Download PDF
Endoscopy 2013; 45(01): 4-11
DOI: 10.1055/s-0032-1325760
Original article
© Georg Thieme Verlag KG Stuttgart · New York

EndoResect study: endoscopic full-thickness resection of gastric subepithelial tumors

C. Schlag
1   II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
,
D. Wilhelm
2   Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
,
S. von Delius
1   II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
,
H. Feussner
2   Chirurgische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
,
A. Meining
1   II. Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
› Author Affiliations
Further Information

Publication History

submitted 18 April 2012

accepted after revision 04 August 2012

Publication Date:
19 December 2012 (online)

Also available at
    Permissions and Reprints

Background and study aims: Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation. New techniques such as use of the over-the-scope clip (OTSC) may enable secure endoscopic closure of perforations. We aimed to evaluate the feasibility of endoscopic resection of small gastric SETs using a grasp-and-snare technique followed by OTSC closure of the gastric wall if necessary.

Patients and methods: In this prospective study 20 consecutive patients who presented with gastric SETs ≤ 3 cm were enrolled. Endoscopic resection was performed using a double-channel endoscope, a tissue anchor and a monofilament snare. If perforation occurred, the aim was to achieve complete closure with a tissue twin grasper and the OTSC. Procedures were performed under laparoscopic control using a 5-mm optic, which was introduced via a single 5-mm trocar through the umbilicus. All patients were followed up for 3 months after the procedure.

Results: In 6 /20 patients a pure endoscopic approach was impossible and a switch to laparoscopic wedge resection was necessary (large tumor size in 2 /6 patients; mainly extraluminal growth in 4 /6 patients). Solely endoscopic resection was successfully performed in the remaining 14 patients. Amongst these, laparoscopic control was impossible in two cases. Perforation occurred in 6 /14 patients but gastric closure with the OTSC was performed successfully in all these cases. No complications occurred and follow-up was unremarkable.

Conclusion: Endoscopic snare resection enables safe treatment of small gastric SETs (diameter ≤ 3 cm) and seems faster and easier to perform than other endoscopic resection techniques, such as endoscopic submucosal dissection (ESD) or submucosal tunneling. Perforations occurring after full-thickness resection can be adequately managed by OTSC closure. Solely endoscopic resection without laparoscopic control seems possible in selected patients with tumors known to have purely intraluminal growth.

 

