Endoscopic Removal of Submucosal Tumors: Preprocedure Diagnosis, Technical Options, and Results

 

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Introduction

Submucosal tumors (SMTs) of the gastrointestinal tract are uncommon and are usually found incidentally at endoscopy. When an SMT is encountered on upper endoscopy, the difficulty in formulating a management plan lies in the uncertainty as to the histopathologic nature of the tumor. Many techniques have been used in attempts to obtain adequate samples for tissue diagnosis, including endoscopic boring biopsy, biopsy after mucosal incision to expose the tumor, endoscopic submucosal tumorectomy, and biopsy after resection of the mucosa [1] [2] [3] [4] [5]. Unfortunately, these methods pose significant risks of hemorrhage and perforation. Endoscopic ultrasonography (EUS) may be a useful adjunctive diagnostic technique. However, it does not always permit the differential diagnosis of various submucosal tumors to be made, and it cannot necessarily distinguish benign from malignant lesions.

Thus, until recently, management of SMT consisted of two relatively unsatisfactory options: (i) observation without a definitive tissue diagnosis, or (ii) surgical resection. Although most SMTs of less than 5 cm are not malignant, this cannot be presumed. Thus, follow-up examinations at regular intervals are recommended to monitor the tumor for changes in size and shape. However, this imposes a tremendous emotional burden on patients, who can become preoccupied with the possibility that the tumor is malignant. On the other hand, open surgical resection of SMTs, especially benign SMTs of the esophagus, is a fairly invasive approach to a benign disease. This is complicated by the fact that patients may feel worse after surgery, particularly those who had been asymptomatic or who had minimal symptoms beforehand [6]. Thus, less invasive techniques such as endoscopic resection are becoming the preferred method of treating SMTs. Recently technical advances in EUS as well as new devices designed for endoscopic mucosal resection have opened the field to many therapeutic possibilities [7] [8].

The decision to resect an SMT should take several factors into consideration, including the patient’s symptoms, the level of certainty of diagnosis, characteristics of the particular tumor, potential for bleeding or obstructive complications, and available therapeutic options. Therapeutic decisions are then tailored to the individual patient and their level of co-morbidity, the tumor in question, and the comfort level and expertise of the physician. This article will focus on the various endoscopic techniques that have been applied to SMTs, through a review of endoscopic resection techniques, the results reported for each technique, and a review the literature on this subject.

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C.-S. Shim, M. D.

Digestive Disease Center, Soon Chun Hyang University College of Medicine ·

657 Hannam-Dong · Yongsan-Ku · Seoul 140-743 · Korea

Fax: +82-2-7099696

Email: csshim@hosp.sch.ac.kr