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.

Classification of submucosal tumors in the gastrointestinal tract

This review is part two of three, which will present an update on the classification of gastrointestinal submucosal tumors. Part one treats of the diagnosis and part three of the therapeutic methods regarding gastrointestinal submucosal tumors. In the past there has been some confusion as to the classification of gastrointestinal submucosal tumors. Changes in classifications have emerged due to recent advances in mainly immunohistochemistry and electron microscopy. The aim of this paper is to update the reader on the current classification. Literature searches were performed to find information related to classification of gastrointestinal submucosal tumors. Based on these searches the twelve most frequent submucosal tumor types were chosen for description of their classification. The factors that indicate whether tumors are benign or malignant are mainly size and number of mitotic counts. Gastrointestinal stromal tumors are defined mainly by their CD117 positivity. In the future, there should be no more confusion between gastrointestinal stromal tumors and other types of submucosal tumors.

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.

Endoscopic ultrasound-guided cutting of holes and deep biopsy for diagnosis of gastric infiltrative tumors and gastrointestinal submucosal tumors using a novel vertical diathermic loop

AIM To report on a more accurate diagnostic possibility offered by endoscopic ultrasound-guided cutting of holes and deep biopsy (EUS-CHDB) for pathologic diagnosis of gastric infiltrative tumors and gastrointestinal submucosal tumors. METHODS Ten consecutive patients who were suspected of having gastric invasive tumors or gastrointestinal submucosal tumors underwent EUS-CHDB with a novel vertical diathermic loop. We reviewed their medical data and analysed the effectiveness and safety of this new method. The final diagnosis was based on the surgical pathology or clinical/imaging follow-up. RESULTS EUS-CHDB was performed successfully in all the ten patients. Neither severe haemorrhage nor perforation occurred in any patient. Among the ten patients, there were three cases of gastric linitis plastica, one case of gastric lymphoma, five cases of gastrointestinal stromal tumors (GISTs), and only one case of chronic non-atrophic gastritis. That is, nine (90%) of the cases CONCLUSION EUS-CHDB may be a technically feasible and safe option for patients with gastric infiltrative tumors or gastrointestinal submucosal tumors. EUS-CHDB may be used as a remedial or even preferred biopsy method for submucosal lesions.

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.

Therapeutic procedures for submucosal tumors in the gastrointestinal tract

This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor (GIST). Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.

Diagnostic procedures for submucosal tumors in the gastrointestinal tract

This review is part one of three, which will present an update on diagnostic procedures for gastrointestinal (GI) submucosal tumors (SMTs). Part two identifies the classification and part three the therapeutic methods regarding GI SMTs. Submucosal tumors are typically asymptomatic and therefore encountered incidentally. Advances in diagnostic tools for gastrointestinal submucosal tumors have emerged over the past decade. The aim of this paper is to provide the readers with guidelines for the use of diagnostic procedures, when a submucosal tumor is suspected. Literature searches were performed to find information on diagnostics for gastrointestinal submucosal tumors. Based on the searches, the optimal diagnostic procedures and specific features of the submucosal tumors could be outlined. Standard endoscppy, capsule endoscopy and push-and-pull enteroscopy (PPE) together with barium contrast X-ray do not alone provide sufficient information, when examining submucosal tumors. Endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI) and fluorodeoxyglucose-labeled positron emission tomography (FDG-PET) are recommended as supplementary tools.

Endoscopic full-thickness resection for gastric submucosal tumors arising from the muscularis propria layer

AIM: To evaluate the efficacy, safety and feasibility of endoscopic full-thickness resection (EFR) for the treatment of gastric submucosal tumors (SMTs) arising from the muscularis propria.

Endoscopic submucosal dissection for small submucosal tumors of the rectum compared with endoscopic submucosal resection with a ligation device

AIMTo evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) for small rectal submucosal tumors (SMTs). METHODSBetween August 2008 and March 2016, 39 patients were treated with endoscopic submucosal resection with a ligation device (ESMR-L) (n = 21) or ESD (n = 18) for small rectal SMTs in this study. Twenty-five lesions were confirmed by histological evaluation of endoscopic biopsy prior to the procedure, and 14 lesions were not evaluated by endoscopic biopsy. The results for the ESMR-L group and the ESD group were retrospectively compared, including baseline characteristics and therapeutic outcomes. RESULTSThe rate of en bloc resection was 100% in both groups. Although the rate of complete endoscopic resection was higher in the ESD group than in the ESMR-L group (100% vs 95.2%), there were no significant differences between the two groups (P = 0.462). In one patient in the ESMR-L group with a previously biopsied tumor, histological complete resection with a vertical margin involvement of carcinoid tumor could not be achieved, whereas there was no incomplete resection in the ESD group. The mean length of the procedure was significantly greater in the ESD group than in the ESMR-L group (14.7 ± 6.4 min vs 5.4 ± 1.7 min, P vs 2.8 ± 1.5 d, P CONCLUSIONBoth ESMR-L and ESD were effective for treatment of small rectal SMTs. ESMR-L was simpler to perform than ESD and took less time.

