Video
The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.
The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.
Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.
A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.
We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.
Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.
The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.
The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.
Case Description
Endoscopic submucosal dissection is an established minimally invasive procedure for the removal of GI premalignant and malignant lesions, with potential for detailed pathologic evaluation.1,2 Submucosal tunneling endoscopic resection (STER) is a well-established technique within the field of endoscopic submucosal dissection that involves tunnel-exposed, endoscopic full-thickness resection for lesions originating from different layers of the GI tract wall.3
GI stromal tumors (GISTs) are potentially malignant subepithelial mesenchymal tumors, arising from interstitial cells of Cajal found in the myenteric plexus.4 Ninety percent occur in the stomach and small intestine. Esophageal GISTs account for less than 1% of all GISTs.2,4,5 Until recently, treatment options included surveillance, surgical resection, tyrosine kinase inhibitor (TKI), and imatinib, depending on the extent of disease and tumor sensitivity to TKI.2,4,6 The advances in third-space endoscopy have led to the development of peroral endoscopic tunnel resection (POET) for the management of submucosal tumors.7,8 STER, like POET in principle, is increasingly favored for lesions originating from the muscularis propria layer.7 We present a rare case of an esophageal GIST that was successfully removed with STER.
A 75-year-old woman with a history of compensated alcohol-related cirrhosis (MELD-Na 7 points, Child Turcotte Pugh class A) underwent an upper EGD for variceal screening, which revealed an incidental 1-cm well-circumscribed upper esophageal submucosal lesion. The patient was subsequently referred to our team for further evaluation. We first performed EUS using the linear US endoscope (TGF-UC180J; Olympus, Center Valley, Penn, USA). The mass was identified in the upper esophagus and measured 1 × 1 cm. The mass was oval with hypoechoic and homogenous echotexture and well-demarcated borders. This mass was noted to arise from the muscularis propria layer, and pathology from biopsies were consistent with GISTs. We discussed treatment options, including surgery, and the patient elected for endoscopic removal of this mass.
For the procedure, a gastroscope (GIF-HQ190; Olympus), electrocautery knife (Hybrid Knife T type, product no. 20150-260; ERBE USA, Marietta, Ga, USA), and through-the-scope hemoclips (Resolution 360 ULTRA clip; Boston Scientific, Natick, Mass, USA) were used. An injection needle (Injector Force Max 4 mm, 23-gauge injection needle, model no. NM4004-0423; Olympus) was used to create a large submucosal injection using a lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the electrocautery knife. Tunnel creation by submucosal dissection was then performed. The mass was identified originating from the muscularis propria layer (Figs. 1 and 2). The submucosal tunnel was extended 2 cm distally from the mass. Resection of the mass was then performed. The mucosal surface of the mass was dissected first with dissection beginning at the distal portion and then proceeded proximally. The remaining attached bands of muscularis propria on the distal portion were resected ensuring complete endoscopic en bloc resection (Video 1, available online at www.videogie.org). The entire defect bed was inspected with no active bleeding noted (Fig. 3). The specimen was then retrieved and sent to pathology (Fig. 4). The mucosal defect was then closed using hemostatic clips (Fig. 5). During the procedure, the patient received 500 mg of ciprofloxacin. The patient was admitted overnight for monitoring and was discharged in stable condition. Final pathology revealed a well-circumscribed lesion with sheets of bland spindle cells with no appreciable mitotic activity extending to the area of cautery or artifact. The capsule was intact. However, the pathologist was unable to comment on margins because the mass was resected totally (Figure 6, Figure 7, Figure 8). A follow-up EGD 4 weeks later revealed a healed defect with scarring (Fig. 9).
Figure 1.
Well-circumscribed lesion.
Figure 2.
Luminal view of smooth-surfaced oval mass seen on submucosal dissection.
Figure 3.
Defect bed post-resection reveals no active bleeding.
Figure 4.
Ex vivo sample of the esophageal mass.
Figure 5.
Mucosal defect closure with hemostatic clips.
Figure 6.
Well-circumscribed mass on pathology (H&E, orig. mag. ×20).
Figure 7.
Esophageal mass positive for CD-117 (c-kit).
Figure 8.
Esophageal mass positive for DOG-1.
Figure 9.
Follow-up EGD showing healed defect with scarring.
Our case highlights the utility of STER in the management of esophageal GISTs with excellent clinical outcomes. STER achieves high complete resection rates and en bloc rates and low risk of perforation, and allows for better wound healing, reduced GI tract leakage, reduced hospital stay, and more precise hemostasis.8, 9, 10 POET and STER are safe and effective if en bloc resection with an intact capsule is achieved. However, because GISTs are more fragile compared to other submucosal tumors and resection with an intact capsule is technically more challenging, additional surgery and monitoring should be considered if piecemeal excision occurs or pathology reveals GISTs with high-risk features.11,12 Further prospective studies are needed to establish the role of STER in larger submucosal tumors.
