Muscularis Propria Layer Research Articles

Efficacy and safety of endoscopic resection for small submucosal tumors originating from the muscularis propria layer in the gastric fundus.

Gastric small submucosal tumors (SMTs) are becoming increasingly common. However, the fundus of stomach is regarded as a difficult area for endoscopic resection (ER). In this study, we investigated the efficacy, safety, and long-term outcomes of ER for small SMTs of the gastric fundus in a large series of patients, research that was previously lacking. 537 consecutive patients with SMTs no more than 20mm in diameter, occurring in the gastric fundus and originating from the muscularis propria layer, which were treated with endoscopic submucosal excavation or endoscopic full-thickness resection (EFTR) were included in this retrospective study at Zhongshan Hospital of Fudan University from January 2013 to September 2016. Clinicopathological, endoscopic, and follow-up data were collected and analyzed. En bloc resection was achieved in 100% of patients, and complete resection was achieved for 530 (98.7%) lesions. Although the total rate of complications was 9.3%, few serious adverse events occurred in only three (0.6%) patients, including major pneumoperitoneum, major hydrothorax, and bleeding. Unlike lager tumor sizes and longer procedure times, endoscopist experience had a positive impact on decreasing the likelihood of complications. Based on statistical analysis, tumors with greater size near the cardia, which were treated by EFTR, were the significant contributors to longer operative times. A median follow-up of 32months was available, and all patients were free from local recurrence or distant metastasis during the study period. Although the gastric fundus presents technical difficulties, ER is effective for the resection of small gastric SMTs with a high complete resection rate and rare serious adverse events.

Endoscopic full-thickness resection for gastric gastrointestinal stromal tumor originating from the muscularis propria.

This study retrospectively reviewed 46 cases of gastric gastrointestinal stromal tumors treated by endoluminal endoscopic full-thickness resection (EFR) microsurgery in our gastrointestinal endoscopy center. We aimed to evaluate the EFR for the treatment of gastric gastrointestinal stromal tumors originating from the muscularis propria. A total of 46 patients with gastric gastrointestinal stromal tumors originated from the muscularis propria layer from January 2012 to June 2015 were treated with EFR. The patients were followed up with gastroscope and computed tomography (CT) for evaluation of therapeutic effect and safety. EFR was successfully accomplished to remove all tumors in 46 patients. The mean procedure time was 82.5±39.8min (56-188min). Except in 3 leiomyomas, pathological examination confirmed gastrointestinal stromal tumor (GIST) in 43 cases. None of the patients had occurred bleeding, peritonitis and other complications after EFR. Thereafter, all patients were followed up with gastro-scope after 1, 6,12 months. EFR is effective and safe for patients with gastric gastrointestinal stromal tumors originated from muscularis propria layer and has the advantage of less invasive treatment and higher tumor resection rate. It should be considered for further application.

Prognostic significance of positive circumferential resection margin post neoadjuvant chemotherapy in patients with esophageal or gastro-esophageal junction adenocarcinoma

BackgroundThe aim of the present study was to assess the prognosis of patients with esophageal or gastroesophageal junction (E/GEJ) adenocarcinoma extending beyond the muscularis propria layer (≥ypT3) and positive circumferential resection margin (CRM), post neoadjuvant chemotherapy. Methods177 patients were retrospectively studied. The majority (94.9%) received ECX (epirubicin, cisplatin, capecitabine), and all had clear proximal/distal resection margins. CRM was defined as positive (CRM+) when it was directly infiltrated (infiltrated CRM) or when tumor cells were detected within 1 mm from CRM (close CRM) and as negative (CRM-) when tumor cells were found in a distance > 1 mm from CRM. ResultsCRM+ was found in 83 patients (46.9%). Of them, infiltrated CRM was recorded in 36 (20.3%) and close CRM in 47 (26.6%). Adjuvant chemotherapy was administered to 132 patients (74.6%). Lymphovascular invasion and primary site in the lower esophagus were independently associated with higher risk of CRM+. Patients with infiltrated CRM, compared to those with close CRM and those CRM-, had the shortest median time-to-relapse (11.4 vs. 15.6 vs. 22.1 months, respectively, p = 0.005) and overall survival (18.7 vs. 23.1 vs. 38.8 months, respectively, p = 0.001). However, CRM status was not an independent predictor of poor outcome. Symptomatic isolated locoregional recurrences were rare in both CRM+ and CRM-patients (4/56 [7.1%] vs. 5/52 [9.6%], p = 0.736), as well as in infiltrated vs. non-infiltrated CRM (CRM- and close CRM) (0/26 [0%] vs. 9/82 [11.0%], p = 0.110). ConclusionAlthough CRM status is associated with poor outcome, it does not represent an independent prognostic factor. The status of CRM did not significantly influence the pattern of cancer relapse.

