Endoscopic resection of gastrointestinal submucosal lesions: a comparison between strip biopsy and aspiration lumpectomy

doi:10.1016/S0016-5107(96)70089-5

Gastrointestinal Endoscopy

Volume 44, Issue 4, October 1996, Pages 404-410

https://doi.org/10.1016/S0016-5107(96)70089-5 Get rights and content

Abstract

Background: Endoscopic diagnosis and treatment of gastrointestinal submucosal lesions is still not established. We evaluated the clinical usefulness of two resection methods for submucosal lesions, using a “nonrandomized surgeon” design.

Methods: The strip biopsy method was evaluated at Tenri Hospital and the aspiration lumpectomy method was used at Kyoto University Hospital. The inclusion criteria for selecting patients were endosonographic findings indicating a tumor location within the submucosa.

Results: Seventy-seven patients were treated. The size of the specimens (mean ± SEM) was 20.7 ± 0.9 mm for the aspiration lumpectomy group and 14.0 ± 0.8 mm for the strip biopsy group ( p < 0.01). Aspiration lumpectomy was adequate for a definitive histologic diagnosis in 95% of the cases (36 of 38) as compared with 77% (30 of 39) of the cases treated by strip biopsy ( p = 0.047). The eradication rate was 87% for the aspiration lumpectomy group, and 74% for the strip biopsy group ( p = 0.274). The complication rate resulting from these procedures (hemorrhage, mean 5%) was acceptable. Repeated endoscopic examinations revealed no recurrence except for one lymphangioma.

Conclusions: Endoscopic resection, especially aspiration lumpectomy, provides a significant benefit for accurate final diagnosis and eradication of submucosal lesions. (Gastrointest Endosc 1996;44:404-10.)

Section snippets

Study design, setting, and end points

This comparative study was a controlled trial with nonrandomized concurrent controls (“nonrandomized surgeon” design7, 8). The patients were randomly allocated to two groups of surgeons, who then performed their operation of choice. Since both groups of endoscopic surgeons were thoroughly familiar with their method of choice, exclusion for technical reasons was unnecessary. No surgeon had to learn or relearn an endoscopic technique, and thus there were no initial inferior results. The relative

RESULTS

Table 1 lists the clinical characteristics of the patients treated by endoscopic resection. The patients included 37 men and 40 women, aged 15 to 80 years, with an overall mean age of 56 years. The tumor localization was statistically significant (p < 0.001) because of the small number of esophageal lesions in the strip biopsy group. All of the 13 colonic lesions were located in the rectum except for one case of a lipoma removed by strip biopsy in the ascending colon. The lesions ranged in size

DISCUSSION

Submucosal lesions should preferably be diagnosed and treated by endoscopic methods, since these are less invasive than surgical laparotomy. Endoscopic submucosal biopsy only allows diagnoses, without any eradication of the lesion. The “button-hole biopsy” technique² was an attempt to improve these methods by allowing the sampling of histologic specimens from an area previously exposed by means of an electrosurgical snare or an ethanol injection. Aspiration cytology,¹³ giant biopsy,¹⁴ and

Acknowledgements

The authors thank Bruce Symons for his helpful suggestions regarding the manuscript.

References (60)

TR Martin et al.
Lift and cut biopsy technique for submucosal sampling
Gastrointest Endosc
(1976)
M Karita et al.
Endoscopic and histologic diagnosis of submucosal tumors of the gastrointestinal tract using combined strip biopsy and bite biopsy
Gastrointest Endosc
(1994)
M Karita et al.
Endoscopic therapy for early colon cancer: the strip biopsy resection technique
Gastrointest Endosc
(1991)
MJ Wiersema et al.
Combined endosonography and fine-needle aspiration cytology in the evaluation of gastrointestinal lesions
Gastrointest Endosc
(1994)
KJ Chang et al.
Endoscopic ultrasound-guided fine-needle aspiration
Gastrointest Endosc
(1994)
JP Papp et al.
Endoscopic removal of colon lipomas
Gastrointest Endosc
(1973)
SA Pfeil et al.
Colonic lipomas: outcome of endoscopic removal
Gastrointest Endosc
(1990)
J Fujisaki et al.
Enucleation of a gastric leiomyoma by a combined laser and snare electro-cutting technique
Gastrointest Endosc
(1988)
T Matsumoto et al.
Endoscopic ultrasonography in rectal carcinoid tumors: contribution to selection of therapy
Gastrointest Endosc
(1991)
A Torii et al.
Endoscopic aspiration mucosectomy as curative endoscopic surgery: analysis of 24 cases of early gastric cancer
Gastrointest Endosc
(1995)

CW Liebert

Symptomatic lymphangioma of the esophagus with endoscopic resection

Gastrointest Endosc

(1983)

T Matsumoto et al.

Submucosal tumors of the terminal ileum managed by endoscopic polypectomy

Gastrointest Endosc

(1990)

M Karita et al.

The successive strip biopsy partial resection technique for large early gastric and colon cancers

Gastrointest Endosc

(1992)

H Inoue et al.

Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions

Gastrointest Endosc

(1993)

H Inoue et al.

