Do we need to conduct full-thickness closure after endoscopic full-thickness resection of gastric submucosal tumors?

Background/AimsSuccessful closure of gastric wall defects is a pivotal step for endoscopic full-thickness resection (EFTR). Our study indicates that for submucosal tumors (SMTs) smaller than 2.5 cm, closing the mucosal layer is safe and feasible when the modified method, ZIP, is used.Materials and MethodsWe retrospectively analyzed 37 patients with gastric SMTs arising from the muscularis propria (MP) who underwent EFTR with defect closure of the mucosal layer. The main procedure involved: (1) making a longitudinal incision of the mucosal and submucosal layers above the lesion, (2) fully exposing the lesion and symmetrically punching holes on both sides of the incision into the submucosal layer, (3) en bloc resection of the lesion using an electrosurgical snare or knife, (4) hooking of metallic clips into the holes and clipping of the mucosal layer successively to close the gastric wall defect. This modified method was named ZIP.ResultsSuccessful complete resection by EFTR was achieved in 37 cases (100%). The median procedure time was 60 min (range: 30–120 min), whereas the closure procedure took a median of 8 min (range: 5–20 min). The median lesion size was 1.0 cm (range: 0.5–2.5 cm). No patients had severe complications. No residual lesions or tumor recurrence were found during the follow-up period.ConclusionClosing the mucosal layer of gastric wall defects after EFTR by ZIP is feasible and effective.     

Endoscopic full thickness resection for gastric tumors originating from muscularis propria

AIM: To do systematic review of current literature for endoscopic full thickness resection(EFTR) technique for gastric tumors originating from muscularis propria.METHODS: An extensive English literature search was done till December 2015; using Pub Med and Google scholar to identify the peer reviewed original and review articles using keywords-EFTR, gastric tumor, muscularis propria. Human only studies were included. The references of pertinent studies were manually searched to identify additional relevant studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations were considered. For the purpose of review, data from individual studies was combined to calculate mean. No other statistical test was applied.RESULTS: A total of 9 original articles were identified. Four articles were from same institute and the time frames of these studies were overlapping. To avoid duplication of data, only the study with patients over the longest time interval was included and other three were excluded. In total six studies were included in the final review. In our systematic review, the mean success rate for EFTR of gastric tumors originating from muscularis propria was 96.8%. The mean procedure time varied from a minimum of 37 min to a maximum of 105 min. There was no reported mortality from the technique itself. The most common histological diagnosis was gastrointestinal stromal tumors and leiomyoma. Gastric wall defect closure by either metallic clips or over the scope clip(OTSC) had similar outcomes although experience with OTSC was limited to smaller lesions(3cm).CONCLUSION: EFTR is a minimally invasive technique to resect gastric submucosal tumors originating from muscularis propria with a high success rate and low complication rate.     

Endoscopic full-thickness resection of superficial colorectal neoplasms using a new over-the-scope clip system: A single-centre study

Background and aimEndoscopic full-thickness resection (EFTR) provides complete en-bloc resection with a histopathological evaluation of submucosal, muscular, and serosal layers. The aim of this study was to investigate the efficacy and safety of a novel over-the-scope device for colorectal EFTR.Material and methodsIn this retrospective, observational, open-label case study, a total of 20 patients with superficial colorectal neoplasms, underwent EFTR using a new endoscopic full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany). Endoscopic treatment outcomes (technical success, rate of EFTR, adverse events) and early follow-up at three months, were analyzed.ResultsWe reported a 100% of technical success, defined as full-thickness resection. Among the R1 resections, histology was negative for neoplasm. Non-lifting adenomas had histology positive for adenocarcinoma: seven T1/G1/sm1; one T1/G1/sm2; one, who underwent a surgical resection, T1/G1/sm3. Mean size of the resected lesions was 26 mm, ranging from 10 to 42 mm. One (5%) patient developed abdominal pain, fever and leukocytosis and was treated conservatively with medical therapy. In all specimens, histological complete resection was confirmed.ConclusionsEFTR is a feasible and effective technique that could become a valid alternative to EMR and ESD in the management of recurrent adenomas, no-lifting lesions and scars of R1 resections. However, prospective studies are needed to further evaluate the device and technique.     

