Efficacy and complications of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors and exploration for influencing factors

Abstract

Background Submucosal tunneling endoscopic resection (STER) has emerged as a feasible technique for resecting upper gastrointestinal (GI) tract submucosal tumors (SMTs) through natural orifice transluminal endoscopic surgery. STER reduces the risk of postoperative perforation and abdominal infections and promotes rapid wound healing. The aim of this meta-analysis was to evaluate the safety and efficacy of STER for small (≤ 3.5 cm) upper GI SMTs and explore the potential factors influencing STER’s efficacy and complication rate.

Methods Comprehensive literature searches were performed to find studies on STER for removal of SMTs. Several English-language databases were searched, including MEDLINE (through PubMed), EMBASE, and the Cochrane Library for the period January 2010 to June 2016. The medical terms “submucosal tunneling endoscopic resection or STER”, “upper gastrointestinal”, and “submucosal tumors” were used in the search. The primary outcome measures were the pooled estimates of the complete resection and en bloc resection rates. The secondary outcome measure was the pooled estimate of complications.

Result Twelve studies including 397 patients and 430 lesions were identified. The pooled estimate of the complete resection rate was 98.1 % (95 % confidence interval [CI]: 95.9 – 99.2 %). The pooled estimate of en bloc resection was 94.9 % (95 % CI: 91.1 – 97.1 %). The pooled estimate of gas-related complications such as pneumoperitoneum and subcutaneous emphysema was 21.5 % (95 % CI: 13.2 – 33.1 %). The pooled estimate of inflammation-related complications including pleural and abdominal effusion was 8.4 % (95 % CI: 5.6 – 12.3 %). Gas-related complications occurred more frequently in the esophagogastric junction than in the stomach. In addition, the pooled estimate of delayed bleeding was 2.2 % (95 % CI: 1.0 – 4.7 %).

Conclusion STER appeared to be an extremely effective technique for removing upper GI SMTs originating from the muscularis propria layer. In addition, the very low rate of complications also shows the safety of this technique. Tumor size, infiltration depth, and location may influence the complication rates.

Zusammenfassung

Hintergrund Die submukosale endoskopische Tunnelresektion (STER) ist eine Technik zur Resektion von submukosalen Tumoren (SMTs) des oberen Gastrointestinaltraktes (GI) mittels transluminaler endoskopischen Chirurgie durch natürliche Körperöffnungen. STER reduziert das Risiko von postoperativen Perforationen und abdominalen Infektionen und fördert die schnelle Wundheilung. Das Ziel dieser Metaanalyse war es, die Sicherheit und Wirksamkeit von STER für kleine (≤ 3,5 cm) obere GI SMTs zu beurteilen, und die potentiellen Einflussfaktoren auf die Wirksamkeit und Komplikationsrate von STER zu erforschen.

Methoden Umfassende Literaturrecherchen wurden durchgeführt, um Studien zu STER zur Entfernung von SMTs zu finden. Es wurden in mehreren englischsprachigen Datenbanken, darunter MEDLINE (über PubMed), EMBASE und Cochrane-Bibliothek für den Zeitraum von Januar 2010 bis Juni 2016 gesucht. Die medizinischen Begriffe ”Submukosale endoskopische Tunnelresektion oder STER“, ”obere gastrointestinale“ und ”submuköse Tumoren“ wurden bei der Suche verwendet. Die primären Zielparameter waren die zusammengefassten Schätzungen der vollständigen Resektions- und En-Block-Resektionsraten. Der sekundäre Zielparameter war die gepoolte Schätzung von Komplikationen.

Ergebnis Zwölf Studien mit insgesamt 397 Patienten und 430 Läsionen wurden identifiziert. Die zusammengefasste Schätzung der vollständigen Resektionsrate betrug 98,1 % (95 %-Konfidenzintervall [KI]: 95,9 % – 99,2 %), die der En-Block-Resektion betrug 94,9 % (95 %-KI: 91,1 % – 97,1 %). Gasbedingte Komplikationen wie Pneumoperitoneum und subkutanes Emphysem traten mit einer zusammengefassten Häufigkeit von 21,5 % (95 %-KI: 13,2 % – 33,1 %) auf, entzündungsbedingte Komplikationen einschließlich Pleura- und Abdominalerguss wurden in 8,4 % (95 %-KI: 5,6 % – 12,3 %) der Fälle diagnostiziert. Gasbedingte Komplikationen traten häufiger in der ösophagogastrischen Verbindung als im Magen auf. Darüberhinaus betrug die zusammengefasste Schätzung der verzögerten Blutung 2,2 % (95 %-KI: 1,0 % – 4,7 %).

Schlussfolgerung STER scheint eine äußerst effektive Technik zur Entfernung von SMTs im oberen Gastrointestinaltrakt zu sein, die aus der Detrusor-Muskel-Schicht stammen. Darüber hinaus zeigt die sehr geringe Komplikationsrate zudem die Sicherheit dieser Technik. Tumorgröße, Infiltrationstiefe und Lage können die Komplikationsraten beeinflussen.

