| Background and Aims:With the development of digestive endoscopy,endoscopic minimally invasive treatment technology has been vigorously developed.However,Tunnel Endoscopy has become the hottest treatment technology in endoscopy over the past decade.The key point of Tunnel Endoscopy is to create a wide tunnel in the loose submucosa through the endoscope.Through this tunnel,we can perform:(1)the removal of mucosal and submucosal lesions;(2)the dissection of the muscularis propria or lesion.The former mainly includes endoscopic submucosal tunnel dissection(ESTD),double tunnel endoscopic submucosal tunnel dissection(DT-ESTD)and endoscopic submucosal multi-tunnel dissection(ESMTD).The latter most widely used in the clinic includes preoral endoscopic myotomy(POEM)and Endoscopic submucosal tunnel resection(STER).However,all the above techniques have certain requirements for the operator's endoscopic operation ability.At present,only large medical centers in China can carry out the treatment on a large scale.Endoscopic treatment is extremely difficult especially for large size of the gastrointestinal epithelial neoplasm.Not only in China,but also in the international only a few regional units can perform these techniques.This research analyses and summarizes the safety and effectiveness of STER and DT-ESTD from the following four parts:(1)STER is applied for treating esophageal muscularis propria tumors;(2)STER is used in the treatment of muscularis propria tumors in gastric esophageal junction;(3)DT-ESTD is used to treat circumferential esophageal neoplastic lesions;(4)DT-ESTD is applied for the treatment of rectal circumferential laterally spreading tumor.Materials and Methods:1.Endoscopic Submucosal Tunnel Resection for Esophageal Submucosal Tumor:A Single-Center StudyBetween September 2011 and July 2017,67 patients with 71 SMTs originating from the muscularis propria layer under went STER in our center.STER procedure consisted of the following step:firstly,submucosal tunnel was created and extended below the SMTs 'oral side onto the anal side after a mucosal incision was made;then resectd the SMTs;finally,the mucosal entry was closed by endoclips.Demographic data,clinical data,outcome of treatment were collected and analyzed to evaluate the safety and effectiveness of STER for esophageal SMTs.2.Endoscopic Submucosal Tunnel Resection for Muscularis Propria Tumors in gastric esophageal junction:A Single-Center StudyBetween July 2012 and May 2017,We enrolled 25 patients who underwent STER for 26 muscularis propria tumors in gastric esophageal junction.Data of all patients were collected prospectively and analysed retrospectively.To evaluate the safety and effectiveness of STER for SMTs in gastric esophageal junction,we analyzed demographic data,clinical data,outcome of treatment.3.Double tunnel endoscopic submucosal tunnel dissection for treating circumferential esophageal neoplastic lesions:A Single-Center StudyBetween December 2011 and August 2017,11 patients with circumferential esophageal neoplastic lesions received DT-ESTD in our center.These patients were enrolled in this study.DT-ESTD procedure consisted of the following step:firstly,confirmed the range of lesions and marked them,circumferential incision were made in oral side and anal side;then double tunnel was created in the submucosal layer;thirdly,dissectd submucosal lesions completely.Demographic data,clinical data,outcome of treatment and complications were analyzed consecutively.4.Double tunnel endoscopic submucosal tunnel dissection for rectal circumferentiallaterally spreading tumor:A Single-Center StudyBetween December 2015 and August 2017,6 patients with rectal circumferential laterally spreading tumor who went DT-ESTD in our center were enrolled in this study.We retrospectively analysed demographic data,clinical data,outcome of treatment,complications and the rate of death.During the follow-up period,all patients received colonoscopy to ele-vate the safety and effectiveness.Results:1.71 SMTs originating from the muscularis propria(MP)layer were identified in 67 patients.All patients underwent STER procedure successfully.Mean procedure time was 50.2 ± 26.9 minutes,and mean tumor size was 19.6 ± 9.6 mm.Among all lesions,the majority(56.3%)located in the lower esophagus,7.0%in the upper esophagus and 36.6%in the median esophagus.Complete resection rate was achieved in 71(100%)lesions