Sclerotherapy needle injections can expand the subserosal and muscularis propria layers and cause a stable mucosal lift in ESD/EMR patients

BackgroundA mucosal lift is needed for ESD and EMR. Most lifts are made via sclerotherapy needle injection. The firm push needed to penetrate the mucosa often leaves the needle tip in the deep wall. The needle is next withdrawn and fluid injected until a sharp lift (due to submucosal expansion) begins to form; the needle is then held steady and the injection finished. The initial injection may result in a subtle deep lift that resolves quickly. It was the authors’ belief that only submucosal expansion could lead to a stable mucosal lift. A colonic ESD case in which a polyp was inadvertently resected via needle knife in an expanded subserosal plane led to a questioning of this position. This study’s purpose was to determine if stable deep wall mucosal lifts can be generated via bowel wall injection.MethodsTransmucosal and intramural injections into bovine large bowel were carried out. Stable lifts and lift cross sections were made and examined grossly and histologically to determine the location of the lift fluid. Clinical ESD videos were also reviewed.ResultsOver 200 intact and cross-sectioned lifts were assessed. Gross inspection revealed two types of lifts (superficial and deep), whereas cross sections and histologic analyses revealed examples of stable expansion of the submucosal, muscularis propria, and subserosal layers post injection. Clinical “deep” lifts were also found. Superficial lifts are more focal and taller, whereas deep wall lifts are broader and less prominent.ConclusionStable deep wall mucosal lifts occur and are likely due to the deep starting point of the needle post insertion. If ESD/EMR are attempted with a deep lift, the chances of failure or perforation are high. Lifts must be carefully scrutinized before starting ESD/EMR. Other means of lift establishment should be evaluated and considered.

Feasibility of a 20-gauge ProCore needle in EUS-guided subepithelial tumor sampling: a prospective multicenter study

BackgroundEndoscopic ultrasonography-guided fine-needle biopsy (EUS-FNB) may facilitate tissue acquisition for a definitive diagnosis of gastrointestinal subepithelial tumors (SETs). This study aimed to determine the diagnostic yield of EUS-FNB using a novel 20-gauge ProCore needle with a coiled sheath in tissue sampling of gastrointestinal SETs.MethodsBetween July 2016 and February 2017, 39 patients with gastrointestinal SETs were prospectively recruited from six university hospitals in Korea. Hypoechoic SETs ≥2 cm in size and originating from the submucosal and/or muscularis propria layer under EUS were eligible. This study was registered on ClinicalTrials.gov (NCT02884154).ResultsA total of 36 patients were included in the final analyses. EUS-FNB was diagnostic in 88.9% of SETs. Tissue adequacy was judged as optimal in 97.2% of FNB specimens according to on-site visual evaluation by endosonographers, and in 88.9% of specimens according to pathologists. A macroscopically optimal core sample was obtained with two needle passes in 94.4% of cases. Technical failure rate was encountered in two cases (5.6%) after two needle passes. There were two cases (5.6%) of bleeding, which was managed endoscopically.ConclusionsEUS-FNB using a 20-gauge ProCore needle is a technically feasible and effective modality for histopathologic diagnosis of gastrointestinal SETs, providing adequate core samples with fewer needle passes;ClinicalTrials.gov number, NCT02884154.

