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Mo1969 Per-Oral Endoscopic Tumor Resection for Submucosal Tumors of the Esophageal and Gastric Cardia
Abstracts
Table 1 Fig 1. Retroflexed view of a patient with a small hiatus hernia (a), followed my mucosal resection along the aspect of the greater curvature (Green) at the level of the GEJ (b,c), and finally a single plication (c) reducing the hernia and valve area (d).
Mo1968 Notes for Subepithelial Tumors: Eftr and Ster -A Single Center Four Year Prospective Series in the Us Stavros N. Stavropoulos*, Rani J. Modayil, Hallie Peller, Maria M. Kollarus, Krishna C. Gurram, Collin E. Brathwaite, David Friedel Winthrop University Hospital, Mineola, NY
Many guidelines recommend surgery for suspected GISTs 2 cm and endoscopic surveillance of those <2cm. This approach, is also applied to other mesenchymal tumors of uncertain behavior (e.g. glomus, granular cell tumors etc.) and creates an inordinate burden of surgery and endoscopy for small SETs the majority of which are low risk. Initial attempts at endoscopic resection, mostly from Asia, using ESD to “excavate” muscularis propria (MP) based SETs may leave microscopic residua and is not applicable to tumors with extraluminal growth. Similarly, device-assisted full thickness resection with devices such as over the scope clips is limited to smaller SETs with intraluminal growth. Recently, Asian pioneers reported 2 endoscopic techniques that achieve R0 en bloc resection of MP-based SETs: Submucosal Tunnel Endoscopic Resection (STER)- an offshoot of POEM utilizing the submucosal tunnel method to ensure secure closure of the full-thickness defect and endoscopic fullthickness resection (EFTR)-direct full thickness resection with closure of the defect with clips or sutures. We present an update of the first large Western series. 83 resections were performed from 4/2012 to 11/2016 by a gastroenterologist with a current experience of >350 POEMs and >500 ESDs. Baseline characteristics (Table 1): 53 female, mean age 59, 25% severely comorbid pts (ASA class 3-4), 78% upper SETs (esophagus, stomach, duodenum). Pathology revealed 77% SETs with malignant potential (35 GISTs, 18 leiomyomas, 1 leiomyosarcoma, 3 granular cell tumor., 1 glomus tumor) Mean size 27mm. Mean resection time 92 min. Complete en bloc resection achieved in 78/83 (94%). Piecemeal/incomplete resection in 4 cases (2 pancreatic rests, one 4 cm granular cell tumor, one 5 cm GIST) and conversion to surgical resection in 1 case (GIST). Laparoscopic gastrotomy for specimen extraction was performed after completion of the endoscopic resection and closure (7 cases) rather than morcelizing the specimen which would preclude proper margin evaluation. One pt required elective laparoscopic conversion due to a large paratumoral vessel that would have made continuation of endoscopic resection potentially hazardous. No significant AEs, except 1 pt with infected pleural effusion after STER requiring esophageal stent and IR drain. EFTR and STER achieve en bloc R0 resection of SETs <5 cm. The excellent outcomes probably reflect extensive prior experience with POEM, advanced closure techniques, and ESD for SETs. EFTR and STER represent a NOTES alternative to laparoscopic resection. Advantages include: 1. Incisionless minimal tissue resection 2. Resection of SETs at locations where laparoscopic “wedge” resection is challenging such as the GE junction, esophagus and cardia 3. Definitive diagnosis and complete resection obviating any further endoscopic surveillance for low risk lesions.
