• artificial intelligence
• endoscopic ultrasonography
• mesenchymal tumor
• stomach

• RS-2023-00223764 Bio&Medical Technology Development Progream of National Research Foundation funded by the Korean government (MSIT)

• Humans
• Endoscopic Ultrasound-Guided Fine Needle Aspiration/methods
• Endoscopic Ultrasound-Guided Fine Needle Aspiration/adverse effects
• Endosonography/methods
• Endoscopy, Gastrointestinal/methods
• Gastrointestinal Neoplasms/pathology
• Gastrointestinal Neoplasms/diagnosis
• Stomach Neoplasms/pathology
• Stomach Neoplasms/diagnosis
• Upper Gastrointestinal Tract/pathology
• Image-Guided Biopsy/methods
• Image-Guided Biopsy/adverse effects
• Esophageal Neoplasms/pathology
• Esophageal Neoplasms/diagnosis

• artificial intelligence
• fine-needle aspiration
• fine-needle biopsy
• subepithelial lesions

Gastrointestinal stromal tumors (GISTs) with a diameter of < 2 cm are called small GISTs. Currently, endoscopic ultrasound (EUS) is widely used as a regular follow-up method for GISTs, which can also provide a preliminary basis for judging the malignancy potential of lesions. However, there are no studies on the accuracy of EUS to assess the malignant potential of small GISTs.

To evaluate the efficacy of EUS in the diagnosis and risk assessment of small GISTs.

We collected data from patients with small GISTs who were admitted to Shengjing Hospital of China Medical University between October 2014 and July 2019. The accurate diagnosis and risk classifications of patients were based on the pathological assessment according to the modified National Institute of Health criteria after endoscopic resection or laparoscopic surgery. Preoperative EUS features (marginal irregularity, cystic changes, homogeneity, ulceration, and strong echogenic foci) were retrospectively analyzed. The assessment results based on EUS features were compared with the pathological features.

A total of 256 patients (69 men and 187 women) were enrolled. Pathological results included 232, 16, 7, and 1 very low-, low-, intermediate-, and high-risk cases, respectively. The most frequent tumor location was the gastric fundus (78.1%), and mitoses were calculated as > 5/50 high power field in 8 (3.1%) patients. Marginal irregularity, ulceration, strong echo foci, and heterogeneity were detected in 1 (0.4%), 2 (0.8%), 22 (8.6%), and 67 (65.1%) patients, respectively. However, cystic changes were not detected. Tumor size was positively correlated with the mitotic index (P < 0.001). Receiver operating curve analysis identified 1.48 cm as the best cut-off value to predict malignant potential (95% confidence interval: 0.824–0.956). EUS heterogeneity with tumor diameters > 1.48 cm was associated with higher risk classification (P < 0.05).

Small GISTs (diameters > 1.48 cm) with positive EUS features should receive intensive surveillance or undergo endoscopic surgery. EUS and dissection are efficient diagnostic and therapeutic approaches for small GISTs.

• Gastrointestinal stromal tumors
• Endoscopic ultrasound
• Diagnosis
• Risk classification

• Male
• Humans
• Female
• Gastrointestinal Stromal Tumors/diagnostic imaging
• Gastrointestinal Stromal Tumors/surgery
• Retrospective Studies
• Stomach Neoplasms/pathology
• Endosonography/methods
• Mitotic Index

• Endoscopic biopsy
• Endoscopic ultrasound
• Endoscopic ultrasound fine-needle aspiration
• Endoscopic ultrasound fine-needle biopsy
• GI stromal tumors
• GIST
• Gastrointestinal stromal tumors
• Subepithelial lesions

• EUS-FNA
• EUS-FNB
• biopsy
• gastrointestinal stromal tumor
• subepithelial lesion

Complete enucleation of oesophageal leiomyoma is the treatment of choice, traditionally performed by open surgery. Minimally invasive thoracoscopic approaches have been proposed as an alternative to thoracotomy. Robotic surgical systems with improved dexterity, tremor filtration and stereoscopic vision are advancement over conventional thoracoscopy and may make the preservation of mucosal integrity relatively easier. We present herein our technique of robotic-assisted thoracoscopic (RATS) enucleation of oesophageal leiomyoma along with surgical outcomes and intermediate follow-up of 11 cases.

The present study retrospectively reviews patients undergoing robotic portal oesophageal leiomyomectomy from March 2012 to October 2019. The collected data were analysed for demographic details, clinical presentation, size, shape, tumour location, operating time, post-operative complications, length of hospital stay and recurrence on follow-up.