Disclosure
Dr Holzwanger is a consultant for Virgo. Dr Gabr is a consultant for Medtronic, ConMed, Olympus, Boston Scientific, Fuji, and Adaptiv Endo. Dr Berzin is a consultant for Boston Scientific, Medtronic, and Fuji. Dr Pleskow is a consultant for Boston Scientific, Medtronic, Olympus, and Fuji. All other authors disclosed no financial relationships relevant to this publication.
Supplementary data
The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.
The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.
Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.
A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.
We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.
Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.
The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.
The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.
References
- 1.Fukami N. Endoscopic submucosal dissection in the esophagus. Gastrointest Endosc Clin N Am. 2023;33:55–66. doi: 10.1016/j.giec.2022.09.003. [DOI] [PubMed] [Google Scholar]
- 2.Dalal I., Andalib I. Advances in endoscopic resection: a review of endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER) Transl Gastroenterol Hepatol. 2022;7:19. doi: 10.21037/tgh-2020-10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Du C., Linghu E. Submucosal tunneling endoscopic resection for the treatment of gastrointestinal submucosal tumors originating from the muscularis propria layer. J Gastrointest Surg. 2017;21:2100–2109. doi: 10.1007/s11605-017-3579-7. [DOI] [PubMed] [Google Scholar]
- 4.Costa F., Casaca R., Monteiro C., et al. Oesophageal GIST. BMJ Case Rep. 2020;13 doi: 10.1136/bcr-2020-238058. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Rubin B.P., Heinrich M.C., Corless C.L. Gastrointestinal stromal tumour. Lancet. 2007;369:1731–1741. doi: 10.1016/S0140-6736(07)60780-6. [DOI] [PubMed] [Google Scholar]
- 6.Judson I., Demetri G. Advances in the treatment of gastrointestinal stromal tumours. Ann Oncol. 2007;18:20–24. doi: 10.1093/annonc/mdm410. [DOI] [PubMed] [Google Scholar]
- 7.Onimaru M., Inoue H., Bechara R., et al. Clinical outcomes of per-oral endoscopic tumor resection for submucosal tumors in the esophagus and gastric cardia. Digest Endosc. 2020;32:328–336. doi: 10.1111/den.13471. [DOI] [PubMed] [Google Scholar]
- 8.Eleftheriadis N., Inoue H., Ikeda H., et al. Submucosal tunnel endoscopy: peroral endoscopic myotomy and peroral endoscopic tumor resection. World J Gastrointest Endosc. 2016;8:86–103. doi: 10.4253/wjge.v8.i2.86. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Rajravelu R.K., Ginsberg G.G. Management of gastric GI stromal tumors: getting the GIST of it. Gastrointest Endosc. 2020;91:823–825. doi: 10.1016/j.gie.2019.11.036. [DOI] [PubMed] [Google Scholar]
- 10.Tan Y., Tang X., Guo T., et al. Comparison between submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric stromal tumors originating from the muscularis propria layer. Surg Endosc. 2017;31:3376–3382. doi: 10.1007/s00464-016-5350-7. [DOI] [PubMed] [Google Scholar]
- 11.Duan T.Y., Tan Y.Y., Wang X.H., et al. A comparison of submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric fundus submucosal tumors. Rev Esp Enferm Dig. 2017;110:160–165. doi: 10.17235/reed.2017.4699/2016. [DOI] [PubMed] [Google Scholar]
- 12.Lv X.H., Wang C.H., Xie Y. 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. doi: 10.1007/s00464-016-4978-7. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.
The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.
Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.
A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.
We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.
Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.
The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.
The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.
The mass was identified at the upper- to mid-esophagus, 25 cm from the central incisors. No varices were seen on further examination of the esophagus. A 4-mm injector force needle was used to create a large submucosal injection using BlueBoost lifting agent proximal to the mass. A longitudinal mucosal incision was then made using the hybrid T-type electrocautery knife, 20 cm from the central incisors.
The cutting current was the preset Endocut Q mode, and the coagulation setting was spray coag mode, effect 2 and 40 W.
Next, tunnel creation by submucosal dissection was performed with a focus on keeping the submucosal space as clean as possible. Carbon dioxide was used for insufflation to prevent pneumoperitoneum.
A smooth-surfaced oval mass was identified originating from the muscularis propria layer. Dissection was extended 2 cm distally beyond the mass. Next, resection of the mass was performed. First, the mucosal surface of the mass was dissected. Dissection began at the distal portion, proceeded to the left and right lateral borders, and then continued toward the proximal portion. The mass was dissected away from the muscularis propria.
We focused on freeing the mass, ensuring this esophageal mass was intact throughout dissection. The attached bands of muscularis propria at the distal portion were carefully resected completely.
Water irrigation was used at this time to ensure better visualization for resection. The remaining attached bands of muscularis propria were resected, ensuring complete en bloc resection. Afterward, the mass was suctioned into the cap and carefully retrieved as shown, and then sent to pathology for processing.
The entire defect bed was inspected post-resection, and no perforation or bleeding was identified.
The mucosal defect was completely closed with through-the-scope hemostatic clips in a longitudinal fashion beginning with approximation of the defect at the distal portion.