Clinical efficacy of endoscopic resection for subepithelial tumors in the esophagogastric junction and gastric cardia: an observational study

Sang Jin Park; Min A Yang; Jae Sun Song; Won Dong Lee; Myoung Jin Ju; Jin Woong Cho

doi:10.5946/ce.2025.219

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Original Article Clinical efficacy of endoscopic resection for subepithelial tumors in the esophagogastric junction and gastric cardia: an observational study: Sang Jin Park¹, Min A Yang¹, Jae Sun Song¹, Won Dong Lee¹, Myoung Jin Ju², Jin Woong Cho¹; DOI: https://doi.org/10.5946/ce.2025.219
Published online: January 7, 2026

¹Department of Internal Medicine, Presbyterian Medical Center, Jeonju, Korea

²Department of Pathology, Presbyterian Medical Center, Jeonju, Korea

Correspondence: Jin Woong Cho Division of Gastroenterology, Department of Internal Medicine, Presbyterian Medical Center, 365 Seowon-ro, Wansan-gu, Jeonju 54987, Korea E-mail: jeja-1004@daum.net

• Received: July 8, 2025 • Revised: August 17, 2025 • Accepted: August 25, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Graphical abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
NOTES
REFERENCES

See letter "Endoscopic resection for gastric subepithelial lesions: overtreatment or the next step in optimization?".

Abstract

Background/Aims
Gastric subepithelial tumors (SETs) located near the esophagogastric junction (EGJ) are difficult to treat surgically and endoscopically. This study aimed to evaluate the effectiveness and safety of endoscopic resection of SETs growing from the muscularis propria located in the EGJ and gastric cardia.
Methods
This study included 26 consecutive patients who underwent endoscopic resection of 27 gastric SETs between November 2012 and May 2023.
Results
Of the 27 gastric SETs, 3 and 24 were located in the EGJ and gastric cardia, respectively. The mean tumor size, operative time, and duration of hospitalization were 21 (6–52) mm, 35.4 (9–65) minutes, and 4.2 (3–7) days, respectively. Endoscopic resection of the SETs achieved an en bloc resection rate of 100% (27/27) and a complete resection rate of 88.9% (24/27). Pathological examination confirmed four gastrointestinal stromal tumors and 23 leiomyomas. No bleeding, peritonitis, or abdominal infection occurred after the endoscopic resections. Residual lesions were identified in three patients (11.1%). No recurrence was observed during follow-up (range, 3–24 months).
Conclusions
SETs in the EGJ and gastric cardia can be resected effectively, even if they originate from the muscularis propria layer.
Keywords: Cardia; Endoscopic submucosal dissection; Esophagogastric junction; Stomach neoplasms

Graphical abstract

INTRODUCTION

Gastric subepithelial tumors (SETs) have been frequently detected with a recent increase in screening endoscopies. While most SETs are considered benign, some tumors may be malignant, particularly if they arise from the muscularis propria (MP) layer.¹^-³ Thus, histological diagnosis of SETs is important for formulating further treatment plans. However, establishing a histological diagnosis of deeply embedded SETs without resection is difficult, even with a biopsy.¹^,⁴^-⁷

The resection of small SETs is indicated diagnostically and therapeutically. Laparoscopic wedge resection is the standard treatment for gastric SETs, including gastrointestinal stromal tumors (GISTs). Nevertheless, SETs located remarkably close to the esophagogastric junction (EGJ) and gastric cardia remain a challenge for laparoscopic surgeons because of the possibility of postoperative stenosis and leakage.⁸

Currently, gastric SETs can be resected using novel endoscopic procedures, such as endoscopic full-thickness resection (EFTR) and endoscopic subserosal dissection (ESSD).⁹^-¹² However, endoscopic removal of tumors located in the EGJ or cardia has been limited due to technical difficulties.⁸^,¹³

This study aimed to evaluate the effectiveness and safety of the endoscopic resection of SETs that are growing from the MP layer of the EGJ and cardia.