Twelve patients underwent robotic portal oesophageal leiomyomectomy with a clinical diagnosis of oesophageal leiomyoma. Of these, 11 patients were included in the study. The average operative time was 110 min, with a mean blood loss of 26 ml. There was no conversion in this series. At a median follow-up of 44 months (range 6–78 months), all patients were symptom-free with no recurrence or diverticula.

Our series demonstrates the safety and feasibility of RATS oesophageal enucleation with good short and intermediate outcomes. In our opinion, the robotic system's technical advantages are particularly beneficial for oesophageal leiomyoma enucleation.

• Oesophageal leiomyoma
• robotic enucleation of oesophageal leiomyoma
• robotic oesophageal surgery

• Endosonography
• Gastrointestinal stromal tumor
• Subepithelial tumor

• Endoscopic ultrasound
• endoscopic resection
• subepithelial lesion

• GIST
• Gastrointestinal stromal tumors
• NET
• Neuroendocrine tumors
• Pediatric oncology
• Pediatric surgery

Subepithelial tumors (SETs) are commonly encountered during upper gastrointestinal endoscopy, especially during national gastric cancer screening programs in Korea. Although the majority of SETs are benign, endoscopists harbor concerns regarding whether a SET is benign or malignant because the diagnosis cannot be established on the basis of routine endoscopic biopsy findings. The differential diagnosis of SETs is important, beginning with meticulous endoscopic examination, including the evaluation of the location, macroscopic shape, color, surface characteristics, mobility, consistency, and size of the tumors. The yield of endoscopic biopsy increases with the use of the bite-on-bite technique for SETs without the rolling or tenting sign, with large openings, and with erosion or ulceration. In this review, a systematic approach for the diagnosis of gastric SETs during conventional endoscopy is introduced.

• Endoscopy
• Stomach
• Subepithelial tumor

Reverse bevel (RB) needle is widely used for endoscopic ultrasound fine needle biopsy (EUS-FNB). A 3-plane symmetrical needle with Franseen geometry (FG) has recently become available.

To compare the clinical efficacy of FG to that of RB needle.

A retrospective cohort study of all adult patients who underwent EUS-FNB for solid and mixed lesions either with 22G RB needle or 22G FG needle between January 2016 and February 2019 was undertaken. All cytology slides were reviewed by an independent gastrointestinal cytopathologist blinded to the needle used and the initial cytology report. The primary and secondary outcomes were to assess the sample adequacy using Euro-cytology criteria and the number of cell clusters, respectively.

Two hundred and twenty six procedures were included in the study. RB needle was used in 128 procedures and FG needle in 98 procedures. The baseline characteristics of both groups were comparable. On multivariable analysis, FG needle (P = 0.02) and location of the lesion (P < 0.01) were independently associated with adequate tissue. Further, the use of FG needle (P = 0.04) and the size of the lesion (P = 0.02) were independently associated with acquisition of increased number of cell clusters.

FG needle is superior to RB needle in acquiring adequate tissue and attaining higher number of cell clusters for solid and mixed lesions.

• Endoscopic ultrasound
• Fine needle aspiration
• Fine needle biopsy
• Reverse bevel
• Franseen geometry
• Tissue acquisition

• Peroral endoscopic resection
• Subepithelial tumor
• Submucosal tumor
• Submucosal tunneling endoscopic resection
• Third space endoscopy

• Bleeding
• Endoscopic resection
• Gastric subepithelial tumor
• Muscularis propria layer
• Perforation
• Snare

Heterotopic pancreas, also known as ectopic pancreas, is pancreatic tissue located outside the pancreatic parenchyma without vascular or ductal communication with the gland. Ectopic pancreas is rarely symptomatic, typically detected incidentally at surgery or autopsy. Eighty-five to 90% are in the upper GI tract, especially the gastric antrum. We report a 54-year-old man with symptomatic gastric heterotopic pancreas presenting as recurrent, initially undiagnosed, abdominal pain. Surgery revealed heterotopic pancreas including excretory ducts, acini, and islet cells. Evidence of acute pancreatitis was present, marked by inflammation and abscess formation. Chronic pancreatitis was diagnosed by fibrosis and dilated ducts containing proteinaceous material. Submucosal location with normal overlying mucosa on endoscopy increases risks of delayed or missed diagnosis. Complications include GI bleeding, acute or chronic pancreatitis, pancreatic necrosis, pseudocyst, gastric outlet obstruction, perforation, and, rarely, pancreatic carcinoma. This rare disorder mimics more common diseases. Low suspicion, nondiagnostic imaging or endoscopy contribute to frequent diagnostic delay.

