Tianying Duan

Submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer.

Objective To estimate the safety and efficacy of submucosal tunneling endoscopic resection (STER) for upper gastrointestinal submucosal tumors (SMTs) originating from the muscularis propria layer. Methods During October 2011 and May 2014, a total of 80 patients with SMTs underwent STER at our hospital. A submucosal tunnel was created from 3–5 cm above the tumor. Endoscopic submucosal dissection of the SMT was performed, and then the mucosal incision was closed with several clips after the tumor was removed. Results All the 80 patients underwent STER successfully, with a mean operation time of 61.2 min. Eighty-three SMTs were removed; among these, 67 were located in the esophagus and 16 in the gastric cardia, 68 were leiomyoma, and 15 were gastrointestinal stromal tumors, and 13 had a diameter no less than 35 mm. The mean tumor size was 23.2 mm; en-bloc resection was performed in 97.6% (81/83) of the tumors. Complications were noted in 8.75% (7/80) of the cases, and all of them resolved without the need for additional surgery. No recurrence was noted during a mean follow-up of 10.2 months. Conclusion STER appears to be a feasible, safe, and effective method for upper gastrointestinal SMTs originating from the muscularis propria layer, even when the size of the tumor was larger than 35 mm.

Endoscopic Incision for the Treatment of Refractory Esophageal Anastomotic Strictures in Children.

Objectives: The aim of the present study was to assess the safety and efficacy of endoscopic incision (EI) for the treatment of refractory anastomotic esophageal strictures in pediatric patients. Methods: We retrospectively reviewed the medical records of pediatric patients with refractory anastomotic strictures after surgical repair of esophageal atresia who underwent ≥3 sessions of endoscopic treatments (dilation and/or stenting). They were treated with EI alone or together with esophageal stenting. Efficacy and safety were evaluated during periodical follow-up. Results: All of the 7 children received the procedure successfully with the operation time of 15 to 60 minutes. Four of them received EI alone, whereas the other 3 received EI with esophageal stenting (EIES). The symptoms remitted in all of the patients, and the dysphagia score decreased from 3–4 to 0–1 during follow-up from 1 to 21 months. The average diameter of stricture was enlarged from 3 mm (range 2–5 mm) to 10.6 mm (range 8–12 mm). One patient suffered from chest pain, which resolved within 3 days. Patient 1 had recurrence 11 months after EIES, and patient 6 had recurrence 3 months after EI. They all underwent an additional EI to maintain patency. No severe complications were observed during operation and periodical follow-up. Conclusions: EI is safe and appears effective for refractory esophageal anastomotic strictures in children in the short term. Large comparative studies are warranted to further confirm our findings. The long-term follow-up is necessary for assessing the long-term efficacy of the new technique.

Endoscopic incision and selective cutting for the treatment of refractory colorectal anastomotic strictures

Dear Editor: Anastomotic benign stricture develops in 3–30 % of patients after surgery for rectal carcinoma. Although most of the strictures can be successfully managed with dilation, refractory stricture that does not respond to repeated dilations is difficult to be managed. Affected patients often suffer from constipation, abdominal pain, bloating, and dyschezia, which severely impair their quality of life. Endoscopic incision and cutting (RIC) is a novel technique for treating refractory esophageal strictures and has shown feasibility and efficacy for refractory colorectal anastomotic stricture in a recent case series. However, RIC leads to a wound surface like circumferential endoscopic submucosal dissection (ESD), which facilitates the formation of postoperative stricture. We modified the procedure by endoscopic incision and selective cutting (EISC) and reported our preliminary experience of EISC for the treatment of refractory colorectal anastomotic stricture. Between July 2011 and March 2015, eight consecutive patients were diagnosed of refractory colorectal anastomotic stricture and received EISC. Refractory stricture was considered because the stricture could not be improved to a diameter of 10 mm or symptom of obstruction was not relieved after three or more sessions of endoscopic treatment. And, malignant stricture was excluded by histological examination. This retrospective study was approved by the ethics committee of the Second Xiangya Hospital of Central South University. Informed consent was obtained from all their patients before the procedure was performed. All the patients were informed of possible adverse events and other possible treatment options. EISC was performed under conscious sedation with diazepam (10 mg). Radial incisions were performed with an IT-knife (KD611L, IT2, Olympus, Tokyo, Japan) along the virtual line that connects the bowel lumen on the anal side and the lumen on the oral side of the stricture. Two incisions were performed at each cutting site and the scar tissue between the two incisions was removed; however, the tissue located between the adjacent sites was retained. Sufficient incision depth was defined as involvement of the muscularis propria layer or the bottom of incision was in the virtual line. After the procedure, the wound surface of stricture site was closely observed for any occurrence of hemorrhage and perforation. Patients were kept nil per os (NPO) for 1 day, a liquid diet for 5 days, and returned gradually to a soft diet within 2 weeks. Hemostatic drugs and prophylactic antibiotics were used for 3 days. Patients were scheduled for a follow-up visit at 3, 6, and 12 months after EISC and then annually for colonoscopy to observe the healing of the wound and check for any sign of recurrence. Of the eight patients, five were male and three female, aging from 42 to 76 years old. The median distance of the stricture from the anal verge was 5.5 cm (range, 3– 8 cm). All the patients underwent the procedure successfully with the median operation time of 9.5 min (range, 7–20 min), and the median hospital stay was 4 days (range, 2–6 days). All symptoms were remitted after a single treatment during a median follow-up of 20 months (range, 3–45 months). The median anastomotic diameter enlarged obviously from 0.55 cm (range, 0.1–0.8 cm) to 1.9 cm (range, 1.8–2.5 cm) and colonoscopy was completed without difficulty in intubating the anastomotic stoma. Current treatment modalities for refractory colorectal stricture mainly include surgical resection and endoscopic therapy. Surgical resection is indicated in cases of established refractory stricture; however, extensive injury and * Deliang Liu liudeliang@medmail.com.cn

A comparison of submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric fundus submucosal tumors

AIM Both submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) are effective methods for gastric fundus submucosal tumors (SMTs). However, there is little data that compares the two methods. The aim of this study was to compare the safety and efficacy of STER and EFTR for the treatment of SMTs in the gastric fundus. METHODS Clinical data was retrospectively collected from patients with gastric fundus SMTs who underwent STER or EFTR at our hospital from April 2011 to May 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, postoperative hospital stay, cost and follow-up data were compared. RESULTS A total of 43 patients were enrolled: 15 underwent STER and the remaining 28 cases underwent EFTR. There were no significant differences between the two groups with regard to gender, age, tumor size, en bloc resection rate, operation time, pathohistological results and cost (p > 0.05). However, patients who underwent EFTR had a longer suture time, required a larger number of clips for closure and a prolonged postoperative hospital stay (p < 0.05). No recurrence was noted in either the STER or the EFTR group during a mean follow-up of 12.1 and 22.8 months, respectively. CONCLUSIONS The treatment efficacy of STER and EFTR for the treatment of gastric fundus SMTs was comparable. However, STER has some advantages over EFTR in terms of suture time, the number of clips required for closure and postoperative hospital stay.