Endoscopic Submucosal Excavation Research Articles

Efficacy and Safety of Endoscopic Resection for Gastric Gastrointestinal Stromal Tumors Originating from the Muscularis Propria.

The role of endoscopic resection (ER) in gastric gastrointestinal stromal tumors (GISTs) has not been fully elucidated. The purpose of this work was to evaluate the clinical effectiveness and safety of ER in patients with GISTs originating from the muscularis propria (MP). A total of 233 consecutive patients with gastric GISTs originating from the MP layer, who underwent ER between February 2012 and May 2023, were included in this study. Clinical characteristics, tumor features, and outcomes were recorded and compared between patients who underwent enbloc resection and piecemeal resection. Among the 233 patients, the median size of GISTs was 12mm (range 5-60mm). Risk assessment categorized 190 patients as very low risk, 26 as low risk, 10 as moderate risk, and 7 as high risk. The procedures performed included endoscopic submucosal excavation (127 cases), endoscopic full-thickness resection (103 cases), and submucosal tunneling endoscopic resection (3 cases). The complete and R0 resection rate was 93.1%. Complications occurred in 4.7% of cases (perioperative perforations 1.7%, perioperative bleeding 1.3%, both 0.9%), resulting in conversion to surgery in 1.3% of cases. Risk factors associated with piecemeal resection were tumor size [odds ratio (OR) 0.402, 95% confidence interval (CI) 0.207-0.783; P = 0.007] and shape (OR 0.045, 95% CI 0.009-0.235; P < 0.001). ER is proven to be an effective and reasonably safe approach for gastric GISTs originating from the MP. Notably, larger tumor size and irregular shape are identified as risk factors for piecemeal resection during ER procedures.

Present situation of minimally invasive surgical treatment for early gastric cancer.

Minimally invasive surgery is a kind of surgical operation, which is performed by using professional surgical instruments and equipment to inactivate, resect, repair or reconstruct the pathological changes, deformities and wounds in human body through micro-trauma or micro-approach, in order to achieve the goal of treatment, its surgical effect is equivalent to the traditional open surgery, while avoiding the morbidity of conventional surgical wounds. In addition, it also has the advantages of less trauma, less blood loss during operation, less psychological burden and quick recovery on patients, and these minimally invasive techniques provide unique value for the examination and treatment of gastric cancer patients. Surgical minimally invasive surgical techniques have developed rapidly and offer numerous options for the treatment of early gastric cancer (EGC): endoscopic mucosal resection (EMR), underwater EMR (UEMR), endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR), endoscopic submucosal excavation (ESE), submucosal tunnel endoscopic resection), laparoscopic and endoscopic cooperative surgery (LECS); Among them, EMR, EFTR and LECS technologies have a wide range of applications and different modifications have been derived from their respective surgical operations, such as band-assisted EMR (BA-EMR), conventional EMR (CEMR), over-the-scope clip-assisted EFTR, no-touch EFTR, the inverted LECS, closed LECS, and so on. These new and improved minimally invasive surgeries are more precise, specific and effective in treating different types of EGC.

Internal and external bidirectional traction facilitating endoscopic submucosal excavation of a huge subepithelial tumor in the fornix of the gastric fundus near the cardia.

Internal and external bidirectional traction facilitating endoscopic submucosal excavation of a huge subepithelial tumor in the fornix of the gastric fundus near the cardia.

CT features of calcified micro-gastric gastrointestinal stromal tumors: a case series

BackgroundDue to the lack of corresponding clinical symptoms, small calcified gastric gastrointestinal stromal tumors (GISTs) are often overlooked in clinical practice. Therefore, there is an unmet need to define the imaging features of calcified micro-gastric GISTs to facilitate diagnosis. This study retrospectively analyzed the computed tomography (CT) features of pathologically confirmed calcified micro-gastric GISTs.MethodsThe medical records (gastroscopy, pre-treatment gastric CT imaging [pre- and post-contrast scans], pathology) of patients with calcified gastric GISTs < 1 cm in diameter confirmed pathologically after endoscopic submucosal dissection, endoscopic submucosal excavation, or endoscopic full-thickness resection were retrospectively reviewed.ResultsSeven patients had 8 calcified gastric GISTs < 1 cm in diameter. Six patients hadsingle lesions, and 1patients had multiple lesions. Six patients had lesions in the gastric fundus, 1 patient had a lesion in the body of the stomach. Lesions had a mean diameter of 5.2 mm (range, 1.3 mm ~ 7 mm). Unenhanced CT scans showed spots and high-density nodular calcifications in 3 submucosal lesions, 2 lesions in the muscularis propria, and 3 subserosal lesions that protruded outside the stomach. Among the 8 lesions, only two had solid soft tissue components surrounding the calcification, with one of these two showing post contrast enhancement of the solid soft tissue component.ConclusionsNovel CT features of gastric GISTs included: commonly found in the gastric antrum, small size (< 1 cm in diameter), calcification, few solid soft tissue components, and no abnormal enhancement in most cases.

