Impact of deep muscle invasion on nodal status and survival in patients with pT2 esophageal squamous cancer.

BACKGROUND: Whether T2 esophageal squamous cell carcinoma should be subclassified remains controversial. We aimed to investigate the impact of the depth of muscularis propria invasion on nodal status and survival outcomes. METHODS: We identified patients with pT2 esophageal squamous cell carcinoma who underwent primary surgery from January 2009 to June 2017. Clinical data were extracted from prospectively maintained databases. Tumor muscularis propria invasion was stratified into superficial or deep. Binary logistic regression was used to determine risk factors for lymph node metastases. The impact of the depth of muscularis propria invasion on survival was investigated using Kaplan‒Meier analysis and a Cox proportional hazard regression model. RESULTS: A total of 750 patients from three institutes were investigated. The depth of muscularis propria invasion (odds ratio [OR]: 3.95, 95% confidence interval [CI]: 2.46-6.35; p < 0.001) was correlated with lymph node metastases using logistic regression. T substage (hazard ratio [HR]: 1.37, 95% CI: 1.05-1.79; p < 0.001) and N status (HR: 1.51, 95% CI: 1.05-2.17; p < 0.001) were independent risk factors in multivariate Cox regression analysis. The deep muscle invasion was associated with worse overall survival (HR: 1.52, 95% CI: 1.19-1.94; p = 0.001) than superficial, specifically in T2N0 patients (HR: 1.38, 95% CI: 1.08-1.94; p = 0.035). CONCLUSIONS: We found that deep muscle invasion was associated with significantly worse outcomes and recommended the substaging of pT2 esophageal squamous cell carcinoma in routine pathological examination.

Clinical impact of esophageal muscle thickness on peroral endoscopic myotomy patients.

BACKGROUND: Peroral endoscopic myotomy (POEM) is a standard procedure for achalasia, an esophageal motility disorder, characterized by a thickened lower esophageal sphincter muscularis propria (LEMP). Visualization of this anatomical stratification has been made possible by the advent of endoscopic ultrasound (EUS). However, the effect of LEMP thickness on treatment outcomes remains unclear. The objective of this study was to investigate whether LEMP thickness affects treatment response post-POEM. METHODS: This was a single-center, prospective cohort study of patients who underwent POEM between 2014 and 2021. Patients who underwent EUS to evaluate the LEMP before POEM were included in the study. We divided the patients into two groups according to muscle thickness measured by EUS (≥ 2.80 mm; group 1, < 2.80 mm; group 2). The pre- and post-procedural clinical parameters were compared between the two groups. RESULTS: Among 278 patients, 189 were enrolled. There were no significant differences in the pre- and post-Eckardt scores, integrated relaxation pressure, and distensibility index between the two groups divided by muscle thickness. Furthermore, there was no statistically significant difference in symptom recurrence, as measured by an Eckardt score > 3, post-procedural complications, or post-POEM GERD symptoms. However, patients with thicker lower esophageal sphincter muscle showed a greater decrease in Eckardt scores (ΔES ≥ 3) which was statistically significant (P = 0.002). CONCLUSION: POEM is an effective and safe treatment method for achalasia, regardless of LES muscle thickness. There was a statistically significant difference in the decrease of Eckardt scores of 3 or greater (ΔES ≥ 3) after POEM in the thicker LEMP group suggesting greater alleviation of symptoms in POEM patients with thicker lower esophageal muscle.

Factors associated with non-lifting of colorectal mucosal lesions.

BACKGROUND: Endoscopic submucosal dissection (ESD) is an effective treatment for colorectal tumors. However, lesions that cannot be lifted after submucosal injection are not indication for ESD. This is because the procedure is difficult, and the lesions are often considered as tumor invasion or submucosal fibrosis. The aims of this study are to evaluate the efficacy and safety of ESD for non-lifting lesions and to analyze the causes of non-lifting phenomenon. METHODS: This retrospective study included 29 patients with non-lifting colon lesions resected by ESD from February 2018 to September 2021. Cases were observed for demographics, endoscopic findings, treatment outcomes, adverse events and endoscopic follow-up. We studied the pathological features of lesions to explore the reasons for non-lifting. RESULTS: Among 29 cases of non-lifting lesions, 20 lesions (69.0%) were 30 mm in diameter or larger. Most of lesions (96.6%) were non-lifting in center, and only one lesions (3.4%) had non-lifting of one side. The en bloc and curative resection rates of ESD were 100 and 86.2%, respectively. There was one (3.4%) delayed bleeding, no perforations and other complications. No tumor recurrence occurred during the follow-up period. For pathological features, 16 (55.2%) non-lifting lesions had submucosal fibrosis and only 4 cases (13.8%) had deep submucosal invasion. There were 9 cases (31.0%) of non-lifting lesions due to musculo-fibrous of muscularis propria anomaly (MMPA). CONCLUSION: MMPA is another reason for non-lifting signs besides invasive carcinomas and submucosal fibrosis. ESD should be considered in patients with large non-lifting adenoma instead of surgery.

