What is the treatment for a transmural mass?

Treatment of Transmural Mass

Surgical resection is the primary treatment for transmural necrotic masses to prevent mortality, with all necrotic tissues requiring complete removal during the initial operation (Grade 1C).

Diagnostic Evaluation

Before determining treatment, proper evaluation of the transmural mass is essential:

• Computed tomography (CT) with contrast is the preferred initial diagnostic tool to determine the extent of transmural necrosis and guide management decisions 1
• CT findings showing absence of post-contrast wall enhancement at any level (esophagus, stomach, duodenum, bowel, colon) indicate transmural necrosis and are an indication for emergency surgery 1
• In cases where CT is unavailable or contraindicated, emergency endoscopy should be performed to evaluate the mass 1
• Endoscopic ultrasonography (EUS) is particularly useful for gastric subepithelial masses to determine the layer of origin and echogenicity, which helps narrow the differential diagnosis 1

Surgical Management

For confirmed transmural necrosis:

• Emergency surgery should be performed as soon as possible to prevent death from perforation, peritonitis, mediastinitis, or other complications 1

• All obvious transmural necrotic tissues must be completely resected during the initial operation 1

• The surgical approach depends on the location:

  • For esophageal and gastric involvement: stripping esophagectomy and gastrectomy through combined abdominal and cervical approach 1
  • For isolated gastric necrosis: total gastrectomy with preservation of native esophagus 1
  • For adjacent organ involvement: extended resections may be required in up to 20% of patients 1

• A feeding jejunostomy is indicated at the end of the operation to provide nutritional support 1

• Esophageal reconstruction should not be performed during the emergency procedure as subsequent stricture formation can compromise functional outcomes 1

Non-Operative Management

Non-operative management is appropriate only for specific cases:

• Patients without evidence of transmural necrosis on imaging can be managed non-operatively 1
• Close clinical and biological monitoring is essential, with any deterioration prompting repeat CT examination 1
• For gastric subepithelial masses without evidence of necrosis, options include:
  • Periodic endoscopic or EUS surveillance for asymptomatic masses 1
  • Endoscopic resection for symptomatic submucosal masses 1
  • Surgical resection for symptomatic masses arising from deeper layers 1

Post-Treatment Management

After surgical or non-operative management:

• Oral feeding should be reintroduced as soon as patients can swallow normally 1
• Enteral feeding via nasogastric tubes or jejunostomy is recommended for patients unable to eat 1
• Regular follow-up is necessary to monitor for complications such as stricture formation 1
• For patients with Grade II CT esophageal injuries, a follow-up visit at 4-6 months post-treatment is recommended as most strictures develop within this timeframe 1

Special Considerations

• Transmural myocardial infarction requires different management focused on coronary reperfusion therapy 1
• In Crohn's disease, transmural inflammation can lead to penetrating complications that may require surgical intervention if medical management fails 1
• For transmural gastrointestinal lymphomas, surgical resection with histopathological evaluation is essential for diagnosis and treatment 2

Complications and Pitfalls

• Delayed surgery in cases of transmural necrosis can lead to perforation, peritonitis, and death 1
• Partial gastric resections are not recommended for necrotic tissue as ongoing necrosis might compromise patient survival 1
• Reoperation should be undertaken promptly if ongoing necrosis is suspected after initial surgery 1
• For transmural esophageal necrosis, tracheobronchial endoscopy should be performed preoperatively to detect potential tracheobronchial involvement 1