Submucosal Tunneling Endoscopic Resection 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.

Resection of a large esophageal schwannoma: operative transition from submucosal tunneling endoscopic resection to partial full-thickness resection.

Resection of a large esophageal schwannoma: operative transition from submucosal tunneling endoscopic resection to partial full-thickness resection.

Endoscopic Tunnel Dissection of an Oesophageal Bronchogenic Cyst: A Case Report

Introduction: A bronchogenic cyst is a very rare congenital malformation typically found in the middle and superior mediastinum. Infrequently, it can be located in the pericar-dium, diaphragm, oesophagus, and stomach. Intramural oesophageal bronchogenic cysts are highly uncommon, and because of this, they have not been extensively studied. They are gen-erally asymptomatic; however, due to their potential to cause complications, such as evolution into malignancy, the removal of these cysts is recommended. Routinely, techniques, including thoracotomy and thoracoscopy, have been adopted for excision. This case report details our success in performing a complete resection of an intramural oesophageal bronchogenic cyst via a novel approach of Submucosal Tunneling Endoscopic Resection (STER). Case Presentation: A 62-year-old woman was referred for an outpatient gastroscopy and co-lonoscopy for further investigation of her unexplained iron deficiency anaemia, abdominal pain, diarrhoea, and weight loss. A single oesophageal nodule was found on gastroscopy, which was further characterized and deemed to be benign on upper endoscopic ultrasound. The lesion was removed via the STER technique. During the procedure, submucosal fibres were dissected and a full-thickness myotomy was performed to completely remove the lesion. Histologically, the lesion showed a cyst lining comprising ciliated columnar epithelium, a finding consistent with a bronchogenic cyst. The patient maintained a normal diet and re-mained asymptomatic throughout the follow-up period. Conclusion: This report documents the successful resection of an oesophageal bronchogenic cyst via the STER technique. This novel approach appears to be a valuable tool with negligible invasiveness. It provides a feasible option for patients.

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.

S1571 Outcomes of Endoscopic Full-Thickness Resection vs Submucosal Tunneling Endoscopic Resection of Gastric Gastrointestinal Stromal Tumors: A Systematic Review and Meta-Analysis

S1571 Outcomes of Endoscopic Full-Thickness Resection vs Submucosal Tunneling Endoscopic Resection of Gastric Gastrointestinal Stromal Tumors: A Systematic Review and Meta-Analysis

One stone two birds - Submucosal tunneling endoscopic resection for a large esophageal submucosal mass and esophageal diverticulum.

A-35-year-old woman presented our hospital with half a year's history of solid food dysphagia. An upper gastrointestinal endoscopy revealed a large submucosal mass in an esophageal diverticulum near the gastroesophageal junction. Endoscopic ultrasound (EUS) confirmed a hypoechoic lesion arising from the muscularis propria layer with the size of 25*14 mm. Therefore, submucosal tunneling endoscopic resection (STER) was proposed to remove the large submucosal lesion in addition to targeted septotomy of the esophageal diverticula. A 2-cm longitudinal mucosal access was made at 3 cm above the submucosal lesion, and a submucosal longitudinal tunnel was created until the submucosal lesion revealed using a DualKnife (Olympus, Japan). Meticulous resection was performed with the DualKnife, and the lateral border of the lesion was dissected from muscularis propria layer. It was completely removed the lesion with en bolc resection, and dissected the septum of the diverticulum using the DualKnife. The tunnel access was closed with several hemoclips. Finally, it has been demonstrated to achieve a perfect outcome for the patient. The patient was discharged three days later with symptom resolved on follow-up and to date.

Modified submucosal tunneling endoscopic resection for the management of a large leiomyoma in the gastric fundus

Modified submucosal tunneling endoscopic resection for the management of a large leiomyoma in the gastric fundus

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.

Esophageal bronchogenic cyst treated with submucosal tunneling endoscopic resection: two case reports

