Comparison of endoscopic resection, laparoscopic resection, and laparoscopic endoscopic cooperative surgery in esophageal or gastric subepithelial lesions in a Thai medical school

The present study was approved by the Institutional Review Board (IRB) of King Chulalongkorn Memorial Hospital (COA No. 1102/2024). The requirement for informed consent was waived due to the retrospective design of the study. All data were anonymized to protect patient confidentiality and ensure compliance with ethical standards in biomedical research.

ER was predominantly used for endophytic tumors (91%), with only one case involving an exophytic tumor (9%). LR was performed on a nearly equal proportion of endophytic (58.3%) and exophytic (41.7%) tumors. LECS was primarily performed for endophytic tumors (84.2%), with a smaller proportion of exophytic tumors (15.8%).

The distribution of surgical approaches based on tumor growth patterns (endophytic vs. exophytic) is summarized in Table 3.

These findings suggest that there is a surgeon preference for ER and LECS approaches for endophytic tumors, while LR is more commonly used for exophytic tumors.

Esophageal tumors were almost treated with ER, reflecting the minimally invasive approach preferred in this area. Tumors at the EGJ were more frequently treated with combined surgery. Fundus, lesser curvature, and antrum tumors were more evenly distributed across all three approaches but slightly favored laparoscopic surgery, indicating that all approaches were considered viable options in these locations.

Tumor location appears to be an important factor in determining the surgical approach selected by the surgeon (Table 4).

Esophageal and gastric SELs encompass a heterogeneous group of lesions that require careful management to ensure optimal clinical outcomes. Minimally invasive techniques, including ER, LR, and LECS, have been widely adopted to achieve complete tumor removal while preserving gastric function. The present study aimed to compare these three approaches in terms of complete oncological resection, technical success, and postoperative complications among patients treated at King Chulalongkorn Memorial Hospital.

Our findings revealed significant differences in complete resection rates among the three techniques. LR demonstrated the highest success rate (100%), followed by LECS (84.2%), while ER had the lowest (45.5%) (P = 0.033). These results align with previous studies indicating that laparoscopic surgery provides a more definitive resection, particularly for tumors arising from the muscularis propria layer. The lower complete resection rate in ER suggests that endoscopic techniques may be less effective for deeply located or larger lesions, where achieving clear margins is more challenging and requires higher technical skill [9, 10]. In the present study, the relatively low complete resection rate observed may be attributable to technical limitations. Notably, procedures performed during the early phase of the study demonstrated a lower complete resection rate compared to those conducted later. These findings underscore the importance of procedural proficiency and the learning curve associated with endoscopic techniques, suggesting that operator experience plays a critical role in achieving optimal oncologic outcomes. Determining the layer of involvement by endoscopic ultrasound (EUS) is critical in planning resection techniques [11]. In the present study, all esophageal SELs were managed using ER. Histopathological examination revealed leiomyoma in all cases, with lesion sizes measuring 0.7 cm, 2.5 cm, and 3.0 cm. The smallest lesion was successfully resected using ESD technique, while the 2 larger lesions were resected via the STER technique. Notably, the largest lesion (3.0 cm) demonstrated a positive resection margin, highlighting the potential limitation of ER in achieving complete resection in larger esophageal lesions. However, ER remains an attractive option for smaller, intraluminal tumors due to its lower invasiveness and quicker recovery time [12, 13].

LECS is a hybrid surgical technique that integrates the advantages of endoscopy and laparoscopy, initially introduced by Hiki et al. [14]. Before the development of LECS, LR was the standard approach for treating SELs. However, the external appearance of gastric SELs is often unremarkable, especially in the endophytic pattern, making it challenging to accurately determine resection margins using LR alone [15,16,17]. This limitation may result in either incomplete or excessive resection, potentially increasing the risk of tumor recurrence or leading to postoperative gastric stasis and altered gastric function. The primary advantages of LECS include precise tumor resection with minimal surgical margins, preservation of gastric motility, and maintenance of postoperative quality of life. This is particularly beneficial for SELs located in the EGJ, as it can prevent the need for total or proximal gastrectomy [17]. In the present study, the LECS group comprised classic LECS in 16 out of 19 cases, NEWS in 1 case, and the CLEAN-NET in 2 cases. These newer LECS techniques have been developed to minimize the risk of tumor spillage and reduce the likelihood of peritoneal contamination and subsequent infection or tumor seeding.