The value of single-channel endoscopic traction and kiss suture technique in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumors.

BACKGROUND: To investigate the value of single forceps endoscopic traction stapling suture technique (SFETSST) in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumor (GMPT). METHODS: Consecutive patients who underwent submucosal tumor excavation (ESE) and endoscopic full-thickness resection (EFR) for GMPT in the Second Affiliated Hospital of Xiamen Medical College from January 2015 to January 2022 were retrospectively collected. They were divided into the SFETSST group and the standard group (patients who receive single forceps traction-free endoscopic suture technique). The healing effects were compared between the two groups. RESULTS: Seventy-seven patients were included in our study with 50 patients included in SFETSST group. The baseline characteristics had no significant difference between the two groups. The technical success rate of wound suture in SFETSST cluster was significantly upper than that within standard cluster (100% vs. 88.89%, P = 0.04). The wound suture time in SFETSST cluster was significantly lower than that within standard cluster (33.19 ± 10.64 min, P < 0.001). Moreover, the incidence rates of intra-operative and postoperative complications in SFETSST cluster were lower than standard cluster (0 vs. 7.41%, P = 0.051 and 0 vs. 11.11%, P = 0.016). Interestingly, the SFETSST cluster had lower cost of consumables (2485.40 ± 591.78 vs. 4098.52 ± 1903.06 Yuan, P = 0.01) and shorter hospital stay (4.96 ± 0.90 vs. 7.19 ± 2.45, P < 0.001) than standard cluster. CONCLUSION: Our study showed that to fully closure the full-thickness defects of digestive tract, SFETSST was effective, safe, and economical, which was worth popularizing.

Deep muscularis propria tumor invasion without lymph node metastasis as a unique subclassification of stage IB gastric cancer: a retrospective study.

BACKGROUND: The prognosis difference based on the depth of tumor muscularis propria invasion in gastric cancer (GC) was still debated, and therapy strategy for stage IB GC patient required further investigation. METHODS: A total of 380 patients with pT2 GC after radical surgery were retrospectively analyzed, including 185 in superficial muscularis propria (sMP) group and 195 in deep muscularis propria (dMP) group. RESULTS: The overall survival (OS) was significantly better for patients in sMP group than for patients in dMP group (P = 0.007). In multivariate analysis, depth of tumor invasion, pN stage, age, primary location, positive expression of p53, elevated maximal LDH, elevated initial CA19-9 and AFP level were independent prognostic factors for OS. The sMP group had a significantly better OS than dMP group (P = 0.014) in pN0 stage. After further stratification, the survival outcomes were not significantly different between deep muscularis propria tumor invasion without lymph node metastasis (dMPN0) group (stage IB) and superficial muscularis propria tumor invasion with stage 1-2 lymph node metastasis (sMPN1-2) group (stage II) (P = 0.100). Patients with adjuvant chemotherapy had a statistically better survival than those without in dMPN0 group (P = 0.045) and dMPN0 patients with adjuvant chemotherapy had better OS than sMPN1-2 patients (P = 0.015). In addition, greater postoperative survival could be observed in sMPN0 patients than dMPN0 patients in p53-positive group (P = 0.002), and similar OS could be seen between dMPN0 patients with p53-positive and T2N1-2 patients (P = 0.872). CONCLUSION: As a unique subclassification of stage IB GC, appropriate adjuvant chemotherapy should be considered for patients with dMPN0 stage. In addition, positive expression of p53, elevated LDH could be potential factors in identifying the different prognoses for stage IB GC patients.