Endoscopic mucosectomy for early cancer using a pre-looped plastic cap

Gastrointest Endosc

(1994)

JL Hedenbro et al.

Endoscopic diagnosis of submucosal gastric lesions. The results after routine endoscopy

Surg Endosc

(1991)

C Crosta et al.

Gastric submucosal neoplasms: new diagnostic and therapeutic procedures

Ital J Surg Sci

(1987)

K Yasuda et al.

Endoscopic ultrasonography in the diagnosis of submucosal tumor of the upper digestive tract

Scand J Gastroenterol

(1986)

T Kajiyama et al.

Endoscopic aspiration lumpectomy of esophageal leiomyomas derived from the muscularis mucosae

Am J Gastroenterol

(1995)

W Van der Linden

Pitfalls in randomized surgical trials

Surgery

(1980)

W Van der Linden

On the generalization of surgical trial results

Acta Chir Scand

(1980)

B Dawson-Saunders et al.

Basic and clinical biostatistics

(1994)

R Simon

Confidence intervals for reporting results of clinical trials

Ann Intern Med

(1986)

LE Braitman

Confidence intervals assess both clinical significance and statistical significance

Ann Intern Med

(1991)

P Lange et al.

Endoscopic fine-needle aspiration cytology of the stomach. A new diagnostic procedure

Endoscopy

(1987)

E Kaneko et al.

Evaluation of the new giant-biopsy forceps in the diagnosis of mucosal and submucosal gastric lesions

Endoscopy

(1983)

M Spandre et al.

Needle biopsy of submucosal lesions of gastrointestinal tract

Surg Endosc

(1990)

GC Caletti et al.

Guillotine needle biopsy as a supplement to endosonography in the diagnosis of gastric submucosal tumors

Endoscopy

(1991)

M Giovannini et al.

Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients

Endoscopy

(1995)

M Ranchod et al.

Smooth muscle tumors of the gastrointestinal tract and retroperitoneum

Cancer

(1977)

