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The fourth space surgery: endoscopic subserosal dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria layer


Background and aims

We developed a novel method of endoscopic subserosal dissection (ESSD) for removal of subepithelial tumors (SETs) originating from the muscularis propria (MP) layer in the upper gastrointestinal (GI) tract. The aim of this study was to evaluate the efficacy, safety, and clinical outcome of this method.


Eleven patients with upper GI SETs originating from the MP layer were treated by ESSD between October 2016 and March 2017. ESSD technique consists of six major procedures: (1) incising the mucosal and submucosal layer around the lesion and exposing MP layer; (2) continuous injection was performed while the injection needle slowly moved from the MP layer toward the subserosal layer; (3) incising MP layer; (4) subserosal injection was performed to further separate the serosa from the MP layer; (5) the mucosa, submucosa, and MP layer including SET were carefully dissected en bloc; and (6) closure of the gastric-wall defect with endoscopic techniques. Primary outcome including clinical procedural success and procedure-related adverse events were documented.


ESSD was successfully performed in 11 patients. The complete resection rate was 100%, and the mean operation time was 51 (range 22–76) min. The mean resected lesion size was 27 (range 15–40) mm. Pathological diagnosis of these lesions included gastrointestinal stromal tumors (8/11), heterotopic pancreas (1/11), hamartoma (1/11), and leiomyoma (1/11). The small perforations occurred in two patients (4 × 4 and 5 × 5 mm, respectively) during the operation. All perforations and defects were closed successfully by endoscopic techniques. No GI bleeding, peritonitis, abdominal abscess, and other adverse events were observed. No lesion residual or recurrence was found during the follow-up period (mean 18 weeks; range 10–29 weeks).


ESSD seems to be an efficacious, safe, and minimally invasive treatment for patients with upper GI SETs originating from the MP layer, making it possible to resect deep lesions, provide precise pathological diagnosis, and maintain the integrity of serosa.

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Correspondence to Lei Wang.

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Drs. Fei Liu, Song Zhang, Wei Ren, Tian Yang, Ying Lv, Tingsheng Ling, Xiaoping Zou, and Lei Wang have no conflicts of interests or financial ties to disclose.

Additional information

Fei Liu and Song Zhang contributed equally to this article.

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Liu, F., Zhang, S., Ren, W. et al. The fourth space surgery: endoscopic subserosal dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria layer. Surg Endosc 32, 2575–2582 (2018). https://doi.org/10.1007/s00464-017-5985-z

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  • Endoscopic resection
  • Endoscopic subserosal dissection (ESSD)
  • Subepithelial tumors (SETs)
  • Gastrointestinal stromal tumors (GISTs)