Comparison And Analysis Of Submucosal Tunneling Endoscopic Resection And Endoscopic Submucosal Excavation In The Treatment Of Managing Esophageal Submucosal Tumors

Background and Aims Esophageal submucosal tumors(SMTs)are a group of protuberances covered with normal mucosa,usually without clinical symptoms.Due to recent popularization of endoscopy,more SMTs were accidentally dIagnosed.In esophagus,leiomyomas and gastrointestinal stromal tumors(GISTs)are two common type and originate from the muscularis propria(MP).The most are benign,but 10.8%leiomyomas might turn into leiomyosarcomas and GISTs have the malignant potential,especially the large ones or with the irregular boundary.The National Comprehensive Cancer Network(NCCN)guidelines recommend that GISTs>2 cm should be dissected,while endoscopic surveillance could be considered for GISTs<2 cm without high-risk EUS features.Conventional thoracotomy,thoracoscopic enucleation and endoscopic resection are commonly applied to remove esophageal SMTs,while endoscopic resection was recently developed as the first strategy due to its micro-invasiveness,rapid recovery and low complication.Submucosal tunneling endoscopic resection(STER)and endoscopic submucosal excavation(ESE)are two common techniques for treating SMTs.ESE is the spin-off approach from endoscopic submucosal dissection(ESD).ESE was reported to successfully manage SMTs from esophagogastric junction,cardia and stomach.Inspired by peroral endoscopic myotomy(POEM)technique,STER was introduced in 2011.It could preserve the mucosa integrity and prevent the undesired perforation during the procedure.Several studies confirmed STER was safe and efficient for esophageal SMT treatment.Nevertheless,few studies were presented for comparing both techniques on esophageal SMTs.Our study aimed to retrospectively analyze their difference and superiority in treating esophageal SMTs originating from the MP layer.Methods From January 2011 to December 2017,the clinical data of patients who underwent STER or ESE for the management of esophageal SMTs originating from the MP layer in our digestive center were collected.Clinical characteristics,operation-ralated parameters and follow-up results were analysed.Results A total of 167 patients were included,of whom 90 patients underwent STER and the other 77 underwent ESE.The mean age was 52.2 years(20-78 years).The male/female ratio was 102/65.The average tumor diameter was 19.1 mm(3-80 mm).There were no differences in complete resection rate,length of hospital stay and complication incidence between STER and ESE(P>0.05).However,operation speed of STER was faster than ESE(STER vs ESE,3.90 mm2/min vs 2.82 mm2/min,P<0.05).For tumors larger than 20 mm,operation-related parameters were quite similar in both groups(P>0.05),while patients underwent STER procedure had a shorter hospitalization(STER vs ESE,7.0 d vs 10.0 d,P<0.05)and lower postoperative complication rate(STER vs ESE,16.3%vs 45.5%,P<0.05).During the follow-up period,2 residual and 4 recurrences in the STER group as well as 1 residual and 2 recurrence in the ESE group occurred.Conclusion Both STER and ESE can be selected in the management of esophageal SMTs originating from the MP layer with desirable complete resection rate and low complication occurrence,but STER is superior to ESE in operation speed and larger lesions,especially for larger tumors.