Submucosal Tunneling Endoscopic Resection For Submucosal Tumor Originating From The Muscularis Propria Layer Of The Esophagus

Background:Gastrointestinal (GI) tract wall can be divided into mucosa, submucosa, muscularis propria (MP) and serosa in total of four layers, while the esophagus lacks a serosa layer of coverage and only own a thin layer of adventitia. The GI submucosal tumors (SMTs) refer to a class of lesions which are originating from the organizations under the mucosa such as muscularis mucosa, submucosa and MP. The esophageal SMTs originating from the MP layer belong to mesenchymal neoplasms which include leiomyoma, GI stromal tumor, leiomyosarcoma, neurofibroma and so on. Leiomyoma is the most common one in clinical, while leiomyosarcoma is the most rare. The incidence of esophageal SMTs originating from the MP layer is increasing year by year and the age of onset has been younger. It is difficult to self-aware for its occult early symptoms. The level of discovery and diagnosis has been significantly improved with the popularity using of endoscopy and the extensive application of endoscopic ultrasonography (EUS). The majority of esophageal SMTs originating from the MP layer are benign lesions, but it will bring serious problems such as bleeding, canceration, obstruction and oppression of vital organs with the further growing of the tumor size. So it’s in need of early excision. Recently, Chinese scholar had invented submucosal tunneling endoscopic resection (STER) inspired by peroral endoscopic myotomy (POEM), and used it for the treatment of upper GI SMTs originating from the MP layer in the international firstly.Object:To assess the clinical feasibility and safety of STER for the treatment of SMTs originating from the MP layer of the esophagus. Methods:Treat the10inpatients whose lesions were proved locating in the MP layer of the esophagus by EUS during October2011to May2012with STER as follows:(1)lavaging the esophagus, then marked the lesion;(2)injecting fluid into the submucosa which is about4～6cm away from the lesion at the oral side, then making a longitudinal incision at the mucosa;(3)creating the submucosal tunnel in order to expose the tumor fully;(4)freeing and removing the tumor;(5)closing the mucosal incision site by metallic endoclips.Results:Of all the10cases, lesions were completely and successfully removed by STER without perforation. The mean age of patients was44.1years, the mean size of tumors was2.2cm, the mean period of hospitalization after operation was8.1days. Two cases developed pneumothorax and pneumoperitoneum, two cases developed pneumomediastinum and subcutaneous emphysema, and one case encountered fever after operation. They were all cured by expectant therapy. No patients developed delayed bleeding, esophagus leakage or serious infection.Conclusions:STER had been proved to be an effective and safe method to remove the tumors originating from the MP layer of the esophagus. And it will be a promising endoscopic procedure for the treatment of GI SMTs originating from the MP layer.