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Safety and efficacy of endoscopic submucosal dissection of large (≥3 cm) subepithelial tumors located in the cardia

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Abstract

Background

Upper gastrointestinal subepithelial tumors (SETs) may harbor potential malignancy. Although it is well recognized that large SETs should be resected, the treatment strategy remains controversial. Compared to surgical resection, endoscopic resection has many advantages such as less invasive, shorter hospital stay, lower costs, and better quality of life. However, Endoscopic resection of large SETs in the cardia is challenging. The purpose of this study was to evaluate the safety and efficacy of endoscopic submucosal dissection (ESD) in the treatment of such SETs.

Methods

A total of 41 patients with large SETs (≥3 cm in diameter) located in the cardia were involved in the study. All patients underwent ESD. Data on therapeutic outcomes and follow-up were collected, for analysis of risk factors of complication rates.

Results

The average tumor size was 4.7 ± 1.7 cm. The average procedure time was 69.3 ± 32.7 min and the average postoperative hospital stay was 3.5 ± 1.1 days. A total of 41 tumors were removed successfully, in which 35 were leiomyomas, three were gastrointestinal stromal tumors, two were lipomas, and one was gastritis cystica profunda. The en bloc resection rate was 90.2%, and was significantly higher for tumors with a round or oval shape (100%) than for those with an irregular shape (75.0%) (P < 0.05). Five patients experienced complications (12.2%), all of which were managed conservatively. The complication rates were significantly higher in patients with a tumor originating from the deep muscularis propria layer and demonstrating a trans-cardia growth pattern. No residual or tumor recurrence was observed and no stricture occurred during the follow-up period (average, 26.7 ± 18.4 months).

Conclusions

ESD is safe and effective to curatively remove most large SETs in the cardia, and may serve as an accurate histopathology measurement to direct future therapy.

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References

  1. Hwang JH, Rulyak SD, Kimmey MB (2006) American Gastroenterological Association Institute. American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses. Gastroenterology 130:2217–2228

    Article  PubMed  Google Scholar 

  2. Demetri GD, von Mehren M, Antonescu CR, DeMatteo RP, Ganjoo KN, Maki RG, Pisters PW, Raut CP, Riedel RF, Schuetze S, Sundar HM, Trent JC, Wayne JD (2010) NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Canc Netw Suppl 2:S1–41

    Google Scholar 

  3. Melstrom LG, Phillips JD, Bentrem DJ, Wayne JD (2012) Laparoscopic versus open resection of gastric gastrointestinal stromal tumors. Am J Clin Oncol 35:451–454

    Article  PubMed  Google Scholar 

  4. De Vogelaere K, Van Loo I, Peters O, Hoorens A, Haentjens P, Delvaux G (2012) Laparoscopic resection of gastric gastrointestinal stromal tumors (GIST) is safe and effective, irrespective of tumor size. Surg Endosc 26:2339–2345

    Article  PubMed  Google Scholar 

  5. Kim SY, Kim KO (2016) Management of gastric subepithelial tumors: the role of endoscopy. World J Gastrointest Endosc 8:418–424

    Article  PubMed  PubMed Central  Google Scholar 

  6. Shi Q, Zhong YS, Yao LQ, Zhou PH, Xu MD, Wang P (2011) Endoscopic submucosal dissection for treatment of esophageal submucosal tumors originating from the muscularis propria layer. Gastrointest Endosc 74:1194–1200

    Article  PubMed  Google Scholar 

  7. Zhou PH, Yao LQ, Qin XY, Cai MY, Xu MD, Zhong YS, Chen WF, Zhang YQ, Qin WZ, Hu JW, Liu JZ (2011) Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria. Surg Endosc 25:2926–2931

    Article  PubMed  Google Scholar 

  8. He Z, Sun C, Wang J, Zheng Z, Yu Q, Wang T, Chen X, Liu W, Wang B (2013) Efficacy and safety of endoscopic submucosal dissection in treating gastric subepithelial tumors originating in the muscularis propria layer: a single-center study of 144 cases. Scand J Gastroenterol 48:1466–1473

    Article  PubMed  Google Scholar 

  9. Białek A, Wiechowska-Kozłowska A, Pertkiewicz J, Polkowski M, Milkiewicz P, Karpińska K, Ławniczak M, Starzyńska T (2012) Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video). Gastrointest Endosc 75:276–286