Subepithelial lesions (SELs) of the upper part of the digestive tract are rare, and it can be difficult to characterize them. Recently, contrast-enhanced endosonography (EUS) and elastometry have been reported as useful adjuncts to EUS and EUS-guided fine needle aspiration (EUS-FNA) in cases of pancreatic mass and lymph node involvement. The aim of this retrospective analysis was to evaluate whether contrast-enhanced EUS can discriminate benign submucosal lesions from malignant ones. We describe our retrospective experience using the contrast agent SonoVue^® (Bracco Imaging, Milan, Italy) in an attempt to increase the diagnostic yield.

Between May 2011 and September 2014, 14 patients (5 men, 9 women; median age 64 years, range 31–80 years) with SELs of the stomach or esophagus underwent EUS with SonoVue^® (low mechanical index). There were 3 esophageal lesions and 11 gastric lesions. Mean size of the lesions was 30 mm (range 11–50 mm). They were discovered after anemia (n = 5), dysphagia (n = 1), and pain (n = 4) and during follow-up for resected gastrointestinal stromal tumors (GISTs) (n = 1) and a standard upper gastrointestinal endoscopy (n = 3). On endoscopic sonograms, 10 of these lesions were hypoechoic and located in the fourth layer (muscularis), and 4 were in the second or third layer (mucosa and submucosa). Contrast enhancement was assessed in the early phase (after several seconds) and late phase (>30 seconds); a final diagnosis was made based on the findings of EUS-FNA using a 19-gauge ProCore (Cook Medical, Bloomington, IN) (n = 9) or 22-gauge FNA system (Cook Medical) (n = 1), the resected specimen (n = 3), or deep biopsy (n = 1). Different immunostaining was used in the pathologic studies (RNA was analyzed later using the C-kit, CD-117, CD-34, desmin, DOG-1, α-smooth actin, caldesmon, PS-100, and Ki-67 antibodies).

Final diagnoses were leiomyoma (n = 4), GIST (n = 5), schwannoma (n = 1), inflammatory tumor of Helvig (n = 1), pancreas rest (n = 2), and fibrosis (n = 1). No complications occurred. All 5 GISTs showed enhancement in the early and late phases, whereas the 8 remaining lesions did not show any enhancement. Only 1 leiomyoma showed heterogeneous enhancement.

The monocentric and retrospective study design and small number of patients.

In cases of SELs of the stomach or esophagus, SonoVue^® could be a complementary tool to endosonography to differentiate GISTs (early and clear enhancement) from other SELs (few or no enhancement), such as leiomyomas or pancreatic rest. These results are similar to those of the few, small studies published on this topic, but more studies with a larger number of patients are needed to confirm these findings.

• Contrast enhancement
• diagnosis
• endosonography
• esophagus
• subepithelial lesions of the stomach

Endoscopic ultrasound (EUS)-guided fine needle aspiration with or without biopsy (FNA/FNB) are the primary diagnostic tools for gastrointestinal submucosal tumors. EUS-guided fine needle aspiration (EUS-FNA) is considered a first line diagnostic method for the characterization of pancreatic and upper gastrointestinal lesions, since it allows for the direct visualization of the collection of specimens for cytopathologic analysis. EUS-FNA is most effective and accurate when immediate cytologic assessment is permitted by the presence of a cytopathologist on site. Unfortunately, the accuracy and thus the diagnostic yield of collected specimens suffer without this immediate analysis. Recently, a EUS-FNB needle capable of obtaining core samples (fine needle biopsy, FNB) has been developed and has shown promising results. This new tool adds a new dimension to the diagnostic and therapeutic utility of this technique. The aim of the present review is to compare the efficacy of EUS-FNA to that afforded by EUS-FNB in the characterization of pancreatic masses and of upper and lower gastrointestinal submucosal tumors.

