Ligation-assisted endoscopic submucosal resection following unroofing technique for small esophageal subepithelial lesions originating from the muscularis propria

BACKGROUND The majority of esophageal subepithelial lesions originating from the muscularis propria(SEL-MPs)are benign in nature,although a subset may exhibit malignant characteristics.Conventional endoscopic resection techniques are time-consuming and lack efficacy for small SEL-MPs.AIM To evaluate the efficacy and safety of ligation-assisted endoscopic submucosal resection(ESMR-L)following unroofing technique for small esophageal SEL-MPs.METHODS From January 2021 to September 2023,17 patients diagnosed with esophageal SEL-MPs underwent ESMR-L following unroofing technique at the endoscopy center of Shenzhen People’s Hospital.Details of clinicopathological characteristics and clinical outcomes were collected and analyzed.RESULTS The mean age of the patients was 50.12±12.65 years.The mean size of the tumors was 7.47±2.83 mm and all cases achieved en bloc resection successfully.The average operation time was 12.2 minutes without any complications.Histopathology identified 2 Lesions(11.8%)as gastrointestinal stromal tumors at very low risk,12 Lesions(70.6%)as leiomyoma and 3 Lesions(17.6%)as smooth muscle proliferation.No recurrence was found during the mean follow-up duration of 14.18±9.62 months.CONCLUSION ESMR-L following roofing technique is an effective and safe technique for management of esophageal SEL-MPs smaller than 20 mm,but it cannot ensure en bloc resection and may require further treatment.

Submucosal tunneling endoscopic resection: An effective and safe therapy for upper gastrointestinal submucosal tumors originating from the muscularis propria layer

AIM To evaluate the effectiveness and safety of submucosal tunneling endoscopic resection(STER) and compare its outcomes in esophageal and cardial submucosal tumors(SMTs) of the muscularis propria(MP) layer.METHODS From May 2012 to November 2017, 173 consecutive patients with upper gastrointestinal(GI) SMTs of the MP layer underwent STER. Overall, 165 patients were included, and 8 were excluded. The baseline characteristics of the patients and SMTs were recorded. The en bloc resection rate, complete resection rate,residual rate, and recurrence rate were calculated to evaluate the effectiveness of STER, and the complication rate was recorded to evaluate its safety. Effectiveness and safety outcomes were compared between esophageal and cardial SMTs.RESULTS One hundred and twelve men and 53 women with a mean age of 46.9 ± 10.8 years were included. The mean tumor size was 22.6 ± 13.6 mm. Eleven SMTs were located in the upper esophagus(6.7%), 49 in the middle esophagus(29.7%), 46 in the lower esophagus(27.9%), and 59 in the cardia(35.7%). Irregular lesions accounted for 48.5% of all lesions. STER achieved an en bloc resection rate of78.7%(128/165) for GI SMTs with an overall complication rate of 21.2%(35/165).All complications resolved without intervention or were treated conservatively without the need for surgery. The en bloc resection rates of esophageal and cardial SMTs were 81.1%(86/106) and 72.1%(42/59), respectively(P = 0.142), and the complication rates were 19.8%(21/106) and 23.7%(14/59), respectively,(P =0.555). The most common complications for esophageal SMTs were gas-related complications and fever, while mucosal injury was the most common for cardial SMTs.CONCLUSION STER is an effective and safe therapy for GI SMTs of the MP layer. Its effectiveness and safety are comparable between SMTs of the esophagus and cardia.

