Endoscopic submucosal dissection as a treatment for gastric subepithelial tumors that originate from the muscularis propria layer: a preliminary analysis of appropriate indications

Abstract

Background: Endoscopic submucosal dissection (ESD) is a well-established method for the treatment of gastrointestinal epithelial tumors. However, the treatment of gastric subepithelial tumors (SETs) that originate from the muscularis propria layer still depends primarily on surgical techniques. We evaluated the appropriate indications for ESD in the treatment of SETs that originate from the muscularis propria layer.

Methods: Thirty-five patients with gastric SETs that originate from the muscularis propria layer who underwent ESD were enrolled, and the charts were retrospectively reviewed to investigate the parameters predictive complete resection and complications.

Results: The mean age of the patients was 54.15 ± 9.3 years, and the male/female ratio was 2:3. Twenty-eight of the 35 SETs (85.7%) were movable, and 15 (45.7%) had a positive rolling sign. The most frequent location of the SETs was high body (n = 14). The most common pathological diagnoses were leiomyoma (60%) and gastrointestinal stromal tumor (28.6%). The complete resection rate was 74.3%. A positive rolling sign (p = 0.022) and small tumor size (≤20 mm; p = 0.038) were significantly associated with complete resection. Two patients (6.1 %) developed perforations that required surgical treatment; their SMTs were neurogenic tumors with fixed lesion. Tumor mobility was significantly associated with perforation (p = 0.017).

Conclusions: The ESD method appears to be relatively safe for use in the complete resection of SETs that originate from the muscularis propria layer. Small tumor size (≤20 mm) and a positive rolling sign are appropriate indications for ESD.

Fig. 1

The degree of muscular connection with a subepithelial tumor as shown by endoscopic ultrasound. A Narrow muscular connection with the tumor: the diameter of the connection with the fourth layer of the tumor is <50 % of the maximal diameter of the tumor base (black arrow hyperechoic demarcation line between the tumor and the muscularis propria layer). B Wide muscular connection with the tumor: the diameter of the connection with the fourth layer is >50 % of the maximal diameter of the tumor base

Fig. 2

A Magnified scan of an H&E slide showing a well-demarcated submucosal tumor with clear circumferential resection margins following endoscopic submucosal dissection. B The deep resection margin (arrow) is negative (R0) (×40). C The resection margin, indicated by green color and an arrowhead, is involved with a gastrointestinal stromal tumor (R1) (×200)

Fig. 3

Endoscopic findings obtained from the endoscopic submucosal dissection of a gastric subepithelial tumor. A The tumor base was surrounded by a bluish submucosal layer (black arrowheads) following the injection of a mixture of glycerol and indigo carmine. B Following the dissection of the submucosal layer, a whitish narrow muscular connection area (black arrow) was observed. C Wide muscular connection area (black arrows) and a muscularis propria layer (empty arrow) adjacent to the tumor were exposed following a circumferential incision around the lesion

Fig. 4

Schematic illustrations of subepithelial tumors with differing growing patterns and muscular connections. A Subserosal. B Submucosal with a wide muscular connection. C Submucosal with a narrow muscular connection. D Intramural type