Pursestring encirclement before endoscopic submucosal excavation of a cecal submucosal tumor.

Pursestring encirclement before endoscopic submucosal excavation of a cecal submucosal tumor.

First case of collagenous fibroma in the terminal ileum treated by endoscopic submucosal excavation

First case of collagenous fibroma in the terminal ileum treated by endoscopic submucosal excavation

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 concept of super minimally invasive surgery (SMIS), endoscopic resection has been an alternative option for 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 endoscopic treatment of GISTs have emerged in recent years and have demonstrated that endoscopic resection techniques are effective and safe for the treatment of GISTs. However, there is currently no consensus on the optimal follow-up strategy and the appropriate tumor size cutoff value for ER treatment. This review aims to discuss the indications, preoperative preparation, procedures, efficacy, safety, postoperative evaluation, follow-up, and perspectives of ER for GISTs. This article is protected by copyright. All rights reserved.

The effect of endoscopic ultrasound on the precise selection of endoscopic treatment for submucosal tumors in the upper gastrointestinal tract

ObjectiveTo summarize and discuss the guiding role of endoscopic ultrasound (EUS) in selecting endoscopic treatments for submucosal tumors (SMTs) in the upper gastrointestinal tract.MethodsA retrospective investigation was conducted on 156 SMT patients who received endoscopic resection guided by EUS in the endoscopy center of the Second Affiliated Hospital of Guangzhou University of Chinese Medicine from May 2019 to September 2021. Next, the size, pathological type, and distribution of lesions were analyzed; the correlation of the tumor origin with distribution of lesions and selection of treatments was explored; and the consistency of preoperative EUS diagnosis and postoperative pathological diagnosis was summarized and analyzed.ResultsThe tumor diameters of the included SMT patients ranged from 0.3 to 4 cm, with a mean diameter of 0.95 cm; the lesions were mostly located in the esophagus, gastric fundus or fundic cardia and gastric body. As for the pathological types, liomyoma was the most common tumor in the esophagus, liomyoma and mesenchymoma were mainly located in the fundic cardia and gastric body, and heterotopic pancreas was mostly discovered in the gastric sinus. Among 38 esophageal SMT patients, some with lesions originating from muscularis mucosa and submucosa under EUS mainly underwent endoscopic submucosal dissection (ESD) and endoscope band ligation (EBL); while others with lesions originated from muscularis propria mainly received submucosal tunneling endoscopic resection (STER). Of 115 gastric SMT patients under EUS, some with lesion origins from the muscularis mucosa and submucosa mainly underwent endoscopic submucosal excavation (ESE), while others from muscularis propria mainly underwent ESE, ESD, and endoscopic full-thickness resection (EFTR). Besides, 3 duodenal SMT patients with lesion origins from submucosa and muscularis propria under EUS were given ESD and ESE, respectively. Additionally, 121 cases showed a consistency between the EUS diagnosis and the postoperative pathological nature, and the consistency rate was 84.6%.ConclusionClarifying the origin layer, size, growth pattern, and pathological nature of the lesion through preoperative EUS can guide the precise selection of endoscopic treatments, thereby ensuring a safe, effective, and complete surgical outcomes and reducing complications.

Case study of colorectal endometriosis treated with endoscopic submucosal excavation.

Colorectal endometriosis (CEM) is a rare and complicated form of deep invasive endometriosis. Its treatment methods include drug therapy and surgery. However, it is often difficult to alleviate symptoms and address problems, such as infertility, using drug treatment alone. Surgical intervention provides a histologic diagnosis, allows assessment of pelvic cysts or masses with features concerning for malignancy, and reduces pain by destroying the endometriotic implants. We consider surgery in women with the following: Persistent pain despite medical therapy; Contraindications to or refusal of medical therapy; Need for a tissue diagnosis of endometriosis; Exclusion of malignancy in an adnexal mass; Obstruction of the bowel or urinary tract. But there is no consensus about the surgical methods. With the rapid development of gastroenteroscopy technology in recent years, many local gastrointestinal tumors that previously required surgical resection can now be removed by endoscopic surgery. Herein, we report one case of CEM treated by endoscopic submucosal excavation (ESE) to provide a new treatment option for the radical resection of single CEM.