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection (EFTR), with or without laparoscopic assistance, is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors (SMTs) arising from the muscularis propria (MP), especially of the gastric wall. To date, evidence concerning duodenal exposed EFTR is lacking, mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure. However, given the non-negligible morbidity and mortality associated with duodenal surgery, the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers. The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.     

Clinical usefulness of endoscopic ultrasonography for the evaluation of ulcerative colitis-associated tumors

AIM:To evaluate the clinical usefulness of endoscopic ultrasonography(EUS) for the diagnosis of the invasion depth of ulcerative colitis-associated tumors.METHODS:The study group comprised 13 patients with 16 ulcerative colitis(UC)-associated tumors for which the depth of invasion was preoperatively estimated by EUS.The lesions were then resected endoscopically or by surgical colectomy and were examined histopathologically.The mean age of the subjects was 48.2 ± 17.1 years,and the mean duration of UC was 15.8 ± 8.3 years.Two lesions were treated by endoscopic resection and the other 14 lesions by surgical colectomy.The depth of invasion of UCassociated tumors was estimated by EUS using an ultrasonic probe and was evaluated on the basis of the deepest layer with narrowing or rupture of the colonic wall.RESULTS:The diagnosis of UC-associated tumors by EUS was carcinoma for 13 lesions and dysplasia for 3 lesions.The invasion depth of the carcinomas was intramucosal for 8 lesions,submucosal for 2,the muscularis propria for 2,and subserosal for 1.Eleven(69%) of the 16 lesions arose in the rectum.The macroscopic appearance was the laterally spreading tumor-non-granular type for 4 lesions,sessile type for 4,laterally spreading tumor-granular type for 3,semipedunculated type(Isp) for 2,type 1 for 2,and type 3 for 1.The depth of invasion was correctly estimated by EUS for 15 lesions(94%) but was misdiagnosed as intramucosal for 1 carcinoma with high-grade submucosal invasion.The 2 lesions treated by endoscopic resection were intramucosal carcinoma and dysplasia,and both were diagnosed as intramucosal lesions by EUS.CONCLUSION:EUS provides a good estimation of the invasion depth of UC-associated tumors and may thus facilitate the selection of treatment.     

Innovative therapeutic endoscopy in the upper gastrointestinal tract: Review of Japan Gastroenterological Endoscopic Society Core Sessions

Workshops on "Innovative Therapeutic Endoscopy" for upper gastrointestinal tract diseases were held four times as the Japan Gastroenterological Endoscopic Society (JGES) Core Sessions at the 93rd to 96th Biannual Meetings of the JGES. A total of 48 research presentations (including two invited lectures) were reported, and various discussions were held on these topics. When the research presentations were categorized according to the therapeutic procedure, endoscopic submucosal dissection (ESD) was the most frequent with 28 presentations (58.3%), followed by laparoscopy endoscopy cooperative surgery (LECS) with six presentations (12.5%). When the research presentations were classified by the target organ of the therapeutic procedures, the duodenum was the most frequent with 26 presentations (54.1%), followed by the stomach with 13 presentations (27.1%). The most important issue was the establishment of a safe and reliable endoscopic resection method for duodenal lesions. Issues related to gastric ESD were establishing an efficient traction method and a method to prevent post-ESD bleeding in high-risk patients. Other important issues were establishment of an efficient traction method and methods of preventing delayed bleeding in high-risk patients who undergo gastric ESD, expansion of indications for minimally invasive treatment using LECS for gastric cancer, the development of endoscopic full-thickness resection (EFTR) for gastric submucosal tumors (SMTs), and improvement of per-oral endoscopic myotomy (POEM) for esophageal achalasia and per-oral endoscopic tumor resection (POET) for esophageal SMTs. Through the JGES Core Sessions, it is expected that the minimally invasive treatments using endoscopes developed in Japan will be further advanced.     

