Submucosal Tunnel Research Articles

Efficacy of endoscopic submucosal tunnel dissection in the management of a large esophageal cavernous hemangioma.

Efficacy of endoscopic submucosal tunnel dissection in the management of a large esophageal cavernous hemangioma.

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.

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

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.

Combined Endonasal and Transseptal Approach to Achieve Binostril Access in Endoscopic Skull Base Approaches to Minimize Nasal Morbidity: A Technical Note

IntroductionOver the years, feasibility & safety of EEAs has become well established & the focus has now shifted to minimising the nasal morbidity. To this end, several modifications in nasal stage have been described that have focussed primarily on preservation of nasal mucosa on right side of nasal cavity (NC). However, the issue of nasal mucosal preservation on left side of NC has largely been ignored. In this paper, the author describes a modified technique that can eliminate mucosal damage in left NC. MethodIn modified technique, trans-septal approach is utilised on left & endonasal on right side. A hemitransfixion incision is used to raise left submucosal tunnel. The mucosa of tunnel lies laterally in apposition with lateral nasal wall, thereby protecting it from injury by repeated passage of instruments. When tunnel mucosa is pushed back medially, left NC appears absolutely normal without any evidence of mucosal damage. ResultsCombined endonasal & trans-septal technique for nasal stage was performed in 51 patients with sellar/suprasellar lesions. Nonfunctional pituitary adenomas were the most common pathology (macroadenomas-n=14; Giant adenomas-n=10) followed by functional adenomas (acromegaly-n=10; prolactinomas- n=3; Cushings’s disease- n=1), craniopharyngiomas (n=6), clival tumours (n=5), & tuberculum sella meningiomas (n=2). ConclusionsA combination of endonasal and trans-septal approaches utilises the advantages of both endoscopic & microscopic approaches sans the disadvantage of restricted space seen in microscopic approaches. It makes binostril approach least disruptive to left nasal mucosa & thus can reduce overall morbidity of EEAs.

Submucosal tunneling biopsy for diagnosing malignant esophageal stricture

Submucosal tunneling biopsy for diagnosing malignant esophageal stricture

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 by blunt dissection for peroral endoscopic myotomy.

Modified submucosal tunneling by blunt dissection for peroral endoscopic myotomy.

Malignant gastric outlet obstruction: direct biopsy in the submucosal tunnel to obtain the diagnosis.

Malignant gastric outlet obstruction: direct biopsy in the submucosal tunnel to obtain the diagnosis.

Management of recurrence after peroral endoscopic myotomy and submucosal tunneling endoscopic septum division.

Management of recurrence after peroral endoscopic myotomy and submucosal tunneling endoscopic septum division.

Причины повторных или этапных операций при мегауретере у детей и меры их профилактики.

Introduction. The second most common pathology of the ureterovesical segment, after vesicoureteral reflux (VUR), is megaureter. At the moment, it is necessary to optimize the approach to performing various types of surgical interventions in children with megaureter. The question of the timing and indications for surgery, their number and the sequence of treatment stages remains open. The aim: to analyze the causes of repeated surgical interventions for megaureter and their prevention. Materials and methods. In the pediatric uroandrology department of the N. Lopatkin Scientific Research Institute of Urology and Interventional Radiology – Branch of the National Medical Research Radiological Centre of the Ministry of Health of Russian Federation, pneumovesiscopic reimplantation of the ureter (UR) according to Cohen was performed in 26 repeated patients over 9 years. 52 interventions were recorded before pneumovesicoscopic UR. 4 (15.4%) patients were previously operated on at a research institute, 4 (15.4%) at the place of residence and then received staged treatment at the N. Lopatkin Scientific Research Institute of Urology and Interventional Radiology – Branch of the National Medical Research Radiological Centre of the Ministry of Health of Russian Federation, 18 (69.23%) patients at the place of residence. Patients underwent from 1-6 surgical interventions, the average value was 2 interventions per 1 patient. Ureteral plication was required in 7 patients. In rare cases, megaureter was combined with ureterocele, duplication of the upper urinary tract and neurogenic bladder dysfunction. Results and Discussion. We combined the reasons for repeated surgical interventions into two blocks: 1inadequate drainage of the ureter, requiring repeated manipulations, including under anesthesia; 2 – complicating factors affecting the quality of the formation of ureterocystoanastomosis, surgical errors in the reimplantation technique and tactical errors that can lead to VUR or obstruction requiring re-operation. The use of original methods: intravesical plication of the ureter, fixation of the ureter at two levels (the entry point of the ureter into the bladder and in the area of the neoostium) is used to increase the length of the submucosal tunnel and create a better anti-reflux mechanism. Conclusion. Understanding the causes of possible complications of ureteral reimplantation allows you to more carefully carry out the stages of the operation, pay attention to key points and improve the results of megaureter correction.

