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Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia

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Abstract

Background and aims

Endoscopic resection of esophageal or cardial subepithelial tumors (SETs) originating from the muscularis propria (MP) is rarely done due to the high risk of perforation, fistula formation, and secondary infection. The aim of this study was to evaluate the preliminary clinical feasibility and safety of tunneling endoscopic muscularis dissection (tEMD) for resection of SETs located in the esophagus and gastric cardia

Methods

Twelve patients with SETs originating from the MP of the esophagus (n = 7) or cardia (n = 5) were treated by tEMD. The procedure included creation of a submucosal tunnel to reach the tumor, dissection of the tumor from the surrounding submucosal tissue and the unaffected MP layer, full-thickness resection of the tumor and affected MP, and subsequent closure of the tunnel mucosal entry with endoscopic clips.

Results

The en bloc resection rate was 100 % (seven lesions affected the deep MP so complete MP resection was performed; five lesions affected the superficial MP for a partial MP resection). The average tumor size was 18.5 ± 6.9 (range 10–30) mm. The mean operating time was 78.3 ± 25.5 (range 50–130) min. The histological diagnoses were two gastrointestinal stromal tumors with very low risk, nine leiomyomas, and one schwannoma. Air leakage and effusion included subcutaneous and mediastinal emphysema in eight patients (66.7 %), pneumothorax in four (33.3 %), pneumoperitoneum in three (25.0 %), and small pleural effusion in two (16.7 %). All air leakage and effusion cases were resolved with conservative management. No patient developed delayed hemorrhage and chronic fistula after tEMD. During the mean follow-up time of 7.1 ± 4.3 (range 2–15) months, no tumor recurrence was found in any patient.

Conclusions

tEMD appears to be a feasible minimally invasive and effective treatment for patients with SETs originating from the MP layer of the esophagus and cardia.

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Disclosure

Drs. Bing-Rong Liu, Ji-Tao Song, Ling-Jian Kong, Feng-Hua Pei, Xin-Hong Wang, and Ya-Ju Du have no conflicts of interest or financial ties to disclose.

Author information

Correspondence to Bing-Rong Liu.

Additional information

B.-R. Liu and J.-T. Song contributed equally to this study.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Video 1 Endoscopic dissection of SET as deep as muscularis propria within submucosal tunnel. Supplementary material 1 (MPG 30024 kb)

Video 2 Endoscopic circumferential full-thickness MP incision at the base of SET. Supplementary material 2 (MPG 46372 kb)

Video 3 Endoscopic snaring of the SET after circumferential full-thickness MP incision. Supplementary material 3 (MPG 37284 kb)

Video 4 Endoscopic observation of full MP defect and submucosal tunnel after removal of the tumor. Supplementary material 4 (MPG 12178 kb)

Video 1 Endoscopic dissection of SET as deep as muscularis propria within submucosal tunnel. Supplementary material 1 (MPG 30024 kb)

Video 2 Endoscopic circumferential full-thickness MP incision at the base of SET. Supplementary material 2 (MPG 46372 kb)

Video 3 Endoscopic snaring of the SET after circumferential full-thickness MP incision. Supplementary material 3 (MPG 37284 kb)

Video 4 Endoscopic observation of full MP defect and submucosal tunnel after removal of the tumor. Supplementary material 4 (MPG 12178 kb)

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Liu, B., Song, J., Kong, L. et al. Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia. Surg Endosc 27, 4354–4359 (2013) doi:10.1007/s00464-013-3023-3

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Keywords

  • Endoscopic resection
  • Therapeutic upper gastrointestinal endoscopy
  • Subepithelial tumors
  • Submucosal endoscopy