Copyright
©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. Sep 27, 2022; 14(9): 918-929
Published online Sep 27, 2022. doi: 10.4240/wjgs.v14.i9.918
Predictors of difficult endoscopic resection of submucosal tumors originating from the muscularis propria layer at the esophagogastric junction
Yu-Ping Wang, Hong Xu, Jia-Xin Shen, Wen-Ming Liu, Yuan Chu, Ben-Song Duan, Jing-Jing Lian, Hai-Bin Zhang, Li Zhang, Mei-Dong Xu, Jia Cao
Yu-Ping Wang, Hong Xu, Yuan Chu, Ben-Song Duan, Jing-Jing Lian, Hai-Bin Zhang, Li Zhang, Mei-Dong Xu, Jia Cao, Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, Shanghai 200120, China
Yu-Ping Wang, Jia-Xin Shen, Wen-Ming Liu, Endoscopy Center, The First Affiliated Hospital of Fujian Medical University, Fuzhou 350004, Fujian Province, China
Hong Xu, Department of Gastroenterology and Hepatology, Hangzhou Red Cross Hospital, Hangzhou 310003, Zhejiang Province, China
Author contributions: Cao J and Xu MD designed the study; Wang YP, Chu Y, Duan BS, Lian JJ and Zhang HB collected the data; Zhang L performed the pathological diagnosis; Wang YP, Shen JX, Liu WM and Xu H analyzed and interpreted the data; Wang YP drafted the manuscript; Xu H and Cao J were responsible for revising the manuscript for important intellectual content; All authors read and approved the final version.
Supported by Science and Technology Commission of Shanghai Municipality, China, No. 19411951505.
Institutional review board statement: The study was reviewed and approved by the Shanghai East Hospital, Tongji University School of Medicine Institutional Review Board, No. 2021-(067).
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at jia_cao@yeah.net. Participants gave informed consent for data sharing.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
https://creativecommons.org/Licenses/by-nc/4.0/ Corresponding author: Jia Cao, MD, Endoscopy Center, Department of Gastroenterology, Shanghai East Hospital, Tongji University School of Medicine, No. 150 Jimo Road, Shanghai 200120, China. jia_cao@yeah.net
Received: March 30, 2022
Peer-review started: March 30, 2022
First decision: June 19, 2022
Revised: July 5, 2022
Accepted: August 16, 2022
Article in press: August 16, 2022
Published online: September 27, 2022
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.
Core Tip: This was the first study to discuss the predictors of difficult endoscopic resection, including various approaches of submucosal tunneling endoscopic resection, endoscopic full-thickness resection and endoscopic submucosal dissection for submucosal tumors originating from the muscularis propria layer at the esophagogastric junction. Our data showed that tumors with greater size and irregular shape were independent predictors of difficult endoscopic resection, which is mainly measured by piecemeal resection, long operative time and intraoperative bleeding.
