Use of endoscopic ultrasound-guided injection in endoscopic resection of solid submucosal tumors

Implementation of cinematic rendering of gastric masses into clinical practice: a pictorial review

High-resolution CT is the gold standard diagnostic imaging study for staging of gastric malignancies. Cinematic rendering creates a photorealistic evaluation using the standard high-resolution CT volumetric data set. This novel display method offers unique possibilities for the evaluation of gastric masses. Here we present further observations of the role of cinematic rendering in the evaluation of gastric masses at a large tertiary care center. We offer three valuable teaching points for the application of the cinematic rendering for gastric masses with several case examples for each teaching point, discuss potential limitations of cinematic rendering, and review future directions for cinematic rendering in this setting.

Distinction of surgically resected gastrointestinal stromal tumor by near-infrared hyperspectral imaging

The diagnosis of gastrointestinal stromal tumor (GIST) using conventional endoscopy is difficult because submucosal tumor (SMT) lesions like GIST are covered by a mucosal layer. Near-infrared hyperspectral imaging (NIR-HSI) can obtain optical information from deep inside tissues. However, far less progress has been made in the development of techniques for distinguishing deep lesions like GIST. This study aimed to investigate whether NIR-HSI is suitable for distinguishing deep SMT lesions. In this study, 12 gastric GIST lesions were surgically resected and imaged with an NIR hyperspectral camera from the aspect of the mucosal surface. Thus, the images were obtained ex-vivo. The site of the GIST was defined by a pathologist using the NIR image to prepare training data for normal and GIST regions. A machine learning algorithm, support vector machine, was then used to predict normal and GIST regions. Results were displayed using color-coded regions. Although 7 specimens had a mucosal layer (thickness 0.4-2.5 mm) covering the GIST lesion, NIR-HSI analysis by machine learning showed normal and GIST regions as color-coded areas. The specificity, sensitivity, and accuracy of the results were 73.0%, 91.3%, and 86.1%, respectively. The study suggests that NIR-HSI analysis may potentially help distinguish deep lesions.

Local application of bacteria improves safety of Salmonella -mediated tumor therapy and retains advantages of systemic infection

Cancer is a devastating disease and a large socio-economic burden. Novel therapeutic solutions are on the rise, although a cure remains elusive. Application of microorganisms represents an ancient therapeutic strategy, lately revoked and refined via simultaneous attenuation and amelioration of pathogenic properties. Salmonella Typhimurium has prevailed in preclinical development. Yet, using virulent strains for systemic treatment might cause severe side effects. In the present study, we highlight a modified strain based on Salmonella Typhimurium UK-1 expressing hexa-acylated Lipid A. We corroborate improved anti-tumor properties of this strain and investigate to which extent an intra-tumoral (i.t.) route of infection could help improve safety and retain advantages of systemic intravenous (i.v.) application. Our results show that i.t. infection exhibits therapeutic efficacy against CT26 and F1.A11 tumors similar to a systemic route of inoculation. Moreover, i.t. application allows extensive dose titration without compromising tumor colonization. Adverse colonization of healthy organs was generally reduced via i.t. infection and accompanied by less body weight loss of the murine host. Despite local application, adjuvanticity remained, and a CT26-specific CD8⁺ T cell response was effectively stimulated. Most interestingly, also secondary tumors could be targeted with this strategy, thereby extending the unique tumor targeting ability of Salmonella. The i.t. route of inoculation may reap the benefits of systemic infection and aid in safety assurance while directing potency of an oncolytic vector to where it is most needed, namely the primary tumor.

Endoscopic submucosal resection of gastric subepithelial lesions smaller than 20 mm: a comparison of saline solution-assisted snare and cap band mucosectomy techniques

BACKGROUND AND AIMS

Application of endoscopic submucosal resection (ESMR) in the management of gastric subepithelial lesions (GSLs) less than 20 mm is gradually increasing because it allows diagnosis and treatment at the same operative session. In this study, we compare and evaluate the benefits of ESMR with an endoscopic cap band mucosectomy technique or saline solution-assisted snare technique in GSLs smaller than 20 mm.

METHODS

This was a retrospective analysis of a prospectively maintained database used at 2 academic tertiary care centers. A total of 63 patients (34 females, mean age 52 years) with endoscopically resected GSLs were included in this study.

RESULTS

The mean tumor size determined by EUS was 12.3 mm (range, 5-20 mm). Sixty-seven percent of the GSLs were localized in the antrum in all groups. The endoscopic cap band mucosectomy technique was used to resect 32 (50.8%) GSLs, whereas 31 (49.2%) were resected with the saline solution-assisted snare technique. The en bloc resection rates were 97% for the saline solution-assisted snare technique and 100% for the endoscopic cap band mucosectomy. Intraoperative bleeding occurred in 1 of 31 patients (3.2%) when ESMR was performed with the saline solution-assisted snare technique. Postoperative bleeding was seen in 1 of 32 patients (3.1%) who underwent the endoscopic cap band mucosectomy technique.

CONCLUSIONS

In GSLs smaller than 20 mm, ESMR with saline solution-assisted snare or endoscopic cap band mucosectomy techniques is safe, the adverse event rate is low, accurate diagnosis is achieved, and treatment with en bloc resection is provided in a single session. Given similar success and adverse event rates, saline solution-assisted ESMR may be the preferred technique because of its lower cost advantages.

