Submucosal Ligation and Suck Endoscopic Separated-Resection a Technique for Excision of Small Gastric Stromal Tumours

Clinical Gastroenterologist International ISSN: 2691-5642

Research Article

Submucosal Ligation and Suck Endoscopic Separated- Resection a Technique for Excision of Small Gastric Stromal Tumors Changchun C1,2*, Cuiping Y3#, Xiaojin Y4#, Yingming L1, Mingfu T1, Xijin W1 and Junli Z5 1Department of Digestive System, The Affiliated Hospital of JiuJiang University, Jiujiang, China 2Department of Digestive Diseases, Jiujiang University, Jiujiang, China 3Department of Gastroenterology, Ruijin Hospital North, Shanghai Jiaotong University School of Medicine, China 4Department of Infection Control, The First Hospital of Jiujiang City, Jiangxi Province, Jiujiang, China 5Department of Geriatric Medicine, Ruijin Hospital, North Shanghai Jiaotong University School of Medicine, China #Authors Contributed Equally Abstract Objective: To evaluate the method of Submucosal Ligation and Suck Endoscopic Separated- Resection (SLSER) in resecting small gastric stromal tumors. Methods: In our hospital, we observed and analyzed 61 resections of small gastric stromal tumors from July 2008 to July 2011, which were performed by submucosal ligation and suck endoscopic separated-resection. The specimens were sent for histological examination. In order to observe tumor shedding and wound healing, the tumors were reviewed by endoscopy on Day 7, and at Months 1, 3, 6 and 12 post-operation. Results: In the 61 cases, the 60 tumors were completely separated, with a complete resection rate of 98%. Only one tumor could not be totally separated, but it necrosed following the device falling off. No perforation, bleeding, other complications or recurrence were observed by endoscopic examination during follow up. We found this technique to be a safe and effective treatment for small gastric stromal tumors. SLSER is a simple operation, with few complications and allows complete resection. Conclusion: SLSER is an ideal method for resecting small gastric stromal tumors. Keywords: Small gastric stromal tumor; Endoscopic treatment; Submucosal ligation and suck endoscopic separated-resection (SLSER)

Introduction bleeding and other serious complications. Domestic scholars mostly agree that SMT needs surgery or regular check-ups. Gastrointestinal Stromal Tumors (GISTs) account for less than 3% of all gastrointestinal tract tumors, and 5.7% of all sarcomas; Tumors from the muscularis propria include stromal tumors, indeed, the majority of sarcomas are gastric in origin. Patients schwannomas and leiomyoma. The long-term follow-up with these commonly manifest with gastrointestinal bleeding or abdominal tumors, necessary because of the high tendency to malignancy, is a pain with 10% to 30% of patients expressing with symptoms of heavy burden to the patient. gastrointestinal obstruction. Endoscopic Mucosal Resection (EMR) can completely resect tumors from the gastrointestinal mucosa and In recent years, Endoscopic Submucosal Dissection (ESD), based the submucosal layer. It is used widely in the diagnosis and treatment on EMR by hook and IT knife, has gradually become a diagnosis and of gastrointestinal mucosal lesions [1]. It is common sense that a treatment technology, which is used to resect tumors of the muscularis Submucosal Tumor (SMT) is a contraindication to EMR, because of propria. At present, ESD still leads to large risk of perforation and the location of SMT, and the fact that EMR is prone to perforation, bleeding when excising muscularis propria tumors, especially for lesions that adhere closely to the muscularis propria, which require skilled operating techniques and take a long time. Few hospitals can Citation: Changchun C, Cuiping Y, Xiaojin Y, Yingming L, Mingfu T, carry out the operation, let alone the basic level hospitals [2]. Under Xijin W, et al. Submucosal Ligation and Suck Endoscopic Separated- these circumstances, we have created a new technique, a Submucosal Resection a Technique for Excision of Small Gastric Stromal Tumors. Ligation and Suck Endoscopic separated-Resection (SLSER) method, Clin Gastroenterol Int. 2019; 1(1): 1005. combining such technological advantages as endoscopic rubber, Submucosal cutting and sucking. The method uses a leather collar to Copyright: © 2019 Changchun Cai snare the tumor so that its basement becomes cucurbita moschata; a Publisher Name: MedText Publications LLC cut in the shape of “—” is then made on the top of the tumor, exposing Manuscript compiled: Dec 13th, 2018 the muscularis propria; the body of the tumor is then sucked outward until it is fully removed from the tissue. The whole process is safe, *Corresponding author: Changchun Cai, Department of diges- convenient and enables complete resection. Using this method, we tive system, the affiliated hospital of JiuJiang University, Institute have realized the potential of the muscularis propria for complete of digestive diseases, Jiujiang, Jiangxi, 332000, China, E-mail: resection. This article reports on the feasibility and safety of the new [email protected] technique for the treatment of small gastric stromal tumors.