Our results showed a higher delayed bleeding rate in the ER group (18.2%), compared to 0% in LR and LECS. Postoperative bleeding following ER is a recognized complication that can occur shortly after the procedure or up to several weeks postoperatively, with the highest incidence observed within the first 24 h. Clinical manifestations may include hematemesis, melena, hemodynamic instability, and a decline in hemoglobin levels. Several risk factors have been associated with postoperative bleeding, including lesion size, resection defect size, and tumor location. Additionally, patient-related factors, such as advanced age and underlying comorbidities, contribute to an increased risk. Procedural factors, including intraoperative bleeding, adequacy of hemostasis, use of anticoagulant or antiplatelet therapy, and the experience level of the endoscopist, also play a critical role in the likelihood of postoperative hemorrhage. Identifying and mitigating these risk factors is essential to improving patient outcomes and minimizing complications following ER [18, 19]. While endoscopic techniques are considered minimally invasive, they carry a high risk of intraoperative perforation. Intraoperative perforation is a recognized complication of ER with reported incidence rates ranging from 1.2% to 5.2%. Several risk factors have been identified, including lesion size, lesion characteristics, anatomical location, and procedure duration. ER performed for lesions exceeding 20 mm in diameter, deeply infiltrating lesions, or those located in the middle and upper gastrointestinal tract has been associated with a higher risk of perforation. Additionally, the presence of fibrosis at the lesion site, piecemeal resection, and procedures exceeding 2 h have been linked to an increased likelihood of perforation [9, 10, 12, 13, 20]. Careful patient selection, preoperative planning, and advanced endoscopic techniques are essential in minimizing the risk of this complication and ensuring optimal procedural outcomes.

In contrast, in the present study, LECS demonstrated the lowest overall complication rate, reinforcing its safety advantage over ER and LR, which is consistent with prior systematic review and meta-analysis studies [4]. Despite these advantages, LECS has inherent limitations, including the risk of peritoneal contamination with tumor cells or gastric contents due to intentional opening of the gastric wall, as well as the requirement for advanced endoscopic and laparoscopic expertise [21, 22].

The findings of the present study highlight the significant role of patient selection in determining the most appropriate surgical approach for the management of esophageal and gastric SELs. Key factors influencing surgical decision-making include tumor growth pattern, anatomical location, depth of tumor, and the technical expertise of the surgeon. For smaller, intraluminal tumors, ER may be a suitable approach; however, preoperative evaluation of tumor depth using EUS is essential to ensure appropriate case selection. Moreover, careful consideration must be given to the risk of perforation, particularly in tumors originating from the muscularis propria layer. Additionally, expertise in endoscopic closure techniques and proficiency in hemostatic management are critical in reducing the risk of intraoperative and postoperative complications.

LR remains a viable and effective approach, particularly for larger or deeply located tumors. However, in the present study, LR was associated with a prolonged hospital stay, consistent with findings from previous meta-analyses [4].

LECS, as an emerging hybrid technique, appears to provide an optimal balance between efficacy and safety, offering precise tumor resection while preserving gastric function and minimizing the risk of postoperative complications.

Several limitations should be acknowledged. First, the sample size was relatively small, which may limit the generalizability of the findings. Second, this retrospective study includes selection bias, as the choice of surgical technique was influenced by surgeon preference based on patient clinical factors, potentially impacting the comparability of outcomes across different approaches. Future research should focus on multi-center studies with larger sample sizes and longer follow-up durations to better understand the long-term benefits and risks associated with each technique.

In summary, the present study provides a comparative analysis of ER, LR, and LECS in the management of esophageal and gastric SELs. While all three techniques demonstrated a high technical success rate, ER was associated with the lowest rate of complete resection and the highest risk of delayed bleeding. These findings highlight the importance of individualized surgical planning, considering factors such as tumor size, location, and depth of invasion, to optimize clinical outcomes in patients with esophageal and gastric SELs.