Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications

Abstract

BackgroundEndoscopic submucosal dissection (ESD) is a well-established method for the treatment of gastrointestinal epithelial tumors. However, the treatment of gastric subepithelial tumors (SETs) that originate from the muscularis propria layer still depends primarily on surgical techniques. We evaluated the appropriate indications for ESD in the treatment of SETs that originate from the muscularis propria layer.MethodsThirty-five patients with gastric SETs that originate from the muscularis propria layer who underwent ESD were enrolled, and the charts were retrospectively reviewed to investigate the parameters predictive complete resection and complications.ResultsThe mean age of the patients was 54.15 ± 9.3 years, and the male/female ratio was 2:3. Twenty-eight of the 35 SETs (85.7 %) were movable, and 15 (45.7 %) had a positive rolling sign. The most frequent location of the SETs was high body (n = 14). The most common pathological diagnoses were leiomyoma (60 %) and gastrointestinal stromal tumor (28.6 %). The complete resection rate was 74.3 %. A positive rolling sign (p = 0.022) and small tumor size (≤20 mm; p = 0.038) were significantly associated with complete resection. Two patients (6.1 %) developed perforations that required surgical treatment; their SMTs were neurogenic tumors with fixed lesion. Tumor mobility was significantly associated with perforation (p = 0.017).ConclusionsThe ESD method appears to be relatively safe for use in the complete resection of SETs that originate from the muscularis propria layer. Small tumor size (≤20 mm) and a positive rolling sign are appropriate indications for ESD.

Hyperechoic demarcation line between a tumor and the muscularis propria layer as a marker for deciding the endoscopic treatment of gastric submucosal tumor

“…In two studies which used similar inclusion criteria and methods, Chun et al (2013) reported that the complete resection rate for SMTs originating in the MP layer of SMTs was 74.3%. These authors also reported that a positive rolling sign (tumor having a narrow muscle connection or no muscle connection) and a tumor size >2 cm were closely related to the complete resection rate.…”

“…The perforation rate for tumors with a wide muscular connection was significantly higher than that for tumors with a narrow muscular connection (34.8% vs. 5.0%; P=0.044). Chun et al (2013) studied 35 SMTs which originated in the MP layer, and reported that perforation was more likely to occur when ESD was used to treat an immobile tumor (40% vs. 0% for highly mobile tumors), whereas the tumor's connection with the fourth layer was not related to the perforation rate. A wide muscular connection was a common finding among growing intraluminal tumors originating in the deep MP layer (Fig.…”

“…However, endoscopic surgery does have some drawbacks, such as the risks of incomplete resection, perforation, and bleeding. Several feasibility studies have shown that when used to treat SMTs originating in the MP layer, standard ESD achieves a complete resection in 64% to 75% of cases (Park et al, 2004;Lee et al, 2006;Bialek et al, 2012;Chun et al, 2013;Hobel et al, 2014;Meng et al, 2015) and produces perforation in 0% to 20% of cases (Probst et al, 2009;Jeon et al, 2010;Shi et al, 2011;Zhang et al, 2011;Bialek et al, 2012;Hobel et al, 2014). Therefore, when choosing an endoscopic procedure, a preoperative evaluation is important for avoiding both unnecessary surgery and the subsequent procedures.…”

“…Endoscopic submucosal dissection (ESD) is an effective technique for completely resecting SMTs originating in the submucosal layer, and is associated with fewer complications than other treatment methods. However, gastric SMTs originating in the MP layer are located deep within the lesion, and the higher incidence of perforation and bleeding limits the use of ESD to remove them (Park et al, 2004;Lee et al, 2006;Zhou et al, 2011;Bialek et al, 2012;Chun et al, 2013;Hobel et al, 2014;Meng et al, 2015). Laparoscopic-assisted endoscopic full-thickness resection (EFR) is a technique in which an iatrogenic perforation of the gastric wall is created for the purpose of removing a deep gastric lesion for patient treatment or to obtain a precise pathological diagnosis (Jeon et al, 2010;Ye et al, 2014).…”

Endoscopic resection of submucosal tumors in muscularis propria: the choice between direct excavation and tunneling resection

“…Endoscopic submucosal excavation (ESE) and submucosal tunneling endoscopic resection (STER) provide definitive histological diagnosis as well as therapeutic approaches for GI submucosal tumors (SMTs) arising from muscularis propria (MP), which used to be a diagnostic dilemma [2]. While ESE is basically a technical extension of ESD-just excavating deeper into MP [3][4][5][6][7]; STER uses a submucosal tunnel as an operating space to resect targeted tumor. This recently rising tunneling technique possesses an obvious advantage of preserving the integrity of covering mucosa as a barrier against air/ liquid leakage.…”