Endoscopic Assisted Enucleation of Small Gastric Subepithelial Lesions: An Early Single Center Experience

Endoscopic Assisted Enucleation of Small Gastric Subepithelial Lesions: An Early Single Center... Journal of the Canadian Association of Gastroenterology, 2018, 1(2), 92–93 doi: 10.1093/jcag/gwy004 Lee tt r to Editor Advance Access publication 1 March 2018 Lee tt r to Editor Endoscopic Assisted Enucleation of Small Gastric Subepithelial Lesions: An Early Single Center Experience 1,2 1 Majid Alsahafi MD, MHSc , Fergal Donnellan MD Division of Gastroenterology, University of British Columbia, 5153 - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada; Department of Medicine, King Abdulaziz University, Building 10, Second Floor, PO Box 80215, Jeddah 21589, Saudi Arabia Dear editor, retrospectively reviewed our prospectively collected data for Gastric subepithelial tumors (SETs) are not uncommonly patients who underwent endoscopic assisted enucleation of discovered on routine endoscopy. While the majority of small gastric SETs at our center. All patients had discussion gastric SETs are benign, some have malignant potential. about management options for gastric SET and provided in- Although observation is generally recommended for SET formed consents. All patients underwent endoscopic ultra- smaller than 2 cm w ith no concerning features, the lack of di- sound examination for lesion characterization using a linear agnosis may precipitate significant anxiety to many patients echoendoscope (Olympus Medical). For the RLUB technique, (1). Small SETs are often associated with a diagnostic chal- a double-channel endoscope (Olympus Medical) was used. lenge, due to low yield of conventional biopsy techniques, Retraction was performed using a 3-pronged anchoring de- including EUS guided biopsies, and require follow-up to vice (OTSC Anchor, Ovesco) followed by a 30 mm endoloop ensure no interval growth suggestive of malignant poten- (Olympus Medical) placement. For the SLUB technique, a tial. Retraction, Ligation, Unroofing, Biopsy (RLUB), and therapeutic gastroscope (Olympus Medical) with an 18  mm Suction, Ligation, Unroofing, Biopsy (SLUB) are two re- transparent attachment cap was used. A  20  mm Endoloop cently described techniques by Binmoeller et al. which were (Olympus Medical) was preloaded into the cap. Ae ft r suc - found to be highly effective to facilitate tissue diagnosis tioning the lesion into the cap, the endoloop was deployed. and lesion removal (2, 3). These procedures were done at a For both procedures, unroofing was performed using a needle single center, and the generalizability of the results to other knife and a polypectomy snare ae ft r ligating the SET, followed centers is unknown. by obtaining biopsies from the exposed SET. All procedures Here, we aimed to report our early experience of the tech- were performed in an outpatient setting under conscious seda - nical success, diagnostic yield and complications using these tion. Follow-up gastroscopy was not routinely done for lesions endoscopic enucleation techniques for gastric SET. We with no malignant potential. Table 1. Characteristics of gastric subepithelial lesions and findings of procedures. Case # Age Size, cm Layer EUS Biopsy Success Diagnosis Follow up Endoscopy rd 1 67 3 3 Non diagnostic Yes Lipoma No visible lesion th 2 82 2 4 Not done Yes GIST No visible lesion th 3 66 3 4 Not done No NA NA rd 4 19 1 3 Not done Yes Heterotopic pancreas NA nd 5 58 3 2 Non diagnostic Yes Non specific (Benign cystic/ Endoloop in sito solid lesion) th 6 61 1.7 4 Not done Yes Neuroma NA nd 7 66 1.1 2 Not done Yes Inflammatory fibroid No visible lesion th 8 65 0.8 4 Not done Yes GIST No visible lesion rd 9 82 1 3 Not done Yes Inflammatory polyp NA NA, not available © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 92 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/92/4916075 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 93 Figure 1. A 2-cm gastric SET is identified in the upper stomach, A. EUS (not shown) revealed the lesion arising from the fourth layer, muscularis propria. Lesion ae ft r retraction, ligation and unroofing, B. Biopsies revealed GIST tumor. Follow-up EGD ae ft r eight weeks revealed no visible lesion, C. Given the malignant potential, an EUS was also performed (not shown) and no re- sidual SET was identified. A total of nine patients underwent endoscopic-assisted enu- want a specific diagnosis to be made or patients who want to cleation between October 2015 and September 2017. Table  1 avoid the need for future surveillance. shows characterization of gastric SET and results of the pro- Correspondence: Dr. Fergal Donnellan, Division of cedures. The mean age was 62.8 years, and 66.6% were female. Gastroenterology, Vancouver General Hospital, University of Gastric SETs were incidentally discovered on gastroscopy in British Columbia, 5153 - 2775 Laurel Street, Vancouver V5Z seven patients, and on CT scan in one patient. One patient pre- 1M9, Canada. e-mail Fergal.Donnellan@vch.ca. sented with anemia and was found to have an ulcerated SET. The endoscopic procedure was successful in eight (88.8%) References out of nine patients. The patient with the unsuccessful proce- 1. ASGE Standards of Practice Committee; Evans J, Chandrasekhara dure had a 3 cm SET and was refereed for surgery. For the five V, Chathadi K, et  al. The role of endoscopy in the management patients who had follow-up gastroscopy or endoscopic ultra- of premalignant conditions of the stomach. Gastrointest Endosc sound or both, ae ft r a median interval of two months, four had 2015;82:1–8 no visible lesion and one had the endoloop still in place. No 2. Binmoeller K, Shah J, Bhat Y, et  al. Retract-ligate-unroof-biopsy: complications were encountered. Figure 1 shows an illustration a novel approach to the diagnosis and therapy of large non-pe- for one of the cases. dunculated stromal tumors (with video). Gastrointest Endosc In conclusion, the results showed that endoscopic-assisted 2013;77:803–8. enucleation of gastric SETs is technically feasible and safe in 3. Binmoeller K, Shah J, Bhat Y, et  al. Suck-ligate-unroof-biopsy by concordance with the previously published studies. Endoscopic using a detachable 20-mm loop for the diagnosis and therapy of enucleation might be a good option for anxious patients who small subepithelial tumors. Gastrointest Endosc 2014;79:750–5. Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/92/4916075 by Ed 'DeepDyve' Gillespie user on 20 June 2018 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the Canadian Association of Gastroenterology Oxford University Press