Therapy and follow-up of upper gastrointestinal subepithelial lesions

AIM: To explore the nature, growth, and malignant transformation of upper gastrointestinal submucosal lesions (SMLs), and evaluate the clinical efficacy, necessity and safety of surgery or endoscopic therapy for SMLs.

METHODS: We retrospectively collected 1915 cases of upper gastrointestinal submucous lesions, which were evaluated by endoscopic ultrasonography from January 2014 to December 2014 at our department. This diagnostic modality provided features about lesion location (esophagus and stomach), size, echo performance, layer of origin, etc. Different therapeutic methods were chosen according to the size, origin, and location of SMLs as well as patient's preferences. Clinical treatments included follow-up, endoscopic therapy (endoscopic snare resection, endoscopic resection, endoscopic submucosal resection, endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), submucosal tunneling endoscopic resection, etc.), and surgery (open surgery, laparoscopy, and thoracoscopy). Endoscopic or surgical treatment of SMLs was performed when lesion size was significantly increased or suspected to have malignant transformation. Successful cases, size of the mass and layer of origin (mucosa layer, muscularis mucosa layer, submucosa layer, and serosal layer), complications (bleeding, perforation) and conversion surgery or not were recorded.

RESULTS: In 1135 cases followed by EUS, median age was 50.7 years ± 10.3 years (range, 19-78 years), and male/female ratio was 1.16. There were 687 esophageal SMLs and 448 gastric SMLs followed by regular endoscopy (range, 3-60 mo). Esophageal cases at initial measurement had a mean size of 0.82 cm ± 0.24 cm, and gastric cases had an initial mean size of 1.31 cm ± 0.44 cm. Of the followed cases of esophagus SMLs, 18 showed an obviously increased size (>2 cm), including 5 significantly increased cases (>3 cm) over a period of 6 mo and 13 moderately increased cases (>2 cm and <3 cm) during 12 mo. Surgical resection was performed in 5 lesions ≥3 cm in size, which were diagnosed as benign lesions in 3 (one leiomyoma and two cysts) and malignant lesions in 2 (1 leiomyosarcoma and 1 malignant granular cell tumor). Of the followed cases of gastric SMLs, 16 had an obviously increased size (>2 cm), including 10 significantly increased cases (>3 cm). Traditional surgery and endoscopic therapy were performed in 10 lesions ≥3 cm in size, which were diagnosed as gastrointestinal stromal tumors (GISTs) in 8 and leiomyomas in 2. A total of 780 cases underwent endoscopic or surgical therapy. Of 112 cases (19 esophageal cases and 93 gastric cases) treated by surgery, 2 (GIST and leiomyosarcoma) developed delayed bleeding, and the success rate of surgical treatment was 98.2%. Of 668 cases who underwent endoscopic therapy, 6 (4 in ESE group and 2 in ESD group) ended up with perforation and 4 of them (4 in ESE group) were converted to surgery; 2 (both in ESE group) developed intraoperative bleeding, which was managed by endoscopic spraying of drugs, electric coagulation and clips to achieve hemostasis; 2 cases in ESE group had failed dissection and then followed by EUS. The success rate of endoscopic therapy was 98.5%. Of 431 esophageal SMLs, there were 371 (86.08%) leiomyomas, 21 (4.87%) GISTs, and 13 (3.02%) cysts. Of 349 gastric SMLs, there were 168 (48.13%) GISTs, 87 (24.92%) leiomyomas, and 60 (17.91%) cases of ectopic pancreas.

CONCLUSION: No matter where the lesion is located, the esophagus or stomach, lesion size significantly increased over a period of 6 mo after initial measurement. However, few further change were observed in size, shape and EUS finding such as echo pattern or regularity of the outer margin over a period of 6-60 mo. Leiomyoma is the most common gastrointestinal SML in the esophagus, while GISTs are common in the stomach. Leiomyoma lesions rarely showed significant change as shown by endoscopic examination. Excessive medical therapy involves known issues associated with cost-effectiveness, patient compliance and risk of complications, and conservative treatment with regular clinical follow-up is recommended.

Endoscopic resection of gastrointestinal lipomas: a single-center experience

BACKGROUND

Gastrointestinal (GI) lipomas are benign, slow-growing subepithelial tumors. Most lipomas are detected incidentally at endoscopy, but they can cause GI bleeding, abdominal pain, intestinal obstruction, and intussusception, particularly if they are larger than 2 cm in diameter. The aim of this study was to investigate the efficacy, safety, and long-term prognosis of endoscopic treatment of GI lipomas.

METHODS

A total of 28 GI lipomas treated endoscopically from January 2005 to June 2012 were retrospectively reviewed. Endoscopic treatment was performed by four methods: the unroofing technique, endoscopic mucosal resection (EMR), EMR after precutting (EMR-P), and endoscopic submucosal dissection (ESD).

RESULTS

Of 28 GI lipomas, 5 were located in the stomach, 2 in the duodenum, and 21 in the colon. Thirteen lipomas were <2 cm in diameter (small lipoma), and the other 15 were ≥2 cm (large lipoma). The unroofing technique was performed in 2 cases, EMR in 17 cases, EMR-P in 4 cases, and ESD in 5 cases. En bloc resection was performed with 21 lesions (75 %), and endoscopic complete resection was achieved with 26 lesions (93 %). Incomplete resection occurred in the 2 cases treated by the unroofing technique. On pathologic examination, complete resection was achieved with 21 lesions (75 %). Delayed bleeding was observed in one patient. There were no serious complications such as perforation or post-procedural stricture. During the mean follow-up period of 19 months (range 2-91 months), no recurrence was observed.