Clinical outcomes of endoscopic resection for the treatment of gastric gastrointestinal stromal tumors originating from the muscularis propria: a 7-year experience from a large tertiary center in China.

BACKGROUND AND AIMS: Few studies have evaluated the value of endoscopic resection (ER) for the treatment of gastric gastrointestinal (GI) stromal tumors (GISTs) originating from the muscularis propria (MP) in a large population, and no studies have evaluated risk factors for piecemeal resection. This study aimed to evaluate the efficacy and safety of ER for gastric GISTs in a real-world setting and to explore factors associated with piecemeal resection. METHODS: From January 2013 to December 2019, 185 patients with gastric GISTs originating from the MP were assessed. Clinicopathological and endoscopic data were collected and analyzed. Baseline characteristics of the en bloc resection and piecemeal resection groups were compared to evaluate predictive factors for piecemeal resection. RESULTS: There were 71 males and 114 females with a mean age of 57.0 ± 9.7 years. The mean size of GISTs was 15 mm (range 4-65 mm). A total of 123 were very low risk, 52 were low risk, and ten were moderate risk. In this study, 103 GISTs were treated with endoscopic submucosal excavation (ESE), 68 GISTs were treated with endoscopic full-thickness resection (EFR), and 14 GISTs were treated with submucosal tunneling ER (STER). Either en bloc resection or complete resection was achieved in 160 (86.5%) patients. No recurrence was noted during follow-up. Only five patients experienced minor complications, with a complication rate of 2.7%. Multivariate analysis demonstrated that size (odds ratio [OR] 1.060, 95% confidence interval [CI] 1.004-1.118; P = 0.035) and shape (OR 5.434, 95% CI 1.638-18.027; P = 0.006) were independent predictors of piecemeal resection. CONCLUSION: ER was effective and safe for the treatment of gastric GISTs originating from the MP. Piecemeal resection did not seem to affect the efficacy of ER, and no recurrence was noted during follow-up. Large size and irregular shape are risk factors related to piecemeal resection of ER.

Clinicopathological features of esophageal schwannomas in mainland China: systematic review of the literature.

OBJECTIVE: Esophageal schwannoma (ES) are rare and mostly benign neurogenic tumors. The clinical misdiagnosis rate of it is high. In this study, the clinicopathologic features of ES in mainland China were studied to better understand the disease and improve the diagnosis and treatment rate. METHODS: A systematic review was conducted in accordance with PRISMA guidelines. The keywords "esophageal schwannoma", "esophageal neurinoma" and "esophageal neurilemoma" were searched for databases such as Pubmed, EMbase, Wanfang Database and Chinese National Knowledge Infrastructure. The search time frame for database was until July 2019. Combined with our patient, the clinicopathological data and the diagnosis and treatment of ES were summarized. RESULTS: ES occurs in the upper part of the mediastinum and in the thoracic esophagus in most patients in the neck, upper and middle segments. CT and PET/CT examinations can be used for diagnosis, but the differentiation value of both benign and malignant ES is similar. The histopathological findings of forceps biopsy specimens are often difficult to diagnose, and deep tissue biopsies may increase pathological accuracy. EUS-FNA is also recommended for ES diagnosis, but it may also be misdiagnosed. Pathological features include a fusiform arrangement in a palisade-like structure or a tumor cell arranged in a network to form a loose structure. ES characteristic immunohistochemistry results showed that S-100 protein has strong immunological activity. CONCLUSION: The definitive diagnosis requires immunohistochemistry, especially immunological reaction with S-100 protein. The appropriate treatment plan should be selected according to the diameter of the lesion. The overall prognosis of ES is good, but attention should be paid to follow-up.

[The clinical value of further accurate staging of pT2 gastric cancer based on the depth of invasion].

