Submucosal Tunnel Endoscopic Resection for Esophageal Submucosal Tumors: A Multicenter Study

Abstract

Background Submucosal tumors (SMTs) are primarily benign tumors, but some may have a malignant potential. Endoscopic submucosal dissection that has been used for removing esophageal SMTs could cause perforation. Submucosal tunnel endoscopic resection (STER) is an improved and an effective technique for treating esophageal SMTs. Aims This study was conducted to evaluate the efficacy and safety of STER for treating esophageal SMTs. Methods A retrospective study design was adopted to analyze the baseline characteristics, clinical outcomes, and follow-up data of patients with esophageal SMTs, which originated from the muscularis propria layer and were treated with STER from September 2011 to May 2018. Results A total of 119 lesions were included from 115 patients who were successfully treated with STER. The mean age of the patients was 49.7 ± 10.7 years. The lesions were primarily located in the middle and lower esophagus. The mean size of the lesions was 19.4 ± 10.0 mm. The mean operation duration was 46.7 ± 25.6 min, and the mean duration of hospitalization was 5.9 ± 2.8 days. The total en bloc resection rate and the complete resection rate were 97.5% and 100%, respectively. Regarding complications, there were 9 (7.8%) cases of perforation, 2 (1.7%) cases of pneumothorax, and 9 (7.8%) cases of subcutaneous emphysema. Histopathological results revealed 113 (95.0%) cases of leiomyoma, 5 (4.2%) cases of gastrointestinal stromal tumors, and 1 (0.8%) case of a granular cell tumor. During the mean 15-month follow-up, there were no cases of recurrence and distant metastasis. Conclusions STER is a safe and feasible technique for treating esophageal SMTs originating from the muscularis propria layer.

Esophageal intramural squamous cell carcinomas presenting as subepithelial lesions removed by endoscopic submucosal dissection

“…[ 19 , 20 ] Furthermore, several studies revealed that endoscopy could achieve en bloc resection in case of esophageal GISTs, and endoscopic resection is safe, effective, and minimally invasive. [ 2 , 8 , 21 , 22 ] Moreover, several lymphomas presented as SELs and treated with endoscopic resection have been reported. [ 23 – 27 ] In addition, according to the literature review, some other rare cases were treated with endoscopy, similar to follicular dendritic cell sarcoma and adenoid cystic carcinoma.…”

“…Esophageal subepithelial lesion (SEL) is rare, accounting for <1% of all esophageal tumors. [ 1 , 2 ] SELs originate from the muscularis mucosa, submucosa, or muscularis propria and are often covered with normal epithelium. [ 3 ] They usually do not produce obvious clinical symptoms and are thus often incidentally found.…”

“…A significant proportion of esophageal SELs are leiomyomas. [ 2 , 4 , 5 ] Because only 1% of esophageal SELs are malignant, they are often overlooked or misdiagnosed. [ 5 ] Therefore, the accurate and timely diagnosis of SELs is very important.…”

“…This has led to the correct diagnosis of several malignant SELs that lacked specific endoscopic presentations. [ 2 , 8 ]…”

Open submucosal tunneling endoscopic resection for special submucosal tumors originating from the muscularis propria

“…Many studies have shown that STER is a safe and effective treatment for the resection of esophageal SMTs; however, we found over the course of the study that for some special esophageal SMTs, such as those located in the upper esophagus or cardia or those > 3.5 cm in size, due to the limited space in the tunnel and the operative difficulty, the operation time would be longer and the complication rates of STER would greatly increase. In 2015, Jun et al [21] first reported successful opening of the mucosa on the distal end of the tunnel during STER to resect a 40-mm esophageal SMT. In 2017, Zhang et al [22] reported 10 cases of SMTs near the cardia that were successfully resected using submucosal tunneling endoscopic resection with double opening (DO-STER), which demonstrated that DO-STER is safe and effective for removing SMTs located within the cardia.…”