METHODS

Patients

A total of 26 consecutive patients with SETs at the EGJ and cardia underwent endoscopic resection at the Presbyterian Medical Center between November 2012 and May 2023. Indications for resection included increased tumor volume and size (tumors exceeding 2 cm). All patients underwent endoscopic ultrasonography (EUS) prior to endoscopic resection. None of the patients showed metastases on computed tomography.

Procedures

Overall, 27 SETs were resected via endoscopic muscularis dissection (EMD), ESSD, or submucosal tunneling endoscopic resection (STER) (Figs. 1, 2). Conscious sedation was used for most of these procedures. General anesthesia was necessary for two patients in whom the procedure time was expected to be long. A single skilled endoscopist performed all procedures using the following instruments: gastroscope (GIF-HQ290 or GIF-H260; Olympus), hook knife (KD-620LR; Olympus), I-type knife (FM-EK0003-2; Finemedix), ITknife2 (KD-611L; Olympus), and electrical cutting device (ERBE ICC 200; ERBE).

Outcome measures

The rates of en bloc resection, complete resection, and recurrence were calculated to evaluate the efficacy of the endoscopic resections. Complete resection was defined as an en bloc resection without residual endoscopic lesions. To evaluate safety, complication rates were recorded. Complications included post-procedural bleeding, peritonitis, and infection.

Statistical analysis

Baseline characteristics and treatment outcomes were compared between the groups. Student’s t-test, Mann-Whitney U-test, and Fisher’s exact test were used. All data were analyzed using IBM SPSS ver. 22.0 (IBM Corp.), with statistical significance set at p<0.05 (two-tailed).

Ethical statements

The Institutional Review Board of the Presbyterian Medical Center approved this study (approval number: 2024-01-003). Informed consent was obtained from all the patients.

RESULTS

General characteristics

This study included 26 consecutive patients with an average age of 54.3 years (range, 25–74 years). One patient had two SETs, while the other 25 had one tumor each. Of the 27 gastric SETs, 3 and 24 were located in the EGJ and cardia, respectively. The mean tumor size was 21 mm (range, 5–52 mm). Pathological examination confirmed the presence of 4 GISTs and 23 leiomyomas (Table 1).

Treatment outcomes

The mean procedure time was 35.4 (range, 9–65) minutes, and the mean hospitalization duration was 4.2 days (range, 3–7 days). Endoscopic resection achieved an en bloc resection rate of 100% (27/27) and a complete resection rate of 88.9% (24/27). No postoperative bleeding or infection was observed, and no recurrence was observed during follow-up (range, 3–24 months). Residual lesions were identified in three patients (11.1%). Cases 1, 5, and 6 underwent incomplete resections. All three cases were leiomyomas and are currently being followed up for 10, 6, and 7 years, respectively. All cases showed slow growth for 4 to 5 years after resection; however, no further growth was observed thereafter, and the patients have not required further treatment other than regular follow-up (Tables 2, 3).

Differences according to resection techniques

Overall, 17 of 27 gastric SETs were treated using EMD. Additionally, 9 SETs were removed using ESSD, and 1 SET was resected using STER (Table 2). To compare the outcomes according to the resection technique, the patients were divided into two categories. Group A: resection without penetration of the MP layer (i.e., EMD) and group B: patients underwent resection beyond the MP layer (i.e., ESSD or STER) (Table 4). No significant differences in baseline characteristics were observed between the two groups. Complete resection was achieved in 14 (82.5%) patients in group A and 10 (100%) patients in group B. Residual lesions were identified in three patients (17.7%) in the EMD group and none in the other group (Table 4).

Comparisons based on different resection periods

To compare outcomes according to the endoscopist’s experience and skill level, patients were divided into two categories. Group I: resections performed before 2020 and Group II: resections performed 2020 and after. There were no significant differences in general characteristics between the two groups (Table 5). Complete resection was achieved in 10 (76.9%) patients in group I and 14 (100.0%) patients in group II (Table 5). Residual lesions were identified in three patients (23.1%) in group I and none in group II. No significant differences in tumor size (group I vs. group II, 17.9 vs. 23.9 mm; p=0.186) and operative time (group I vs. group II, 33.9 vs. 36.8 minutes; p=0.676) were observed between the two groups. The correlation coefficients between the tumor size and operative time were 0.795 and 0.547 for groups I and II, respectively (Table 6).

