Clinical Scorecard: Evaluation of Embryonic Natural Orifice Transluminal Endoscopic Surgery for Submucosal Tumors with Preservation of Mucosal Integrity in a Beagle Model

At a Glance

Key Highlights

• E-NOTES achieved complete resection of simulated gastric MP-SMTs in a beagle model with intact mucosa preservation
• No severe complications such as perforation, peritonitis, or major bleeding occurred; minor bleeding was controllable endoscopically
• Postoperative recovery was rapid with complete mucosal healing confirmed at 60 days and histopathological verification of full-thickness muscularis propria excision

Guideline-Based Recommendations

Diagnosis

• Use endoscopic ultrasonography (EUS) to detect and characterize gastrointestinal submucosal tumors
• Recognize limitations of conventional endoscopy and imaging in definitive pathological diagnosis of SMTs

Management

• Consider E-NOTES as a novel minimally invasive technique for resection of MP-SMTs preserving mucosal integrity
• Use E-NOTES to reduce risks associated with EFTR and laparoscopic approaches such as perforation, infection, and excessive tissue removal
• Reserve EFTR, LECS, or laparoscopic wedge resection for cases unsuitable for E-NOTES or requiring wider surgical field

Monitoring & Follow-up

• Perform postoperative endoscopy to assess mucosal healing and completeness of resection
• Monitor for intra- and postoperative complications including bleeding, perforation, and infection
• Assess functional recovery including resumption of oral intake within 24 hours post-procedure

Risks

• Potential intraoperative minor bleeding manageable endoscopically
• Risks of perforation and major bleeding minimized by mucosal preservation with E-NOTES
• Delayed perforation and intra-abdominal infection risks associated with EFTR are reduced with E-NOTES

Patient & Prescribing Data

Preclinical canine model (beagles) simulating gastric MP-SMT resection

E-NOTES demonstrated feasibility, safety, and efficacy with minimal invasiveness, low complication rates, and rapid recovery, supporting further translational research

Clinical Best Practices

• Preoperative fasting and water deprivation to reduce gastric content and intraoperative risks
• Use of single umbilical access for E-NOTES to minimize peritoneal trauma and provide broad operative field
• Layer-by-layer retrograde dissection from serosa inward to preserve mucosal integrity
• Endoscopic control of minor intraoperative bleeding to avoid conversion to laparoscopy
• Postoperative endoscopic and histopathological evaluation to confirm complete resection and mucosal healing

References

• American Society for Gastrointestinal Endoscopy (ASGE) guidelines on EFTR