Subepithelial Lesions Research Articles

Impact of Size on Endoluminal Approaches to Submucosal Tumors of the Stomach

Gastric subepithelial lesions (SELs) represent a heterogenous group of mass lesions that arise from the gastric mucosa. Several endoscopic techniques can be used to manage gastric SELs once the decision is made to pursue resection, including endoscopic submucosal resection, endoscopic submucosal dissection, submucosal tunnel endoscopic resection, and endoscopic full-thickness resection. In addition to other clinical and anatomic factors, lesion size has important implications on the ability to obtain a complete resection while minimizing risk of adverse events. This article reviews technical considerations and available data regarding how size may impact the endoscopic approach to gastric SEL resection.

Gastric Glomus Tumor Resected by Submucosal Tunneling Endoscopic Resection

ABSTRACT Gastric glomus tumor (GGT) is a rare mesenchymal neoplasm, that is usually asymptomatic. Although benign, malignant transformation has been reported. A 59-year-old man presented with dyspepsia refractory to treatment with proton-pump inhibitor over 6 months. Esophagogastroduodenoscopy revealed a 30 mm subepithelial lesion in the distal gastric antrum, in contact with the pylorus, but biopsies were nonspecific. Upper endoscopic ultrasound revealed a well-defined submucosal echogenic lesion measuring 30 × 20 mm, without muscularis propria involvement. A fine-needle aspiration biopsy showed GGT features. En bloc endoscopic resection was performed using the submucosal tunneling endoscopic resection technique. The histopathological study of the specimen confirmed the diagnosis of a GGT with free margins. The patient remains symptom-free after a 9-month follow-up. We highlight the rare diagnosis of GGT and the possibility of curative en bloc endoscopic resection with submucosal tunneling endoscopic resection.

A Case of Superficial Esophageal Neuroendocrine Carcinoma with Marked Morphological Changes in a Short Period.

A de novo whitish subepithelial lesion (SEL) with irregular vascular hyperplasia was detected in the lower thoracic esophagus during endoscopic surveillance. Special types of esophageal cancer were suspected; however, endoscopic biopsy specimens were inadequate for a diagnosis. Ten days later, endoscopic ultrasound showed a 7-mm homogeneously hypoechoic round mass in the submucosa, and a biopsy confirmed a histological diagnosis of esophageal neuroendocrine carcinoma (eNEC). Based on the clinical diagnosis of cT2N0M0, subtotal esophagectomy followed by adjuvant chemotherapy was performed immediately after endoscopic reexamination revealing a 20-mm reddish SMT. We herein report the marked changes in endoscopic findings of eNEC within 1.5 months.

Exploring the clinicopathological characteristics of submucosal tumor-like esophageal squamous cell carcinoma and the diagnostic significance of endoscopic ultrasound: a comprehensive analysis.

Completely intramural growth submucosal squamous cell carcinoma of the esophagus, also known as SMT-like esophageal squamous cell carcinoma (ESCC), represents a rare and distinct form of esophageal cancer. Its white light endoscopic manifestations resemble those of esophageal subepithelial lesions, and biopsy pathology is often negative, leading to potential oversight or misdiagnosis. This study aimed to comprehensively summarize the clinicopathological and endoscopic ultrasound (EUS) characteristics of patients with SMT-like ESCC while also evaluating the immunohistochemical expression of these patient. This study collected clinical data, including demographic and clinicopathological data, as well as EUS findings, from six patients with SMT-like ESCC. Immunohistochemical analysis was also conducted on tumor tissues to assess the expression of CK7, CK19, CK20, TTF-1, SMA, S-100, Melan-A, CD117, Mucin (MUC) 2, and MUC5. In EUS, SMT-like ESCC is characterized by nonuniform hypoechoic lesions with indistinct borders, often exhibiting a burr or serrated appearance. Most of these lesions involved multiple levels. Cytological specimens obtained through EUS-guided fine needle aspiration (EUS-FNA) revealed suspected squamous cell carcinoma with positive expression of CK5/6, P40, and P63, further confirming the diagnosis of ESCC. Additionally, four patients exhibited CK7+/CK20- immune-expression profiles, and all patients had positive CK19 expression. TTF-1, SMA, S-100, Melan-A, CD117, MUC2, and MUC5 were negative. Combining EUS with EUS-FNA is a valuable approach for diagnosing and differentiating SMT-like ESCC. Furthermore, the characteristic CK7+/CK20- immune profile suggested a potential origin from the esophageal submucosa glands.

