Lee AY, Lim SG, Cho JY, Kim S, Lee KM, Shin SJ, Noh CK, Lee GH, Hur H, Han SU, Son SY, Song JH. Comparison of treatment strategies for submucosal tumors originating from the muscularis propria at esophagogastric junction or cardia. World J Gastroenterol 2025; 31(23): 106261 [DOI: 10.3748/wjg.v31.i23.106261]
Corresponding Author of This Article
Sun Gyo Lim, MD, PhD, Professor, Department of Gastroenterology, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon 16499, South Korea. mdlsk75@ajou.ac.kr
Research Domain of This Article
Gastroenterology & Hepatology
Article-Type of This Article
Retrospective Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Ah Young Lee, Joo Young Cho, Department of Gastroenterology, CHA Gangnam Medical Center, CHA University College of Medicine, Seoul 06135, South Korea
Sun Gyo Lim, Kee Myung Lee, Sung Jae Shin, Choong-Kyun Noh, Gil Ho Lee, Department of Gastroenterology, Ajou University School of Medicine, Suwon 16499, South Korea
Seokhwi Kim, Department of Pathology, Ajou University School of Medicine, Suwon 16499, South Korea
Hoon Hur, Sang-Uk Han, Sang-Yong Son, Jeong Ho Song, Department of Surgery, Ajou University School of Medicine, Suwon 16499, South Korea
Author contributions: Lee AY contributed to data curation, formal analysis, and writing of the original draft of the manuscript; Lim SG contributed to conceptualization, visualization, supervision, writing-review, and editing; Cho JY, Kim S, Lee KM, Shin SJ, Noh CK, Lee GH, Hur H, Han SU, Son SY, Song JH contributed to methodology, investigation; Young J contributed to writing-review and editing; and all authors approved the final version of the manuscript for publication.
Institutional review board statement: All procedures were conducted in accordance with the ethical standards of the Hospital Ethics Committee and Institutional Review Board of Ajou University Hospital (approval No. AJOUIRB-DB-2024-311).
Informed consent statement: The need for written informed consent from the patients was waived due to the retrospective nature of the study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data that support the findings of this study are not publicly available, as they are proprietary to the corresponding author; however, detailed summaries and analyses are provided within the article and its supplementary materials.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sun Gyo Lim, MD, PhD, Professor, Department of Gastroenterology, Ajou University School of Medicine, 164 World Cup-ro, Yeongtong-gu, Suwon 16499, South Korea. mdlsk75@ajou.ac.kr
Received: February 20, 2025 Revised: April 1, 2025 Accepted: May 30, 2025 Published online: June 21, 2025 Processing time: 120 Days and 10.2 Hours
Abstract
BACKGROUND
The spectrum of gastric submucosal tumors (SMTs) in the upper gastrointestinal system ranges from non-neoplastic to malignant lesions, with gastrointestinal stromal tumors exhibiting inherent malignant potential. However, the diagnosis of SMTs remains challenging, and treatment methods, especially for tumors located at the cardia or esophagogastric junction (EGJ), are not well established. Minimally invasive techniques - such as endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER), and laparoscopic wedge resection (LWR) - have been developed for these lesions. However, comparative data on their feasibility, safety, and clinical outcomes in these locations remain limited.
AIM
To compare ESD, STER, and LWR for SMTs at the EGJ or cardia, focusing on procedural feasibility.
METHODS
This single-center retrospective study included patients with SMTs less than 45 mm from the muscularis propria, growing intraluminally at the EGJ or cardia, and treated with ESD, STER, or LWR between July 2014 and September 2022. The primary outcome was relapse-free survival during follow-up.
RESULTS
The median age (interquartile range) was 53.0 (40.0-57.5), 43.0 (39.0-57.0), and 56.0 (43.0-64.0) years for ESD, STER, and LWR, respectively. The median follow-up time (interquartile range) was 60.0 (26.5-66.5), 24.0 (13.0-38.0), and 35.0 (21.0-60.0) months. LWR had the largest tumors (30.0 mm) and the highest rate of high-risk gastrointestinal stromal tumors (68.0%, P < 0.001). Tumor recurrence occurred in one LWR patient (4.0%, P = 0.600). En bloc and macroscopic resection rates were 100% (P = 1.000), but microscopic resection rates differed (P = 0.021). Significant minor complications occurred in 5 patients (10.0%), all grade IIIa. Tumor location (cardia/fundus, P = 0.006) and prolonged procedure time (P < 0.001) were significantly associated with complications.
