| BackgroundThe term submucosal tumor(SMT),collectively used to define protuberant lesions underneath the normal and intact mucosa,usually originate from gastrointestinal muscularis mucosa,submucosa or muscularis propria.In recent years,with the popularization of digestive endoscopy and the rapid development and maturity of endoscopic ultrasonography,the detection rate of gastric submucosal tumors has been greatly increased.And endoscopic resection of gastric SMTs has received extensive attention and recognition.Compared with laparoscopic surgery or laparotomy,the endoscopic approach has the advantages of more minimally invasive,shorter operation time,shorter hospital stay,lower cost,and also has the ability to obtain enough and representative cells and/or tissues for the differentiation and risk assessment of benign and malignant tumors.However,because this technique still has the risk of positive resection margins,tumor spillage or rupture,potential bleeding and perforation,there is no uniform standard for the optimal surgical approach for endoscopic resection of gastric submucosal masses in current international guidelines.In recent years,our hospital(Digestive Endoscopy Center of Nanfang Hospital,Southern Medical University)most commonly used ESD or CASL to resect gastric submucosal masses ≤10 mm and achieved ideal results.The aim of this study was to compare the safety and efficacy of CASL and ESD in the treatment of gastric submucosal tumors ≤10 mm,so as to provide a reference basis for the endoscopic minimally invasive treatment of gastric submucosal tumors,and then standardize the endoscopic treatment of gastric submucosal tumors.MethodsIn our retrospective study,181 patients with gastric submucosal tumors≤10 mm who were diagnosed and treated with cap-assisted endoscopic mucosal resection or endoscopic submucosal dissection at the Nanfang Hospital,Southern Medical University from June 2018 to August 2021 were retrospectively collected.In addition,on the basis of the retrospective cohort study,a single-center,prospective,randomized controlled non-inferiority clinical trial of cap-assisted endoscopic mucosal resection versus endoscopic submucosal dissection for the resection of gastric submucosal tumors≤10 mm was conducted by our team in December 2021.The purpose of the study is to compare and analyze the incidence of surgical complications,the rate of en-bloc resection,and perioperative management of CASL and ESD for gastric submucosal mass(≤10mm).ResultsIn the retrospective study,a total of 181 subjects were included,84(46.4%)patients with SMTs were treated with ESD and 97(53.6%)were treated with CASL.There were no significant differences between the CASL group and the ESD group in terms of gender,the history of diabetes or hypertension,the therapy of anti-coagulation or antiplatelet,tumor location,origin and the histomorphological and cytomorphological features,but there had differences and statistical significance in age and tumor size.The baseline of this study was balanced using propensity score matching.The en-bloc resection rates of SMTs in the two groups were 99.0%and 98.8%,respectively(P=0.918),which were not statistically significant differences.There were no significant differences between the ESD and CASL groups in terms of intraoperative perforation,active intraoperative bleeding,pulsatile intraoperative bleeding,postoperative hospital observation days,postoperative related complications(fever,abdominal pain,peritonitis),and time to first liquid diet,indwelling nasogastric tube for gastrointestinal decompression and antibiotics to prevent infection(P>0.05).However,there were significant statistical differences between the two groups in surgical resection time,intraoperative estimated blood loss,number of titanium clips used,and surgical costs(P≤0.05).A total of 139 patients were effectively followed up in this study,with no statistically significant difference in the mean follow-up length between the two groups,and no residual tumor cases,recurrence and death in both groups.In the prospective clinical study,we have now included a total of 79 subjects.Thirty-nine(49.4%)patients with SMTs were treated with ESD and 40(50.6%)patients with SMTs were treated with CASL.There were no significant differences between the CASL group and the ESD group in terms of gender,age,the history of diabetes or hypertension,the therapy of anti-coagulation or antiplatelet,tumor size,tumor location,origin and pathological feature.The CASL group was not inferior to the ESD group in terms of procedure-related complications,with a confidence interval for the procedure-related complications rate of-16%to 4.5%in the two groups,which didn’t include 10%.In addition,the incidence of en-bloc resection in the ESD and CASL groups were 94.9%and 95.0%,respectively.There were no significant differences between the ESD and CASL groups in terms of en-bloc resection(P=0.979).Furthermore,there was no significant difference between the ESD and CASL groups in postoperative hospital observation days,postoperative related complications(fever,abdominal pain,peritonitis),time to first liquid diet and antibiotics for the prevention of infection(P>0.05).However,there were significant statistical differences between the two groups in surgical resection time,intraoperative estimated blood loss,number of titanium clips used,surgical costs,and postoperative indwelling nasogastric tube for gastrointestinal decompression(P<0.05).ConclusionThe results of this study showed that CASL was safe and effective in the treatment of gastric submucosal tumors≤10 mm and was not inferior to ESD,particularly with an experienced endoscopy team.CASL has the advantages of high en-bloc resection rate,less surgical complications,shorter operation time,lower operation cost and fewer medical consumables in the treatment of gastric submucosal tumors ≤10 mm.Thus,CASL is a safe and effective technique which can replace ESD in the treatment of gastric submucosal masses ≤ 10 mm.However,large-scale studies are still needed to further validate our data. |
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