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Hence it cannot be applied in preliminary hospitals. In 1996, Kajiyama et al.10 reported 38 cases in which a transparent cap was used to remove small submucosal GI tumors, with few adverse events. The tumor was first aspirated into the cap, grasped at its base with a snare, removed by electrocautery and then retrieved by aspirating into the cap.
To assess the effectiveness and safety of cap-assisted endoscopic resection and the usefulness of endoscopic ultrasonography (EUS) for managing small rectal subepithelial tumors (SETs).
Patients with small rectal SETs ≤ 10 mm in diameter were enrolled in this study at our hospital from October 2014 to December 2017. First, EUS was performed to evaluate the lesions. Then, cap-assisted endoscopic resection was performed by suctioning the SET into a transparent cap, ligating with a metal snare and then resecting the tumor. The wound was closed using endoclips if necessary.
Forty patients were enrolled in the study. EUS showed lesions originating from muscularis mucosa or submucosa with an average diameter of 5.4 × 3.1 mm. The en bloc resection rate was 85.0% obtained by cap-assisted endoscopic resection, with a mean total procedure time of 17.6 min. No immediate perforation happened. Immediate bleeding occurred in five patients; all cases were managed successfully by endoscopy. No delayed bleeding was observed. Pathology examination showed that 70.0% of the lesions were neuroendocrine tumors (G1). One case of recurrence was seen in follow-up; it was managed successfully by endoscopic submucosal dissection. There was no tumor recurrence in a median follow-up period of 41 months in the remaining 39 patients.
Most small rectal SETs arising from the muscularis mucosa or submucosa are neuroendocrine tumors and require proper treatment. Cap-assisted endoscopic resection is simple, effective and safe for resecting such lesions, and EUS is useful for case screening.
Evaluar la eficacia y la seguridad de la resección endoscópica asistida por capuchón y la utilidad de la ultrasonografía endoscópica (USE) para el tratamiento de pequeños tumores subepiteliales (TSE) rectales.
Los pacientes con TSE rectales pequeños ≤10 mm de diámetro se enrolaron en este estudio en nuestro hospital desde octubre de 2014 hasta diciembre de 2017. Primero, se realizó una USE para evaluar las lesiones. Luego, se realizó una resección endoscópica asistida por capuchón aspirando el TSE en un capuchón transparente, ligándolo con una asa metálica de polipectomía y luego resecando el tumor. La herida se cerró usando endoclips, si ello era necesario.
Cuarenta pacientes fueron enrolados en el estudio. La USE mostró lesiones originadas en la muscularis mucosae o submucosa con un diámetro promedio de 5,4 × 3,1 mm. La tasa de resección en bloque fue del 85,0% obtenida mediante resección endoscópica asistida por capuchón, con un tiempo total medio de procedimiento de 17,6 min. No se produjo ninguna perforación en el momento. Se produjo una hemorragia inmediata en cinco pacientes; todos los casos se trataron con éxito mediante una endoscopia. No se observó ningún retraso en el sangrado. El examen patológico mostró que el 70% de las lesiones eran tumores neuroendocrinos (G1). En el seguimiento se observó un caso de recurrencia, el cual se trató con éxito mediante una disección endoscópica de la submucosa. No hubo recurrencia de tumores en un período de seguimiento medio de 41 meses en los 39 pacientes restantes.
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Gastric perforation was not uncommon, seen in nearly 15% of patients, and bleeding was also reported in 5%. Modifications of traditional endoscopic mucosal resection have been reported including cap assisted and ligation devices, with similarly impressive resection rates and DY, but unfortunately also with significant complication rates [55,56]. The endoscopic tunneling technique, while initially reported for per oral endoscopic myotomy, was first reported to be successful for resection of SEM in the English literature in 2012 by Xu et al [57], Gong et al [58], and Inoue et al [59].
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Giant gastric lipoma presenting as GI bleed: Enucleation or Resection?
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Asymptomatic incidental lipomas usually only require observation. Small symptomatic lesions around 2 cm in size can be successfully treated with endoscopic management using techniques such as aspiration lumpectomy or strip biopsy [17]. Larger lipomas, 4 cm or greater, can be removed endoscopically with the unroofing technique [18].
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ESMR adapts a variety of endoscopic mucosal resection techniques to removing lesions from the submucosa (third layer). ESMR involves raising the lesion away from the fourth layer, the muscularis propria, either by injection of saline solution (strip biopsy) or suction of the lesion into a cap fitted to the endoscope (aspiration lumpectomy), followed by electrosurgical snare resection.7,64,70,71 Subepithelial lesions that are confined to layers 1 to 3 and up to 20 mm in size are amenable to safe resection.7,64,72
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In ESMR-C a transparent plastic cylinder is placed on the end of an endoscope into which the target mucosal lesion is suctioned and then resected with an electrosurgical snare. Case reports and series have described the use of ESMR in the diagnosis and resection of subepithelial tumors that are benign or of low malignant potential.4-6,14-19 Kojima et al5 evaluated the diagnostic utility of endoscopic resection in 54 patients with subepithelial lesions involving the submucosa and muscularis propria.
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Our purpose was to prospectively determine the diagnostic yield of endoscopic submucosal-mucosal resection (ESMR) compared with forceps biopsy for lesions limited to the submucosa (third endosonographic layer) of the GI tract.
A prospective head-to-head comparison was performed.
The study was performed in a tertiary care hospital.
Study patients were 23 adults with subepithelial lesions limited to the submucosa.
All submucosal lesions underwent forceps biopsy followed by endoscopic submucosal resection. Biopsy speciments were obtained with large-capacity “jumbo” forceps. A total of 4 double passes (8 biopsy specimens) were collected from each lesion with use of the bite-on-bite technique. Endoscopic resection was then performed with an electrosurgical snare or cap-fitted endoscopic mucosal resection device.
The main outcome measurement was the diagnostic yield of biopsy forceps compared with endoscopic submucosal resection.
Twenty-three patients with lesions limited to the submucosa were identified by endoscopic ultrasonography. All lesions underwent forceps biopsy followed by ESMR. The diagnostic yield of the jumbo forceps biopsy was 4 of 23 (17%), whereas the diagnostic yield of ESMR was 20 of 23 (87%) (P = .0001, McNemar test).
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^☆: From the First Department of Internal Medicine, and the First Department of Surgery, Kyoto University, Kyoto, Japan; and the Department of Gastroenterology, Tenri Hospital, Nara, Japan.

^☆☆: Reprint requests: Toru Kajiyama, MD, First Department of Internal Medicine, Kyoto University, Sakyo Ward, Kyoto, 606-01, Japan.

^★: 37/1/72671

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Endoscopic resection of gastrointestinal submucosal lesions: a comparison between strip biopsy and aspiration lumpectomy☆,☆☆,★

Abstract

Section snippets

Study design, setting, and end points

RESULTS

DISCUSSION

Acknowledgements

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Gastrointest Endosc

Endoscopic diagnosis of submucosal gastric lesions. The results after routine endoscopy

Surg Endosc

Gastric submucosal neoplasms: new diagnostic and therapeutic procedures

Ital J Surg Sci

Endoscopic ultrasonography in the diagnosis of submucosal tumor of the upper digestive tract

Scand J Gastroenterol

Endoscopic aspiration lumpectomy of esophageal leiomyomas derived from the muscularis mucosae

Am J Gastroenterol

Pitfalls in randomized surgical trials

Surgery

On the generalization of surgical trial results

Acta Chir Scand

Basic and clinical biostatistics

Confidence intervals for reporting results of clinical trials

Ann Intern Med

Confidence intervals assess both clinical significance and statistical significance

Ann Intern Med

Endoscopic fine-needle aspiration cytology of the stomach. A new diagnostic procedure

Endoscopy

Evaluation of the new giant-biopsy forceps in the diagnosis of mucosal and submucosal gastric lesions

Endoscopy

Needle biopsy of submucosal lesions of gastrointestinal tract

Surg Endosc

Guillotine needle biopsy as a supplement to endosonography in the diagnosis of gastric submucosal tumors

Endoscopy

Fine-needle aspiration cytology guided by endoscopic ultrasonography: results in 141 patients

Endoscopy

Smooth muscle tumors of the gastrointestinal tract and retroperitoneum

Cancer