CONCLUSION
ESD, STER, and LWR are effective for SMTs at the EGJ and cardia, with minor complications associated with tumor location and procedure time, and comparable recurrence rates.
Core Tip: This study compares endoscopic submucosal dissection, submucosal tunneling endoscopic resection, and laparoscopic wedge resection for submucosal tumors originating from the muscularis propria at the esophagogastric junction and cardia. Despite technical challenges, all methods demonstrated safety, practicality, and high en bloc resection rates, with laparoscopic wedge resection showing superior microscopic complete resection. Recurrence rates were comparable across methods, even for high-risk gastrointestinal stromal tumors. These findings underscore the feasibility of minimally invasive approaches for treating submucosal tumors in challenging anatomical locations, advancing diagnostic precision and treatment efficacy while minimizing patient burden.
Citation: Lee AY, Lim SG, Cho JY, Kim S, Lee KM, Shin SJ, Noh CK, Lee GH, Hur H, Han SU, Son SY, Song JH. Comparison of treatment strategies for submucosal tumors originating from the muscularis propria at esophagogastric junction or cardia. World J Gastroenterol 2025; 31(23): 106261
The etiology of gastric submucosal tumors (SMTs) in the upper gastrointestinal system varies from non-neoplastic lesions to true neoplasia[1]. All gastrointestinal stromal tumors (GISTs) have malignant potential[2], and some presumed SMTs have cancerous features, indicating the need for more precise diagnostic and treatment methods. Despite advancements in endoscopic ultrasound (EUS), computed tomography (CT), and esophagogastroduodenoscopy (EGD), the diagnosis of SMTs remains challenging[3-6] and treatment approaches have not yet been well established. Accurate diagnosis of SMTs using fine needle aspiration is challenging due to sampling errors, technical difficulties with hard tissues such as GISTs and leiomyomas, variability in equipment and physician skill, and occasional inability to cytologically determine the malignant potential of samples[7-9]. Other methods, such as jumbo forceps, which have 17% accuracy[10], and the unroofing technique, which has 93.7% diagnostic yield[11], are limited by complications, time, and cost, which makes resection often preferable because of the reduced financial, temporal, and psychological burden on patients[12].
Concerns regarding positive margins, tumor spillage, and potential perforation during resection exist[13]. These concerns are more pronounced for SMTs located at the cardia or esophagogastric junction (EGJ), where stenosis or leakage must be considered. Historically, many SMTs in the EGJ or cardia have been surgically resected because of these technical challenges[14]; however, several studies on the feasibility of laparoscopic and endoscopic treatments have emerged[15,16]. We aimed to compare the endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER) introduced by Inoue et al[14], and laparoscopic wedge resection (LWR) for the resection of SMTs originating from the muscularis propria (MP) at the cardia and EGJ, particularly in technically challenging cases, and to evaluate the feasibility of minimally invasive procedures.
MATERIALS AND METHODS
Study design
We retrospectively reviewed the medical records of 76 patients aged 20-75 years who were diagnosed with primary SMTs at the EGJ or cardia and underwent endoscopic or laparoscopic surgical resection at Ajou University Hospital between July 2014 and September 2022. After applying the exclusion criteria, 50 patients were included in the final analysis. Inclusion criteria included tumor size < 4.5 cm, MP origin, intraluminal growth on EUS, and no lymph node metastasis. LWR is recommended for tumors ≥ 25 mm or those originating from the outer muscle layer on EUS[14,16-19]. For EGJ tumors, STER is advised, prioritizing patient preferences when selecting LWR, STER, or ESD (Video 1). Patients with severe cardiorespiratory dysfunction or intolerance to sedation or anesthesia were excluded. The primary outcome was relapse-free survival during follow-up, while the secondary outcomes included microscopically and macroscopically complete en bloc resection rates, postoperative adverse events, operative time, and hospitalization duration. The study protocol was approved by the Institutional Review Board of Ajou University Hospital (Approval No. AJOUIRB-DB-2024-311). Given the retrospective design of this study, written informed consent was not required.