DISCUSSION

Some gastric SETs originating from the MP layer have malignant potential. It is important to distinguish GIST from other types of SETs. If the size of the SETs is ≥1 cm, EUS or biopsy is recommended.⁵ However, it is difficult to distinguish GIST or leiomyoma through EUS alone. Moreover, the diagnostic yield of EUS-fine-needle aspiration is relatively low (46%–48%), and tumors originating in the MP layers make it more difficult to obtain tissues for accurate diagnosis.¹^-³^,⁷ Mitotic counts, which are important in determining the prognosis of GIST, could be relatively underestimated unless the entire tumor is resected.¹⁰ Resection of SETs may enhance diagnostic accuracy, and if the entire tumor is removed, the procedure is curative.

Traditionally, surgery is standard treatment for gastric SETs. However, tumors located in the EGJ and cardia are difficult to resect. Since Hiki et al.¹⁴ reported the successful use of combined laparoscopic and endoscopic surgery for the removal of a tumor near the EGJ in 2008, published reports of effective resection of SETs around the EGJ by combining endoscopy and laparoscopy have steadily increased.⁸ This hybrid technique could be effectively used for large GISTs, but is limited by a longer duration of hospitalization, low cost benefit, and invasive nature in patients compared to endoscopic treatment.

Endoscopic techniques for the resection of gastric SETs

Endoscopic submucosal dissection (ESD) techniques for SETs are referred to in various terms.¹⁵ In our study, we used the term “endoscopic muscularis dissection”. For cases of SETs with a narrow muscular connection identified on EUS, ESD is expected to be used effectively with minimal damage to the muscle layer.³^,¹⁶ Complete resection rates of conventional ESD for tumors from the MP layer have been inconsistent among studies, varying from 68.2% to 92.4%.¹⁷ In a large-scale study by He et al.,¹⁸ the complete resection rate of SETs by ESD was 92%, and the perforation rate was 14%. However, only 13.1% of these tumors were located in the gastric cardia. As mentioned, SETs of MP origin located at the EGJ and gastric cardia are difficult to completely resect using endoscopy, and several advanced techniques have been attempted.²^,¹³^,¹⁹^-²²

EFTR is emerging as a novel procedure for resecting SETs, especially when dealing with SETs embedded within the MP layer.⁹^,¹³^,¹⁹^,²⁰ However, EFTR has limited applications depending on the location and size of the tumor. As EFTR creates an artificial wall defect, there may be a risk of shedding tumor cells, and complete closure is important to prevent peritonitis.³

In contrast, STER is a method of forming a tunnel that has several advantages, such as mucosal integrity and easy closure of the mucosal defect.²⁰ However, this technique requires sufficient space in the submucosal tunnel with a direct view, and it was performed in only one case that conformed to the conditions in our study. In contrast, ESSD can be performed with better visibility than STER; hence, it is effectively used for tumors of the lesser curvature or gastric cardia.¹⁰ ESSD is a new countermeasure for the resection of gastrointestinal SETs with exophytic growth.²²

In the present study, among the 27 SETs located in the gastric cardia and EGJ, nine were resected with ESSD, and the complete resection rate was 100% without complications (Table 3). Because of the relatively thick subserosa of the gastric cardia and its lesser side, ESSD can be used effectively and safely for the resection of deeply embedded tumors in these areas.¹⁰^,¹¹ Considering the limitations of EFTR and STER, we suggest that ESSD should be used as a new alternative for the treatment of SETs around the gastric cardia.

Choice of resection techniques

The endoscopic resection method was planned prior to starting the procedure according to the location and EUS findings of the target SETs. (1) EMD was planned if the tumor growth pattern was endophytic and had a narrow muscular connection. (2) If the tumor growth pattern was exophytic, subserosal, and/or large, ESSD was planned for complete resection of the tumor. Among the tumors located at the EGJ, STER was performed in only one case in which sufficient submucosal tunnel space could be secured (Table 2). The complete resection was achieved in 14 (82.5%) patients with EMD, whereas it was achieved in 100.0% in patients with ESSD and STER. We found that more invasive resection techniques, such as ESSD or STER, had higher complete resection rates than conventional ESD. Additionally, the lack of experience with endoscopic resection contributes to incomplete resection.

