Heading toward the Right Direction—Solution Package for Endoscopic Submucosal Tunneling Resection in the Stomach

Abstract

BackgroundThe emerging submucosal tunneling and endoscopic resection (STER) technique provides definitive histological diagnosis as well as a therapeutic method for the gastric submucosal tumors (SMTs). We aim to present our experience and discuss key technical issues of STER.Methods45 patients with gastric SMTs arising from MP received STER. First, a mucosal incision was made 3cm proximal to the tumour, a submucosal tunnel was subsequently built from the incision to the tumor. The tumor was gradually exposed and dissected from surrounding tissue and retrieved from the tunnel. The initial mucosal incision was closed by metal clips. For SMTs in the gastric fundus near cardia, the submucosal tunnel was built from lower esophagus, through the angle of His, to the tumor for resection.ResultsSTER was successfully performed in 43 patients; the other two were converted to surgery. Mean operating time was 79.3min (range 45–150min). Mean tumor size was 1.4cm (range 0.5–5cm). Of the total 47 resected SMTs, 36 were GISTs, 10 were leiomyomas and 1 was schwannoma. Complete resection was achieved in all patients. Intra-procedural peumoperitoneum occurred in 3 cases because of iatrogenic perforation, no special treatment was given. 7 patients presented with mild abdominal pain/distention and fever were given antibotics. No severe post-operative complication happened. No tumor recurrence occurred in the median 11 month follow-up period.ConclusionBased on short-term follow-up observation, STER is a feasible, safe and minimally invasive method for the diagnosis and treatment of small (<3cm) SMTs in gastric body, antrum and proximal cardia.

Current status of submucosal tunneling endoscopic resection for gastrointestinal submucosal tumors originating from the muscularis propria layer (Review)

“…Lu et al (18) treated 18 patients with gastric fundus SMTs using STER; 19 tumors were removed, en bloc resection was achieved for all the patients and the mean tumor size was 21 mm (range, 8-50 mm). Lu et al (19) treated 45 patients with gastric SMTs using STER, 43 cases were successfully treated and 47 tumors were removed. The SMTs were all located in the cardia, the gastric fundus proximate to the cardia or the gastric antrum.…”

“…Although the majority of the SMTs in the MP layer are solitary, multiple studies have reported the presence of multiple SMTs (11,13,18,19,21,22). Chen et al (21) reported a patient simultaneously exhibiting esophageal and cardia SMT, and the two SMTs were successfully removed using STER with a single tunnel.…”

“…Typically, epinephrine is added to the solution to decrease the risk of intraoperative bleeding. For rectal or gastric SMTs, the submucosal injection is performed 2-3 cm from the SMT (19,20,30).…”

“…Currently, >20 studies have been published with outcome data based on >700 patients (6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)(20)22,29,30,(32)(33)(34)(35). In these studies, therapeutic success was recorded for >77% of patients and en bloc resection was achieved in >85% of patients, while irregularly shaped or larger tumors were risk factors in piecemeal resection (33).…”

“…Mucosal lacerations may occasionally occur and the majority are small (<1 cm) and may be closed using ≥1 clip. In the aforementioned >20 studies, mucosal laceration occurred in a total of 15 patients and in each case the laceration was closed using clips without leakage (10,15,16,18,19,29). Two case reports have reported on large esophageal mucosal lacerations, which were managed using stent insertions (26,28).…”