Clinical Practice Update
AGA Clinical Practice Update on Management of Subepithelial Lesions Encountered During Routine Endoscopy: Expert Review

https://doi.org/10.1016/j.cgh.2022.05.054Get rights and content

Best Practice Advice Statements

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Best Practice Advice 1

Forceps bite-on-bite or deep-well biopsies or tunnel biopsies can sometimes establish a pathologic diagnosis of SEL.

Best Practice Advice 2

EUS is the modality of choice to evaluate indeterminate SEL of the GI track and/or if non-diagnostic tissue by forceps biopsies.

Best Practice Advice 3

SEL arising from the submucosa can be sampled using tunnel biopsies (or deep-well biopsies), EUS guided fine-needle aspiration (FNA), EUS guided fine-needle biopsy (FNB), or advanced endoscopic techniques (unroofing or endoscopic submucosal resection).

Best Practice Advice 4

SEL arising from muscularis propria should be sampled (preferably using FNB or FNA) to determine whether the lesion is a GIST or leiomyoma. Structural assessment and staining will allow differentiation of mesenchymal tumors and assessing their malignant potential.

Best Practice Advice 5

Endoscopic resection techniques have been described for removal of SEL and should be limited to endoscopists skilled in advanced tissue resection techniques.

Best Practice Advice 6

Management of each SEL depends on the size of the lesion, histopathology, their malignant potential, and presence of symptoms.

Best Practice Advice 7

SEL that have an endoscopic appearance consistent with a lipoma or pancreatic rest and normal mucosal biopsies do not need further evaluation or surveillance.

Best Practice Advice 8

For SEL arising from muscularis propria that are less than 2 cm in size, surveillance using EUS should be considered.

Best Practice Advice 9

Gastric GIST larger than 2 cm should be considered for resection.

Best Practice Advice 10

Subepithelial lesions that are ulcerated, bleeding, or causing symptoms should be considered for resection.

Abbreviations used in this paper

BPA
Best Practice Advice
EMR
endoscopic mucosal resection
ESD
endoscopic submucosal dissection
ESMR
endoscopic submucosal resection
EUS
endoscopic ultrasound
FNA
fine-needle aspiration
FNB
fine-needle biopsy
FTR
full-thickness resection
GI
gastrointestinal
GIST
gastrointestinal stromal tumor
MP
muscularis propria
NCCN
National Comprehensive Cancer Network
OTSC
over-the-scope clips
SEL
subepithelial lesion
STER
submucosal tunnel endoscopic resection

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Conflicts of interest This author discloses the following: Amrita Sethi serves as a consultant for Boston Scientific, Fujifilm, Intuitive Surgical, Medtronic, and Olympus and also is an editorial member for GIE and associate editor for TIGE. The remaining authors disclose no conflicts.

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