Endoscopic Assisted Enucleation of Small Gastric Subepithelial Lesions: An Early Single Center Experience

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Canadian Association of Gastroenterology
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© The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.
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2515-2084
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10.1093/jcag/gwy004
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Abstract

Journal of the Canadian Association of Gastroenterology, 2018, 1(2), 92–93 doi: 10.1093/jcag/gwy004 Lee tt r to Editor Advance Access publication 1 March 2018 Lee tt r to Editor Endoscopic Assisted Enucleation of Small Gastric Subepithelial Lesions: An Early Single Center Experience 1,2 1 Majid Alsahafi MD, MHSc , Fergal Donnellan MD Division of Gastroenterology, University of British Columbia, 5153 - 2775 Laurel Street, Vancouver, BC, V5Z 1M9, Canada; Department of Medicine, King Abdulaziz University, Building 10, Second Floor, PO Box 80215, Jeddah 21589, Saudi Arabia Dear editor, retrospectively reviewed our prospectively collected data for Gastric subepithelial tumors (SETs) are not uncommonly patients who underwent endoscopic assisted enucleation of discovered on routine endoscopy. While the majority of small gastric SETs at our center. All patients had discussion gastric SETs are benign, some have malignant potential. about management options for gastric SET and provided in- Although observation is generally recommended for SET formed consents. All patients underwent endoscopic ultra- smaller than 2 cm w ith no concerning features, the lack of di- sound examination for lesion characterization using a linear agnosis may precipitate significant anxiety to many patients echoendoscope (Olympus Medical). For the RLUB technique, (1). Small SETs are often associated with a diagnostic chal- a double-channel endoscope (Olympus Medical) was used. lenge, due to low yield of conventional biopsy techniques, Retraction was performed using a 3-pronged anchoring de- including EUS guided biopsies, and require follow-up to vice (OTSC Anchor, Ovesco) followed by a 30 mm endoloop ensure no interval growth suggestive of malignant poten- (Olympus Medical) placement. For the SLUB technique, a tial. Retraction, Ligation, Unroofing, Biopsy (RLUB), and therapeutic gastroscope (Olympus Medical) with an 18  mm Suction, Ligation, Unroofing, Biopsy (SLUB) are two re- transparent attachment cap was used. A  20  mm Endoloop cently described techniques by Binmoeller et al. which were (Olympus Medical) was preloaded into the cap. Ae ft r suc - found to be highly effective to facilitate tissue diagnosis tioning the lesion into the cap, the endoloop was deployed. and lesion removal (2, 3). These procedures were done at a For both procedures, unroofing was performed using a needle single center, and the generalizability of the results to other knife and a polypectomy snare ae ft r ligating the SET, followed centers is unknown. by obtaining biopsies from the exposed SET. All procedures Here, we aimed to report our early experience of the tech- were performed in an outpatient setting under conscious seda - nical success, diagnostic yield and complications using these tion. Follow-up gastroscopy was not routinely done for lesions endoscopic enucleation techniques for gastric SET. We with no malignant potential. Table 1. Characteristics of gastric subepithelial lesions and findings of procedures. Case # Age Size, cm Layer EUS Biopsy Success Diagnosis Follow up Endoscopy rd 1 67 3 3 Non diagnostic Yes Lipoma No visible lesion th 2 82 2 4 Not done Yes GIST No visible lesion th 3 66 3 4 Not done No NA NA rd 4 19 1 3 Not done Yes Heterotopic pancreas NA nd 5 58 3 2 Non diagnostic Yes Non specific (Benign cystic/ Endoloop in sito solid lesion) th 6 61 1.7 4 Not done Yes Neuroma NA nd 7 66 1.1 2 Not done Yes Inflammatory fibroid No visible lesion th 8 65 0.8 4 Not done Yes GIST No visible lesion rd 9 82 1 3 Not done Yes Inflammatory polyp NA NA, not available © The Author(s) 2018. