Submucosal tunneling techniques: current perspectives

Figures & data

Table 1 Clinical outcomes of POEM for esophageal achalasia

Author (year)	Country	# of patients	Technical success, % (n)	Clinical success for symptom remission, %, at follow-up period (months)	Major complications,# % (n)	Additional surgery, %
Inoue (2010)^Citation16	Japan	17	100 (17)	100 (5)	0 (0)	0
Zhou (2011)^Citation17	People’s Republic of China	42	100 (42)	97.6 (2.5)	0 (0)	0
von Renteln (2012)^Citation18	Germany	16	100 (16)	100 (3)	0 (0)	0
Costamagna (2012)^Citation19	Italy	11	91 (10)	100 (1)	0 (0)	0
Minami (2014)^Citation20	Japan	28	100 (28)	100 (3)	0 (0)	0
Lee (2013)^Citation21	Korea	13	100 (13)	100 (3)	0 (0)	0
von Renteln (2013)^Citation22	Europe, North America	70	100 (70)	82.4 (12)	4.3 (3)	0

Note:

# Major complications of perforation, mediastinitis, bleeding.

Abbreviation: POEM, per oral endoscopic myotomy.

Table 2 Clinical outcomes of endoscopic treatment using submucosal tunneling technique for GI subepithelial tumors

Author (year)	Country	# of patients	Location (details)	Tumor maximum size (mm)	Layer of origin	Distance from tumors to entry site (cm)	Technical success, % (n)	Complete resection, % (n)	Complications rate, % (n)	Additional surgery, % (n)
Lee (2012)^Citation23	Korea	1	Stomach (body)	16	MP	4	100 (1)	100 (1)	0 (0)	0
Inoue (2012)^Citation24	Japan	9	Esophagus, stomach (cardia)	29.4	MP	5	77.8 (7)	85.7 (6)	0 (0)	22.2 (2)#
Xu (2012)^Citation25	People’s Republic of China	15	Esophagus, stomach	19	MP	5	100 (15)	100 (15)	13.3 (2)	0
Gong (2012)^Citation26	People’s Republic of China	12	Esophagus, stomach (cardia)	19.5	MP	5	100 (12)	83.3 (10)	16.7 (2)	0
Ye (2014)^Citation27	People’s Republic of China	85	Esophagus, stomach	19.2	MP	5	100 (85)	100 (85)	9.4 (8)	0
Wang (2013)^Citation28	People’s Republic of China	18	Esophagus	33	–	Approximately 3–5	13 (100)	100 (18)	16.7 (3)	0

Note:

# Giant tumor >6 cm, two patients.

Abbreviations: GI, gastrointestinal; MP, muscularis propria.

Table 3 Clinical outcomes of tissue sampling methods for GI subepithelial tumors

Author (year)	Method	Country	# of lesions	Location	Mean tumor maximum size (mm)	Rate of overall diagnosis (cytology)# % (n)	Rate of overall final definitive diagnosis (IH)⋇ % (n)	Major complications rate % (n)	Minor complications rate % (n)
Gress (1997)^Citation33	EUS-FNA	US	27	GI tract	27	81 (22)	–	0 (0)	0 (0)
Ando (2002)^Citation34	EUS-FNA	Japan	23	GI tract	35.5	91 (21)	91 (21)	0 (0)	0 (0)
Hoda (2009)^Citation36	EUS-FNA	US	112	Upper GI	28.5	83.9 (94)	61.6 (10)	0 (0)	0 (0)
Mekky (2010)^Citation37	EUS-FNA	Japan	141	Stomach	29.9	82.3 (116)	34 (48)	0 (0)	0 (0)
Fernández-Esparrach (2010)^Citation38	EUS-TCB^#	Spain	40	Upper GI	–	60 (24)	55 (22)	–	–
Lee (2010)^Citation39	EPR-UT	Korea	16	Upper GI	16.3	93.7 (15)	93.7 (15)	0 (0)	56 (9), oozing
de la Serna-Higuera (2011)^Citation40	SINK	Spain	14	Upper GI	31.2	92.8 (13)	78.6 (11)	0 (0)	0 (0)
Binmoeller (2013)^Citation41	SLUB	US	24	GI tract	10	100 (24)	100 (24)	0 (0)	8.3 (2) abdominal pain
Kobara (2013)^Citation43	TBB	Japan	8	Upper GI	20.3	100 (8)	100 (8)	0 (0)	0 (0)