A modified endoscopic full-thickness resection for gastrointestinal stromal tumors: A new closure technique based on the instruction of super minimally invasive surgery.

Endoscopic resection, including endoscopic submucosal excavation (ESE) and endoscopic full-thickness resection (EFTR), is an effective and safe method for gastrointestinal stromal tumors (GISTs). While during traditional EFTR, closure of the defect using a loop-and-clip closure technique or just clips always follows the full-thickness resection, this usually results in the occurrence of gas-related complications, such as pneumoperitoneum [1] [2]. What is more, it is time-consuming and not easy to perform for some lesions larger than 2.0 cm.

Endoscopic submucosal excavation of a rectal submucosal tumor assisted by a curvilinear echoendoscope.

A 62-year-old woman undergoing screening colonoscopy was found to have a submucosal protrusion in the mid-rectum. Evaluation with a curvilinear echoendoscope revealed it to be a 1.8×1.1cm, hypoechoic mass originating from muscularis propria (MP) . Endoscopic submucosal excavation (ESE) was attempted, but despite adequate dissection of the submucosa, the mass remained poorly defined appearing as a slight elevation in the background of flat muscle. Repeat visualization of the lesion status post submucosal dissection was performed with the curvilinear echoendoscope. A biopsy forceps was introduced as a movable landmark which could be visualized on both synchronized endosonographic and optical views, so as to clearly identify the margin of the lesion . Incision of the MP overlying the identified margin allowed for precise exposure of the mass, which was further excavated and finally resected.

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

Background and AimEndoscopic 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.MethodsESE 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.ResultsAll 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).ConclusionsNSI-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.

Safety and Efficacy of Endoscopic Treatment of Solitary Gastric Neurofibroma.

PurposeThe 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 MethodsWe 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.ResultsA 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.ConclusionEFTR and ESE can serve as feasible, safe, and effective treatments for solitary GN.

Factors predicting technical difficulties during endoscopic submucosal excavation for gastric submucosal tumor.

ObjectiveEndoscopic submucosal excavation (ESE) has been established as an effective method for removal of gastric submucosal tumors (SMTs). The aim of the present study was to explore risk factors for technical difficulties in ESE.MethodsIn this retrospective study, we collected clinical data from patients who underwent ESE for gastric SMTs. Difficult ESE was defined as a procedure time ≥90 minutes, piecemeal resection, and/or occurrence of major adverse events. Univariate and multivariate analyses were performed to explore the risk factors for a difficult ESE.ResultsESE was successfully performed in 96.5% (195/202) of patients from April 2011 to December 2019. The average tumor size was 17.41 mm, and en bloc resection was achieved in 97.4% of patients (190/195). Five patients (2.56%, 5/195) had complications, including two with delayed bleeding, two with fever, and one with chest pain accompanying ST-T changes in an electrocardiogram. Twenty-four patients (11.88%, 24/202) had a difficult ESE. Logistic analysis showed that outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE.ConclusionESE may be safe and effective to treat patients with gastric SMTs. Outgrowth behavior and an inexperienced surgeon were risk factors for a difficult ESE.

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.

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. 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. 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: 24.62min (95% CI 20.04, 29.20)]. STER and ESE were associated with similar efficacy and safety; however, ESE was associated with a significantly decreased time to complete the procedure.

Safety and efficacy of endoscopic resection for the treatment of duodenal subepithelial lesions

Endoscopic management of duodenal subepithelial lesions is challenging, and there are only a few studies on this topic. This study aimed to evaluate the safety and efficacy of endoscopic resection for the treatment of duodenal subepithelial lesions. We retrospectively analyzed the clinical data, including epidemiologic characteristics, therapeutic outcomes, complications, and follow-up results, of 49 patients with duodenal subepithelial lesions who underwent endoscopic resection at our hospital between August 2010 and September 2019. We performed 35 endoscopic submucosal dissection, 9 endoscopic mucosal resection, 3 endoscopic submucosal excavation, and 2 endoscopic full-thickness resection. The en bloc resection rate and R0 resection rate were 95.9% and 89.8%, respectively. Delayed perforations developed in 2 (4.1%) patients; surgical intervention was required for both. Coagulation syndrome developed in 1 (2.0%) patient; however, it was treated conservatively. Delayed bleeding or other serious complications did not occur. One patient underwent complementary surgery after endoscopic resection. One (2.3%) recurrence occurred in patients who underwent endoscopic resection at a median follow-up duration of 24 months (range, 1-88 months). Endoscopic resection is an effective, safe, and minimally invasive method for the histopathologic assessment and curative treatment of duodenal subepithelial lesions originating from the submucosal or muscularis propria.