Clinical implications of doubling time of gastrointestinal submucosal tumors

AIM To evaluate the efficacy of doubling time(DT) of gastrointestinal submucosal tumors(GIST).METHODS From April 1987 through November 2012, a total of 323 patients were given a final histopathological diagnosis of GISTs on surgical resection or endoscopic ultrasound-guided fine-needle aspiration(EUS-FNA) in Kitasato University East Hospital or Kitasato University Hospital. We studied 53 of these patients(34 with resected tumors and 19 with unresected tumors) whose tumors could be measured on EUS on at least two successive occasions. The histopathological diagnosis was GIST in 34 patients, leiomyoma in 5, schwannoma in 3, ectopic pancreas in 1, hamartoma in 1, cyst in 1, Brunner's adenoma in 1, and spindle-cell tumor in 7. We retrospectively calculated the DT of GISTs on the basis of the time course of EUS findings to estimate the growth rate of such tumors.RESULTS The DT was 17.2 mo for GIST, as compared with 231.2 mo for leiomyoma, 104.7 mo for schwannoma, 274.9mo for ectopic pancreas, 61.2 mo for hamartoma, 49.0 mo for cyst, and 134.7 mo for Brunner's adenoma. The GISTs were divided into risk classes on the basis of tumor diameters and mitotic figures(Fletcher's classification). The classification was extremely low risk or low risk in 28 patients, intermediate risk in 3, and high risk in 3. DT of GIST according to risk was 24.0 mo for extremely low-risk plus low-risk GIST, 17.1 mo for intermediate-risk GIST, and 3.9 mo for high-risk GIST. DT of GIST was significantly shorter than that of leiomyoma plus schwannoma(P < 0.05), and DT of high-risk GIST was significantly shorter than that of extremely low-risk plus low-risk GIST(P < 0.05).CONCLUSION For GIST, a higher risk grade was associated with a significantly shorter DT. Small SMTs should initially be followed up within 6 mo after detection.

Endoscopic submucosal tunnel dissection of upper gastrointestinal submucosal tumors: A comparative study of hook knife vs hybrid knife

AIM to compare the efficacy and safety of a hook knife(HO) with a hybrid knife(HK) during endoscopic submucosal tunnel dissection(EStD) procedure.METHODS Between August 2012 and December 2015, the ESt D procedure was performed for 83 upper GI submucosal lesions, which originated from the muscularis propria layer identified by upper endoscopy and endoscopic ultrasonography. Of these, 34 lesions were treated by a HO, whereas 49 lesions were treated by a HK. Data regarding age, gender, presenting symptoms, tumor location and size, procedure time, complications, en bloc resection rate and others were analyzed and compared between the two groups.RESULTS there were no significant differences in the age, gender, presenting symptoms and tumor location between the two groups. EStD was successfully completed in all the patients, and no case was converted to laparoscopy. the mean procedure time was significantly shorter in the HK group than in the HO group(41.3 ± 20.3 min vs 57.2 ± 28.0 min, p = 0.004). the mean frequency of device exchange was 1.4 ± 0.6 in the HK group and significantly less than 3.3 ± 0.6 in the HO group(p < 0.001). the differences in tumor size and histopathological diagnoses were not significant between the two groups(p = 0.813, p = 0.363, respectively). Both groups had an equal en bloc resection rate and complete resection rate. Additionally, the complication rate was similar between the two groups(p = 0.901). During the follow-up, no recurrence occurred in either group.CONCLUSION We demonstrate for the first time that HO and HK do not differ in efficacy or safety, but HK reduces the frequency of device exchange and procedure time.

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.

Misdiagnosis of hemangioma of left triangular ligament of the liver as gastric submucosal stromal tumor:Two case reports

BACKGROUND Extragastric lesions are typically not misdiagnosed as gastric submucosal tumor(SMT).However,we encountered two rare cases where extrinsic lesions were misdiagnosed as gastric SMTs.CASE SUMMARY We describe two cases of gastric SMT-like protrusions initially misdiagnosed as gastric SMTs by the abdominal contrast-enhanced computed tomography(CT)and endoscopic ultrasound(EUS).Based on the CT and EUS findings,the patients underwent gastroscopy;however,no tumor was identified after incising the gastric wall.Subsequent surgical exploration revealed no gastric lesions in both patients,but a mass was found in the left triangular ligament of the liver.The patients underwent laparoscopic tumor resection,and the postoperative diagnosis was hepatic hemangiomas.CONCLUSION During EUS procedures,scanning across different layers and at varying degrees of gastric cavity distension,coupled with meticulous image analysis,has the potential to mitigate the likelihood of such misdiagnoses.

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.

Minimally invasive surgery for submucosal(subepithelial) tumors of the stomach

Minimally invasive surgery has become common in the surgical resection of gastrointestinal submucosal tumors(SMTs). The purpose of this article is to review recent trends in minimally invasive surgery for gastric SMTs. Although laparoscopic resection has been main stream of minimally invasive surgery for gastrointestinal SMTs, recent advances in endoscopic procedures now provide various treatment modalities for gastric SMTs. Moreover, investigators have developed several hybrid techniques that include the advantages of both laparoscopic and endoscopic procedure. In addition, several types of reduced port surgeries, modification of conventional laparoscopic procedures, have been recently applied to the surgical resection of SMTs. Meanwhile, robotic surgery for SMTs requires further evidence and improvement.