IntroductionAlthough esophageal bronchogenic cysts are benign diseases, they may be accompanied by serious complications and have the possibility of recurrence. Therefore, once confirmed, it is necessary to treat the esophagobronchial cyst when the contraindication is excluded. Endoscopic treatment is usually used for lesions with small diameter and shallow origin, and has the advantages of small surgical trauma and risk, which can reduce the psychological burden of patients to a certain extent, help them to recover quickly, and lower hospital costs.Case presentationCase 1 is a 54-year-old Han Chinese man admitted to our hospital who complained of difficulty swallowing in the past 6 months. Case 2 is a 41-year-old Han Chinese man who was hospitalized in the past 3 months due to chest discomfort. Endoscopic ultrasound revealed a hypoechoic cystic lesion arising from the muscularis propria. Submucosal tunneling endoscopic resection was performed using a dual knife, and a cystic mass was observed between the mucosa and the muscular layers of the esophagus. On locating the cyst, an incision was made on the oral side of the lesion for evacuation. The cyst wall was excised using endoscopic argon plasma coagulation. We successfully removed the esophageal bronchogenic cyst lesion in the intrinsic muscle layer using submucosal tunneling endoscopic resection.ConclusionEsophageal bronchogenic cysts are rare in clinical practice and lack specificity in clinical manifestations. Multiple methods can be used to determine the location and nature of the lesion and ultimately determine the treatment plan. Surgical resection and endoscopic treatment are two different treatment methods, and appropriate treatment plans need to be selected on the basis of the origin layer, size, and relationship with the esophagus of the lesion to reduce complications and improve prognosis.

Endoscopic resection for calcifying fibrous tumors of the gastrointestinal tract.

Calcifying fibrous tumors (CFTs) are rare mesenchymal lesions that can occur in various sites throughout the body, including the tubular gastrointestinal (GI) tract. To analyze the clinical findings of 36 patients with GI tract CFTs to provide guidance for diagnosis and treatment. This retrospective study included 36 patients diagnosed with CFTs of the GI tract. We collected demographic and clinical information and conducted regular follow-ups to assess for local recurrence. The stomach was the most commonly involved site, accounting for 72.2% of the 36 CFTs. Endoscopic mucosal resection (n = 1, 2.8%), endoscopic submucosal dissection (n = 14, 38.9%), endoscopic full-thickness resection (n = 16, 44.4%), and submucosal tunneling endoscopic resection (n = 5, 13.9%) were used to resect calcifying fibrous tumors. Overall, 34 (94.4%) CFTs underwent complete endoscopic resections with a mean procedure time of 39.8 ± 29.8 min. The average maximum diameter of the tumors was 10.6 ± 4.3 cm. No complications, such as bleeding or perforation, occurred during an average hospital stay of 2.9 ± 1.2 d. In addition, two patients developed new growth of CFTs near the primary tumor sites, and none of the patients developed distant metastases during the follow-up period. GI tract CFTs are rare and typically benign tumors that can be effectively managed with endoscopic procedures.

Efficacy and safety of piecemeal submucosal tunneling endoscopic resection for giant esophageal leiomyoma

Background and AimsGiant esophageal leiomyoma usually requires a thoracotomy or thoracoscopic surgery, which is more invasive than an endoscopic treatment. The purpose of this study is to evaluate the efficacy and safety of piecemeal submucosal tunneling endoscopic resection (P-STER) for giant leiomyoma originating from the muscularis propria (MP) layer of the esophagus. MethodsThis is a retrospective study. Patients with giant esophageal leiomyoma (transverse diameter ≥ 3 cm) who underwent P-STER were enrolled from November 2012 to May 2023. Clinical data and results were investigated. ResultsA total of 16 patients were enrolled for analysis. The lesion mean transverse diameter and longitudinal diameter were 4.22 ± 1.20 cm and 6.20 ± 1.57 cm, respectively. Our mean operation time was 195.38 ± 84.99 min. The mean number of piecemeal resected was 4.31 ± 2.36. An adverse event noted was an esophageal fistula that occurred in one case (6.25%) and was treated conservatively. The mean length of hospital stay was around 11.81 ± 7.30 days. The mean total hospitalization cost was U.S. dollars (USD) $5976.50 ± 2866.39. No recurrence or metastasis was found during the follow-up period. ConclusionsP-STER can be an effective and safe treatment for giant leiomyoma originating from the MP layer of the esophagus.

Stretching the limits of submucosal tunneling endoscopic resection.

Stretching the limits of submucosal tunneling endoscopic resection.

A comparative analysis of prognostic regression models and machine learning algorithms in surgical decision-making of cardial submucosal tumors