• Efficacy
• Safety
• Gastrointestinal masses
• Fine needle aspiration and biopsy

Gastrointestinal stromal tumors (GISTs) are the most common malignant subepithelial lesions (SELs) of the gastrointestinal tract. They originate from the interstitial cells of Cajal located within the muscle layer and are characterized by over-expression of the tyrosine kinase receptor KIT. Pathologically, diagnosis of a GIST relies on morphology and immunohistochemistry [KIT and/or discovered on gastrointestinal stromal tumor 1 (DOG1) is generally positive]. The prognosis of this disease is associated with the tumor size and mitotic index. The standard treatment of a GIST without metastasis is surgical resection. A GIST with metastasis is usually only treated by tyrosine kinase inhibitors without radical cure; thus, early diagnosis is the only way to improve its prognosis. However, a GIST is usually detected as a SEL during endoscopy, and many benign and malignant conditions may manifest as SELs. Conventional endoscopic biopsy is difficult for tumors without ulceration. Most SELs have therefore been managed without a histological diagnosis. However, a favorable prognosis of a GIST is associated with early histological diagnosis and R0 resection. Endoscopic ultrasonography (EUS) and EUS-guided fine needle aspiration (EUS-FNA) are critical for an accurate diagnosis of SELs. EUS-FNA is safe and effective in enabling an early histological diagnosis and adequate treatment. This review outlines the current evidence for the diagnosis and management of GISTs, with an emphasis on early management of small SELs.

• Gastrointestinal stromal tumor
• Endoscopic ultrasonography-guided fine needle aspiration
• Endoscopic ultrasonography
• Diagnosis
• Therapy

• Early Detection of Cancer/methods
• Endosonography
• Gastrectomy/methods
• Gastrointestinal Stromal Tumors/diagnosis
• Gastrointestinal Stromal Tumors/mortality
• Gastrointestinal Stromal Tumors/pathology
• Gastrointestinal Stromal Tumors/therapy
• Gastroscopy/methods
• Humans
• Interstitial Cells of Cajal/pathology
• Laparoscopy/methods
• Prognosis
• Protein Kinase Inhibitors/therapeutic use
• Stomach/cytology
• Stomach/pathology
• Stomach Neoplasms/diagnosis
• Stomach Neoplasms/mortality
• Stomach Neoplasms/pathology
• Stomach Neoplasms/therapy
• Time Factors
• Treatment Outcome

• Aged
• Disease Progression
• Esophageal Neoplasms/pathology
• Esophageal Neoplasms/surgery
• Esophageal Neoplasms/therapy
• Female
• Gastrointestinal Stromal Tumors/pathology
• Gastrointestinal Stromal Tumors/surgery
• Granular Cell Tumor/pathology
• Granular Cell Tumor/surgery
• Humans
• Leiomyoma/pathology
• Leiomyoma/surgery
• Leiomyoma/therapy
• Leiomyosarcoma/pathology
• Leiomyosarcoma/surgery
• Male
• Middle Aged
• Symptom Assessment
• Tumor Burden
• Watchful Waiting

• Subepithelial tumor
• biopsy
• endoscopic ultrasound
• gastrointestinal stromal tumor

• biopsy
• endoscopic resection
• endoscopic ultrasound
• submucosa tumor

• Endoscopic Mucosal Resection/methods
• Esophageal Mucosa/pathology
• Esophageal Mucosa/surgery
• Esophageal Neoplasms/pathology
• Esophageal Neoplasms/surgery
• Female
• Humans
• Male
• Middle Aged
• Multivariate Analysis
• Retrospective Studies
• Treatment Outcome
• Tumor Burden

To report on a more accurate diagnostic possibility offered by endoscopic ultrasound-guided cutting of holes and deep biopsy (EUS-CHDB) for pathologic diagnosis of gastric infiltrative tumors and gastrointestinal submucosal tumors.

Ten consecutive patients who were suspected of having gastric invasive tumors or gastrointestinal submucosal tumors underwent EUS-CHDB with a novel vertical diathermic loop. We reviewed their medical data and analysed the effectiveness and safety of this new method. The final diagnosis was based on the surgical pathology or clinical/imaging follow-up.

EUS-CHDB was performed successfully in all the ten patients. Neither severe haemorrhage nor perforation occurred in any patient. Among the ten patients, there were three cases of gastric linitis plastica, one case of gastric lymphoma, five cases of gastrointestinal stromal tumors (GISTs), and only one case of chronic non-atrophic gastritis. That is, nine (90%) of the cases treated by EUS-CHDB showed positive findings.

EUS-CHDB may be a technically feasible and safe option for patients with gastric infiltrative tumors or gastrointestinal submucosal tumors. EUS-CHDB may be used as a remedial or even preferred biopsy method for submucosal lesions.

• Endoscopic ultrasound
• Cutting holes
• Deep biopsy
• Vertical diathermic loop
• Gastric linitis plastica
• Gastrointestinal submucosal tumors

• Adult
• Aged
• Biopsy/instrumentation
• Biopsy/methods
• Female
• Humans
• Male
• Middle Aged
• Retrospective Studies
• Stomach/pathology
• Stomach Neoplasms/diagnosis
• Ultrasonography, Interventional/instrumentation
• Ultrasonography, Interventional/methods

• Giant esophageal leiomyoma
• VATS
• enucleation
• minimally invasive surgery

Accurate diagnosis of subepithelial lesions (SELs) in the gastrointestinal tract depends on a variety of methods: endoscopy, endoscopic ultrasound and different types of biopsy. Making an error-free diagnosis is vital for the subsequent application of an appropriate treatment.