Choosing the optimal endoscopic treatment strategy for SETs remains challenging. Chun et al.¹⁶ reported that ESD is indicated for small SETs (size ≤20 mm). In the current study, the mean resected tumor size using EMD was 17.9 mm, which was smaller than that in the ESSD or STER groups (26.3 mm). This finding is consistent with previous studies, and shows that ESD or EMD can be used effectively and safely even for SETs at the EGJ and gastric cardia. Among the patients who underwent EMD, residual lesions were identified in three cases (17.6%), but none of the patients who underwent complete resection experienced recurrence. Taken together, EMD can be effectively and safely used for the resection of small-sized (≤20 mm) SETs, while ESSD should be considered for the resection of large-sized (≥20 mm) deeply embedded tumors located in the EGJ and gastric cardia.

Endoscopist’s experience and prerequisites for the procedure

In patient group I, where the operator's experience was relatively limited, a complete resection rate of 76.9% (10/13) and three cases of residual lesions were identified. However, complete resection was achieved in all patients since 2020 (100.0%, 14/14).

Endoscopic manipulation for resection of tumors at the EGJ and gastric cardia is technically difficult. These procedures require manipulation of the deep layers of the stomach wall, particularly in anatomically complex areas, such as the EGJ and cardia. Therefore, these procedures should only be performed by endoscopists with extensive experience in ESD and therapeutic endoscopy. It is desirable to first observe the procedure by an experienced doctor, and then begin the procedure under their guidance. Han et al.¹⁰ mentioned that an operator with more than 100 gastric ESD experiences may start ESSD, which was used in 9 patients in this study.

In the present study, one skilled operator with experience of more than 2000 gastric ESD cases performed all procedures. The operator showed a higher complete resection rate after accumulating experience in more than ten cases; however, there were no specific benchmarks for the learning curve. Meanwhile, the operator accumulated experience with other advanced endoscopic techniques, which may have had an impact on improving their skill levels. Therefore, it is difficult to define the number of cases that would lead to proficiency in the resection of SETs at the EGJ and cardia at approximately 10.

The effect of endoscopist experience on the relationship between tumor size and procedure time was evaluated using Pearson’s correlation coefficient. We found that the correlation coefficient in group II, in which patients who had endoscopic resections since 2020, was 0.547, which was lower than that in group I (0.795). Generally, the procedure time increased as the tumor size increased (Pearson’s correlation coefficient approaches 1). However, the correlation coefficient was lower in group II than in group I. This may be attributed to the operator becoming more skilled, and thus, the procedure time did not increase significantly even when the tumor size increased. This reflects an increase in the skills of the endoscopist.

The endoscopic resection of SETs in the EGJ and gastric cardia requires highly advanced techniques. For safe and effective treatment, it is necessary to perform the procedure at a large specialized center with multidisciplinary support capable of performing emergency surgery in cases of complications, such as perforation. Although a standardized method has not yet been established, many technological developments have been made recently to increase complete resection rates and reduce complications. For ESD to be used more safely and effectively as a standard treatment, operators must have a comprehensive understanding of the anatomical structure of the stomach wall and substantial procedural experience.

Limitations

The present study has several limitations. This is a retrospective study. As such, selection bias may be unavoidable. The sample size was small, which may have affected the establishment of statistical significance. In the future, large-scale population-based studies should be conducted.

In conclusion, endoscopic resection can be used effectively for SETs in the EGJ and gastric cardia. It is a promising treatment alternative to surgery for tumors located in the EGJ and gastric cardia.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Acknowledgments

I would like to express my sincere gratitude to Dr. Cho and other supervising physicians at the Gastroenterology Center of Presbyterian Medical Center.

