Transcardiac tunneling technique for endoscopic submucosal dissection of gastric fundus tumors arising from the muscularis propria

Abstract

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.

Endoscopic versus surgical resection of GI stromal tumors in the upper GI tract

“…To our knowledge, our study contains the largest number of GIST in the UGIT resected by the endoscopic procedure, considering that previous studies only included small number of case series attached to clinical data of gastric SETs resected by ESD, STER or EFTR, [15][16][17][18][19][20][27][28][29][30] and their follow-up duration was relatively short, ranging from 2 to 21 months, 15,17,20,27,28,30,31 or even not presented. 16,18,29 Endoscopically resected cases in our study were followed up for 46 months on average, longer than previous studies, but nevertheless, the recurrence rate was 2.2%. This was compatible with previously published data reporting no recurrence during relatively shortterm duration of follow-up.…”

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

“…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.…”

“…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).…”

A comparison of submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric fundus submucosal tumors

“…Endoscopic full-thickness resection (EFTR) has proved to be a safe and effective endoscopic method for the treatment of gastric fundus SMTs that originate from the muscularis propria (MP) layer, with a high rate of complete resection (5)(6)(7)(8)(9)(10). Submucosal tunneling endoscopic resection (STER) is a novel endoscopic technique and has been shown to be safe and effective for the treatment of gastric SMTs (11)(12)(13)(14). However, there is little data that compares STER and EFTR for the treatment of SMTs in the gastric fundus.…”