Endosonography in Guiding Local Resection and Ampullary Preservation of a High-Risk Peri-Ampullary GIST - A Novel Approach

Gastrointestinal stromal tumors (GIST) typically develop in the stomach or small intestine and rarely involve the ampulla of vater, with only 13 cases reported in the world literature. Most authors advocate performing pancreaticoduodenectomy (PD) for such lesions. We present a case of a high-risk, invasive peri-ampullary GIST and the multidisciplinary management approach to resection. A 61-year-old male presented to his primary care provider (PCP) for medication management. He had a history of chronic back pain and peptic ulcer disease (PUD). On routine laboratory testing, his Hgb was 8.8g/dL and endorsed 2 weeks of melena. Repeat Hgb was 9.2g/dL, Iron 17ug/dL, Ferritin 6ng/mL. Upper endoscopy revealed a 2.5cm submucosal lesion with a central ulceration (Fig 1). Standard forceps biopsy was obtained which revealed CD117 and DOG1 positive spindle cell subtype GIST but was insufficient for risk assessment. CT of abdomen and pelvis was read as a 2.6x1.4cm intraluminal mass involving the duodenum extending to the level of the ampulla. Endoscopic Ultrasound (EUS) was performed showing a hypoechoic round mass in the region of the major papilla arising from the muscularis propria layer to involve the mucosa and measuring 2.5cm by 1.6cm in maximum cross-sectional dimensions (Fig 2). Biliary and pancreatic ducts were of normal caliber and a core biopsy was obtained with a 22guage fine needle biopsy (FNB) needle (SharkCoreTM, Medtronic). Liver chemistry evaluation was normal. Core biopsy histopathology confirmed GIST but was unable to risk stratify by mitotic index. He subsequently underwent duodenal excision with complex reconstruction, pyloric exclusion, and Billroth II jejunostomy (Fig 3). Tumor capsule remained intact, a small portion of pancreatic head was resected due to tumor adherence. Final pathology showed a mixed-subtype, high-risk GIST involving duodenum and pancreas. His hospitalization was complicated by gastrojejunal anastomotic ulcer bleed and AKI. He recovered, and his renal function returned to normal. PD carries significant morbidity and mortality. Inconclusive risk-stratification of the GIST led to a multidisciplinary discussion regarding most effective yet least risky surgical approach to resection. Current literature suggests similar outcomes with local resection compared to PD for GIST's. Given the EUS findings of preserved ductal anatomy, our patient was referred and underwent successful local resection of the GIST with ampullary sparing.2552_A Figure 1. Endoscopic view of submucosal Gastrointestinal Stromal Tumor (GIST) and proximity to the ampulla of Vater.2552_B Figure 2. Endoscopic Ultrasound (EUS) with fine needle biopsy of GIST arising from the muscularis propria (MP).2552_C Figure 3. Intra-operative resection of GIST. Note proximity of tumor to the major papilla at the site of the biliary catheter.

Submucosal Tunneling Endoscopic Resection for Large and Irregular Submucosal Tumors Originating from Muscularis Propria Layer in Upper Gastrointestinal Tract.

The majority of submucosal tumors (SMTs) are benign. However, large SMTs with irregular outer shapes are proved to harbor a higher risk for malignancy. Submucosal tunneling endoscopic resection (STER) has emerged as a feasible technique for resecting SMTs. To evaluate the safety and efficacy of STER for large and irregular SMTs with a diameter no <35 mm originating from the muscularis propria layer, and to share the technical skills of STER for complete and en bloc resection. We retrospectively reported 10 cases in which the new technique of STER was performed to remove large and irregular SMTs with a diameter no <35 mm of upper gastrointestinal tract in our hospital between April 2014 and April 2017. All 10 (100%) patients underwent STER successfully, with a mean operation time of 156 minutes. Among the 10 SMTs, 3 (30%) were located in the esophagus, 7 (70%) were in the cardia. All the SMTs had a maximum diameter no <35 mm, ranging from 35 to 100 mm. The mean size was 57.2 mm. En bloc resection was achieved in 8 (80%) of the tumors. Only two (20%) of the SMTs were resected into more than one piece. Complication occurred in 1 (10%) of the patients as a representation of pneumothorax. No recurrence was noted during a median follow-up of 15 months. In this retrospective study, STER may be an effective and safe technique resecting large and irregular SMTs with a diameter no >40 mm in transverse diameter and no >100 mm in longitudinal diameter.