ESD
Both ESD and STER were performed by a single expert with experience of having handled > 1000 ESD cases under general anesthesia with tracheal intubation. All procedures were performed using a forward-viewing endoscope (GIF Q260J/GIF Q290J, Olympus, Tokyo, Japan) fitted with a transparent distal cap (D-201, Olympus, Tokyo, Japan). As described by Lv et al[20], CO2 insufflation was used in all procedures to minimize gas-related complications. The lesion was circumferentially marked with a dual-tip knife (KD-655 L, Olympus, Tokyo, Japan) set to the endocut Q mode (60 W, Effect 3). Using a 23-gauge injection needle (NM-600 L-0423, Olympus, Tokyo, Japan), a mixture of 2% indigo carmine (Korea United Pharmaceutical Co., Korea) and 1% epinephrine was injected around the lesion to lift it off the MP; however, only the mucosa, not the tumor, was lifted. Dual-tip and insulation-tip knives (KD-611 L, Olympus, Japan) were selectively used for fine or blunt dissection to separate the tumor from the MP (Figure 1).
Figure 1 Endoscopic submucosal dissection.
A: Endoscopic view of a submucosal tumor in the cardia of the stomach; B: Endoscopic ultrasonography showing a hypoechoic submucosal tumor in the muscularis propria; C: Circumferential markings around the lesion; D and E: Mucosal incision along the marked points after submucosal injection; F: The tumor was completely resected macroscopically; G: Resected specimen; H: Endoscopic view at the 3-month follow-up.
STER
A fluid cushion was formed by submucosal injection of diluted indigo carmine, akin to ESD, using a needle 5 cm proximal to the SMT. A 1.5-2 cm longitudinal mucosal incision was made with a dual-tip knife at the esophageal mucosa for entry. The tunnel was created by dissecting the deep submucosal layer near the MP from the entry point to the tumor, ensuring ample workspace for resection and preserving the overlying mucosa. The tumor was dissected with a dual-tip knife, and an insulation-tip knife was used to carefully separate the submucosal tissue and MP around the tumor, avoiding direct contact with the tumor. Fully mobilized tumors were extracted from the submucosal space through a mucosal incision using a swirling net (ET2011, Olympus, Tokyo, Japan) for retraction. Submucosal tumors usually have an oval shape, which allows for smooth removal through mucosal entry. After ensuring complete hemostasis in the submucosal tunnel, the mucosal entry was closed using hemostatic clips (Figure 2).
Figure 2 Submucosal tunneling endoscopic resection.
A: Endoscopic view of the submucosal tumor in the cardia; B: Endoscopic ultrasound image showing a tumor originating from the muscularis propria; C: Incision 3-4 cm proximal to the tumor to create a submucosal tunnel after fluid cushion injection; D: Exposed tumor within the submucosal tunnel; E and F: Endoscopic dissection of the lesion through a tunnel; G: Tumor retrieval after en bloc resection; H: Endoscopic view at the 3-month follow-up.
LWR
All procedures were performed by four experienced surgeons, each with over 400 laparoscopic gastrectomy cases. The hepatogastric ligament was divided for tumors near the lesser curvature. For tumors near the posterior wall or greater curvature, the splenogastric ligament was separated to facilitate stomach rotation and tumor exposure. The gastric wall was detached from the omental tissue at the tumor site, and the associated vessels were ligated. To lift the tumor, the normal gastric wall was clamped with curved forceps or sutures were placed around the tumor. Wedge resection was done with a laparoscopic linear stapler, starting from the distal side of the normal gastric wall. If active bleeding occurred along the incision line, continuous 3-0 absorbable sutures controlled it (Figure 3)[17].
Figure 3 Laparoscopic wedge resection.
A: Endoscopic view of the submucosal tumor in the cardia; B: Endoscopic ultrasound image showing a tumor originating from the muscularis propria; C and D: Dissection of the anterior wall of the stomach to obtain an intragastric view with the submucosal tumor marked with clips; E and F: A laparoscopic linear stapler was used to perform wedge resection; G: Surgical suturing of the stomach; H: Endoscopic follow-up 6 months later showing no deformities.
