The Application Of Endoscopic Resection In The Treatment Of The Muscular Propria Tumors At Esophagus And Cardia

Objective:This study aimed to evaluate the clinical treatment values of endoscopic resection,using submucosal excavation(ESE)and submucosal tunneling endoscopic resection(STER)to treat the muscularis propria tumors(MPTs)at esophagus and cardia,and to compare the efficacy and safety between ESE and STER,we also wanted to analyse the risk factors of the postoperative complication preliminarily.Methods :We collected the information of the patients who underwent ESE or STER in Digestive Endoscopic Center of Cheng du Military General Hospital from January 2013 to October 2016,and then made a retrospective analysis on the clinical and pathologic data of the 53 patients who met the inclusion criteria.29 patients received ESE treatments,and 24 patients received STER treatments.Main outcome measurements included operation time,intraoperative complications,en bloc resection rate,postoperative adverse events and tumors recurrence.Based on postoperative pathology and lesion location,subgroup analysis was also performed.Results:1.This study included 53 patients,the rate of male and femal was 16: 37,the mean age was 50.38±8.15 years old,and the average diameter of the lesions was 20.13±13.56 mm.According to the MPTs` location,esophagus accounted for 43.3%(23/53),and cardia accounted for 56.6%(30/53).According to the MPTs`postoperative pathology,the rate of leiomyoma(LM)is 28.3%(15/53),gastrointestinal stromal tumors(GISTs)is 67.9%(36/53),and the other(neuroendocrine tumor,lipoma and so on)is 3.8%(2/53).2.The judgment of endoscopic ultrasonography(EUS)to MPTs: The accuracy rate of the original layer is 100%;Recombination rate of the lesions`nature is 62.3%,and the accuracy is 87.5%(21/24)and 44.4%(12/27)in GISTs and LM.If the MPTs`shape were irregular under the EUS,the accuracy of GISTs we diagnosed was significantly higher than LM(?~2=6.24,P=0.012).3.The enbloc resection rate of the 53 patients in our study was 96.2%(51/53)and it was similar between these two groups(STER 95.8% VS ESE 96.6%,P>0.05).The STER`operation time was significantly longer than that in ESE(140.46±73.48 min VS 60.03±51.29 min,P < 0.05).The all intraoperative complications happened in cardia,and the rate was 11.3%(6/53);the rate of obvious intraoperation bleeding and intraoperation perforation were 9.4%(5/53)and 1.9%(1/53);the intraoperative complications of STER was lower than that of ESE(4.2% VS 17.2%,P>0.05).The total postoperative complications rate was 22.6%(12/53,4 patients with two kinds of complications),the rate of infection,gas related complications,a small amount of pleural effusion and delayed bleeding were 11.3%(6/53),11.3%(6/53),5.7%(3/53)and 1.9%(1/53);whats more,the postoperative complications rate of STER was significantly higher than that of ESE(37.5% VS 10.3%,P < 0.05),especially the gas related complications(25.0% VS 0,P < 0.05).There was no significant difference between the two groups in the average postoperative hospitalization day and fasting days.4.In ESE,compared with STER in esophageal MPTs,the operative time was shorter(43.42±17.89 min VS 156.27±69.23 min,P<0.001),the number of clips was less(1.58±2.87 VS 7.45±1.29,P<0.001),the rate of postoperative complications was lower(0 VS 45.5%,P=0.014),the rate of intraoperative complications was similar.In STER,compared with ESE in cardiac MPTs,the operative time was longer(127.08±77.01 min VS 71.76±63.50 min,P<0.001),the rate of postoperative complications was similar,but the rate of intraoperative complications was lower(7.7% VS 29.4%,P=0.196).5.Combining the results of single factor analysis and multivariate Logistic regression model,we could draw the conclusion that the risk factors of postoperative complications in MPTs were large diameter,irregular shape,STER operation and long operation time.6.The follow up and prognosis:the average follow-up time was 4.62±6.53 months(2 to20 months),and the mean follow-up frequency was 1.30±0.70 times(1 to 4 times),in addition,there were no relapses in our study.Conclusion:1.Both of ESE and STER are the safe and effective methods which are minimal invasive operation in the treatment of MPTS.Compared with ESE,STER has longer operative time,but has a clear vision,and has lower intraoperative obvious bleeding.Compared with ESE,gas related complications is more common in STER,but it is mild and disappeare after conservative treatment.2.In ESE,compared with STER in esophageal MPTs,the operative time was shorter,the number of clips was less,the rate of postoperative complications was lower and the rate of intraoperative complications was similar,so ESE is recommended for the treatment of MPTs in esophagus.In STER,compared with ESE in cardiac MPTs,the operative time was longer,and the rate of postoperative complications was similar,but the rate of intraoperative complications was lower,so ESE is recommended for the treatment of MPTs in esophagus.3.EUS has a good diagnostic efficiency on MPTs,especially when the MPTs`shape were irregular under the EUS,diagnosis of GISTs is more accurate.4.we can draw the conclusion that the risk factors of postoperative complications in MPTs are large diameter,irregular shape,STER operation and long operative time.