Endosonographic Findings and the Natural Course of Chronic Gastric Anisakiasis: A Single-Center Experience

Background Chronic gastric anisakiasis is a rare, usually asymptomatic, and difficult to diagnose infection incidentally discovered during endoscopy, resembling a subepithelial tumor (SET). Because its endoscopic ultrasonography (EUS) findings are not established, it is occasionally misdiagnosed as gastrointestinal mesenchymal tumors and removed by endoscopic or surgical resection. We aimed to assess the characteristic EUS findings of chronic gastric anisakiasis and the clinical course during follow-up. Methods The database of all patients who underwent EUS at Pusan National University Hospital (Busan, Korea) between January 2011 and December 2016 was retrospectively analyzed. A total of 28 SET cases with EUS features suggesting chronic gastric anisakiasis were included in the study. The EUS, histopathologic, and follow-up endoscopic features were analyzed. Results On EUS, the lesions were mainly located in the submucosal and/or propria muscle layers. Twenty-seven lesions (27/28, 96%) showed hypoechoic echogenicity, and 22 lesions (22/28, 79%) were heterogeneous. Hyperechoic tubular structures suggesting denaturalized Anisakidae larvae were seen in 22 lesions (22/28, 79%). Endoscopic biopsies revealed significant eosinophil infiltration (≥30 per high-power field) in 12 lesions (12/21, 57%). During the median follow-up period of 9 months (range, 1–55 months), SETs decreased or subsided in 26 lesions (26/28, 93%) with no change in the size of the two lesions (2/28, 7%). Conclusions Chronic gastric anisakiasis, although rare, should be included in the differential diagnoses for gastric SETs, especially in regions where raw fish is widely consumed. EUS findings suggesting chronic gastric anisakiasis are heterogeneously hypoechoic lesions with hyperechoic tubular structures, mainly in the submucosal and/or muscularis propria layers. Because chronic gastric anisakiasis decreases or subsides in most cases, follow-up endoscopy 6–12 months later is recommended.

Clinical Values of Dental Floss Traction Assistance in Endoscopic Full-Thickness Resection for Submucosal Tumors Originating from the Muscularis Propria Layer in the Gastric Fundus.

Endoscopic full-thickness resection (EFTR) derived from endoscopic submucosal dissection has gradually been accepted and even promoted for the treatment of submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. However, there are some difficulties when EFTR is used to treat MP lesions in the gastric fundus. This study intends to explore whether EFTR can be made simpler, safer, and more effective with the traction assistance of dental floss. The clinical data of patients (trial group) with lesions in the MP layer in the gastric fundus undergoing EFTR with traction assistance of dental floss at Zhongshan Hospital, in 2016, were reviewed retrospectively. The control group was matched with the trial group according to tumor size. The differences in tumor resection time, patient hospitalization time, and complication rate were evaluated. There was no significant difference in the average age of the two groups, each of which comprised 24 cases (58.7 ± 11.8 years versus 56.6 ± 7.9 years, t = 0.663, P = .511). However, there was a statistically significant difference in the operative time between the two groups (10.8 ± 2.8 minutes versus 19.0 ± 4.7 minutes, t = 7.298, P < .05). There was no statistically significant difference in the length of the postoperative hospital stay (3.2 ± 0.5 days versus 3.2 ± 0.5 days, t = 0.291, P = .772). In the trial group, there were 19 cases of gastrointestinal stromal tumors (group 1) and 5 cases of leiomyoma. The control group had similar results. Neither group experienced postoperative delayed bleeding, perforation, or other complications. When EFTR is used to treat SMTs originating from the MP in the gastric fundus, dental floss traction assistance can relieve the tumor boundary to simplify the surgical procedure and save the operation time.

P-014 - Diagnostic and therapeutic efficacy of endoscopic enucleation for subepithelial tumors originating from muscularis propria layer

P-014 - Diagnostic and therapeutic efficacy of endoscopic enucleation for subepithelial tumors originating from muscularis propria layer

Invasive inflammatory fibroid polyp of the stomach: a case report and literature review