Endoscopic therapy for gastric stromal tumors originating from the muscularis propria

AIM:To explore endoscopic therapy methods for gastric stromal tumors originating from the muscularis propria.METHODS:For 69 cases diagnosed as gastric stromal tumors originating from the muscularis propria,three types of endoscopic therapy were selected,based on the size of the tumor.These methods included endoscopic ligation and resection(ELR),endoscopic submucosal excavation(ESE) and endoscopic full-thickness resection(EFR).The wound surface and the perforation of the gastric wall were closed with metal clips.Immunohistostaining for CD34,CD117,Dog-1,S-100 and smooth muscle actin(SMA) was performed on the resected tumors.RESULTS:A total of 38 cases in which the tumor size was less than 1.2 cm were treated with ELR;three cases were complicated by perforation,and the perforations were closed with metal clips.Additionally,18 cases in which the tumor size was more than 1.5 cm were treated with ESE,and no perforation occurred.Finally,13 cases in which the tumor size was more than 2.0 cm were treated with EFR;all of the cases were complicated by artificial perforation,and all of the perforations were closed with metal clips.All of the 69 cases recovered with medical treatment,and none required surgical operation.Immunohistostaining demonstrated that among all of the 69 gastric stromal tumors diagnosed by gastroscopy,12 cases were gastric leiomyomas(SMA-positive),and the other 57 cases were gastric stromal tumors.CONCLUSION:Gastric stromal tumors originating from the muscularis propria can be treated successfully with endoscopic techniques,which could replace certain surgical operations and should be considered for further application.

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 full thickness resection for gastric tumors originating from muscularis propria

AIM: To do systematic review of current literature for endoscopic full thickness resection(EFTR) technique for gastric tumors originating from muscularis propria.METHODS: An extensive English literature search was done till December 2015; using Pub Med and Google scholar to identify the peer reviewed original and review articles using keywords-EFTR, gastric tumor, muscularis propria. Human only studies were included. The references of pertinent studies were manually searched to identify additional relevant studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations were considered. For the purpose of review, data from individual studies was combined to calculate mean. No other statistical test was applied.RESULTS: A total of 9 original articles were identified. Four articles were from same institute and the time frames of these studies were overlapping. To avoid duplication of data, only the study with patients over the longest time interval was included and other three were excluded. In total six studies were included in the final review. In our systematic review, the mean success rate for EFTR of gastric tumors originating from muscularis propria was 96.8%. The mean procedure time varied from a minimum of 37 min to a maximum of 105 min. There was no reported mortality from the technique itself. The most common histological diagnosis was gastrointestinal stromal tumors and leiomyoma. Gastric wall defect closure by either metallic clips or over the scope clip(OTSC) had similar outcomes although experience with OTSC was limited to smaller lesions(<3cm).CONCLUSION: EFTR is a minimally invasive technique to resect gastric submucosal tumors originating from muscularis propria with a high success rate and low complication rate.

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.

Muscularis mucosae in desmoplastic stroma formation of early invasive rectal adenocarcinoma

The origin of myofibroblasts or myofibroblastic cells in the desmoplastic stroma associated with carcinoma invasion has been controversial. In the early invasive area of a rectal adenocarcinoma reported here, an obvious transition between the muscularis mucosa and the bundles of eosinophilic stromal cells observed in the carcinomatous stroma was demonstrated both in morphology and in their cytoskeletal phenotype, which conceivably suggests that the smooth muscle cells of the muscularis mucosa could convert to the eosinophilic stromal cells, namely myofibroblasts. Moreover, type I procollagen was demonstrated in both protein and mRNA levels in the areas of eosinophilic stromal cells with a lesser degree of differentiated smooth muscle phenotype that showed a transition from the muscularis mucosa, implying that the myofibroblastic cells converted from smooth muscle cells of the muscularis mucosa could be responsible for type I collagen production. These findings suggest that the muscularis mucosae may not be a passive barrier through which colorectal carcinomas infiltrate into the submucosa, but may play an active role in the formation and remodeling of tumor stroma.

