Endoscopic Removal of Gastrointestinal Stromal Tumors in the Stomach: A Single-Center Experience

Endoscopic resection of gastrointestinal stromal tumors

Surgical resection is regarded as the main modality for the treatment of gastrointestinal stromal tumors (GISTs). With the advancement of endoscopic techniques and the introduction of super minimally invasive surgery (SMIS), endoscopic resection has been an alternative option to surgery. Recently, various endoscopic resection techniques have been used for the treatment of GISTs, including endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFR), submucosal tunneling endoscopic resection (STER), and laparoscopic and endoscopic cooperative surgery (LECS). Studies on the safety and efficacy of the endoscopic treatment of GISTs have emerged in recent years. Endoscopic resection techniques have demonstrated to be effective and safe for the treatment of GISTs. However, there is currently no consensus on the optimal follow-up strategy and the appropriate cut-off value of tumor size for endoscopic resection. In this review we discussed the indications, preoperative preparation, procedures, efficacy, safety, postoperative evaluation, follow-up, and perspectives of endoscopic resection modalities for GISTs.

A novel technique for endoscope progression in gastroscopy resection: forward-return way for dissection of stromal tumor in the muscularis propria of the gastric fundus

Background

The fundus of the stomach is a challenging region for endoscopic resection of gastrointestinal stromal tumors (GISTs), especially in the anterior wall of the fornix at the side of the greater curvature. This study aimed to introduce the Forward-Return Way (FRW) technique in gastric fundus operations and provide evidence of its advantages. The FRW technique allows the gastroscope to access the stomach fornix without entering the gastric antrum after passing through the gastric cardia. Using FRW, the gastroscope body makes a forward return along the wall of the posterior wall of the upper gastric body and the wall of the greater curvature.

Methods

The clinical data of patients with stromal tumors in muscularis propria at the gastric fundus (STMF) at the Fourth Hospital of China Medical University between May 2020- March 2021 were reviewed. The novel FRW technique was used in the procedures, and the beneficial effects, suitability, applicable lesion site, and success rates of FRW were analyzed.

Results

A total of 10 cases were reviewed, and the FRW technique was successfully performed in 7 cases (70%). The gastroscope's tip reached the area just below the gastric cardia, allowing endoscopists to successfully access all angles and sites of the stomach's fundus in all seven patients. The lesion was easily accessed, and the gastroscope was stable with good left-right and forward-backwards movements.

Conclusion

The FRW technique significantly facilitates the resection of the GISTs by aligning the endoscopy body movement direction with the observation direction. Gastrointestinal Stromal Tumor; forward-return of gastroscopy along the gastric body wall; muscularis propria; gastric fundus.

Effects of Endoscopic Submucosal Excavation With Non-Submucosal Injection on Stromal Tumors in Stomach

Background and Aim

Endoscopic submucosal excavation (ESE) is commonly used to treat gastrointestinal stromal tumors (GISTs), especially for tumor sizes within 2 cm; compared with the conventical ESE, the efficacy and safety of the no-submucosal injection (NSI) ESE remains unclear. The aim of this study was to assess the clinical efficacy and safety of NSI-ESE for gastric stromal tumors.

Methods

ESE was performed in 102 patients at our hospital between January 2018 and January 2020, and the clinical features, surgical outcomes, complications, cost of performance, pathological diagnosis, and risk classification were evaluated.

Results

All tumors were completely resected by endoscopic resection (ER), with a complete resection rate of 100%. It was achieved by ESE/EFTR (endoscopic full-thickness resection) in 49 cases with submucosal injection, and by ESE/EFTR in 53 cases with NSI-ESE. The mean surgical time in cases with submucosal injection was 25.86 ± 4.45 min, compared to the cases without submucosal injection (17.23 ± 3.47 min), and the difference was significant (p < 0.001); the exposure time of tumor, the time of complete excavation of tumor, procedure cost, and hospital stay in the NSI-ESE group were all lower than those cases with submucosal injection (p < 0.05). In the risk classification, 95 (93.1%) cases had a very low risk, 4 (4.0%) cases had a low risk, and 2 (2.0%) cases had a high risk. No recurrence or metastasis was observed during the follow-up period of 18 ± 6 months (range: 13–25 months).

Conclusions

NSI-ESE is a feasible, effective, and safe treatment for gastric GISTs; compared to the conventional ESE, NSI-ESE has the following advantages: it decreases procedure time, it lowers the risk of perforation, and it is cost-effective.

Clinical outcomes of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors originating from the muscularis propria: a 7-year experience from a large tertiary center in China

BACKGROUND AND AIMS

Few studies have evaluated the value of endoscopic resection (ER) for the treatment of gastric gastrointestinal (GI) stromal tumors (GISTs) originating from the muscularis propria (MP) in a large population, and no studies have evaluated risk factors for piecemeal resection. This study aimed to evaluate the efficacy and safety of ER for gastric GISTs in a real-world setting and to explore factors associated with piecemeal resection.

METHODS

From January 2013 to December 2019, 185 patients with gastric GISTs originating from the MP were assessed. Clinicopathological and endoscopic data were collected and analyzed. Baseline characteristics of the en bloc resection and piecemeal resection groups were compared to evaluate predictive factors for piecemeal resection.

RESULTS

There were 71 males and 114 females with a mean age of 57.0 ± 9.7 years. The mean size of GISTs was 15 mm (range 4-65 mm). A total of 123 were very low risk, 52 were low risk, and ten were moderate risk. In this study, 103 GISTs were treated with endoscopic submucosal excavation (ESE), 68 GISTs were treated with endoscopic full-thickness resection (EFR), and 14 GISTs were treated with submucosal tunneling ER (STER). Either en bloc resection or complete resection was achieved in 160 (86.5%) patients. No recurrence was noted during follow-up. Only five patients experienced minor complications, with a complication rate of 2.7%. Multivariate analysis demonstrated that size (odds ratio [OR] 1.060, 95% confidence interval [CI] 1.004-1.118; P = 0.035) and shape (OR 5.434, 95% CI 1.638-18.027; P = 0.006) were independent predictors of piecemeal resection.

