In medical research, as in many other fields, the journey is often as rewarding and
important as the destination itself. Thus, as endoscopic pioneers set their goals
to tackle new approaches such as natural orifice transluminal endoscopic surgery (NOTES),
1
along the way (literally and figuratively) they “discovered” a novel arena for endoscopic
maneuvers, one that lay within the wall of the gut. If the lumen was historically
the first space, and the peritoneal cavity the second, then the intramural space has
come to represent the “third space.” Unlike the others, this space remains virtual
and has to be created by dissecting and expanding the tissue layer between the mucosa
and the muscularis propria, allowing the endoscope to gain access. Submucosal tunneling
in this fashion was initially described by Sumiyama and colleagues
2
and was adopted for esophageal myotomy by Pasricha et al
3
in 2007, culminating in its application in patients with achalasia by Inoue et al
4
in what has now become known as the POEM (per oral endoscopic myotomy) procedure.
However, as illustrated by Kobara et al
5
in this issue of the journal, we are only just beginning to realize the full potential
of the many diagnostic and therapeutic interventions possible in this space, collectively
best termed as submucosal operations (SuMO). In this study, the investigators used
submucosal endoscopy with a special cap to obtain core biopsy specimens from gastric
subepithelial tumors (SETs) originating from the muscularis propria in 8 patients
and were successful in obtaining an accurate histologic diagnosis in all cases.Abbreviations:
ESD (endoscopic submucosal dissection), EUS (endoscopic ultrasonography), GIST (gastrointestinal stromal tumors), NOTES (orifice transluminal endoscopic surgery), POEM (per oral endoscopic myotomy), SET (subepithelial tumors), SINK (single-incision needle-knife), STER (submucosal tunneling and endoscopic resection), SuMO (submucosal operations)To read this article in full you will need to make a payment
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References
- NOTES: current status and new horizons.Gastroenterology. 2012; 142: 704-710.e1
- Submucosal endoscopy with mucosal flap safety valve.Gastrointest Endosc. 2007; 65: 688-694
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- Yield of tissue sampling for subepithelial lesions evaluated by EUS: a comparison between forceps biopsies and endoscopic submucosal resection.Gastrointest Endosc. 2006; 64: 29-34
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- Endoscopic partial resection with the unroofing technique for reliable tissue diagnosis of upper GI subepithelial tumors originating from the muscularis propria on EUS (with video).Gastrointest Endosc. 2010; 71: 188-194
- EUS-guided single-incision needle-knife biopsy: description and results of a new method for tissue sampling of subepithelial GI tumors (with video).Gastrointest Endosc. 2011; 74: 672-676
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- Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia.Endoscopy. 2012; 44: 225-230
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© 2013 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
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- Bloc biopsy by using submucosal endoscopy with a mucosal flap method for gastric subepithelial tumor tissue sampling (with video)Gastrointestinal EndoscopyVol. 77Issue 1
- PreviewSubepithelial tumors (SETs) include widely malignant tumors such as GI stromal tumors, malignant lymphomas, carcinoid tumors, gastric cancers similar to SETs, and benign tumors such as leiomyomas, aberrant pancreas, and lipomas. Currently, minimally invasive local resection techniques such as hybrid natural orifice transluminal endoscopic surgery (NOTES), which consists of endoscopic full-thickness gastric resection, have been developed for the treatment of GI stromal tumors.1 However, there is no consensus regarding the optimal strategy for the tissue diagnosis of SETs before determining the plans for further management such as surgical resection or observation.
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