Treatment Of Submucosal Tumors Research Articles

504 Safety of Endoscopic Submucosal Dissection in an Outpatient Setting

503 Peri-Operative Managements of Complications of Submucosal Tunneling Endoscopic Resection (Ster) for the Treatment of Upper Gastrointestinal Submucosal Tumors Originating From the Muscularis Propria Layer Mei-Dong Xu*, Ping-Hong Zhou, LI-Qing Yao Endoscopy Center, Zhongshan Hospital, Fudan University, Shanghai, China Objective: To investigate the managements of complications of submucosal tunneling endoscopic resection (STER) for the resection of upper gastrointestinal (GI) submucosal tumors (SMTs) originating from the muscularis propria (MP). Methods: A total of 290 patients with SMTs originating from the MP of the upper GI tract who underwent STER between September 2010 and June 2013 were enrolled. The medical records were thoroughly investigated. Results: All SMTs were successfully resected with STER. The overall rates of en bloc resection and piecemeal resection were 95.4% and 4.6% respectively. The average size of the resected tumors was 21.0 11.8 mm (range 10.0-70.0mm). The mean time of STER procedure was 56 3 8 minutes (range 15-200 minutes). Mucosal tear occurred in 3 cases (1.0%, 3/ 290) and large hemorrhage (blood loss O 200 ml) occurred in 5 patients (1.7%, 5/ 290) during the operation. Subcutaneous emphysema occurred in 61 patients (21.0%, 61/290), 13 cases with air insufflation and 48 cases with CO2 insufflation. Pneumothorax occurred in 22 cases, including 15 cases with CO2 insufflation and 7 cases with air insufflation. Subcutaneous emphysema were fundamentally absorbed after the operation within 1w2 hours in patients with CO2 insufflation while were absorbed after 5w10 days in patients with air insufflations. In patients with pneumothorax, 5 cases (1.7%, 5/290) needed to be treated with thoracic drainage using venotomy catheter because of large compressed lung. 15 cases (5.2%, 15/290) with pneumoperitoneum were successfully treated with peritoneocentesis decompression. Postoperative CT revealed minimal pleural effusion accompanied with minimal bilateral lung inflammation in 49 patients (16.9%, 49/290) which can generally be self-absorbed without specific treatment. 11 patients had pleural effusion accompanied with fever or segmental atelectasis, which required thoracic drainage (3.8%, 11/290). 1 case had an esophageal-pleural fistula 3 days post-surgery due to displacement of the clips, which was treated successfully via closed thoracic drainage. During follow-up, secondary esophageal diverticulum occurred in 2 cases. Conclusions: STER is a safe, effective minimally invasive procedure for the treatment of SMTs originating from the MP. Common complications of STER are gas-related, which can be successfully treated by conservative treatments.

Laparoscopic Resection of Gastric Submucosal Tumors: Outcomes of 141 Consecutive Cases in a Single Center

Purpose: The treatment of choice for gastric submucosal tumors (SMT) is surgical resection. Recent advanced techniques has facilitated more extensive application of laparoscopic surgery to most types of resectable gastric SMTs. The aim of this study was to verify the efficacy of laparoscopic resection for treatment of gastric SMT through analysis of outcomes obtained at a single center. Methods: A total of 141 patients who underwent laparoscopic resection for treatment of gastric SMT were enrolled between April 2003 and June 2011. Analysis of the demographics, tumor characteristics, and surgical or oncological outcomes of these patients was performed. Results: Gastrointestinal stromal tumors (GIST) were the most common pathologic findings (90 cases), and the upper third of the stomach was the most common location (70 cases). Wedge resections were performed in 128 patients and major gastrectomies were performed in 13 patients. The mean surgical time was 102 minutes, which was reduced to a stable 70 minutes after the 30 th case. The surgical time for tumors located on the posterior or lesser portion of the upper third of the stomach was longer than that for other lesions. Twelve postoperative complications, including two cases of intra-abdominal bleeding, one case of marginal ulcer bleeding, and one case of leakage occurred. However, there was no occurrence of complications after the 70 th case. During the follow-up period, two patients suffered recurrent GIST. Conclusion: Laparoscopic surgery for treatment of gastric SMT is safe and feasible, particularly as the surgeon develops greater skill with increased experience. Laparoscopic resection is useful for treatment of any type of gastric SMT.

