Endoscopic full thickness resection versus submucosal tunneling endoscopic resection for removal of submucosal tumors: a review article

Abstract

Submucosal tumors (SMT) are protuberant lesions with intact mucosa that have a wide differential. These lesions may be removed by standard polypectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), or surgically. However, in lesions that arise from the muscularis propria, full thickness resection is recommended. This can be completed using either endoscopic full thickness resection (EFTR) or submucosal tunneling endoscopic resection (STER). EFTR can be accomplished by completing a full thickness resection followed by defect closure or by securing gastrointestinal wall patency before resection. STER is an option that first creates a mucosal dissection proximal to the lesion to allow a submucosal tunnel to be created. Using this tunnel, the lesion may be resected. When comparing STER to EFTR, there was no significant difference when evaluating tumor size, operation time, rate of complications, or en bloc resection rate. However, suture time, amount of clips used, and overall hospital stay were decreased in STER. With these differences, EFTR may be more efficacious in certain parts of the gastrointestinal tract where a submucosal tunnel is harder to accomplish.

Keywords: Endoscopic full thickness resection (EFTR); submucosal tumor (SMT); submucosal tunneling endoscopic resection (STER).

Figure 1

This is a representation of step-by-step approach in EFTR for the removal of a submucosal lesion. (A) To begin, the submucosal tumor was identified and submucosal injections were applied; (B) next, the mucosal and submucosal layers were dissccled to expose the tumor; (C) full thickness of the tumor was completed; (D) tumor is shown in its entirety; (E) the closure of the gastric defect is completed using endoscopic sutures. EFTR, endoscopic full thickness resection.

Figure 2

This is a representation of the step-by-step approach using STER for the removal of a submucosal lesion. (A) The submucosal lesion is identified in the fundus of the stomach; (B) a submucosal injection was completed to create a submucosal fluid cushion to aid in the incision; (C) an incision was made proximal to the submucosal lesion; (D) the scope was inserted into the proximal incision as the submucosal and muscular layers were separated using methylene blue to better differentiate the layers; (E) the lesion was resected using a snare; (F) the defect following mucosotomy was closed using the placement of clips. STER, submucosal tunneling endoscopic resection.