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),
1along 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
- Khashab M.A.
- Kalloo A.N.
NOTES: current status and new horizons.
Gastroenterology. 2012; 142: 704-710.e1
2and was adopted for esophageal myotomy by Pasricha et al
- Sumiyama K.
- Gostout C.J.
- Rajan E.
- et al.
Submucosal endoscopy with mucosal flap safety valve.
Gastrointest Endosc. 2007; 65: 688-694
3in 2007, culminating in its application in patients with achalasia by Inoue et al
- Pasricha P.J.
- Hawari R.
- Ahmed I.
- et al.
Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.
Endoscopy. 2007; 39: 761-764
4in what has now become known as the POEM (per oral endoscopic myotomy) procedure. However, as illustrated by Kobara et al
- Inoue H.
- Minami H.
- Kobayashi Y.
- et al.
Peroral endoscopic myotomy (POEM) for esophageal achalasia.
Endoscopy. 2010; 42: 265-271
5in 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.
- Kobara H.
- Mori H.
- Fujihara S.
- et al.
Bloc biopsy using submucosal endoscopy with mucosal flap method for gastric subepithelial tumor tissue sampling (with video).
Gastrointest Endosc. 2013; 77: 141-144
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)
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- 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
- Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia.Endoscopy. 2007; 39: 761-764
- Peroral endoscopic myotomy (POEM) for esophageal achalasia.Endoscopy. 2010; 42: 265-271
- Bloc biopsy using submucosal endoscopy with mucosal flap method for gastric subepithelial tumor tissue sampling (with video).Gastrointest Endosc. 2013; 77: 141-144
- EUS-guided FNA for the diagnosis of GI stromal cell tumors: sensitivity and cytologic yield.Gastrointest Endosc. 2009; 70: 254-261
- EUS-guided sampling of suspected GI stromal tumors.Gastrointest Endosc. 2009; 69: 1218-1223
- Accuracy of EUS in the evaluation of small gastric subepithelial lesions.Gastrointest Endosc. 2010; 71: 722-727
- Clinical impact of EUS-guided Trucut biopsy results on decision making for patients with gastric subepithelial tumors ≥2 cm in diameter.Gastrointest Endosc. 2011; 74: 1010-1018
- 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
- Diagnostic yield and safety of jumbo biopsy forceps in patients with subepithelial lesions of the upper and lower GI tract.Gastrointest Endosc. 2012; 75: 1147-1152
- 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
- Intraprocedural tissue diagnosis during ERCP employing a new cytology preparation of forceps biopsy (Smash protocol).Am J Gastroenterol. 2011; 106: 294-299
- Submucosal endoscopic tumor resection for subepithelial tumors in the esophagus and cardia.Endoscopy. 2012; 44: 225-230
- Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos).Gastrointest Endosc. 2012; 75: 195-199
- Endoscopic full-thickness resection of a gastric subepithelial tumor by using the submucosal tunnel technique with the patient under conscious sedation (with video).Gastrointest Endosc. 2012; 75: 457-459
© 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.