Risk factors for complications of therapeutic endoscopy for upper gastrointestinal subepithelial lesions.

To study the risk factors for complications after endoscopic therapy for upper gastrointestinal subepithelial lesions (SELs). Retrospective analysis was performed on 184 patients in the Department of Gastroenterology in the Third Xiangya Hospital, Central South University after therapeutic endoscopy [endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFR), endoscopic submucosal excavation (ESE), and submucosal tunneling endoscopic resection (STER)] for the upper gastrointestinal SELs from 2014-09-01 to 2019-09-30. The clinic data were collected and risk factors for postoperative complications were analyzed. Among the 184 patients, 22 patients were in the complication group (including 3 cases of delayed bleeding, 2 cases of delayed perforation, and 17 cases of electrocoagulation syndrome) and 162 patients were in the non-complication group. There was no significant difference between the complication group and the non-complication group in gender, age over 70 year, basic diseases, lesion location, lesion invasion layers, pathological results, endoscopic therapy, and preventive closure of wounds (all P>0.05). The differences between the two groups in lesion diameter over 40 mm, operative time over 120 minutes, and rate of intraoperative perforation were significant (all P<0.05). Logistic regression analysis showed that lesion diameter over 40 mm and operative time over 120 minutes were independent risk factors for postoperative complications. For the patients with upper gastrointestinal SELs after endoscopic minimally invasive therapy with the lesion diameter over 40 mm and the operative time over 120 minutes, it needs to highly alert to the occurrence of postoperative complications.

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.

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. 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. 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. 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.

Antibiotics for fever in patients without perforation after gastric endoscopic submucosal dissection and endoscopic submucosal excavation may be unnecessary: a propensity score-matching analysis

BackgroundEndoscopic submucosal dissection (ESD) and endoscopic submucosal excavation (ESE) have been widely used and have gradually become the main endoscopic treatment for gastrointestinal mucosal and submucosal lesions. Whether antibiotics are necessary for fever after gastric ESD and ESE remain unclear. The aim of this study was to analyse the value of using antibiotics in patients without perforation after ESD or ESE with fever.MethodsIn this retrospective study, patients with fever without perforation after ESD or ESE from January 2014 to January 2019 were included and divided into 2 groups: the antibiotic group and the non-antibiotic group. Fever and hospitalization time were compared between the 2 groups after propensity score matching.ResultsOverall, 253 patients meeting the inclusion criteria were enrolled in the present study, with 186 patients in the non-antibiotic group and 67 patients in the antibiotic group before matching, 55 patients in the non-antibiotic group and 55 patients in the antibiotic group after matching with all baseline characteristics balanced (p > 0.05). The duration of fever was not significantly different between the 2 groups (p = 0.12). However, the median hospitalization stay in the antibiotic group was longer than that in the non-antibiotic group (8 vs 7, p = 0.007).ConclusionsAntibiotics may be unnecessary for fever in patients without perforation and without serious co-morbidities after gastric ESD or ESE.

Long-term Outcomes of Endoscopic Resection for Gastric Subepithelial Tumors.

The purpose of the current study was to analyze the safety and efficacy of endoscopic resection for gastric subepithelial tumors (SETs) using long-term patient outcome data. A retrospective analysis of 73 consecutive patients with gastric SETs was performed from June 2014 to December 2016. The treatment methods included submucosal dissection, submucosal excavation or endoscopic full-thickness resection (EFTR). In addition to epidemiological data (sex and age), tumor size, surgical parameters, length of stay, complications, costs, and endoscopic, clinicopathologic, and follow-up data were analyzed to compare treatments. The complete resection rate was 97.3% (71/73). Three patients experienced complications (4.1%), including 2 with delayed perforation and 1 with perioperative infection. The median postoperative feeding time was 3 days, and the median postoperative hospital stay was 5 days. The median follow-up period was 19 months, with no patient death or tumor recurrence. Among the 38 patients with gastrointestinal stromal tumors, the complete resection rate was 97.4% (37/38). The complete resection and complication rates between the endoscopic submucosal excavation (ESE) group and the EFTR group were not statistically significant. There was no recurrence or metastasis detected among either group; however, the ESE group had earlier postoperative feeding, a shorter postoperative hospital stay, and less hospitalization expenses. Endoscopic resection for gastric SETs (<3 cm) is safe and feasible concerning medium-term and long-term effects. Compared with the EFTR group, the ESE group had earlier postoperative feeding, a shorter postoperative hospital stay, and less hospitalization expenses. Even so, gastric SETs with malignant potential are at risk of recurrence. Larger prospective multicenter studies are warranted.