  • References

  • 1 Hedenbro JL, Ekelund M, Wetterberg P. Endoscopic diagnosis of submucosal gastric lesions. The results after routine endoscopy. Surg Endosc 1991; 5: 20-23
    CrossrefPubMedGoogle Scholar
  • 2 Humphris JL, Jones DB. Subepithelial mass lesions in the upper gastrointestinal tract. J Gastroenterol Hepatol 2008; 23: 556-566
    CrossrefPubMedGoogle Scholar
  • 3 Hwang JH, Rulyak SD, Kimmey MB et al. American Gastroenterological Association Institute technical review on the management of gastric subepithelial masses. Gastroenterology 2006; 130: 2217-228
    CrossrefPubMedGoogle Scholar
  • 4 Hwang JH, Saunders MD, Rulyak SJ et al. A prospective study comparing endoscopy and EUS in the evaluation of GI subepithelial masses. Gastroinest Endosc 2005; 62: 202-208
    CrossrefPubMedGoogle Scholar
  • 5 Karaca C, Turner BG, Cizginer S et al. Accuracy of EUS in the evaluation of small gastric subepithelial lesions. Gastrointest Endosc 2010; 71: 722-727
    CrossrefPubMedGoogle Scholar
  • 6 Hunt GC, Smith PP, Faigel DO. Yield of tissue sampling for submucosal lesions evaluated by EUS. Gastrointest Endosc 2003; 57: 68-72
    PubMedGoogle Scholar
  • 7 Cantor MJ, Davila RE, Faigel DO. Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection. Gastrointest Endosc 2006; 64: 29-34
    CrossrefPubMedGoogle Scholar
  • 8 Hoda KM, Rodriguez SA, Faigel DO. EUS-guided sampling of suspected GI stromal tumors. Gastrointest Endosc 2009; 69: 1218-1223
    CrossrefPubMedGoogle Scholar
  • 9 Ji JS, Lee BI, Choi KY et al. Diagnostic yield of tissue sampling using a bite-on-bite technique for incidental subepithelial lesions. Korean J Intern Med 2009; 25: 101-105
    PubMedGoogle Scholar
  • 10 Polkowski M, Gerke W, Jarosz D et al. Diagnostic yield and safety of endoscopic ultrasound-guided trucut [corrected] biopsy in patients with gastric submucosal tumors: a prospective study. Endoscopy 2009; 41: 329-334
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Mekky MA, Yamao K, Sawaki A et al. Diagnostic utility of EUS-guided FNA in patients with gastric submucosal tumors. Gastrointest Endosc 2010; 71: 913-919
    CrossrefPubMedGoogle Scholar
  • 12 Philipper M, Hollerbach S, Gabbert HE et al. Prospective comparison of endoscopic ultrasound-guided fine-needle aspiration and surgical histology in upper gastrointestinal submucosal tumors. Endoscopy 2010; 42: 300-305
    Article in Thieme ConnectPubMedGoogle Scholar
  • 13 Fernández-Esparrach G, Sendino O, Solé M et al. Endoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover study. Endoscopy 2010; 42: 292-299
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 Elmunzer BJ, Trunzo JA, Marks JM et al. Endoscopic full-thickness resection of gastric tumors using a novel grasp-and-snare technique: feasibility in ex vivo and in vivo porcine models. Endoscopy 2008; 40: 931-935
    Article in Thieme ConnectPubMedGoogle Scholar
  • 15 Elmunzer BJ, Waljee AK, Taylor JR et al. Endoscopic full-thickness resection of gastric lesions using a novel grasp-and-snare technique: evaluation in a porcine survival model. Surg Endosc 2010; 24: 1573-1580
    CrossrefPubMedGoogle Scholar
  • 16 Kirschniak A, Kratt T, Stüker D et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc 2007; 66: 162-167
    CrossrefPubMedGoogle Scholar
  • 17 Repici A, Arezzo A, De Caro G et al. Clinical experience with a new endoscopic over-the-scope clip system for use in the GI tract. Dig Liver Dis 2009; 41: 406-410
    CrossrefPubMedGoogle Scholar
  • 18 Kirschniak A, Subotova N, Zieker D et al. The over-the-scope clip (OTSC) for the treatment of gastrointestinal bleeding, perforations, and fistulas. Surg Endosc 2011; 25: 2901-2905
    CrossrefPubMedGoogle Scholar
  • 19 Sandmann M, Heike M, Faehndrich M. Application of the OTSC system for the closure of fistulas, anastomosal leakages and perforations within the gastrointestinal tract. Z Gastroenterol 2011; 49: 981-985
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Wilhelm D, von Delius S, Burian M. Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric subepithelial masses – analysis of 93 interventions. World J Surg 2008; 32: 1021-1028
    CrossrefPubMedGoogle Scholar
  • 21 Miettinen M, Lasota J. Gastrointestinal stromal tumors: pathology and prognosis at different sites. Semin Diagn Pathol 2006; 23: 70-83
    CrossrefPubMedGoogle Scholar
  • 22 Kantsevoy SV, Adler DG. ASGE technology committee et al. Endoscopic mucosal resection and endoscopic submucosal dissection. Gastrointest Endosc 2008; 68: 11-18
    CrossrefPubMedGoogle Scholar
  • 23 Suzuki H, Ikeda K. Endoscopic mucosal resection and full thickness resection with complete defect closure for early gastrointestinal malignancies. Endoscopy 2001; 33: 437-439
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Ikeda K, Fritscher-Ravens A, Mosse CA et al. Endoscopic full-thickness resection with sutured closure in a porcine model. Gastrointest Endosc 2005; 62: 122-129
    CrossrefPubMedGoogle Scholar
  • 25 Ikeda K, Mosse CA, Park PO et al. Endoscopic full-thickness resection: circumferential cutting method. Gastrointest Endosc 2006; 64: 82-89
    CrossrefPubMedGoogle Scholar
  • 26 Kaehler G, Grobholz R, Langner C et al. A new technique of endoscopic full-thickness resection using a flexible stapler. Endoscopy 2006; 38: 86-89
    Article in Thieme ConnectPubMedGoogle Scholar
  • 27 Kaehler GF, Langner C, Suchan KL et al. Endoscopic full-thickness resection of the stomach: an experimental approach. Surg Endosc 2006; 20: 519-521