To evaluate the efficacy of deep biopsy via the endoscopic submucosal dissection (ESD) technique for SELs in the upper gastrointestinal tract.

It was a case series study. Deep biopsy via the ESD technique was completed in 38 patients between November 2012 and October 2014. Thirty-eight SELs in the upper gastrointestinal tract of varying size (very small ≤ 1 cm, small 1–2 cm and large ≥ 2 cm) by means of the ESD technique after an incision with an electrosurgical knife of the overlying layers and revealing a small part of the lesion were biopsied under direct endoscopic view.

Deep biopsy via the ESD technique was diagnostic in 28 of 38 patients (73.3%; 95% CI: 59.7–89.7%). The diagnostic yield for SELs with a clear endophytic shape increased to 91.3%. An evident endophytic appearance of a subepithelial lesion, the mean number of biopsied samples (6.65 ±1.36) and the total size in length of all samples per case (19.88 ±8.07 mm) were the main criteria influencing the positiveness of deep biopsy in the diagnostic group compared to the nondiagnostic one (p = 0.001; p = 0.025; p = 0.008).

Deep biopsy via the ESD technique is an effective and safe method for the diagnosis of SELs especially with a clear endophytic appearance in a large number of biopsied samples.

• deep biopsy
• endoscopic submucosal dissection
• gastrointestinal stromal tumor
• subepithelial lesions

• Endosonography
• Epithelium
• Female
• Humans
• Male
• Middle Aged
• Reproducibility of Results
• Retrospective Studies
• Stomach Neoplasms/diagnostic imaging
• Stomach Neoplasms/pathology

• Duodenum
• Endoscopic resection
• Subepithelial tumor

AIM: To do systematic review of current literature for endoscopic full thickness resection (EFTR) technique for gastric tumors originating from muscularis propria.

METHODS: An extensive English literature search was done till December 2015; using PubMed and Google scholar to identify the peer reviewed original and review articles using keywords-EFTR, gastric tumor, muscularis propria. Human only studies were included. The references of pertinent studies were manually searched to identify additional relevant studies. The indications, procedural details, success rates, clinical outcomes, complications and limitations were considered. For the purpose of review, data from individual studies was combined to calculate mean. No other statistical test was applied.

RESULTS: A total of 9 original articles were identified. Four articles were from same institute and the time frames of these studies were overlapping. To avoid duplication of data, only the study with patients over the longest time interval was included and other three were excluded. In total six studies were included in the final review. In our systematic review, the mean success rate for EFTR of gastric tumors originating from muscularis propria was 96.8%. The mean procedure time varied from a minimum of 37 min to a maximum of 105 min. There was no reported mortality from the technique itself. The most common histological diagnosis was gastrointestinal stromal tumors and leiomyoma. Gastric wall defect closure by either metallic clips or over the scope clip (OTSC) had similar outcomes although experience with OTSC was limited to smaller lesions (< 3 cm).

CONCLUSION: EFTR is a minimally invasive technique to resect gastric submucosal tumors originating from muscularis propria with a high success rate and low complication rate.

• Endoscopic full thickness resection
• Gastric tumor
• Muscularis propria
• Over the scope clip

• biopsy
• diagnostic yield
• endoscopy
• gastric neoplasm
• sensitivity

• Aged
• Biopsy/methods
• Female
• Gastroscopy
• Humans
• Male
• Neoplasm Staging
• Prospective Studies
• Stomach Neoplasms/pathology

• Aberrant pancreas
• Duodenum
• Endoscopic resection
• Endoscopic ultrasonography

• Diagnosis, Differential
• Duodenal Neoplasms/diagnostic imaging
• Duodenal Neoplasms/pathology
• Duodenal Neoplasms/surgery
• Duodenum/diagnostic imaging
• Duodenum/pathology
• Endoscopy
• Endosonography
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Pancreas/diagnostic imaging
• Pancreas/pathology
• Pancreatic Neoplasms/diagnostic imaging
• Pancreatic Neoplasms/pathology
• Pancreatic Neoplasms/surgery

