Post written by Francesc Bas-Cutrina, MD, and Joan B. Gornals, MD, PhD, from the Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge, Bellvitge Biomedical Research Institute (IDIBELL), Universitat de Barcelona, Catalonia, Spain.

Endoscopic band ligation (EBL) without resection has been described in ablative treatment for Barrett’s esophagus or eradication of esophageal varices. Few studies have specifically evaluated EBL in GI subepithelial tumor (SET) treatment, but they are mostly retrospective. The main aim of the BANDING-SET study was to evaluate the feasibility of EBL without resection plus single-incision needle-knife (SINK) biopsy sampling in management of small GI SETs.

In approximately 2% of endoscopic procedures, a GI subepithelial lesion is discovered incidentally, triggering an EUS for its study. In more than half of these situations, we are faced with a small SET of unknown histology.

According to current clinical practice guidelines, this will require periodic endoscopic or EUS surveillance because of its potential risk of being a malignant tumor. It is questionable whether this recommendation is cost-effective. Removal of these types of lesions has been carried out to date mainly by interventional endoscopy techniques using electrocautery, but these procedures are not free of adverse events such as bleeding and perforation.

After a satisfactory initial retrospective study, including a GI stromal deep-layer tumor, we believed a strategy of combining EBL plus SINK biopsy sampling could offer great potential in management of small SETs. The purpose of this prospective multicenter study was to offer a novel approach in management of small GI SETs, combining therapeutic and diagnostic efforts.

Of 273 patients screened, 122 were included with SETs (gastric location, 77%; superficial layer dependence, 63%). The primary endpoint was achieved in 73.6% of patients.

At 1-year follow-up, the success rate was 68.4%. A favorable clinical impact was observed in 97 cases (79.5%). Pathology diagnosis was known in 70%. Potentially malignant lesions were present in 25%. The related adverse event rate was 4% (all mild: 2 bleeding, 2 abdominal pain). On multivariable analysis, the 10-mm SET group was associated with a greater success rate (1 year, 87%) and clinical impact rate (92.7%).

This strategy proposal seems to be safe, effective, feasible, and acceptable in the management of small GI SETs. EBL complemented with SINK biopsy sampling offers an overall favorable positive impact, and SETs ≤10 mm with superficial dependence are the best candidates.

On the contrary, this technique is not the most suitable for SETs >10 mm and those with deep dependency.

Lastly, this study provides new and relevant information regarding management of small SETs, offering a possible solution that may alleviate patients from frequent surveillance and worry.

Image sequence of a successfully performed case. (EUS characterization: gastric wall solid lesion, fusiform morphology, 8.2 × 5.7 mm, well-defined edges, hypoechoic internal pattern, muscularis propria layer depending; pathologic diagnosis confirmed a fusocellular GI stromal tumor). EBL, Endoscopic band ligation; SINK, single-incision needle-knife biopsy sampling.

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