    Article  PubMed  Google Scholar 

  10. Lee IL, Lin PY, Tung SY, Shen CH, Wei KL, Wu CS (2006) Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer. Endoscopy 38:1024–1028

    Article  PubMed  Google Scholar 

  11. Wang H, Tan Y, Zhou Y, Wang Y, Li C, Zhou J, Duan T, Zhang J, Liu D (2015) Submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer. Eur J Gastroenterol Hepatol 27:776–780

    Article  PubMed  Google Scholar 

  12. Tan ES, Wang H, Lua GW, Liu F, Shi XG, Li ZS (2016) Fibrin glue spray as a simple and promising method to prevent bleeding after gastric endoscopic submucosal dissection. Dig Surg 33:455–461

    Article  CAS  PubMed  Google Scholar 

  13. Li L, Wang F, Wu B, Wang Q, Wang C, Liu J (2013) Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria. Exp Ther Med 6:391–395

    Article  PubMed  PubMed Central  Google Scholar 

  14. Zhang J, Huang K, Ding S, Wang Y, Nai T, Huang Y, Zhou L (2016) Clinical applicability of various treatment approaches for upper gastrointestinal submucosal tumors. Gastroenterol Res Pract 2016:9430652

    PubMed  PubMed Central  Google Scholar 

  15. Chun SY, Kim KO, Park DS, Lee IJ, Park JW, Moon SH, Baek IH, Kim JH, Park CK, Kwon MJ (2013) Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications. Surg Endosc 27:3271–3279

    Article  PubMed  PubMed Central  Google Scholar 

  16. Lee CM, Kim HH (2014) Minimally invasive surgery for submucosal (subepithelial) tumors of the stomach. World J Gastroenterol 20:13035–13043

    Article  PubMed  PubMed Central  Google Scholar 

  17. Chu YY, Lien JM, Tsai MH, Chiu CT, Chen TC, Yang KC, Ng SC (2012) Modified endoscopic submucosal dissection with enucleation for treatment of gastric subepithelial tumors originating from the muscularis propria layer. BMC Gastroenterol 12:124

    Article  PubMed  PubMed Central  Google Scholar 

  18. Zhang Y, Ye LP, Zhou XB, Mao XL, Zhu LH, He BL, Huang Q (2013) Safety and efficacy of endoscopic excavation for gastric subepithelial tumors originating from the muscularis propria layer: results from a large study in China. J Clin Gastroenterol 47:689–694

    Article  PubMed  Google Scholar 

  19. Inoue H, Ikeda H, Hosoya T, Onimaru M, Yoshida A, Eleftheriadis N, Maselli R, Kudo S (2012) Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia. Endoscopy 44:225–230

    Article  CAS  PubMed  Google Scholar 

  20. Schmidt A, Bauder M, Riecken B, von Renteln D, Muehleisen H, Caca K (2015) Endoscopic full-thickness resection of gastric subepithelial tumors: a single-center series. Endoscopy 47:154–158

    PubMed  Google Scholar 

  21. Chen K, Zhou YC, Mou YP, Xu XW, Jin WW, Ajoodhea H (2015) Systematic review and meta-analysis of safety and efficacy of laparoscopic resection for gastrointestinal stromal tumors of the stomach. Surg Endosc 29:355–367

    Article  PubMed  Google Scholar 

  22. Bischof DA, Kim Y, Dodson R, Carolina Jimenez M, Behman R, Cocieru A, Blazer DG 3rd, Fisher SB, Squires MH 3rd, Kooby DA, Maithel SK, Groeschl RT, Clark Gamblin T, Bauer TW, Karanicolas PJ, Law C, Quereshy FA, Pawlik TM (2014) Open versus minimally invasive resection of gastric GIST: a multi-institutional analysis of short- and long-term outcomes. Ann Surg Oncol 21:2941–2948

    Article  PubMed  Google Scholar 

  23. Ponsaing LG, Kiss K, Loft A, Jensen LI, Hansen MB (2007) Diagnostic procedures for submucosal tumors in the gastrointestinal tract. World J Gastroenterol 13:3301–3310

    Article  PubMed  PubMed Central  Google Scholar 

  24. Nishida T, Blay JY, Hirota S, Kitagawa Y, Kang YK (2016) The standard diagnosis, treatment, and follow-up of gastrointestinal stromal tumors based on guidelines. Gastric Cancer 19:3–14