Author Contributions

Conceptualization: SJP, JWC; Data curation: SJP, MAY; Formal analysis: SJP, WDL; Investigation: SJP, MAY, JSS, WDL; Methodology: WDL, JWC; Project administration: MAY, JSS, WDL; Resources: SJP, JSS, MJJ; Software: MAY; Supervision: JWC; Validation: MAY, WDL, MJJ; Visualization: all authors; Writing–original draft: SJP; Writing–review & editing: all authors.

Fig. 1.

Endoscopic subserosal dissection for a gastrointestinal stromal tumor. (A) A subepithelial tumor identified in the gastric cardia. (B,C) The incision extending into the muscularis propria layer. (C) The subserosal layer is seen clearly. (D) The wound surface is shown as an intact serosa after tumor removal. (E) Incision closure with clips. (F) Macroscopic appearance of the resected tumor.

Fig. 2.

Submucosal tunneling endoscopic resection for a leiomyoma in the esophagogastric junction (EGJ). (A) Endoscopic view of a subepithelial tumor (SET) in the EGJ and gastric cardia. (B) Establishment of a submucosal tunnel. (C) Exposure of the SET. (D) Macroscopic appearance of the resected tumor.

Table 1.

Baseline characteristics and outcomes of endoscopic resection

Outcome	Total (n=27)
Age (yr)	54.3±12.23
Sex (male/female)	7/20
Tumor size (mm)	21.0±11.65
<20	14 (51.9)
20–30	7 (25.9)
≥30	6 (22.2)
Tumor location
Esophagogastric junction	3 (11.1)
Gastric cardia	24 (88.9)
Pathological diagnosis
Leiomyomas	23 (85.2)
Gastrointestinal stromal tumors	4 (14.8)
Growing pattern on endoscopic ultrasonography
Endoluminal only	18 (66.7)
With exophytic growing	9 (33.3)

Values are presented as mean±standard deviation or number (%).

Table 2.

Treatment outcomes

Outcome	Result (n=27)
En bloc resection	27 (100.0)
Complete resection	24 (88.9)
Operative time (min)	35.4±17.3
Duration of hospitalization (day)	4.2±0.89
Complications
Bleeding	0 (0)
Peritonitis or abdominal infection	0 (0)
Remnant/recurrent	3 (11.1)
Resection technique
ESD with muscular dissection	17 (63.0)
ESSD	9 (33.3)
STER	1 (3.7)

Values are presented as number (%) or mean±standard deviation.

ESD, endoscopic submucosal dissection; ESSD, endoscopic subserosal dissection; STER, Submucosal tunneling endoscopic resection.

Table 3.

Clinical characteristics and treatment outcomes

Case no.	Sex/age (yr)	Location	Tumor size (mm)	Resection technique	Procedure time (min)	Complete resection	Pathology
1	F/25	Cardia	35	EMD	54	No	Leiomyoma
2	F/55	EGJ	13	EMD	30	Yes	Leiomyoma
3	F/65	Cardia	22	EMD	23	Yes	Leiomyoma
4	M/70	Cardia	15	EMD	28	Yes	Leiomyoma
5	F/62	Cardia	15	EMD	20	No	Leiomyoma
6	F/50	Cardia	20	EMD	60	No	Leiomyoma
7	F/55	Cardia	10	EMD	9	Yes	Leiomyoma
8	F/52	Cardia	5	EMD	17	Yes	Leiomyoma
9	F/52	Cardia	6	EMD	17	Yes	Leiomyoma
10	F/58	Cardia	15	EMD	32	Yes	Leiomyoma
11	F/55	EGJ	37	STER	65	Yes	Leiomyoma
12	F/73	Cardia	22	ESSD	60	Yes	GIST
13	F/40	Cardia	18	EMD	26	Yes	Leiomyoma
14	F/58	Cardia	15	ESSD	30	Yes	Leiomyoma
15	M/42	Cardia	22	ESSD	21	Yes	Leiomyoma
16	F/67	Cardia	7	ESSD	20	Yes	Leiomyoma
17	F/36	Cardia	35	EMD	53	Yes	Leiomyoma
18	F/55	Cardia	22	EMD	20	Yes	Leiomyoma
19	M/74	Cardia	15	ESSD	30	Yes	Leiomyoma
20	F/46	Cardia	10	EMD	52	Yes	GIST
21	F/57	Cardia	18	ESSD	30	Yes	Leiomyoma
22	M/71	Cardia	30	ESSD	60	Yes	GIST
23	F/53	EGJ	52	ESSD	66	Yes	Leiomyoma
24	M/34	Cardia	25	EMD	50	Yes	Leiomyoma
25	M/62	Cardia	14	EMD	28	Yes	GIST
26	F/43	Cardia	25	EMD	20	Yes	Leiomyoma
27	M/57	Cardia	45	ESSD	35	Yes	Leiomyoma