CONCLUSIONS

Endoscopic treatment appears to be a safe and effective treatment for GI lipomas, including large lipomas (≥2 cm in diameter).

Endoscopic ultrasound-guided fine needle injection for cancer therapy: the evolving role of therapeutic endoscopic ultrasound

Endoscopic ultrasound (EUS) is central to the diagnosis and staging of many malignancies, but now has an evolving role in cancer therapy. EUS-guided fine needle injection (FNI) is already used for palliative interventions such as treatment of pain through nerve blockade and to guide biliary decompression when conventional ERCP is not possible. More recently, EUS-FNI has been used to deliver specific anti-tumor agents for pancreatic cyst ablation and local control of tumor growth in patients with unresectable solid malignancies. The agents used to date include ethanol, brachytherapy seeds, and chemotherapeutic agents such as paclitaxel. In addition, FNI of new immunomodulating cell cultures such as mixed lymphocyte and dendritic cell cultures has also been reported, as has FNI of several different viral vectors for antitumor therapy. Although experience with these agents remains preliminary, EUS-FNI is a minimally invasive approach to deliver local antitumor agents, and is likely to have an expanding role in cancer therapy.

Endoscopic dissection of large endogenous myogenic tumors in the esophagus and stomach is safe and feasible: a report of 42 cases

OBJECTIVE

Submucosal myogenic tumors, including leiomyoma and stromal tumors, are currently treated primarily by open surgery or laparoscopic excision. The aim of this retrospective study was to evaluate the feasibility of endoscopic dissection (ED) for resecting endogenous esophageal leiomyoma (EL) and gastric stromal tumors (GSTs) with diameters of 5 cm.

METHODS

We enrolled 42 patients with endogenous EL and GST who had undergone endoscopic surgery (endoscopic group). These cases were compared retrospectively with 22 patients who had undergone thoracotomy or laparotomy (control group). Endoscopic group (n = 42) received ED for EL and GST resection, including circumferential removal of superficial mucosa of targeted tumor. Control group (n = 22) received thoracotomy or laparotomy for resection of esophageal and gastric myogenic tumors. Main outcome measures were operative time, intraoperative bleeding and perforation, postoperative complications, and hospital stays and costs were compared between groups.

RESULTS

Endogenous EL and GST were successfully removed from all patients. Bleeding and perforation occurred in seven and five EL and GST patients, respectively. Bleeding was corrected with argon plasma coagulation (APC). Perforation was endoscopically repaired with clips. Mean operative time was 49 min for endoscopic EL and 55 min for GST resection. No major bleeding or perforation occurred postoperatively. Endoscopic treatment had shorter length of stay and lower hospital costs than conventional procedures.

CONCLUSIONS

ED is safe and feasible for resection of endogenous EL and GST in selected cases.

Endoscopic removal of gastric ectopic pancreas: an initial experience with endoscopic submucosal dissection

AIM

To evaluate the therapeutic usefulness and safety of endoscopic resection in patients with gastric ectopic pancreas.

METHODS

A total of eight patients with ectopic pancreas were included. All of them underwent endoscopic ultrasonography before endoscopic resection. Endoscopic resection was performed by two methods: endoscopic mucosal resection (EMR) by the injection-and-cut technique or endoscopic mucosal dissection (ESD).

RESULTS

We planned to perform EMR in all eight cases but EMR was successful in only four cases. In the other four cases, saline spread into surrounding normal tissues and the lesions became flattened, which made it impossible to remove them by EMR. In those four cases, we performed ESD and removed the lesions without any complications.

CONCLUSION

If conventional EMR is difficult to remove gastric ectopic pancreas, ESD is a feasible alternative method for successful removal.

Endoscopic alcohol injection therapy of giant gastric leiomyomas: an alternative method to surgery

Leiomyomas are the most common benign mesenchymal tumours of the upper gastrointestinal tract. They rarely cause symptoms when they are smaller than 5 cm in diameter. Observation with repeated endoscopies is recommended in asymptomatic patients with small lesions. Surgical resection remains the main therapy option for symptomatic and complicated patients. The treatment of esophageal leiomyoma has been enhanced by improvements in diagnostic and therapeutic endoscopic techniques; however, the same cannot be said for gastric leiomyoma management. The present article describes the management of two cases involving giant gastric leiomyomas that were  successfully treated using endoscopic injection of alcohol. To the authors' knowledge, the present study is the first report of the treatment of such hemorrhagic gastric tumours using this alternative and low-cost technique. Endoscopic local ethanol injection may be the treatment of choice in carefully selected patients with hemorrhagic leiomyomas of the upper gastrointestinal tract.

