title: Endoscopy dissection of small stromal tumors emerged from the muscularis propria in the upper gastrointestinal tract: Preliminary study.
abstract: OBJECTIVE
  To investigate the feasibility and safety of the treatment of an upper gastrointestinal (GI) submucosal tumor with endoscopic submucosal dissection (ESD).
  
  
  METHODS
  A total of 20 patients with esophageal and gastric submucosal tumors emerged from the muscular layer identified by endoscopic ultrasonography were collected from January 2009 to June 2010. Extramural or dumbbell-like lesions were excluded by an enhanced computerized tomography (CT) scan. All patients had intravenous anesthesia with propofol and then underwent the ESD procedure to resect these submucosal tumors. The incision was closed by clips as much as possible to decrease complications, such as bleeding or perforation, after resection of the tumor. All the specimens were collected and evaluated by hematoxylin, eosin and immunohistochemical staining, with antibodies against CD117, CD34, desmin, α-smooth muscle actin and vimentin to identify the characteristics of the tumors. Fletch's criteria was used to evaluate the risk of gastrointestinal stromal tumors (GISTs). All patients underwent a follow-up endoscopy at 3, 6 and 12 mo and CT scan at 6 and 12 mo.
  
  
  RESULTS
  The study group consisted of 5 men and 15 women aged 45-73 years, with a mean age of 60.2 years. Three tumors were located in the esophagus, 9 in the gastric corpus, 4 in the gastric fundus, 3 lesions in the gastric antrum and 1 in the gastric angulus. Apart from the one case in the gastric angulus which was abandoned due to being deeply located in the serosa, 94.7% (18/19) achieved complete gross dissection by ESD with operation duration of 60.52 ± 30.32 min. The average maximum diameter of tumor was 14.8 ± 7.6 mm, with a range of 6 to 30 mm, and another lesion was ligated by an endoscopic ligator after most of the lesion was dissected. After pathological and immunohistochemical analysis, 12 tumors were identified as a GI stromal tumor and 6 were leiomyoma. Mitotic count of all 12 GIST lesions was fewer than 5 per 50 HPF and all lesions were at very low (9/12, 75.0%) or low risk (3/12, 25.0%) according to Fletch's criteria. Procedure complications mainly included perforation and GI bleeding; perforation occurred in 1 patient and conservative treatment succeeded by a suturing clip and no post-operative GI bleeding occurred. All patients were followed up for 6.5 ± 1.8 mo (range, 3-12 mo) by endoscopy and abdominal CT. Local recurrence and metastasis did not occur in any patient.
  
  
  CONCLUSIONS
  ESD shows promise as a safe and feasible technique to resect esophageal and gastric submucosal tumors and the incidence of complications was very low. Clinical studies with more subjects and longer follow-up are needed to confirm its treatment value.
authors.affiliation: Zhi-Gang Huang, Xue-Song Zhang, Shi-Liang Huang, Xiao-Gang Yuan, Department of Gastroenterology, Lihuili Hospital of Ningbo Medical Center, Ningbo 315040, Zhejiang Province, China.
authors.forename: Zhi-Gang
authors.initials: ZG
authors.lastname: Huang
authors.forename: Xue-Song
authors.initials: XS
authors.lastname: Zhang
authors.forename: Shi-Liang
authors.initials: SL
authors.lastname: Huang
authors.forename: Xiao-Gang
authors.initials: XG
authors.lastname: Yuan
keywords: Endoscopic submucosal dissection; Leiomyoma; Stromal tumors; Upper gastrointestinal tract