Clinical Analysis On Endoscopic Treatments And Wound Closure Or Exclusion Of Large Gastric Submucosal Tumors Originating From The Muscularis Propria Layer

BackgroundAs endoscopic treatments continues to advance,wound closure technology and equipment continue to innovate,endoscopic submucosal dissection(ESD)can resect gastric submucosal tumors originating from the muscularis propria layer completely,and endoscopic full-thickness resection(EFTR)developed on the basis of ESD,can resect the tumors that ESD can’t resect completely,closely adherent to the serous membrane.Postoperative wound can be closed by metal clips,metal clips combined with nylon rope,or other ways.The current study shows that,endoscopic treatments for less than 3 cm gastric submucosal tumors originating from the muscularis propria layer,have good clinical effect,while there are a few reports on larger gastric submucosal tumors originating from the muscularis propria layer.We also found that endoscopic closure of the postoperative wound usually was difficult and time-consuming,and we did some wound exclusion for the wound difficult to close,with complete deep muscularis,or have full-thickness defect of gastric wall but not penetrating into the abdominal cavity,with firm abdominal connective tissue closely adherent to the defect,there was no perforation or infection occurred.PurposeThis study aimed to analyse and evaluate the efficacy of endoscopic treatments and wound closure or exclusion of larger gastric submucosal tumors originating from the muscularis propria layer with length no less than 3 cm,and preliminarily explore the feasibility of wound exclusion for the wound with complete deep muscularis,or have full-thickness defect of gastric wall but not penetrating into the abdominal cavity.MethodsThe clinical data of 67 patients with large gastric submucosal tumors originating from the musculus propria tumor who received endoscopic treatments in the Department of Gastroenterology,The First Affiliated Hospital of Zhengzhou University from October 2016 to October 2020 were reviewed and analyzed.By statistical analysis of the data of tumor location,size,methods of endoscopic treatment,operation time,resection time,wound closure time,closure methods,en bloc resection rate,complete resection rate,intraoperative and postoperative complications,postoperative fasting time and length of hospital stay,and wound healing condition of 67 patients,we analysed and evaluated the efficacy of endoscopic treatments and wound closure or exclusion of larger gastric submucosal tumors originating from the muscularis propria layer with length no less than 3cm.Among the 67 patients,25 cases were treated with ESD and 42 cases were treated with EFTR,and according to having gastric wall defect or not,and wound closure or exclusion,they were divided into 4 groups:group of having gastric defect with wound closure,group of having gastric wall defect with wound exclusion,group of not having gastric wall defect with wound closure,and group of not having gastric wall defect with wound exclusion.Results1.Clinical analysis on endoscopic treatments of large gastric submucosal tumors originating from the muscularis propria layer25 patients were treated with ESD,gastrointestinal stromal tumors(GISTs)in 12 cases,leiomyoma in 13 cases.The length of tumor was(3.7±0.8)cm and the resection time was(74.7±35.9)min.Perforation occurred in 4 patients(16.0%)during the operation,en blot resection was performed in 24 cases(96.0%)and complete resection in 23 cases(92.0%).The VAS score of abdominal pain was(3.8±1.8)points on first postoperative day.4 patients(16.0%)with postoperative fever(body temperature ≥38.0℃).The postoperative fasting time was(3.7±1.8)d,and the postoperative length of stay was(7.3±1.8)d.42 patients were treated with EFTR,gastrointestinal stromal tumors(GISTs)in 25 cases,leiomyoma in 17 cases.the length of tumor was(3.9±1.0)cm,and the ressection time was(99.4±41.4)min.The complete resection was performed in 42 patients(100%).Two cases(4.8%)had intraoperative major bleeding.The VAS score of abdominal pain was(3.9±1.6)points on first postoperative day.6 patients(14.3%)with postoperative fever(body temperature≥38.℃).The postoperative fasting time was(4.0±1.6)d,and the postoperative length of stay was(7.5±1.8)d.All 67 patients completed the treatment successfully,and all patients were discharged with a better health condition,no one was readmitted due to operation related complications.The patients were followed up for 3-36 months,and median follow-up was 6 months,with no recurrence.2.Clinical analysis on wound closure or exclusion of large gastric submucosal tumors originating from the muscularis propria layer2.1 Clinical analysis on groups of having gastric defect with wound closure or exclusionThere were 34 cases in group of having gastric defect with wound closure,including 30 cases after EFTR and 4 cases after ESD with intraoperative perforation.The length of tumor was(4.0±1.0)cm,the operation time was(135.6±50.5)min,the wound closure time was(39.9±16.3)min,4 cases wound closure with metal clips,9 cases with purse string suture,21 cases with apposition suture,and 17cases with double apposition suture among the 21 cases.The operation cost was(23175.4±5227.7)yuan.There were 12 cases in group of having gastric defect with wound exclusion,all were patients after EFTR with defect of the gastric wall but not penetrating into the abdominal cavity.The length of tumor was(3.5±0.6)cm,the operation time was(106.1±41.2)min,the operation cost was(16589.6±1154.2)yuan.No serious postoperative complications occurred in the two groups,and the median follow-up time was 6 months and 6.5 months,respectively.The wound healed well after operation.2.2 Clinical analysis on groups of not having gastric defect with wound closure or exclusionThere were 10 cases in group of not having gastric defect with wound closure with patients after ESD.The length of tumor was(3.5±0.7)cm,the operation time was(84.6±40.1)min,the wound closure time was(19.4±8.8)min,6 cases wound closure with metal clips,4 cases with purse string suture.The operation cost was(20093.4±3607.9)yuan.There were 11 cases in group of not having gastric defect with wound exclusion,all were patients after ESD with complete deep muscularis.The length of tumor was(3.5±0.4)cm,the operation time was(78.4±35.5)min,the operation cost was(16995.0±810.9)yuan.No serious postoperative complications occurred in the two groups,and the median follow-up time was 5.5 months and 6.5 months,respectively.The wound healed well after operation.ConclusionThe endoscopic treatments of large gastric submucosal tumors originating from the muscularis propria layer and postoperative wound closure or exclusion both have good clinical effect,wound exclusion for the wound with complete deep muscularis,or have full-thickness defect of gastric wall but not penetrating into the abdominal cavity,did not increase the occurence of postoperative complications.But this study has a small sample size,so the results have certain limitations and needs further large sample studies.