Post-procedure management
In the absence of abnormal findings, patients maintained a nothing by mouth status for 2 days after ESD and STER and 1 day after LWR, receiving intravenous proton pump inhibitors and antibiotics for 3 days postoperatively. Daily monitoring included complete blood counts and radiographic checks for pneumothorax, mediastinal emphysema, and pleural effusion. During hospitalization, signs of emphysema, abdominal pain, fever, dyspnea, and bleeding (hematemesis and melena) were monitored. Patients with GISTs > 2 cm or with a mitotic count ≥ 5 per 50 high-power fields had follow-up CT and EGD every 6 months for the first year and annually thereafter. Other patients had annual CT and EGD follow-ups.
Pathological examination
Tissue specimens were fixed in formalin for histopathological examination, which focused on the cell type and mitotic count per 50 HPFs, conducted by a single pathologist. Immunohistochemical analysis of CD117, CD34, smooth muscle actin, desmin, and S-100 markers was used to classify the tumor subtypes. Complete resection was defined as en bloc resection with negative lateral margins confirmed by a single experienced pathologist. The tumor histological classification followed the World Health Organization criteria for digestive system tumors[21].
Statistical analysis
Quantitative data with skewed distributions were reported as medians with interquartile ranges, and were compared using the Wilcoxon rank-sum test. Categorical data were presented as counts and percentages and analyzed using the χ2-test. Recurrence-free survival was estimated using the Kaplan-Meier method. Statistical significance was set at P < 0.05.
RESULTS
We enrolled 76 patients with hypoechoic submucosal tumors of the MP at the EGJ or cardia. Excluding patients who did not meet the inclusion criteria, we analyzed 50 patients, of whom 15 underwent ESD, 10 underwent STER, and 25 underwent LWR based on tumor size, outer muscle origin, and patient preference (Figure 4). The median age and sex distributions were similar across the ESD, STER, and LWR groups. Tumor location differed significantly between the groups (P = 0.013), with most tumors in the cardia posterior wall in the LWR group (68.0%) compared to the ESD (40.0%) and STER (60.0%) groups. The median tumor diameter was significantly larger in the LWR group (30.0 mm) than in the ESD (18.0 mm) and STER (21.0 mm) groups (P < 0.001). Tumor regularity on EUS, echogenicity, and pre-procedure symptoms did not differ significantly between the groups. All tumors originated from the MP, with 100% involvement of the inner muscle layer in the ESD and STER groups and 84% involvement in the LWR group (Table 1).
The en bloc and macroscopic complete resection rates were 100% in all three groups. In contrast, complete microscopic resection showed significant differences, with R0 resection rates of 86.7%, 60.0%, and 96.0% in the ESD, STER, and LWR groups, respectively (P = 0.021). The median procedure times were 75.0 (ESD group), 84.0 (STER group), and 70.0 minutes (LWR group, P = 0.075). The length of hospital stays was 6.0 (ESD group), 6.0 (STER group), and 5.0 days (LWR group, P = 0.017). The fasting durations were 2.0 (ESD group), 3.0 (STER group), and 1.0 day (LWR group, P < 0.001). The tumor diameters were 27.0 mm (ESD group), 28.5 mm (STER group), and 36.0 mm (LWR group, P = 0.002). Leiomyomas were most common in the STER (90.0%) and ESD (66.7%) groups, whereas high-risk GISTs were predominant in the LWR group (68.0%, P < 0.001). Complications included delayed bleeding and pneumoperitoneum in two ESD (13.3%) and one LWR (4.0%) patients (P = 0.325, Table 2). A 20-gauge needle was used to manage pneumoperitoneum, and delayed bleeding was resolved with endoscopic hemostasis without long-term complications. The median follow-up periods were 60.0 (ESD group), 24.0 (STER group), and 35.0 months. Tumor recurrence occurred in one patient who underwent LWR (Table 3 and Figure 5). This patient had a 39 mm GIST with a mitotic count > 10 per 50 HPFs located at the cardia posterior wall (Figure 5B). Five years post-surgery, a 1.4 cm × 1.6 cm peritoneal nodule recurred and was excised. Adjuvant Glivec therapy was initiated. CT scans were performed every 6 months, and no recurrence was observed for 10 years after LWR. In the additional analysis of factors associated with complications, significant complications were linked to tumors located on the fundal side of the cardia (P = 0.006) and procedures lasting ≥ 100 minutes (P < 0.001). Other factors, such as age, sex, tumor size and shape, MP layer involvement, histology, and procedure type, were not significantly associated with complications (Table 4).