Background and Aims. Endoscopic submucosal dissection (ESD) has been accepted as a treatment modality for gastrointestinal epithelial tumors. Recently, ESD has been applied to resect subepithelial tumors (SETs) in the gastrointestinal tract, but clinical evidence on its efficacy and safety is limited. The aim of this study was to investigate the efficacy and safety of ESD for gastric SETs and to assess possible predictive factors for incomplete resection. Patients and Methods. Between January 2006 and December 2013, a total of 49 patients with gastric SET underwent ESD at our hospital. Clinicopathologic characteristics of patients and SETs, therapeutic outcomes, complications, and follow-up outcomes were evaluated. Results. The overall rates of en bloc resection and complete resection were 88% (43/49) and 84% (43/49), respectively. Complete resection rates in tumors originating from the submucosal layer were significantly higher than those in tumors originating from the muscularis propria layer (90% versus 56%, P = 0.028). In multivariate logistic regression analyses, tumor location (upper third: odds ratio [OR] 12.639, 95% confidence interval [CI] 1.087–146.996, P = 0.043) and layer of tumor origin (muscularis propria: OR 8.174, 95% CI 1.059–63.091, P = 0.044) were independently associated with incomplete resection. Procedure-related bleeding and perforation rates were both 4%. No recurrence was observed in patients with complete resection at a median follow-up period of 29 months (range: 7–83 months). Conclusions. ESD is an effective, safe, and feasible treatment for gastric SETs. The frequency of incomplete resection increases in tumors located in the upper third of the stomach and in those originating from the muscularis propria layer.

• Adult
• Aged
• Aged, 80 and over
• Carcinoma/pathology
• Choristoma/pathology
• Cross-Over Studies
• Duodenal Neoplasms/pathology
• Endoscopes, Gastrointestinal
• Endoscopic Ultrasound-Guided Fine Needle Aspiration/adverse effects
• Endoscopic Ultrasound-Guided Fine Needle Aspiration/instrumentation
• Endoscopy, Gastrointestinal/instrumentation
• Esophageal Neoplasms/pathology
• Female
• Gastrointestinal Neoplasms/pathology
• Gastrointestinal Stromal Tumors/pathology
• Humans
• Leiomyoma/pathology
• Lymphoma/pathology
• Male
• Middle Aged
• Operative Time
• Pancreas
• Prospective Studies
• Punctures/instrumentation
• Stomach Neoplasms/pathology

Most of subepithelial lesion (SEL) being identified was accidentally discovered as small bulging lesion covered with normal mucosa from endoscopic screening. The type of treatment and prognosis vary depending on the type of tumor, it would be crucial to perform an accurate differential diagnosis. Since the differentiation of SEL relied on the indirect findings observed from the mucosal surface using an endoscopy only in the past, it was able to confirm the presence of lesion only but difficult to identify complex detailed nature of the lesion. However, after the endoscopic ultrasonography (EUS) was introduced, it became possible to identify extrinsic compression, and size of intramural tumors, internal properties and contour so that it gets possible to have differential diagnosis of lesions and prediction on the lesion whether it is malignant or benign. In addition, the use of EUS-guided fine needle aspiration and EUS-guided core biopsy made it possible to make histological differential diagnosis. This study intended to investigate endoscopic and EUS findings, histological diagnosis, treatment regimen and impression of colorectal SELs.

• Colorectum
• Subepithelial lesion
• Subepithelial tumor

• EMR
• ESD
• GIST
• NET
• carcinoid
• gastroscopy
• submucosal tumor

• Biopsy, fine needle
• Endoscopic ultrasound-guided fine needle aspiration
• Perirectum
• Rectum

AIM: To assess the diagnostic yield and safety of a deep and large biopsy technique under the guidance of endoscopic ultrasound (EUS) for diagnosis of gastric infiltrating tumors with negative malignant endoscopy biopsies.

METHODS: From January 2009 to March 2014, 36 patients in whom gastric infiltrating tumors had been diagnosed by EUS received negative results for malignancy after endoscopic biopsies. The deep and large biopsy technique combined bite-on-bite technique with or without endoscopic mucosal resection (EMR) to obtain submucosal tissue from lesions. EUS was used to select the appropriate biopsy sites. If the lesion protruded into the cavity, EMR was performed for removal of the overlying mucosa and then bite-on-bite technique was conducted in the resected area to obtain submucosal tissue. If the lesion appeared to be flat or was difficult to lift by injection, the bite-on-bite technique was directly used.