Objective: To investigate the clinical value of pT2 gastric cancer staging pT2a and pT2b according to the depth of muscularis propria invasion in evaluating the prognosis of gastric cancer. Methods: According to the 8th edition of TNM staging system for gastric cancer proposed by the Union for International Cancer Control (UICC) and the American Joint Committee on Cancer (AJCC), patients with gastric cancer who underwent radical surgery in the Fourth Hospital of Hebei Medical University from January 1, 2008 to January 1, 2015 were selected and divided into pT2a and pT2b stage group according to the depth of tumor invasion. The 5-year overall survival (OS) and disease-free survival (DFS) were compared between the two groups. Results: The median follow-up time of 1 411 patients with postoperative pathological pT2 stage was 68.8 months, and 1 347 patients (95.46%) received complete follow-up data. The 5-year OS rate was 65.85%, and the 5-year DFS rate was 67.83 %. The 5-year OS rate and 5-year DFS rate of 709 pT2a patients were 72.50% and 73.91%, respectively. The 5-year OS rate and 5-year DFS rate of 638 pT2b patients were 58.46% and 61.13%, respectively, significantly different from those of the pT2a group (P<0.001). Hierarchical analysis was performed according to N staging. The 5-year OS rates of pT2aN0M0 (274 cases), pT2aN1M0 (192 cases), pT2aN2M0 (147 cases), pT2aN3aM0 (59 cases) and pT2aN3bM0 (37 cases) were 83.58 %, 72.40 %, 68.71 %, 54.24 % and 35.12 %, respectively. The 5-year DFS rates were 84.67 %, 77.08 %, 67.35 %, 54.24 % and 35.14 %, respectively. In the pT2b group, the 5-year OS rates of pT2bN0M0 (209 cases), pT2bN1M0 (166 cases), pT2bN2M0 (127 cases), pT2bN3aM0 (78 cases) and pT2bN3bM0 (58 cases) were 76.08%, 62.05%, 56.69%, 37.18% and 17.24%, respectively, and the 5-year DFS rates were 80.86%, 69.28%, 54.33%, 35.90% and 15.52%, respectively. Under the same N stage, the OS rates of patients in the pT2a group were better than those in the pT2b group (P values were 0.023, 0.034, 0.034, 0.043 and 0.018, respectively). When the N stage was N0 and N1, there was no significant difference in the 5-year DFS rate between the pT2a group and the pT2b group (P values were 0.199 and 0.090, respectively). When the N stages were N2, N3a and N3b, the difference between the pT2a stage group and the pT2b stage group was statistically significant (P values were 0.027, 0.022 and 0.025, respectively). Conclusions: In the 8th edition of AJCC/UICC gastric cancer staging system, pT2 stage can be divided into pT2a stage (invasion of superficial muscularis) and pT2b stage (invasion of deep muscularis) according to the infiltration depth of muscularis propria. There are significant differences in prognosis between the two groups. Combined with the number of lymph node metastasis, the prognosis of patients with pT2 gastric cancer can be more accurately evaluated.

Clinical significance of urothelial carcinoma ambiguous for muscularis propria invasion on initial transurethral resection of bladder tumor.

PURPOSE: To evaluate the clinical significance of invasive urothelial carcinoma that is ambiguous for muscularis propria invasion on initial transurethral resection of bladder tumor (TURBT). METHODS: All consecutive in-house TURBTs with invasive urothelial carcinoma from 1999 to 2017 that underwent radical cystectomy (RC) were grouped as follows: invasion of the lamina propria (INLP; n = 102; 24%), invasion of muscularis propria (INMP; n = 296; 69%) and ambiguous for muscularis propria invasion (AMP; n = 30; 7%). AMP was defined as extensive invasive carcinoma displaying thin muscle bundles where it is difficult to determine with certainty if those muscle bundles represent muscularis mucosae or muscularis propria (detrusor). Cases with any amount of small cell carcinoma or prior therapy were excluded. RESULTS: The average age was 66 years in INLP, 67 years in INMP, and 65 years in AMP. RC showed invasive carcinoma stage pT2 or above in 50/102 (49%) of INLP vs. 255/296 (86%) of INMP (P ≤ 001) vs. 25/30 (83.33%) of AMP (P = 0.002). Lymph nodes showed metastatic carcinoma in 18/98 (18.36%) of INLP vs. 96/272 (35.29%) of INMP (P = 0.002), and 6/25 (24%) in AMP (P = 0.729). The average follow-up was 48 months (range 0-192). Survival of AMP patients was similar to INLP and both were significantly better than INMP (P = 0.002 and P = 0.016). CONCLUSION: The great majority of patients with AMP on initial TURBT have advanced disease on RC and emphasizes the need for early repeat TURBT or even consideration of early cystectomy to lower the risk of worse pathological findings and to prolong survival.

