Submucosal Tunneling Endoscopic Resection for En Bloc Removal of Large Esophageal Gastrointestinal Stromal Tumors

Accepted Manuscript Novel technique of Submucosal Tunneling Endoscopic Resection (STER) for enbloc Removal of Large Esophageal Gastrointestinal Stromal Tumor (GIST) Nikhil A. Kumta, MD, MS, Monica Saumoy, MD, Amy Tyberg, MD, Michel Kahaleh, MD PII: DOI: Reference:

S0016-5085(16)35442-7 10.1053/j.gastro.2016.11.044 YGAST 60854

To appear in: Gastroenterology Accepted Date: 28 November 2016 Please cite this article as: Kumta NA, Saumoy M, Tyberg A, Kahaleh M, Novel technique of Submucosal Tunneling Endoscopic Resection (STER) for en-bloc Removal of Large Esophageal Gastrointestinal Stromal Tumor (GIST), Gastroenterology (2017), doi: 10.1053/j.gastro.2016.11.044. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Novel technique of Submucosal Tunneling Endoscopic Resection (STER) for en-bloc Removal of Large Esophageal Gastrointestinal Stromal Tumor (GIST)

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Authors: Nikhil A. Kumta MD, MS, Monica Saumoy MD, Amy Tyberg MD, Michel Kahaleh MD Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY.

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CONTRIBUTIONS:

Nikhil Kumta, MD: drafting of the manuscript, technical and material support

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Monica Saumoy, MD: drafting of the manuscript, technical and material support Amy Tyberg, MD: drafting of the manuscript; critical revision of the manuscript for intellectual content

Michel Kahaleh, MD: drafting of the manuscript; critical revision of the manuscript for important intellectual content; study supervision

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Conflict of interest:

Amy Tyberg, MD: research support from NinePoint Medical, Merit Michel Kahaleh, MD: research support from NinePoint Medical, Merit, Boston Scientific, Apollo. Consultant for Boston Scientific and Olympus

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The other authors have noCOI to report related to this publication

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Funding Support: none

Writing Assistance: none

Corresponding Author:

Michel Kahaleh, M.D., AGAF, FACG, FASGE Professor of Medicine

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Chief of Endoscopy Weill Cornell Medicine New York, New York 10021

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T 646-962-4000 F 646-962-0110

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[email protected]

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Novel technique of Submucosal Tunneling Endoscopic Resection (STER) for en-bloc Removal of Large Esophageal Gastrointestinal Stromal Tumor (GIST) Authors: Nikhil A. Kumta MD, MS1, Monica Saumoy MD1, Amy Tyberg MD1, Michel Kahaleh

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1: Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, NY.

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Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal subepithelial tumors of the gastrointestinal tract. GISTs have malignant potential, with size (>5 cm) and

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mitotic count (>5/50 high power fields) the most useful predictors of malignant behavior.1 The management of localized GISTs has traditionally been surgical resection with avoidance of tumor rupture. In the era of modern medicine, we are encountering older patients with a higher proportion of comorbidities that have significant perioperative surgical risk. Herein, we describe a novel endoscopic technique for en-bloc removal of a large esophageal GIST using

Description of Technology:

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submucosal tunneling endoscopic resection (STER).

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Submucosal tunneling endoscopic resection (STER) is an adaption of both peroral endoscopic myotomy and endoscopic submucosal dissection techniques. A longitudinal mucosal incision is

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made 5 cm proximal to the tumor after submucosal injection with normal saline and indigo carmine.2 The endoscope is advanced into the submucosal space and submucosal tunneling is performed to 1-2 cm distal to the lesion to secure enough working space for tumor resection.3 Enucleation of the tumor is carried out by dissecting connecting muscle fibers to facilitate enbloc resection. During tunneling and dissection, close attention is paid to hemostasis with coagulation of any visible blood vessels. The tumor is then extracted from the tunnel through the mucosal entry site.4 Lastly, the mucosal incision site is closed with hemostatic clips or endoscopic suturing.

