Other Novel Applications of Submucosal Tunneling in Humans

The submucosal tunneling technique was originally developed to provide safe access to the peritoneal cavity for natural orifice transluminal endoscopic surgery procedures. With this technique, the submucosal tunnel becomes the working space for partial myotomy and tumor resection. The submucosal space has come to represent the "third space" distinguished from gastrointestinal lumen (first space) and peritoneal cavity (second space). New applications continue to be developed and further clinical applications in the future are anticipated. This article summarizes the current applications of submucosal tunneling endoscopic resection for subepithelial tumors and describes other related uses of submucosal tunneling.