Snare-assisted endoscopic resection of gastric subepithelial tumors originating from the muscularis propria layer: a multicenter study.

BACKGROUND AND AIM: Although successful endoscopic resection of gastric subepithelial tumors (SETs) originating from the muscularis propria (MP) layer has been frequently reported, it requires a relatively complicated technique and has a high perforation rate. In this retrospective study, we evaluated the efficacy and safety of the snare-assisted endoscopic resection (SAER) method which is performed using a snare and insulated-tip (IT) knife via a single-channel endoscope to reduce the perforation rate. METHODS: In this study, fifty-six patients with gastric SETs originating from the MP layer treated by the SAER method at three institutions between July 2017 and December 2017 were reviewed. The procedure involved multiple steps as shown in Fig. 2. Data were obtained on demographics, SET features, histopathological diagnoses, procedure time, en bloc resection rate, R0 resection (negative margins) status, and adverse events. RESULTS: Endoscopic resection was successfully performed in all patients. The median overall procedure time was 43.5 min (range 26-106 min). The mean size of resected specimens was 19.73 mm (range 10-33 mm). The overall rate of en bloc resection was 96.4% (54/56). In addition, the perforation rate was 7.1% (4/56), and defects in the stomach wall were very small and easily closed using metallic clips. No postprocedural bleeding occurred in any case. CONCLUSIONS: The SAER method is an effective, safe, less costly technique for the removal of some gastric SETs originating from the MP layer with an appropriate size.

The retrospective comparison between submucosal tunneling endoscopic resection and endoscopic submucosal excavation for managing esophageal submucosal tumors originating from the muscularis propria layer.

BACKGROUND: Submucosal tunneling endoscopic resection (STER) and endoscopic submucosal excavation (ESE) were recently introduced to cure submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. This study aimed to compare clinical performance and safety of STER and ESE in treating esophageal SMTs originating from the MP layer. METHODS: From January 2011 to December 2017, retrospective data collection and follow-up were applied for all STER or ESE cases with esophageal SMTs originating from the MP layer in our endoscopy center, including clinical characteristics, procedure success, efficacy, and adverse events. Subgroup analysis was further done based on tumor size and origin. RESULTS: 90 STER and 77 ESE were enrolled in this study. There were no significant difference for patient characteristics, procedure performance, and complications for ESE and STER intervention (P > 0.05). STER was faster than ESE (3.90 mm2/min vs 2.82 mm2/min, P < 0.05). For large tumors (≥ 20 mm), both techniques had the similar performance (P > 0.05), while STER led to the shorter hospitalization (4.0d vs 7.0d, P < 0.05) and lower postoperative complication (16.3% vs 45.5%, P < 0.05). For small tumors (< 20 mm), STER achieved faster operation (STER vs ESE, 2.57 mm2/min vs 1.83 mm2/min, P < 0.05). Regardless of tumor origin, there were no significant difference for both techniques, but STER resulted in short hospitalization for SMTs from the deep MP layer (STER vs ESE, 5.0d vs 7.0d, P < 0.05). During the follow-up, 2 residual and 4 recurrence occurred in the STER group, as well as 1 residual and 2 recurrence in the ESE group. CONCLUSIONS: Both STER and ESE were effective for treating esophageal SMTs originating from the MP layer. STER might be better due to its faster operation, less complications, and shorter hospitalization.

Segmental Ileal Dilatation Presenting with Neonatal Intestinal Obstruction.

Segmental ileal dilatation is an uncommon cause of neonatal intestinal obstruction. This report highlights a rare combination of abnormal distribution of muscles in the muscularis propria and partial loss of interstitial cells of Cajal as causative factors for segmental intestinal dilatation.

Comparison of different endoscopic resection techniques for submucosal tumors originating from muscularis propria at the esophagogastric junction.

