For SMTs <10 mm, both ESE and STER have satisfactory therapeutic results, it is not necessary to pursue a difficult procedure when a simple method is available. For SMTs >10 mm, STER is a preferable choice in terms of preventing air leakage symptoms, especially, when perforation is likely to happen.

The promising endoscopic resection techniques for upper gastrointestinal submucosal tumors (SMTs) are challenged when performed in the gastric fundus. Here, we report on the development of a transcardiac endoscopic tunneling technique (TCTT) for the resection of tumors in this area. A total of 18 patients with gastric fundus SMTs arising from the muscularis propria on endoscopic ultrasound underwent TCTT. The procedure involved the excavation of a submucosal tunnel from the esophagus, through the cardia, to the gastric SMT for resection. The tunnel was closed by clips after retrieval of the tumor. The mean tumor size was 2.1 cm (range 0.8 - 5.0 cm). The mean procedure time was 75.1 minutes (range 40 - 100 minutes). Complete resection was achieved in all cases. Iatrogenic perforation occurred in one case. This and one other patient developed mild pneumoperitoneum on the day after the procedure; symptoms resolved under conservative management. No patient developed gastrointestinal leakage, delayed bleeding, or secondary infection. Therefore, in this pilot study, TCTT provided a definitive histological diagnosis as well as a feasible, safe, and easy therapeutic approach for gastric fundus SMTs arising from muscularis propria in the circular area within 8 cm below the cardia.

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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.

Small (<2 cm) or incidentally found gastrointestinal submucosal tumors pose challenges to gastroenterologists due to the potential malignancy of tumors and current suboptimal diagnostic methods. On the basis of the development of endoscopic submucosal dissection, recent technical advances, including endoscopic submucosal excavation, submucosal tunneling and endoscopic resection, and endoscopic full-thickness resection, have been able to resect submucosal tumors in the muscularis propria. These techniques provide definitive histologic diagnosis as well as a minimally invasive therapeutic approach to such tumors. Current studies, despite with promising results, are limited to small, retrospective studies, focusing on introducing new methods and varied in technical details. This review provides a thorough discussion of technical details of each endoscopic method, and compares different methods in terms of tumor sites, to ensure safety and optimize treatment outcomes.