Double-nylon purse-string suture in closing postoperative wounds following endoscopic resection of large(≥3 cm)gastric submucosal tumors

BACKGROUND Endoscopic full-thickness resection(EFTR)of gastric submucosal tumors(SMTs)is safe and effective;however,postoperative wound management is equally important.Literature on suturing following EFTR for large(≥3 cm)SMTs is scarce and limited.AIM To evaluate the efficacy and clinical value of double-nylon purse-string suture in closing postoperative wounds following EFTR of large(≥3 cm)SMTs.METHODS We retrospectively analyzed the data of 85 patients with gastric SMTs in the fundus of the stomach or in the lesser curvature of the gastric body whose wounds were treated with double-nylon purse-string sutures after successful tumor resection at the Endoscopy Center of Renmin Hospital of Wuhan University.The operative,postoperative,and follow-up conditions of the patients were evaluated.RESULTS All tumors were completely resected using EFTR.36(42.35%)patients had tumors located in the fundus of the stomach,and 49(57.65%)had tumors located in the body of the stomach.All patients underwent suturing with double-nylon sutures after EFTR without laparoscopic assistance or further surgical treatment.Postoperative fever and stomach pain were reported in 13(15.29%)and 14(16.47%)patients,respectively.No serious adverse events occurred during the intraoperative or postoperative periods.A postoperative review of all patients revealed no residual or recurrent lesions.CONCLUSION Double-nylon purse-string sutures can be used to successfully close wounds that cannot be completely closed with a single nylon suture,especially for large(≥3 cm)EFTR wounds in SMTs.

Endosonographic surveillance of 1-3 cm gastric submucosal tumors originating from muscularis propria

AIM To observe the natural course of 1-3 cm gastric submucosal tumors originating from the muscularis propria(SMTMPs).METHODS By reviewing the computerized medical records over a period of 14 years(2000-2013), patients with 1-3 cm gastric SMTMPs who underwent at least two endoscopic ultrasound(EUS) examinations were enrolled. Tumor progression was defined as a ≥ 1.2 times enlargement in tumor diameter observed during EUS surveillance. All patients were divided into stationary and progressive subgroups and further analyzed. We also reviewed the patients in the progressive subgroup again in 2016.RESULTS A total of 88 patients were studied, including 25 in the progressive subgroup. The mean time of EUS surveillance was 24.6 mo in the stationary subgroup and 30.7 mo in the progressive subgroup. Risk factors for tumor progression included larger tumor size and irregular border. Initial tumor size > 14.0 mm may be considered a cut-off size for predicting tumor progression. Seventeen patients underwent surgery, of whom 13 had gastrointestinal stromal tumors(GISTs) and 4 had leiomyomas. Tumor progression was found only in patients with GISTs. All of the tumors exhibited benign behaviors without metastasis until 2016.CONCLUSION Most 1-3 cm gastric SMTMPs(71.6%) are indolent. Tumor progression was found only in GISTs, and it is a good predictor for differentiating GISTs from leiomyomas. Predictors of tumor progression include larger tumor size(> 14.0 mm) and irregular border.

Gastric pyloric gland adenoma resembling a submucosal tumor:A case report

BACKGROUND Pyloric gland adenoma(PGA)is a recently described and rare tumor.Submucosal tumor(SMT)-like PGA is more difficult to diagnose and differentiate from other submucosal lesions.CASE SUMMARY We present the case of a 69-year-old man with a 10 mm SMT-like elevated lesion with an opening in the upper part of the gastric body,referred to our hospital for further endoscopic treatment.Magnifying endoscopy with narrow-band imaging,endoscopic ultrasonography,and complete endoscopic submucosal dissection were performed on the patient.Histopathological findings revealed tightly packed tubular glands lined with cuboidal or columnar cells that had round-tooval nuclei containing occasional prominent nucleoli and an eosinophilic cytoplasm similar to that in non-neoplastic gastric pyloric glands.Additionally,immunohistochemical analysis showed positive staining for both mucin 5AC and mucin 6.Therefore,we arrived at the final diagnosis of gastric PGA.Although there was no apparent malignant component in this tumor,PGA has been considered a precancerous disease with a high risk of transformation into adenocarcinoma.CONCLUSION PGA should be considered when detecting gastric SMT-like lesions.Physicians and pathologists should focus on PGA due to its malignant potential.

Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction

BACKGROUND Endoscopic resection approaches,including endoscopic submucosal dissection(ESD),submucosal tunneling endoscopic resection(STER)and endoscopic fullthickness resection(EFTR),have been widely used for the treatment of submucosal tumors(SMTs)located in the upper gastrointestinal tract.However,compared to SMTs located in the esophagus or stomach,endoscopic resection of SMTs from the esophagogastric junction(EGJ)is much more difficult because of the sharp angle and narrow lumen of the EGJ.SMTs originating from the muscularis propria(MP)in the EGJ,especially those that grow extraluminally and adhere closely to the serosa,make endoscopic resection even more difficult.AIM To investigate the predictors of difficult endoscopic resection for SMTs from the MP layer at the EGJ.METHODS A total of 90 patients with SMTs from the MP layer at the EGJ were included in the present study.The difficulty of endoscopic resection was defined as a long procedure time,failure of en bloc resection and intraoperative bleeding.Clinicopathological,endoscopic and follow-up data were collected and analyzed.Statistical analysis of independent risks for piecemeal resection,long operative time,and intraoperative bleeding were assessed using univariate and multivariate analyses.RESULTS According to the location and growth pattern of the tumor,44 patients underwent STER,14 patients underwent EFTR,and the remaining 32 patients received a standard ESD procedure.The tumor size was 20.0 mm(range 5.0–100.0 mm).Fourty-seven out of 90 lesions(52.2%)were regularly shaped.The overall en bloc resection rate was 84.4%.The operation time was 43 min(range 16–126 min).The intraoperative bleeding rate was 18.9%.There were no adverse events that required therapeutic intervention during or after the procedures.The surgical approach had no significant correlation with en bloc resection,long operative time or intraoperative bleeding.Large tumor size(≥30 mm)and irregular tumor shape were independent predictors for piecemeal resection(OR:7.346,P=0.032 and OR:18.004,P=0.029,respectively),long operative time(≥60 min)(OR:47.330,P=0.000 and OR:6.863,P=0.034,respectively)and intraoperative bleeding(OR:20.631,P=0.002 and OR:19.020,P=0.021,respectively).CONCLUSION Endoscopic resection is an effective treatment for SMTs in the MP layer at the EGJ.Tumors with large size and irregular shape were independent predictors for difficult endoscopic resection.

Early gastric cancer presenting as a typical submucosal tumor cured by endoscopic submucosal dissection:A case report

BACKGROUND Submucosal tumor(SMT)-like gastric cancer is rare,and almost all cases undergo curative surgical treatment because the submucosal layer is usually deeply invaded by tumor cells or because histopathologic types of SMT-like gastric cancer are undifferentiated or poorly differentiated.No report has been issued on an SMT-like gastric cancer cured by endoscopic resection alone or on changes in the endoscopic features of this type of tumor over several years.CASE SUMMARY We describe an exceptional case of a 53-year-old male with a 1.5 cm-sized SMTlike lesion covered by normal-appearing mucosa discovered by esophagogastroduodenoscopy(EGD)at the gastric antrum.Endoscopic ultrasound(EUS)visualized a homogeneous,well-circumscribed hypoechogenic lesion arising from the second sonographic layer with associated subtle obliteration of the third sonographic layer.Initial endoscopic biopsy was negative for neoplasm.The patient refused to undergo an invasive procedure and was subsequently lost to follow-up.Three years after initial detection,EGD revealed the lesion had become markedly erythematous,and at 4 years after initial EGD it had increased in size to 1.8 cm and developed a central ulcer and a heterogeneous EUS echo.Finally,endoscopic submucosal dissection(ESD)was performed,and histopathologic examination revealed a moderately differentiated adenocarcinoma had minutely invaded the submucosal layer(invasion depth 169μm)but without lymphovascular invasion and with negative resection margins.Fortunately,no additional surgical treatment was required.He has been followed for 4 years after ESD without any evidence of local or distant recurrence.CONCLUSION This report describes an extremely rare case of early gastric cancer presenting as SMT that was cured by ESD after a treatment delay of 4 years and the endoscopic changes that occurred during this period.The report highlights the importance of considering the possibility of gastric cancer when SMT is encountered in clinical practice.

