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. 2019 Nov;18(5):5277-5282.
doi: 10.3892/ol.2019.10894. Epub 2019 Sep 19.

A Novel Technique for Removing Large Gastric Subepithelial Tumors With ESD Method in the Subcardia Region

Free PMC article

A Novel Technique for Removing Large Gastric Subepithelial Tumors With ESD Method in the Subcardia Region

Bingtuan Liu et al. Oncol Lett. .
Free PMC article


Previously, patients with tumors larger than 4 cm in sub-cardia region usually received open gastrectomy. Due to its anatomic features, the cardia is often considered as a contraindicated area for endoscopic resection. Herein, we report a novel technique of endoscopic submucosal dissection (ESD) which facilitates the removal of gastric subepithelial tumors (SMTs) larger than 4 cm in the subcardia and fundus region. This is a retrospective case series of patients with SMTs larger than 4 cm in the subcardia and fundus regions who received the novel procedure of ESD between October 2015 and October 2016. The novel procedure of ESD involved a median linear incision of the mucosa being made in the central area of the tumor, followed by the submucosal dissection. The residual defect was finally closed using titanium endoclips. The endoscopical outcomes, histopathological findings as well as other complications were assessed. Eight patients fulfilled the entry criteria. The mean lesion size was 45.6±7.5 mm (range: 40.0-65.0 mm), and the mean operating time was 83±13 min (range: 60-100 min). The en bloc resection rate was 100%. Although perforations occurred in 5 out of 8 patients, they were successfully closed with endoclips. The median length of inpatient hospital stay was 6 days (range: 5-8 days). No patients needed further gastrectomy. The median follow-up was 36 months and none of the patients developed local recurrence or distant metastasis. The advanced procedure of ESD is feasible and safe for tumors more than 4 cm in the subcardia region. It could be applied as a novel technique for treating patient without surgical interventions.

Keywords: endoscopic submucosal dissection; gastric subepithelial tumors; subcardia region.


Figure 1.
Figure 1.
The advanced ESD procedure. A solution mixed with 0.9% saline, methylene blue and diluted epinephrine was injected into the submucosal layer of the tumor. A hook-knife was directly used to make a median linear incision of the mucosa in the position with the central, superficial mucosa area of the tumor. The incision was made to expose the body of the tumor in the center areas. Then the en bloc resection was carried out with the insulated-tip knife until the tumor was completely dissected. After the tumor was dissected, the residual defect was closed using titanium endoclips. (A) Endoscopic view of an SMT in the subcardia region of the stomach. (B) EUS images showing a narrow connection of tumor with the fourth hypoechoic EUS layer, indicating the origin from the superficial muscularis propria. (C) A median linear incision was made into the mucosa. (D) A submucosal dissection was made to expose the SMT. (E) Endoscopic dissection of the tumor. (F) Endoscopic view of residual defect after the body of the tumor dissection. (G) The residual defect was closed using endoclips. (H) View of tumor after dissection. (I) Histopathology of the tumor suggested leiomyomas. ESD, endoscopic submucosal dissection; SMT, subepithelial tumor; EUS, endoscopic ultrasonography.

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