Notes:

# Rate of overall diagnosis including cytologic identification of suspicious (spindle) cells;

⋇ rate of overall definitive diagnosis including IH analysis.

Abbreviations: EUS-TCB, endoscopic ultrasound-guided Tru-Cut biopsy using 19-gauge core needle; EUS-FNA, endoscopic ultrasound-guided fine-needle aspiration; EPR-UT, endoscopic partial resection using the unroofing technique; SINK, single-incision needle-knife; SLUB, suck ligate unroof biopsy; TBB, tunneling bloc biopsy using submucosal endoscopy with a mucosal flap; GI, gastrointestinal; IH, immunohistochemistry.

Figure 1 Endoscopic findings using submucosal tunneling technique of tumor enucleation in a SET located in the esophagogastric junction.

Notes: (A) Endoscopic finding showed a flat elevated subepithelial lesion in the esophagogastric junction, which might lead to stenosis by enlargement of the tumor in the future. (B) After making an entry site at 2 cm from the tumor’s edge, a submucosal tunnel was created by submucosal dissection using a needle-knife form. After the tumor was identified and exposed in the tunnel, submucosa around the tumor was dissected. A white-colored tumor in the submucosal layer was enucleated completely. Finally, the entry site was sutured completely with hemoclips. (C) Macroscopic image of the resected specimen (20×12 mm). IH findings resulted in a gastric leiomyoma. (D) Follow-up endoscopy 2 weeks after operation revealed no tumor or esophagogastric stenosis.
Abbreviations: SET, subepithelial tumor; IH, immunohistological.

Figure 2 TBB procedure using submucosal endoscopy with the mucosal flap method for GI subepithelial tumors.

Notes: (A) Endoscopic submucosal dissection: a 10 mm opening flap was created by mucosal incision and submucosal dissection. (B) SEMF: a short tunnel approaching the tumor was created by additional submucosal dissection. (C) Bloc biopsy: a bloc specimen, measuring 5×5×2 mm, was obtained using a needle-knife and the cutting mode of the electrosurgical unit. (D) Tissue collection into a transparent cap. Specimen was removed into a long attachment, using grasping forceps. (E) Clip closure of flap. Opening flap was completely closed with hemoclips.
Abbreviations: TBB, tunneling bloc biopsy; GI, gastrointestinal; SEMF, submucosal endoscopy with mucosal flap.

InoueHMinamiHKobayashiYPeroral endoscopic myotomy (POEM) for esophageal achalasiaEndoscopy201042426527120354937

 PubMed Web of Science ®Google Scholar

ZhouPHCaiMYYaoLQPeroral endoscopic myotomy for esophageal achalasia: report of 42 casesZhonghua Wei Chang Wai Ke Za Zhi2011149705708 [Chinese]21948538

 PubMedGoogle Scholar

von RentelnDInoueHMinamiHPeroral endoscopic myotomy for the treatment of achalasia: a prospective single center studyAm J Gastroenterol2012107341141722068665

 PubMed Web of Science ®Google Scholar

CostamagnaGMarcheseMFamiliariPTringaliAInoueHPerriVPeroral endoscopic myotomy (POEM) for oesophageal achalasia: preliminary results in humansDig Liver Dis2012441082783222609465

 PubMedGoogle Scholar

MinamiHIsomotoHYamaguchiNPeroral endoscopic myotomy for esophageal achalasia: clinical impact of 28 casesDig Endosc20142614551