F, female; M, male; EMD, endoscopic muscularis dissection; EGJ, esophagogastric junction; STER, submucosal tunneling endoscopic resection; ESSD, endoscopic subserosal dissection; GIST, gastrointestinal stromal tumors.

Table 4.

Comparison of outcomes according to resection techniques

Outcome	Group A (n=17)	Group B (n=10)	p-value
Age (yr)	50.6±11.98	60.7±10.27	0.035
Sex, male	3 (17.6)	4 (40.0)	0.365
Tumor size (mm)	17.9±8.74	26.3±14.42	0.071
Tumor location
Esophagogastric junction	1 (5.9)	2 (20.0)	0.535
Gastric cardia	16 (94.1)	8 (80.0)
Pathological diagnosis
Leiomyomas	15 (88.2)	8 (80.0)	0.613
Gastrointestinal stromal tumors	2 (11.8)	2 (20.0)
Growing pattern (exophytic)	3 (17.6)	6 (60.0)	0.039
En bloc resection	17 (100.0)	10 (100.0)
Complete resection	14 (82.4)	10 (100.0)	0.274
Operative time (min)	31.7±15.80	41.7±17.73	0.151
Duration of hospitalization (day)	4.1±0.70	4.4±1.17	0.438
Complications
Bleeding	0 (0)	0 (0)
Peritonitis or abdominal infection	0 (0)	0 (0)
Remnant/recurrent	3 (17.6)	0 (0)	0.274

Values are presented as mean±standard deviation or number (%).

Group A, patients who underwent endoscopic muscularis dissection; group B, patients who underwent endoscopic subserosal dissection or submucosal tunneling endoscopic resection.

Table 5.

Comparison of outcomes during different periods

Outcome	Group I (n=13)	Group II (n=14)	p-value
Age (yr)	54.8±12.50	53.9±12.44	0.862
Sex, male	1 (7.7)	6 (42.9)	0.77
Tumor size (mm)	17.9±9.64	23.9±12.93	0.186
Tumor location
Esophagogastric junction	2 (15.4)	1 (7.1)	0.596
Gastric cardia	11 (84.6)	13 (92.9)
Pathological diagnosis
Leiomyomas	12 (92.3)	11 (78.6)	0.596
Gastrointestinal stromal tumors	1 (7.7)	3 (21.4)
En bloc resection	13 (100.0)	14 (100.0)
Complete resection	10 (76.9)	14 (100.0)	0.098
Operative time (min)	33.9±19.04	36.8±16.11	0.676
Duration of hospitalization (day)	4.1±0.75	4.4±1.00	0.425
Complications
Bleeding	0 (0)	0 (0)
Peritonitis or abdominal infection	0 (0)	0 (0)
Remnant/recurrent	3 (23.1)	0 (0)	0.098

Values are presented as mean±standard deviation or number (%).

Group I, patients who underwent endoscopic resection before 2020; group II, patients who underwent endoscopic resection in 2020 and after.

Table 6.

Comparison of tumor size and operative time between groups I and II

Outcome	Total (n=27)	Group I (n=13)	Group II (n=14)	p-value
Tumor size (mm)	21 (5–52)	17.9 (5–37)	23.9 (7–52)	0.186
Operative time (min)	35.4 (9–65)	33.9 (9–65)	36.8 (20–66)	0.676
Pearson's correlation coefficient (γ)	0.639	0.795	0.547

Values are presented as mean (range) or number (%).

Group I, patients who underwent endoscopic resection before 2020; group II, patients who underwent endoscopic resection in 2020 and after.