Background and aimsNon-tunneling and submucosal tunneling endoscopic resection (STER) techniques are the most frequent treatments for cardial submucosal tumor (SMT). Here, we analyzed common machine learning (ML) algorithms and compared them with traditional regression models in surgical decision-making for cardial SMTs. MethodsUsing key baseline predictive factors, ML algorithms and logistic regression (LR) were conducted in 246 patients. For the ML algorithms, gradient boosting machines (GBM), artificial neural networks (ANN), random forests (RF), and support vector machines (SVM), were included. For small sample-sized data, a technique for k-fold cross-validation was exploited to avoid over-fitting. Meanwhile, we tuned the parameters through several replications. Then, we quantified the discrimination (area under the curve, AUC) and predictive ability (Brier score, F1 score, specificity, sensitivity, and accuracy) of models. We divided patients (n ​= ​246) into STER-treated (n ​= ​97) and non-tunneling endoscopic resection (NTER)-treated (n ​= ​149) groups. ResultsLR outperformed among all groups (Brier score ​= ​0.1398, F1 score ​= ​0.7391, AUC ​= ​0.8729, and predictive accuracy ​= ​80.65 ​%). In comparison to ML algorithms, an outperformance of the traditional regression approach was also found in a low-dimensional setting for surgical decision prediction of cardial SMTs. ConclusionsThe traditional regression approach outperformed ML algorithms for the prediction of the best surgical method in patients with SMTs.

Endoscopic resection for esophageal gastrointestinal stromal tumors: a multi-center feasibility study

Background: Esophageal gastrointestinal stromal tumors (E-GISTs) are highly uncommon and have not been thoroughly examined. Objectives: The objective of this multi-center study was to assess the viability of endoscopic resection (ER) in the treatment of E-GISTs and to explore its clinical implications. Design: This was a multi-center retrospective study. Consecutive patients referred to the four participating centers. Methods: E-GISTs among the consecutive subepithelial tumors (SETs) treated by ER methods were enrolled from April 2019 to August 2022. Clinicopathological, endoscopic, and follow-up data were collected and analyzed. Results: A total of 23 patients with E-GISTs were included for analysis, accounting for 1.9% of all the esophageal SETs (1243 patients). The average size of the tumor lesions was 2.3 cm (range 1.0–4.0 cm). We observed that tumors larger than 2.0 cm were more likely to grow deeper, with a statistically significant difference ( p &lt; 0.001). End bloc resection was achieved in all 23 patients. The mean operation time was 53.6 min (range 25–111 min). One patient experienced significant intraoperative bleeding, which was promptly managed endoscopically without necessitating surgery. The average hospital stay was 4.5 days (range 3–8 days). The overall median follow-up period was 31 months (range 13–47 months). No tumor recurrence, residual tumor, distal metastasis, or death was observed during the follow-up period. Conclusion: Based on our limited data, our study indicates that ER may be a feasible and effective option for treating esophageal GISTs measuring 4 cm or less. We suggest submucosal tunnel endoscopic resection as the preferred approach, as all E-GISTs in our study were situated in the muscularis propria layer. Additionally, tumors larger than 2 cm were more prone to deeper growth or extraluminal extension.

Endoscopic Treatment for Gastric Subepithelial Tumor.

Most gastric subepithelial tumors (SETs) are asymptomatic and are often incidentally discovered during endoscopic procedures conducted for unrelated reasons. Although surveillance is sufficient for the majority of gastric SETs, certain cases necessitate proactive management. Laparoscopic wedge resection, although a viable treatment option, has its limitations, particularly in cases where SETs (especially those with intraluminal growth) are not visualized on the peritoneal side. Recent advances in endoscopic instruments and technology have paved the way for the feasibility of endoscopic resection of SETs. Several promising endoscopic techniques have emerged for gastric SET resection, including submucosal tunneling endoscopic resection, endoscopic full-thickness resection (EFTR), laparoscopic and endoscopic cooperative surgery (LECS), and non-exposure EFTR (non-exposed endoscopic wall-inversion surgery and non-exposure simple suturing EFTR). This study aimed to discuss the indications, methods, and outcomes of endoscopic therapy for gastric SETs. In addition, a simplified diagram of the category of SETs according to the therapeutic indications and an algorithm for the endoscopic management of SET is suggested.

Application Research of Sodium Hyaluronate in Endoscopic Submucosal Tunnel Resection (STER) for Esophageal Cancer