BACKGROUND: To compare the outcomes of submucosal tunneling endoscopic resection (STER) and submucosal excavation (ESE) for the treatment of submucosal tumors (SMTs) arising from the muscularis propria (MP) at the esophagogastric junction (EGJ). METHODS: A retrospective analysis of patients with SMTs at EGJ who underwent STER and ESE from October 2011 to October 2017 was performed. The outcomes evaluated were operation time, complete resection rate, adverse events, and tumor recurrence. RESULTS: Ninety patients were included in this study. Complete resection rates in the STER group were higher than those of the ESE group (100 vs. 92%, p < 0.05). For tumors ≤15 mm, both techniques achieved 100% complete resection rate; but for tumors > 15 mm, complete resection rate was higher in the STER group than the ESE group (100% vs. 77.8%, p < 0.05). Subgroup analyses revealed that the operation time of STER for in cardiac-gastric group was longer than that for ESE (145.14 ± 42.43 min vs. 70.32 ± 39.84 min, p <  0.05). The air leakage symptoms were more frequent in STER group (90.9% vs. 50.0%, p < 0.05). No tumor recurrence occurred in both the STER and ESE groups. CONCLUSIONS: For SMTs ≤15 mm, both STER and ESE have similar satisfactory therapeutic outcomes. However, in the cardiac-gastric subgroup, STER had a longer operative time compared to the ESE procedure. For SMTs > 15 mm, STER is the preferred choice due to its higher complete resection rate.

Usefulness of the thread-traction method in endoscopic full-thickness resection for gastric submucosal tumor: a comparative study.

BACKGROUND: Endoscopic full-thickness resection (EFTR) has shown great prospects in treating gastric submucosal tumors (SMTs) from the muscularis propria. However, it is very difficult sometimes to ideally expose the tumor and gain adequate visualization for the dissection site. In the present study, we applied the thread-traction (TT) method to assist EFTR in treating gastric SMTs and investigated the feasibility and effectiveness of this strategy. METHODS: A total of 28 patients were involved in the study. 13 patients were treated by TT-assisted EFTR (TT group) and the others by non-assisted EFTR (NA group). Data on clinical characteristics and therapeutic outcomes were collected for analysis. RESULTS: The average tumor size was 1.6 ± 0.4 cm. En bloc resection rate was 92.9%. Histopathological evaluation indicated that 22 tumors were gastrointestinal stromal tumors (78.6%), all at low- or very low-risk, and 6 tumors were leiomyomas (21.4%). The total complication rate was 32.1%. All complications were managed intra-operatively or conservatively. Both the total procedure time and the perforation time were significantly shorter in patients of TT group than those of NA group (71.9 ± 30.5 vs. 107.5 ± 35.8 min, P = 0.010; 38.3 ± 22.0 vs. 68.6 ± 24.2 min, P = 0.002). The pain score evaluated by visual analogue system after operation was significantly lower in patients of TT group than those of NA group (4.5 ± 1.1 vs. 5.8 ± 1.4, P = 0.014). Although complication rate was lower in patients of TT group than those of NA group, the difference was not statistically significant (15.4% vs. 46.7%, P = 0.114). No residual or recurrent tumors were observed during a mean follow-up period of 17.9 ± 4.4 months. CONCLUSIONS: The TT method could effectively assist EFTR to shorten operation time and decrease the risk of complications.

[Submucosal tunneling endoscopic resection for submucosal tumors originating from muscularis propria layer at esophagogastric junction].

Objective: To evaluate the short-term outcomes and safety of submucosal tunneling endoscopic resection (STER) for submucosal tumors (SMT) originating from muscularis propria (MP) layer at esophagogastric junction. Methods: The clinical data of 31 patients with SMT originating from MP layer at esophagogastric junction underwent STER were collected and retrospectively analyzed. Results: The success rate of STER of the thirty-one patients was 100%. The mean tumor size was (2.5±1.3) cm and the average operative time was (95.9±56.7) min. Perforation occurred in 3 patients and was successfully clipped by endo-clips during operation. One patient developed delayed bleeding and the bleeding was stopped by endoscopic hemostasis. Twenty-nine leiomyomas and two stromal tumors (GIST) were finally pathologically diagnosed. No local recurrence and distant metastasis were noted during the mean 15.4 months follow-up of 20 cases. According to the lesion size, 31 patients who received STER were divided into two groups. The operation time of maximum diameter ≥3.5 cm group was (134.0±70.6) min, significantly longer than (80.3±42.6) min of maximum diameter <3.5 cm group (P=0.014). However, the en bloc removal rate, postoperative hospital stay and the complication incidence between the two groups had no obvious differences (P>0.05). Univariate analysis showed that the piecemeal removal group had longer tumor diameter, higher incidence of irregular tumor morphology, and longer operative time than the en bloc removal group (all P<0.05). Stepwise logistic regression analysis showed that irregular shape was a risk factor for failure of en bloc removal (OR=18.000, 95% CI: 1.885~171.88, P=0.012). Conclusion: As a new method of minimally invasive treatment, STER technology appears to be a safe and effective option for patients with SMT originating from MP layer at esophagogastric junction.