Assessment of four types of endoscopic ligation in treatment of submucosal tumors in upper gastrointestinal tract

Objective To evaluate the clinical efficacy and safety of 4 types of endoscopic nylon ligation in the treatment of submucosal tumors in upper gastrointestinal tract. Methods Those with submu- cosal tumors located in esophagus, stomach or duodenum were enrolled in the study. All patients were trea- ted with endoscopic nylon ligation, which included direct ligation, ligation with a transparent cap, ligation with dual-channel endoscope, and ligation in combination with endoscopic submucosal dissection （ESD）. The patients were followed up endoscopically for evaluation of efficacy and safety of the procedures. Results A total of 128 patients were recruited into the present study from June 2006 to December 2008. The tumors were in esophagus in 28 patients, in stomach in 82 and in duodenum in 18. Direct ligation was applied in 3 patients, ligation with a transparent cap in 105, ligation with a dual-channel endoscope in 8, and ligation plus ESD in 12. Endoscopic follow-up was completed in 111 patients. Reduced lesion size was observed in 16 patients （ I4.4% ） , residue nylon in 16 （ 14. 4% ） and no lesion in 71 others （63.9%）. The overall ef- fective rate was 92.8%. No delayed perforation or bleeding occurred. Conclusion Endoscopic ligation with nylon thread in combination with other assistant approaches is effective and safe for the treatment of submuco- sal tumors in upper gastrointestinal tract. Key words: Gastrointestinal neoplasms; Nylon thread ligation; Endoscopic submucosal dissection

Value of endoscopic ultrasonography in choice of endoscopic therapy strategies for submucosal tumors in upper gastrointestinal tract

Objective To evaluate the diagnostic value of endoscopic uhrasonography （EUS） for submucosal tumors in upper gastrointestinal tract, and its influence on choice of endoscopic therapies. Methods A total of 82 submucosal tumors from upper gastrointestinal tract were examined by EUS, and treated by various endoscopic therapeutic techniques including fulguration with high frequency current （ FHFC）, endoscopic mucosal resection （EMR） and endoscopic band ligation according to origin, size and property of the lesion. The diagnoses of 58 resected samples were determined by routine pathological examination and immu- nohistochemistry. All patients were followed up with routine endoscopy and EUS. Results FHFC was applied in 26 lesions originated from muscularis mucosa, EMR was used in 17 flat lesions originated from muscularis mucosa, and endoscopic band ligation in 38 lesions from muscularis propria and 1 tumor from muscularis mucosa. The diagnostic accuracy of EUS was 91.4% （53/58）. Except for post-operative bleeding in 1 patient, no other complications were observed. A total of 79 cases were followed up for 3-24 months, and no recurrence was found. Conclusion EUS can display the origin and property of submucosal tumors in upper gastrointestinal tract and guide the selection of endoscopic therapy, which is effective and safe in treatment of submucosal tumor in upper gastrointestinal tract. Key words: Endoscopic ultrasonography; Submucosal tumor; Endoscopic therapy

ENDOSCOPIC SUBMUCOSAL DISSECTION FOR GASTRIC SUBMUCOSAL TUMOR, ENDOSCOPIC SUB‐TUMORAL DISSECTION

Gastric submucosal tumor (SMT) is frequently found during screening endoscopy, but definitive diagnosis based on histological confirmation is relatively difficult. Even without accurate diagnosis before treatment, open or laparoscopic surgery is currently carried out to remove SMT. The purpose of this study was to demonstrate the feasibility of endoscopic submucosal dissection (ESD) in diagnostic treatment for submucosal tumor (SMT) of the stomach. Subjects in this case study comprised nine patients who had undergone ESD for gastric SMT. Before treatment, endoscopic ultrasonography was carried out in all cases to evaluate depth and origin of the SMT. Then ESD was only indicated for tumors of submucosal layer or muscularis mucosa origin. Using an endoscopic sub-tumoral dissection technique with a hook knife and a flex knife, local complete resections were achieved in all patients without severe complications. These results suggest the clinical benefits of ESD avoiding oversurgery for the diagnostic treatment of gastric SMT of the submucosal layer and muscularis mucosa origin.

