Suck-ligate-unroof-biopsy by using a detachable 20-mm loop for the diagnosis and therapy of small subepithelial tumors (with video).
BACKGROUND
The diagnosis and therapy of subepithelial tumors (SETs) can be challenging.


OBJECTIVE
Proof-of-concept evaluation of the suck-ligate-unroof-biopsy (SLUB) technique for small (<2 cm), non-pedunculated SETs.


METHODS
Pilot feasibility study.


METHODS
Tertiary-care referral center.


METHODS
Twenty-three patients (median age 60 years) meeting the inclusion criteria after preliminary EUS.


METHODS
SET ligation was performed with a detachable 20-mm loop deployed through an 18-mm diameter, soft, oblique, transparent, cap attachment. The SLUB technique comprised (1) suction to draw the SET into the cap; (2) ligation below the SET, confirmation by repeat EUS; (3) unroofing of the overlying mucosa with a needle-knife; and (4) biopsy specimens taken from the exposed tumor.


METHODS
Technical success, histology and/or immunohistochemistry yield, adverse events, completeness of resection.


RESULTS
SLUB was attempted on 24 SETs and was technically successful in all. Location was the stomach (n = 19), small bowel (n = 1), colon (n = 2), and rectum (n = 2). Median size by EUS was 10 mm (range 6-15 mm). Biopsy specimens provided an immunohistologic diagnosis in all cases: GI stromal tumor (n = 5), leiomyoma (n = 8), carcinoid tumor (n = 5), Vanek's tumor (n = 2), granuloma (n =1), and pancreatic heterotopia (n = 3). Follow-up endoscopy and EUS in 13 patients showed well-healed scars with no residual tumor, including all 9 patients with premalignant neoplastic lesions. The only adverse event was self-limited pain in 2 patients.


CONCLUSIONS
Single center, single operator, small sample size.


CONCLUSIONS
Loop ligation of small, non-pedunculated SETs is feasible by using a cap attachment for suction. Unroofing after ligation is safe and provides sufficient tissue for immunohistochemistry. Ligation combined with unroofing appears to lead to complete ablation by ischemia and tumor enucleation.
Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
Kenneth F
KF
Binmoeller
Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
Janak N
JN
Shah
Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
Yasser M
YM
Bhat
Paul May & Frank Stein Interventional Endoscopy Center, California Pacific Medical Center, San Francisco, California, USA.
Steve D
SD
Kane
D001706:Biopsy / Q000295:instrumentation / Q000379:methods*; D002276:Carcinoid Tumor / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D002828:Choristoma / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D016099:Endoscopy, Gastrointestinal / Q000295:instrumentation*; D019160:Endosonography; D005240:Feasibility Studies; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000473:pathology / Q000601:surgery*; D046152:Gastrointestinal Stromal Tumors / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006099:Granuloma / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D006801:Humans; D007889:Leiomyoma / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery*; D008026:Ligation; D008297:Male; D008875:Middle Aged; D010179:Pancreas; D010865:Pilot Projects; D012189:Retrospective Studies; D024162:Second-Look Surgery; D013396:Suction