Figure 5 A patient who underwent laparoscopic wedge resection.
A: A histology specimen from a patient who underwent a macroscopically complete resection during laparoscopic wedge resection, but with R1 resection in the final pathology report, showed no evidence of recurrence for > 5 years; B: Kaplan-Meier estimate of recurrence-free survival. ESD: Endoscopic submucosal dissection; STER: Submucosal tunneling endoscopic resection; LWR: Laparoscopic wedge resection.
The diagnosis, surveillance, and treatment of SMTs remain the subject of ongoing debate[6,22,23]. Additionally, GISTs without high-risk features on EUS can become malignant or increase in size by 10%-30%[24] during long-term follow-up[23]. Despite its diagnostic and therapeutic benefits, resection of SMTs at the EGJ and cardia is challenging, highlighting the need for minimally invasive approaches. Our study compared less invasive resection methods for SMTs of MP origin at the EGJ or cardia. While the LWR group had larger and higher-risk GISTs, recurrence was rare and comparable across the groups. Notably, the STER group showed a higher rate of microscopic R1 resections; however, no metastasis or recurrence occurred during follow-up, indicating a limited clinical impact. Complication rates did not differ significantly among the groups.
ESD, STER, and LWR are feasible options for SMTs of MP origin in the EGJ and cardia; however, their specific characteristics must be considered. Resection of SMTs at the cardia and EGJ is challenging because of the angle of the patient and irregular contraction of the lower esophageal sphincter[25], making the choice of an appropriate resection method crucial. Despite concerns regarding mucosal defects, ESD is effective even for tumors tightly adherent to the MP[18,26,27] and has a shorter learning curve and better visual field control than STER. In contrast, STER, although technically demanding for large SMTs, offers benefits such as direct vision through the submucosal tunnel[19], maintenance of mucosal integrity, and promotion of wound healing with minimal bleeding and infection risks[28]. Additionally, given the technical challenges of ESD at the EGJ and concerns regarding postoperative gastroesophageal reflux following LWR due to structural alterations, STER is often recommended for patients with SMTs in this location. LWR is a relatively common and straightforward technique. Previous studies excluded LWR for intraluminal growth patterns because of concerns about tumor seeding[29]; however, recent research, including this study, showed no increased risk of dissemination, even in GISTs with ulceration[30]. Consequently, LWR is preferred for large tumors that require familiar handling and rapid removal, STER for maintaining mucosal integrity, and ESD for small tumors that require meticulous resection.
The concept of a positive microscopic resection margin or R1 resection can be considered differently for esophageal/gastric cancers and SMTs. In our study, most cases involved leiomyomas (27 out of 50), which were mostly encapsulated, and stromal tumors generally did not invade the adjacent tissue layers. Therefore, for ESD and STER, endoscopy was used to carefully observe and consider the characteristics of these SMTs to minimize the stomach resection area by not excessively extending the margins, unlike in LWR. Therefore, the resection margins for SMTs during ESD or STER are not extensive[31,32]. Our study showed significantly more microscopic R1 resection margins in the ESD and STER groups than in the LWR group. However, no clinical recurrences were observed in patients with microscopic R1 resection, suggesting that the microscopic positive margins in the ESD and STER groups may be due to electrocautery artifacts and that macroscopic complete resection and the degree of recurrence are more important in the clinical settings and course of SMTs (Figure 5B).
In this study, LWR was recommended for SMTs > 25 mm based on previous studies, which reported that the mean tumor size treated with STER ranged from approximately 21 to 25 mm. Additionally, the tumor size limit was set to 45 mm. Previous studies and the European Society for Medical Oncology guidelines recommend a laparoscopic approach for tumors < 50 mm to prevent tumor rupture, noting that larger tumors pose technical challenges[33,34]. Moreover, Inoue et al[14] noted that lesions infiltrating the proper muscle layer are difficult to dissect safely with endoscopic resection, particularly for tumors > 40 mm, owing to visualization issues. Larger tumors in the cardia may lack adequate space for removal through the EGJ and laryngopharynx. Therefore, our study used a 45-mm cut-off to compare LWR, STER, and ESD. There have been cases of ESD or STER for large SMTs[35-37]; however, our study did not find a clear correlation between size and complications, indicating the need for further research on the optimal cut-off size for performing minimally invasive resections.