Laparoscopic surgery for submucosal tumors located at the esophagogastric junction and the prepylorus

Laparoscopic partial gastric resection is widely accepted as a treatment for gastric submucosal tumors (SMTs). However, SMTs of either end of the stomach are generally managed by subtotal gastrectomies or total gastrectomies. This study was conducted to evaluate surgical techniques for management of SMTs located at the ends of the stomach. Among 63 patients who were diagnosed and underwent laparoscopic surgery for gastric SMTs at Seoul National University Bundang Hospital from May 2003 to May 2007, 11 SMTs located at the ends of the stomach were identified. The clinicopathologic results of these 11 SMTs were analyzed. Laparoscopic partial wedge resections or tumor excisions were successfully performed on all patients except for those who had prepyloric tumors. Six men and five women had SMTs at the ends of the stomach. The patients ranged in age from 21-63 years (mean 43.4 +/- 13.5 years). Of six esophagogastric junctional tumors that showed low, homogeneous contrast enhancement on computed tomography (CT) scans, five were treated by laparoscopic transgastric enucleation and one by tumor-everting resection. One esophagogastric junctional tumor that leaned toward the fundus and showed a 6-cm-diameter endophytic mass with heterogeneous enhancement on CT scan was resected by laparoscopic wedge resection. The mean operation time was 100 min (range 60-210 min). Three laparoscopy-assisted distal gastrectomies and one laparoscopic wedge resection were performed on SMTs located near the prepyloric antrum. There were no intra- or postoperative complications. Duration of postoperative hospital stay ranged from 4-7 days. Laparoscopic local resection is an effective treatment for SMTs located at the esophagogastric junction and can be used instead of a total or proximal gastrectomy. However, gastrectomies should be considered for SMTs located near the pylorus because of the small volume of the lower third of the stomach.

Use of endoscopic ultrasound-guided injection in endoscopic resection of solid submucosal tumors.

Submucosal tumor (SMT) is a common disease. We used endoscopic ultrasound (EUS)-guided puncture to inject saline before resection of SMTs, and evaluated the usefulness of this method. We selected 16 symptomatic patients with solid SMTs in the upper gastrointestinal tract, confirmed by endoscopy and EUS. We first used EUS-guided puncture to inject saline to separate the submucosal lesions from the deeper normal tissues. Lesions in the muscularis mucosa and submucosa were then removed directly by snare cauterization. Lesions in the muscularis propria were treated by means of a two-step approach: first, we incised the superficial tissue of the tumors using an electrosurgical needle, and second, we enucleated SMTs as much as possible by tightening the snare around them and creating pseudo-stalks. After snare excision of SMTs, the cleavages of the superficial tissues were closed using metal clips. Among the 16 patients, one lesion was in the muscularis mucosa, six were in the submucosa, and nine were in muscularis propria. All the lesions were resected thoroughly. No perforation occurred nor had any recurrences been observed at follow-up of 12 - 17 months. EUS-guided puncture to inject saline before resection is a safe and accurate procedure in the treatment of submucosal tumors.

Endoscopic treatment of upper gastrointestinal tumors

The art and science of gastrointestinal endoscopy will continue to evolve at an amazing pace, with both endoscopists and industry providing new techniques and technologies for us to learn, investigate and apply to the benefit of our patients. It is not difficult to imagine that the next decade may see the maturation of a distinct specialty of gastrointestinal endoscopic surgery, currently in its adolescence, which crosses traditional boundaries. Practitioners will originate from a variety of backgrounds--gastroenterological, surgical or radiological--but must be trained specifically to perform the wide range of endoscopic procedures already in existence and those continually being introduced. Such 'endotherapists' will be an integral part of multidisciplinary units where optimal management strategies are planned based on available scientific evaluation of techniques irrespective of who performs them. Currently, numerous gastroinestinal diseases including both benign and malignant conditions have been managed using only endoscopic measurements. Control of gastrointestinal bleeding (variceal and non-variceal), dilation of benign and malignant strictures, antireflux management for esophagogastric reflux, endoscopic curative resection of premalignant and malignant lesions, treatment of submucosal tumors, percutaneous endoscopic gastrostomy or jejunostomy, stenting for malignant stricture of hollow viscus or pancreaticobiliary diseases, tumor ablation, and removal of biliary or pancreatic duct stones, etc. have been widely performed and various fascinating techniques and instruments have been continuously developed. It would be difficult to handle all of these various treatment modalities in a limited space. In this review we would like to discuss the fields of gastrointestinal tumors.

Surgical treatment of submucosal tumors of the hard palate

Two cases have been presented to illustrated to illustrate the principles of total excisional biopsy for palatal tumors and the postoperative management of the resulting defect with the use of palatal splints. Total excisional biopsy is curative for benign tumors and for some malignant-grade tumors, and is the preferred method of treatment when possible. Total excision of the lesion with adequate margins negates the possibility of seeding the tumor into surrounding tissue or of leaving behind residual tumor.