Endoscopic full-thickness resection for treating small tumors originating from the muscularis propria in the gastric fundus: An improvement in technique over 15 years

BACKGROUND The fundus of the stomach is regarded as a difficult area for endoscopic resection of small tumors originating from the muscularis propria(MP tumors).Three endoscopic resection techniques have been developed to treat these tumors,including ligation-assisted endoscopic full-thickness resection(L-EFTR),snareassisted EFTR(S-EFTR),and endoscopic submucosal dissection-assisted EFTR(EEFTR).To date,no studies have compared these techniques.AIM We aimed to evaluate and compare S-EFTR with L-EFTR and E-EFTR for treating small MP tumors in the gastric fundus.METHODS We retrospectively reviewed patients with primary small MP tumors in the gastric fundus and treated by these three techniques between January 2016 and December 2018 at Shengjing Hospital,China.Standard demographic and clinicopathologic data,including sex,age,tumor size,surgeon details,and pathological results,were collected.Data regarding operation duration,cost,enbloc resection,and severe complications were also extracted and compared.RESULTS A total of 36 patients(27 women)with a mean age of 55.8±10.20 years were included in this study.The mean tumor size was 9.0±3.98 mm.All the methods showed a 100%en-bloc resection rate and 0%severe complication rate.There was no statistically significant difference among the three groups in the operation duration(P=0.148).The cost comparison for the whole procedure was as follows:E-EFTR>L-EFTR>S-EFTR(5837.5±7212.96 CNY,5970.7±3465.27 CNY,5852.0±6438.25 CNY,respectively,P<0.001).CONCLUSION S-EFTR,L-EFT,and E-EFTR are all effective for resection of small MP tumors in the gastric fundus.S-EFTR is superior in terms of cost-effectiveness.

Abnormal layering of muscularis propria as a cause of chronic intestinal pseudo-obstruction:A case report and literature review

Visceral myopathy is one of the causes of chronic intestinal pseudo-obstruction. Most cases pathologically reveal degenerative changes of myocytes or muscularis propia atrophy and fibrosis. Abnormal layering of muscularis propria is extremely rare. We report a case of a 9-mo-old Thai male baby who presented with chronic intestinal pseudo-obstruction. Histologic findings showed abnormal layering of small intestinal muscularis propria with an additional oblique layer and aberrant muscularization in serosa. The patient also had a short small bowel without malrotation, brachydactyly,and absence of the 2nd to 4th middle phalanges of both hands. The patient was treated with cisapride and combined parenteral and enteral nutritional support.He had gradual clinical improvement and gained body weight. Subsequently, the parenteral nutrition was discontinued. The previously reported cases are reviewed and discussed.

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.

Clinical Control Study of Endoscopic Full-thickness Resection and Laparoscopic Surgery in the Treatment of Gastric Tumors Arising from the Muscularis Propria

Background： Gastric stromal tumors arising from the muscularis propria are located in deeper layers. Endoscopic resection may be contraindicated due to the possibility of perforation. These tumors are therefore usually removed by surgical or laparoscopic procedures. This study evaluated the curative effects, safety and feasibility of endoscopic full-thickness resection （EFR） of gastric stromal tumors originating from the muscularis propria. Methods： This study enrolled 92 patients with gastric stromal tumors 〉2.5 cm originating from the muscularis propria. Fifty patients underwent EFR, and 42 underwent laparoscopic intragastric surgery. Operation time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rates were compared in these two groups. Results： EFR resulted in complete resection of all 50 gastric stromal tumors, with a mean procedure time of 85± 20 min, a mean hospitalization time of 7.0± 1.5 days and no complications. Laparoscopic intragastric surgery also resulted in a 100% complete resection rate, with a mean operation time of 88 ± 12 min and a mean hospitalization period of 7.5 ± 1.6 days. The two groups did not differ significantly in operation time, complete resection rates, hospital stay or incidence of complications （P 〉 0.05）. No patient in either group experienced tumor recurrence. Conclusions： EFR technique is effective and safe for the resection of gastric stromal tumors arising from the muscularis propria.