CONCLUSION

ER was effective and safe for the treatment of gastric GISTs originating from the MP. Piecemeal resection did not seem to affect the efficacy of ER, and no recurrence was noted during follow-up. Large size and irregular shape are risk factors related to piecemeal resection of ER.

Safety and Efficacy of Endoscopic Treatment of Solitary Gastric Neurofibroma

PURPOSE

The studies on solitary gastric neurofibroma (GN) consist of only individual case reports, with little data and relevant information. We aimed to summarize the clinical features, endoscopic features, imaging findings, and pathological features and study the safety and efficacy of endoscopic treatment of solitary GN.

PATIENTS AND METHODS

We retrospectively collected and analyzed clinical data of patients who underwent endoscopic treatment in Department of Gastroenterology of a well-known tertiary hospital from August 2007 to September 2019 and were accurately diagnosed as having solitary GN.

RESULTS

A total of 788 patients with gastric submucosal tumors underwent endoscopic treatment, among whom 11 patients were found to have solitary GNs. The incidence of solitary GNs was 1.4%. All 11 patients were treated with endoscopy. Five patients underwent endoscopic full-thickness resection (EFTR) and six patients underwent endoscopic submucosal excavation (ESE). The en bloc resection rate of the 11 lesions was 100.0%. The median endoscopic operation time was 80 minutes. Average length of hospital stay was 6.4 ± 1.6 days. The median follow-up time was 29 months. No recurrence, distant metastasis, or disease-related death occurred during the follow-up.

CONCLUSION

EFTR and ESE can serve as feasible, safe, and effective treatments for solitary GN.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

The therapeutic effect of the digestive endoscopy tunneling technique on upper gastrointestinal muscularis propria tumors

OBJECTIVE

To analyze the therapeutic effect of digestive endoscopy tunneling technology on upper gastrointestinal muscularis propria tumors.

METHODS

A total of 120 patients with upper gastrointestinal tumors in the muscularis propria treated in our hospital in the past two years were recruited as the study cohort. They were treated using the digestive endoscopic tunneling technique, specifically, endoscopic submucosal tunneling tumor resections, and their clinical data, surgical conditions, pathological results, incidences of complications (CR), and anxiety scores were recorded. A postoperative follow-up was conducted on the patients.

RESULTS

A total of 122 tumors were removed from 120 patients, including two patients who had two tumors each. The largest diameter among the tumors was 4.2 cm, and the average diameter was (2.01±1.56) cm. There were 86 tumors located in the superficial layer of the muscularis propria and 36 pieces in the deep layer. No significant differences were found in the patients' clinical data (P > 0.05). The 120 patients all successfully completed their operations. The operation times ranged between 26 min and 158 min. The en bloc resection rate was 95.8%, and the average postoperative hospital stay was 3.8 days. The pathological diagnoses showed that there were 72 leiomyomas, accounting for 59.0% of the total, and 44 stromal tumors, accounting for 36.1%. There were 2 glomus tumor cases, accounting for 1.6%, and 4 nerve sheath tumor cases, accounting for 3.3%. No patient had delayed gastrointestinal bleeding or mucosal perforations. The probability of subcutaneous emphysema and pneumothorax was 1.7%, the probability of pneumoperitoneum was 0.8%, the probability of retrosternal pain was 10.0%, and the total incidence of CR was 14.2%. No tumor recurrence or residual phenomenon was found at the 3, 6, or 12 month follow ups after the treatment, and the patients' satisfaction rate was as high as 98.3%. Their anxiety scores also decreased significantly over time (P < 0.001).

CONCLUSION

Digestive endoscopy tunnel technology can effectively improve the surgical success rate of patients with upper gastrointestinal muscularis propria tumors, reduce the probability of CR, and reduce patients' psychological pressure. It has significant effects in the treatment of upper gastrointestinal muscularis propria tumors and should be widely applied in clinical practice.

Endoscopic Submucosal Dissection of Gastrointestinal Stromal Tumours: A Retrospective Cohort Study

Background

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal neoplasms. Endoscopic submucosal dissection (ESD) has been used to remove submucosal tumours for many years. However, whether ESD can be recommended for the treatment of GISTs is still controversial. Therefore, we evaluated the efficacy and safety of ESD for treating GISTs.

Patients and Methods

We retrospectively analysed 75 GIST patients who underwent ESD in our hospital from January 2016 to December 2018, and the demographic data, clinical presentation of tumours, operative parameters, postoperative complications and length of hospital stay were analysed.

Results

Seventy-five patients successfully underwent en bloc resection, and 74 (98.7%) patients underwent complete resection of the lesions, with an average tumour size of 1.7 cm (range 0.3–6.0 cm). The median operation time was 84.8 min (range 20–180 min). Forty-two (56.0%) patients underwent endoscopic purse-string suture with no conversions to an open operation. The median postoperative length of hospitalization was 6.6 days (range 3–14 days). Out of a total of 75 GIST patients, 48 (64.0%) were considered very low risk, 19 (25.3%) were low risk, 5 (6.7%) were mild risk, and 3 (4.0%) were high risk. The median follow-up was 24.0 months (range 6–45 months). During hospitalization and follow-up, no complications, recurrence or metastasis occurred.

Conclusion

Based on our study from a medical centre, ESD is a safe and effective method for treating GISTs. However, further studies are needed.