Colorectal Endoscopic Full-Thickness Resection: A Portuguese Multicenter Experience Based on a Retrospective Cohort

Introduction: Endoscopic full-thickness resection (EFTR) is a minimally invasive endoscopic technique that allows the resection of complex colorectal lesions, such as non-lifting, peri-appendicular, peri-diverticula, and subepithelial lesions. Published data suggest that EFTR has a technical success and R0 resection rates of 89 and 79%, respectively, and an adverse event rate of 12%. This study summarizes the EFTR experience in nine Portuguese centers with regard to its efficacy and safety. Methods: This was a multicenter uncontrolled retrospective study, including 129 colorectal EFTRs between March 2017 and September 2023. The main outcomes were procedural and technical success, R0 resection, curative resection, adverse events, and recurrence rate. Results: 129 EFTR procedures were conducted, with a technical success rate of 88.4% (114/129). Most lesions were in the right colon, with a median resection size of 25 [10–45] mm. R0 and curative resection rates were 75.9% (85/112) and 58.0% (65/112), respectively. Adverse events occurred in 13.2% (17/129) of patients, mostly due to immediate perforation, appendicitis, or delayed bleeding, needing surgery in 5.4% (7/129). Local recurrence occurred in 5.4% (5/92) of resections. Conclusion: This real-life multicenter study highlights the utility of colorectal EFTR for management of complex and carefully chosen lesions, with an acceptable adverse events rate and need for surgery.

Thoracoscopic and endoscopic cooperative surgery for esophageal gastrointestinal stromal tumor: a case report

BackgroundEsophageal gastrointestinal stromal tumors (GISTs) are relatively rare, accounting for 2–5% of all GISTs. Typically, the treatment is surgery in nature. However, no standard procedure established for esophageal GISTs, and in many cases, subtotal esophagectomy or local resection via thoracoscopy or mediastinoscopy is performed. Thoracoscopic and endoscopic cooperative surgery (TECS) is a surgical approach similar to laparoscopic and endoscopic cooperative surgery used for gastric GIST; however, no reports of its use for esophageal GIST have been published to date. We herein report such a case along with a review of past literature.Case presentationThe patient was a 60-year-old man. Upper gastrointestinal contrast imaging revealed a subepithelial lesion in the esophagus. An 18 × 17 mm subepithelial lesion was identified in the left wall, 35 cm from the upper incisors, during upper gastrointestinal endoscopy, and was diagnosed as a GIST through endoscopic ultrasound-guided fine needle biopsy. TECS was therefore performed. The patient was placed in a prone position with his face to the left. After confirming the lesion under endoscopy and left thoracoscopy, the periesophageal area of the lesion was dissected under thoracoscopy. Subsequently, an endoscopic full-layer resection was performed. Finally, the excision site of the lesion was sutured under thoracoscopy. The operation took a total of 3 h and 22 min, with a blood loss of 50 mL.ConclusionsThe appropriate surgical procedure for esophageal GIST should be considered according to the location and size of the lesion. TECS ensures that the resection margins are secured using an endoscopic or thoracoscopic approach. Furthermore, TECS is minimally invasive, avoiding esophagectomy and reconstruction, which makes it a potential surgical option for esophageal GISTs.

