Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction

Abstract

Background: Endoscopic resection approaches, including endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness 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.

Keywords: Endoscopic full-thickness resection; Endoscopic submucosal dissection; Esophagogastric junction; Muscularis propria; Submucosal tumor; Submucosal tunneling endoscopic resection.

Figure 1

The procedure of submucosal tunneling endoscopic resection. A: Endoscopic view of the tumor; B: Endoscopic ultrasonography view of the tumor; C: The submucosal tumor exposed using the submucosal tunnel technique; D: Endoscopic view of the submucosal tunnel after the tumor was removed; E: The mucosal entry closed by clips; F: The piecemeal resected tumor.

Figure 2

Case illustration of endoscopic full-thickness resection. A: Endoscopic view of the tumor; B: Endoscopic ultrasonography view of the tumor; C: The submucosal tumor exposed by full-thickness resection; D: The wound surface after removal of the tumor; E: The gastric wall defect was closed with endo-clips; F: The horseshoe-shaped specimen.

Figure 3

Tumor size. A: There was a significant negative correlation between age and tumor size; B: Tumor size at different ages in the submucosal tunneling endoscopic resection group, endoscopic full-thickness resection group and endoscopic submucosal dissection group are shown. The circle dots above the horizontal line represent tumors larger than 4 cm. STER: Submucosal tunneling endoscopic resection; EFTR: Endoscopic full-thickness resection; ESD: Endoscopic submucosal dissection.