Severe adverse events were absent in all groups. Despite concerns from previous studies[26], no perforations occurred in the ESD group, and there were no procedure-related abdominal infections across all groups despite the lack of clipping in the ESD group. According to the Clavien-Dindo system[38], grade IIIa adverse events, such as delayed bleeding or pneumoperitoneum, occurred in three patients who underwent ESD (one with both) and in two patients who underwent LWR. A long procedure time (> 100 minutes) or tumor location in the fundus significantly increased the relative risk of grade IIIa adverse events, which was attributed to technical issues and operator proficiency, with no significant differences observed among the procedures (Table 4). However, no grade IIIb or higher complications were observed, indicating no significant impact in the clinical setting. There were no cases of postoperative gastroesophageal reflux disease or strictures. Ko et al[39] reported that LWR for SMTs within 5 cm of the EGJ often leads to gastroesophageal reflux disease due to deformities, but our study found none of these issues in any group, even when considering the vagus nerve pathway area and acid pocket associated with the EGJ and cardia[40]. Although the STER group had a slightly longer procedure time, this was not clinically significant considering the early adoption and initial variability of STER[14]. Fasting and hospital durations were significantly shorter in the LWR group and approximately 1 day longer in the STER group; however, the hospital stay duration for STER was similar to that reported in previous studies[41]. The extended duration of patients who underwent STER was for careful observation, given that STER was first introduced in 2012[14] and is not due to complications or discomfort, and thus holds no clinical significance.
In our study, only one patient experienced recurrence; however, after appropriate treatment, no recurrence was observed for 10 years. This finding suggests that less invasive treatments may be viable options for patients with intermediate- to high-risk GISTs, although close monitoring remains essential. This study has several implications. This is the first study to compare less invasive treatments, such as laparoscopic and endoscopic resection methods, including the newer STER technique and ESD, for SMTs of MP origin in challenging locations, such as the EGJ and cardia, broadening treatment options, and providing significant clinical insights. By focusing on tumors with intraluminal growth patterns, we enhanced the comparative significance of ESD, STER, and LWR. This analysis not only highlights the specific indications for each procedure in resecting SMTs under challenging conditions but also offers practical guidance for future clinical decision-making. In addition, the high proportion of GISTs in our study underscores the relevance of our findings in real clinical settings, where resection is often recommended, while also broadening the perspective on minimally invasive resection for other SMTs, such as schwannomas, granular cell tumors, glomus tumors, and neuroendocrine tumors. This makes our study useful for clinical decision-making regarding the appropriate resection method.
One of the major limitations of our study was its retrospective nature, which may have introduced bias in recurrence rates based on SMT characteristics. Additionally, the small sample size, particularly for ESD and STER, limits the generalizability of the results. A single expert performed both ESD and STER, while LWR was conducted by four surgeons, potentially influencing procedural outcomes. Further research is needed to assess the impact of operator experience. The relatively short follow-up period may have underestimated recurrence rates, although previous SMT studies also had shorter follow-ups than cancer studies. Large-scale prospective studies are required to validate these findings.
CONCLUSION
ESD, STER, and LWR are effective treatment options for SMTs originating from the MP layer of the EGJ and cardia. Although grade IIIa complications occurred[38], they were minor and associated with tumor location and procedure time. Despite LWR involving more high-risk GISTs, the recurrence rates did not differ significantly among the methods.
Footnotes
Provenance and peer review: Unsolicited article; Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Gastroenterology and hepatology
Country of origin: South Korea
Peer-review report’s classification
Scientific Quality: Grade B, Grade B, Grade B, Grade B
Novelty: Grade A, Grade A, Grade B, Grade B
Creativity or Innovation: Grade B, Grade B, Grade B, Grade B
Scientific Significance: Grade A, Grade B, Grade C, Grade C
P-Reviewer: Serban ED; Shukla A; Syed KA S-Editor: Wei YF L-Editor: A P-Editor: Zhao S
Wang XY, Xu MD, Yao LQ, Zhou PH, Pleskow D, Li QL, Zhang YQ, Chen WF, Zhong YS. Submucosal tunneling endoscopic resection for submucosal tumors of the esophagogastric junction originating from the muscularis propria layer: a feasibility study (with videos).Surg Endosc. 2014;28:1971-1977.
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