Key words

submucosal tunneling endoscopic resection - large and irregular submucosal tumors - muscularis propria - esophagus - cardia - meta-analysis

Schlüsselwörter

Submukosale endoskopische Tunnelresektion - große und unregelmäßige submuköse Tumoren - Detrusor-Muskel - Speiseröhre - Kardia - Meta-Analyse

• References

• 1 Chen TH, Hsu CM, Chu YY. et al. Association of endoscopic ultrasonographic parameters and gastrointestinal stromal tumors (GISTs): can endoscopic ultrasonogaraphy be used to screen gastric GISTs for potential malignancy?. Scand J Gastroenterol 2016; 51: 374-377
• 2 Kushnir VM, Keswani RN, Hollander TG. et al. Compliance with surveillance recommendations for foregut subepithelial tumors is poor: result of a prospective multicenter study. Gastrointest Endosc 2015; 81: 1378-1384
• 3 Sumiyama K, Gostout CJ, Rajan E. et al. Submucosal endoscopy with mucosal flap safety valve. Gastrointest Endosc 2007; 65: 688-694
• 4 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 5 Xu MD, Yao LQ, Zhou PH. et al. Submucosal endoscopic tumor resection for upper gastrointestinal submucosal tumors originating from muscularis propria layer. Chin J Dig Endosc 2011; 28: 606-610
• 6 Werner YB, Rösch T. POEM and submucosal tunneling. Curr Treat Options Gastroenterol 2016; 14: 163-177
• 7 Stroup DF, Berlin JA, Morton SC. et al. Meta-analysis of observational studies in epidemiology-a proposal for reporting. JAMA 2000; 283: 2008-2012
• 8 Li B, Liu J, Lu Y. et al. Submucosal tunneling endoscopic resection for tumors of the esophagogastric junction. Minim Invasive Ther Allied Technol 2016; 25: 141-147
• 9 Inoue H, Ikeda T, Hosoya M. et al. Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia. Endoscopy 2012; 44: 225-230
• 10 Wang H, Tan Y, Zhou Y. et al. Submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer. Eur J Gastroenterol Hepatol 2015; 27: 776-780
• 11 Li QL, Chen WF, Zhang C. et al. Clinical impact of submucosal tunneling endoscopic resection for the treatment of gastric submucosal tumors originating from the muscularis propria layer (with video). Surg Endosc 2015; 29: 3640-3646
• 12 Zhang C, Hu JW, Chen T. et al. Submucosal tunneling endoscopic resection for upper gastrointestinal multiple submucosal tumors originating from the muscular propria layer: a feasibility study. Indian J Cancer 2015; 51 (Suppl. 02) 52-55
• 13 Ye LP, Zhang Y, Mao XL. et al. Submucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layer. Surg Endosc.  2014; 28: 524-530
• 14 Zhou DJ, Dai ZB, Wells MM. et al. Subepithelial tunneling and endoscopic resection of submucosal tumors at the esophagogastric junction. World J Gastroenterol 2015; 21: 578-583
• 15 Gong W, Xiong Y, Zhi F. et al. Preliminary experience of endoscopic submucosal tunnel dissection for upper gastrointestinal submucosal tumors. Endoscopy 2012; 44: 231-235
• 16 Wang XY, Xu MD, Yao LG. et al. Submucosal tunneling endoscopic resection for submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a feasibility study (with videos). Surg Endosc 2014; 28: 1971-1977
• 17 Lu J, Jiao T, Li Y. et al. Heading toward the right direction – solution package for endoscopic submucosal tunneling resection in the stomach. PLoS One 2015; 10: e0119870
• 18 Liu BR, Song JT, Kong LJ. et al. Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia. Surg Endosc 2013; 27: 4354-4359
• 19 Lee SH, Kim SJ, Lee TH. et al. Human applications of submucosal endoscopy under conscious sedation for pure natural orifice transluminal endoscopic surgery. Surg Endosc 2013; 27: 3016-3020
• 20 Ponsaing LG, Kiss K, Hansen MB. Classification of submucosal tumors in the gastrointestinal tract. World J Gastroenterol 2007; 13: 3311-3315
• 21 Cai JQ, Chen K, Mou YP. et al. Laparoscopic versus open wedge resection for gastrointestinal stromal tumors of the stomach: a single-center 8-year retrospective cohort study of 156 patients with long-term follow-up. BMC Surg 2015; 15: 58
• 22 Kim SY, Kim KO. Management of gastric subepithelial tumors: the role of endoscopy. World J Gastrointest Endosc 2016; 8: 418-424
• 23 Bang CS, Baik GH, Shin IS. et al. Endoscopic submucosal dissection of gastric subepithelial tumors: a systematic review and meta-analysis. Korean J Intern Med 2016; 31: 860-871
• 24 Jain D, Mahmood E, Desai A. et al. Endoscopic full thickness resection for gastric tumors originating from muscularis propria. World J Gastrointest Endosc 2016; 8: 489-495
• 25 Werner YB, Rösch T. POEM and submucosal tunneling. Curr Treat Options Gastroenterol 2016; 14: 163-177
• 26 Kataoka Y, Tsuji Y, Sakaguchi Y. et al. Bleeding after endoscopic submucosal dissection: Risk factors and preventive methods. World J Gastroenterol 2016; 22: 5927-5935
• 27 Huh CW, Youn YH, Jung da H. et al. Early attempts to eradicate Helicobacter Pylori after endoscopic resection of gastric neoplasm significantly improve eradication success rates. PLoS One.  2016; 11: e0162258
• 28 Ren Z, Zhong Y, Zhou P. et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012; 26: 3267-3272
• 29 Lv XH, Wang CH, Xie Y. et al. Efficacy and safety of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors: a systematic review and meta-analysis. Surg Endosc 2017; 31: 49-63