Endoscopic Resection of Submucosal Tumors of the Esophagus. A Prospective Case Series

Abstract

Endoscopic Resection of Submucosal Tumors of the Esophagus. A Prospective Case Series Till Wehrmann, Ksenia Martchenko, Andrea Riphaus, Nikos Stergiou The introduction of endoscopic ultrasonography (EUS) and of endoscopic mucosal resection offered a new alternative to simple observation or surgical resection for the management of esophageal submucosal tumors. Methods: During a 4-year period endoscopic resection was attempted in 17 consecutive patients (mean age, 53611 years, 8 females) with esophageal submucosal tumors confirmed by endoscopy and miniprobe-EUS (20 MHz). The mean tumor diameter was 14611 mm (8-34 mm). Former EUS-guided cytology was benign in 11 cases, however, endoscopic resection was intended in most cases also for diagnostic purposes. Several patients were symptomatic (retrosternal pain, n=4, dysphagia, n=3, recurrent bleeding, n=2) but most tumors had been detected incidentally. Results: In the majority of cases the tumor was ligated with a rubber band and than resected with a snare (n=9), in the other cases simple snare resection (‘‘lift and cut’’, n=5) or cap resection (n=3) was performed. A macroscopically complete endoscopic resection could be achieved in 16/17 patients, the remaining patient was managed surgically. Endoscopic hemostasis was necessary in 7 cases (41%, always successful) and blood transfusions were not required. No other side effects occurred. Histology revealed a granular cell tumor in 11 patients, a leiomyoma in 3 cases, and a lipoma as well as a stromal tumor in one patient each, respectively. All tumors were judged histologically as benign and a microscopically complete resection (R0) was obtained in all cases, with the exception of the patient with the stromal tumor. Therefore, surgical resection was necessary in only two of the 17 patients (12%). During a prospective follow-up of 1267 months tumor reccurrence was not detected in any case. Conclusions: Endoscopic resection of esophageal submucosal tumors is safe and effective. The probability to achieve a curative treatment (R0-resection with benign histology) is high (> 80%), especially if the tumor diameter is < 3 cm. *W1501 Endoscopic Treatment of Anastomotic Strictures Following Resection of Esophageal CA: Increased Success Using Submucosal Corticosteroid Injection Marc F. Catalano, Suku George, Miriam Thomas, Joseph E. Geenen Esophageal CA is the 3rd leading digestive malignancy in the U.S. Most pts have advanced disease at Dx. Surgical resection remains the only effective curative option. Complications include anastomotic strictures approaching 10%. Few successful, long-term endoscopicRx options have been reported. AIM:Determine the safety and effectiveness of endoscopic balloon dilatation of anastomotic strictures following esophagectomy. METHOD: 15 pts (12 M, 3 W, age 49-73) presented with symptoms of dysphagia w or w/o odynophagia, 6wks-8mo following esophagectomy. All pts had esophagectomy for T1-T3 disease. Barium x-ray studies following surgery demonstrated anastomotic strictures prior to referral for endotherapy. Endotherapy was performed using (8-20mm) CRE through-the-scope balloon at 45-90 PSI at 1-min intervals and repeated as necessary. In cases whereby advancement was not initially possible using CRE balloon, guidewire Savary dilation was performed. Pts with refractory strictures, despite repeated dilation, underwent steroid injection (40g Kenalog) at the stricture site. Rx success was defined as resolution of dysphagia. RESULTS: All pts had anastomotic strictures#5mm that failed to allow passage of the standard upper scope. All dilations were successfully completed under fluoroscopy. Pts underwent 4-10 dilation sessions at 2-4 wk intervals (mean 5.5 sessions). 4 pts required guidewire dilation prior to balloon dilation (inability to advance the CRE balloons beyond the stricture). 7 pts had Kenalog injection at the anastomotic site (4 quadrants) because of refractory strictures following the initial dilatation. All pts had resolution of symptoms following complete serial dilation. All were placed on high-dose PPI following initial endoscopic dilation. 3 stricture recurrences occurred at 2, 4 and 9 mo and were treated successfully by repeat dilation with the use of Kenalog (good long-term success). No complications were encountered during therapy. CONCLUSION: Anastomotic strictures following esophagectomy for adenocarcinoma is an infrequent postsurgical complication. Endoscopic balloon dilation is an effective nonsurgical method for Rx of these anastomotic strictures. Up to 50% of these anastomotic strictures may be refractory to simple balloon dilation and will require concomitant steroid injection for long-term success.