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology. 92 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/92/4916075 by Ed 'DeepDyve' Gillespie user on 20 June 2018 Journal of the Canadian Association of Gastroenterology, 2018, Vol. 1, No. 2 93 Figure 1. A 2-cm gastric SET is identified in the upper stomach, A. EUS (not shown) revealed the lesion arising from the fourth layer, muscularis propria. Lesion ae ft r retraction, ligation and unroofing, B. Biopsies revealed GIST tumor. Follow-up EGD ae ft r eight weeks revealed no visible lesion, C. Given the malignant potential, an EUS was also performed (not shown) and no re- sidual SET was identified. A total of nine patients underwent endoscopic-assisted enu- want a specific diagnosis to be made or patients who want to cleation between October 2015 and September 2017. Table  1 avoid the need for future surveillance. shows characterization of gastric SET and results of the pro- Correspondence: Dr. Fergal Donnellan, Division of cedures. The mean age was 62.8 years, and 66.6% were female. Gastroenterology, Vancouver General Hospital, University of Gastric SETs were incidentally discovered on gastroscopy in British Columbia, 5153 - 2775 Laurel Street, Vancouver V5Z seven patients, and on CT scan in one patient. One patient pre- 1M9, Canada. e-mail Fergal.Donnellan@vch.ca. sented with anemia and was found to have an ulcerated SET. The endoscopic procedure was successful in eight (88.8%) References out of nine patients. The patient with the unsuccessful proce- 1. ASGE Standards of Practice Committee; Evans J, Chandrasekhara dure had a 3 cm SET and was refereed for surgery. For the five V, Chathadi K, et  al. The role of endoscopy in the management patients who had follow-up gastroscopy or endoscopic ultra- of premalignant conditions of the stomach. Gastrointest Endosc sound or both, ae ft r a median interval of two months, four had 2015;82:1–8 no visible lesion and one had the endoloop still in place. No 2. Binmoeller K, Shah J, Bhat Y, et  al. Retract-ligate-unroof-biopsy: complications were encountered. Figure 1 shows an illustration a novel approach to the diagnosis and therapy of large non-pe- for one of the cases. dunculated stromal tumors (with video). Gastrointest Endosc In conclusion, the results showed that endoscopic-assisted 2013;77:803–8. enucleation of gastric SETs is technically feasible and safe in 3. Binmoeller K, Shah J, Bhat Y, et  al. Suck-ligate-unroof-biopsy by concordance with the previously published studies. Endoscopic using a detachable 20-mm loop for the diagnosis and therapy of enucleation might be a good option for anxious patients who small subepithelial tumors. Gastrointest Endosc 2014;79:750–5. Downloaded from https://academic.oup.com/jcag/article-abstract/1/2/92/4916075 by Ed 'DeepDyve' Gillespie user on 20 June 2018

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Journal of the Canadian Association of GastroenterologyOxford University Press

Published: Mar 1, 2018

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