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection(EFTR),with or without laparoscopic assistance,is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors(SMTs)arising from the muscularis propria(MP),especially of the gastric wall.To date,evidence concerning duodenal exposed EFTR is lacking,mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure.However,given the non-negligible morbidity and mortality associated with duodenal surgery,the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers.The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.

Effect of endoscopic full-thickness resection assisted by distal serosal turnover with floss traction for gastric submucosal masses

BACKGROUND Complex and high-risk surgical complications pose pressing challenges in the clinical implementation and advancement of endoscopic full-thickness resection(EFTR).Successful perforation repair under endoscopy,thereby avoiding surgical intervention and postoperative complications such as peritonitis,are pivotal for effective EFTR.AIM To investigate the effectiveness and safety of EFTR assisted by distal serosal inversion under floss traction in gastric submucosal tumors.METHODS A retrospective analysis of patients with gastric and duodenal submucosal tumors treated with EFTR assisted by the distal serosa inversion under dental floss traction from January 2023 to January 2024 was conducted.The total operation time,tumor dissection time,wound closure time,intraoperative bleeding volume,length of hospital stay and incidence of complications were analyzed.RESULTS There were 93 patients,aged 55.1±12.1 years.Complete tumor resection was achieved in all cases,resulting in a 100% success rate.The average total operation time was 67.4±27.0 min,with tumor dissection taking 43.6±20.4 min.Wound closure times varied,with gastric body closure time of 24.5±14.1 min and gastric fundus closure time of 16.6±8.7 min,showing a significant difference(P<0.05).Intraoperative blood loss was 2.3±4.0 mL,and average length of hospital stay was 5.7±1.9 d.There was no secondary perforation after suturing in all cases.The incidence of delayed bleeding was 2.2%,and the incidence of abdominal infection was 3.2%.No patient required other surgical intervention during and after the operation.CONCLUSION Distal serosal inversion under dental-floss-assisted EFTR significantly reduced wound closure time and intraoperative blood loss,making it a viable approach for gastric submucosal tumors.

Endoscopic fenestration in the diagnosis and treatment of delayed anastomotic submucosal abscess:A case report and review of literature

BACKGROUND Abscess formation is one of the complications after radical resection of rectal cancer;cases with delayed postoperative anastomotic abscess are rare.Here,we report a rare case of postoperative anastomotic abscess with a submucosal neoplasm appearing after rectal surgery.Ultimately,the patient was diagnosed and treated by endoscopic fenestration.In addition,we review the literature on the appearance of an abscess as a complication after rectal cancer surgery.CASE SUMMARY A 57-year-old man with a history of rectal malignancy resection complained of a smooth protuberance near the anastomotic stoma.Endoscopic ultrasonography revealed a hypoechoic structure originating from the muscularis propria,and a submucosal tumor was suspected.The patient was subsequently referred to our hospital and underwent pelvic contrast-enhanced computed tomography,which revealed no thickening or strengthening of the anastomotic wall.In order to clarify the origin of the lesion and obtain the pathology,endoscopic fenestration was performed.After endoscopic procedure,a definitive diagnosis of delayed anastomotic submucosal abscess was established.The patient achieved good recovery and prognosis after the complete clearance of abscess.CONCLUSION Endoscopic fenestration may be safe and effective for the diagnosis/treatment of delayed intestinal smooth protuberance after rectal cancer surgery.