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue. Treatment of heterotopic pancreas may include expectant observation, endoscopic resection or surgery. The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection (EMR) for resection of heterotopic pancreas of the stomach. Two patients (both female, mean age 32 years) were referred for management of gastric subepithelial tumors. Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa. Band ligation-assisted EMR was performed in both cases without complications. Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa. Margins were free of pancreatic tissue. Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

Ligation-assisted endoscopic mucosal resection of gastric heterotopic pancreas

Heterotopic pancreas is a congenital anomaly characterized by ectopic pancreatic tissue. Treatment of heterotopic pancreas may include expectant observation, endoscopic resection or surgery. The aim of this report was to describe the technique of ligation-assisted endoscopic mucosal resection (EMR) for resection of heterotopic pancreas of the stomach. Two patients (both female, mean age 32 years) were referred for management of gastric subepithelial tumors. Endoscopic ultrasound in both disclosed small hypoechoic masses in the mucosa and submucosa. Band ligation-assisted EMR was performed in both cases without complications. Pathology from the resected tumors revealed heterotopic pancreas arising from the submucosa. Margins were free of pancreatic tissue. Ligation-assisted EMR is technically feasible and may be considered for the endoscopic management of heterotopic pancreas.

EUS-assisted band ligation of small duodenal stromal tumors and follow-up by EUS

BACKGROUND

Duodenal GI stromal tumors (GISTs), with potential for malignant transformation, arise in muscularis propria. It is difficult to endoscopically resect lesions in the muscularis propria by using standard electrosurgical techniques.

OBJECTIVES

Our purpose was to investigate the efficacy of a new method for resection of these tumors, EUS-assisted band ligation.

DESIGN

Prospective study.

SETTING

Shenjing Hospital of China Medical University.

PATIENTS

Nineteen elderly or high surgical risk patients with small duodenal GISTs.

INTERVENTION

A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. EUS was used to determine whether the hypoechoic mass was confined completely by the band.

MAIN OUTCOME MEASUREMENTS

Beginning 2 weeks after banding, the lesions were observed endoscopically once per week until healing was complete. Thereafter, all patients underwent EUS every 2 to 3 months on schedule.

RESULTS

The tumors sloughed completely. The mean time required for complete healing after band ligation was 4.7 weeks. Bleeding occurred in 2 patients 7 days after ligation because the lesion sloughed. The bleeding was self-limiting and not life threatening. No perforation or other complications occurred. Follow-up ranged from 18 to 63 months, during which time no recurrence was observed.

LIMITATION

New technique with limited data.

CONCLUSION

EUS-assisted band ligation with systematic follow-up by EUS is an effective and safe treatment for small duodenal GISTs.

Cross-sectional imaging of gastric neoplasia

The detection of gastric neoplasia has traditionally been limited to barium examination and direct visualization at endoscopy. The rapid development of techniques such as multidetector computed tomography (MDCT) and endoscopic ultrasound (EUS) has resulted in more accurate diagnosis and staging of gastric neoplasia. In this review we describe the normal anatomy of the stomach with multi-modality illustrations and review the imaging manifestations of gastric neoplasia, including adenocarcinoma, lymphoma, neuroendocrine and gastro-intestinal stromal tumours. We also describe the optimal techniques for up-to-date and accurate gastric imaging, outlining the role of MDCT and EUS.

Endoscopic management of gastrointestinal smooth muscle tumor

AIM: To systematically evaluate the efficacy and safety of endoscopic resection of gastrointestinal smooth muscle tumors (SMTs, including leiomyoma and leiomyosarcoma) and to review our preliminary experiences on endoscopic diagnosis of gastrointestinal SMTs.

METHODS: A total of 69 patients with gastrointestinal SMT underwent routine endoscopy in our department. Endoscopic ultrasonography (EUS) was also performed in 9 cases of gastrointestinal SMT. The sessile submucosal gastrointestinal SMTs with the base smaller than 2 cm in diameter were resected by “pushing” technique or “grasping and pushing” technique while the pedunculated SMTs were resected by polypectomy. For those SMTs originating from muscularis propria or with the base size ≥ 2 cm, ordinary biopsy technique was performed in tumors with ulcers while the “Digging” technique was performed in those without ulcers.

RESULTS: 54 cases of leiomyoma and 15 cases of leiomyosarcoma were identified. In them, 19 cases of submucosal leiomyoma were resected by “pushing” technique and 10 cases were removed by “grasping and pushing” technique. Three cases pedunculated submucosal leiomyoma were resected by polypectomy. No severe complications developed during or after the procedure. No recurrence was observed. The diagnostic accuracy of ordinary and the “Digging” biopsy technique was 90.0% and 94.1%, respectively.

CONCLUSION: Endoscopic resection is a safe and effective treatment for leiomyomas with the base size ≤ 2 cm. The “digging” biopsy technique would be a good option for histologic diagnosis of SMTs.

Therapeutic procedures for submucosal tumors in the gastrointestinal tract

This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor (GIST). Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.

Endoscopic ultrasound of the upper gastrointestinal tract and mediastinum: diagnosis and therapy

Endoscopic ultrasound (EUS) has developed significantly over the last two decades and has had a considerable impact on the imaging and staging of mass lesions within or in close proximity to the gastrointestinal (GI) tract. In conjunction with conventional imaging such as helical computed tomography and magnetic resonance imaging, the indications for EUS include (1) differentiating between benign and malignant lesions of the mediastinum and upper GI tract, (2) staging malignant tumors of the lung, esophagus, stomach, and pancreas prior to surgery or oncological treatment, (3) excluding common bile duct stones before laparoscopic cholecystectomy, thereby avoiding the need for endoscopic retrograde cholangiopancreatography (ERCP) in some patients, and (4) assessing suspected lesions that are either equivocal or not seen on conventional imaging. In recent years, EUS has charted a course similar to that taken by ERCP, evolving from a purely diagnostic modality to one that is interventional and therapeutic. These indications include (5) obtaining a tissue diagnosis by EUS-guided fine-needle aspiration or trucut-type needle biopsy and (6) providing therapy such as coeliac plexus neurolysis and pancreatic pseudocyst drainage--in many cases, more accurately and safely than conventional techniques. Emerging investigational techniques include EUS-guided enteric anastomosis formation and fine-needle injection therapy for malignant disease.