Modified submucosal tunneling endoscopic septum division for symptomatic esophageal diverticula: a prospective case series (with video)

Background and aimsSubmucosal tunneling endoscopic septum division (STESD) is a valid endoscopic modality for treating esophageal diverticula. However, it requires highly skilled endoscopists. Here we propose a modified STESD method. MethodsThis is a single center prospective case series. We consecutively enrolled 8 patients diagnosed with esophageal diverticula. All the patients underwent the modified STESD by one experienced endoscopist. ResultsOnly one patient had intraoperative bleeding and was successfully stopped endoscopically. The size of the diverticula were 3.16 ± 1.14 cm as mean ± SD. The operation time ranged from 27 to 68 min with the mean value of 40.88 min. The number of clips ranged from 4 to 8. The success rate was 100%. None of the patients had symptom recurrences during 2 - 25 months of follow-up. ConclusionsThe modified STESD method for esophageal diverticula is effective and safe, further large prospective controlled studies are needed.

Bariatric endoscopic antral myotomy: a pilot study assessing technical feasibility, physiologic changes, and preliminary efficacy

Background and AimsGastric balloons and endoscopic sleeve gastroplasty appear to work by delaying gastric emptying. We hypothesized that pylorus-sparing antral myotomy would inhibit the antral pump inducing gastric retention and similarly result in weight loss. MethodsSingle-center pilot study to assess bariatric endoscopic antral myotomy (BEAM) via submucosal tunneling. Primary outcomes included feasibility, safety, and efficacy at 6 and 12 months. Secondary outcomes included changes in gastric emptying rate and GCSI score. ResultsSix subjects underwent successful BEAM. One required needle decompression, and another developed pulmonary embolism, treated without sequela. At 6 and 12 months, patients achieved 9.1±8.9% and 12.2±7.1% TWL (P<0.0005). Gastric emptying rate was delayed by 36.6% in those with ≥10% TWL. GCSI increased significantly at 12 months, particularly early satiety. ConclusionThis pilot study suggests BEAM is feasible and appears to induce delayed gastric emptying that is associated with significant weight loss, without symptoms of gastroparesis.

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.

Ultrasound-based predictive indicators for treatment outcomes in pediatric vesicoureteral reflux

PurposeTo evaluate the effectiveness of preoperative ultrasound (US) measurements in predicting pediatric vesicoureteral reflux (VUR) treatment outcomes.MethodsThis prospective study enrolled 35 patients (53 renal units) aged 1–16 years who underwent subureteric injection therapy for primary VUR between July 2020 and June 2022. Preoperative ultrasound examinations measured the bladder wall thickness at the ureteral orifice, ureteral submucosal tunnel length, distal ureteral diameter, patient demographics, VUR grade, presenting complaints, bladder–bowel dysfunction, and renal scarring, and the impact of these variables on treatment success was analyzed.ResultsAmong the patients, 91.4% were female, with a mean age of 6.83 ± 3.84 years. A comparison between the treatment success and failure groups revealed no significant differences in the age, sex, VUR grade, laterality, bilaterality, presenting complaints, bladder–bowel dysfunction, bladder wall thickness, or distal ureteral diameter (p > 0.05). However, renal scarring occurred in 16 (38.1%) patients in the treatment success group and 10 (90.9%) in the treatment failure group (p = 0.002). The treatment failure group had shorter detrusor-to-ureteral orifice distances and smaller detrusor-ureteral orifice distance-to-distal ureteral diameter (D/U) ratios than that of the success group (p = 0.004 and p = 0.006, respectively). Patients with a detrusor-to-ureteral orifice distance < 7.4 mm had an 81.82% likelihood of treatment failure.ConclusionUltrasound measurements of the detrusor-to-ureteral orifice distance and D/U ratio proved reliable in predicting the success of endoscopic subureteric injection therapy for VUR.

Autologous skin-grafting surgery with novel continuous liquid infusion stent for prevention of esophageal stenosis after complete circular endoscopic submucosal tunnel dissection.

Autologous skin-grafting surgery with novel continuous liquid infusion stent for prevention of esophageal stenosis after complete circular endoscopic submucosal tunnel dissection.

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.

Intraoperative Bronchospasm in a Peroral Endoscopic Myotomy Surgery: Not So Poetic!

Peroral endoscopic myotomies (POEM) done primarily for treating achalasia cardia patients not responding to medical therapy involve creating a submucosal tunnel, followed by a myotomy and a mucosal incision. Common intraoperative complications of such procedures include subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, and hemodynamic instability. This is a case of a 56-year-old 62 kg nil-comorbid female patient diagnosed with achalasia cardia who was taken up for a POEM under general anesthesia. She developed an episode of bronchospasm postinsufflation of the abdomen with carbon dioxide.