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Journal of Peking University(Health Sciences) ›› 2019, Vol. 51 ›› Issue (1): 171-176. doi: 10.19723/j.issn.1671-167X.2019.01.029

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Comparative treatment analysis of upper gastroenterology submucosal tumors originating from muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation

Xue-li TIAN,Yong-hui HUANG(),Wei YAO,Yuan LI,Jing-jing LU   

  1. Department of Gastroenterology, Peking University Third Hospital, Beijing 100191, China
  • Received:2018-07-25 Online:2019-02-18 Published:2019-02-26
  • Contact: Yong-hui HUANG E-mail:huangyonghui@medmail.com.cn
  • Supported by:
    Supported by the National Natural Science Foundation of China(81470905)

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Abstract:

Objective:To evaluate the efficacy and safety of submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) for upper gastroenterology submucosal tumors (SMT) originating from the muscularis propria (MP) layer. Methods: Clinicopathological and endoscopic data of 42 cases with upper gastroenterology tumors originating from the MP layer who were treated with STER (n=28) or ESE (n=14) between April 2013 and December 2016 in Peking University Third Hospital were retrospectively analyzed. The treatment and complications of the two groups were compared. Results: In the study, 42 cases were all resected by therapeutic endoscopy successfully.There was no significant difference (STER vs. ESE) in gender, age, mean tumor size [1.5 (1.0-6.0) cm vs. 1.3 (0.5-2.0) cm,P=0.056]. STER was superior to ESE with reduced sutured time [3.5 (1.0-11.0) min vs. 8.0 (2.0-33.0) min, P=0.006], but more resection time [46.5 (11.0-163.0) min vs.19.5 (6.0-56.0) min, P=0.007]. There was statistical difference between the two groups in resection time or sutured time, but no significant difference (STER vs. ESE) in total operative time [52.0 (14.0-167.0) min vs. 31.5 (10.0-88.0) min, P=0.080]. En bloc resection rates (92.9% vs. 85.7%), hospital stay duration and complications (10.7 vs. 0.0) were similar in the STER and ESE groups. One case developed mediastinal emphysema and 2 pneumonia after operation in STER group, and all of them recovered uneventfully after conservative treatments; There were no complications in the ESE group. After operation, 28 cases of leiomyoma and 14 cases of stromal tumor were diagnosed by routine pathological and immunohistochemical staining. Among them, 6 cases of stromal tumors in group STER were all extremely low risk, 4 cases of stromal tumors in group ESE were extremely low risk, 4 cases of stromal tumors in group ESE were medium risk (the size of the lesion was about 1.0-2.0 cm, and mitotic figures counted (6-8)/50 high power field). The median follow-up time of all the patients was 46.5 (24-60) months, and the shortest follow-up time for medium risk stromal tumors was 32 months. No residual tumor, recurrence and implantation in the tunnel were observed. Conclusion: STER or ESE can be used as an effective and safe option for treatment of submucosal tumors originating from the muscularis propria of the upper digestive tract. Compared with STER, ESE had shorter resection time but longer wound closure time. There was no significant difference in total operation time.

Key words: Upper gastroenterology submucosal neoplasms, Endoscopes, Comparative study, Submucosal tunneling endoscopic resection, Endoscopic submucosal excavation

CLC Number: 

  • R735

Figure 1

Endoscopic submucosal excavation A, Endoscopic view of the submucosal tumor in the gastric fundus. B, Endoscopic ultrasound showed the tumor originating from the muscularis propria. C, Circumferential markings of the lesion. D, A fluid cushion created by a submucosal injection. E, The mucosal incision along the marking points. F, Complete dissection of tumor. G, Closure of tunnel entry with clips. H, tumor in vitro."

Figure 2

Submucosal tunneling endoscopic resection A, Endoscopic view of the submucosal tumor in the esophagus. B, Endoscopic ultrasound view of the same lesion, showing the tumor originating from the muscularis propria. C, An longitudinal mucosal incision 5 cm proximal to the submucosal tumor. D, Endoscopic dissection to create a submucosal tunnel to the lesion. E, The entire exposed tumor. F, Tunnel after en bloc resection of the tumor. G, Closure of tunnel entry with clips. H, The resected specimen."

Table 1

Baseline characteristics of patients in the STER and ESE groups"

Items STER (n=28) ESE (n=14) P value
Patients 27 14 -
Gender, n (%)
Male 11 (40.7) 6 (42.9) 1.000
Female 16 (59.3) 8 (57.1)
Age/years, x?±s 50.1 (9.7) 56.3 (14.3) 0.105
Tumor size/cm, median (range) 1.5 (1.0-6.0) 1.3 (0.5-2.0) 0.056
Pathological diagnosis, n (%)
Leiomyoma 22 (78.6) 6 (42.9) 0.021
GIST 6 (21.4) 8 (57.1)

Table 2

Comparison of treatment effectiveness between STER and ESE groups"

Items STER (n=28) ESE (n=14) P value
Resection time/min, median(range) 46.5 (11.0-163.0) 19.5 (6.0-56.0) 0.007
Suture time/min, median (range) 3.5 (1.0-11.0) 8.0 (2.0-33.0) 0.006
Total operation time/min, median (range) 52.0 (14.0-167.0) 31.5 (10.0-88.0) 0.080
En bloc resection, n (%) 26 (92.9) 12 (85.7) 0.457
Complete resection, n (%) 28 (100) 14 (100) -
Residual, n (%) 0 (0) 0 (0) -
Recurrence, n (%) 0 (0) 0 (0) -
Follow up-time/months, median (range) 49.5 (24-60) 43.5 (24-58) 0.126

Table 3

Comparison of treatment safety between STER and ESE groups"

Items STER (n=28) ESE (n=14) P value
Complications, n (%) 3 (10.7) 0 (0) 0.539
Gas-related 1 (3.6) 0 -
Infection 2 (7.1) 0 -
Bleeding 0 0 -
Others 0 0 -
Hospital stay duration/d, median (range) 7 (4-15) 7 (5-11) 0.420
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