RESULTS: Twenty-eight of the 36 patients were treated by EMR followed by bite-on-bite technique, while 8 patients only underwent bite-on-bite technique. Histological results showed 23 of the 36 lesions were poorly differentiated adenocarcinomas, 2 diffuse large B cell lymphomas, 4 mucosa-associated lymphoid tissue-type lymphomas, and 7 undiagnosed. The deep and large biopsy technique provided a definitive and conclusive diagnosis in 29 (80.6%) of the 36 patients. The 12 gastric linitis plastica and 6 lymphoma patients received chemotherapy and avoided surgery. Minor oozing of blood in 2 mucosal resection wounds was managed by argon plasma coagulation and in 5 cases after deep biopsies by epinephrine (0.001%). Neither severe hemorrhage nor perforation occurred in any patient.

CONCLUSION: The deep and large biopsy technique is superior to ordinary endoscopic biopsy for achieving an accurate diagnosis of gastric infiltrating tumors. This procedure guided by EUS is an effective and safe diagnostic method for gastric infiltrating tumors in which endoscopic biopsy results were negative for malignancy.

• Endoscopic ultrasonography
• Endoscopic biopsy
• Diagnosis
• Gastric linitis plastica
• Gastric lymphoma

• Adenocarcinoma/diagnostic imaging
• Adenocarcinoma/pathology
• Adenocarcinoma/therapy
• Adult
• Aged
• Endosonography
• Female
• Gastric Mucosa/diagnostic imaging
• Gastric Mucosa/pathology
• Gastric Mucosa/surgery
• Gastroscopy
• Humans
• Image-Guided Biopsy/methods
• Lymphoma, B-Cell, Marginal Zone/diagnostic imaging
• Lymphoma, B-Cell, Marginal Zone/pathology
• Lymphoma, B-Cell, Marginal Zone/therapy
• Lymphoma, Large B-Cell, Diffuse/diagnostic imaging
• Lymphoma, Large B-Cell, Diffuse/pathology
• Lymphoma, Large B-Cell, Diffuse/therapy
• Male
• Middle Aged
• Neoplasm Invasiveness
• Patient Selection
• Predictive Value of Tests
• Prognosis
• Retrospective Studies
• Stomach Neoplasms/diagnostic imaging
• Stomach Neoplasms/pathology
• Stomach Neoplasms/therapy

AIM: To evaluate the safety and feasibility of endoscopic resection using band ligation (EMR-B) for the diagnostic and therapeutic removal of tumors located in the esophageal subepithelial region having originated from the submucosa.

METHODS: From May 2009 to September 2014, after medical chart and endoscopic ultrasonography report review, a total of 15 esophageal tumors located in the submucosal layer were resected by EMR-B. Previous symptom, location, pathology, complete resection rate, incidence of complications, incidence of minor complication, size, length of procedures time and follow up months were evaluated. To evaluate local recurrence at the resection site, periodic follow-up endoscopic examination was undertaken in all of the patients. The first endoscopic examination was performed about 6 mo after the endoscopic resection. Thereafter, the endoscopic follow up were scheduled annually.

RESULTS: The mean age was 50.3 ± 9.67 years. The mean tumor size was 6.93 ± 3.15 mm and most of the lesions size was between 5-10 mm in diameter (10/15, 66.6%). In all patients, endoscopic en bloc resection was achieved. In one patient, the vertical margin was involved. The mean procedural time was 8.86 ± 3.66 min. In all patients, no evidence of severe complications such as perforation or bleeding occurred. Minor complications such as chest pain (2/15, 13.3%) and heartburn (3/15, 13.3%) were reported but they symptoms were controlled by proton pump inhibitors, ulcermin and/or analgesics. Histologic assessments of the removed specimens revealed 10 granular cell tumors (66.6%), 4 leiomyomas (16.6%) and one lipoma (6.6%). No recurrence was observed during the mean follow up period of 45 ± 3.5 mo (range: 5-64 mo).

CONCLUSION: EMR-B might be considered safe and effective for the diagnosis and treatment of lesions measuring less than 10 mm in diameter.

• Band ligation
• Endoscopic mucosal resection
• Esophagus
• Submucosal tumor
• Ultrasonography

• Adult
• Aged
• Endosonography
• Esophageal Neoplasms/pathology
• Esophageal Neoplasms/surgery
• Esophagectomy/adverse effects
• Esophagectomy/methods
• Esophagoscopy/adverse effects
• Esophagoscopy/methods
• Feasibility Studies
• Female
• Humans
• Ligation
• Male
• Middle Aged
• Neoplasm Recurrence, Local
• Postoperative Complications/etiology
• Retrospective Studies
• Time Factors
• Treatment Outcome
• Tumor Burden

AIM: To study the clinical, endoscopic, sonographic, and cytologic features of ectopic pancreas (EP).