Gastric submucosal lesion caused by an embedded fish bone:A case report

BACKGROUND Submucosal tumors(SMTs)refer to elevated lesions that originate from the layers below the mucosa of the digestive tract,including the muscularis,submucosa and muscularis propria.With the development and application of endoscopy and endoscopic ultrasonography(EUS),the detection rate of SMTs has increased significantly in recent years.Various diseases can lead to SMTs.However,a foreign body embedded in the gastric antrum showing clinical manifestations of a SMT is rare.CASE SUMMARY We report the case of a 47-year-old woman,who presented with upper abdominal discomfort for one year,and was subsequently diagnosed with a gastric submucosal lesion caused by an embedded foreign body by EUS and computed tomography.Considering the size and potential complications of this lesion,endoscopic full-thickness resection was performed to achieve full resection in our endoscopy center.A fish bone was found in the lesion during the operation,and was successfully removed,and the defect was later closed with endoscopic pursestring sutures.CONCLUSION This case report highlights the management strategies of SMTs,the importance of being familiar with diagnostic methods related to submucosal lesions,and being able to conduct effective treatment when this rare condition is highly suspected.

Combined thoracoscopic and endoscopic surgery for a large esophageal schwannoma

A 47-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy identified a submucosal tumor in the left wall of the esophagus that was diagnosed as a benign schwannoma on biopsy. Computed tomography revealed a tumor of length 60 mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. On endoscopy, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its oral end was dissected from the mucosal and muscular layers. This was followed by the resection of the entire tumor by left-sided thoracoscopy. The esophageal defect was closed in layer by continuous suture from the thoracic side. Endoscopic closure was achieved by using clips. No postoperative complications were observed. Oral diet was resumed from postoperative day 7 and the patient was discharged on postoperative day 9. This combined approach has not been described for similar tumors. Our experience demonstrated that large esophageal tumors can be safely excised with minimally invasive surgery by using a combination of thoracoscopy and endoscopy.

Dynamic enhanced computed tomography imaging findings of an inflammatory fibroid polyp with massive fibrosis in the stomach

Inflammatory fibroid polyp(IFP) is a rare benign lesion of the gastrointestinal tract. We report a case of computed tomography(CT) imaging finding of a gastric IFP with massive fibrosis. CT scans showed thickening of submucosal layer with overlying mucosal hyperenhancement in the gastric antrum. The submucosal layer showed increased enhancement on delayed phase imaging. An antrectomy with gastroduodenostomy was performed because gastric cancer was suspected, particularly signet ring cell carcinoma. The histopathological diagnosis was an IFP with massive fibrosis. The authors suggest that when the submucosal layer of the gastric wall is markedly thickened with delayed enhancement and preservation of the mucosal layer, an IFP with massive fibrosis should be considered in the differential diagnosis.

Endoscopic full-thickness resection using an over-the-scope device:A prospective study

BACKGROUND Endoscopic submucosal dissection to treat mucosal and submucosal lesions sometimes results in low rates of microscopically margin-negative(R0)resection.Endoscopic full-thickness resection(EFTR)has a high R0 resection rate and allows for the definitive diagnosis and treatment of selected mucosal and submucosal lesions that are not suitable for conventional resection techniques.AIM To evaluate the efficacy and safety of EFTR using an over-the-scope clip(OTSC).METHODS This prospective,single-center,non-randomized clinical trial was conducted at the endoscopy center of Shengjing Hospital of China Medical University.The study included patients aged 18-70 years who had gastric or colorectal submucosal tumors(SMTs)(≤20 mm in diameter)originating from the muscularis propria based on endoscopic ultrasound(EUS)and patients who had early-stage gastric or colorectal cancer(≤20 mm in diameter)based on EUS and computed tomography.All lesions were treated by EFTR combined with an OTSC for wound closure between November 2014 and October 2016.We analyzed patient demographics,lesion features,histopathological diagnoses,R0 resection(negative margins)status,adverse events,and follow-up results.RESULTS A total of 68 patients(17 men and 51 women)with an average age of 52.0±10.5 years(32-71 years)were enrolled in this study,which included 66 gastric or colorectal SMTs and 2 early-stage colorectal cancers.The mean tumor diameter was 12.6±4.3 mm.The EFTR procedure was successful in all cases.The mean EFTR procedure time was 39.6±38.0 min.The mean OTSC defect closure time was 5.0±3.8 min,and the success rate of closure for defects was 100%.Histologically complete resection(R0)was achieved in 67(98.5%)patients.Procedure-related adverse events were observed in 11(16.2%)patients.The average post-procedure length of follow-up was 48.2±15.7 mo.There was no recurrence during follow-up.CONCLUSION EFTR combined with an OTSC is an effective and safe technique for the removal of select subepithelial and epithelial lesions that are not amenable to conventional endoscopic resection techniques.