Endoscopic full-thickness resection for gastric submucosal tumors arising from the muscularis propria layer

AIM: To evaluate the efficacy, safety and feasibility of endoscopic full-thickness resection (EFR) for the treatment of gastric submucosal tumors (SMTs) arising from the muscularis propria.METHODS: A total of 35 gastric SMTs arising from the muscularis propria layer were resected by EFR between January 2010 and September 2013. EFR consists of five major steps: injecting normal saline into the submucosa; pre-cutting the mucosal and submucosal layers around the lesion; making a circumferential incision as deep as the muscularis propria around the lesion using endoscopic submucosal dissection and an incision into the serosal layer around the lesion with a Hook knife; a full-thickness resection of the tumor, including the serosal layer with a Hook or IT knife; and closing the gastric wall with metallic clips.RESULTS: Of the 35 gastric SMTs, 14 were located at the fundus, and 21 at the corpus. EFR removed all of the SMTs successfully, and the complete resection rate was 100%. The mean operation time was 90 min (60-155 min), the mean hospitalization time was 6.0 d (4-10 d), and the mean tumor size was 2.8 cm (2.0-4.5 cm). Pathological examination confirmed the presence of gastric stromal tumors in 25 patients, leiomyomas in 7 and gastric autonomous nerve tumors in 2. No gastric bleeding, peritonitis or abdominal abscess occurred after EFR. Postoperative contrast roentgenography on the third day detected no contrast extravasation into the abdominal cavity. The mean follow-up period was 6 mo, with no lesion residue or recurrence noted.CONCLUSION: EFR is efficacious, safe and minimally invasive for patients with gastric SMTs arising from the muscularis propria layer. This technique is able to resect deep gastric lesions while providing precise pathological information about the lesion. With the development of EFR, the indications of endoscopic resection might be extended.     

消化道黏膜下肿物内镜下切除及其并发症防治

目的探讨消化道黏膜下肿物(gastrointestinal submucosal tumor,SMT)的内镜下切除方法及其并发症的防治。方法对382例SMT采用内镜黏膜下挖除术(ESE)、胃镜与腹腔镜双镜联合、内镜黏膜下隧道肿瘤切除术(STER)以及内镜全层切除术(EFTR)进行肿物切除。结果 ESE切除332例,胃镜与腹腔镜双镜联合切除36例(其中20例为腹腔镜为主内镜辅助腹腔镜治疗,16例为瘤体较大,与浆膜层分界不清,单独内镜下挖除瘤体困难,术中转外科腹腔镜与胃镜双镜联合治疗),STER切除10例,EFTR切除4例。术中穿孔24例,其中内镜下瘤体剥离后发生胃壁穿孔转外科腹腔镜下缝合穿孔7例、内镜下尼龙绳荷包缝合9例、内镜下钛夹缝合6例、内镜下OTSC金属夹闭合器达到严密缝合2例。术后发生迟发性出血1例。术后感染1例。无死亡病例发生。结论 ESE、胃镜与腹腔镜双镜联合、STER以及EFTR是目前切除SMT微创、有效、安全、可行的方法。穿孔是其主要并发症,大多数穿孔可在内镜下达到严密缝合。     

EFR治疗胃固有肌层肿物25例

目的探讨内镜全层切除术(EFR)治疗源于固有肌层的胃黏膜下肿物(SMT)的疗效和安全性。方法 25例于2011年1月至2013年9月于我院接受EFR治疗的胃SMT患者纳入研究,肿瘤经EUS和增强CT检查诊断为来源于固有肌层。对其治疗结果、并发症发生情况、近期随访结果等进行回顾性分析。结果 25例均完整切除病灶,病灶长径1.0~5.5 cm,黏膜切开至黏膜切口完整缝合时间为60~180 min,使用止血夹5~30枚,住院天数3~9 d,医疗费用8 000~20 000元。术后病理诊断间质瘤22例,平滑肌瘤2例,神经鞘瘤1例,切缘均为阴性。术后无出血,1例出现腹膜炎。出院后3个月内镜复查未见病变残留、复发。结论 EFR治疗来源于固有肌层的胃SMT安全、有效,可成为胃SMT的治疗选择。     

Suitable closure for post-duodenal endoscopic resection taking medical costs into consideration