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Clinical efficacy of endoscopic resection for subepithelial tumors in the esophagogastric junction and gastric cardia: an observational study

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Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study

Clinical efficacy of endoscopic resection for subepithelial tumors in the esophagogastric junction and gastric cardia: an observational study

Fig. 1. Endoscopic subserosal dissection for a gastrointestinal stromal tumor. (A) A subepithelial tumor identified in the gastric cardia. (B,C) The incision extending into the muscularis propria layer. (C) The subserosal layer is seen clearly. (D) The wound surface is shown as an intact serosa after tumor removal. (E) Incision closure with clips. (F) Macroscopic appearance of the resected tumor.

Fig. 2. Submucosal tunneling endoscopic resection for a leiomyoma in the esophagogastric junction (EGJ). (A) Endoscopic view of a subepithelial tumor (SET) in the EGJ and gastric cardia. (B) Establishment of a submucosal tunnel. (C) Exposure of the SET. (D) Macroscopic appearance of the resected tumor.

Graphical abstract

Fig. 1.

Fig. 2.

Graphical abstract

Clinical efficacy of endoscopic resection for subepithelial tumors in the esophagogastric junction and gastric cardia: an observational study

Outcome	Total (n=27)
Age (yr)	54.3±12.23
Sex (male/female)	7/20
Tumor size (mm)	21.0±11.65
<20	14 (51.9)
20–30	7 (25.9)
≥30	6 (22.2)
Tumor location
Esophagogastric junction	3 (11.1)
Gastric cardia	24 (88.9)
Pathological diagnosis
Leiomyomas	23 (85.2)
Gastrointestinal stromal tumors	4 (14.8)
Growing pattern on endoscopic ultrasonography
Endoluminal only	18 (66.7)
With exophytic growing	9 (33.3)

Outcome	Result (n=27)
En bloc resection	27 (100.0)
Complete resection	24 (88.9)
Operative time (min)	35.4±17.3
Duration of hospitalization (day)	4.2±0.89
Complications
Bleeding	0 (0)
Peritonitis or abdominal infection	0 (0)
Remnant/recurrent	3 (11.1)
Resection technique
ESD with muscular dissection	17 (63.0)
ESSD	9 (33.3)
STER	1 (3.7)

Case no.	Sex/age (yr)	Location	Tumor size (mm)	Resection technique	Procedure time (min)	Complete resection	Pathology
1	F/25	Cardia	35	EMD	54	No	Leiomyoma
2	F/55	EGJ	13	EMD	30	Yes	Leiomyoma
3	F/65	Cardia	22	EMD	23	Yes	Leiomyoma
4	M/70	Cardia	15	EMD	28	Yes	Leiomyoma
5	F/62	Cardia	15	EMD	20	No	Leiomyoma
6	F/50	Cardia	20	EMD	60	No	Leiomyoma
7	F/55	Cardia	10	EMD	9	Yes	Leiomyoma
8	F/52	Cardia	5	EMD	17	Yes	Leiomyoma
9	F/52	Cardia	6	EMD	17	Yes	Leiomyoma
10	F/58	Cardia	15	EMD	32	Yes	Leiomyoma
11	F/55	EGJ	37	STER	65	Yes	Leiomyoma
12	F/73	Cardia	22	ESSD	60	Yes	GIST
13	F/40	Cardia	18	EMD	26	Yes	Leiomyoma
14	F/58	Cardia	15	ESSD	30	Yes	Leiomyoma
15	M/42	Cardia	22	ESSD	21	Yes	Leiomyoma
16	F/67	Cardia	7	ESSD	20	Yes	Leiomyoma
17	F/36	Cardia	35	EMD	53	Yes	Leiomyoma
18	F/55	Cardia	22	EMD	20	Yes	Leiomyoma
19	M/74	Cardia	15	ESSD	30	Yes	Leiomyoma
20	F/46	Cardia	10	EMD	52	Yes	GIST
21	F/57	Cardia	18	ESSD	30	Yes	Leiomyoma
22	M/71	Cardia	30	ESSD	60	Yes	GIST
23	F/53	EGJ	52	ESSD	66	Yes	Leiomyoma
24	M/34	Cardia	25	EMD	50	Yes	Leiomyoma
25	M/62	Cardia	14	EMD	28	Yes	GIST
26	F/43	Cardia	25	EMD	20	Yes	Leiomyoma
27	M/57	Cardia	45	ESSD	35	Yes	Leiomyoma