Primary gastric dedifferentiated liposarcoma resected endoscopically:A case report

BACKGROUND Liposarcoma is one of the most common adult mesenchymal tumors but is uncommon in the gastrointestinal tract and extremely rare in the stomach.Furthermore,the histological subtypes of liposarcoma usually reported in the stomach are well-differentiated or myxoid,and few reports have been issued on small-sized gastric liposarcomas resected endoscopically and followed up.Herein,we report a case of primary gastric dedifferentiated liposarcoma(DL)that was resected endoscopically.CASE SUMMARY A 67-year-old female Korean patient was referred to our institution for further evaluation of a gastric submucosal tumor(SMT)located in the lesser curvature of the gastric body by esophagogastroduodenoscopy.Endoscopic ultrasound revealed a well-circumscribed,slightly heterogeneous,isoechoic,17 mm×10 mm sized mass originating from the third sonographic layer.Computed tomography showed no evidence of significant lymph node enlargement or distant metastasis.Endoscopic resection was undertaken using the snare resection technique after mucosal precutting to provide a definitive histopathologic diagnosis,which proved to be consistent with DL,based on its morphology and the immunoexpressions of MDM2 and CDK4.The patient was planned for surgery because the deep resection margin was positive for malignancy.After declining any invasive procedure or adjuvant treatment,the patient was placed under close follow-up,and at one year after endoscopic resection,remained disease free.CONCLUSION This is the first reported case of a small primary gastric DL resected endoscopically and followed up.This report demonstrates that when diagnosis of a SMT is uncertain,the use of invasive techniques,including endoscopic resection,should be considered.

圈套器和止血夹肿瘤牵拉技术在胃黏膜下肿瘤内镜切除中的应用:倾向评分匹配分析

背景:包括内镜黏膜下剥离术(ESD)和内镜全层切除术(EFR)在内的内镜技术可用以切除较小的胃黏膜下肿瘤(SMT)。我们团队开发了一种圈套器和止血夹肿瘤牵拉方法,用以辅助SMT的内镜切除。本研究旨在评估这一技术的安全性和有效性。方法:本研究采用倾向评分匹配(PSM)分析,比较圈套器和止血夹辅助的ESD/EFR(圈套器牵拉组)与传统ESD/EFR(传统技术组)用于切除胃SMT的手术时间、整块切除率、围手术期并发症发生率及内镜治疗相关的费用。结果:2012年1月至2019年3月间收治的253例胃SMT患者纳入研究。PSM获得51对病例,两组围手术期并发症发生率和内镜耗材费用的差异均无统计学意义,但圈套器牵拉组中位手术时间缩短(39 vs 60 min,P=0.005),整块切除率提高(100%vs 88.2%,P=0.027)。结论:圈套器牵拉辅助的ESD/EFR用于胃SMT具有更高的手术效率和整块切除率,而且不会增加围手术期并发症发生风险和手术耗材费用。因此,该方法似乎是胃SMT内镜切除的良好选择。