Endoscopic resection of large subepithelial esophageal lesions via submucosal tunneling endoscopic resection and endoscopic submucosal dissection: a single-center, retrospective cohort study

Figures & data

Figure 1. Flow chart of the study profile. SEL: submucosal esophageal lesions; ESD: endoscopic submucosal excavation; STER: submucosal tunneling endoscopic resection.

Figure 2. Endoscopic submucosal dissection for a large subepithelial esophageal lesion. (A) Endoscopic view of oval-like tumor. (B) Endoscopic ultrasonography view of the tumor. (C) Submucosal injection with fluid mixture. (D) Incision of the covering mucosa. (E) Peeling the lesions. (F) The wound after resection. (G) Closure of the mucosal incision by clips. (H) The resected specimen.

Figure 3. Submucosal tunneling endoscopic resection for a large submucosal esophageal lesion. (A) Endoscopic view of a ring-like tumor surrounding the esophagus. (B) Endoscopic ultrasonography view of the tumor. (C) A 2-cm longitudinal mucosal incision was made approximately 5 cm proximal to the SEL. (D) The submucosal tunnel is established. (E) The SEL is exposed using the submucosal tunnel technique. (F) Separating the tumor from the MP layer using the hybrid knife. (G) The mucosal entry incision is sealed with several clips. (H) Irregularly-shaped completely resected specimen (maximal diameter).

Table 1. Characteristics of 56 patients and subepithelial esophageal lesions after resection.

Characteristics	STER	ESD	p Value
	(n = 42)	(n = 14)
Age, median (range), years	50 (18–79)	45 (19–74)	.956
Sex, female/male, n	14/28	4/10	1
Symptoms, n (%)			.633
Symptomatic, n (%)	15	6
Asymptomatic, n (%)	27	8
Size
Longitudinal length			.011
≥70 mm, n (%)	1	4
＜70 mm, n (%)	41	10
Transverse diameter			.342
≥30 mm, n (%)	15	7
＜30 mm, n (%)	27	7
Tumor shape, n (%)			1
Regular	30	10
Irregular	12	4
Growth pattern, n (%)			.317
Extraluminal	11	6
intraluminal	31	8
Location, n (%)			.839
Upper esophagus	6	2
Middle esophagus	14	6
Lower esophagus	22	6
Histopathology, n (%)			.03
Leiomyoma	38	9
Leiomyosarcoma	2	0
Lipoma	0	1
Lymphoma	0	1
Castleman	1
Branchiogenic cyst		1
Adenosarcoma		1
Schwannoma	1
Granular cell		1

ESD: endoscopic submucosal dissection; STER: submucosal tunneling endoscopic resection.

Table 2. Outcomes after resection in patients in submucosal tunneling endoscopic resection and endoscopic submucosal dissection.

Outcome	STER (n = 42)	ESD (n = 14)	p Value
Complete resection, n (%)	37 (88.1%)	11 (78.6%)	.398
Perforation, n (%)	5 (11.9%)	6 (42.9%)	.020
Major adverse events, n (%)	4 (9.5%)	5 (35.7%)	.035
Major pneumothorax/pleural effusion	1 (2.4%)	3 (21.4%)
Massive hemorrhage	1 (2.4%)	0
Pulmonary embolism	1 (2.4%)	1 (7.1%)
Pulmonary infection	0	1 (7.1%)
Procedure time, min, median (range)	99 (45–200)	62.5 (22–165)	.03
Operation speed, mm^2/min, median (range)	10.3 (5.46–18.3)	18.02 (10.9–61.5)	<.001
Hospital stay, d, median (range)	6 (4–12)	9 (4–21)	.020
Follow-up time, month, median (range)	24 (11–48)	22 (11–44)	.496

ESD: endoscopic submucosal dissection; STER: submucosal tunneling endoscopic resection.

Table 3. Comparison between the complete resection group and piecemeal resection group.

Characteristics	Complete resection (n = 48)	Piecemeal resection (n = 8)	p Value
Age, median (range) years	45.5 (18–79)	43.5 (20–56)	.155
Sex, n			.703
Female (18)	15	3
Male (38)	33	5
Longitudinal length			.348
≥70 mm (12)	9	3
<70 mm (44)	39	5
Transverse diameter			.008
≥35 (12)	7	5
<35 (44)	41	3
Tumor shape			.005
Regular (40)	38	2
Irregular (16)	10	6
Location			.595
Upper (8)	6	2
Middle (20)	18	2
Lower (28)	24	4
Tumor growth pattern^a			<.001
Extraluminal (17)	10	7
Intraluminal (39)	38	1
Type of ER, n			.398
ESD (14)	11	3
STER (42)	37	5
Histology			.329
Leiomyoma (47)	39	8
Other (9)	9	0

^aSignificant risk factors for piecemeal resection in multivariate analysis (extraluminal growth pattern, OR 14.2218 (1.3394, 151.0076) p = .0276).

Table 4. Comparison between nonperforation group and perforation group.

Characteristics	nonperforation (n = 45)	Perforation (n = 11)	p Value
Age, median (range) years	50 (18–79)	44 (19–51)	.090
Sex, female/male, n	15/30	3/8	1
Longitudinal length			.251
≥70 mm (n = 5)	3	2
<70 mm (n = 51)	42	9
Transverse diameter			<.001
≥35 mm (n = 12)	2	10
<35 mm (n = 44)	43	1
Tumor shape			.008
Regular (n = 40)	36	4
Irregular (n = 16)	9	7
Procedure time			.026
≥100 (n = 18)	7	11
<100 (n = 38)	4	34
Location			.229
Upper (n = 8)	5	3
Middle (n = 20)	19	1
Lower (n = 28)	24	4
Tumor growth pattern			<.001
Extraluminal (n = 17)	8	9
Intraluminal (n = 39)	37	2
Type of ER, n^a			.020
ESD (n = 14)	8	6
STER (n = 42)	37	5
Histology			.183
Leiomyoma (n = 46)	35	11
Other (n = 10)	10	0

^aSignificant risk factors for perforation in multivariate analysis (type of ER: OR 0.0842 (0.0073,0.9698), p value = .0472).