BackgroundInflammatory fibroid polyps (IFPs) are rare mesenchymal lesions that affect the gastrointestinal tract. IFPs are generally considered benign, noninvasive lesions; however, we report a case of an invasive gastric IFP. To the best of our knowledge, this is only the second case report of an invasive gastric IFP.Case presentationA 62-year-old woman presented with complaints of epigastric pain and vomiting. Computed tomography showed a 27-mm, hyper-enhancing tumor in the prepyloric antrum. Upper endoscopy also showed a submucosal tumor causing subtotal obstruction of the gastric outlet. Because a gastrointestinal stromal tumor was suspected, distal gastrectomy was performed. Histopathological examination revealed spindle cell proliferation in the submucosal layer. The spindle cells had invaded the muscularis propria layer and extended to the subserosal layer. The tumor was finally diagnosed as an IFP based on immunohistochemical findings. No mutations were identified in the platelet-derived growth factor receptor alpha (PDGFRA) gene via molecular genetic analysis.Discussion and conclusionsAfter the discovery that IFPs often harbor PDGFRA mutations, these growths have been considered neoplastic lesions rather than reactive lesions. Based on the present case, IFPs might be considered not only neoplastic but also potentially invasive lesions.

Mo1126 COMPARISON BETWEEN ENDOSCOPIC SUBMUCOSAL DISSECTION AND SUBMUCOSAL TUNNELING ENDOSCOPIC RESECTION FOR ESOPHAGEAL SUBMUCOSAL TUMORS ORIGINATING FROM THE MUSCULARIS PROPRIA LAYER

Endoscopic submucosal dissection (ESD) or submucosal tunneling endoscopic resection (STER) is widely acknowledged as an important treatment option for esophageal submucosal tumor from the muscularis propria layer. However, the clinical outcomes of ESD or STER for esophageal submucosal tumor have not been completely evaluated. The aim of this study is to compare the two different treatments. We retrospectively collected the data of 876 patients who had undergone ESD or STER for esophageal submucosal tumors from January 2011 to September 2015 in the Endoscopy Center of Zhongshan Hospital. Gender, age, tumor size, depth and shape, procedure time, complications, postoperative length of stay, and follow-up were compared between ESD and STER groups. 424 patients received ESD, while 452 patients received STER. There was no significant differences in age, gender, tumor size, depth and shape, en bloc resection rate, complications, postoperative hospital stay (p > 0.05). The patients receiving STER had apparently a longer procedure time due to closing the tunnel entrance (ESD vs STER, 23.2 ± 16.5 min vs 44.0 ± 25.8 min, p＜0.001). No recurrence and death was occurred in the STER and ESD groups during a mean follow-up of 50.0 and 51.8 months, respectively. Both ESD and STER would likely be effective and safe alternatives for resecting SMTs ≤ 10mm. Accounting for safety and preventing perforation, we are inclined to STER for SMTs > 10mm. Additionally, the choice between the two procedures will also depend on the depth and shape of submucosal tumors.Tabled 1Patients’ clinical characteristicsCharacteristicESD groupSTER groupP valueNumber of patients424452Mean age (SD), year51.1 ± 10.550.3 ± 10.20.453Gender, Female/Male149/275136/3160.111Location no. (%)0.107Upper6245Middle204232Lower158175Macroscopic appearance no. (%)0.188regular368378irregular5674Tumor size, mean (SD), mm1.2 ± 0.81.5 ± 0.70.078Invasion depth no. (%)0.883Superficial MP358380Deep MP6672Pathology no. (%)0.070Leiomyoma403431GIST108Granular cell tumors82Schwannoma29Clarifying fibrous tumors12Procedure time, min23.2 ± 16.544.0 ± 25.8＜0.001En bloc resection rate no. (%)417 (98.3%)446 (98.7%)0.692Complications no. (%)0.436Perforation41Pneumothorax/hydrothorax86Major bleeding12Postoperative hospital stay, day2.4 ± 1.82.8 ± 1.90.099Follow-up, month51.8 ± 16.450.3 ± 15.10.112Recurrence001Data are presented as number (no.) and rate (%). Abbreviations: MP, muscularis propria; GIST, gastrointestinal stromal tumors. Open table in a new tab

Su1112 EFFICACY AND SAFETY OF SNARE TRACTION FOR ENDOSCOPIC SUBMUCOSAL DISSECTION OF EARLY ESOPHAGEAL CARCINOMA AND PRECANCEROUS LESIONS