Endoscopic band ligation of small gastric stromal tumors and follow-up by endoscopic ultrasonography

BACKGROUND

Gastrointestinal stromal tumor (GIST) is a relatively common gastric submucosal tumor with potential for malignant transformation. The efficacy of a new method for resection of these tumors, endoscopic band ligation, was evaluated.

METHODS

The study included 29 patients with small gastric stromal tumors arising in the gastric muscularis propria as determined by endoscopy, endoscopic ultrasonography (EUS), and deep endoscopic biopsies. A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. Beginning two weeks after banding, the lesions were observed endoscopically once per week until healing was complete. Thereafter, all patients underwent EUS every two to three months on schedule.

RESULTS

The 28 GISTs sloughed completely. The mean time required for complete healing after band ligation was 4.8 weeks. One lesion did not slough because they were not completely ligated. The lesion was ligated for the second time and sloughed completely. Bleeding occurred in one patient three days after ligation because the lesion sloughed early. The bleeding was managed successfully with metallic clips. No perforation and other complications occurred. Followup ranged from 36 to 51 months, during which time only one recurrence was observed four months postoperatively.

CONCLUSIONS

Endoscopic band ligation with systematic followup by EUS is an effective and safe treatment for small GISTs.

A safe and efficient strategy for endoscopic resection of large, gastrointestinal lipoma

BACKGROUND

Gastrointestinal (GI) lipomas are benign, slowly growing, submucosal tumors, which may cause gastrointestinal bleeding, anemia, intussusception, and bowel obstruction. The aim of this study is to explore the safe and effective strategy for endoscopic removal of large GI lipomas.

METHODS

During last 10 years, fifteen large and symptomatic GI lipomas were resected under endoscopy in our hospital. In them, two large lipomas with small stalk (< 2 m in diameter) were resected by polypectomy; ten large lipomas with base size greater than 2 cm in diameter were removed using a "subtotal resection." Three other large lipomas with small stalk (< 2 m in diameter) were resected by multistep resection. Endoscopic ultrasonography (EUS) and miniprobe endoscopic ultrasound were performed in six cases from January 2000 to July 2004 to confirm that those lesions were lipomas that were superficial to the muscularis propria.

RESULTS

All 15 lesions were successfully removed and were histopathologically confirmed to be lipomas. No severe complications, such as perforation or hemorrhage, developed after endoscopic removal. No recurrence was observed after 1-8 years follow-up endoscopic examination.

CONCLUSIONS

Various, large GI lipomas can be removed safely by electrosurgical snare resection under endoscopy following the guidance of the present therapeutic strategy.

Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection

BACKGROUND

In most circumstances, subepithelial tumors lack distinct endoscopic and ultrasonographic features. Consequently, definitive diagnosis usually requires tissue acquisition and pathologic confirmation. Establishing a tissue diagnosis is difficult because the yield of forceps biopsies is low. However, prospective data evaluating tissue sampling techniques for subepithelial lesions are currently lacking.

OBJECTIVE

Our purpose was to prospectively determine the diagnostic yield of endoscopic submucosal-mucosal resection (ESMR) compared with forceps biopsy for lesions limited to the submucosa (third endosonographic layer) of the GI tract.

DESIGN

A prospective head-to-head comparison was performed.

SETTING

The study was performed in a tertiary care hospital.

PATIENTS

Study patients were 23 adults with subepithelial lesions limited to the submucosa.

INTERVENTION

All submucosal lesions underwent forceps biopsy followed by endoscopic submucosal resection. Biopsy specimens were obtained with large-capacity "jumbo" forceps. A total of 4 double passes (8 biopsy specimens) were collected from each lesion with use of the bite-on-bite technique. Endoscopic resection was then performed with an electrosurgical snare or cap-fitted endoscopic mucosal resection device.

MAIN OUTCOME MEASUREMENT

The main outcome measurement was the diagnostic yield of biopsy forceps compared with endoscopic submucosal resection.

RESULTS

Twenty-three patients with lesions limited to the submucosa were identified by endoscopic ultrasonography. All lesions underwent forceps biopsy followed by ESMR. The diagnostic yield of the jumbo forceps biopsy was 4 of 23 (17%), whereas the diagnostic yield of ESMR was 20 of 23 (87%) (P = .0001, McNemar test).

CONCLUSION

In the evaluation of subepithelial lesions limited to the submucosa, ESMR has a significantly higher diagnostic yield than jumbo forceps biopsy with use of the bite-on-bite technique.

American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses

This literature review and the recommendations therein were prepared for the American Gastroenterological Association Institute Clinical Practice and Economics Committee. The paper was approved by the Committee on January 19, 2006, and by the AGA Institute Governing Board on April 20, 2006.

Endoscopic resection of gastrointestinal submucosal tumors assisted by endoscopic ultrasonography

BACKGROUND

The resection and histologic examination of the lesions is generally considered the treatment of choice in order to achieve diagnosis in gastrointestinal submucosal tumors. Moreover, the degree of malignancy of the tumor depends on certain features that can only be studied on the entire resected piece.