AIM:To compare closure methods,closure times and medical costs between two groups of patients who had post-endoscopic resection(ER) artificial ulcer floor closures.METHODS:Nineteen patients with duodenal adenoma,early duodenal cancer,and subepithelial tumors that received ER between September 2009 and September 2014 at Kagawa University Hospital and Ehime Rosai Hospital,an affiliated hospital of Kagawa University,were included in the study.We retrospectively compared two groups of patients who received postER artificial ulcer floor closure:the conventional clip group vs the over-the-scope clip(OTSC) group.Delayed bleeding,procedure time of closure,delayed perforation,total number of conventional clips and OTSCs and medical costs were analyzed.RESULTS:Although we observed delayed bleeding in three patients in the conventional clip group,we observed no delayed bleeding in the OTSC group(P = 0.049).We did not observe perforation in either group.The mean procedure times for ulcer closure were 33.26 ± 12.57 min and 9.71 ± 2.92 min,respectively(P = 0.0001).The resection diameters were 18.8 ± 1.30 mm and 22.9 ± 1.21 mm for the conventional clip group and the OTSC group,respectively,with significant difference(P = 0.039).As for medical costs,the costs of all conventional clips were USD $1257 and the costs of OTSCs were $7850(P = 0.005).If the post-ER ulcer is under 20 mm in diameter,a conventional clip closure may be more suitable with regard to the prevention of delayed perforation and to medical costs.CONCLUSION:If the post-ER ulcer is over 20 mm,the OTSC closure should be selected with regard to safety and reliable closure even if there are high medical costs.     

Endoscopic Full-Thickness Resection of Submucosal Gastric Tumors

Background and Aims  

Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal lesions, such as early cancer or submucosal tumor. The aim of this pilot study was to evaluate a novel EFTR prototype device for full-thickness resection of the gastric wall containing artificial submucosal lesions.     

Preliminary study of photodynamic diagnosis using 5-aminolevulinic acid in gastric and colorectal tumors

AIM: To investigate the utility of photodynamic diagnosis (PDD) using 5-aminolevulinic acid (5-ALA) to detect gastric/colorectal tumors.METHODS: This prospective single-center study investigated inter-subject variability in patients with early-stage gastric/colorectal tumor indicated for endoscopic resection. Subjects were patients with gastric or colorectal tumors who had undergone endoscopic resection between November 2012 and November 2013. Selection criteria included age 20-80 years, either sex, and provision of informed consent. Patients were orally administered 20 mg/kg of 5-ALA enteric-coated capsules (SBI ALApromo Co., Tokyo, Japan). Administration of 5-ALA was followed by endoscopic resection of gastric or colorectal tumors, and the resected specimens were examined using a video autofluorescence processor and a fluorescence endoscope (SAFE-3000 and EB-1970AK, respectively; Pentax, Tokyo, Japan). The primary endpoint was the presence of fluorescence in tumors. Endoscopic, macroscopic, and histopathologic findings of tumors were assessed. We also evaluated adverse events of the present procedure as a secondary endpoint and examined each patient for the presence of known adverse effects of 5-ALA, namely, hematocytopenia, liver dysfunction, hypotension, nausea, and photosensitivity.RESULTS: We enrolled 10 patients (7 men, 3 women) (n = 13 lesions: 10 gastric/3 colorectal tumors). Fluorescence was detected in 7/13 (53.8%) lesions. No significant differences in sex (male: 55.6% vs female: 50.5%, P = 1.00), age (67.1 ± 1.9 years vs 65.0 ± 2.0 years, P = 0.45), tumor color (reddish: 60.0% vs discolored: 33.3%, P = 0.56), tumor diameter (15.0 ± 2.1 mm vs 14.2 ± 2.3 mm, P = 0.80), macroscopic type (protruded: 70.0% vs depressed 0%, P = 0.07), histologic type (differentiated type: 58.3% vs 0%, P = 0.46), invasion depth (mucosal layer: 55.6% vs submucosal layer: 33.3%, P = 1.00), lymphatic invasion (present: 33.3% vs absent: 50.0%, P = 1.00), venous invasion (present: 0% vs absent: 54.5%, P = 1.00) or procedure time of endoscopic resection (36.3 ± 8.3 min vs 36.7 ± 9.0 min, P = 0.98) were observed between the patients with and without fluorescence. Fluorescence detection rate tended to be high for elevated lesions. Liver dysfunction developed in 4/10 (40.0%) patients. The extent of the liver dysfunction was a slight increase in transaminases and total bilirubin levels, which spontaneously improved in the patients. None of the patients developed photosensitivity.CONCLUSION: Results of this preliminary study suggest the utility of PDD using 5-ALA for screening of gastric and colorectal cancers.     