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Mo1969 Per-Oral Endoscopic Tumor Resection for Submucosal Tumors of the Esophageal and Gastric Cardia Masaki Ominami*, Kazuya Sumi, Tetsuya Tatsuta, Yuichiro Ikebuchi, Haruo Ikeda, Manabu Onimaru, Kenichi Goda, Hiroaki Ito, Haruhiro Inoue Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan Background: Submucosal tumors (SMT) of the esophageal and gastric cardia require treatment when they increase in size or the patient experiences symptoms, such as dysphagia, even if the SMT is relatively small and benign. Surgical resection is needed for SMTs that originate from the muscularis propria. Surgical resection of SMTs in the esophageal and gastric cardia is more difficult and more invasive than for those in other portions of the stomach or gastrointestinal tract. In addition, surgery can cause esophageal strictures and deterioration of patients’ quality of life. We developed per-oral endoscopic tumor resection (POET) as a minimally invasive endoscopic treatment for SMTs of the esophageal and gastric cardia and reported this procedure (Inoue H, et al. Endoscopy, 2012). At the same time this procedure was reported independently as submucosal tunneling endoscopic resection (STER) (Xu MD, Zhou PH, et al. Gastrointest Endosc, 2012). POET and STER are similar procedure. However, knowledge about the feasibility and therapeutic outcomes of POET is limited. Aim: We aimed to evaluate the feasibility, short-term outcomes, and safety of POET for SMTs of the esophageal and gastric cardia. Methods: This is a case series study at our university hospitals. Between September 2008 and November 2016, 34 patients with SMTs of the esophageal and gastric cardia who underwent POET at Showa University Northern Yokohama Hospital and Koto Toyosu Hospital were included in this study. The POET procedure is as follows: (1) creation of a submucosal tunnel from 5 cm above the tumor; (2) dissection of the SMT from the overlying mucosa and submucosa; (3) isolation of the SMT from the muscular layer using trianle-tip and insulated-tip knives; and (4) closing the orifice using the clips. All procedures of POEM were performed with carbon dioxide insufflation under general anesthesia. We measured the treatment outcomes: successful resection rate, tumor diameter, procedure time, length of hospitalization after POET, and adverse events. Results: There were 21 men and 13 women and their mean age was 51 12 years. The successful resection rate was 88% (30/34), the mean tumor diameter was 29 17 mm, the mean procedure time was 104 81 minutes, and the mean length of hospitalization after POET was 5.5 1.7 days. Histopathology showed 28 leiomyomas, 2 schwannomas, 2 gastrointestinal stromal tumors, 1 bronchogenic cyst, and 1 heterotopic pancreas, which were all benign. We could not complete POEM in 4 cases (2 schwannomas, 1 bronchogenic cyst, and 1 leiomyoma) because of the large tumor size (>35 mm). However, complete resection was achieved by converting to surgery in these 4 cases. None of the patients had a severe adverse event. Conclusion: POET enables the safe removal of SMTs of the esophageal and gastric cardia with minimal invasiveness if the tumor is not large.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB499
Table 1 Fig 1. Retroflexed view of a patient with a small hiatus hernia (a), followed my mucosal resection along the aspect of the greater curvature (Green) at the level of the GEJ (b,c), and finally a single plication (c) reducing the hernia and valve area (d).
Mo1968 Notes for Subepithelial Tumors: Eftr and Ster -A Single Center Four Year Prospective Series in the Us Stavros N. Stavropoulos*, Rani J. Modayil, Hallie Peller, Maria M. Kollarus, Krishna C. Gurram, Collin E. Brathwaite, David Friedel Winthrop University Hospital, Mineola, NY
Many guidelines recommend surgery for suspected GISTs 2 cm and endoscopic surveillance of those <2cm. This approach, is also applied to other mesenchymal tumors of uncertain behavior (e.g. glomus, granular cell tumors etc.) and creates an inordinate burden of surgery and endoscopy for small SETs the majority of which are low risk. Initial attempts at endoscopic resection, mostly from Asia, using ESD to “excavate” muscularis propria (MP) based SETs may leave microscopic residua and is not applicable to tumors with extraluminal growth. Similarly, device-assisted full thickness resection with devices such as over the scope clips is limited to smaller SETs with intraluminal growth. Recently, Asian pioneers reported 2 endoscopic techniques that achieve R0 en bloc resection of MP-based SETs: Submucosal Tunnel Endoscopic Resection (STER)- an offshoot of POEM utilizing the submucosal tunnel method to ensure secure closure of the full-thickness defect and endoscopic fullthickness resection (EFTR)-direct full thickness resection with closure of the defect with clips or sutures. We present an update of the first large Western series. 83 resections were performed from 4/2012 to 11/2016 by a gastroenterologist with a current experience of >350 POEMs and >500 ESDs. Baseline characteristics (Table 1): 53 female, mean age 59, 25% severely comorbid pts (ASA class 3-4), 78% upper SETs (esophagus, stomach, duodenum). Pathology revealed 77% SETs with malignant potential (35 GISTs, 18 leiomyomas, 1 leiomyosarcoma, 3 granular cell tumor., 1 glomus tumor) Mean size 27mm. Mean resection time 92 min. Complete en bloc resection achieved in 78/83 (94%). Piecemeal/incomplete resection in 4 cases (2 pancreatic rests, one 4 cm granular cell tumor, one 5 cm GIST) and conversion to surgical resection in 1 case (GIST). Laparoscopic gastrotomy for specimen extraction was performed after completion of the endoscopic resection and closure (7 cases) rather than morcelizing the specimen which would preclude proper margin evaluation. One pt required elective laparoscopic conversion due to a large paratumoral vessel that would have made continuation of endoscopic resection potentially hazardous. No significant AEs, except 1 pt with infected pleural effusion after STER requiring esophageal stent and IR drain. EFTR and STER achieve en bloc R0 resection of SETs <5 cm. The excellent outcomes probably reflect extensive prior experience with POEM, advanced closure techniques, and ESD for SETs. EFTR and STER represent a NOTES alternative to laparoscopic resection. Advantages include: 1. Incisionless minimal tissue resection 2. Resection of SETs at locations where laparoscopic “wedge” resection is challenging such as the GE junction, esophagus and cardia 3. Definitive diagnosis and complete resection obviating any further endoscopic surveillance for low risk lesions.