METHODS: This was a retrospective study performed at an academic referral center including two hospitals. Institutional review board approval was obtained. Patients referred to the University Hospital or Denver Health Medical Center Gastrointestinal Endoscopy Lab for gastroduodenal subepithelial lesions (SEL) with a final diagnosis of EP between January 2009 and December 2013 were identified. Patients in this group were selected for the study if they underwent endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) or deep biopsy. A review of the medical record was performed specifically to review the following information: presenting symptoms, endoscopic and EUS findings, computed tomography or magnetic resonance imaging findings, pathology results, procedure-related adverse events, and subsequent treatments after EUS-FNA. EUS with FNA or deep submucosal biopsy was performed in all patients on an outpatient basais by one of two physicians (Attwell A, Fukami N). Review of all subsequent clinic notes and operative reports was performed in order to determine follow-up and final diagnoses.

RESULTS: Between July 2009 and December 2013, 10 patients [3 males, 7 females, median age 52 (26-64) years] underwent EUS for a gastroduodenal SEL and were diagnosed with EP. One patient was symptomatic. Six (60%) lesions were in the antrum, 3 (30%) in the body, and 1 (10%) in the duodenum. A mucosal dimple was noted in 6 (60%). Mean lesion size was 17 (8-25) mm. Gastrointestinal wall involvement: muscularis mucosae, 10%; submucosa, 70%; muscularis propria, 60%; and serosa, 10%. Nine (90%) lesions were hypoechoic and 5 (50%) were homogenous. A duct was seen in 5 (50%). FNA was attempted in 9 (90%) and successful in 8 (80%) patients after 4 (2-6) passes. Cytology showed acini or ducts in 7 of 8 (88%). Superficial biopsies in 7 patients (70%) showed normal gastric mucosa. Deep endoscopic biopsies were taken in 2 patients and diagnostic in one. One patient (10%) developed pancreatitis after EUS-FNA. Two patients (20%) underwent surgery to relieve symptoms or confirm the diagnosis. The main limitation of the study was the fact that it was retrospective and performed at a single medical center.

CONCLUSION: EUS features of EP include antral location, mucosal dimple, location in layers 3-4, and lesional duct, and FNA or biopsy is accurate and effective.

• Endoscopic ultrasound
• Pancreatitis
• Ectopic pancreas
• Endoscopy
• Subepithelial mass

• Adult
• Carcinoma/pathology
• Carcinoma/virology
• Choristoma/diagnostic imaging
• Choristoma/pathology
• Choristoma/surgery
• Colorado
• Duodenal Diseases/diagnostic imaging
• Duodenal Diseases/pathology
• Duodenal Diseases/surgery
• Endoscopic Ultrasound-Guided Fine Needle Aspiration
• Female
• Gastric Mucosa/pathology
• Hospitals, University
• Humans
• Intestinal Mucosa/pathology
• Male
• Middle Aged
• Pancreas
• Predictive Value of Tests
• Retrospective Studies
• Stomach Diseases/diagnostic imaging
• Stomach Diseases/pathology
• Stomach Diseases/surgery

AIM: To compare the accuracy of endoscopic ultrasonography (EUS) vs EUS-guided biopsy in the diagnosis of large gastric folds.

METHODS: Thirty-four patients with suspected large gastric folds who underwent EUS and EUS-guided biopsy from July 2011 to December 2013 were included. The diagnostic accuracy and safety of EUS-guided biopsy were evacuated according to the final results.

RESULTS: Twenty-nine patients were finally diagnosed. The overall accuracy rate of EUS-guided biopsy was 75.9%. Severe complications such as perforation and severe bleeding were not seen during and after the process of EUS-guided biopsy. Deep biopsy guided by EUS was easier to cause bleeding than large mucosal biopsy (P < 0.05). According to the characteristics of ultrasound imaging of each lesion, the diagnostic accuracy rate of EUS for gastric cancer was 69%, sensitivity 63.2%, and specificity 80.0%; accuracy 62.1%, sensitivity 25.0%, and specificity 76.2% for lymphoma.

CONCLUSION: EUS-guided biopsy is an effective diagnostic method for large gastric folds.

• Endoscopic ultrasound guided biopsy
• Large gastric folds
• Diagnosis

• Endoscopic ultrasound
• fine needle aspiration
• gastrointestinal tract
• submucosal tumor

• diagnosis
• gastric subepithelial tumor
• histology
• scoring system