Chinese researchers identified tumor outgrowth and surgeon inexperience as key risk factors when performing endoscopic submucosal excavation (ESE) for the removal of gastric submucosal tumors (SMTs), according to a study published in the Journal of International Medical Research. 

Most gastric SMTs are gastrointestinal stromal tumors (GISTs), which usually present with nonspecific symptoms such as abdominal pain. Currently, treatment for gastric SMTs centers on surgical and endoscopic resection. There are various methods in which endoscopic resection can be done, including ESE. Endoscopic resection is usually preferred over surgical resection, as it is minimally invasive and shortens hospital stays. 

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ESE is a modified endoscopic submucosal dissection (ESD) technique. Studies have shown that it has a high complete resection rate as well as an acceptable complication rate. However, ESE is known to be a technically difficult procedure. Hence, the authors of this study sought to determine any risk factors for the occurrence of technical difficulties when performing ESE.

The researchers recruited 202 patients with gastric SMTs between April 2011 and December 2019. They recorded relevant data about their condition and their ESE procedure, such as tumor size, length of hospital stay, and complications (if any). The surgeons performed ESE under general anesthesia. An ESE was considered “difficult” if it met the following criteria: 

  • A procedure time lasting 90 minutes or more
  • Piecemeal resection
  • The occurrence of major adverse events, such as perforation or major bleeding.

Among the 202 patients, 128 were diagnosed with GISTs. Surgeons managed to remove 195 SMTs, with a mean surgical time of 39.23 minutes. Twenty-four patients (11.88%) were classified as having had a “difficult” ESE, and 11 patients (5.45%) had a procedure time of 90 minutes or more.

Statistical analysis identified tumor outgrowth and surgeon inexperience as key risk factors for both a long procedure time and a difficult ESE. An experienced surgeon was defined as having prior experience treating at least 100 patients with ESD.

Overall, this study demonstrated that ESE is a safe and effective method to treat patients with gastric SMTs. 


Liu J, Tan Y, Liu D, Li C, Le M, Zhou H. Factors predicting technical difficulties during endoscopic submucosal excavation for gastric submucosal tumorJ Int Med Res. Published online September 7, 2021. doi:10.1177/03000605211029808