Endoscopic submucosal dissection(ESD) has been rapidly gaining popularity worldwide recently due to high en bloc resection rate, minimally invasive procedure, patient rapid recovery and reduced health-care cost. However, ESD is associated with more complications, such as bleeding and perforation, especially in esophageal cases without good visualization of the dissection layer. Therefore, the efficacy and safety of snare traction for ESD of early esophageal carcinoma (EEC) or precancerous lesions was investigated. 57 EEC or precancerous patients were enrolled in the study and randomly divided into two groups . 26 cases underwent ESD with snare traction (snare group). In snare group, a snare was clamped to the oral side of the lesion after the circumferential incision and pushed in the anal direction during ESD. 31 cases underwent routine ESD without snare traction (non-snare group). The total dissection time, en bloc resection rate , average dissection area per minute, times of muscularis propria injury and incidence of perforation were statistically analyzed. ESD was successful in all 57 cases with 100% en bloc resection and there was no perforation during ESD or after ESD in all these cases. No significant difference was found between the two groups with respect to the dissection area (17.01±8.42cm2 vs 17.41±7.08cm2, P>0.1). The total dissection time of ESD was shorter in the snare group than in the non-snare group (57.10±9.65min vs 87.12±10.24min，P<0.05) . The average dissection area per minute is higher in the snare group than in the non-snare group(29.78±7.06 mm2/min vs 18.44±6.58mm2/min, P<0.05).Moreover, the muscularis propria injuries in the snare group were obviously less than the non-snare group (1.32±1.06 vs 2.50±1.12，P<0.05). Snare traction is potential for decreasing the injury of muscularis propria layer and total dissection time during ESD for esophageal cancerous lesions with easy control. It could be recommended as a safe and effective procedure for ESD of EEC and precancerous lesions.

Endoscopic mucosa-sparing lateral dissection for treatment of gastric submucosal tumors: a prospective cohort study.

In our previous work, we developed a modified method for the removal of gastric submucosal tumors (SMTs), called endoscopic mucosa-sparing lateral dissection (EMSLD). This prospective study aimed to evaluate the efficacy and postoperative outcomes of EMSLD. We prospectively enrolled 25 consecutive patients with gastric SMTs, who received EMSLD treatment. Clinicopathological characteristics and operation-related outcomes were analyzed. The mean age of patients was 49.3 ± 9.7 years, and the mean tumor size was 14.6 ± 6.1 mm. En bloc resection was achieved in all cases. The mean procedure time was 47.3 ± 25.9 minutes, and the estimated blood loss was 4.8 ± 3.5 mL. Endoscopic full-thickness resection was performed in six patients (24 %) because the tumors originated from the deep muscularis propria layer. All perforations and resection defects were successfully closed by the retained mucosa and endoclips. No serious complications related to EMSLD were encountered during or after the procedure. EMSLD was reliable and effective for the removal of gastric SMTs. However, large-scale randomized controlled trials are needed.

Treatment of cardial submucosal tumors originating from the muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation.

Submucosal tunneling endoscopic resection (STER) is increasingly used for the treatment of submucosal tumors (SMTs) originating from the muscularis propria layer; however, endoscopic submucosal excavation (ESE) is still performed in many hospitals for its low-skill and experience requirements. This study aimed to compare STER with ESE for cardial SMTs. From March 2013 to February 2017, patients with cardial SMTs undergoing STER (n = 47) and ESE (n = 40) were retrospectively assessed. Clinicopathological, endoscopic, and complication data were compared between STER and ESE groups. The 87 enrolled patients included 31 females and 56 males, aged 48.2 ± 9.8years. Mean tumor size was 22.0mm (range 5.0-80.0mm) as evaluated by pathology. Demographic and lesion features were similar in both groups. Despite similar hospital stay duration and cost, ESE was superior to STER with reduced operation time (34 vs. 46min, P = 0.013) and less clips required (3 vs. 5, P = 0.000). En bloc resection rates, complete resection rates, hospital stay duration, cost, complications, and hemoglobin levels were similar in both groups. Irregular-shaped SMTs were more likely to achieve piecemeal resection in both STER and ESE groups (all P < 0.05). Meanwhile, the piecemeal resection rate was significantly higher for larger tumors in the STER group. Compared with ESE, STER does not show overt advantages for cardial SMTs. However, ESE is superior to STER for reduced operation time. Irregular tumor shape seems to be a risk factor for piecemeal resection in both STER and ESE.