Outcome	Group A (n=17)	Group B (n=10)	p-value
Age (yr)	50.6±11.98	60.7±10.27	0.035
Sex, male	3 (17.6)	4 (40.0)	0.365
Tumor size (mm)	17.9±8.74	26.3±14.42	0.071
Tumor location
Esophagogastric junction	1 (5.9)	2 (20.0)	0.535
Gastric cardia	16 (94.1)	8 (80.0)
Pathological diagnosis
Leiomyomas	15 (88.2)	8 (80.0)	0.613
Gastrointestinal stromal tumors	2 (11.8)	2 (20.0)
Growing pattern (exophytic)	3 (17.6)	6 (60.0)	0.039
En bloc resection	17 (100.0)	10 (100.0)
Complete resection	14 (82.4)	10 (100.0)	0.274
Operative time (min)	31.7±15.80	41.7±17.73	0.151
Duration of hospitalization (day)	4.1±0.70	4.4±1.17	0.438
Complications
Bleeding	0 (0)	0 (0)
Peritonitis or abdominal infection	0 (0)	0 (0)
Remnant/recurrent	3 (17.6)	0 (0)	0.274

Outcome	Group I (n=13)	Group II (n=14)	p-value
Age (yr)	54.8±12.50	53.9±12.44	0.862
Sex, male	1 (7.7)	6 (42.9)	0.77
Tumor size (mm)	17.9±9.64	23.9±12.93	0.186
Tumor location
Esophagogastric junction	2 (15.4)	1 (7.1)	0.596
Gastric cardia	11 (84.6)	13 (92.9)
Pathological diagnosis
Leiomyomas	12 (92.3)	11 (78.6)	0.596
Gastrointestinal stromal tumors	1 (7.7)	3 (21.4)
En bloc resection	13 (100.0)	14 (100.0)
Complete resection	10 (76.9)	14 (100.0)	0.098
Operative time (min)	33.9±19.04	36.8±16.11	0.676
Duration of hospitalization (day)	4.1±0.75	4.4±1.00	0.425
Complications
Bleeding	0 (0)	0 (0)
Peritonitis or abdominal infection	0 (0)	0 (0)
Remnant/recurrent	3 (23.1)	0 (0)	0.098

Outcome	Total (n=27)	Group I (n=13)	Group II (n=14)	p-value
Tumor size (mm)	21 (5–52)	17.9 (5–37)	23.9 (7–52)	0.186
Operative time (min)	35.4 (9–65)	33.9 (9–65)	36.8 (20–66)	0.676
Pearson's correlation coefficient (γ)	0.639	0.795	0.547

Table 1. Baseline characteristics and outcomes of endoscopic resection

Values are presented as mean±standard deviation or number (%).

Table 2. Treatment outcomes

Values are presented as number (%) or mean±standard deviation.

ESD, endoscopic submucosal dissection; ESSD, endoscopic subserosal dissection; STER, Submucosal tunneling endoscopic resection.

Table 3. Clinical characteristics and treatment outcomes

Table 4. Comparison of outcomes according to resection techniques

Values are presented as mean±standard deviation or number (%).

Group A, patients who underwent endoscopic muscularis dissection; group B, patients who underwent endoscopic subserosal dissection or submucosal tunneling endoscopic resection.

Table 5. Comparison of outcomes during different periods

Values are presented as mean±standard deviation or number (%).

Group I, patients who underwent endoscopic resection before 2020; group II, patients who underwent endoscopic resection in 2020 and after.

Table 6. Comparison of tumor size and operative time between groups I and II

Values are presented as mean (range) or number (%).

Group I, patients who underwent endoscopic resection before 2020; group II, patients who underwent endoscopic resection in 2020 and after.