    CrossrefPubMedGoogle Scholar
  • 28 Abe N, Takeuchi H, Yanagida O et al. Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor. Surg Endosc 2009; 23: 1908-1913
    CrossrefPubMedGoogle Scholar
  • 29 Zhou PH, Yao LQ, Qin XY et al. Endoscopic full-thickness resection without laparoscopic assistance for gastric submucosal tumors originated from the muscularis propria. Surg Endosc 2011; 25: 2926-2931
    CrossrefPubMedGoogle Scholar
  • 30 von Renteln D, Schmidt A, Vassiliou MC et al. Natural orifice transluminal endoscopic surgery gastrotomy closure with an over-the-endoscope clip: a randomized, controlled porcine study (with videos). Gastrointest Endosc 2009; 70: 732-739
    CrossrefPubMedGoogle Scholar
  • 31 Arezzo A, Kratt T, Schurr MO et al. Laparoscopic-assisted transgastric cholecystectomy and secure endoscopic closure of the transgastric defect in a survival porcine model. Endoscopy 2009; 41: 767-772
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Voermans RP, van Berge Henegouwen MI, Bemelman WA et al. Novel over-the-scope-clip system for gastrotomy closure in natural orifice transluminal endoscopic surgery (NOTES): an ex vivo comparison study. Endoscopy 2009; 41: 1052-1055
    Article in Thieme ConnectPubMedGoogle Scholar
  • 33 von Renteln D, Rösch T, Kratt T et al. Endoscopic full-thickness resection of submucosal gastric tumors. Dig Dis Sci 2012; 57: 1298-1303
    CrossrefPubMedGoogle Scholar
  • 34 von Renteln D, Vassiliou MC, Rothstein RI. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy 2009; 41: 1056-1061
    Article in Thieme ConnectPubMedGoogle Scholar
  • 35 Demetri GD, von Mehren M, Antonescu CR et al. NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Canc Netw 2010; 8 (Suppl. 02) 1-41
    PubMedGoogle Scholar
  • 36 Trupiano JK, Stewart RE, Misick C et al. Gastric stromal tumors: a clinicopathologic study of 77 cases with correlation of features with nonaggressive and aggressive clinical behaviors. Am J Surg Pathol 2002; 26: 705-714
    CrossrefPubMedGoogle Scholar
  • 37 Igwilo OC, Byrne MP, Nguyen KD et al. Malignant gastric stromal tumor: unusual metastatic patterns. South Med J 2003; 96: 512-515
    CrossrefPubMedGoogle Scholar
  • 38 Miettinen M, Sobin LH, Lasota J. Gastrointestinal stromal tumors of the stomach: a clinicopathologic, immunohistochemical, and molecular genetic study of 1765 cases with long-term follow-up. Am J Surg Pathol 2005; 29: 52-68
    CrossrefPubMedGoogle Scholar
  • 39 Schubert D, Kuhn R, Nestler G et al. Laparoscopic-endoscopic rendezvous resection of upper gastrointestinal tumors. Dig Dis 2005; 23: 106-112
    CrossrefPubMedGoogle Scholar
  • 40 Heinrich MC, Corless CL. Gastric GI stromal tumors (GISTs): the role of surgery in the era of targeted therapy. J Surg Oncol 2005; 90: 195-207
    CrossrefPubMedGoogle Scholar
  • 41 Białek A, Wiechowska-Kozłowska A, Pertkiewicz J et al. Endoscopic submucosal dissection for treatment of gastric subepithelial tumors (with video). Gastrointest Endosc 2012; 75: 276-286
    CrossrefPubMedGoogle Scholar
  • 42 Park YS, Park SW, Kim TI et al. Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife. Gastrointest Endosc 2004; 59: 409-415
    CrossrefPubMedGoogle Scholar
  • 43 Rösch T, Sarbia M, Schumacher B et al. Attempted endoscopic en bloc resection of mucosal and submucosal tumors using insulated-tip knives: a pilot series. Endoscopy 2004; 36: 788-801
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 Hoteya S, Iizuka T, Kikuchi D et al. Endoscopic submucosal dissection for gastric submucosal tumor, endoscopic sub-tumoral dissection. Dig Endosc 2009; 21: 266-269
    CrossrefPubMedGoogle Scholar
  • 45 Lee IL, Lin PY, Tung SY et al. Endoscopic submucosal dissection for the treatment of intraluminal gastric subepithelial tumors originating from the muscularis propria layer. Endoscopy 2006; 38: 1024-1028
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Hwang JC, Kim JH, Kim JH et al. Endoscopic resection for the treatment of gastric subepithelial tumors originated from the muscularis propria layer. Hepatogastroenterology 2009; 56: 1281-1286
    PubMedGoogle Scholar
  • 47 Jeong ID, Jung SW, Bang SJ et al. Endoscopic enucleation for gastric subepithelial tumors originating in the muscularis propria layer. Surg Endosc 2011; 25: 468-474
    CrossrefPubMedGoogle Scholar
  • 48 Inoue H, Ikeda H, Hosoya T et al. Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia. Endoscopy 2012; 44: 225-230
    Article in Thieme ConnectPubMedGoogle Scholar
  • 49 Gong W, Xiong Y, Zhi F et al. Preliminary experience of endoscopic submucosal tunnel dissection for upper gastrointestinal submucosal tumors. Endoscopy 2012; 44: 231-235
    Article in Thieme ConnectPubMedGoogle Scholar
  • 50 Xu MD, Cai MY, Zhou PH et al. Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos). Gastrointest Endosc 2012; 75: 195-199
    CrossrefPubMedGoogle Scholar
  • 51 Lee CK, Lee SH, Chung IK et al. Endoscopic full-thickness resection of a gastric subepithelial tumor by using the submucosal tunnel technique with the patient under conscious sedation (with video). Gastrointest Endosc 2012; 75: 457-459
    CrossrefPubMedGoogle Scholar
  • 52 Ludwig K, Wilhelm L, Scharlau U et al. Laparoscopic-endoscopic rendezvous resection of gastric tumors. Surg Endosc 2002; 16: 1561-1565
    CrossrefPubMedGoogle Scholar
  • 53 Walsh RM, Ponsky J, Brody F et al. Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors. J Gastrointest Surg 2003; 7: 386-392
    CrossrefPubMedGoogle Scholar