The Clinical Study Of Submucosal Tunneling Endoscopic Resection In The Treatment Of The Upper Gastrointestinal Submucosal Tumor

Objective:Endoscopic submucosal dissection (ESD) which is a kind of minimally invasive technology is to use all kinds of electric knives to resect gastrointestinal benign or malignant lesions under endoscopy. It is reported that ESD is a safe and effective method for gastrointestinal lesions with high probability of en bloc resection, few complications, less pain and short hospitalization days, and low recurrence rate. But recently it has developed a new kind of minimally invasive treatment technology--submucosal tunneling endoscopic resection (STER) on the basis of ESD and tunneling technique. The purpose of the study is to explore the clinical value of STER by comparing the STER and ESD in the treatment of the upper gastrointestinal submucosal tumor (SMT).Methods:31patients who were found upper gastrointestinal submucosal tumors by gastroscope and endoscopic ultrasonography (EUS) and then treated either by STER or by ESD in endoscopy central of Qilu Hospital, Shandong University between July2012and May2013were selected. In STER group, there were14patients, including6men and8women. The age ranged37～67years old and the average age was51±9years old. In ESD group, there were17patients, including10men and7women. The age ranged28～67years old and the average age was52±12years old. With STER, we should repeatedly inject the physiological saline mixed with methylene blue into submucosa which was2.0～4.0cm far away from the lesion, and cut open mucosa longitudinally1.5～2.0cm, and then dissect the mucosa and create a tunnel along the submucosa and inherent muscularis to the bottom to reveal the lesion with hook knife, Dual knife or IT knife. All lesion tissues were taken to do histological and immunohistochemical examination. In the end, the wound were handled with metal tongs. There were follow-up gastroscopic examinations for all patients one and three month later of post-operation to evaluate the wound healing. We should gather and statistics the maximum diameter of the lesions, the long diameter of the wounds, the operation time, the probability of en block resection, the incidence of bleeding and perforation, the postoperative hospitalization days in STER and ESD, and then apply SPSS17.0software to analyze them to evaluate the feasibility, safety and effectiveness of STER for treatment of upper gastrointestinal submucosal tumors.Results:In all patients, there were18cases of patients with esophageal lesions,1case with cardiac lesions,12cases with gastric lesions. According to the reports of the pathological biopsy, among31cases, there were21cases of leiomyomas,2cases of lipomyomas,4cases of stromal tumors,2cases of heterotopic pancreases,2cases of hyperplastic polyps. In STER group and ESD group, the maximum diameter of lesions was0.5～2.0cm,0.6～2.0cm respectively(P=0.832); The long diameter of the wounds was1.5～2.0cm,1.5～3.0cm respectively(P=0.019); The operation time was45～145min,35～90min respectively(P=0.000); The post-operative hospitalization time was6-9days,4-10days respectively(P=0.290). In STER group, there were13cases dissected en bloc,5cases bleeding,1case perforating, and all of the wounds were completely closed with metal tongs. In ESD group, there were13cases being dissected en bloc,3cases bleeding,2cases perforating, and it is9cases that the wounds were completely closed with metal tongs. The bleeding was treated by endoscopic biopsy forceps clamps, metal tongs and (or) the APC. The perforations were closed with metal tongs. One month later of post-operation,10cases of wounds (10/14) were healed completely in STER group. And in ESD group,10cases (10/17) were healed completely. There were14cases (14/14) in STER and15cases (15/17) in ESD healed completely three months later of post-operation. In STER group, there was not submucosa infection and submucosal fistula formation according to follow-up endoscopic.Conclusions:In the treatment of upper gastrointestinal submucosal tumors, STER compared to ESD is a new safe and effective minimally invasive treatment technology with smaller wound, higher rate of en bloc resection, lower incidence of bleeding and perforation, higher rate of the wound closed completely, and the faster healing of the wound. And STER has better feasibility and safety for treatment of tumors originating from submucosal or inherent musularis. But it is not applicable for tumors in mucosal layer, mucosal muscular layer and submucosal layer involving shallow.What’s more, it is complex and will take more time. So a physician who has adequate experience in endoscopic therapy is required.