Case Information and Methods • The root of the tumor is separated by the snare’s traction. The tumor is loosely trapped, and is gathered by moving the snare to Case information the tumor basement by jiggling the ring under the endoscope; This study included 61 patients who were diagnosed with GISTs this tightens and confirms the full separation of the tumor and detected by histomorphology between July 2008 and July 2011. the muscularis propria. Among these cases, 32 were male and 29 were female. Age ranged from 38 years to 69 years, and the average age was 56.2 years. Patients • Tumor is resected. The snare is elevated 1cm to 2 cm from the with Submucosal tumors found by endoscopy and confirmed with substrate and is given electric resection. endoscopic ultrasonography inspection and patients with muscularis • Specimen processing Neutral formaldehyde solution is used to propria of tumors less than 14 mm in diameter, confirmed by fix the tumor tissue that is subsequently detected pathologically. pathology and immunohistochemistry [3], underwent the SLSER Immunohistochemistry included CD117, CD34, S100 protein, operation. All patients were in the range of normal for blood cell SMA and Desmin. analysis, coagulation function and platelet count, and were not given anticoagulant drugs. All patients signed the informed consent Efficacy pre-operation, and the study was approved by the hospital's Ethics If complete separation resection was achieved, the process was Committee at Jiujiang University. considered successful in terms of efficacy. The criteria for a complete resection included that the removed tumor was complete and without Equipment defect, that the ligation ring in the wound basement had shrunk to 5 The following equipment was used: Fujioun 4400 Gastroscope mm or so, that the mucosa was coved above the healed wound, and (Japan), PENTAX 3830UT Endoscopic ultrasonography system that no residual tumor remained. The criteria for a part separation (Japan), COOK snaring ligator and transparent cap (United States), resection included that defects could be seen in the resection of the Olympus HOOK or IT knife (CITY, COUNTRY), snaring instrument tumor, that the diameter of the ligation ring in the substrate was (Japan), and the ERBE ICC-200 high frequency cutting device greater than 8 mm, and that there was residual tumor in the wound. (Germany). The wound was reviewed by endoscopy on Day 7 and Months 1, 3, 6 Procedure and 12 post-operation and evaluated for local recurrence. The procedure is described here in six steps. Statistical analysis • The snaring instrument links and wraps the tumor in the Data presented are mean ± Standard Deviation (SD). The polycyclic way. The transparent cap of the Gastroscope tip closes statistical significance of the difference was assessed using t-test. P on the main body of the stromal tumor, and forces it out of the values <0.05 were considered significant. cavity. If the transparent cap and the tumor are on a tangential Results plane, we apply pressure to the proximal tumor using the brim General condition of the cap and attract it for about 10 seconds to 15 seconds. When the red mucous membrane fills the field of vision, we Tumors that were low echo lesions of the muscularis propria of release a ligation ring and position it in the tumor basement the stomach were identified by ultrasound and endoscopic diagnosis, (or neck). After deeply drawing it once again, the second ring is and were determined GISTs by pathological examination. There were released. The two rings should either avoid overlap and be kept 61 cases of GISTs with diameters of less than or equal to 14 mm. in a vertical arrangement, or partially overlap so as to increase Patients volunteered to undergo EMBLSSR. Of the 61 tumors in total, the friction. 39 came from males and 22 from females; 40 out of 61 lesions were located in the stomach fundus, 12 in the gastric body and nine in the • The top of the tumor is cut in the shape of “—”. gastric antrum. • After the ligation, the tumor turns ischemic and colours purple. Surgical situation Then, a hook knife (or IT knife) is used to cut the top of the All 61 patients underwent surgery, so the resection rate was tumor body in a straight line, about 1/2 to 2/3 of the diameter 100%. Sixty out of 61 (98%) cases were completely separated and of the tumor. At this time the formation of the tumor would resected. Only one case was incompletely separated and resected. The probably be very difficult to correct. We suck the tumor to the residual tumors and ligation rings of 61 cases fell off synchronously side of the transparent cap and cut it. by endoscopic review without recurrence after 3 months. Operation • The transparent cap attracts the stromal tumor so that it can times ranged from 7 minutes to 29 minutes, and the median time was be separated from the tissue. The transparent cap is directly 18 minutes. The length of hospital stay ranged from 3 days to 5 days, attracted to the top of the mesenchymal tumor. The field of and the average was 3.7 days. Artificial ulcers were seen at Day 7 of vision gradually fills with white hard tissue. We maintain the post-operative observation, without recurrence at Months 1, 3, 6 or gravitational force and pull the endoscopy to about 10 cm. 12 post-operation. When the endoscopic tension can be obviously felt, we gently Pathological findings shake the endoscope so that the stromal tumor is gradually isolated from the muscularis propria, until the ligation ring on All of the patients were diagnosed with GISTs prior to treatment, the outside of the mucosa gradually declines to the pseudo- by dig deep biopsy for pathology. Chunk specimens were obtained and roots. We then remove the attractive force and observe the basal were pathologically examined. All the diagnosed cases were positive ring; if not satisfied, the above operation is repeated once or with CD117, and 92% were positive with CD34. Immunohistochemical several times, until the tumor is integrally separated and the results confirmed gastric stromal tumors, and the risk classification of substrate are completely ligated. stromal tumors in the stomach was extremely low.