Endoscopic full-thickness resection of gastric stromal tumor arising from the muscularis propria

Background Gastric stromal tumors are the most common type of tumor originating from mesenchymal tissue. The traditional method for the treatment of gastric stromal tumor is surgical operation or therapeutic laparoscopy. More recently, endoscopic micro-traumatic surgery has become possible for gastric stromal tumors, with any perforation caused by endoscopic therapy mended endoscopically. We assessed the effectiveness of endoscopic full-thickness resection （EFR） in the treatment of gastric stromal tumors arising from the muscularis propria. Methods Of the 42 gastric stromal tumors, each 〉2.0 cm in diameter, arising from the muscularis propria, 22 were removed by EFR and 20 by laparoscopic surgery. Tumor expression of CD34, CDl17, Dog-l, S-100, and smooth muscle actin （SMA） was assessed immunohistochemically. Operating time, complete resection rate, length of hospital stay, incidence of complications, and recurrence rates were compared between the two groups. Continuous data were compared by using independent samples t-tests and categorical data by using Xz tests. Results Comparisons of the 22 gastric stromal tumors treated with EFR and the 20 treated with laparoscopic surgery showed similar operation times （60-155 minutes （mean, （90±17） minutes） vs. 50-210 minutes （mean, （95±21） minutes）, P 〉0.05）, complete resection rates （100% vs. 95%, P 〉0.05）, and length of hospital stay （4-10 days （mean, （6.0±1.8） days） vs. 4-12 days （mean, （7.3±1.7） days）, P 〉0.05）. None of the patients treated with EFR experienced complications, whereas one patient treated with laparoscopy required a conversion to laparotomy and one experienced postoperative gastroparesis. No recurrences were observed in either group. stromal tumors diagnosed by gastroscopy and endoscopic remaining 36 were stromal tumors. mmunohistochemical staining showed that of the 42 gastric ultrasound, six were leiomyomas （SMA-positive） and the Conclusions Gastric stromal tumors arising from the muscularis propria can be completely removed by EFR. EFR may replace surcjical or laparoscopic procedures for the removal of gastric stromal tumors.

Hyperechoic demarcation line between a tumor and the muscularis propria layer as a marker for deciding the endoscopic treatment of gastric submucosal tumor

Minimally invasive endoscopic resection has been rapidly adopted as a new technique for treating patientswith gastric submucosal tumors （SMTs） originating in the muscularis propria （MP） layer. This study was conducted toevaluate the information obtained from endoscopic ultrasonography （EUS） to determine the appropriate endoscopicdissection method for treating SMTs originating in the MP layer. Between February 2014 and May 2016, a total of 50patients with gastric SMTs originating in the MP layer were enrolled in this study. The clinical features of the patientsand their endoscopic, EUS, and histopathologic findings, as well as their postoperative follow-up data, were analyzedin this retrospective study. The mean age of the patients was （55.0±10.2） years, and the male/female ratio was 17：33.Endoscopic submucosal dissection （ESD） was performed on 43 patients and an endoscopic full-thickness resection（EFR） was performed on seven patients. The most frequent location for an SMT was in the upper body region of thestomach （n=16）, and the most common pathological diagnosis was a gastrointestinal stromal tumor （GIST） （n=32）.The overall rates for complete resection were 95.3% （41/43） and 100.0% （7/7） when the SMTs were treated by ESDand EFR, respectively. The presence of a complete tumor capsule was significantly associated with a complete re-section （P=0.001）. Of the cases treated by ESD, nine patients developed perforation, one of whom required laparo-scopic surgery. The remaining patients were closed with clips or purse-string sutures. The presence of an MP2-typetumor （P=0.018） and a wide connection with the MP layer （P=0.044） were significantly associated with perforation. Apreoperative evaluation of the integrity and the location of a tumor capsule and the length of the tumor connection withthe MP layer by EUS can improve the complete resection rate and reduce the occurrence of intraoperative complica-tions. Tumors with a complete capsule originating from the superficial MP layer or with a narrow connection with theMP layer are appropriate candidates for treatment by ESD.

