Su1305 A SAFE AND COST EFFECTIVE STRATEGY FOR THE MANAGEMENT OF SMALL ASYMPTOMATIC GASTRIC SUBEPITHELIAL TUMORS: A CASE SERIES

Abstract

Gastric subepithelial tumors (SETs) are relatively common incidental findings encountered on endoscopy. Current ASGE guidelines for small SETs (<2cm) arising from the second and third echolayers recommend tissue acquisition for diagnosis or endoscopic mucosal resection (EMR) for lesions that are symptomatic or increase in size over time. If tissue acquisition is non-diagnostic, it is recommended that these patients have endoscopic ultrasound (EUS) surveillance at poorly defined intervals. In addition to the cumulative risk of anesthesia and significant cost of repeated endoscopy, diagnosis may be challenging because of the low diagnostic yield of tissue acquisition methods currently available for these SETs and the limited accuracy of EUS with endosonographic imaging alone. We propose that routine EMR of asymptomatic gastric SETs <2cm arising from the second and third echolayers is a safe and more cost effective strategy for management than current surveillance recommendations. Provation was queried to identify patients undergoing EUS with a coded diagnosis of “gastric nodule” or “intramural lesion” from September 2017 through September 2019 at our institution. Inclusion criteria for analysis were gastric SETs <2cm arising from the second and third echolayers and removed with EMR. These cases were reviewed for EMR-related complications and pathology of removed specimens. Of the 96 cases identified, 13 patients with 14 distinct lesions met inclusion criteria. All lesions were removed via endoscopic cap band mucosectomy. The mean age of patients was 58.6 years with a female predominance (69.2%). The mean size of these gastric SETs was 7.4 mm. Lesions were most commonly located in the gastric antrum (64%). Pancreatic heterotopia (29%), gastric mucosa (29%), and inflammatory fibroid polyps (23%) were most the most commonly reported pathologic findings. Notably, no carcinoid or other neoplastic lesions were identified. Hemostatic clips were used in 50% of removed lesions. No procedural complications such as perforation were identified. Currently available tissue acquisition methods for small gastric SETs are not always diagnostic, obligating many patients to the EUS surveillance pathway. This results in repeated procedures with a cumulative risk of adverse events. Our results are consistent with published literature showing that asymptomatic SETs <2 cm originating from the second and third echolayers are often benign and can be safely removed by EMR. The more universal use of EMR in this context would increase diagnostic yield, reduce procedural risks, and provide substantial cost savings by eliminating the need for surveillance. As evidence mounts for the safe and efficacious use of EMR in this context, updated guidelines to include this as a viable option need to be considered.