Kd 610l

All patients were placed under general anesthesia for resection of their GIST tumors and divided into either the endoscopic group or the surgical group. In the endoscopic group, all endoscopic resections were performed by skilled gastrointestinal endoscopists with a standard endoscopic therapy protocol (Figures 2,3). In brief, the patient was sedated with propofol (1.0 mg/kg) or midazolam (0.035 mg/kg) and the cardiorespiratory functions were continuously monitored throughout the entire procedure. After injection of 0.9% saline solution, containing epinephrine (1:10,000) and the indigo carmine dye, into the submucosal layer, the endoscopist completely separated the GIST tumor from the surrounding gastric tissue with a Dual knife (KD-650L; Olympus Optical Co. Ltd) or insulated-tip knife (KD-610L; Olympus Optical Co. Ltd). Clips were used to close the incision to prevent bleeding and perforation. A complete endoscopic resection of gastric GISTs was defined as the absence of any residual tumor visible endoscopically after tumor resection.
The most common methods for 268 endoscopically resected GISTs were, in the descending order, endoscopic submucosal enucleation with ESD (N=136, 50.7%), EFTR (N=88, 32.8%), ESE (N=29, 10.8%), STER (N=12, 4.5%), and EMR (N=3, 1.2%).

All ESD procedures were performed in hospitalized patients. Immediately before the procedure, midazolam hydrochloride or propofol was administered intravenously for sedation. All patients were examined using a video endoscope with or without a water-jet function (GIF-HQ290, GIF-Q260, and GIF-H260; Olympus, Tokyo, Japan) while lying in the left lateral decubitus position. After the endoscopic examination of the gastric lesions, the area surrounding each lesion was marked using argon plasma coagulation (VIO 300D; ERBE, Tübingen, Germany). A saline solution containing epinephrine (0.01 mg/mL) and 0.8% indigo carmine was injected into the submucosal layer to elevate the lesion from the muscle layer. A dual knife (KD-650Q; Olympus, Tokyo, Japan) or insulated-tip knife (KD-610L; Olympus Optical, Tokyo, Japan) was used to make a circumferential incision and dissection. Hemoclips or hemostatic forceps were used to control the bleeding or exposed vessels. All patients underwent chest and abdominal radiography immediately after ESD and on the first day after ESD to detect adverse outcomes, such as pneumonia or perforation. After ESD, all patients were administered proton pump inhibitors for 4–8 weeks.

All ESD procedures were performed by three expert ESD endoscopists (B.W.K., B.I.L., J.S.K). Patients were moderately sedated with midazolam and propofol, while the ESD was performed. A video endoscope with a water-jet function (GIF-HQ290, GIF-Q260J; Olympus, Tokyo, Japan) was used. A disposable distal transparent cap (D-201-11804; Olympus, Tokyo, Japan) was mounted on the tip of the endoscope in all cases. To identify the target lesion, chromoendoscopy with Lugol’s solution or narrow band imaging with magnification was used. The area around the lesion was marked with argon plasma coagulation. A mixture of 10% glycerol solution and diluted epinephrine (1:200,000) was injected into the submucosal layer under the lesion. Epinephrine (1:1000, total epinephrine 1 mg) were mixed in a 200-mL container of Glycerol, and 8 mL of the solution was drawn into 10-mL disposable syringe to use for SSEN. Carbon dioxide was used for the insufflation. The ESD procedure was performed mainly with a dual knife (KD-650Q; Olympus,Tokyo, Japan) or with an IT-knife 2 (KD-610L; Olympus, Tokyo, Japan) or with hook knife (KD-620LR; Olympus, Tokyo, Japan). Hemostatic forceps (Coagrasper, FD-410LR; Olympus, Tokyo, Japan) with a soft coagulation mode were used to control bleeding during the procedure.