www.giejournal.org
Mo1969 Per-Oral Endoscopic Tumor Resection for Submucosal Tumors of the Esophageal and Gastric Cardia Masaki Ominami*, Kazuya Sumi, Tetsuya Tatsuta, Yuichiro Ikebuchi, Haruo Ikeda, Manabu Onimaru, Kenichi Goda, Hiroaki Ito, Haruhiro Inoue Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan Background: Submucosal tumors (SMT) of the esophageal and gastric cardia require treatment when they increase in size or the patient experiences symptoms, such as dysphagia, even if the SMT is relatively small and benign. Surgical resection is needed for SMTs that originate from the muscularis propria. Surgical resection of SMTs in the esophageal and gastric cardia is more difficult and more invasive than for those in other portions of the stomach or gastrointestinal tract. In addition, surgery can cause esophageal strictures and deterioration of patients’ quality of life. We developed per-oral endoscopic tumor resection (POET) as a minimally invasive endoscopic treatment for SMTs of the esophageal and gastric cardia and reported this procedure (Inoue H, et al. Endoscopy, 2012). At the same time this procedure was reported independently as submucosal tunneling endoscopic resection (STER) (Xu MD, Zhou PH, et al. Gastrointest Endosc, 2012). POET and STER are similar procedure. However, knowledge about the feasibility and therapeutic outcomes of POET is limited. Aim: We aimed to evaluate the feasibility, short-term outcomes, and safety of POET for SMTs of the esophageal and gastric cardia. Methods: This is a case series study at our university hospitals. Between September 2008 and November 2016, 34 patients with SMTs of the esophageal and gastric cardia who underwent POET at Showa University Northern Yokohama Hospital and Koto Toyosu Hospital were included in this study. The POET procedure is as follows: (1) creation of a submucosal tunnel from 5 cm above the tumor; (2) dissection of the SMT from the overlying mucosa and submucosa; (3) isolation of the SMT from the muscular layer using trianle-tip and insulated-tip knives; and (4) closing the orifice using the clips. All procedures of POEM were performed with carbon dioxide insufflation under general anesthesia. We measured the treatment outcomes: successful resection rate, tumor diameter, procedure time, length of hospitalization after POET, and adverse events. Results: There were 21 men and 13 women and their mean age was 51 12 years. The successful resection rate was 88% (30/34), the mean tumor diameter was 29 17 mm, the mean procedure time was 104 81 minutes, and the mean length of hospitalization after POET was 5.5 1.7 days. Histopathology showed 28 leiomyomas, 2 schwannomas, 2 gastrointestinal stromal tumors, 1 bronchogenic cyst, and 1 heterotopic pancreas, which were all benign. We could not complete POEM in 4 cases (2 schwannomas, 1 bronchogenic cyst, and 1 leiomyoma) because of the large tumor size (>35 mm). However, complete resection was achieved by converting to surgery in these 4 cases. None of the patients had a severe adverse event. Conclusion: POET enables the safe removal of SMTs of the esophageal and gastric cardia with minimal invasiveness if the tumor is not large.
Volume 85, No. 5S : 2017 GASTROINTESTINAL ENDOSCOPY AB499