Analysis Of Characteristics And Endoscopic Treatment Of Upper Gastrointestinal Submucosal Tumor

Background and ObjectiveSubmucosal tumor(SMT)is a lesion derived from mesenchymal tissue,which is characterized by a bulging change under endoscopy.It is usually difficult to diagnose the nature of SMT by routine endoscopy and to distinguish its benign and malignant.Patients with SMT usually have no obvious symptoms,most of SMTs are found during routine endoscopy examinations.With the development of endoscopic techniques,SMT is increasingly being discovered.At the same time,more and more patients are beginning to receive endoscopic treatment of SMT.However,we need to analyze the predilection sites,tumor size,nature and postoperative recurrence of submucosal tumors in the digestive tract.There are not only benign tumors,such as leiomyoma,lipoma,ectopic pancreas,cysts,granulosa cell tumors,hemangioma.,but also gastrointestinal stromal tumors with malignant potential.Therefore,distinguishing tumors of different nature and selecting treatment methods pose new challenges for doctors.Routine endoscopy often fails to identify the nature of SMT.The purpose of this study was to summarize the nature,origin,distribution,and characteristics of the upper digestive tract SMT,and analyzing the effect of endoscopic treatment of this type of tumor in our hospital in order to facilitate the development of endoscopic treatment in the future.At the same time,we explored the role of endoscopic ultrasound in the diagnosis of submucosal tumors in the upper digestive tract,providing a basis for endoscopic diagnosis and treatment decisions.Materials and MethodsFrom February 2012 to February 2017,the retrospective analysis was performed in the Second Affiliated Hospital of Zhengzhou University.264 cases of SMT were involved,including 174 cases of esophageal submucosal tumors,87 cases of gastric submucosal tumors,and 3 cases of duodenal submucosal tumors.The patients ranged in age from 24 to 84.The diameter of tumors was ranged from 0.4 to 4cm.Of the 264 patients,135 were male and 129 were female.All patients underwent endoscopic treatment and were diagnosed by pathological biopsy.Patients with serious cardiopulmonary diseases were excluded,anesthetic risks were assessed,surgical benefits and risks were informed,and informed consent was signed.All patients were fasted for 10-12 hours before endoscopy.Before gastroscopy,patients were routinely given dacronine gel orally,which was used to lubricate and anesthetize the larynx and remove the foam and mucus in the lumen,and were operated on under endotracheal intubation or intravenous anesthesia.At the same time,the foam and mucus in the lumen were completely removed,and tracheal intubation anesthesia or intravenous anesthesia was performed.During the examination,conventional endoscopy was used to locate the lesion,and then ultrasonic endoscopy was used to diagnose SMT,and the size,origin,boundary and echo characteristics of the lesion were defined.Then endoscopic treatment was evaluated to select the treatment measures.The specimens were sent for pathological examination after endoscopic treatment.The size of the specimen is measured,and then the specimen is fixed,sliced and HE stained.If the pathological examination cannot determine the nature of the lesion,immunohistochemical examination can be performed to confirm the nature of the lesion.Results(1)There were 264 cases of upper gastrointestinal submucosal tumors.The upper gastrointestinal submucosal tumors were classified according to the lesion location,including 174 cases of esophageal SMT,87 cases of stomach SMT,and 3 cases of duodenum.The upper gastrointestinal submucosal tumors were classified according to the nature of the lesions :191 cases of leiomyoma,32 cases of stromal tumor,14 cases of lipoma,12 cases of heterotopy of the pancreas,4 cases of schwannoma,3 cases of venous tumor,3 cases of neuroendocrinoma,3 cases of cyst,2 cases of granulosa cell tumor.(2)The origin of esophageal SMT is mainly mucosal muscle layer,which is mainly benign tumors,such as leiomyoma.There were 160 cases(91.95%)of leiomyomas,3 cases(1.72%)of cysts,2 cases(1.15%)of schwannomas,3 cases(1.72%)of lipomas,3 cases(1.72%)of venous tumors,stromal tumors.1 case(0.57%),2 cases of granulosa cell tumor(1.15%).But there are malignant tumors,such as stromal tumors.Among the esophageal submucosal tumors,the most common is leiomyoma.The distribution of leiomyomas was: cervical segment(22.5%),upper thoracic segment(26.9%),middle thoracic segment(18.1%),and lower thoracic segment(32.5%).The origin of leiomyomas: mucosal muscle layer(59.38%),submucosa(18.75%),and muscularis propria(21.88%).The echogenic characteristics of the endoscopic ultrasound show a uniform low echo.