METHODS

We revised the cases of patients who underwent endoscopic resection of gastrointestinal submucosal tumors in the period from 1997 through 2002.

RESULTS

Fifty submucosal lesions were resected in 45 patients (64.4% men). Patient mean age was 55.31 years. Of the lesions, 52% were gastric tumors and 88% were located in the second layer. Mean size was 12.34 mm, and 54% were smaller than 10 mm. Resection with submucosal injection of saline solution and diluted adrenaline was performed on 46% of the lesions, and standard resection using polypectomy snare on 48%. Ligation was used in three cases. Resection was successful in 98% and major complications were observed in 4% (two cases of bleeding, endoscopically resolved).

CONCLUSIONS

The endoscopic resection of submucosal tumors is a safe and efficient technique: It has few associated complications and allows diagnosis in all the cases and cure of the lesion in the great majority of cases.

Submucosal lesions

Most of the submucosal lesions encountered on endoscopy are benign; however, the fact that some of them may be malignant considerably influences the attitude toward the whole group. This article reviews the current status of endosonography in the management of submucosal lesions and focuses on determining the risk of malignancy. The predictive value of various endoscopic ultrasonography (EUS) features and their combinations and the capabilities and limitations of EUS-guided fine needle biopsy are discussed. Other issues addressed include differentiation between extraluminal compressions and true submucosal lesions, EUS-assisted endoscopic removal of submucosal lesions, and the potential role of catheter-based endosonography in the setting of submucosal lesions. Problems related to the surveillance of patients with submucosal lesions who are not candidates for surgical treatment are outlined. An overview of the recent changes in the pathologic classification of gastrointestinal mesenchymal tumors and their impact on the role of EUS in the management of submucosal lesions is given.

Endoscopic ultrasound-guided fine-needle injection

With the development of linear array echoendoscopes and the ability to perform endoscopic ultrasound (EUS)-guided fine-needle aspiration, the delivery of therapeutic agents with fine-needle injection (FNI) emerged. EUS-guided FNI is an attractive delivery system because of its minimal invasiveness and low complication rate. This approach is effective in performing celiac plexus neurolysis for pain relief in patients with pancreatic cancer. The most exciting area of interest involves the delivery of antitumor agents in patients with locally advanced cancer, such as cancer of the pancreas or esophagus. The involvement of EUS-guided FNI in tumor therapy adds a host of potential new applications that continue to swing the pendulum of EUS from a diagnostic to a therapeutic modality.

Role of endoscopic miniprobe ultrasonography in diagnosis of submucosal tumor of large intestine

AIM: To evaluate the role of miniprobe ultrasonography under colonoscope in the diagnosis of submucosal tumor of the large intestine, and to determine its imaging characteristics.

METHODS: Thirty-five patients with submucosal tumors of the large intestine underwent miniprobe ultrasonography under colonoscope. The diagnostic results of miniprobe ultrasonography were compared with pathological findings of specimens by biopsy and surgical resection.

RESULTS: Lipomas were visualized as hyperechoic homogeneous masses located in the submucosa with a distinct border. Leiomyomas were visualized as hypoechoic homogeneous mass originated from the muscularis propria. Leiomyosarcomas were shown with inhomogeneous echo and irregular border. Carcinoids were presented as submucosal hypoechoic masses with homogenous echo and distinct border. Lymphangiomas were shown as submocosal hypoechoic masses with cystic septal structures. Malignant lymphomas displayed as hypoechoic masses from mucosa to muscularis propria, while pneumatosis cystoids intestinalis originated from submucosa with a special sonic shadow. One large leiomyoma was misdiagnosed as leiomyosarcoma.

CONCLUSION: Endoscopic miniprobe ultrasonography can provide precise information about the size, layer of origin, border of submucosal tumor of the large intestine and has a high accuracy in the diagnosis of submucosal tumor of the large intestine. Pre-operative miniprobe ultrasonography under colonoscope may play an important role in the choice of therapy for submucosal tumor of the large intestine.

Endoscopic band ligation without electrosurgery: a new technique for excision of small upper-GI leiomyoma

BACKGROUND

Leiomyoma is a relatively common submucosal tumor in the upper-GI tract. The efficacy of a new method for resection of these tumors, endoscopic band ligation, was evaluated.

METHODS

The study included 59 patients with 64 small upper-GI leiomyomas arising in the muscularis propria as determined by endoscopy, EUS, and EUS-guided FNA. The distribution of the 64 leiomyomas was the following: esophageal, 50; gastric, 12; duodenal, 2. A standard endoscope with a transparent cap attached to the tip was used. The cap was placed over the lesion, maximum sustained suction was applied, and an elastic band was released around the base. Beginning 2 weeks after banding, the lesions were observed endoscopically once per week until healing was complete.

RESULTS

The 50 esophageal leiomyomas sloughed completely. The mean time required for complete healing after band ligation was 3.6 weeks. Nine of the 12 gastric leiomyomas sloughed completely; the resulting ulcer defect was healed at a mean of 4.5 weeks. The other 3 lesions did not slough because they were not completely ligated. The two duodenal lesions sloughed completely after banding, and the mean time until healing of the defect was 4.5 weeks. No perforation occurred. Follow-up ranged from 16 to 31 months, during which time no recurrence was observed.