while the block resection rate in 68(95.8%)lesions.Perforation occurred in 4 patient(6.0%))which was treated by endoclips.Pneumothorax occurred in 2 patients(2.9%)and was managed by thoracic drainage successfully.Subcutaneous emphysema occurred in 7 patients(13.4%)and disappeared spontaneously.During a median follow-up of 29.2 months,patients were free of local recurrence or distant metastasis.2.26 SMTs were identified in 25 patients.All patients underwent STER procedure successfully.Among all lesions,the majority(42.3%)located in the cardia,38.5%in the esophagus and cardia and 19.2%in the gastric cardia.Mean procedure time was 59.9 ± 37.9 minutes,and mean tumor size was 24.9 ± 14.8 mm.Complete resection rate was achieved in 25(100%)lesions while the block resection rate in 24(96%)lesions.Gastric mucosal rupture occurred in 3 patient(12.0%),which was treated by endoclips.Pneumothorax occurred in 2 patients(2.9%)and was managed by thoracic drainage successfully.Subcutaneous emphysema occurred in 7 patients(13.4%)and disappeared spontaneously.During a median follow-up of 29.2 months,patients were free of local recurrence or distant metastasis.3.11 patients with circumferential esophageal neoplastic lesions went DT-ESTD successfully.Among all lesions,the majority(10/11,90.9%)located in the median esophagus.The tumor morphology is dominated by mixed type(9/11,81.8%).The mean tumor length was 60.0 ± 18.4cm and the mean length of the resected specimen was 76.8 ±22.2mm.Mean procedure time was 172.7 ± 74.7 minutes;mean hospitalization time was 9.4 ± 2.7 days.Curative resection rate was achieved in 8(72.8%)lesions while en block resection rate in 11(100%)lesions.Subcutaneous emphysema occurred in 4 patients(36.4%).Pulmonary infection occurred in 2 patients(13.4%)and was treated by antibiotics successfully.Mean follow-up time was 24.8 ± 20.4 months.During follow-up period,1(9.0%)patient received surgery and 2(18.2%)patients received chemoradiotherapy.All the patients were free of recurrence or distant metastasis.All patients were treated by Oral prednisone tablets for prevention of esophageal stricture.However,esophageal stricture occurred in 6(60%)patients,then they received balloon dilation and mean expansion frequency was 7.0 ± 3.5 times.During follow-up,2 patients died.One was died from perforation and mediastinal infection when patient received balloon dilation six months after operation;the aged one was died from other disease one year after operation.4.6 patients with 6 rectal circumferential laterally spreading tumor accepted DT-ESTD successfully.Among all lesions,most of them(83.3%)were granular type,one of them(16.7%)was non-granular type.According to Paris Classfication,4(66.7%)cases were mixed-type,2(33.3%)cases were type 0-?a.Pit pattern composed with type ?Land IV.The mean tumor length was 7.2 ± 1.8cm.Mean procedure time was 338.3 ± 147.6 minutes.Both curative resection and en block resection rate were 100%.The mean hospitalization time was 8.5 ± 1.4 days.Mean follow-up time was 12.7 ± 4.5 months.Postoperative stricture occurred in 4(66.7%)patients,they received balloon dilation and mean expansion frequency was 1.3 ± 0.6 times.4(66.7%)patients had complaints when defecating.5(83.3%)patients accepted trentment by methalazine suppositories placed in rectum,symptoms such like anal pain and tenesmus improved.No disease-related deaths occurd.Conclusion:1.Our study demonstrated that STER is a safe,and effective treatment for SMTs originating from the MP layer in esophagus.Further studies are warranted to evaluate the long-term efficacy and safty.2.Our study demonstrated that STER is a safe,and effective treatment for SMTs originating from the MP layer in gastric esophageal junction.Further studies are warranted to evaluate the long-term efficacy and safty.3.DT-ESTD is a more efficient technique,which is easier than routine treatment.Our study demonstrated that DT-ESTD is a safe,and effective technique for treating circumferential esophageal neoplastic lesions,with high rate of en bloc resection and low complications.Further studies are warranted to evaluate the long-term efficacy and safty.4.Our study demonstrated that DT-ESTD is a safe,and effective technique for treating rectal circumferential laterally spreading tumor.Further studies are warranted to evaluate the long-term efficacy and safty. |
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