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Video description: The accompanying video demonstrates successful submucosal tunneling endoscopic resection (STER) for en-bloc removal of a large esophageal GIST (Video 1). The patient is a 69 year old

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man with multiple comorbidities (hypertension, congestive heart failure, chronic obstructive pulmonary disease, atrial fibrillation, obstructive sleep apnea, pacemaker placement) referred for a subepithelial esophageal mass. Endoscopic ultrasound demonstrated a large (4 cm)

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hypoechoic lesion in the muscularis propria with no extraluminal component. Fine needle

aspiration confirmed gastrointestinal stromal tumor (GIST). After multidisciplinary discussion

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with surgery, and consideration given to the patient’s age, co-morbidities, and high perioperative surgical risk of morbidity and mortality, the decision was made to proceed with endoscopic removal with submucosal tunneling endoscopic resection (STER).

The esophageal lesion was identified in the lower esophagus, proximal to the esophagogastric

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junction. Optical coherence tomography (OCT) was utilized to verify the orientation of the lesion prior to tunneling and its relation with the muscularis. OCT showed the GIST in the 7 to 9 o'clock orientation. Five cm proximal to the GIST, a submucosal bleb was created using an injection needle (Carr-Locke injection needle; US Endoscopy, Mentor, OH) filled with a solution

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consisting of normal saline and indigo carmine. A mucosal incision was then created using a multipurpose knife (HybridKnife, T-type; ERBE, Tübingen, Germany). The endoscope was

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advanced into the submucosa and submucosal tunneling was performed to expose the GIST. Any visible vessels were coagulated using the multipurpose knife or coagulation grasper forceps (Coagrasper Hemostatic Forceps; Olympus, Center Valley, PA). An electrosurgical knife (DualKnife; Olympus, Center Valley, PA) was also used for dissection. During the dissection an inadvertent mucosal defect was identified. Due to the size of the lesion and resultant narrow working space within the submucosal tunnel, we opted to utilize the mucosotomy defect to help facilitate removal. The GIST was inverted through the mucosotomy site into the gastric lumen

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and a snare was used to excise the GIST. The specimen was removed en-bloc and pinned on cork (Figure 1). The mucosotomy defect and mucosal incision were closed using multiple endoscopic sutures (OverStitch; Apollo Endosurgery, Austin, TX). Given the length of the

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mucosotomy defect, a fully covered metal esophageal stent was placed and the proximal end was sutured to the esophageal wall to reduce migration risk. The total procedure time was 4 hours. Swallow study on post-operative day 1 showed passage of contrast through the stent into

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the stomach with no evidence of leak. The patient was discharged home on post-operative day 3. Pathology demonstrated high grade GIST (T3, high mitotic rate) with high risk of progressive

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disease. The margins of the tumor were negative. At one month follow-up, the patient had mild abdominal discomfort with no dysphagia or reflux. There was no evidence of tumor recurrence. Take Home Message:

STER is an evolving technique for the resection of upper gastrointestinal submucosal tumors.

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This procedure should be only be performed by endoscopists with expertise in endoscopic submucosal dissection and peroral endoscopic myotomy. Compared to ESD technique, STER has advantages in maintaining gastrointestinal tract mucosal integrity and reducing the risk of postoperative gastrointestinal leaks.5 Challenges include working within a narrow submucosal

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tunnel, tumor size and shape, increased vascularity of the submucosal space on the gastric side, vascularity of GISTs, difficulty in maintaining orientation, intricacy of dissection around the

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distal aspect of the tumor, and the need to avoid puncture of the GIST capsule.2 This novel technique seems more suitable for resection of submucosal tumors originating from the deep muscularis propria, even if there is a high risk of perforation. This case highlights the potential of STER as a minimally invasive, safe, and effective technique for en-bloc resection of a large esophageal GIST without the need for surgical excision. However, large-scale prospective studies are needed to evaluate this technique.

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Legend: Video: Submucosal Tunneling Endoscopic Resection (STER) for en-bloc Removal of Large Esophageal Gastrointestinal Stromal Tumor (GIST)

References:

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Figure 1: Resected gastrointestinal stromal tumor (GIST) specimen

Stamatakos M et al. World J Surg Oncol. 2009;7(5):61-65.

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Khashab MA et al. Curr Opin Gastroenterol. 2014;30(5):444-452.

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Li B et al. Minim Invasive Ther Allied Technol. 2016;25(3):141-147.

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Liu BR et al. Gastrointest Endosc Clin N Am. 2016;26(2):271-282.

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Chen T et al. Ann Surg. 2016:[Epub ahead of print].

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