Hyperechoic demarcation line between a tumor and the muscularis propria layer as a marker for deciding the endoscopic treatment of gastric submucosal tumor

Abstract

Minimally invasive endoscopic resection has been rapidly adopted as a new technique for treating patients with gastric submucosal tumors (SMTs) originating in the muscularis propria (MP) layer. This study was conducted to evaluate the information obtained from endoscopic ultrasonography (EUS) to determine the appropriate endoscopic dissection method for treating SMTs originating in the MP layer. Between February 2014 and May 2016, a total of 50 patients with gastric SMTs originating in the MP layer were enrolled in this study. The clinical features of the patients and their endoscopic, EUS, and histopathologic findings, as well as their postoperative follow-up data, were analyzed in this retrospective study. The mean age of the patients was (55.0±10.2) years, and the male/female ratio was 17:33. Endoscopic submucosal dissection (ESD) was performed on 43 patients and an endoscopic full-thickness resection (EFR) was performed on seven patients. The most frequent location for an SMT was in the upper body region of the stomach (n=16), and the most common pathological diagnosis was a gastrointestinal stromal tumor (GIST) (n=32). The overall rates for complete resection were 95.3% (41/43) and 100.0% (7/7) when the SMTs were treated by ESD and EFR, respectively. The presence of a complete tumor capsule was significantly associated with a complete resection (P=0.001). Of the cases treated by ESD, nine patients developed perforation, one of whom required laparoscopic surgery. The remaining patients were closed with clips or purse-string sutures. The presence of an MP2-type tumor (P=0.018) and a wide connection with the MP layer (P=0.044) were significantly associated with perforation. A preoperative evaluation of the integrity and the location of a tumor capsule and the length of the tumor connection with the MP layer by EUS can improve the complete resection rate and reduce the occurrence of intraoperative complications. Tumors with a complete capsule originating from the superficial MP layer or with a narrow connection with the MP layer are appropriate candidates for treatment by ESD.

摘要

目 的

近年微创内镜技术作为治疗起源于固有肌层的黏膜下肿瘤的新型方式迅速发展。本研究旨在通过观察超声内镜下起源于固有肌层的肿瘤包膜完整性及所处位置(位于浅肌层或深肌层)、与浆膜层的位置关系和肿瘤与固有肌层紧密接触长度占肿瘤包膜长度的比例来评估完整切除率、穿孔及出血等并发症发生率、预后情况, 进一步指导内镜下治疗方式的选择。

创新点

首次提出通过超声内镜术前评估肿瘤包膜的完整性、在固有肌层中所处的位置及与固有肌层连接的长度选择内镜下治疗方式, 可以提高完整切除率及降低术中并发症的发生。

方 法

收集浙江省人民医院及浙江省立同德医院2014 年02 月至2016 年6 月接受内镜治疗的胃固有肌层肿瘤患者资料, 总结并分析其临床特点、内镜及超声内镜表现、临床结果及术后随访资料。

结 论

肿瘤包膜的完整性与完全切除率密切相关。起源于深肌层以及与固有肌层为宽连接的黏膜下肿瘤在内镜黏膜下剥离术(ESD)中穿孔可能性较大。通过超声内镜术前评估起源于固有肌层的胃黏膜下肿瘤包膜的完整性、所处的位置以及与固有肌层连接的长度, 有助于提高完整切除率和减少术中并发症的发生。