Glomus tumor in the stomach:Computed tomography and endoscopic ultrasound findings

A 57-year-old man presented with intermittent dull abdominal pain after a period of 1 year.Abdominal computed tomography(CT) was performed.Except for the endoscopy,the work-up for possible medical causes remained inconclusive.An open-abdomen,partial surgical excision of the stomach was performed after the unsuccessful endoscopic resection.The pathology report revealed a glomus tumor of the stomach.Importantly,glomus tumors of the stomach are rare and are almost always benign.Therefore,the most important current role of imaging associated with the diagnostic approach and therapeutic plan for a glomus tumor is to differentiate it from other gastric submucosal tumors(SMTs).We report this case with representative radiologic findings,including CT and endoscopic ultrasound(EUS) reports,and also correlate them with clinical and pathologic presentations that can help in the early detection and differentiation of gastric SMTs from other SMTs.As such,the purpose of this report is to provide a better understanding of relevant CT and EUS features.Alternative treatments should be considered carefully according to the imaging results.     

Diagnosis of gastric submucosal tumors and estimation of malignant risk of GIST by endoscopic ultrasound. Comparison between B mode and contrast-harmonic mode

Backgroundstandard B-mode EUS assessment and EUS-guided tissue acquisition present sub-optimal diagnostic yield in the differential diagnosis of gastric submucosal tumors (SMTs).Aimsto evaluate the performances of contrast-enhanced harmonic endoscopic ultrasonography (CH-EUS) to differentiate gastric SMTs and predict malignancy risk of gastrointestinal stromal tumors (GIST).Methodsa retrospective analysis was performed retrieving consecutive patients with gastric SMTs who underwent EUS between 2009 and 2014. Patients with available EUS video recordings and histological diagnosis were included. De-identified videos were presented to experts who made a diagnosis on B-mode EUS and CH-EUS.Resultsfifty-four patients (29 female, 64-year-old) were included. Final diagnoses were 40 GISTs (8 high-grade), 9 leiomyomas, 5 rare SMTs. The sensitivity, specificity, and accuracy of B-mode and CH-EUS for the differential diagnosis of GIST were 95.0% vs. 85.0%, 57.1% for both techniques, and 85.2% vs. 77.8%, respectively. The sensitivity, specificity, and accuracy of B-mode and CH-EUS for the estimation of the malignancy GISTs risk were 62.5% vs. 100%, 83.3% vs. 82.1%, and 78.9% vs. 86.1%, respectively.ConclusionsCH-EUS showed better diagnostic performance than B-mode EUS in differentiating leiomyomas and risk stratification of GIST. When considering high-grade GISTs, the addition of CH-EUS allowed an improvement in diagnostic accuracy.     