CONCLUSIONS

Endoscopic band ligation is an effective and safe treatment for small upper-GI leiomyoma.

Individual variations in mucosa and total wall thickness in the stomach and rectum assessed via endoscopic ultrasound

Endoscopic ultrasound is a unique tool to acquire in vivo data on alimentary tract wall thicknesses of sufficient resolution needed in radiation dosimetry studies. Through their different echo texture and intensity, five layers of differing echo patterns for superficial mucosa, deep mucosa, submucosa, muscularis externa and serosa/adventitia exist within the walls of organs composing the alimentary tract. In this study, retrospective image analyses of patient video data were made for ten examinations of the stomach and eight examinations of the rectum covering a range of patient ages. Thicknesses for stomach mucosa ranged from 1030 +/- 130 microm to 1640 +/- 80 microm (total stomach wall thicknesses from 2.80 +/- 0.12 to 4.23 +/- 0.03 mm). Measurements made for the rectal images revealed rectal mucosal thicknesses from 660 +/- 50 microm to 1130 +/- 250 microm (total rectal wall thicknesses from 2.28 +/- 0.05 to 3.55 +/- 0.43 mm). The mucosa accounted for approximately 32 +/- 7% and approximately 32 +/- 8% of the total thickness of the stomach and rectal wall, respectively. These values can thus be utilized to investigate uncertainties in alimentary tract dosimetry that are based upon fixed reference individual definitions of organ wall structure.

Miniature ultrasonic probes for diagnosis and treatment of digestive tract diseases

AIM: To investigate the clinical value of miniature ultrasonic probes (MUPs) for the diagnosis and treatment of digestive tract diseases.

METHODS: Endoscopic ultrasonography (EUS) was performed for patients with its indications with 7.5-20 MHz MUPs and double-cavity electronic endoscope. According to the diagnosis of MUPs, patients who had indications of treatment received endoscopic resection or surgical excision. Postoperative histological results were compared with the preoperative diagnosis of MUPs. A few patients without endoscopic resection or surgical excision were periodically followed up with MUPs.

RESULTS: A total of 537 patients were examined by MUPs, of them, 256 were diagnosed with gastrointestinal submucosal lesions, 146 with pseudo-submucosal lesions, 50 with digestive tract cancers, 17 with peptic ulcer, 11 with cholecystolithiasis, 8 with chronic pancreatitis, and 2 with achalasia and 47 were diagnosed as normal. After MUPs examinations, 220 patients received endoscopic resection or surgical excision, and the postoperative histological results of 211 patients were completely consistent with the preoperative diagnosis of MUPs. The diagnostic accuracy of MUPs was 95.9%. The result of follow-up with MUPs indicated that gastrointestinal leiomyoma, lipoma, phlebangioma and cyst were unchanged within 1-2 years. The patients who received endoscopic resection or centesis did not have any complications.

CONCLUSION: MUPs are of value in diagnosing gastrointestinal submucosal lesions, staging of digestive tract cancers and biliary-pancreatic diseases. They play a very important role in making therapeutic plans.

Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife

BACKGROUND

Submucosal tumors often are found incidentally at upper endoscopy. Although the majority of the ones less than 5 cm in size are benign, periodic monitoring for incremental changes in size, which can be stressful and bothersome to patients, is essential. If relatively easy and safe, an endoscopic method of removal would be optimal treatment. Conventional endoscopic enucleation technically is difficult and often leads to serious complications, such as bleeding and perforation. A novel method for endoscopic enucleation of submucosal tumors with an insulated-tip electrosurgical knife is reported.

METHODS

En bloc enucleation was attempted by using an insulated-tip electrosurgical knife in 15 patients (10 men, 5 women; median age 48 years) with submucosal tumors of the esophagus (5) or stomach (5 cardia/fundus, 4 body, one antrum). EUS was performed to determine the layer of origin and the exact size of the submucosal tumor.

RESULTS

Tumors arose in the muscularis propria in 11 cases, submucosa in two, and muscularis mucosa in one. Enucleation was relatively easy and successful in 14 cases. In one case, however, piecemeal resection was unavoidable because of fibrotic adhesions with the surrounding tissue; this tumor later was confirmed to be a glomus tumor. Median procedure time was 35 minutes (8-180 minutes) and median size of the submucosal tumors was 2x1.7 cm. The largest lesion, located in the esophagus, measured 6x3 cm. Histopathologic diagnoses included leiomyoma (9), GI stromal tumor (4), stromal tumor of unknown malignant potential (1), and glomus tumor (1). A small perforation occurred in one patient with a 2.5-cm tumor in the anterior wall of proximal gastric body but was managed successfully by endoscopic clip application. Follow-up endoscopy at 2 months in this patient revealed no tumor recurrence and complete healing of the treatment-related ulcer.

CONCLUSIONS

En bloc endoscopic enucleation of submucosal tumors by using an insulated-tip electrosurgical knife appears to be safer, easier, and less time consuming compared with previously described methods. However, further investigation and comparative studies are required to confirm the safety and efficacy of this method.

Endoscopic diagnosis and treatment of submucosal tumors of gastrointestinal tract

AIM: To improve the diagnoses and treatment for submucosal tumors of gastrointestinal tract.