Adenocarcinoma arising in sigmoid colon neovagina 53\xa0years after construction

BackgroundIn view of the rarity of vaginal agenesis, malignancy arising in the neovagina is extremely rare.Case presentationHere, we report a 76-year-old female with an adenocarcinoma arising in the sigmoid colon neovagina which was constructed 53 years ago for congenital vaginal agenesis. Vaginal endoscopy to examine vaginal bleeding revealed a protruding lesion occupying three quarters of the lumen in the vicinity of anastomosis of the residual vagina and sigmoid colon. Transvaginal ultrasonography revealed the muscularis propria layer (hypoechoic fourth layer) to be interrupted. CT revealed no distant metastasis. Total pelvic exenteration was performed based on the diagnosis of neovaginal cancer at the anastomosis site. The 45-mm tumor showed well-differentiated adenocarcinoma with a mucinous adenocarcinoma component. Immunohistochemistry showed no p16-overexpressing tumor cells, suggesting the lack of human papilloma virus infection.ConclusionsAlthough rare, clinicians should be aware of cancer that arises in the ectopic intestine when anastomosed with other organs.

Isobaric tags for relative and absolute quantification-based proteomic analysis that reveals the roles of progesterone receptor, inflammation, and fibrosis for slow-transit constipation.

Progesterone receptor, inflammation, neurotransmitter expression, and fibrosis are involved in slow-transit constipation. The aim of the present study was to examine whether patients with slow-transit constipation have an overexpression of progesterone receptor and serotonin, which may impair the fibrosis of muscularis propria in colorectal wall. High-resolution colon manometry was used to record the colorectal peristaltic contractions of the proximal ascending and sigmoid colon in patients. Protein samples prepared from frozen sigmoid colon tissue and the proximal margin of the ascending colon of four female patients were compared using isobaric tags for relative and absolute quantification labeling technique coupled to 2D liquid chromatography-tandem mass spectrometry analysis. Immunohistochemical staining of progesterone receptor, serotonin, and fibronectin was performed in paraffin-embedded sigmoid colon tissues and the proximal margin of the ascending colon or ileum from 43 patients with slow-transit constipation. Among these differentially regulated proteins based on isobaric tags for relative and absolute quantification and liquid chromatography-tandem mass spectrometry analysis, 56 proteins involved in the response to progesterone, inflammation, matrix remodeling, fibrosis, and muscle metabolism. Immunohistochemical staining confirmed that there was significantly higher expression of progesterone receptor (t=19.19, P=0.000) and serotonin (t=13.52, P=0.004) in sigmoid colon than in the proximal margin of the ascending colon and ileum. Progesterone receptor and fibronectin expression in the outer layer of muscularis propria were higher than in the middle layer. These results demonstrate that progesterone receptor, along with inflammation and fibrosis, may take part in slow-transit constipation development.

Limitations of endoscopic ultrasonography in the diagnosis of esophageal submucosal tumor

Objective To investigate the diagnostic value of endoscopic ultrasonography(EUS) for esophageal submucosal tumor (SMT). Methods Clinical data of 388 patients with esophageal SMT, who underwent EUS and endoscopic treatment in Tianjin Medical University General Hospital were collected from May 2010 to September 2016. The golden standard for the origin of esophageal SMT was the diagnosis during endoscopic treatment, and the golden standard of pathological type was the combination of postoperative pathological and immunohistochemical findings. The diagnostic accuracy of EUS for esophageal SMT was evaluated. Results The conventional endoscopy revealed that 31.70% (123/388) and 43.81% (170/388) esophageal SMTs were located in the middle and lower segments of esophagus, respectively. The diagnostic consistency of EUS for the origin of lesion was 71.51% (251/351), while the diagnostic consistency of EUS for lesion originated from the muscularis mucosae, submucosa and muscularis propria layer was 92.90% (170/183), 34.38% (11/32), and 51.47% (70/136), respectively. The diagnostic consistency of EUS for the type of lesion was 81.00% (260/321), while the diagnostic consistency of leiomyoma, esophageal cyst, and lipoma were 88.42% (252/285), 14.81% (4/27), and 80.00% (4/5), respectively. Conclusion EUS can preliminarily diagnose the origin and pathological type of esophageal SMT, but there are limitations on the diagnosis of uncommon lesions, which need combination of pathological and immunohistochemical findings. Key words: Endoscopic ultrasonography; Esophageal neoplasms, submucosal; Diagnosis; Accordance rate

Efficacy and complications of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors and exploration for influencing factors.

