Objective: Endoscopic resection of giant submucosal tumors (SMTs) in the esophagus and gastric cardia is challenging. The aim of this study was to investigate the safety and efficacy of various endoscopic procedures for resection of esophageal or gastric cardia SMTs with longitudinal diameter ≥7 cm and/or transverse diameter ≥3.5 cm. Methods: In this retrospective cohort study, we analyzed data of 109 patients with giant esophageal/cardia SMTs originating in the muscularis propria who had undergone endoscopic resection in Zhongshan Hospital from July 2017 to February 2022. Inclusion criteria were as follows: (1) SMT diameter ≥7 cm longitudinally or ≥3.5 cm transversely; (2) presence of symptoms requiring intervention; and (3) tumor originating in the muscularis propria. Exclusion criteria included severe comorbidities, coagulation disorders, prior surgery, or tumor adjacent to vital organs precluding endoscopic treatment. The primary outcomes were en bloc and piecemeal resection rates, whereas secondary outcomes comprised adverse events and long-term survival. Results: Among the 109 patients who had successfully undergone endoscopic resection, the median tumor diameters were 7.5 (4.0-15.0) cm, and 4.5 (1.5-7.0) cm. Submucosal tunneling endoscopic resection, endoscopic full-thickness resection, and endoscopic submucosal excavation were performed on 77, 22, and 10 patients, respectively. The median duration of the procedures was 90 (30-300) minutes. The overall en bloc resection rate was 78.9% (86/109), and piecemeal resection rate 21.1% (23/109). Major adverse events occurred in 12.8% of patients (14/109), comprising pneumothorax or pleural effusion (n=12), esophageal-pleural fistula (n=3), severe delayed bleeding (n=1), tunnel infection with abdominal abscess (n=1), pulmonary abscess (n=1), abdominal abscess (n=1), and postoperative esophageal stricture (n=1). During a median follow-up period of 33.6 (15.4-70.4) months, no tumor recurrences or metastases were detected. Multivariate analysis revealed that transverse diameter ≥4.5 cm was an independent risk factor for piecemeal resection (OR=6.016, 95%CI: 2.180-16.597, P<0.001); longitudinal diameter ≥9.0 cm (OR=2.728, 95%CI: 1.005-7.405, P=0.049) and transverse diameter ≥4.5 cm (OR=2.942, 95%CI: 1.099-7.874, P=0.032) were independent risk factors for prolonged operation time; and longitudinal diameter ≥9.0 cm (OR=5.040, 95%CI: 1.425-17.828, P=0.012) and piecemeal resection (OR=6.280, 95%CI: 1.741-22.656, P=0.005) were independent risk factors for major adverse events. Conclusion: Endoscopic resection is a safe and effective treatment modality for giant esophageal or gastric cardia SMTs of longitudinal diameter ≥9.0 cm and transverse diameter ≥4.5 cm.
目的： 食管及贲门巨大黏膜下肿瘤（SMT）的内镜下切除具有较大的挑战性。本研究旨在评估内镜下多种术式针对长径≥7 cm或横径≥3.5 cm的食管或贲门SMT实施切除的安全性和有效性。 方法： 为回顾性观察性研究。回顾性分析2017年7月至2022年2月期间，在复旦大学附属中山医院内镜中心接受内镜下切除治疗的109例食管或贲门巨大SMT患者的临床资料。病例纳入标准：（1）食管或贲门巨大SMT，长径≥7.0 cm或横径≥3.5 cm；（2）存在典型或非典型症状，患者要求积极治疗；（3）肿瘤起源于固有肌层。病例排除标准：（1）患者存在严重的心、肺、肝、肾功能不全，无法耐受内镜治疗；（2）患者存在凝血功能障碍或正在接受抗凝治疗，且无法在术前停药；（3）患者既往有食管或贲门手术史，影响内镜治疗的安全性；（4）术前影像学评估提示肿瘤与重要邻近结构（如大血管、气管等）关系密切，内镜治疗风险大。主要结局指标为整块切除率和分片切除情况；次要观察指标包括术后（围手术期和随访期间）主要不良事件（住院时间延长、入住重症监护室、采取干预措施或输血）发生情况和长期随访结果；并分析影响内镜下切除的潜在风险因素。 结果： 109例成功接受内镜下切除的患者肿瘤的中位长径为7.5 cm（范围：4.0~15.0 cm），中位横径为4.5 cm（范围：1.5~7.0 cm）。采用黏膜下隧道内切除术（STER）、内镜下全层切除术（EFTR）和内镜黏膜下挖除术（ESE）切除的例数分别为77、22和10例。中位手术时间为90（范围：30~300）min。全组整块切除率为78.9%（86/109），分片切除23例（21.1%）。主要不良事件的发生率为12.8%（14/109），分别为气胸或胸腔积液12例，食管-胸膜瘘3例，严重延迟性出血、隧道感染合并腹腔脓肿、肺脓肿、腹腔脓肿和术后食管狭窄各1例。在中位随访33.6（15.4~70.4）个月期间，未观察到肿瘤复发或转移。多因素分析显示，肿瘤横径≥4.5 cm是分片切除的独立危险因素（OR=6.016，95%CI：2.180~16.597，P<0.001）。肿瘤长径≥9.0 cm（OR=2.728，95%CI：1.005~7.405，P=0.049）和横径≥4.5 cm（OR=2.942，95%CI：1.099~7.874，P=0.032）是导致手术时间延长的独立危险因素。肿瘤长径≥9.0 cm（OR=5.040，95%CI：1.425~17.828，P=0.012）和分片切除（OR=6.280，95%CI：1.741~22.656，P=0.005）是发生主要不良事件的独立危险因素。 结论： 对于长径<9.0 cm、横径<4.5 cm的巨大食管或贲门SMT，内镜下切除是一种安全且有效的治疗方式。.