Effect of submucosal tunneling endoscopic resection for submucosal tumors at esophagogastric junction and risk factors for failure of en bloc resection.

BACKGROUND AND AIMS: Most submucosal tumors (SMTs) in the esophagogastric junction (EGJ) are irregularly shaped and different from those in the esophagus, where submucosal tunneling endoscopic resection (STER) has been proven effective and safe. However, few reports paid attention to STER for SMTs in the EGJ. The aim of the study was not only to evaluate the effect of STER in patients with SMTs in the EGJ but to analyze the risk factors for failure of en bloc resection. METHODS: A consecutive of 47 patients with SMTs originating from the muscularis propria (MP) layer in the EGJ underwent STER were retrospectively included between September 2012 and December 2016. Thirty-five tumors underwent en bloc resection, and the other 12 tumors received piecemeal resection. The tumor size, operation time, en bloc resection rate, complications, residual, and local recurrence were achieved and compared between the two groups. RESULTS: Forty-six of 47 lesions (97.9%) were successfully resected. The mean lesion size was 29.7 ± 16.3 mm. Both the en bloc resection rate and complete resection rate were 74.5% (35/47). No severe complications occurred in the 47 patients. Patients in the piecemeal resection group had more irregularly shaped lesions, longer tumor diameter, larger tumor size (≥40 mm), longer operation time, and longer hospital stay after procedure (P < 0.05), and there were no statistically differences between the two groups in in-operative complications, post-operative complications, and residual rate (P > 0.05). By univariate analysis and stepwise logistic regression analysis, irregular shape and tumor diameter ≥20 mm were two risk factors for failure of en bloc resection. CONCLUSIONS: STER is an effective and safe technique for the treatment of SMTs arising from the MP layer in the EGJ. Irregular shape and tumor diameter ≥20 mm are the reliable risk factors for en bloc resection failure.

Treatment of cardial submucosal tumors originating from the muscularis propria layer: submucosal tunneling endoscopic resection versus endoscopic submucosal excavation.

BACKGROUND AND AIMS: Submucosal tunneling endoscopic resection (STER) is increasingly used for the treatment of submucosal tumors (SMTs) originating from the muscularis propria layer; however, endoscopic submucosal excavation (ESE) is still performed in many hospitals for its low-skill and experience requirements. This study aimed to compare STER with ESE for cardial SMTs. METHODS: From March 2013 to February 2017, patients with cardial SMTs undergoing STER (n = 47) and ESE (n = 40) were retrospectively assessed. Clinicopathological, endoscopic, and complication data were compared between STER and ESE groups. RESULTS: The 87 enrolled patients included 31 females and 56 males, aged 48.2 ± 9.8 years. Mean tumor size was 22.0 mm (range 5.0-80.0 mm) as evaluated by pathology. Demographic and lesion features were similar in both groups. Despite similar hospital stay duration and cost, ESE was superior to STER with reduced operation time (34 vs. 46 min, P = 0.013) and less clips required (3 vs. 5, P = 0.000). En bloc resection rates, complete resection rates, hospital stay duration, cost, complications, and hemoglobin levels were similar in both groups. Irregular-shaped SMTs were more likely to achieve piecemeal resection in both STER and ESE groups (all P < 0.05). Meanwhile, the piecemeal resection rate was significantly higher for larger tumors in the STER group. CONCLUSION: Compared with ESE, STER does not show overt advantages for cardial SMTs. However, ESE is superior to STER for reduced operation time. Irregular tumor shape seems to be a risk factor for piecemeal resection in both STER and ESE.

Factors affecting the effectiveness and safety of submucosal tunneling endoscopic resection for esophageal submucosal tumors originating from the muscularis propria layer.