无腹腔镜辅助的内镜全层切除术治疗源于固有肌层的胃黏膜下肿瘤

目的探讨无腹腔镜辅助的内镜全层切除术（EFR）治疗源于固有肌层的胃黏膜下肿瘤（SMT）的疗效和可行性。方法2007年7月至2009年8月经辅助检查和前期治疗明确诊断为起源于固有肌层的胃SMT患者20例,择期行全麻下EFR治疗：（1）黏膜下注射生理盐水,预切开肿瘤周围黏膜和黏膜下层,显露肿瘤;（2）采用内镜黏膜下剥离术（ESD）技术沿肿瘤周围分离固有肌层至浆膜层;（3）应用Hook刀沿肿瘤边缘切开浆膜;（4）胃镜直视下应用Hook、IT刀或圈套器完整切除包括浆膜在内的肿瘤;（5）应用金属夹缝合胃创面。结果20例源于固有肌层的胃SMT中,病灶位于胃底9例、胃体11例。EFR成功切除所有病变,完整切除率为100％,未使用腹腔镜辅助;EFR时间为60—145min,平均85min。切除肿瘤最大直径1．8～3．5cm,平均2．6cm;病理诊断为问质瘤13例、平滑肌瘤4例、血管球瘤2例、神经鞘瘤1例。术后无一例出现胃出血、腹膜炎体征及腹腔脓肿,术后3d造影无一例造影剂外漏和胃排空障碍。住院天数3～8d,平均5．5d。术后随访1～12个月,平均7个月,无一例病变残留或复发。结论EFR治疗源于固有肌层的胃SMT是安全、有效的,可以切除更深的胃壁肿瘤,并提供准确的病理诊断资料,它的开展可进一步扩大内镜治疗的适应证。     

Accuracy of endoscopic ultrasonographic impression compared with pathologic diagnosis in gastrointestinal submucosal tumors]

BACKGROUND/AIMS: Endoscopic ultrasonography (EUS) is a valuable imaging modality for the evaluation of gastrointestinal submucosal tumor (SMT). EUS is helpful in assessing the layer of origin, tumor diameter, shape, border characteristics, and internal echo patterns of SMTs and thus makes it possible to predict histologic diagnosis with educated guess. However, some studies have found no significant differences in EUS features between benign and malignant mesenchymal tumors. By comparing EUS impressions with histologic diagnosis, we evaluated the accuracy of EUS in differential diagnosis of gastrointestinal SMTs. METHODS: 58 cases of gastrointestinal SMTs with both EUS findings and pathologic reports were compared retrospectively from August 2001 to September 2003. RESULTS: 34 patients had lesions in the stomach and 13, 8, 3 in the esophagus, duodenum, and colon respectively. Benign lesions were predominant (46 of 58). The EUS and pathologic diagnosis coincided in 46/58 (79.3%) of the cases. Use of EUS led to the correct diagnosis in 7/9 (77.8%) of malignant GISTs (gastrointestinal stromal tumor) and leiomyosarcomas. Two small malignant gastric GISTs were diagnosed as benign with EUS. CONCLUSIONS: EUS is a useful tool in the differential diagnosis of gastrointestinal SMTs and predicting malignant lesions. However, some malignant GISTs were diagnosed as benign tumor with EUS examination.     

Accuracy of high‐frequency catheter‐based endoscopic ultrasonography according to the indications for endoscopic treatment of early gastric cancer

Background and Aim: The development of endoscopic treatment, such as endoscopic submucosal dissection, extends the indications for endoscopic resection in patients with early gastric cancer (EGC). Endoscopic ultrasonography (EUS) is the first‐choice imaging modality for determining the depth of invasion of gastric cancer. The aim of the present study was to prospectively assess the accuracy of EUS for determining the depth of EGC, according to the accepted/extended indications. Methods: We prospectively included a total of 181 lesions in 178 patients, with an endoscopic diagnosis of EGC, who underwent EUS for staging the depth of tumor invasion using a 20‐MHz catheter probe. We investigated the accuracy of EUS for determining the depth of endoscopically‐suspected EGC and then analyzed the difference in the accuracy of EUS according to the accepted/extended indications. Results: Of the 178 patients, five patients were dropped because of the absence of final histological results. For the 176 lesions in 173 patients, the accuracy of EUS assessment for the depth of tumor invasion was 80.7% (142 of 176 lesions). The accuracy of EUS for the lesions with accepted indications and with extended indications was 97.6% (40 of 41 lesions) and 83.6% (46 of 57 lesions), respectively (P = 0.040). Of the lesions with extended indications, the accuracy of EUS decreased especially for the lesions with ulceration and those with minute submucosal invasion (79.2% and 42.9%, respectively). Conclusions: The accuracy of EUS for the lesions with the extended indications was lower than that for the lesions with the accepted indications. In particular, lesions with ulceration and minute submucosal invasion should be carefully considered prior to endoscopic treatment by pretreatment EUS staging.     