 Web of Science ®Google Scholar

LeeBHShimKYHongSJPeroral endoscopic myotomy for treatment of achalasia: initial results of a korean studyClin Endosc201346216116723614126

 PubMedGoogle Scholar

Von RentelnDFuchsKHFockensPPeroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter studyGastroenterology2013145230931123665071

 PubMed Web of Science ®Google Scholar

LeeCKLeeSHChungIKEndoscopic full-thickness resection of a gastric subepithelial tumor by using the submucosal tunnel technique with the patient under conscious sedation (with video)Gastrointest Endosc201275245745921679944

 PubMed Web of Science ®Google Scholar

InoueHIkedaHHosoyaTSubmucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardiaEndoscopy201244322523022354822

 PubMed Web of Science ®Google Scholar

XuMDCaiMYZhouPHSubmucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos)Gastrointest Endosc201275119519922056087

 PubMed Web of Science ®Google Scholar

GongWXiongYZhiFLiuSWangAJiangBPreliminary experience of endoscopic submucosal tunnel dissection for upper gastrointestinal submucosal tumorsEndoscopy201244323123522354823

 PubMed Web of Science ®Google Scholar

YeLPZhangYMaoXLZhuLHZhouXChenJYSubmucosal tunneling endoscopic resection for small upper gastrointestinal subepithelial tumors originating from the muscularis propria layerSurg Endosc201428252453024013472

 PubMed Web of Science ®Google Scholar

WangLRenWZhangZYuJLiYSongYRetrospective study of endoscopic submucosal tunnel dissection (ESTD) for surgical resection of esophageal leiomyomaSurg Endosc201327114259426623955726

 PubMed Web of Science ®Google Scholar

GressFGHawesRHSavidesTJIkenberrySOLehmanGAEndoscopic ultrasound-guided fine-needle aspiration biopsy using linear array and radial scanning endosonographyGastrointest Endosc19974532432509087830

 PubMed Web of Science ®Google Scholar

AndoNGotoHNiwaYThe diagnosis of GI stromal tumors with EUS-guided fine needle aspiration with immunohistochemical analysisGastrointest Endosc2002551374311756912

 PubMed Web of Science ®Google Scholar

HodaKMRodriguezSAFaigelDOEUS-guided sampling of suspected GI stromal tumorsGastrointest Endosc20096971218122319394006

 PubMed Web of Science ®Google Scholar

MekkyMAYamaoKSawakiADiagnostic utility of EUS-guided FNA in patients with gastric submucosal tumorsGastrointest Endosc201071691391920226456

 PubMed Web of Science ®Google Scholar

Fernández-EsparrachGSendinoOSoléMEndoscopic ultrasound-guided fine-needle aspiration and trucut biopsy in the diagnosis of gastric stromal tumors: a randomized crossover studyEndoscopy201042429229920354939

 PubMed Web of Science ®Google Scholar

LeeCKChungIKLeeSHEndoscopic partial resection with the unroofing technique for reliable tissue diagnosis of upper GI subepithelial tumors originating from the muscularis propria on EUS (with video)Gastrointest Endosc201071118819419879567

 PubMed Web of Science ®Google Scholar

de la Serna-HigueraCPérez-MirandaMDíez-RedondoPEUS-guided single-incision needle-knife biopsy: description and results of a new method for tissue sampling of subepithelial GI tumors (with video)Gastrointest Endosc201174367267621872716

 PubMed Web of Science ®Google Scholar

BinmoellerKFShahJNBhatYMKaneSDSuck-ligate-unroof-biopsy by using a detachable 20-mm loop for the diagnosis and therapy of small subepithelial tumors (with video)Gastrointest Endosc Epub11122013

 Web of Science ®Google Scholar

KobaraHMoriHFujiharaSBloc biopsy by using submucosal endoscopy with a mucosal flap method for gastric subepithelial tumor tissue sampling (with video)Gastrointest Endosc201377114114523021164

 PubMed Web of Science ®Google Scholar