(3)There were 87 cases of gastric submucosal tumors,including 31 cases of leiomyoma(35.60%),31 cases of stromal tumors(35.60%),11 cases of ectopic pancreas(12.64%),10 cases of lipoma(11.49%),neuroendocrine There were 2 cases(2.30%)and 2 cases(2.30%)of schwannomas.The most common histological types of gastric SMT are stromal tumors and leiomyomas,the most common sites of which are the fundus and antrum.The leiomyomas are mainly distributed in the cardia,and the stromal tumors are mostly located in the fundus.The ectopic pancreas is more common in the gastric antrum,and the lipoma is often distributed in the gastric antrum.(4)There were only 3 cases of duodenal submucosal tumors,including 1 ectopic pancreas,1 neuroendocrine tumor,and 1 lipoma.These 3 SMTs were located in the duodenal bulb.The ectopic pancreas originates from the muscularis propria and the endoscopic echogenicity is a mixed echo.This neuroendocrine tumor originates from the muscularis propria and the echo is characterized by hypoechoic.The lipoma originates from the submucosa and the echo is characterized by a uniform high echo.(5)In this study,32 cases of stromal tumors were diagnosed by pathological examination and immunohistochemistry.There were 29 cases of extremely low-risk cases and 3 cases of low-risk cases.Divided by location: 1 case of esophageal stromal tumor and 31 cases of gastric stromal tumor.All 32 cases of gastrointestinal stromal tumors were reviewed endoscopy 1 year later,and no recurrence was found.There were 2 cases of neuroendocrine tumors,both located in the stomach.The pathological diagnosis was G1 neuroendocrine tumors.(6)The results of endoscopic ultrasonography and pathological diagnosis of 264 patients with upper gastrointestinal submucosal tumor were compared.The coincidence rate of endoscopic diagnosis and pathological examination of upper gastrointestinal submucosal tumor was 90.53%.Kappa consistency test was used for data analysis,and the Kappa value was 0.804,P<0.05.The endoscopic diagnosis results and pathological diagnosis were consistent.(7)264 cases of upper gastrointestinal submucosal tumors were treated with endoscopy,fewer cases of complications and most cases improved after conservative treatment.Among them,9 cases(3.40%)had obvious upper abdominal pain after operation,and no special treatment was given,and then gradually relieved.There were 7 cases(2.65%)with obvious bleeding after operation.The endoscopic electrocoagulation was used to stop the bleeding and the wound was closed with titanium clip.The bleeding was successfully stopped.Endoscopic full-thickness resection was performed in 5 patients,and no serious infection occurred after operation.Except for the case of endoscopic full-thickness resection,a total of 3 cases(1.14%)had perforation,and the perforation site was closed by titanium-string purse suture.The time of fasting water was appropriately extended after operation,and the situation improved after anti-infective treatment.Of the 264 cases of upper gastrointestinal submucosal tumors,131 were treated with EMR,49 were treated with ESD,55 were treated with ESE,5 were treated with EFR,and 24 were treated with STER.The complete resection rate was 93.18%.There were 261 cases(98.86%)with SMT diameter ≤ 3 cm,only 3 cases(1.14%)with tumor diameter > 3 cm,and the largest SMT diameter was 4 cm.Because the number of cases of endoscopic treatment of SMT with diameter >3cm is small,it can not draw valid conclusions.Therefore,endoscopic treatment of submucosal tumors of the upper digestive tract with a diameter of less than 3 cm is safe and effective.Conclusions(1)Submucosal tumors of the upper digestive tract is mainly benign tumor,which is most common in the esophagus,followed by the stomach and the duodenum.Esophageal submucosal tumors are most common in leiomyomas,and the stomach is most common in leiomyomas and stromal tumors.(2)Endoscopic ultrasonography is of great value in the diagnosis of submucosal tumors of the upper digestive tract.(3)Endoscopic treatment of submucosal tumors of the upper digestive tract with a diameter of less than 3 cm is safe and effective.