Endoscopic Ultrasound and Gastric Sub-Epithelial Lesions: Ultrasonographic Features, Tissue Acquisition Strategies, and Therapeutic Management

Background and objectives: Subepithelial lesions (SELs) of the gastrointestinal (GI) tract present a diagnostic challenge due to their heterogeneous nature and varied clinical manifestations. Usually, SELs are small and asymptomatic; generally discovered during routine endoscopy or radiological examinations. Currently, endoscopic ultrasound (EUS) is the best tool to characterize gastric SELs. Materials and methods: For this review, the research and the study selection were conducted using the PubMed database. Articles in English language were reviewed from August 2019 to July 2024. Results: This review aims to summarize the international literature to examine and illustrate the progress in the last five years of endosonographic diagnostics and treatment of gastric SELs. Conclusions: Endoscopic ultrasound is the preferred option for the diagnosis of sub-epithelial lesions. In most of the cases, EUS-guided tissue sampling is mandatory; however, ancillary techniques (elastography, CEH-EUS, AI) may help in both diagnosis and prognostic assessment.

Solitary fibrous tumor of the stomach

Abstract Introduction/Objective Solitary fibrous tumor (SFT) is an uncommon fibroblastic tumor that originates from the mesenchymal tissue. It has been rarely reported within the stomach. None of these reported tumors have occurred in a background of autoimmune atrophic gastritis as was seen in our patient. Methods/Case Report Case report Results (if a Case Study enter NA) An 85-year-old female with history of anemia and autoimmune atrophic gastritis presented with two-month history of dysphagia and abdominal discomfort. Upper gastrointestinal endoscopy showed a 1 cm subepithelial lesion in the gastric body along the greater curvature. Upper endoscopic ultrasound showed mildly hypoechoic lesion in the submucosa of the stomach with the differential of leiomyoma, neuroendocrine tumor, gastrointestinal stromal tumor, and an atypical looking lipoma. The entire gastric lesion was lifted with submucosal saline injection and then resected using cap endoscopic mucosal resection (EMR) snare cautery. Gross examination showed a well-circumscribed lesion with firm, tan-white cut surface. On microscopy, a bland appearing spindle cell proliferation within a collagenous stroma was seen with alternating hypercellular and hypocellular areas and few dilated vessels. No significant mitosis, nuclear pleomorphism or necrosis was identified. Immunohistochemical stains were performed and the lesional cells were positive for STAT6. Markers for gastrointestinal stromal tumor (CD117, DOG1), smooth muscle tumor (desmin, smooth muscle actin) and schwannoma (S100, SOX10) were negative. Nuclear staining for STAT6 is a sensitive and specific marker for SFTs. This particular SFT was considered to be of low risk and non-malignant considering its small size, lack of mitotic activity and tumor necrosis. The etiology for SFT is not entirely clear but molecular studies have shown that the NAB2::STAT6 translocation in a spindle cell neoplasm is a diagnostic hallmark for SFTs. Conclusion Solitary fibrous tumors have been rarely reported within the stomach. Complete surgical resection with negative margins is the mainstay of treatment as they may recur after an incomplete resection.

Value of image enhancement of endoscopic ultrasound for diagnosis of gastrointestinal subepithelial lesions.

Among subepithelial lesions (SELs), gastrointestinal stromal tumors (GISTs) should be identified and surgically treated at an early stage. However, it is difficult to diagnose SELs smaller than 20 mm. In recent years, endoscopic ultrasound (EUS) elastography (EUS-EG) and contrast-enhanced harmonic EUS (CH-EUS) have been reported to be useful for the diagnosis of SELs, although the diagnostic accuracy of a combination of EUS techniques with image enhancement is unknown. Patients with SELs who underwent EUS-guided tissue acquisition, EUS shear-wave elastography (EUS-SWE), EUS strain elastography (EUS-SE), and CH-EUS from January 2019 to June 2023 were enrolled. To assess the diagnostic accuracy for differentiating GISTs from other SELs, shear-wave velocity on EUS-SWE, the strain ratio on EUS-SE, and vascularity on CH-EUS were determined and their diagnostic accuracies were compared. Forty-three patients were enrolled. When the cut-off value was set at 3.27 m/s, the sensitivity, specificity, and diagnostic accuracy of shear-wave velocity were 28.6%, 86.2%, and 34.9%, respectively. When the cut-off value was set at 3.79, the sensitivity, specificity, and diagnostic accuracy of the strain ratio were 93.1%, 64.3%, and 83.7%, respectively. The sensitivity, specificity, and diagnostic accuracy of CH-EUS were 79.3%, 92.3%, and 83.7%, respectively. When EUS-SE was combined with CH-EUS, the sensitivity and diagnostic accuracy were the highest among binary combinations of image enhancement modalities. EUS-SE and CH-EUS are useful for differentiating GISTs from other SELs. Furthermore, the use of both modalities may further improve the identification of GISTs.

Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study.

The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM. This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis. Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%). ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

Efficacy of EUS-guided keyhole biopsies in diagnosing subepithelial lesions of the upper gastrointestinal tract.

Background and study aims Tissue acquisition is required for diagnosis of subepithelial lesions (SELs). However, obtaining adequate tissue remains challenging. This study investigated an EUS-guided technique using a forceps to create a channel and take multiple biopsies from the center of the lesion, therefore called endoscopic ultrasound-guided keyhole biopsy (EUS-KB). Patients and methods A retrospective cohort study was conducted in 56 patients with SELs in the upper gastrointestinal tract who were scheduled to undergo EUS-KB. The primary aim was to assess diagnostic yield, defined as the percentage of procedures where EUS-KB resulted in a definitive histopathological diagnosis. Furthermore, factors influencing diagnostic yield were investigated. Additional outcomes included technical success and adverse events. Results Technical success was achieved in 55 of 60 biopsies (91.7%). EUS-KB provided a diagnosis in 44 of 55 biopsies (80.0%), histology mostly showing gastrointestinal stromal tumor or leiomyoma. The diagnostic yield was not significantly influenced by the size or location of the SEL. Adverse events occurred in one patient (1.7%). Conclusions EUS-KB is a feasible and safe technique for obtaining a classifying diagnosis for SELs in the upper gastrointestinal tract. It could offer an alternative diagnostic modality, especially in lesions smaller than 20 mm.

A subepithelial lesion algorithm for endoscopic (SAFE) resection in the upper gastrointestinal tract.

Complete excision of upper gastrointestinal subepithelial lesions (U-SELs) eliminates diagnostic uncertainty, obviates the need for surveillance, and may be necessary for definitive diagnosis and management. Current guidelines lack precision and cohesion, and surgery is associated with significant morbidity. We describe and report on the outcomes of our SEL algorithm for endoscopic (SAFE) resection. U-SELs were enrolled prospectively over 115 months until March 2023. All subjects underwent axial (computed tomography) imaging and endoscopic ultrasonography (EUS) to exclude a large exophytic component or invasion into local structures, and assess for muscularis propria (MP) involvement. 106 U-SELs (41 esophageal, 65 gastric) were resected (mean patient age 60.6 [SD 13.4]; 51.9% male). Esophageal U-SELs underwent endoscopic submucosal dissection (ESD; n = 22) or submucosal tunneling endoscopic resection (STER) if MP involvement was suspected (n = 19). Gastric U-SELs underwent STER (n = 6 at cardia), ESD (n = 47), or exposing endoscopic full-thickness resection (e-EFTR; n = 12). Technical success rates were 97.6% and 92.3%, respectively. Among the noncardiac gastric U-SELs, five resections (9.6%) were completed laparoscopically owing to deep and broad full-thickness involvement; five (9.6%) required laparoscopic gastrotomy and surgical retrieval after successful resection and closure owing to a large lesion size (mean 47 mm). There was no delayed bleeding, perforation, or recurrence at 13 months. U-SELs may be effectively and safely treated by endoscopic resection. The SAFE approach provides a framework that facilitates structured decision-making. Esophageal U-SELs suspected of involving the MP should undergo STER. Gastric SELs are best managed by ESD, with a view to proceeding to e-EFTR. A laparoscopic upper gastrointestinal surgeon should be available in case surgical retrieval of the specimen or laparoscopic completion is required.

S1576 The Efficacy and Safety of Endoscopic Full Thickness Resection of Gastric Subepithelial Lesions. A Single Center Experience

S1576 The Efficacy and Safety of Endoscopic Full Thickness Resection of Gastric Subepithelial Lesions. A Single Center Experience

S1572 Efficacy of Endoscopic Full-Thickness Resection for Duodenal Subepithelial Lesions: A Systematic Review and Meta-Analysis

S1572 Efficacy of Endoscopic Full-Thickness Resection for Duodenal Subepithelial Lesions: A Systematic Review and Meta-Analysis

Gastric dysplasia arising from a submucosal heterotopic gastric gland.

