Submucosal tunneling endoscopic resection (STER) has been widely performed for esophageal submucosal tumors originating from the muscularis propria, because it is important to remove the tumor while it is still covered with normal mucosa. However, there are possibilities to encounter lesions that are impossible to remove through endoscopic tunnel, due to their giant size and cervical location. Under the circumstances, thoracoscopic surgery is the foremost choice reported in previous studies, though it is highly traumatic and long-term lower life qualities. With the advancement of endoscopic techniques, EFTR for giant esophageal SMTs has been reported to be a less-invasive alternative to surgery, ensure en bloc removal as well. This study aims to compare feasibility and safety of EFTR with thoracoscopic surgery for difficult esophageal submucosal tumor that submucosal tunnel is not able to create.
Methods
One hundred and twelve patients who underwent either a endoscopic full-thickness resection (n = 15; 13.4%) or a thoracoscopic surgery (n =97; 86.6%) from November 2016 to October 2023 at the first affiliated hospital of Zhengzhou University, were matched according to a propensity score 1:1, including age, sex, and size, location and pathology of tomors(Table.1). The aim was to determine intraoperative data, as well as complications and postoperative courses.
Results
In total, 15 patients treated with EFTR and 97 patients treated with thoracoscopic surgery were balanced into 15 pairs (Table.2 ). There were no significant differences in the operating time, hospital stay and duration of antibiotic use after surgery between the EFTE group and the thoracoscopic group (P>0.05). The gastric tube decompression duration and postoperative fasting time were 7.3 versus 13.1 and 8.9 versus 12.9 for the EFTE group and the thoracoscopic group in the propensity score matched cohort,,respectively. However, there was no difference in total cost (P>0.05).
Conclusions
Comparable with thoracotomy, EFTR is a feasible and safe therapy for difficult esophageal SMTs that not suitable for submucosal tunnel access, which is associated with a similar intraoperative outcome and a better postoperative course.

Xuan-Jiang Zhao

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