Objective: This study aims to evaluate the efficacy and safety of submucosal injection using a mixture containing sodium hyaluronate in submucosal tunneling endoscopic resection (STER) for esophageal submucosal tumors (SMTs). Methods: A total of 42 patients with SMTs participated in this study from January 2020 to October 2023. The patients were randomly divided into the experimental group (n=21) and the control group (n=21). The experimental group received a mixture of 5ml sodium hyaluronate injection (50mg) + 25ml fructose sodium chloride injection + 0.1ml methylene blue injection as submucosal injection. The control group received 30ml fructose sodium chloride injection + 0.1ml methylene blue injection. Submucosal injection started 5cm proximal to the SMT in the esophagus using the mixture until effective mucosal elevation for subsequent STER surgery. Results: There was no statistically significant difference in the average diameter of resected specimens between the experimental group (1.9±1.3 cm) and the control group (2.0±1.1cm, P&gt;0.05). The average operation time in the experimental group (70.05±9.93 min) was significantly shorter than the control group (96.29±12.15 min, P&lt;0.05). The average submucosal injection volume in the experimental group (13.52±2.77ml) was significantly lower than the control group (26.38±3.47ml, P&lt;0.05). In cases with bleeding &lt;5ml, the experimental group had 18 cases (86%), while the control group had 4 cases (19%); in cases with bleeding &gt;5ml, the experimental group had 3 cases (14%), and the control group had 17 cases (81%), showing a statistically significant difference (P&lt;0.05). Conclusion: Submucosal injection using a mixture containing sodium hyaluronate for STER surgery not only exhibits excellent efficacy but also high safety.

The efficacy of full-thickness endoscopic resection of subepithelial tumors in the gastric cardia.

Gastric subepithelial tumors (SETs) may harbor potential malignancy. Although it is well recognized that large SETs should be resected, the precise treatment strategy remains controversial. Compared to surgical resection, endoscopic resection (ER) has many advantages; however, ER of SETs in the cardia is challenging. To evaluate the safety and efficacy of endoscopic full-thickness resection (EFTR) for the treatment of gastric cardia SETs. We retrospectively reviewed data from all patients with SETs originating from the muscularis propria layer in the gastric cardia that were treated by EFTR or submucosal tunneling ER (STER) at Zhongshan Hospital Fudan University between November 2014 and May 2022. Baseline characteristics and clinical outcomes, including procedure times and complications rates, were compared between groups of patients receiving EFTR and STER. A total of 171 tumors were successfully removed [71 (41.5%) tumors in the EFTR and 100 (58.5%) tumors in the STER group]. Gastrointestinal stromal tumors (GISTs) were the most common SET. The en bloc resection rate was 100% in the EFTR group vs 97.0% in STER group (P > 0.05). Overall, the EFTR group had a higher complete resection rate than the STER group (98.6% vs 91.0%, P < 0.05). The procedure time was also shorter in the EFTR group (44.63 ± 28.66 min vs 53.36 ± 27.34, P < 0.05). The most common major complication in both groups was electrocoagulation syndrome. There was no significant difference in total complications between the two groups (21.1% vs 22.0%, P = 0.89). EFTR of gastric cardia SETs is a very promising method to facilitate complete resection with similar complications and reduced operative times compared to STER. In cases of suspected GISTs or an unclear diagnosis, EFTR should be recommended to ensure complete resection.

Fibrin sealant for closure of mucosal penetration at the oesophagus or cardia during submucosal tunnelling endoscopic resection for gastrointestinal submucosal tumours.

To assess the efficacy and safety of a fibrin sealant for the prevention of leak resulting from mucosal penetration at the esophagus or cardia during a STER procedure to remove gastrointestinal submucosal tumors (SMTs). Between April 2014 and October 2022, a total of 290 patients with oesophageal or cardiac SMTs underwent STER at our centre. We retrospectively identified patients with oesophageal or cardia SMTs who underwent STER and experienced mucosal penetration of the cardia or oesophagus during the procedure. A total of 31 mucosal penetrations in 30 procedures were included. Of the 31 mucosal penetrations, 12 occurred in the cardia, and the other 19 occurred in the oesophagus. All 31 sites received the fibrin sealant to close the mucosal penetration. Clinical characteristics, procedure-related parameters, detailed data of the mucosal penetrations, and treatment outcomes using the fibrin sealant were reviewed for all 30 patients to assess the efficacy and safety of the fibrin sealant for closure of mucosal penetration at the cardia or oesophagus. For the 31 mucosal penetrations, the mean size was 0.08 ± 0.06cm2 (range 0.01-0.25cm2). Mucosal closure using the fibrin sealant was performed successfully in all 31 mucosal penetrations. Of the 31 mucosal penetrations, clips were used in 13 cases. All 30 patients were discharged after a median of 7days (range 4-20day) postoperatively. During a mean 62months (range 6-107months) follow-up, all 31 mucosal penetrations successfully healed without the occurrence of infection, ulcer, oesophagitis, chest infection or abdominal infection. For the closure of mucosal penetration during STER at the cardia or oesophagus, a fibrin sealant is both safe and efficacious. It is necessary to conduct more research on the viability, effectiveness, and safety of using a fibrin sealant to close wider mucosal penetrations.

Submucosal tunneling endoscopic full-thickness resection for management of a rare case of esophageal GI stromal tumor

Video 1The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.