A submucosal heterotopic gastric gland (SHGG) is characterized by benign ectopic gastric tissue within the submucosa. Neoplasms arising from SHGGs are rare, and their definitive diagnosis via endoscopic biopsy is often challenging. We report the case of a 74-year-old man undergoing screening esophagogastroduodenoscopy, which revealed a subepithelial lesion with a central orifice in the upper body of the stomach. Endoscopic submucosal dissection (ESD) was performed because the endoscopic biopsy revealed a suspected pyloric gland adenoma. Pathological examination of the resected specimen confirmed SHGG with focal dysplasia. The patient recovered uneventfully and remained free of recurrence over a 5-year follow-up period. This case highlights the utility of ESD in both the treatment and accurate pathological diagnosis of neoplasms arising from SHGGs.

Laparoscopic endoscopic cooperative surgery for gastric subepithelial lesion during laparoscopic sleeve gastrectomy for severe obesity

BackgroundThe frequency of pathologies detected incidentally before, during, and after a bariatric surgery, such as subepithelial lesion (SEL) of the stomach, is likely to rise as bariatric surgery becomes more common.Case presentationA 49-year-old female patient presented with severe obesity, for which laparoscopic sleeve gastrectomy (LSG) was planned. During a preoperative examination, endoscopy revealed a 10 mm SEL in the posterior wall of the upper body of the stomach. Excision of the SEL was performed simultaneously with the LSG. Endoscopy demonstrated that the SEL was situated on the remnant side of the stomach. Endoscopic resection using laparoscopic endoscopic cooperative surgery was performed for the SEL, and the thinned gastric wall was closed by hand-sewing. Thereafter, LSG was performed. Pathological analysis of the SEL led to a diagnosis of leiomyoma. The patient was discharged on postoperative day 6.ConclusionSurgeons should be prepared to manage incidentally detected pathologies before, during, and after bariatric surgery and to choose the surgical method most suitable to the individual patient.

Compromiso gástrico por enfermedad relacionada con IgG4

Introduction: IgG4-related disease (IgG4-RD) is a recently described entity, characterized by IgG4+ infiltration of plasma cells and storiform pattern sclerosis mediated by CD4+ lymphocytes and follicular helper T-cells (Tfhs). Most patients present with adenopathy and weight loss. Among the most affected sites are the pancreas, salivary and lacrimal glands, aorta, and retroperitoneum. Gastric involvement is rare. Diagnosis is based on histopathological examination of the involved organ, clinical manifestations, and serological results. Glucocorticoid therapy is the first line management. Case report: a 38-year-old male patient with symptoms suggestive of upper gastrointestinal (GI) bleeding, upper GI endoscopy revealed a gastric corpus ulcer, suspicious of an ulcerated gastric subepithelial lesion, possibly a gastrointestinal stromal tumor (GIST). Consequently, laparoscopic subtotal gastrectomy was performed. Histology was compatible with an ulcerated IgG4-related fibrosclerosing tumor. Glucocorticoid therapy was started with patient´s favorable response. Conclusion: in this paper, we will review the cases of IgG4-RD with gastric involvement reported in the literature to describe the most important features of this condition.

Endoscopic submucosal resection (ESD) and endoscopic full-thickness resection (EFTR) via balloon-assisted enteroscopy (BAE) in small bowel subepithelial lesions: experience in treating fifteen cases.