BACKGROUND AND AIMS: Submucosal tunneling endoscopic resection (STER) has been proved to be effective and safe for esophageal submucosal tumors (SMTs) originating from the muscularis propria (MP) layer. This study was aimed to further evaluate the effectiveness, safety, and influencing factors especially the types of mucosal incision of STER in a larger population. METHODS: A total of 89 patients undergoing STER with esophageal SMTs were retrospectively enrolled in this study from May 2012 to November 2016. Clinicopathological, endoscopic, and adverse events (AEs) data were collected and analyzed. Different incision methods were compared to evaluate the optimum incision method. RESULTS: There were 27 females and 62 males with mean age of 46.5 ± 10.3 years. The medium size of the tumors was 16.0 mm (ranging 10.0-60.0 mm). Inverted T incisions were made in 29 (32.6%) patients, transverse incisions in 12 (13.5%) while longitudinal incisions in 48 (53.9%). En bloc resection was achieved in 70 (78.7%) patients. The residual rate was 1.1% (1/89), and no recurrence was noted even after piecemeal resection. The rate of AEs was 21.3% (19/89), and all of the AEs were cured without intervention or treated conservatively without the need for surgery. The en bloc resection rate was comparable among the three incision groups (P = 0.868); however, the incidence of AEs in the inverted T incision was lower than that in the longitudinal incision (P = 0.003). Fewer clips were used in the inverted T incision group than in the transverse incision group (P = 0.003). CONCLUSIONS: Although STER failed to achieve en bloc resection in 21.3% patients, it was still an effective therapy owing to low residual rate and no recurrence rate after piecemeal resection. STER was safe with no severe AEs; however, minor AEs were common. Inverted T incision seems to be the optimum entry point.

Comparison between submucosal tunneling endoscopic resection and video-assisted thoracoscopic enucleation for esophageal submucosal tumors originating from the muscularis propria layer: a randomized controlled trial.

BACKGROUND AND AIMS: Surgical resection is considered the first treatment option for submucosal tumors (SMTs) originating from the muscularis propria layer while submucosal tunneling endoscopic resection (STER) is proved to be a safe and effective method for treating SMTs. This study aimed to compare video-assisted thoracoscopic enucleation (VATE) with STER for treating esophageal SMTs. METHODS: Sixty-six patients with small esophageal SMTs were prospectively randomized from July 2014 to December 2015. After exclusion of 8 patients, 58 subjects scheduled for STER or VATE were enrolled. Clinicopathological, endoscopic, and adverse events (AEs) data were collected and analyzed between STER and VATE. RESULTS: Forty-six males and 12 females with a mean age of 46.1 ± 9.4 years were randomized to the STER (n = 30) and VATE (n = 28) groups, respectively. Demographics and lesion features were similar between the two groups. Median procedure time was shorter in the STER group than the VATE group (44.5 vs. 106.5 min, P < 0.001); cost was lower in the STER group (4499.46 vs. 6137.32 USD, P = 0.010). Median decrease in hemoglobin levels post-procedure was - 1.6 g/L in the STER group and 14.7 g/L after VATE (P = 0.001). Lower postoperative pain scores were found in the STER group compared with the VATE group (2 vs. 4, P < 0.001). No recurrent or residual tumors were found in either group. En bloc resection rates, complete resection rates, hospital times, and post-procedure AEs were similar between two groups. The en bloc resection rates for SMTs < 20.0 mm were 100% in both groups while STER achieved only 71.4% en bloc resection rate for SMTs ≥ 20.0 mm. CONCLUSION: STER and VATE are comparably effective for esophageal SMTs; however, STER is superior to VATE with shorter operation time and decreased cost, and seems safer than VATE. STER is recommended for SMTs < 20.0 mm while VATE is recommended for SMTs with a transverse diameter > 35.0 mm. Clinical trail registration statement: This study is registered at http://www.chictr.org.cn/showproj.aspx?proj=4814 . The registration identification number is ChiCTR-TRC-14004759. The registration date is April 30, 2014.

IgG4-related stomach muscle lesion with a renal pseudotumor and multiple renal rim-like lesions: A rare manifestation of IgG4-related disease.

We describe a 74-year-old man with immunoglobulin G4-related disease (IgG4-RD) presenting with gastric cancer, stomach and kidney lesions. For 15 years, the patient had been treated under a diagnosis of sclerosing cholangitis, which was revealed to be IgG4-RD only when the cancer was found. Histology revealed the gastric cancer and IgG4-related lesion in the muscularis propria to be separate. This case suggests that the stomach muscle can also be a site of involvement of IgG4-RD.