Submucosal tunneling endoscopic resection (STER) has emerged as a feasible technique for resecting upper gastrointestinal (GI) tract submucosal tumors (SMTs) through natural orifice transluminal endoscopic surgery. STER reduces the risk of postoperative perforation and abdominal infections and promotes rapid wound healing. The aim of this meta-analysis was to evaluate the safety and efficacy of STER for small (≤ 3.5 cm) upper GI SMTs and explore the potential factors influencing STER's efficacy and complication rate. Comprehensive literature searches were performed to find studies on STER for removal of SMTs. Several English-language databases were searched, including MEDLINE (through PubMed), EMBASE, and the Cochrane Library for the period January 2010 to June 2016. The medical terms "submucosal tunneling endoscopic resection or STER", "upper gastrointestinal", and "submucosal tumors" were used in the search. The primary outcome measures were the pooled estimates of the complete resection and en bloc resection rates. The secondary outcome measure was the pooled estimate of complications. Twelve studies including 397 patients and 430 lesions were identified. The pooled estimate of the complete resection rate was 98.1 % (95 % confidence interval [CI]: 95.9 - 99.2 %). The pooled estimate of en bloc resection was 94.9 % (95 % CI: 91.1 - 97.1 %). The pooled estimate of gas-related complications such as pneumoperitoneum and subcutaneous emphysema was 21.5 % (95 % CI: 13.2 - 33.1 %). The pooled estimate of inflammation-related complications including pleural and abdominal effusion was 8.4 % (95 % CI: 5.6 - 12.3 %). Gas-related complications occurred more frequently in the esophagogastric junction than in the stomach. In addition, the pooled estimate of delayed bleeding was 2.2 % (95 % CI: 1.0 - 4.7 %). STER appeared to be an extremely effective technique for removing upper GI SMTs originating from the muscularis propria layer. In addition, the very low rate of complications also shows the safety of this technique. Tumor size, infiltration depth, and location may influence the complication rates.

Comparison between submucosal tunneling endoscopic resection and video-assisted thoracoscopic enucleation for esophageal submucosal tumors originating from the muscularis propria layer: a randomized controlled trial.

Surgical resection is considered the first treatment option for submucosal tumors (SMTs) originating from the muscularis propria layer while submucosal tunneling endoscopic resection (STER) is proved to be a safe and effective method for treating SMTs. This study aimed to compare video-assisted thoracoscopic enucleation (VATE) with STER for treating esophageal SMTs. Sixty-six patients with small esophageal SMTs were prospectively randomized from July 2014 to December 2015. After exclusion of 8 patients, 58 subjects scheduled for STER or VATE were enrolled. Clinicopathological, endoscopic, and adverse events (AEs) data were collected and analyzed between STER and VATE. Forty-six males and 12 females with a mean age of 46.1 ± 9.4years were randomized to the STER (n = 30) and VATE (n = 28) groups, respectively. Demographics and lesion features were similar between the two groups. Median procedure time was shorter in the STER group than the VATE group (44.5 vs. 106.5min, P < 0.001); cost was lower in the STER group (4499.46 vs. 6137.32 USD, P = 0.010). Median decrease in hemoglobin levels post-procedure was - 1.6g/L in the STER group and 14.7g/L after VATE (P = 0.001). Lower postoperative pain scores were found in the STER group compared with the VATE group (2 vs. 4, P < 0.001). No recurrent or residual tumors were found in either group. En bloc resection rates, complete resection rates, hospital times, and post-procedure AEs were similar between two groups. The en bloc resection rates for SMTs < 20.0mm were 100% in both groups while STER achieved only 71.4% en bloc resection rate for SMTs≥ 20.0 mm. STER and VATE are comparably effective for esophageal SMTs; however, STER is superior to VATE with shorter operation time and decreased cost, and seems safer than VATE. STER is recommended for SMTs < 20.0mm while VATE is recommended for SMTs with a transverse diameter > 35.0mm. Clinical trail registration statement: This study is registered at http://www.chictr.org.cn/showproj.aspx?proj=4814 . The registration identification number is ChiCTR-TRC-14004759. The registration date is April 30, 2014.