The study objective was to evaluate the primary feasibility of endoscopic submucosal resection (ESD) and endoscopic full-thickness resection (EFTR) via balloon-assisted enteroscopy (BAE) to treat small bowel subepithelial lesions (SELs). A retrospective case series study was performed. The first fifteen consecutive patients who underwent ESD (n = 10) and EFTR (n = 5) via BAE to remove small bowel SELs from November 2016 to December 2023 were included. The main outcome measures were the technique success rate, operative time and complication rate. This research focused on 15 cases of jejunoileal SELs, four cases of lipomyoma, three cases of ectopic pancreas, two cases of NETs, three cases of benign fibrous tumours and three cases of angioma. The overall technique success rate was 86.7%, with 100% (10/10) and 60% (3/5) for BAE-ESD and BAE-EFTR, respectively, in removing small bowel SELs. Two cases of EFTR failed, as the BAE operation was unsuitable for tumour resection and suture repair of a perforated wound. No serious bleeding or any postoperative complications occurred. The median time of endoscopic resection via BAE for SELs was 44min (range 22-68min). ESD and EFTR via BAE might be alternative choices for treating small SELs in the small bowel, with the advantages of clear and accurate positioning and minimal invasiveness. However, its superiority over surgery still needs to be further investigated.

Clinical safety of a novel over-the-scope gastroduodenal full-thickness resection device for the treatment of upper GI tract lesions: a multicenter experience

BACKGROUND AND AIMSA novel gastroduodenal full-thickness resection device system was developed for resection of upper gastrointestinal (GI) tract lesions. Our study aimed to evaluate the efficacy and safety of the gastroduodenal full-thickness resection device system. METHODSConsecutive patients who received endoscopic resection of upper GI tract lesion (6/2020-8/2022) using gastroduodenal full-thickness resection device were evaluated from eight U.S. centers. Primary endpoints included technical success and R0 resection. Secondary endpoints were en bloc resection, residual lesions at follow-up endoscopy, and immediate/delayed adverse events. RESULTSForty-four patients (mean age 60.9±15.8 years) received 45 resections for gastric (35, 80%) and duodenal (9, 20%) leions. 34 (77%) were subepithelial and 10 (23%) were epithelial lesions. Technical success and en bloc resection were achieved in 43 (96%) and 41 (91%) patients, respectively. Furthermore, R0 resection was achieved in 32 (71%) patients including 24 (69%) of 35 with neoplastic lesions. Pathologic diagnosis included neuroendocrine tumor in 14 (32%), gastrointestinal stromal tumor in 10 (23%), and gastric cancer/high grade dysplasia in 7 (16%). Minor immediate and delayed bleeding occurred in 17 (38%) and 2 (4%) patients. One patient had delayed perforation, managed conservatively. On follow-up, 19 (90%) of 21 patients had no residual lesion. CONCLUSIONIn this multicenter series, gastroduodenal full-thickness resection device demonstrated high rates of technical success and acceptable rate of R0 resection. Immediate minor bleeding was common, while serious adverse events were rare. Gastroduodenal full-thickness resection device should be considered in patients with gastroduodenal subepithelial lesions as an alternative to long-term surveillance.

Ligation-assisted endoscopic submucosal resection following unroofing technique for small esophageal subepithelial lesions originating from the muscularis propria.

The majority of esophageal subepithelial lesions originating from the muscularis propria (SEL-MPs) are benign in nature, although a subset may exhibit malignant characteristics. Conventional endoscopic resection techniques are time-consuming and lack efficacy for small SEL-MPs. To evaluate the efficacy and safety of ligation-assisted endoscopic submucosal resection (ESMR-L) following unroofing technique for small esophageal SEL-MPs. From January 2021 to September 2023, 17 patients diagnosed with esophageal SEL-MPs underwent ESMR-L following unroofing technique at the endoscopy center of Shenzhen People's Hospital. Details of clinicopathological characteristics and clinical outcomes were collected and analyzed. The mean age of the patients was 50.12 ± 12.65 years. The mean size of the tumors was 7.47 ± 2.83 mm and all cases achieved en bloc resection successfully. The average operation time was 12.2 minutes without any complications. Histopathology identified 2 Lesions (11.8%) as gastrointestinal stromal tumors at very low risk, 12 Lesions (70.6%) as leiomyoma and 3 Lesions (17.6%) as smooth muscle proliferation. No recurrence was found during the mean follow-up duration of 14.18 ± 9.62 months. ESMR-L following roofing technique is an effective and safe technique for management of esophageal SEL-MPs smaller than 20 mm, but it cannot ensure en bloc resection and may require further treatment.