New classifications of intraoperative bleeding and muscularis propria injury in endoscopic resection

With the development of endoscopic techniques and equipment,endoscopic surgery has been widely performed to treat many diseases,such as early gastrointestinal cancer,submucosal tumors,and achalasia.Endoscopic surgery can be classified as digestive endoscopic tunnel technique (DETT) and non-tunnel technique.The non-tunnel technique includes endoscopic mucosal resection,endoscopic piecemeal mucosal resection,endoscopic submucosal dissection (ESD),multi-band mucosectomy,endoscopic submucosal excavation,and endoscopic full-thickness resection.[1] Endoscopic submucosal tunnel dissection (ESTD),peroral endoscopic myotomy (POEM),and submucosal tunneling endoscopic resection (STER) are considered types of DETT.Endoscopic resection is safer and more minimally invasive than open surgery and video-assisted surge ry.[2,3] The complication rate of resection is regarded as the main standard to evaluate the safety of endoscopic surgery,while bleeding and “perforation” are reported to be the most common intraoperative complications.[4,5]

Screening for Differentially Expressed Genes of Gastric Stromal Tumor Originating from Muscularis Propria

INTRODUCTION Gastric stromal tumor （GST） is a set of gastrointestinal mesenchymal tumors those originate from interstitial cells of Cajal. Its early diagnosis and treatment are critical to prognosis. The occurrence of GST remains obscure; this study used Affymetrix expression spectrum chip to detect the gene expression spectrum of GST and explore new molecular target that is used in the treatment and prognosis of GST.

Endoscopic full-thickness resection and laparoscopic surgery for treatment of gastric stromal tumors

AIM: To assess the effectiveness of endoscopic full-thickness resection (EFR) and laparoscopic surgery in the treatment of gastric stromal tumors arising from the muscularis propria.

Identification of the layered morphology of the esophageal wall by optical coherence tomography

AIM： To assess each layer of the optical coherence tomography （OCT） image of the esophageal wall with reference to the histological structure, METHODS： Resected specimens of fresh pig esophagus was used as a model for the esophageal wall. We injected cyanoacrylate adhesive into the specimens to create a marker, and scanned them using a miniature OCT probe. The localization of these markers was assessed in the OCT images. Then we compared the OCT-imaged morphology with the corresponding histological section, guided by the cyanoacrylate adhesive markers. We prepared a second set of experiments using nylon sutures as markers. RESULTS： The OCT image of the esophageal specimen has a clear five-layered morphology. First, it consisted of a relatively less reflective layer; second, a more reflective layer; third, a less reflective layer; fourth, a more reflective layer; and fifth, a less reflective layer. Comparing the OCT images with marked histological sections showed that the first layer corresponded to stratified squamous epithelium; the second to lamina propria; the third to muscularis mucosa; fourth, submucosa; and fifth, muscularis propria with deeper structures of the esophageal wa CONCLUSION： We demonstrated that the OCT image of the normal esophageal wall showed a five- layered morphology, which corresponds to histological esophageal wall components.

Value of histomorphometric tumour thickness and smoothelin for conventional m-classification in early oesophageal adenocarcinoma

AIM To test the validity of tumour thickness measurement in distinguishing between the different infiltration depths, especially when the duplication of muscularis mucosae cannot be demarcated clearly. METHODS We re-evaluated 100 completely embedded Barrett's adenocarcinomas regarding m-classification, maximum tumour thickness, and muscularis mucosae duplication. For validation, smoothelin staining was performed on a subset of cases. RESULTS The m1-, m2-and m3-classified adenocarcinomasshowed a significant lower tumour thickness compared to the m4-and sm1-classified lesions(P < 0.001). Smoothelin staining determined a clear muscularis mucosae duplication in 64% of the tested samples and enabled the differentiation of the two layers in diffuse and merged splits. CONCLUSION Tumour thickness in early oesophageal adenocarcinoma significantly correlates with the depth of infiltration and demonstrates its worth as an accurate p T classification in non-polypoid lesions. We created a new algorithm, which combines histomorphology with morphometric analyses. It is noteworthy that it facilitates the assessment of mucosal vs submucosal infiltration depth. The smoothelin staining strengthened our results of the tumour thickness evaluation and can be used in cases of doubt.