Discussion differs from ESE and STER; separation is not achieved by water injection into the Submucosal layer or gradually by electric knife. Gastrointestinal stromal tumors derive from cajal cells, and With SLSER, the tumor was firstly limited, the basal layer was ligated, are the most common submucosal tumors in the digestive tract. the tumor was cut and attracted to separate, so that the tumor falls out Even when the tumor diameter is less than 3 cm, they can still be and the ligation ring shrinks inside for ligation. The technique was a low-grade malignant. Because of this unique low-grade malignant simple operation, and its safety was improved significantly. After the tendency, medical intervention must be emphasized. Potential tumor underwent the preliminary segregation, it was separated again risks need long-term follow-up, so choice of resection is extremely by ligation ring until it was dragged outside and resected completely. important. Surgical approaches to GISTs are inconsistent because of We found that both endogenous and exogenous GISTs could be the variation in size, location and degree of malignancy, and there excised completely. The snare ring had not shifted after resection. is currently a lack of consensus opinion. GISTs of greater than 3 cm Under the remaining mucosa tissue resistance, no supplementary in diameter are often treated by surgical resection or laparoscopic haemostatic treatment, such as haemoclips, were required. resection. Sun et al. [4] suggested that GISTs of less than 12 mm be treated by mucosal ligation; however, remnants may be recurring, In summary, this method is simple and safe. Operational time is there is a lack of pathological diagnosis and tumors may fall off short and it is suitable for use in basic medical units. Although no incompletely. It has previously been proposed that a high frequency relapse was found in our patients as determined by endoscopy, long- electric trap be directly used to resect a tumor following endoscopic term follow up for patients undergoing this new procedure is required band ligation, although this procedure can be associated with serious to observe the long-term effects. The SLSER technique can be used complications, such as incomplete resection, no way to ligate due to in primary health care units because it is a relatively simple, easy and the high tension of the wall of stomach, and possible acute perforation safe technology. of the stomach if the tumor directly falls away. Complications increase References significantly with exogenous tumors. Recently, endoscopy and 1. Lee IL, Lin PY, Tung SY, Shen CH, Wei KL, Wu CS. 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