METHODS: Endoscopic ultrasonograpy (EUS) was conducted in 136 patients with submucosal tumors (SMT) in gastrointestinal tract. Endoscopic therapy or surgical operation was taken according to the different layers of SMT.

RESULTS: A total of 33 cases of stromal tumors derived from mucosa; 2 cysts, 8 lipomas, 12 etopic pancreases in stomach and 5 varics in gastric fundus from submucosa; 60 benign stromal tumors and 16 malignant stromal tumors from muscularis; 24 benign stromal tumors from mucosa, 6 benign stromal tumors from muscularis, 4 gastric lipomas, 2 cysts, 6 etopic pancreas in stomach were resected by endoscopy; 28 cases of benign stromal tumors derived from muscularis, 15 malignant stromal tumors, 2 lipoma and 2 etopic pancreas were removed by surgery. 97.7% of SMTs diagnosed by EUS were confirmed further by pathology.

CONCLUSION: Different layers of gastrointestinal tract with SMTs can be distinguished clearly by EUS, leading to definite diagnosis of SMTs. EUS is important to select treating methods of SMTs in gastrointestinal tract. Endoscopic therapy is an effective method for submucosal tumor of gastrointestinal tract.

Diagnostic value of endoscopic ultrasonography for gastrointestinal leiomyoma

AIM: To investigate the clinical pathologic features of gastrointestinal leiomyoma and the diagnostic value of endoscopic ultrasonography (EUS) on gastrointestinal leiomyoma.

METHODS: A total of 106 patients with gastrointestinal leiomyoma diagnosed with EUS were studied. The location, size and layer origin of gastric and esophageal leiomyomas were analyzed and compared. The histological diagnosis of the resected specimens by endoscopy or surgery in some patients was compared with their results of EUS.

RESULTS: The majority of esophageal leiomyomas were located in the middle and lower part of the esophagus and their size was smaller than 1.0 cm, and 62.1% of esophageal leiomyomas originated from the muscularis mucosae. Most of the gastric leiomyomas were located in the body and fundus of the stomach with a size of 1-2 cm. Almost all gastric leiomyomas (94.2%) originated from the muscularis propria. The postoperative histological results of 54 patients treated by endoscopic resection or surgical excision were completely consistent with the preoperative diagnosis of EUS, and the diagnostic specificity of EUS to gastrointestinal leiomyoma was 94.7%.

CONCLUSION: The size and layer origin of esophageal leiomyomas are different from that of gastric leiomyomas. Being safe and accurate, EUS is the best method not only for gastrointestinal leiomyoma diagnosis but also for the follow-up of patients.

Treatment of benign esophageal tumors by endoscopic techniques

Gastrointestinal endoscopy has changed in recent years from a largely diagnostic to a highly therapeutic procedure. Technical advances in endoscopic ultrasound as well as new devices designed for endoscopic mucosal resection (EMR) have opened the field to many therapeutic possibilities. Endoscopic resection is technically challenging, and while our colleagues in the Far East have been using such techniques for over a decade, EMR in the West is still in its infancy. The decision to resect a benign esophageal tumor must take several factors into account including whether the patient is symptomatic; characteristics of the particular tumor (including the potential for malignant transformation, risk of bleeding, and obstruction); and the available therapeutic options. Endoscopic resection of benign esophageal tumors is an attractive option as it is a safe and minimally invasive procedure. Its use is limited, however, to smaller tumors arising from the mucosal or submucosal layers. In this article we examine the techniques used in endoscopic mucosal resection and review the literature on this subject.

Yield of tissue sampling for submucosal lesions evaluated by EUS

BACKGROUND

Evaluation of submucosal nodules or large gastric folds is a common indication for EUS. Establishing a tissue diagnosis is challenging because the yield of forceps biopsies is low. The aim of this study was to determine the diagnostic yield of EUS-guided endoscopic submucosal-mucosal resection and forceps biopsy for submucosal nodules and large gastric folds.

METHODS

Patients who underwent EUS from March 1997 through January 2002 for evaluation of submucosal nodules or large gastric folds were identified, and the procedure and pathology reports reviewed. Patients were included who underwent endoscopic submucosal-mucosal resection (n = 45) or large-capacity ("jumbo") biopsy (n = 36) of submucosal lesions (arising from third endosonographic layer) or large gastric folds. Endoscopic submucosal-mucosal resection was performed with an electrosurgical snare or with a cap-fitted endoscopic mucosal resection device.

RESULTS

Sixty-six patients (62% men; mean age, 61 years; range 27-80 years) underwent 69 EUS procedures to obtain tissue samples of subepithelial lesions. Diagnostic yields were as follows: endoscopic submucosal-mucosal resection 40/45 (89%; 95% CI [80%, 98%]), jumbo biopsy 15/36 (42%; 95% CI [26%, 58%]) (p < 0.001 by two-tailed Fisher exact test). There were 9 complications: 7 instances of bleeding (6 endoscopic submucosal-mucosal resection, 1 jumbo biopsy), 3 requiring hospitalization (2 endoscopic submucosal-mucosal resection, 1 jumbo biopsy) and 2 requiring transfusion; 1 chest pain and odynophagia (esophageal endoscopic submucosal-mucosal resection); and 1 oversedation (requiring administration of reversal agents).

CONCLUSIONS

For submucosal lesions and large gastric folds, endoscopic submucosal-mucosal resection has a better diagnostic yield than the jumbo biopsy, but may have a higher complication rate.