    Article  CAS  PubMed  Google Scholar 

  25. Hoda KM, Rodriguez SA, Faigel DO (2009) EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc 69:1218–1223

    Article  PubMed  Google Scholar 

  26. Zhang XC, Li QL, Yu YF, Yao LQ, Xu MD, Zhang YQ, Zhong YS, Chen WF, Zhou PH (2016) Diagnostic efficacy of endoscopic ultrasound-guided needle sampling for upper gastrointestinal subepithelial lesions: a meta-analysis. Surg Endosc 30:2431–2441

    Article  PubMed  Google Scholar 

  27. Sepe PS, Moparty B, Pitman MB, Saltzman JR, Brugge WR (2009) EUS-guided FNA for the diagnosis of GI stromal cell tumors: sensitivity and cytologic yield. Gastrointest Endosc 70:254–261

    Article  PubMed  Google Scholar 

  28. Lee JH, Choi KD, Kim MY, Choi KS, Kim DH, Park YS, Kim KC, Song HJ, Lee GH, Jung HY, Yook JH, Kim BS, Kang YK, Kim JH (2011) Clinical impact of EUS-guided Trucut biopsy results on decision making for patients with gastric subepithelial tumors ≥2 cm in diameter. Gastrointest Endosc 74:1010–1018

    Article  PubMed  Google Scholar 

  29. Lee HH, Hur H, Jung H, Jeon HM, Park CH, Song KY (2011) Analysis of 151 consecutive gastric submucosal tumors according to tumor location. J Surg Oncol 104:72–75

    Article  PubMed  Google Scholar 

  30. Gong W, Xiong Y, Zhi F, Liu S, Wang A, Jiang B (2012) Preliminary experience of endoscopic submucosal tunnel dissection for upper gastrointestinal submucosal tumors. Endoscopy 44:231–235

    Article  CAS  PubMed  Google Scholar 

  31. Ye LP, Zhang Y, Mao XL, Zhu LH, Zhou X, Chen JY (2014) Submucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layer. Surg Endosc 28:524–530

    Article  PubMed  Google Scholar 

  32. Chen H, Xu Z, Huo J, Liu D (2015) Submucosal tunneling endoscopic resection for simultaneous esophageal and cardia submucosal tumors originating from the muscularis propria layer (with video). Dig Endosc 27:155–158

    Article  PubMed  Google Scholar 

  33. Liu BR, Song JT, Kong LJ, Pei FH, Wang XH, Du YJ (2013) Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia. Surg Endosc 27:4354–4359

    Article  PubMed  Google Scholar 

  34. Zhou DJ, Dai ZB, Wells MM, Yu DL, Zhang J, Zhang L (2015) Submucosal tunneling and endoscopic resection of submucosal tumors at the esophagogastric junction. World J Gastroenterol 21:578–583

    Article  PubMed  PubMed Central  Google Scholar 

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Author notes

  1. Jun Li and Jian Tang have been contributed equally to this work.

Authors and Affiliations

  1. Department of Gastroenterology, Changhai Hospital, Second Military Medical University, 168 Changhai Road, Shanghai, 200433, China

    Jun Li, Jian Tang, Jie Chen, Xingang Shi, Feng Liu & Zhaoshen Li

  2. Department of Gastroenterology, Raja Perempuan 2 Hospital, Kelantan, Malaysia

    G. W. Lua

Authors
  1. Jun Li
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  2. Jian Tang
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  3. G. W. Lua
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  4. Jie Chen
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  5. Xingang Shi
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  6. Feng Liu
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Contributions

Study conception and design (FL); acquisition, analysis, and interpretation of data (JL, JT); drafting of the manuscript (JL); critical revision of the manuscript for important intellectual content (FL, GL); technical or material support (JC, XS, ZL); study supervision (FL, ZL). The article has been approved by all authors to be published.

Corresponding authors

Correspondence to Feng Liu or Zhaoshen Li.

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Disclosure

Drs. Jun Li, Jian Tang, GW Lua, Jie Chen, Xingang Shi, Feng Liu, and Zhaoshen Li have no conflict of interest or financial ties to disclose.

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Li, J., Tang, J., Lua, G.W. et al. Safety and efficacy of endoscopic submucosal dissection of large (≥3 cm) subepithelial tumors located in the cardia. Surg Endosc 31, 5183–5191 (2017). https://doi.org/10.1007/s00464-017-5585-y

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  • DOI: https://doi.org/10.1007/s00464-017-5585-y

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