Retract-ligate-unroof-biopsy: a novel approach to the diagnosis and therapy of large nonpedunculated stromal tumors (with video).
BACKGROUND
We report a novel technique of retract-ligate-unroof-biopsy (RLUB) for the diagnosis and treatment of large nonpedunculated upper GI stromal tumors originating from the muscularis propria.


OBJECTIVE
Proof-of-concept evaluation of the RLUB technique.


METHODS
Pilot and feasibility study.


METHODS
Tertiary care center.


METHODS
Sixteen patients (median age 71 years) fulfilling the following inclusion criteria: poor surgical candidates with lesions that are broad based with a benign appearance, originating from the muscularis propria, size 2 cm or larger.


METHODS
A double-channel endoscope was used to simultaneously retract the stromal tumor while advancing an endoloop beyond the tumor for ligation. The overlying tissue was incised ("unroofed") to expose and partially enucleate the tumor, and multiple biopsy samples were obtained. After unroofing, an additional endoloop was placed below the previous one by using the loop-over-loop technique to reinforce enucleation and ischemic ablation.


METHODS
Successful ligation, immunohistochemistry and mitotic index yield, therapeutic ablation, adverse events.


RESULTS
Technical success was achieved in 13 of 16 patients (81%). Immunohistology of biopsy specimens: GI stromal tumor (n = 10), leiomyoma (n = 3). Twelve of 13 patients (92%) with follow-up (median 22 weeks, range 1-82.5 weeks) had confirmed tumor ablation by endoscopy and EUS. One patient with partial resolution was re-treated, but was subsequently lost to follow-up. Delayed bleeding occurred in 2 patients that required hospitalization and blood transfusions, both successfully controlled with repeat endolooping. One patient reported transient pain.


CONCLUSIONS
Single center, single operator, small sample size.


CONCLUSIONS
The RLUB technique is feasible as a platform for full-thickness treatment of stromal tumors. Limitations encountered included technical challenges and delayed bleeding. Further developmental work is needed.
Paul May and Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, CA 94115, USA. BinmoeK@sutterhealth.org
Kenneth F
KF
Binmoeller
Janak N
JN
Shah
Yasser M
YM
Bhat
Steve D
SD
Kane
D055011:Ablation Techniques; D000368:Aged; D000369:Aged, 80 and over; D001706:Biopsy / Q000009:adverse effects / Q000379:methods*; D005240:Feasibility Studies; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D046152:Gastrointestinal Stromal Tumors / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D006801:Humans; D007150:Immunohistochemistry; D007889:Leiomyoma / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D008026:Ligation; D008297:Male; D008875:Middle Aged; D008940:Mitotic Index; D010865:Pilot Projects; D019106:Postoperative Hemorrhage / Q000209:etiology*; D014463:Ultrasonography