Comparison between air and carbon dioxide insufflation in the endoscopic submucosal excavation of gastrointestinal stromal tumors

AIM:To evaluate the safety and efficacy of CO2 insufflation compared with air insufflation in the endoscopic submucosal excavation(ESE) of gastrointestinal stromal tumors.METHODS:Sixty patients were randomized to undergo endoscopic submucosal excavation,with the CO2 group(n = 30) and the air group(n = 30) undergoingCO2 insufflation and air insufflation in the ESE,respectively.The end-tidal CO2 level(pETCO2) was observed at 4 time points:at the beginning of ESE,at total removal of the tumors,at completed wound management,and 10 min after ESE.Additionally,the patients' experience of pain at 1,3,6 and 24 h after the examination was registered using a visual analog scale(VAS).RESULTS:Both the CO2 group and air group were similar in mean age,sex,body mass index(all P > 0.05).There were no significant differences in PetCO2 values before and after the procedure(P > 0.05).However,the pain scores after the ESE at different time points in the CO2 group decreased significantly compared with the air group(1 h:21.2 ± 3.4 vs 61.5 ± 1.7;3 h:8.5 ± 0.7 vs 42.9 ± 1.3;6 h:4.4 ± 1.6 vs 27.6 ± 1.2;24 h:2.3 ± 0.4 vs 21.4 ± 0.7,P < 0.05).Meanwhile,the percentage of VAS scores of 0 in the CO2 group after 1,3,6 and 24 h was significantly higher than that in the air group(60.7 ± 1.4 vs 18.9 ± 1.5,81.5 ± 2.3 vs 20.6 ± 1.2,89.2 ± 0.7 vs 36.8 ± 0.9,91.3 ± 0.8 vs 63.8 ± 1.3,respectively,P < 0.05).Moreover,the condition of the CO2 group was better than that of the air group with respect to anal exsufflation.CONCLUSION:Insufflation of CO2 in the ESE of gastrointestinal stromal tumors will not cause CO2 retention and it may significantly reduce the level of pain,thus it is safe and effective.

Endoscopic submucosal dissection for large laterally spreading tumors involving the ileocecal valve and terminal ileum

Endoscopic submucosal dissection is a challenging technique that enables en-bloc resection for large colorectal tumors, as laterally spreading tumors, particularly difficult, if the ileocecal valve and terminal ileum is involved. Herein, we report on one of 4 cases. The procedures, using a bipolar needle knife (B-Knife) to reduce the perforation risk and carbon dioxide instead of conventional air insufflation for patient comfort, achieved curative resections without any complications.

Oval mucosal opening bloc biopsy after incision and widening by ring thread traction for submucosal tumor

Gastric submucosal tumors(SMTs) less than 2 cm are generally considered benign neoplasms, and endoscopic observation is recommended, but SMTs over 2 cm, 40% of which are gastrointestinal stromal tumors(GISTs), have malignant potential. Although the Japanese Guidelines for GIST recommend partial surgical resection for GIST over 2 cm with malignant potential as well as en bloc large tissue sample to obtain appropriate and large specimens of SMTs, several reports have been published on tissue sampling of SMTs, such as with endoscopic ultrasound sound fine needle aspiration, submucosal tunneling bloc biopsy, and the combination of bite biopsy and endoscopic mucosal resection. Because a simpler, more accurate method is needed for appropriate treatment, we developed oval mucosal opening bloc biopsy after incision and widening by ring thread traction for submucosal tumor(OMOB) approach. OMOB was simple and enabled us to obtain large samples under direct procedure view as well as allowed us to restore to original mucosa.

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.

Unusual gastric tumors and tumor-like lesions: Radiological with pathological correlation and literature review

Although gastric tumors have overlapping radiologic appearances, some unusual tumors may present specific imaging features. Using multidetector computed tomography(MDCT), with water as a negative oral contrast agent and intravenous contrast medium, can provide critical information for the diagnosis of gastric diseases. In addition, MDCT can evaluate the involvement of the gastric wall and extragastric extent of the disease, as compared with gastroenteroscopy and double-contrast upper gastrointestinal study. Regarding lesion location and size, enhancing and growth patterns, presence of calcification or fat, and involvement of the gastric wall and adjacent structures, CT may provide useful information. In this review article, we review the relevant literature and discuss the CT features and the histopathologic findings of different types of gastric lesions. The lesions are divided into benign(glomus tumors, schwannomas, leiomyomas, and lipomas), malignant(gastrointestinal stromal tumors, mucinous carcinomas, lymphomas, and carcinoid tumors), and tumor-like lesions(ectopic pancreas and bezoar). Familiarity with imaging appearances and pathologic findings can help physicians make an accurate diagnosis.