Endoscopic management of gastrointestinal smooth muscle tumor

AIM: To systematically evaluate the efficacy and safety of endoscopic resection of gastrointestinal smooth muscle tumors (SMTs, including leiomyoma and leiomyosarcoma) and to review our preliminary experiences on endoscopic diagnosis of gastrointestinal SMTs. METHODS: A total of 69 patients with gastrointestinal SMT underwent routine endoscopy in our department. Endoscopic ultrasonography (EUS) was also performed in 9 cases of gastrointestinal SMT. The sessile submucosal gastrointestinal SMTs with the base smaller than 2 cm in diameter were resected by "pushing" technique or "grasping and pushing" technique while the pedunculated SMTs were resected by polypectomy. For those SMTs originating from muscularis propria or with the base size ≥ 2 cm, ordinary biopsy technique was performed in tumors with ulcers while the "Digging" technique was performed in those without ulcers. RESULTS: 54 cases of leiomyoma and 15 cases of leiomyosarcoma were identified. In them, 19 cases of submucosal leiomyoma were resected by "pushing" technique and 10 cases were removed by "grasping and pushing" technique. Three cases pedunculated submucosal leiomyoma were resected by polypectomy. No severe complications developed during or after the procedure. No recurrence was observed. The diagnostic accuracy of ordinary and the "Digging" biopsy technique was 90.0% and 94.1%, respectively. CONCLUSION: Endoscopic resection is a safe and effective treatment for leiomyomas with the base size ≤2 cm. The "digging" biopsy technique would be a good option for histologic diagnosis of SMTs.     

Treatment of leakage via metallic stents placements after endoscopic full-thickness resection for esophageal and gastroesophageal junction submucosal tumors

Objective: The objective of this study is to evaluate the feasibility and efficacy of endoscopic full-thickness resection (EFTR) and fully covered retrievable self-expandable metal stents (SEMSs) placement for this kind of tumors.

Methods: A total of six consecutive patients, presenting with esophageal and GE junction SMTs, received EFTR and SEMSs placement at the our endoscopic center between January 2015 and June 2015. Their medical records were thoroughly investigated.

Results: EFTR was performed successfully in all cases. The en bloc resection rate was 100%. The final pathological diagnoses were leiomyomas in all six cases. No patients developed delayed bleeding. SEMSs were placed immediately after EFTR during the same endoscopic session except patient #1. Complete healing of esophageal leakage after stent placement was achieved for 6/6 patients (100%) without the need for surgical interventions. Stent migration occurred in one patient. No residual tumor or tumor recurrence was observed during the follow-up period.

Conclusions: EFTR combined with fully covered retrievable self-expandable metallic stents placement is a feasible and effective new method for providing radical treatments for SMTs from the deep MP layer of esophagus and GE junction. Standardization of the procedure should be studied further.     

“悬吊法”在胃底固有肌层肿瘤内镜全层切除术中的应用

背景随着内镜技术的发展,对于起源于固有肌层的胃黏膜下肿瘤(submucosal tumor,SMT)临床医师常采用内镜全层切除术(endoscopic full-thickness resection,EFTR)切除;然而对于胃底黏膜下肿瘤应用传统方法有诸多缺点,应用悬吊法辅助EFTR可解决传统方法的弊端,对其效果及安全性的临床研究尚不多.目的探讨“悬吊法”在胃底固有肌层肿瘤内镜全层切除术中的应用价值.方法回顾性分析天津市第五中心医院消化内科2017-08/2021-06期间22例胃底固有肌层肿瘤的患者接受EFTR的临床资料.按不同手术方式分为传统EFTR组和改良“悬吊法”+EFTR组.对照组12例患者进行传统EFTR,观察组10例患者进行改良“悬吊法”+EFTR.比较两组方法的手术时间、术中出血量、创面缝合时间、住院时间.结果观察组比对照组患者手术时间、创面缝合时间短,术中出血量少,两组间具有统计学差异(P<0.05).结论“悬吊法”+EFTR可更好地缩短手术时间及创面缝合时间,降低术中出血量,对于治疗胃底固有肌层肿瘤是一种安全的、可行的、有效的方法,适合在临床应用.